Navigating the Pharmaceutical Benefits Scheme: federal versus state government funding for high-cost medicines – a problem for public hospitals.

The funding of medication supply in Australian public hospitals is divided between the federal government's Pharmaceutical Benefits Scheme (PBS) and thestate or territory government who pay for the remaining medications not covered under the PBS. For some high-cost medications, such as the monoclonal antibody blinatumomab, the current criteria for PBS funding in public hospitals are challenging. The strict requirement for inpatient admission, due to the risk of potentially serious adverse effects, alongside a lack of PBS reimbursement, while a hospital inpatient, may result in the state bearing the cost. A retrospective review of five patients receiving blinatumomab at our hospital found that, on average, patients remained inpatients for longer than that stipulated to meet PBS funding criteria, predominantly due to adverse effects associated with the medication. This resulted in the state government paying for the medication in full. The upcoming National Medicines Policy review should address the increasing complexity of new medications and their access and funding.

An evaluation of automated dispensing cabinets and inventory robots for centralised distribution of medication in an Australian hospital.

ObjectiveIn Australian hospitals, a central distribution system is often utilised to supply medication to clinical areas. This study investigated the impact of automated dispensing cabinets (ADCs) and inventory robots in medication distribution within an Australian hospital.MethodsA prospective observational study of pharmacy technician medication supply to clinical areas was conducted over a 2-week period pre- and post-implementation of ADCs and inventory robots. Information was collected on the time taken to perform all tasks required to provide a weekly medication supply service for medication other than drugs of addiction.ResultsThere was no significant reduction of total duration for medication supply, pre-implementation mean 73.08min versus post-implementation 68.59min (P=0.567). An instance of automation downtime occurred during the post-implementation period for which manual downtime procedures were implemented. Without downtime, a significant reduction in overall time taken was observed, 74.25min versus 63.18min (P=0.019). Pre-restocking medication selection errors were reduced non-significantly after implementation of inventory robots, 11 (0.43%) versus 4 (0.21%) errors (P=0.090).ConclusionsImplementation of ADCs and robots did not significantly reduce the total time to provide a weekly medication supply service when downtime occurred, although a significant reduction was observed when downtime did not occur. Pharmacy medication selection errors were non-significantly lower.What is known about the topic?Australian hospitals are increasingly implementing automated technology such as ADCs and inventory robotics in an attempt to improve efficiency and accuracy of medication supply; however, limited literature is available in an Australian setting.What does this paper add?This paper describes the impact of implementing ADCs in clinical areas (e.g. inpatient wards) and inventory robots in a main store pharmacy on the medication supply process. This paper highlights the benefit of improved efficiency and accuracy in selecting medication in pharmacy for distribution and identifies time to restock the ADCs is significantly increased.What are the implications for practitioners?Implementing ADCs and inventory robotics in Australian hospitals can provide benefits in efficiency and accuracy; however, robust downtime procedures are essential.

Etiology and Management of Peristomal Pseudoepitheliomatous Hyperplasia.

This is a report of a 48-year-old male patient who presented with worsening peristomal dermatitis. He proceeded to form a nodular hyperplastic overgrowth that was proven to be pseudoepitheliomatous hyperplasia on histological examination. On surgical exploration, he was found to have an apparent peristomal enterocutaneous fistula propagating this hyperplastic growth. This report reviews the etiology and management of peristomal complications with special attention to pseudoepitheliomatous hyperplasia.

Development of a sublingual/oral formulation of ketamine for use in neuropathic pain: Preliminary findings from a three-way randomized, crossover study.

BACKGROUND AND OBJECTIVE: Enterally administered low-dose ketamine is being used increasingly to treat pain states. However, suitable oral or sublingual formulations are not available. The objective of the study was to develop a lozenge formulation of ketamine for use in patients with neuropathic pain, and to investigate its storage stability and bioavailability after oral or sublingual administration. METHODS: A lozenge containing 25 mg of ketamine was formulated and manufactured in a hospital pharmacy setting. Stability was assessed by high-performance liquid chromatography (HPLC) during storage at 25 degrees C or 2-8 degrees C for up to 14 weeks. Bioavailability after both oral and sublingual administration was evaluated in six patients with chronic neuropathic pain. Ketamine and its metabolite norketamine in plasma were measured by HPLC. RESULTS: The lozenge formulation was chemically stable for at least 14 weeks. Oral and sublingual bioavailabilities [median (interquartile range)] were 24% (17-27%) and 24% (19-49%), respectively. There was substantial metabolism to norketamine for both routes. The mean norketamine/ketamine area under the plasma concentration-time curve from baseline to 8 hours ratios were 5 and 2.1 after oral or sublingual administration, respectively. CONCLUSION: The ketamine lozenge showed acceptable storage stability. Bioavailability was sufficiently high and reproducible to support its use in routine pain management. There was extensive first-pass conversion to norketamine. Efficacy studies are warranted to evaluate sublingual and oral administration of our new lozenge formulation of ketamine in patients with chronic pain states. Investigation of the role of the metabolite norketamine, which is also an NMDA receptor antagonist, is particularly important because this may contribute significantly to clinical efficacy.

Patch repair of ileoanal pouch-vaginal fistula with Permacol collagen implant.

Though uncommon, ileoanal pouch-vaginal fistulas after restorative proctocolectomy present quite a challenge. Multiple salvage procedures, including endoanal, transabdominal, and trans-vaginal, have been used. Because of high recurrence rates, multiple operations are not uncommon, and ultimate pouch failure rates have been reported as high as 45 per cent. The Permacol Collagen Implant is a surgical implant that has been used successfully in a variety of operations ranging from urological to maxillofacial. Its properties allow fibroblast infiltration and revascularization so that it gradually becomes permanently incorporated into the surrounding tissue, providing strength and inhibiting scarring and contraction. We report the first documented case of Permacol use in repair of ileoanal pouch-vaginal fistula and we feel that it warrants further investigation as an option in the treatment of these fistulas.

Probiotics: a practical review of their role in specific clinical scenarios.

The use of probiotics (live viable microbial organisms) in the treatment of specific diseases has evolved into an extremely valuable option yet to be optimally used in clinical medicine. Probiotics have been shown to have immunomodulating properties and enhance the mucosal barrier. This review will briefly discuss the use of probiotics in inflammatory bowel disease, pancreatitis, liver transplantation, and various uses in diarrhea. When using probiotics, one must be cautious of the sometime overzealous claims that are commonly made when dealing with medical foods. As we begin to appreciate the degree of complexity that our indigenous microbial population has on health, it is only then that we can begin to understand the importance in disease. In the arena of probiotics, numerous fundamental questions remain unanswered.