A What rush?

<<Rant Alert>>

Thanks TGA

It would seem the TGA would now like Australian doctors speak more like our cousins across the Pacific Ocean in America, that is. There is a updated list of the politically correct names we should all now be using for a select group of drugs. https://www.tga.gov.au/updating-medicine-ingredient-names-list-affected-ingredients. I know these are really the International Nonproprietary Names but it seems that most of the names are being changes to what Americans call their drugs rather than what generations of Australian doctors have called them.

 

adrenaline 6adrenaline 9adrenaline 3 adreanline 3

Adrenaline shall now be called epinephrine. the sight of a white pointer rushing at you on a small yellow kayak, the feeling as you catch a 100 foot wave or jump from a perfectly good plane  or a solid mountain top, or as you touch 300kph in top gear will now forevermore be an EPINEPHRINE RUSH. Doesn’t really sound the same does it?

Noradrenaline, the alpha receptor specialist, likewise shall be known as norepinephine. Must venlafaxine now be called a serotonin, “norepinephrenergic” reuptake inhibitor? Maybe the Americans were getting confused with North American Aerospace Defense Command when someone called for a box of Norad?

Amethocaine my old friend, a sight for a sore eye, now is tetracaine but it may be better if you have four eyes.

Apparently amphoterin gains a “B”. Not sure what happened to amphotericin A. Maybe the “B” is for better.

All the phenobarbitones are now phenobarbitals but that just doesn’t sound right, too aggressive, these drugs are supposed to be more sedate. Amylobarbital, barbital, secbarbital, nembutal (well that one seems to have snuck in for a while), thiopental…

There are few changes that just seem stupid. Where am I to put methylrosanilinium chloride? Oh, if you told me it was crystal violet then maybe I’d  have a better idea.

I will not be moving the “u” and writing an “o” in frusemide. Just to make that clear. It’s like calling my best mate “Buroce”, sorry Bruce I’m not making fun of you it just won’t happen.

Maybe I can drop the “e” from eformetrol, it might make it sound less rude.

Lignocaine remains lignocaine in my mind and you can put that lidocaine and epinephrine right back and give me what I asked for sister!

There are bunch of other changes which just confuse me like dosulepin instead of dothiepin.

There is a list of minor changes too. Such as we are now supposed to drop the “y” in amoxycillin an change it to a “i”. Also pericyazine become periciazine. Surely there are enough vowels in there already, give the consonants a go please. And of course, son’t forget about the “ph” in cephalexin, cephamandole, cephazolin, cephalothin…..  I see even Wikipedia still call this group cephalosporins. Okay a couple with the “f” have already settled into our local formulary …. ceftriaxone, ceftazidime, and cefotetan….

Its not just antibiotics that loose the ph its also Phytic acid becomes fytic acid. I guess it goes the way of telephone, physiotherapy, phallus, physics and farmaceuticals. Dammed its happened already. Mooo

We loose the “o” in oestrogen and all its cousins like oestradiol and oestriol. It is a word rooted in the latin word oestrus.  Bit like orthopaedic, paediatric and gynaecology…..

Tioguanine, etacrynic acid, beclometasone  and indometacin all seem to be missing a “h” Do the INN committee members have something about touching the tongue to their toot?

Its wong I tell you all wong. See you need that extra consonant otherwise you’ll be making fun of all sorts of people.

Give me Paraffin – soft white any day over soft white paraffin.

Enough….read the list. As I read through the list I wonder how many TGA committee meetings in Canberra it took to devise this list. Or was someone bored one Friday afternoon. No new drugs to approve, hey let’s change some names?

Yep Thanks TGA for surrendering to all things America, sorry INN.

At least we bought a French submarine…. Hopefully they will be launched with a nice bottle of Australian Champagne oops sparkling white, preferably from the Clare or Barossa valley.

Oh by the way, we are still apparently permitted to call paracetamol, well paracetamol. So shove that non-INN acetaminophen suppository up your bum America.

<<Rant Over>>

How do I choose a new drug?

I wonder whether I choose a new drug in the same way I picked my new car_DSC9496-001.

The car buying process involved a lots of research, a bit of procrastination and then some negotiation.

