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Background Atrial fibrillation (AF) is a growing epidemic. Current models of care delivery are inadequate in meeting the needs of the population with AF. Furthermore, quality of life is known to be poor in patients with AF and is associated with adverse patient outcomes. Objective The aim of this study was to determine if nurse-led education and cardiovascular risk factor modification, undertaken using the principles of motivational interviewing, facilitated by an electronic decision support tool to ensure the appropriate use of oral anticoagulation (OAC), could improve health-related quality of life (HRQoL), guideline adherence to OAC, and cardiovascular risk factor profiles in individuals with AF. Methods This was a multicenter, prospective, randomized controlled feasibility study of 72 individuals with AF. The intervention involved 1 face-to-face nurse-delivered education and risk factor management session with 4 follow-up telephone calls over a 3-month period to monitor progress. The primary outcome measure was HRQoL as assessed by the Short Form-12 survey. Results A total of 72 participants were randomized, with 36 individuals in each arm completing follow-up. Mean age was 65 ± 11 years and 44% were women. At 3 months follow-up, no significant differences between groups were observed for the physical or mental component summary scores of the Short Form-12, nor any of the subscales. Appropriate use of OAC did not differ between groups at final follow-up. Conclusions A brief nurse-delivered educational intervention did not significantly impact on HRQoL or risk factor status in individuals with AF. Further research should focus on interventions of greater intensity to improve outcomes in this population. Trial registration ACTRN12615000928516.

Background: Atrial fibrillation (AF) is a growing global epidemic, with its prevalence expected to significantly rise over coming decades. AF poses a substantial burden on health care systems, largely due to hospitalizations. Home-based clinical characterization has demonstrated improved outcomes in cardiac populations, but its impact on AF remains poorly defined. To test this hypothesis in AF, we developed the Home-Based Education and Learning Program for Patients With Atrial Fibrillation (HELP-AF) study. Methods: The HELP-AF study is a prospective multicentre randomized controlled trial that will recruit 620 patients presenting to hospital emergency departments (EDs) with symptomatic AF (ANZCTR Registration: ACTRN12611000607976). Patients will be randomized to either the HELP-AF intervention or usual care. The intervention consists of 2 home visits by a nurse or pharmacist trained in the structured educational visiting (SEV) method. Patients in the control group will receive usual discharge follow-up care. Results: The primary endpoints are total unplanned hospital admissions and quality of life. Secondary endpoints include AF symptom severity and burden score; time to first hospital admission; total unplanned days in hospital; total AF-related hospital admissions (including atrial flutter); total cardiac and noncardiac hospital admissions; total AF- or atrial flutter-related; cardiac- and noncardiac-related ED presentations; and all-cause mortality. An economic evaluation will also be performed. Clinical endpoints will be adjudicated by independent blinded assessors. Follow-up will be at 24 months. Conclusions: This study will assess the efficacy of a home-based structured patient-centred educational intervention in patients with AF. Refereed/Peer-reviewed

Funding Acknowledgements Type of funding sources: None. OnBehalf Centre for Heart Rhythm Disorders Background Education is critical to empower individuals to self-monitor and manage their condition. Significant variability exists in the provision of education for atrial fibrillation (AF), whilst individual patient factors including health literacy and education level attainment may impact on knowledge levels. Objective assessment of knowledge may help to target education to areas of need, and result in improved patient outcomes. Objective To describe the development and validation of a knowledge questionnaire for AF. Methods A multidisciplinary expert team of healthcare professionals developed the questionnaire, in conjunction with consumers, with question content based upon areas deemed most critical to AF and related self-management. The multiple choice questionnaire consists of 20 items, each worth 5 points, to give a total score out of 100. The questionnaire assesses five domains specific to AF: general knowledge, complications, medications, risk factors and action. The questionnaire was developed in English. The questionnaire was tested on 10 randomly selected patients with AF for face validity and 19 healthcare professionals for content validity. The final version was completed by 454 individuals with AF. Exploratory factor analysis was used to determine construct validity with factor loadings of 0.40 and above considered acceptable. Reliability was assessed using Cronbach’s alpha, with a value greater than 0.7 acceptable. Results Face and content validity were considered acceptable, after minor changes to wording. The cohort of 454 individuals with AF had a mean age of 66.9 ± 12 years and 43% were female. Mean (SD) total score was 57.7 ± 15.8. Exploratory factor analysis was undertaken using the principal components method. This resulted in a Kaiser–Meyer–Olkin Measure of Sampling Adequacy of .64 and a Bartlett"s Test of Sphericity being significant at 0.00. Seven factors were selected and analysed using principal component analysis with varimax rotation. All items loaded on one of the seven factors. Internal consistency demonstrated a Cronbach’s alpha of 0.65. Conclusion The Atrial Fibrillation Knowledge Questionnaire is a valid measure to assess knowledge in individuals with AF.

