Nijole Bernaitis

Protection against radiotherapy-induced toxicity

Radiation therapy is a highly utilized therapy in the treatment of malignancies with up to 60% of cancer patients receiving radiation therapy as a part of their treatment regimen. Radiation therapy does, however, cause a wide range of adverse effects that can be severe and cause permanent damage to the patient. In an attempt to minimize these effects, a small number of compounds have been identified and are in use clinically for the prevention and treatment of radiation associated toxicities. Furthermore, there are a number of emerging therapies being developed for use as agents that protect against radiation-induced toxicities. The aim of this review was to evaluate and summarise the evidence that exists for both the known radioprotectant agents and the agents that show promise as future radioprotectant agents.

The Sex, Age, Medical History, Treatment, Tobacco Use, Race Risk (SAMe TT2R2) Score Predicts Warfarin Control in a Singaporean Population

BACKGROUND Warfarin reduces stroke risk in atrial fibrillation (AF) patients but requires ongoing monitoring. Time in therapeutic range (TTR) is used as a measure of warfarin control, with a TTR less than 60% associated with adverse patient outcomes. The Sex, Age, Medical history, Treatment, Tobacco use, Race (SAMe-TT2R2) score has been identified as a model able to predict warfarin control, but this has been tested in mainly Caucasian populations. Therefore, the aim of this study was to determine the ability of the SAMe-TT2R2 score to predict warfarin control in a Singaporean population consisting of Chinese, Malay, and Indian race. METHODS Retrospective data were collected from the National Heart Centre Singapore for AF patients receiving warfarin between January and June 2014. The TTR and the SAMe-TT2R2 score were calculated for each patient. RESULTS The 1137 non-valvular AF patients had a mean TTR of 58.0 ± 34.3% and a median SAMe-TT2R2 score of 3. The categorized SAMe-TT2R2 scores (2 versus >2) showed a significant reduction in mean TTR for the entire population (63.2% versus 55.8%, P = .0004) and also when categorized according to race for Chinese (62.7% versus 56.9%, P = .0075) and Malay (68.4% versus 50.6%, P = .0131) populations. CONCLUSION The SAMe-TT2R2 tool is effective in predicting warfarin control in a Singaporean population as patients with a score greater than 2 had poor control. The minimum score for non-Caucasian patients is 2; thus, in these patients, the presence of any additional risk factors identified in the SAMe-TT2R2 tool categorizes them as unlikely to achieve adequate warfarin control and possible candidates for alternative anticoagulants.

Quality of warfarin control in atrial fibrillation patients in South East Queensland, Australia

Warfarin is widely prescribed to decrease the risk of stroke in atrial fibrillation (AF) patients. Due to patient variability in response, regular monitoring is required, and time in therapeutic range (TTR) used to indicate quality of warfarin control with a TTR>60% is recommended. Recently, an Australian Government review of anticoagulants identified the need to establish current warfarin control and determine the potential place of the newer oral anticoagulants.

The Use of Fish Oil with Warfarin Does Not Significantly Affect either the International Normalised Ratio or Incidence of Adverse Events in Patients with Atrial Fibrillation and Deep Vein Thrombosis: A Retrospective Study

Background: Warfarin is a leading anticoagulant in the management of atrial fibrillation (AF) and deep vein thrombosis (DVT). Drug interactions influence the safety of warfarin use and while extensive literature exists regarding the effect on warfarin control and bleeding incidence with many medicines, there is little evidence on the influence of complementary medicines. The aim of this study was to assess the influence of fish and krill oil supplementation on warfarin control and bleeding incidence in AF and DVT patients. Methods: A retrospective analysis was conducted utilising patient information from a large private pathology clinic. AF and DVT patients receiving long-term warfarin therapy (>30 days) at the clinic and taking fish and krill oil supplements were eligible for study inclusion. Results: Of the 2081 patients assessed, a total of 573 warfarin users met the inclusion criteria with 145 patients in the fish and krill oil group (supplement group) and 428 patients in the control group. Overall, it was found that fish and krill oils did not significantly alter warfarin time in therapeutic range (TTR) or bleeding incidence, even when compared by gender. Conclusion: Omega-3 supplementation with fish and krill oil does not significantly affect long-term warfarin control and bleeding and thromboembolic events when consumed concurrently in patients managed at an anticoagulation clinic.

Factors influencing warfarin control in Australia and Singapore

INTRODUCTION Warfarin is widely used for patients with non-valvular atrial fibrillation (NVAF). Variations in warfarin control, as measured by time in therapeutic range (TTR), have been reported across different regions and ethnicities, particularly between Western and Asian countries. However, there is limited data on comparative factors influencing warfarin control in Caucasian and Asian patients. Therefore, the aim of this study was to determine warfarin control and potential factors influencing this in patients with NVAF in Australia and Singapore. METHODS Retrospective data was collected for patients receiving warfarin for January to June 2014 in Australia and Singapore. TTR was calculated for individuals with mean patient TTR used for analysis. Possible influential factors on TTR were analysed including age, gender, concurrent co-morbidities, and concurrent medication. RESULTS The mean TTR was significantly higher in Australia (82%) than Singapore (58%). At both sites, chronic kidney disease significantly lowered this TTR. Further factors influencing control were anaemia and age<60years in Australia, and vascular disease, CHA2DS2-VASc score of 6, and concurrent platelet inhibitor therapy in Singapore. DISCUSSION Warfarin control was significantly higher in Australia compared to Singapore, however chronic kidney disease reduced control at both sites. The different levels of control in these two countries, together with patient factors further reducing control may impact on anticoagulant choice in these countries with better outcomes from warfarin in Australia compared to Singapore.