Reading several months of Wheels, Top Gear & Car & Driver

Like reading the MJA/BMJ/NEJM

Reading Carsguide & Caradvice websites

The 6 Minute and Australian Doctor equivalent

Watched Youtube reviews and forums like VW Watercooled Australia to get the gossip on reliability and after sales service

Not sure if there is any medical equivalent, maybe GPDU

Then I did talk with a salesperson

The Drug Rep

And went for test drive

No real equivalent experience here. It isn’t really appropriate to ask for a sample of Targin to see how it helps my chronic pain, or shoot up Saxenda for a month to see if I loose weight.


So should I use drug reps as my primary source of information about new drugs?

Should I even see drug reps?

There is certainly support out there if I do go down this path. There are doctors out there who already say no to drug representatives.  http://www.nofreelunch.org/ and http://noadvertisingplease.org/

Dr Brett Montgomery has written on the subject here  https://theconversation.com/why-i-dont-see-drug-reps-a-gps-take-on-big-pharma-spruiking-32435

Dr Ben Goldacre has blogged on his BadScience website and written on the influence of pharmaceutical companies on drug utilisation.  After eventually making it through Bad Pharma I felt a little pessimistic about the whole process. It’s a bit like House of God, essential junior doctor reading.

A list of problems include

  • Missing clinical data which the rep probably doesn’t know about either
  • Positive paper publication bias
  • Ghost writers instead of academics
  • No decent independent head to head studies, so what if me2 is better than placebo is it better than the first drug?
  • Kick backs to medical journals
  • Half blind public agencies
  • Statistical manipulations and sub- subgroups analysis
  • Glossed over serious adverse effects. “The risk of thyroid cancer with Saxenda is over rated!” or “No that only happens in beagles”
  • Glossy brochures and advertising in journals.
  • Pushy drug reps and their inducements – which do seem limited to lunch rather than international flights these days.
  • Leaving behind drug samples as starter packs
  • Subsidising patients support groups and turning them into pharmaceutical lobby groups
  • Product familiarisation campaigns
  • Breaking news on popular media dressed up as “news” stories
  • Chatting in the ear of the clinic nurses, who also look after the sample cupboard. I wonder if any rep has suggested that the oppositions product be pushed to the back or even in the bin?
  • Paying specialists to “educate” GPs
  • Creating a “disease” to sell a product, eg fibanserin for a woman’s poor libido

As a health professional am I impervious to drug rep propaganda. I think the evidence suggests NO.

A few hints include the average sales force expenditure for pharmaceutical companies is $875 million annually and that is just in the USA. Being Australian, I am of course more skeptical and cynical but even so it has been estimated that in 2012 $30 million was spent by pharmaceutical companies trying to persuade doctors to use their product. I think it safe to assume no one would spend that kind of money if there wasn’t some return.

I think I can say that drug are not evil and may be a source of information but they need to handled with care.

Where are you putting that Mars Bar?

mars2

I saw a recent suggestion that rectal administration of a chocolate bar could be used to reverse hypoglycaemia in a patient who was unable to take anything orally.

This led to a range of comments from colleagues mostly of surprise. There were the suggestions that maybe a Poly Woffle has a better likeness to a stool. I helpfully hinted that the wrapper needs to be removed first.

Use of rectal chocolate bars seemed a little strange but not directly counter intuitively. As a pharmacist, I had the joy of preparing suppositories albeit for my undergraduate manufacturing examination, where a pass required a homogeneous and perfectly contoured little bullet. Suppositories have a long history of medicinal uses, although in the Australian context they are not always a popular choice.

But a chocolate bar!

Mars bars contain Milk Chocolate 40%,  Nougat 33% and Caramel 27%. Specific ingredients are Sugar, Glucose Syrup (Sources include Wheat), Milk Solids, Vegetable Fat, Cocoa Butter, Cocoa Mass, Barley Malt Extract, Cocoa Powder, Emulsifier (Soy Lecithin), Salt , Egg White, Natural Flavour (Vanilla Extract). A 36 gram bar gives you 20.8 grams of sugar and 6.2 grams of fat, and reassuringly 0.5g of fibre. There is some glucose in it and that is what we need to reverse hypoglycaemia. Sucrose will do the same but it first needs to broken down to glucose and fructose by the enzyme, sucrase. Sucrase, unfortunately lives in the brush border of the small bowel not the rectum. This kind of makes sense given that the food goes into the mouth and waste comes out of the rectum and from an evolutionary perspective it is best to absorb the good stuff higher up in the bowel after it has passed the taste bud test.

