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Objectives: This study assessed yoga as an adjuvant strategy for symptoms of combat-related posttraumatic stress disorder (PTSD). Methods: Subjects had significant, combat-related PTSD. Control data were collected during an eight-week waiting period. Trauma-sensitive yoga sessions of 90 minutes duration were provided every seven days for eight weeks. Assessments included the PTSD checklist (PCL); the Depression, Anxiety and Stress Scale (DASS); the Pittsburgh Sleep Quality Index (PSQI); the Adult/Adolescent Sensory Profile (AASP); the SF36 Quality of Life instrument; and a brief, structured pre-enrolment assessment of attitudes towards yoga. Biomarkers were also assessed. Results: Thirty participants were recruited, with 28 completing the protocol ( Mage=63.5 years). For most variables, there was no significant change in results after the waiting period. Comparing measurements obtained immediately prior to the commencement of the intervention to those taken after completion of eight yoga sessions, significant changes included an increase in the serum dehydroepiandrosterone concentration, decreased total PCL score (and all PCL sub-scales), decreases in all DASS sub-scale scores and significant improvements in PSQI and SF36 scores. No adverse events were reported. Conclusions: A range of benefits were observed after yoga, consistent with the theoretical construct for the long history of yoga as a strategy to reduce stress and promote well-being.

Background Non-Hodgkin lymphoma (NHL) is a large group of primary malignancies of solid lymphoid tissue. Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of NHL. DLBCL has an aggressive natural history but responds well to chemotherapy. The objective of this study was to review the use of chemotherapy, identify its side effects, and examine the response to chemotherapy in patients with NHL at Dr. Soetomo General Hospital. Methods This study was a retrospective observational study using secondary data obtained from patients’ medical records from 2016 to 2018. Demographic data (age, sex), clinical characteristics, chemotherapy regimens, side effects of chemotherapy, and response to chemotherapy were recorded. Results Results revealed that of the 43 patients (age ranged from 21 to 80 years) who were included in this study, the prevalence of DLBCL was higher in male patients (74%) and about 44% patients were at stage III. R-CHOP (rituximab-cyclophosphamide, doxorubicin, vincristine/oncovin, prednisone) (53%) was the most used chemotherapy regimen in this study. A total of 65% of patients showed good responses and 35% showed no response to the therapy. The most common side effect was myelosuppression, including 25% and 8% of the patients having anemia and leukopenia, respectively. Conclusions R-CHOP is the most used regimen. Most of patients with NHL have a complete response and the predominant side effect is anemia.

Background Nasopharyngeal cancer (NPC) is the most common neck/head cancer occurring in Indonesia and is the fourth most malignant after breast cancer, cervical cancer, and lung cancer. It is known that the cost of chemotherapy may not be separated from quality of life (QoL) to reflect the success of therapy, especially in cancer patients. Thus, studies on the correlation between chemotherapy cost and the QoL in NPC patients are needed. Methods The participants were recruited by a consecutive sampling method. All patients diagnosed with NPC using a paclitaxel-cisplatin chemotherapy regimen in August–March 2019 for first until the third chemotherapy cycle were assessed for their the chemotherapy cost and QoL before the first chemotherapy cycle and after the third cycle using the EORTC QLQ-C30 questionnaire. Chemotherapy cost and QoL were analyzed using SPSS version 20 to find out the correlation. Results Data from 26 patients showed a notable increase in the QoL after the third chemotherapy cycle. Thus, there was a relationship between chemotherapy cost and QoL in NPC patients. The total cost of chemotherapy increased with the increase in cycles of chemotherapy. We further analyzed the correlation between QoL and the cost of chemotherapy. We found that there was a correlation between the cost and the aspects of global health status, the QoL. Conclusions It is concluded that chemotherapy that is followed by the increase in cost in chemotherapy improves the QoL.