Dedicated warfarin care programme results in superior warfarin control in Queensland, Australia

Warfarin is used to prevent stroke in patients with atrial fibrillation (AF). Ongoing monitoring of International normalised ratio (INR) and time in therapeutic range (TTR) commonly used to assess the quality of warfarin management are required. Anticoagulant clinics have demonstrated improved TTRs, particularly in countries with poorer control in primary care settings. Reported TTR in Australia has been relatively high; so, it is unknown if benefit would be seen from dedicated warfarin clinics in Australia. The aim of this study was to compare the level of warfarin control in patients managed by their general practitioner (GP) and a warfarin care programme (WCP) by Sullivan Nicolaides Pathology.

Impact of Aspirin on Warfarin Control as Measured by Time in Therapeutic Range

Warfarin is an oral anticoagulant widely prescribed for a variety of thromboembolic indications including venous thromboembolism (VTE) deep vein thrombosis (DVT) and the prevention of stroke associated for atrial fibrillation (AF).1 Warfarin requires ongoing monitoring of Internationalised Normalised Ratio (INR) due to a narrow therapeutic index and interactions with numerous drugs.2 The time in therapeutic range (TTR) is often used to indicate the quality of warfarin therapy due to the established correlation between higher mean TTR and reduced complications such as bleeding and thromboembolism.3 This article is protected by copyright. All rights reserved.

Appraising the role of the virtual patient for therapeutics health education

BACKGROUND Face-to-face instruction, paper-based case-studies and clinical placements remain the most commonly used teaching methods for therapeutics curricula. Presenting clinical content in a didactic manner presents challenges in engaging learners and developing their clinical reasoning skills which may be overcome by inclusion of the virtual patient (VP). Currently there is limited literature examining the use of the VP in therapeutics teaching and learning. This review aimed to determine the role of VPs in therapeutics education, specifically the impact on student experiences, performance, and clinical skills. METHODS A search of primary literature was conducted with search terms including virtual patient, education, health, AND learning. Boolean operators were applied to include studies from health relevant fields with article titles and abstracts vetted. RESULTS Nine of the 21 included studies were control-matched, and all but one compared VPs to traditional teaching. VPs enhanced the learning experience in all 17 studies that measured this outcome. Fourteen studies measured performance and clinical skills and 12 found VPs were beneficial, while two did not. The VP was not superior to traditional teaching in all studies, but the VP appeared beneficial to the student learning experience. Discrepancy was found between the impact of VPs on short- and long-term knowledge. IMPLICATIONS The VP appears to enhance the student learning experience and has a role in therapeutics education, however a blended-learning (BL) approach may be required to account for individual learning styles. Additional investigation is required to clarify the efficacy of the VP, particularly as a component of BL, on longer-term knowledge retention.

Long-Term Statin Administration Does Not Affect Warfarin Time in Therapeutic Range in Australia or Singapore

Background: Warfarin requires ongoing monitoring of the International Normalised Ratio (INR). This is because numerous factors influence the response, including drug interactions with commonly-prescribed medications, such as statins. The administration of statins with warfarin may change INR; however, there is limited information regarding the effects on warfarin control as measured by time in therapeutic range (TTR). Statins may also alter bleeds with warfarin, but there are conflicting reports demonstrating both increased and decreased bleeds, and limited data on diverse ethnic populations. Therefore, the aim of this study was to determine the effect of statin administration on warfarin control and bleeds in patients in Australia and Singapore. Methods: Retrospective data were collected for patients on warfarin between January and June 2014 in Australia and Singapore. Patient data were used to calculate TTR and bleed events. Concurrent statin therapy was assessed and comparisons of TTR and bleed incidence were made across patient subgroups. Results: Warfarin control in Australia and Singapore was not significantly affected by statins, as measured by TTR (83% and 58%, respectively), frequency of testing, and warfarin doses. In Australia, statin use did not significantly affect bleeds, whilst in Singapore the bleed incidence was significantly lower for patients on statins. Conclusions: Chronic concurrent administration of statins with warfarin does not adversely affect warfarin TTR in Australia or Singapore. In Singapore, patients on statins, compared to no statins, had a lower bleed incidence and this requires further investigation, especially given the potential genetic influences of ethnicity on both statin and warfarin metabolism.

Simulated patient cases using DecisionSim™ improves student performance and satisfaction in pharmacotherapeutics education

BACKGROUND AND PURPOSE Pharmacy education is continuously evolving and incorporation of technology is more prevalent. Computer-based patient cases are being utilised to illustrate complex concepts and develop clinical decision-making skills by enabling deliberate practice and continued feedback to scaffold student learning. Simulations are received positively by students but there is limited information on the benefit to student performance. The study aim was to determine the benefits of computer-based cases for oncology therapeutics in terms of student satisfaction and performance. EDUCATIONAL ACTIVITY AND SETTING Computer based oncology cases were designed using DecisionSim™ technology and introduced to final year pharmacy students. Student satisfaction was measured using a questionnaire with a 5-point Likert scale (1 strongly agree to 5 strongly disagree), and an option for open-ended comments. Performance was measured using results of assessment items in the oncology course compared to a similar course (psychiatric/neurology). FINDINGS Students found the simulated oncology cases engaged them in learning (median 1.5), had a role in therapeutics education (median 1), and developed decision making skills (median 1). Thematic analysis of open comments suggested it was most beneficial as a self-directed study tool. The students performed significantly higher (p < 0.05) in the oncology end of semester exam (78.6 ± 8.6) compared to psychiatric/neurology (70.7 ± 9.6). SUMMARY A computer-based simulation for oncology pharmacotherapeutics can engage students and develop decision making skills. DecisionSim™ enhanced both student satisfaction and performance in management of oncology cases, and is a beneficial educational tool for teaching complex therapeutic topics to pharmacy students.