The upper part of the rectum drains into the superior mesenteric vein which drains into the liver via the portal vein. The middle and inferior rectal veins in contrast drain the lower part of the rectum and venous blood is returned to the systemic circulation via the inferior vena cava and thus avoids hepatic first pass metabolism by the liver. So use of some drugs as a suppository has an advantage, although potentially toxicity is increased as liver metabolism is bypassed.

Drugs aside, is their any evidence for benefit from per rectum glucose?

Long, Geiger and Kenny published in Metabolism in 1967 a small study following radiolabelled glucose infused per rectum compared to intravenously. They showed that if you killed of gut flora with neomycin, then the expired radiolabelled CO2 following rectal administration was diminished greatly. They suggested rectally absorption of glucose was minimal and the CO2 expired was due to the effect of gut flora.

In 1984, Aman and Wranne published a small study using six diabetic children as in their words “volunteers” in Acta Paediat Scand. The title kind of gives away their findings “Treatment of Hypoglycemia in Diabetes: Failure of Absorption of Glucose through Rectal Mucosa” The authors gave their “volunteered” children aged 5 yo 10 years old, their normal insulin dose, half a serve of breakfast then exercised them to ensure hypoglyaemia. They were sent to bed and given a dose of 30% glucose solution via a rectal tube. One of the children’s glucose was 1.4mmmol/L and they were so worried that child got intravenous glucose leaving just five subjects. Two more were given milk, leaving just three subjects. One child who got 100ml of the solution up the bum, managed after an hour to get a blood sugar rise from 1.8 to 2.4 mmol/L and I suspect still symptomatic. Anal leakage was also an a problem. Aman and Wranne quite reasonably suggested that “For the unconscious hypoglycemic child, glucose intravenously or glucagon by injection is still necessary.”

A letter published in 1985 in Diabetes care by Attval, Lager and Smith used healthy volunteers, thankfully a little older and better able to consent to having tubes pushed up their bums. In this case a dose of glucose 1g/kg was dissolved in water and inserted. The mean maximal increase in serum glucose was 19%, compared to 64% per oral. The time to that increase rectally was 30 to 40 minutes after administration. Oral peak was at 20 minutes.

For historical purposes only Tallerman published a study On the rectal absorption of glucose in Quarterly Journal of Medicine in 1920. He noted the change was slow. Interestingly this was done  prior to Banting and Best introducing insulin into clinical medicine in 1922.

Interestingly, glucagon which I would normal inject in severe hypoglycaemia, has been studied by Parker etal in a suppository form and it works quite well. Unfortunately, and possibly thankfully for me and my patients, it is only available in Australia in an injectable form.

Is there an alternative for an unconscious hypoglycaemic patient?

Yes, you can given parenteral glucagon if available. And you can place glucose into the mouth. A New Zealand study by Harris et al published in the Lancet in 2013 in neonates showed that a 40% glucose gel was effective as reversing hypoglyacemia.  The gel was massaged into the buccal cavity and the babe encouraged to feed. The use of the gel was more effective than feeding alone. Now this doesn’t exactly transfer to the unconscious adult. There is the issue of teeth to contend with. But there is evidence that there are glucose transporters within the the oral cavity.

So in conclusion, and without any obvious evidence, I think hypoglycaemic bottoms are safe from chocolate bars and squirting glucose into the mouth seems a more reasonable approach if intravenous access is not readily available. Honey which contains up to 35% glucose would be a useful substitute. Except in neonates of course, because of the risk of botulism.

BEACH GONE, DARKNESS RETURNS.

Haven’t posted on my blog for a while but think that I should resurrect it.

A recent media release got my attention…

From the Family Medicine Research Centre.  University of Sydney 11 April 2016

The current contract with Australian Government Department of Health (DoH) for a partial contribution to the costs of the BEACH (Bettering the Evaluation and Care of Health) program finishes on 30th June 2016.

We have been informed that there will be no further funding from DoH for the BEACH program.

