0022-3565/08/3251-1–9$20.00THE JOURNAL OF PHARMACOLOGY AND EXPERIMENTAL THERAPEUTICS Copyright © 2008 by The American Society for Pharmacology and Experimental Therapeutics JPET 325:1–9, 2008 Printed in U.S.A. Perspectives in Pharmacology Exploiting Complexity and the Robustness of NetworkArchitecture for Drug Discovery Marc K. Hellerstein Department of Nutritional Sciences, University of California, Berkeley, California; Division of Endocrinology and Metabolism,Department of Medicine, University of California, San Francisco, California; and KineMed, Inc, Emeryville, California
peace of mind with medication™
the newsletter of Manrex Pty ltd – weBsterCare • issue no. 104 • feBruary 2008 • weBsterCare 2008
Q&a with Gerard StevenS part 3
More answers to questions
What is happening in the rest of
Benefits Scheme. The problem the world?
is that it is designed for simply My job often takes me to dispensing medication into conferences and meetings in the original packs. However, foreign parts. From what I can see, the Australian government has here in Australia we have the most commissioned a trial to identify complete medication management who in the community will benefit systems. It's about the most from DAAs. So software and the visual they can work out who appeal and impact of will be funded in the Gerard Stevens saying hello there,
what we have. I look future. Webster-pak is Australia Day is big in the Stevens
carefully at packaging the most recognisable family. Matt and Tan have come up
concepts and pharmacy services of all the DAAs. This funding is with one huge Australia Day party
overseas to see if there is anything designed to encourage pharmacists to celebrate. Oz flags, balloons,
better. So far the answer is no. Even to provide this service. streamers, BBQ aprons, tea towels
in the US they mostly use unit dose. Many thousands of patients and just about every true blue
If they had Unit Dose 7 it would are admitted to hospital every song played all day. Talk about
save them a lot of aggravation. year after an adverse effect from Australians all, let us rejoice.
I keep telling them, and at last medication errors. Much of this Webster-pak has been on TV and
they are showing interest. I point could be avoided if medications radio and in the papers. It is all to do
out that it's Webstercare—it takes were taken the way they are with the new government funding
the guesswork out of taking prescribed. Statistics can tell us arrangements for a trial of dose
how many people go to hospital. administration aids. We like it.
What's happening in Australia?
But there are many more who New Year Note: Jessica the dog does
Here we have one of the most do not end up in hospital after a not like fireworks and wants them
cost-effective government funded medication misadventure. These banned. She doesn't care how good
medication supply systems in can never be counted, but their the harbour bridge looks. She is
the world—the Pharmaceutical problems are just as great. getting up a petition among other
dogs in the area. Many people say
she is barking mad but Jessica says,
Words of Wisdom
just you wait.
I've just finished reading Ken
Some people are wise and some are otherwise. Follett's 1,000 page epic, ‘World
The nicest thing about the future is that it always starts tomorrow. without End', the sequel to ‘Pillars of
I didn't say it was your fault, I said I was blaming you.
the Earth'. I can't believe I read it all.
No more for now, Mr. Follet, this fan
Times have not become more violent—they have just become is sequelled out.
Keep on Webstering.
Life is like a dogsled team. If you're not the lead dog, the scenery never changes.
manrex pty ltd – WeBSterCare • aBn 29 974 510 173 • 17-19 mOOre Street, leICHHardt nSW 2040
tel: (02) 9563 4900 • Fax: (02) 9563 4955 • Free Call: 1800 244 358 • emaIl: [email protected]
did You Know?
thiS month — dYSphaGia
manrex continuinG education SerieS
by Paul Hannan Dysphagia is difficulty in swallowing. contribute to swallowing disorders their medication. Some medications About 50% of aged care home residents can cause xerostomia or a dry have identifiable signs and symptoms mouth, including anticholinergics, of dysphagia. While swallowing • Stroke or cerebrovascular angiotensin-converting enzyme (ACE) impairment increases with age, ageing inhibitors and many short- and long- alone does not cause dysphagia. In • Parkinson's disease acting antihistamines. The dryness older people healthy swallowing • Chronic reflux oesophagitis or of the mouth can lead to a feeling of occurs more slowly, while remaining gastro-oesophageal reflux disease impaired swallowing. coordinated and effective. • Neuromuscular disorders such as If swallowing disorders are Huntington's or multiple sclerosis The act of swallowing occurs in three unrecognised or untreated, residents phases. In the first phase, food or may become malnourished and liquid is contained in the mouth by • Motor neuron disease dehydrated. Choking, aspiration and the tongue and palate. The tongue • Sjogren's syndrome (due to sometimes complete obstruction may moves the food around in the mouth decrease in salivary flow) occur. Aspiration is the accidental for chewing. This phase is the only one • Myasthenia gravis sucking in of food particles or fluids under voluntary control.