Background Indonesian Ministry of Health advocate doctors, especially in government-owned healthcare facility, to prescribe generic drugs including amoxicillin. Although BPOM (the National Agency of Drug and Food Control) already guarantees that the generic amoxicillin and the branded one were interchangeable, lack of confidence in generic drugs still remains among patients, pharmacists, and doctors. This issue supported by lack of publication confirmed the therapeutic equivalence of branded and generic drugs. This study aims to evaluate and compare the in vitro microbiological assay of different generic and branded amoxicillin that are available in Indonesian market, especially those used in government-owned healthcare facilities. Methods Microbiological assays for five samples of amoxicillin tablet containing 500 mg amoxicillin available in Indonesia were determined using a method from Indonesia Pharmacopeia. Samples were coded as Products A to E. The assay was carried out by measuring the diameter of the inhibition zones in the plate agar incubated with Escherichia coli and Staphylococcus aureus. The obtained data were evaluated to determine the sample potency and compared with the amoxicillin reference standard. Results Minor and insignificant differences (p > 0.05) were found in the diameters of the inhibition zones. Potency ratio measured both in E. coli and S. aureus were all between 95% and 105%. The lowest of the tested samples were from Product C, which resulted to ratio potencies of 96.3% and 95.5% in E. coli and S. aureus, respectively. Conclusions All five samples were in the range of the acceptance criteria. Therefore, from the view of the microbiological assay, these products are in equivalence in quality and are interchangeable.

Background It was reported that hemodialysis (HD) with either a new or reused dialyzer raises medical problems that require therapeutic regimens. This study aimed to investigate the medical problems and their management in patients undergoing HD. Methods This study was conducted by prospectively observing patients with chronic kidney disease undergoing HD. The incidence of medical problems and the treatment given were recorded. Results Among 351 cases of HD, medical problems occurred in 15.7% of cases, including hypotension as the most dominant, followed by muscle cramps, shivering, headache, asphyxia, fever, chest pain, and pruritus. Hypotension was ameliorated with intravenous 40% dextrose and normal saline. Muscle cramps were overcome with 40% dextrose, normal saline, methampyrone, and calcium gluconate. Shivering was managed by warming the patients followed by intravenous methampyrone, 40% dextrose, and normal saline. Meanwhile, headache was reduced by paracetamol or intravenous methampyrone and 40% dextrose. Fever was treated by intravenous methampyrone or oral paracetamol. Pruritus was managed by intravenous dexamethasone and diphenhydramine. Conclusions Medical problems occurring during HD are prevalent and need immediate therapy. Pharmacists and clinicians should work in collaboration to improve the patients’ quality of life.

Background Stress ulcer is a superficial and asymptomatic lesion and causes bleeding. As many as 50% of death cases are reported as the result of stress ulcer bleeding. Stress ulcer prophylaxis (SUP) is a drug used to prevent gastrointestinal tract injuries due to stress ulcers. The inappropriate use of SUP drugs can cause adverse drug reactions, and thus SUP drugs are only given to patients in accordance with guidelines in order to avoid the overuse of SUP drugs. The aim of this present study is to analyse the suitability of SUP drug usage based on the criteria from the American Society of Health-System Pharmacists (ASHP) and the drug costs of SUP overuse. Methods An observational descriptive study was conducted from April 24, 2019, to May 17, 2019, in the inpatient surgical ward of Dr. Soetomo General Hospital. Data were obtained from patient medical health records. Results One hundred fifty-two patients used 1404 SUP drugs. Approximately 48% of usage did not suit the ASHP criteria and was considered as medication overuse. The cost of excessive SUP usage during the study period was more than US $65, which is 30.08% of the total drug cost of prescribed stress ulcer drugs. Conclusions The present study suggests that the relatively high excessive drug costs for SUP show a need for monitoring of the application of SUP therapy guidelines.

Background: Neuropsychiatric symptoms (NPS) in dementia impact profoundly on the quality of life of people living with dementia and their care givers. Evidence for the effectiveness and safety of current therapeutic options is varied. Cannabinoids have been proposed as an alternative therapy, mainly due to their activity on CB1 receptors in the central nervous system. However, little is known regarding the safety and effectiveness of cannabinoid therapy in people with dementia. A literature review was undertaken to identify, describe and critically appraise studies investigating cannabinoid use in treating NPS in dementia. Methods: We undertook a systematic review adhering to PRISMA guidelines. Twenty-seven online resources were searched, including Medline, PsycINFO and Embase. Studies assessing the safety and or effectiveness of cannabinoids in treating NPS in dementia in people aged ⩾ 65 years were included. Study quality was assessed using the Johanna Briggs Institute and Cochrane Collaboration critical appraisal tools. Results: Twelve studies met the inclusion criteria. There was considerable variability across the studies with respect to study design (50% randomized controlled trials), intervention [dronabinol (33%), nabilone (25%) or delta-9 tetrahydrocannabinol (THC; 42%)] and outcome measures. Dronabinol (three studies) and THC (one study) were associated with significant improvements in a range of neuropsychiatric scores. The most common adverse drug event (ADE) reported was sedation. A high risk of bias was found in eight studies. The highest-quality trial found no significant improvement in symptoms or difference in ADE rate between treatment arms. Included studies used low doses of oral cannabinoids and this may have contributed to the lack of demonstrated efficacy. Conclusion: While the efficacy of cannabinoids was not proven in a robust randomized control trial, observational studies showed promising results, especially for patients whose symptoms were refractory. In addition, the safety profile is favourable as most of the ADEs reported were mild. Future trials may want to consider dose escalation and formulations with improved bioavailability.