BEACH has always struggled to gain sufficient funds each year. However, this notification comes when we also have a large shortfall in funding coming from other organisations such as NGOs and pharmaceutical companies, due to closure of many Government instrumentalities and authorities, and the heavy squeeze on pharmaceutical companies’ profits, resulting from changes to the PBS.

We therefore have no choice but to close the BEACH program. This will leave Australia with no valid, reliable and independent source of data about activities in general practice.

We also have no funds available to produce the annual BEACH report and the ‘decade of Australian general practice activity’ report for this year. Officially, the program will close on the 30th of June, after contracted deliverables to the DoH and other funding organisations are complete. We are committed to supporting the GPs who are currently participating in the study, and will ensure that they are able to complete the study and receive their quality improvement points. However, we cannot support any more GPs to start the study given the short timeframe involved.

The BEACH team wishes to thank all the organisations who have supported BEACH over the last 18 years, in any capacity.

Most importantly we thank the 11,000+ GPs throughout Australia who have participated one or more times in the program, making a big contribution and generously giving their time to do so.

BEACH has been the only continuous national study of general practice in the world which relies on random samples of GPs, links management actions to the exact problem being managed, and provides extensive measurement of prevalence of diseases, multimorbidity and adverse medication events (to name just a few subjects of the many SAND sub-studies conducted in the BEACH program).

Without the GPs, we would not have had the data to report.

Without BEACH there will be very little reliable, independent national information about GP clinical activity in the future.

This loss of BEACH data turns off a light on General Practice in Australia, returning us the dark ages. We will now have to depend upon the muddies waters of government data which may be spun for political gain. And half-arsed efforts by groups like the Gratton Institute who recently wrote a report on chronic disease care in Australia and suggested

“Ineffective management of heart disease, asthma, diabetes and other chronic diseases costs the Australian health system more than $320 million each year in avoidable hospital admissions”

Closure of BEACH program after 18 years.

If you would like to know more about Beach contact Professor Helena Britt
Tel: +612 9845 8150  Mob +61 411 197 938

helena.britt@sydney.edu.au
Director, Family Medicine Research Centre, University of Sydney .

Looking for a new challenge?

Rural GP (Obstetrics)

We are looking for a VR GP with obstetrics to join our team at the Kangaroo Island Medical Clinic.

The KI Medical Clinic is located in Kingscote on Kangaroo Island, SA’s ecotourism jewel.  Although located in an RA4 Area, the Island is only 25 mins to Adelaide by plane and offers a great lifestyle – surfing, fishing, kayaking, bushwalking, wildlife and fine food and wine experiences.   Kangaroo Island has a resident population of approx. 4,600, with more than 150,000 tourist visitors each year.

The clinic is currently staffed by 6 GP’s (who also provide emergency on-call services to the KI Health Service), supported by 2 practice nurses, a practice manager and administration team, all with a commitment to providing high quality care to our patients.

The clinic is involved with medical student education through Flinder’s University and registrar teaching.

At this boutique rural practice, we can offer:

  • A 3-4 day working week
  • Up to 8 weeks annual/up-skilling leave for associates
  • Rural retention allowance and relocation incentives are available
  • A dynamic and supportive practice team
  • Combine the opportunity to practise your emergency and procedural medicine skills with a great lifestyle in the perfect location

Essential requirements:

  • FACRRM or FRACGP
  • Adv Dip Obstetrics
  • Emergency medicine experience

For more information please contact our Practice Manager, Genevieve Willson on 08 8553 2037 or at practice.manager@kimedical.com.au; or to see more of what Kangaroo Island and the KI Medical Clinic have to offer, visit https://www.youtube.com/watch?v=RGpy3W-EPYM.

 

 

 

Genevieve Clark
Practice Manager

 

64 Murray St

Kingscote SA 5223

Ph: 8553 2037

Fax: 8553 2437

genevieve.clark@kimedical.com.au

 

Repost – The art of delivery

I would like to update this post with a link to a Coroner’s report from the 8th July 2014 concerning the death of a newborn. This occurred in the setting of a woman who previously had a uterine perforation as a result of a D&C, undergoing a prostaglandin induction. She developed hyperstimulation which caused uterine rupture at the site of perforation, and despite an emergency Cesarean section her baby died.