Background Stroke is one of the most devastating complications of atrial fibrillation (AF) and is associated with poor patient outcomes. Recent registry data has demonstrated improved use of stroke prevention therapy with the advent of direct-acting oral anticoagulants, but little data exists in the Australian health care setting. Purpose To examine the use of oral anticoagulant therapy in a cohort of individuals presenting to the emergency department (ED) due to AF. Methods A total of 437 consecutive individuals who presented to the ED with a primary diagnosis of AF to three tertiary hospitals in our city in South Australia between March 2013 and March 2014 were included. Data were collected retrospectively from electronic medical record review. CHA2DS2-VASc and HAS-BLED scores were calculated and any documented contraindications to the use of oral anticoagulation (OAC) taken in to consideration. Results Mean age was 69±15 years and 49.9% were male. A total of 244 (55.8%) individuals had a prior diagnosis of AF at index presentation. 179 (73.4%) of these individuals recorded a CHA2DS2-VASc score of ≥2. A total of 124 of these individuals were appropriately anticoagulated (69.3%) whilst 37 individuals were not treated with OAC and did not have a documented contraindication (20.7%). Anticoagulation status was unknown in 18 individuals due to a lack of documentation (10.0%). A CHA2DS2-VASc score of 0 was recorded in 25 individuals with a prior diagnosis of AF at index presentation with 3 individuals (12%) inappropriately overtreated with OAC. The remaining 193 individuals (44.2%) presented with a first episode of AF. In 129 (66.8%) of these individuals a CHA2DS2-VASc score of ≥2 was recorded and only 10 individuals had a documented contraindication to the use of OAC. In 119 (61.7%) individuals there were no documented contraindications to the use of OAC. In 74 (62.2%) of these presentations OAC was not commenced, whilst in 45 (37.8%) individuals OAC was prescribed. Conclusions Significant opportunity exists to improve the use of stroke prevention therapy in AF. Despite repeated opportunities to commence this therapy within the hospital setting, it remains frequently underutilised in individuals at high risk of stroke. Funding Acknowledgement Type of funding source: None

Assessment of risk factors for stroke and applying anticoagulation accordingly is one of the crucial fundamentals of comprehensive management of atrial fibrillation (AF). As the most prevalent sustained cardiac arrhythmia, AF is known to confer a fivefold increased risk of thromboembolic complications such as ischaemic stroke or transient ischaemic attack.1 International practice guidelines recommend the use of the CHA2DS2-VASc (C - Congestive heart failure; H - Hypertension, A - Age 75 and above, D - Diabetes Mellitus, S - prior Stroke or Transiant Ischaemic Attack or thromboembolism, V - Vascular disease history, A - Age 65-74, S - Female sex) score to predict the yearly risk of stroke and to determine if treatment with oral anticoagulation is warranted. Vitamin K antagonists as well as non-vitamin K antagonist oral anticoagulants (NOACs) are effective for the prevention of strokes in AF. However, regardless of the choice of anticoagulant, stringent adherence to the treatment regimen is crucial. Patients should play an active role in the decision to commence anticoagulation, and patient preferences should be taken into consideration, aiming to tailor the treatment as much as possible which may consequently improve treatment adherence.1 Unfortunately, adherence and persistence with anticoagulation treatment regimens is often suboptimal.2 The management of AF has become complex and the traditional healthcare consultation may no longer allow one healthcare professional enough time to educate the patient about stroke prevention therapy, engage in shared decision making and discuss the importance of adherence for optimal outcomes. Nevertheless, engaging with patients to identify their values, preferences and beliefs, explaining the rationale of stroke prevention as part of AF management and providing information about treatment options, is crucial to reach an informed or …