At least half of all residents of Australian residential aged care facilities have dementia. Most residents living with dementia will at some stage experience behavioural and psychological symptoms of dementia (BPSD), which can be challenging to manage and distressing for the resident, their family and carers. This literature review examined the prevalence of antipsychotic use in Australian residential aged care facilities, which may be used to manage BPSD only after non-pharmacological treatments have failed. Sixteen studies assessing care between 2000 and 2017 were identified and reviewed. The proportion of residents prescribed an antipsychotic ranged from 13% to 42%. Evidence from six Australian interventions showed that the antipsychotic use can be reduced, especially when non-pharmacological interventions that are individualised to the person and the behaviour are implemented. Research has shown that antipsychotics can be tapered and ceased without re-emergence of behavioural symptoms in many instances. Multidisciplinary, multi-strategic approaches have demonstrated effectiveness in reducing antipsychotic use by up to 3% (absolute reduction) in the aged-care setting. Refereed/Peer-reviewed

Background Residents of aged care facilities use increasingly complex medication regimens. Reducing unnecessary medication regimen complexity (eg, by consolidating the number of administration times or using alternative formulations) may benefit residents and staff. Objective To develop and validate an implicit tool to facilitate medication regimen simplification in aged care facilities. Method A purposively selected multidisciplinary expert panel used modified nominal group technique to identify and prioritize factors important in determining whether a medication regimen can be simplified. The five prioritized factors were formulated as questions, pilot-tested using non-identifiable medication charts and refined by panel members. The final tool was validated by two clinical pharmacists who independently applied the tool to a random sample of 50 residents of aged care facilities to identify opportunities for medication regimen simplification. Inter-rater agreement was calculated using Cohen’s kappa. Results The Medication Regimen Simplification Guide for Residential Aged CarE (MRS GRACE) was developed as an implicit tool comprising of five questions about 1) the resident; 2) regulatory and safety requirements; 3) drug interactions; 4) formulation; and 5) facility and follow-up considerations. Using MRS GRACE, two pharmacists independently simplified medication regimens for 29/50 and 30/50 residents (Cohen’s kappa=0.38, 95% CI 0.12–0.64), respectively. Simplification was possible for all residents with five or more administration times. Changing an administration time comprised 75% of the two pharmacists’ recommendations. Conclusions Using MRS GRACE, two clinical pharmacists independently simplified over half of residents’ medication regimens with fair agreement. MRS GRACE is a promising new tool to guide medication regimen simplification in aged care., Video abstract

Allergic reactions to both penicillins and cephalosporins are relatively common. Patients who have had a previous allergic reaction to a penicillin derivative may also be prone to a further reaction if treated with cephalosporins. This case illustrates several important points about potential cross-reactivity between penicillin derivatives and cephalosporins, as well as the benefits of an extended-hours pharmacy service in a long-term care facility. Refereed/Peer-reviewed

Background: Despite the large burden medication-related morbidity and mortality places on the Australian health care system, there is little known about the extent of this problem in a women’s health (obstetric and gynecology) setting. Objective: Determine the frequency and nature of medication-related problems (MRPs) occurring in a women’s health unit (WHU) of an Australian teaching hospital. Methods: A prospective audit of consecutive cases of patients treated in the WHU at a tertiary-level teaching hospital was undertaken by a clinical pharmacist over a 5-week period. Data collected included the following: patient characteristics, type of MRP (using a modified version of the Hepler-Strand classification system), medication involved (according to the World Health Organisation Anatomical Therapeutic Chemical classification system), and clinical significance (using a 2-level severity index). Results: A total of 454 potential MRPs were identified over the 5-week period among 241 patients. A total of 39 MRPs (8.6%) identified were deemed to be of moderate/high clinical significance. The highest number of MRPs (221; 49%) was identified among women admitted following a cesarean delivery, with 83 of 85 women in this group experiencing at least 1 MRP. Additional factors associated with an increased likelihood of patients experiencing a MRP included increased age, length of hospital stay, and number of regular medications taken prior to and during admission ( P < 0.05). Conclusion: The widespread nature of identified MRPs in this setting suggests that various approaches to minimizing these problems and mitigating the associated burden on the health care system are warranted.