• Post-radiation therapy into the lungs. Aspiration pneumonia The second phase of swallowing begins • Medication with anticholinergic (infection of the lungs due to when the brain makes the decision effects eg tricyclic antidepressants, aspiration) has a high mortality rate of to swallow. At this point a complex series of reflexes begin. The food is • Phenothiazides eg Mellerill®, thrust from the mouth into the throat. Largactil®, Stelazine® (may cause At the same time, a muscular valve tardive dyskinesia) Eating while in an upright position at the bottom of the pharynx opens, • Olanzapine (Zyprexa®) helps prevent choking and aspiration allowing food to enter the oesophagus, • Poor dentition of food. Residents should remain and other muscles close the airway to Difficulty swallowing liquids is usually sitting upright or standing for 15 to 20 prevent food from entering the airways. associated with poor muscular control minutes after eating a meal. This second phase of swallowing takes before the swallow. This is common Many people with dysphagia have less than half a second.
in people with neurological diseases difficulty swallowing thin liquids The third phase of swallowing begins such as Parkinson's and MS.
such as water, tea, coffee and juices. when food enters the oesophagus. Patients with Alzheimer's disease may Thin liquids splash into the pharynx The oesophagus, which is about not be able to swallow fluids or food before the swallowing mechanism nine inches long, is a muscular tube when they reach the final stages of is triggered, increasing the risk of that produces waves of coordinated aspiration. Thickening thin fluids contractions. As the oesophagus Strokes commonly lead to dysphagia is not always recommended for all contracts, a muscular valve at the end and patients may benefit from residents—check with a speech of the oesophagus opens and food is rehabilitation to retrain swallowing pathologist. If the swallowing problem propelled into the stomach. The third is due to lack of saliva, sucking phase of swallowing takes six to eight popsicles, ice chips or lemon ice or seconds to complete.
drinking lemon-flavoured water may The whole process involves over 40 Some medications are a high risk for increase saliva production, which pairs of muscles. causing oesophageal injury, leading to increases swallowing frequency. Reflux oesophagitis should be treated Signs and symptoms
dysphagia. These include:• Bisphosphonates eg alendronate with proton pump inhibitors such as A variety of symptoms indicate that (Fosamax®), risedronate Zoton®, Somac®, Nexium® or Losec® a resident has a swallowing disorder: or domperidone (Motilium®).
Drooling—Food leakage from mouth— • Potassium chloride (Slow K®, Food retention in mouth—Coughing or choking during or just after eating—or drinking—Change in voice or speech, Dysphagia is an unpleasant, hoarseness—Facial droop—Increased frightening and potentially life- congestion or secretions after a meal— • Quinidine (Kinidin Durules®) threatening condition which Refusal or reluctance to have food • Tetracyclines eg doxycycline affects a large number of aged care placed in mouth.
residents. Recognition and proper Residents presenting with these • Clindamycin (Dalacin C®) assessment is essential. A complete symptoms should have an assessment • Ferrous sulphate evaluation of dysphagia should by a speech therapist.
(Ferrogradumet®, FGF®, Fefol®, include a medication review and may result in the elimination of Residents should be encouraged to medications or changes in dosage.
Conditions and medications that may drink sufficient water when they take
Medical news from all over
The Multi Dose advantageWebster-pak is the most widely recognised multi dose system in Australia. Originally created for community/home care it soon spread into residential aged care. Since then we have developed the system to keep it in line with your changing needs and technological advances. How does it help?• All medications for one week in one pack. • All medications for one The use of statins commonly
dosage time in a single prescribed to reduce cholesterol
has been shown to reduce
the risk of death from either
• You can always see chronic airways limitation or
what pills have been influenza/pneumonia. This
used and what is left. data was obtained from Health
Maintenance organisations in the
• Widely recognised, so USA. Regular statin use was based
very little orientation on at least 90 days of treatment.
needed for staff.
