Australian Doctor Australian Doctor 15th September 2017 | Page 16

Asthma: Symbicort ® Maintenance And Reliever Therapy( Symbicort ® SMART ™)

PBS Information: Restricted benefit. For single maintenance and reliever therapy in patients ≥12 years who have experienced frequent asthma symptoms while receiving treatment with oral or inhaled corticosteroids or a combination of an inhaled corticosteroid and a long acting beta-2-agonist( Symbicort Turbuhaler 400 / 12 and Symbicort Rapihaler 200 / 6 is not recommended nor PBS subsidised for use in maintenance and reliever therapy).

Asthma: Symbicort ® Maintenance Therapy

PBS Information: Restricted benefit. Patients ≥12 years who previously had frequent episodes of asthma while receiving treatment with oral corticosteroids or optimal doses of inhaled corticosteroids( Symbicort Turbuhaler 400 / 12 is indicated in patients ≥18 years).

BEFORE PRESCRIBING PLEASE REVIEW FULL PRODUCT INFORMATION AVAILABLE ON REQUEST FROM ASTRAZENECA ON 1800 805 342 OR www. astrazeneca. com. au / PI

Symbicort ® Turbuhaler ®( budesonide and eformoterol fumarate dihydrate) for oral inhalation. Indications: Asthma: Treatment of asthma where use of a combination( inhaled corticosteroid and long acting β 2

-agonist) is appropriate in adults and adolescents. COPD: Symptomatic treatment of moderate to severe chronic obstructive pulmonary disease( COPD),( FEV 1

≤50 % predicted normal) in adults with frequent symptoms despite long acting bronchodilator use, and / or a history of recurrent exacerbations. Symbicort is not indicated for the initiation of bronchodilator therapy in COPD. Dosage: Asthma: There are two alternative treatment regimens for asthma: Symbicort Maintenance and Reliever Therapy( SMART TM) or Symbicort Maintenance Therapy. Refer to Product Information for full details on dosage. Symbicort Maintenance and Reliever Therapy( SMART TM) for Asthma: Symbicort 100 / 6 and 200 / 6: Adults and adolescents > 12 years: 2 inhalations per day given as either 1 inhalation twice daily or 2 inhalations in either the morning or evening. For some patients, a maintenance dose of Symbicort 200 / 6 2 inhalations twice daily may be appropriate. Patients may take an additional inhalation as needed in response to symptoms, up to 6 inhalations at one time. If patients experience a three-day period of deteriorating symptoms after taking the appropriate dose, the patient should be re-assessed. A total daily dose of up to 12 inhalations can be used temporarily. Symbicort 400 / 12: The 400 / 12 strength should not be used for Symbicort Maintenance and Reliever therapy. Symbicort Maintenance Therapy for Asthma: Symbicort 100 / 6 and 200 / 6: Adults and adolescents ≥12 years: 1-2 inhalations twice daily. Symbicort 400 / 12: Adults ≥18 years: 1-2 inhalations twice daily. Dosage: COPD: Symbicort 200 / 6: 2 inhalations twice daily. Symbicort 400 / 12: 1 inhalation twice daily. Contraindications: Hypersensitivity to any of the ingredients. Precautions: Symbicort therapy should not be initiated to treat a severe exacerbation. Not for initiation of inhaled steroids in patients transferring from oral steroids; impaired adrenal function; infections of the respiratory system; increased susceptibility to sympathomimetic amines; severe cardiovascular conditions; hypokalaemia; diabetes; impaired renal and hepatic function; pregnancy( category B3); lactation; children < 12 years. Pneumonia: Physicians should remain vigilant for the possible development of pneumonia in patients with COPD as the clinical features of pneumonia and exacerbations frequently overlap. Pneumonia has been reported following the administration of inhaled corticosteroids *. Interactions: CYP3A4 inhibitors( eg. ketoconazole); beta-receptor blockers; beta-adrenergic stimulants; sympathomimetic amines( eg. ephedrine); MAOIs; tricyclics antidepressants; quinidine; disopyramide; procainamide; phenothiazines; antihistamines associated with QT interval prolongation e. g. terfenadine, astemizole; if hypokalaemia: xanthine derivatives, mineralocorticoids, diuretics, digoxin. Adverse effects: Common: tremor, palpitations, oropharyngeal candidiasis, headache, throat irritations, coughing, hoarseness; others, see full PI. Date of first inclusion in the ARTG: 27 May 2002( Symbicort Turbuhaler 100 / 6 and 200 / 6); 5 May 2004( Symbicort Turbuhaler 400 / 12). Date of most recent amendment: 28 March 2017.