Background: There is a relative paucity of information to characterise potential changes in medication regimen complexity and prevalence of prescribing of potentially inappropriate medications after hospitalisation, both in Australia and elsewhere. Objective: To evaluate medication regimen complexity and the prevalence of potentially inappropriate medications before and after admission to hospital. Setting General medical units of a tertiary care hospital in Australia. Methods: Retrospective cohort study of patients aged 65 years and above. Medication complexity was measured by using the Medication Regimen Complexity Index (MRCI). Main outcome measure The primary outcome was the change in the Medication Regimen Complexity Index for all prescribed medications after hospitalization. Results: A convenience sample of 100 patients was included in the study. There was a significant change in the mean medication complexity score (as measured using the MRCI), increasing from 29 at the time of admission to 32 at the time of discharge (p < 0.05). Factors such as baseline medication regimen complexity (pre-admission MRCI) and length of stay in the hospitals appear to influence the change in medication complexity. However, the proportion of patients prescribed at least one potentially inappropriate medicine (PIM) decreased significantly, from 52% pre-hospitalization to 42% at discharge (p = 0.04). Conclusions: Relative to the time of admission, overall medication complexity increased and the proportion of patients who were prescribed PIMs decreased after hospitalisation. Refereed/Peer-reviewed

There is evidence to support a link between treatment with high-dose cyproterone acetate and the development of meningioma. This report describes a case where an elderly man with intellectual disability who was treated with cyproterone for problematic sexual behavior developed a meningioma. The case was the subject of a residential medication management review provided under the auspices of a program funded by the Commonwealth Government of Australia. A discussion of clinical and ethical implications of the case is provided. Refereed/Peer-reviewed

Background: Patient education delivered through pharmacist counselling is important in promoting the safe and effective use of anticoagulants. Aim: To evaluate the extent to which patients retain information after counselling from a clinical pharmacist about the anticoagulant warfarin; to perform a brief analysis of the cost-analysis of warfarin counselling; and to investigate relationships between case-specific characteristics and patient outcomes. Method: A total of 22 patients was recruited. Eligibility criteria included age ≥18 years, new initiation of warfarin in hospital, intact cognition and an expectation of self-administration of warfarin after discharge. Key elements of knowledge were assessed immediately after counselling and 6 weeks after counselling. The duration of each counselling session was recorded as a surrogate for costs involved, and case-specific characteristics were documented. Results: Participants demonstrated an ability to recall an average (mean standard deviation) of 79.9 14.6% of key information elements immediately after counselling, significantly higher than was observed 6 weeks after counselling (71.0 11.7%; p = 0.02). The percentage of participants achieving an ‘acceptable’ score for knowledge was 68.2%, both immediately after counselling and 6 weeks later. No significant relationships between specific case characteristics and patient outcomes, duration of counselling or overall warfarin knowledge retention scores 6 weeks after counselling were demonstrable. Conclusion: These findings imply that more emphasis should be placed on educating patients on the critical information elements for warfarin counselling. Further research is required to explore potential relationships between case-specific characteristics and patient outcomes, as well as the costs associated with the counselling process. Refereed/Peer-reviewed

Evidence from systematic reviews and meta-analysessupport the provision of pharmacy services to a range ofpatient groups. This includes patient groups with highburden conditions such as diabetes, asthma, hypertensionand hyperlipidaemia [1]. Evidence is an important factorthat guides the development and delivery of new clinicalpharmacy services. In the context of finite resources, tar-geting clinical pharmacy services to patient groups withdemonstrated benefits is consistent with the principles ofevidence-based decision making.It is widely stated in science, however, that ‘absence ofevidence is not evidence of absence’. Vulnerable patientgroups, such as those with dementia, refugees, and theculturally and linguistically diverse (CALD) are under-represented in pharmacy practice research. These vul-nerable patient groups are often at high risk of adverse drugevents (ADEs). The provision of clinical pharmacy ser-vices for people with intellectual disability (ID) is an ex-cellent example.In this issue of IJCP, O’Dwyer et al. [2] present a nar-rative review of pharmacy services for people with intel-lectual disability. The conclusions that can be drawn from aliterature review are usually dependent on the quality of theincluded studies. This review is equally important for whatis not included. O’Dwyer et al. identified no randomised ornon-randomised controlled studies of pharmacist services.The two intervention studies were conducted in a singleinstitution [3, 4]. Three of the six reports of pharmacistparticipation in service provision for people with ID werepublished more than 35 years ago [5–7].As acknowledged by O’Dwyer et al., the lack of pub-lished research does not necessarily reflect lack of serviceprovision [2]. It is possible that clinical pharmacists havenot documented the services they provide. While examplesof innovative practice undoubtedly exist, the lack ofpractice-based research to inform service delivery remainsa concern [8]. This is particularly true given the high ratesof psychotropic use, frequent off-label prescribing, andminimal evidence for medication efficacy [9, 10]. Althoughthere is currently no rigorous body of evidence to supportprovision of clinical pharmacy services to people with ID,extrapolation of evidence from other clinical areas suggeststhat benefits are likely [11]. Furthermore, a recent an-tipsychotic discontinuation study reported that nearly halfof participants with ID achieved complete discontinuationand this was associated with improved behavioural func-tioning [12].Twenty-five years ago Hepler and Strand called on thepharmacy profession to mature ‘by accepting its socialresponsibility to reduce preventable drug-related mor-bidity and mortality’ [13]. There is an urgent need for thepharmacy profession to develop a research agenda topromote the quality use of medications in vulnerablepatient groups. In the interim, however, there is a socialresponsibility to target services to vulnerable patientgroups at high risk of ADEs for whom minimal evidencecurrently exists.