Background: The Beers criteria are used to identify potentially inappropriate medications (PIMs) in the elderly. Few studies have examined the Beers criteria in elderly hospitalised patients in Australia. Aim: To identify the prevalence of PIM use in elderly patients admitted to an Australian hospital using the 2003 Beers criteria. Method: A prospective cross-sectional study of 100 elderly inpatients was undertaken using the Beers criteria to identify and compare PIM on admission and discharge. Logistic regression analysis examined the risk factors for PIM use. Results: 42% of patients had at least one PIM on admission compared to 39% at discharge. The most common PIMs were amitriptyline, senna, amiodarone and benzodiazepines (nitrazepam and diazepam). Excluding senna, the prevalence decreased to 36% at admission and 24% at discharge. At admission (including and excluding senna), PIM was not significantly associated with age, gender, living arrangements, number of comorbidities and number of medications. At discharge, PIM (including senna) was significantly associated with age (OR 1.1; 95%CI 1.02–1.3; p = 0.02), female gender (OR 3.6; 95%CI 1.3–10; p = 0.01) and number of medications (OR 1.2; 95%CI 1.0–1.3; p = 0.02). When senna was excluded PIM at discharge was only significantly higher in female patients (OR 5.4; 95%CI 1.7–16.9; p = 0.004). Conclusion: The Beers criteria detected a high prevalence of PIM use in elderly hospitalised patients. Refereed/Peer-reviewed

Background Bone cement impregnated with high doses of aminoglycosides is used to treat infection associated with joint arthroplasty. Aim To examine serum tobramycin and creatinine concentrations in patients who received high-dose tobramycin and vancomycin impregnated bone cement during revision joint arthroplasty. Method This was a prospective cohort case series of 10 patients aged 58 to 82 years undergoing revision joint arthroplasty with high-dose tobramycin and vancomycin impregnated bone cement. Serum tobramycin and creatinine concentrations were monitored post surgery. Results Sterile tobramycin 3.6 g and vancomycin 1.0 g powder was mixed into each 40 g of Palacos bone cement, resulting in total maximum doses of tobramycin 7.2 g and vancomycin 2.0 g. At the time of hospital discharge renal function was unchanged in 9 patients. A 75-year-old male patient with preexisting renal impairment developed significant and persistent worsening of his renal function. Conclusion Bone cement impregnated with high doses of aminoglycosides should be used with caution in patients with a history of renal impairment.

OBJECTIVE: To describe how clinical pharmacy is helping to improve medication use at a South Indian teaching hospital by addressing medication use problems, which are commonly encountered in India. SUMMARY: Clinical pharmacy is practiced in many countries and makes a significant contribution to improved drug therapy and patient care. India is a country with significant problems with medication use, but until recently Indian pharmacists have not been educated for a patient-care role. Postgraduate pharmacy practice programs have been established at 2 pharmacy colleges in South India as a result of a joint Indo-Australian program of cooperation. At a teaching hospital associated with the colleges, clinical pharmacy services such as drug information, medication counseling, drug therapy review, adverse drug reaction reporting, and the preparation of antibiotic guidelines are assisting clinicians to improve drug therapy and patient care. Seven hundred twenty-seven requests for drug information were received from July 1997 to February 2001, and 543 suspected adverse drug reactions were evaluated from November 1997 to February 2001. The most common drug classes causing adverse drug reactions were antibiotics, nonsteroidal antiinflammatory drugs, and antitubercular agents. Physician opinion and service utilization have also been surveyed: 82% of respondents had sought drug information from the Clinical Pharmacy Department and 71% of respondents had sought advice on individual patient management. The success of this program is raising awareness of clinical pharmacy among pharmacy educators elsewhere in India and has led to the introduction of clinical pharmacy services at other Indian hospitals.

Background Hypothermia is a rarely reported and under-recognised adverse reaction to antipsychotics. Although the mechanism of antipsychotic-induced hypothermia is not fully understood, antipsychotics that are more potent antagonists at 5-HT2 than at dopamine2 receptors appear more likely to cause hypothermia. Aim To describe a case of hypothermia possibly associated with olanzapine. Clinical features A 94-year-old woman was admitted to hospital with acute confusion and hypothermia (31.9 °C). Her medical history included hypothyroidism, and delusions and hallucinations, for which olanzapine had been prescribed 4 days before admission. On admission she was found to have hypercalcaemia, iron deficiency, normal free thyroxine, raised thyroid stimulating hormone, evidence of recent exposure to pesticides, and a generalised erythematous rash. Outcome Withdrawal of olanzapine 4 days after admission was associated with an increase in body temperature (36–37 °C) and resolution of her confusion and rash. Conclusion Clinicians should consider the possibility of drug-induced illness in hypothermic patients who are taking antipsychotics.