The Coroner’s report can be found at the SA Courts website. The report does go for 47 pages.

The report follows arguments as to whether the perforation was a contraindication to an induction of labour with prostaglandin and whether the woman should have been offered a cesarean section for delivery of her baby. In addition, the Coroner raises the case of Roger v Whitaker to discuss material risk. 

Exactly how much should we tell our patients – as a reminder……..

“…a risk is material if, in the circumstances of the particular case, a reasonable person in the patient’s position if warned of the risk, would be likely to attach significance to it, or if the medical practitioner is or should  reasonably be aware that the particular patient, if warned of the risk, would be likely  to attach significance to it “

This tragic case reported by the Coroner also highlights how quickly a labour can go wrong when something bad like a uterine rupture happens. Prostaglandins in a 8 pm, 9:20 hyperstimulation (albiet recognised only in hindsight), 10:20 fetal tachycardia, 10:40 fetal bradycardia, 11:30 Cesarean section to delivery a baby who was resuscitated but ultimately died of hypoxic ischaemic encephalopathy 4 days later. The mother required a subtotal hysterectomy.

The Coroner also noted the difference in contraindications listed in the product information for prostaglandin gel and oxytocin which may well have been required for the remainder of this woman’s induction.

Back to my original post which did ended with a healthy mother and baby

Recently, I helped care for a young woman whose patience has finally been strained by her pregnancy. She had endured the previous 39 weeks pretty well I thought but with three nights of sleep deprivation because of irregular contraction she asked for an induction. I do wonder how well young Mums will cope with a new baby when they ask for an induction in this not uncommon situations. I put out of my mind the nearly 12 years of my own sleep deprivation due to on-call and then toddlers and thought through what I could offer her.

I know that the NICE Guidelines suggest that spontaneous labour is more likely after sweeping the membranes.

My own experience suggests the outcome can be better judged on a toss of a coin. More sophisticated studies have suggested better odd in favour of membrane sweeping. Cochrane suggests the NNT is about eight, that is if you can find eight women to put up with the discomfit.

I know a variety of other methods proposed.

  • I had seen one poor young woman disabled with terrible diarrhoea deliver a flat baby because she thought a bottle of castor oil would do the trick.
  • I usually use a list of corrugated roads, long walks, hot curries, hot sex, raspberry leaf tea. Which I guess reflects where I have worked after leaving the comfort of teaching hospital obstetrics. Some suggestions go down better than others.
  • Some midwives adds nipple stimulation to the list, but my opinion is the babe’s going to traumatise the nipples enough in the first few days so I suggest keeping that in reserve.

With consent, I examined my patient and gave her a bishop score of 5 then performed a stretch and sweep. There was an expected grimace. But according to Cochrane I had done my bit to reduces the chance of my patient still being pregnant at 42 weeks by 0.53.

Two days later and still incubating and with little restful sleeping, my patient asked whether she could really have an induction? So we discussed a plan and settled on dinoprostone gel then an amiotomy if favourable the next morning.

I explained that an induction with prostaglandin was safe and unlikely to increase the risk of a caesarean section beyond what she would face should she go into labour on her own.

In my experience, if a course of prostaglandins failed then we could try again after a good night’s sleep with the same or a mechanical method or decide on a caesarean. I have never used the mechanical alternatives a Foleys or Cook catheter as a form of induction.

That night her bishop score was now five (her cervix being a little easier to find), she had been having only irregular contractions; had the strip and stretch has done anything? We proceeded with our planned dinoprostone gel and amniotomy in next morning.

Within 30 minutes of inserting dinoprostone gel, she had started to be more uncomfortable with contractions. And then she has a contraction that continued beyond a minute. She looked more uncomfortable and worried. “Is this what labour is going to be”, she asked? She was still on the cardiotocograph. I watched the tocograph line continue its plateau, expecting any minute it would begin to return to normal. At two minutes the tocograph had no intention of returning to baseline and the uterus was still contracting. The fetal heart rate was still fine at that stage. Best find something to settle this contraction down. Instinctively, I thought lets get the gel out. So armed with speculum, saline and gauze swabs. But this made little difference. I have since been told the prostglandin is absorbed quite quickly and I had wasted my time.

