Across the dividing range - bridging the divides: Pharmacy opportunities across the hospital/community and inter-professional divides in rural and remote Australia

Rural and remote areas of Australia offer many opportunities for innovation in healthcare services. Some true healthcare 'network' models based around rural pharmacy can be established and evaluated. The lines between community and hospital pharmacy are often blurred and communication between health professionals enhanced. The blurring divide between hospital and community pharmacy in rural and remote areas has provided significant advances in practice. Projects have been set up to investigate the feasibility of community pharmacists integrating care for patients. These projects take advantage of the dual roles and the enhanced interaction between pharmacists and other health professionals in the bush. Opportunities for provision of clinical services beyond the traditional supply role have been taken in a number of remote communities

Can telepharmacy provide pharmacy services in the bush?

Rural and remote community pharmacies service large areas of rural Queensland, and because of the distances involved often do not meet the patients for whom they provide medication. Telepharmacy would improve the quality of pharmaceutical services provided in rural and remote areas, by allowing community pharmacists to have realtime contact with dispensing doctors, aboriginal health workers and patients via a video-phone. We used commercial (analogue) videophones to connect community pharmacists to dispensing doctors, patients in depot pharmacies (i.e. those with no pharmacist) and aboriginal health workers. However, various problems occurred and only 10 video-phone interactions were recorded during the six-month project. In all of the recorded interactions, the video-phone was actually used as a conventional telephone because a video-connection could not be established at the time of the call. (This may have been due to telephone network problems in the rural areas.) Despite these problems, all project participants showed great enthusiasm for the potential benefits of such a service.

Medication management at home: medication risk factor prevalence and inter-relationships

Background and objective: Patients can have medication-related risk factors associated with poor health outcomes that become evident through visiting them in their homes. These medication-related risk factors may not be apparent in pharmacy and general practitioner (GP) records. The aim was to determine the prevalence and inter-relationships of medication-related risk factors for poor patient health outcomes identifiable through 'in-home' observations. Methods: The design was a cross-sectional study of 204 general practice patients living in their own homes and at risk of medication-related poor health outcomes. Medication-related risk factors were identified in the patients' homes by community pharmacists and GPs. Results and discussion: The prevalence of risk factors varied from 8.3% (multiple medication storage locations) to 55.9% (confused by generic and trade names). There were many relationships observed between the medication-related risk factors, with expired medication having the most relationships with other risk factors followed by therapeutic duplication and poor adherence (9, 6 and 6 relationships respectively). Conclusion: Visiting patients' homes may identify medication-related risk factors not otherwise apparent through patient visits to the health practitioner when medications may be brought for review (i.e. 'brown bag' reviews).

Free mycophenolic acid should be monitored in renal transplant recipients with hypoalbuminemia

The current approach for therapeutic drug monitoring in renal transplant recipients receiving mycophenolate mofetil (MMF) is measurement of total mycophenolic acid (MPA) concentration. Because MPA is highly bound, during hypoalbuminemia the total concentration no longer reflects the free (pharmacologically active) concentration. The authors investigated what degree of hypoalbuminemia causes a significant change in protein binding and thus percentage free MPA. Forty-two renal transplant recipients were recruited for the study. Free and total concentrations of MPA (predose, and 1, 3, and 6 hours post-MMF dose samples) and plasma albumin concentrations were determined on day 5 posttransplantation. Six-hour area under the concentration-time curve (AUC(0-6)) values were calculated for free and total MPA, and percentage free MPA was determined for each patient. The authors found a significant relationship between low albumin concentrations and increased percentage free MPA (Spearman correlation = -0.54, P < 0.0001). Receiver operating characteristic (ROC) curve analysis was performed on the albumin versus percentage free MPA data. The cutoff value of albumin determined from the ROC analysis that differentiated normal from elevated percentage free MPA (defined as greater than or equal to3%) in this patient population was 31 g/L. At this cutoff value albumin was found to be a good predictor of altered free MPA percentage, with a sensitivity and specificity of 0.75 and 0.80, respectively, and an area under the ROC curve of 0.79. To rationalize MMF dosing regimens in hypoalbuminemic patients (plasma albumin less than or equal to 31 g/L), clinicians should consider monitoring the free MPA concentration.

Polycationic lipophilic-core dendrons as penetration enhancers for the oral administration of low molecular weight heparin

Two polycationic lipophilic-core carbohydrate-based dendrons 2a-b and five polycationic lipophilic-core peptide dendrons 3-6, containing four arginine or lysine terminal residues, were synthesized and then tested in rats as penetration enhancers for the oral delivery of low molecular weight heparin. Better results were obtained with dendrons containing terminal lysine residues than terminal arginine. A significant anti-factor Xa activity was obtained when low molecular weight heparin was coadministered with dendron 5. (c) 2005 Elsevier Ltd. All rights reserved.

Ciguatoxins: Cyclic polyether modulators of voltage-gated Iion channel function

Ciguatoxins are cyclic polyether toxins, derived from marine dinoflagellates, which are responsible for the symptoms of ciguatera poisoning. Ingestion of tropical and subtropical fin fish contaminated by ciguatoxins results in an illness characterised by neurological, cardiovascular and gastrointestinal disorders. The pharmacology of ciguatoxins is characterised by their ability to cause persistent activation of voltage-gated sodium channels, to increase neuronal excitability and neurotransmitter release, to impair synaptic vesicle recycling, and to cause cell swelling. It is these effects, in combination with an action to block voltage-gated potassium channels at high doses, which are believed to underlie the complex of symptoms associated with ciguatera. This review examines the sources, structures and pharmacology of ciguatoxins. In particular, attention is placed on their cellular modes of actions to modulate voltage-gated ion channels and other Na+-dependent mechanisms in numerous cell types and to current approaches for detection and treatment of ciguatera.

Relevance of the deletion polymorphisms of the glutathione S-transferases GSTT1 and GSTM1 in pharmacology and toxicology

Although cytosolic glutathione S-transterase (GST) enzymes occupy a key position in biological detoxification processes, two of the most relevant human isoenzymes. GST1-1 and GSTM1-1, are genetically deleted (non-functional alleles GSTT1*0 and GsTM1*0) in a high percentage of the human population, with major ethnic differences. The structures of the GSTT and GSTM gene areas explain the underlying genetic processes. GSTT1-1 is highly conserved during evolution and plays a major role in phase-II biotransformation of a number of drugs and industrial chemicals. e.g. cytostatic drugs, hydrocarbons and halogenated hydrocarbons. GSTM1-1 is particularly relevant in the deactivation of carcinogenic intermediates of polycyclic aromatic hydrocarbons. Several lines of evidence Suggest that hGSTT1-1 and/or hGSTM1-1 play a role in the deactivation of reactive oxygen species that are likely to be involved in cellular processes of inflammation, ageing and degenerative diseases. There is cumulating evidence that combinations of the GSTM1*0 state with other genetic traits affecting the metabolism of carcinogens (CYP1A1, GSTP1) may predispose the aero-digestivc tract and lung, especially in smokers, to a higher risk of cancer. The GSTM1*0 status appears also associated with a modest increase in the risk of bladder cancer, consistent with a GSTM1 interaction with carcinogenic tobacco smoke constituents. Both human GST deletions, although largely counterbalanced by overlapping substrate affinities within the GST superfamily, have consequences when the organism comes into contact with distinct man-made chemicals. This appears relevant in industrial toxicology and in drug metabolism.