Background The elderly population is increasing worldwide. Due to age-related physiological changes that affect the pharmacokinetics and pharmacodynamics of drugs, the elderly are predisposed to adverse drug reactions. Prescribing of potentially inappropriate medications (PIMs) has been found to be prevalent among the elderly and PIM use has been associated with hospitalisations and mortality. Objectives This study aims to identify the prevalence and nature of pre-admission inappropriate prescribing by using the STOPP (screening tool of older people’s prescriptions) criteria amongst a sample of hospitalised elderly inpatients in South Australia. Setting Medical, surgical and rehabilitation wards of a public teaching hospital in Adelaide, South Australia. Main outcome measure Pre-admission prevalence of PIM. Method Medication management plans of 100 patients of ≥65 years old were prospectively studied to determine the prevalence of pre-admission PIM use. Sixty-five criteria of STOPP were applied to identify PIMs. Results The total number of pre-admission medications screened during the study period was 949; the median number of medicines per patient was nine (range 2–28). Overall the STOPP criteria identified 138 PIMs in 60 % of patients. The most frequently encountered PIM was opiates prescribed in patients with recurrent falls (12.3 %), followed by benzodiazepines in fallers (10.1 %) and proton pump inhibitors when prescribed for peptic ulcer disease for long-term at maximum doses (9.4 %). The number of medications were found to have a positive correlation with pre-admission PIM use (rs = 0.49, P < 0.01). Conclusions Pre-admission PIM use is highly prevalent among the studied population. Strategies to reduce PIM use should be undertaken by physicians and pharmacists. The use of the STOPP criteria in clinical practice to reduce prescriptions of inappropriate medications requires further investigation.

SHPA has signed a memorandum of agreement with the US Commission for Certification in Geriatric Pharmacy (CCGP), which will assist Australian pharmacists to achieve CCGP certification in geriatric pharmacy. In this paper two SHPA members provide details about the CCGP certification process and the resources that they found useful when preparing to sit for the CCGP exam. Benefits of certification include the application of new knowledge in daily clinical practice, and accreditation to provide medication review services to the elderly. (author abstract)

A 74-year-old man who was receiving warfarin for atrial fibrillation experienced an abrupt increase in his international normalized ratio (INR) after taking acetaminophen. To investigate this effect, the patient's anticoagulation therapy was stabilized, and he was given acetaminophen 1 g 4 times/day for 3 days. His INR rose from 2.3 before receiving acetaminophen to 6.4 on the day after acetaminophen was discontinued. Warfarin was stopped for 2 days, and the patient's INR returned to 2.0. Warfarin was restarted at the same dosage, and his INR remained within 2.0-3.0 for 6 months. Factor VII activity decreased from 29.4% before acetaminophen therapy to 15.5% when his INR was 6.4, and factor X activity fell from 27.0% to 20.2%. His warfarin plasma concentration was 1.54 microg/ml before acetaminophen compared with 1.34 microg/ml when his INR was 6.4. No significant changes in drug intake, clinical status, diet, or lifestyle were noted. Changes in INR of this magnitude with the addition of another drug during stable anticoagulation therapy suggest a drug interaction. The lack of an increase in warfarin plasma concentration associated with the increased INR suggests a possible pharmacodynamic mechanism for this interaction. Acetaminophen or a metabolite may enhance the effect of oral coumarin anticoagulants by augmenting vitamin K antagonism. Thus, the anticoagulant effect of warfarin may be significantly elevated after only a few days of acetaminophen therapy. Patients receiving warfarin should be counseled to have their INR monitored more frequently when starting acetaminophen at dosages exceeding 2 g/day.

Nitrous oxide abuse by healthcare practitioners such as dentists and anaesthetists has been extensively described, but recreational use in community settings also occurs. Described here is the case of a 37 year old woman abusing nitrous oxide from charger cartridges for a whipped cream dispenser. The medical and neuropsychiatric sequelae of nitrous oxide abuse are discussed with reference to features observed in this case. (author abstract)