We turned her onto her left side and started oxygen. As the midwife went for the IV trolley, I grabbed a bottle of Nitrolingual. Two sprays under the tongue didn’t seem to make any difference. The contraction distracted her even from the GTN headache I explained she may get. The patient now had a startled kangaroo look in her eye

I asked the midwife to get some salbutamol ready, it is fiddly to prepare. 0.25ml of 5mg/5ml solution in a 1ml syringe, dilute to 10ml with normal saline in a 10ml syringe then give a 50mcg bolus (2ml) IV.

As I gained IV access, pregnant women always seem easy to cannulate, I heard the baby’s heart rate drop below 100. By the time the first dose of salbutamol went in the heart rate was 80. I waited a minute then gave another. With my hand on her belly I’m sure the uterus felt less tense; the tocograph agreed and started to return to baseline. The baby’s heart rate picked up, and quickly rose to 180. There seemed enough variability, however.

Things seemed to quite stable now the contraction had settled. I had salbutamol at hand. Mum looked more settled, her heart rate was normal. The CTG revealed were no further decelerations, although I was looking at a persisting reflex tachycardia likely due to the anoxia caused by the contraction or the salbutamol. It was time to phone a friend. The on-call tertiary hospital consultant was helpful. She reinforced what I had done with the exception of the vaginal washout was fine. She recommended waiting an hour and if the CTG became more normal then to attempt the amniotomy. If not, then a Cesarean was indicated.

Over the next hour the CTG settled to normality and I did the amniotomy. The fluid was clear.

My patient finally went onto have a normal healthy little girl. Although, it was by Cesarean section after slow progress beyond 6cm and further decelerations with an epidural in place. Baby was delivered deflexed OP, cried at delivery with cord pH 7.21. She is thriving and Mum is managing very well.

The tertiary hospital consultant also suggested that Cervidil was probably more useful than the gel since the Cervidil could be removed in hyperstimulation. I had heard about the prostaglandin on a string when I did my DRANZCOG training, but the hospital did not adopt it because of the cost compared to the gel. This has been my first experience with this side effect of gel after being involved in about 500 inductions over the last 8 years. Was this enough reason to change my practice? Should I give up on dinoprostone gel even though I have never had a problem before? Or should I seek comfort that if similar happened the Cervidil string will allow easy removal? Or should I fiddle with pushing a Foleys or Cooks catheter into a cervix?

 

Permissions obtained for this story

 

One reason why healthcare is so $$$$$$ in Australia.

Have you ever looked at a medical device and thought why is this so expensive?

Firstly, there is the price hurdle to get an item to Australia.

For example, the DermLite II Pro HR by 3Gen will cost $US895 from them; to buy the same in Australia will cost you $AU 1529 (including GST) . Given the current exchange rate that amounts to around $500 to get it into to Australia. I would have to spend three times that to actually get to the US to buy one off the shelf there. It seems someone is making a lot of money.

Unfortunately 3Gen wont sell ship to Australia but by searching eBay you may be able to find a US based seller who may and at a little bit less than the 3Gen price.

DL2HR

Then, there is definition of medical equipment which seems to be an invitation to add a couple of zero’s to the price

I use a LED H7 Lenserhead torch to do minor surgery with. I like the extra light and it does a great job. Nice whitelight. Just don’t look the patient in the eye with it on. It cost me something like $60. At a medical conference  I went to recently, a company rep tried to persuade me to consider their “medical” product. Now admittedly it did produce a nice light, but it also cost $1200. I remain content with my alternative.

A tiny grommet (sorry, myringotomy tube) placed in my young fella’s ear drum cost $150! Apparently, I can buy a fluoroplastic myringotomy tube for only $US68 for a box of 10! Mind you I was quoted $90 UPS shipping to get them here. But me and 8 of my friends would have been way ahead.

850

So why it is that we must pay so much extra for medical and surgical equipment?

I can appreciate that we need to use a higher grade of equipment which needs to be tested to greater tolerances. Afterall, industrial grade silicone proved to be the undoing of Poly Implant Prosthese.

I am not advocating buying screws from Bunnings, although I was tempted when I saw how much the Herbert screw in my scaphoid cost me, but I think that it is reasonable that the Hon Dutton and Hockey cast their eyes wider at  saving healthcare dollars than hit Australians with the proposed co-payment.