A simple test that can be given • Fully accountable system. by any physician predicts with 87% accuracy a person's risk of • Resident photo on developing dementia within pack—right there at the six years. The test is a 14-point index combining medical history, cognitive testing and physical examination. Risk factors for developing dementia are, an age of 70 or older, low physical also the flexi-pak
functioning on everyday tasks, coronary bypass surgery and a body mass index of less than 18. Designed for residents who People who score 0 to 3 on the test need medications when going have a 6% chance of developing dementia within six years. A score out for the day.
of 4 to 6 indicates a 25% chance. • The Flexi-pak People with a score of 7 or higher have a 54% chance of developing dementia within six years. There is a higher occurrence
of congestive heart failure
patient to tear off a day or a in rural Australia compared
to metropolitan areas. The
percentage of rural patients
• Each compartment is over 60 with CHF was 16.1%.
labelled with the patient's It was 12.4% in metropolitan
areas. This may be because
name, day, dosage time there are less specialist
referral and echocardiograms.
The use of recommended
• The Flexi-pak folder pharmacotherapies was also
helps keep everything lower in rural compared to
Life in the aged care home business gets more complicated every day.
At Webstercare we are dedicated to making your life as simple as we can.
And what could be simpler than picking up the phone and calling
1800 244 358 to find out about our medication management reports?
Webstercare's reports provide detailed information that will help you with
all your decision-making for a resident's medication review.
A new funding instrument to determine the level of funding from
the government, ACFI, arrives on the 20th March 2008. Many of
our reports provide information to help you deal with that. They
Superwoman, Wonder Woman,
provide documentation for accreditation requirements and ACFI Julia Gillard—they all tremble in
implementation. An example is use of psychotropics and diagnoses. Your the aura of the Webster woman of
pharmacy can provide the reports. every year, Zoe Diplos. Approach
her presence with your Webster-
Ask your pharmacist or ask us. We will welcome your phone call. A problems and get your tlc, your
summary booklet of the latest reports will be delivered to your door. Just brow soothed and a mountain of
call Webstercare on 1800 244 358.
Zoe says: Are you no longer as
young as you were? Why not be
proud and say, yes, I'm a senior
• I'm the life of the party—even if
it lasts until 8 p.m.
• I'm very good at opening
childproof caps—with a
• I'm usually interested in going
home before I get to where I am
• I'm awake for hours before my
body allows me to get up.
• I'm smiling all the time because I
can't hear a thing you're saying.
• I'm very good at telling stories—
over and over and over and over.
• I know everything I can't find
is in a safe, secure place—
• I'm sure they are making adults
much younger these days.
Take two after meals with water And most important of all:
• If you're only as old as you feel,
Credit card companies keep writing to me to offer me credit. how could I be alive at 150?
For that, I am deeply indebted.
Scientists have located the gene that causes obesity. His name is Gene Harris and he invented Krispy Kreme doughnuts.
My father taught me a valuable lesson, don't trust anybody. He didn't tell Gerard Stevens and Paul Hannan me—he robbed me.
saying hello to another year and goodbye for this edition. Signing off Business conventions are important because they demonstrate how many with one of the wisest sayings we people a company can operate without.
have heard in a long time: I have always wanted to be the last man on earth, just to see if all those women When life hands you lemons, ask for were lying to me.
tequila and salt. manrex, webStercare, webSterSYStem, unit doSe 7, webSter-paK and flexi-paK are reGiStered trade marKS of manrex p/l webStercare.
SOGC CLINICAL PRACTICE GUIDELINES SOGC CLINICAL PRACTICE 155 (Replaces guideline No 147), February 2005 Guidelines for Vaginal Birth After PreviousCaesarean Birth This guideline has been prepared and reviewed by the Clinical 1. Provided there are no contraindications, a woman with 1 previous Practice Obstetrics Committee and approved by the Executive