Byline: Christopher. Alderman, Jisha. Lucca The principle of multidisciplinary care is fundamental to achieving optimal patient outcomes across a wide range of disciplines, and it is clear that this holds true for psychiatry as much as any other specialty. Any psychiatrist with a busy practice understands the competing priorities that require attention during any standard psychiatric consultation, regardless of the setting where the patient is seen. Establishing rapport, gathering history, arranging for further investigations, providing psychoeducation, and arranging follow-up all vie for attention, and at the same, it is often necessary to select and safely prescribe a rational choice of pharmacotherapy, depending on the nature of presentation. To be able to accomplish all of this in a timely fashion presents a significant challenge for any clinician. Perhaps, the biggest change that has impacted on the management of mental illness in recent times has been the exponential developments that have been witnessed in psychopharmacology.[sup][1] From relatively modest beginnings in the 1950s, new generations of antidepressants and antipsychotics have been embraced in psychiatric practice, and various other drugs such as anticonvulsants have been repurposed and have emerged as legitimate alternatives for use in the management of psychiatric illnesses. Consequently, the range of psychotropic drugs prescribed by the average clinician has expanded, and there are now dozens of alternative pharmacotherapy approaches for common psychiatric presentations. Furthermore, as well as the originator brands of most psychotropic drugs, in many cases, there is a multiplicity of competing generic products for each molecular entity, meaning that the prescriber may need to familiarize themselves with even more products to have a complete understanding of the treatment used by their patients. Many people with significant mental illness will also have serious medical comorbidities such as cardiovascular disease, diabetes mellitus, chronic obstructive pulmonary disease, or chronic pain syndromes.[sup][2],[3],[4] These patterns of comorbidity may occur spontaneously, as a result of genetic predisposition, or may also be the result of the influence of various epigenetic factors (among these, the effects of psychotropic drug treatment). In reality, many people who require pharmacotherapy for a psychiatric illness will also require concurrent treatment for medical comorbidities. The cumulative effect of these phenomena is that management of drug therapy for those who consult a psychiatrist has become a very complex task indeed. An approach that has been advocated as a means to achieve the best possible outcomes from pharmacotherapy has been described as incorporating the so-called “quality use of medicines” (QUM) principles.[sup][5] Summarized succinctly, these principles advocate three key approaches: selecting management options wisely (considering the place of medicines in treating illness and maintaining health, recognizing that there may be better options than medicine in many cases), choosing suitable medicines where necessary (taking into account patient preferences, the nature of the clinical condition, risks and benefits, dosage and duration of treatment, coexisting conditions and other drug treatments, monitoring considerations, and costs), and using medicines safely and effectively (monitoring outcomes, minimizing misuse, and improving consumers' ability to solve problems related to medication). Logic dictates that the philosophies of the QUM principles are sound, and equally, it is self-evident that these principles are applicable when prescribing in psychiatric practice. Even so, when the QUM principles are deconstructed it becomes apparent that their application in any form of prescribing requires a broad range of skills, experience, and knowledge. To be able to safely and effectively prescribe treatment in accordance with QUM principles doubtlessly requires an understanding of pharmacology, incorporating a working understanding of dose-response relationships, and adverse drug reaction and drug interaction profiles, but it is clear that considerably more than this is needed to prescribe psychotropic drug therapy. …