Symbicort ® Rapihaler ®( budesonide and eformoterol fumarate dihydrate) for oral inhalation. Indications: Asthma: Treatment of asthma where use of a combination( inhaled corticosteroid and long acting β 2

-agonist) is appropriate in adults and adolescents. COPD: Symptomatic treatment of moderate to severe chronic obstructive pulmonary disease( COPD),( FEV 1

≤50 % predicted normal) in adults with frequent symptoms despite long acting bronchodilator use, and / or a history of recurrent exacerbations. Symbicort is not indicated for the initiation of bronchodilator therapy in COPD. Dosage: Asthma: There are two alternative treatment regimens for asthma: Symbicort Maintenance and Reliever Therapy( SMART TM) or Symbicort Maintenance Therapy. Refer to Product Information for full details on dosage. Symbicort Maintenance and Reliever Therapy( SMART TM) for Asthma: Symbicort 50 / 3 and 100 / 3: Adults and adolescents > 12 years: 4 inhalations per day given as either 2 inhalations twice daily or 4 inhalations in either the morning or evening. For some patients, a maintenance dose of Symbicort 100 / 3 4 inhalations twice daily may be appropriate. Patients may take 2 additional inhalations as needed in response to symptoms, up to 12 inhalations at one time. If patients experience a three-day period of deteriorating symptoms after taking the appropriate dose, the patient should be reassessed. A total daily dose of up to 24 inhalations can be used temporarily. Symbicort 200 / 6: The 200 / 6 strength should not be used for Symbicort Maintenance and Reliever Therapy. Symbicort Maintenance Therapy for Asthma: Symbicort 50 / 3 and 100 / 3: Adults and adolescents ≥12 years: 2 or 4 inhalations twice daily. Symbicort 200 / 6: Adults ≥12 years: 2 inhalations twice daily. Dosage: COPD: Symbicort 200 / 6: 2 inhalations twice daily. Contraindications: Hypersensitivity to any of the ingredients. Precautions: Symbicort therapy should not be initiated to treat a severe exacerbation. Not for initiation of inhaled steroids in patients transferring from oral steroids; impaired adrenal function; infections of the respiratory system; increased susceptibility to sympathomimetic amines; severe cardiovascular conditions; hypokalaemia; diabetes; impaired renal and hepatic function; pregnancy( category B3); lactation; children < 12 years. Pneumonia: Physicians should remain vigilant for the possible development of pneumonia in patients with COPD as the clinical features of pneumonia and exacerbations frequently overlap. Pneumonia has been reported following the administration of inhaled corticosteroids *. Interactions: CYP3A4 inhibitors( eg. ketoconazole); beta-receptor blockers; beta-adrenergic stimulants; sympathomimetic amines( eg. ephedrine); MAOIs; tricyclics antidepressants; quinidine; disopyramide; procainamide; phenothiazines; antihistamines associated with QT interval prolongation e. g. terfenadine, astemizole; if hypokalaemia: xanthine derivatives, mineralocorticoids, diuretics, digoxin. Adverse effects: Common: tremor, palpitations, oropharyngeal candidiasis, headache, throat irritations, coughing, hoarseness; others, see full PI. First inclusion in the ARTG: 22 February 2006( Symbicort Rapihaler 200 / 6), 20 April 2011( Symbicort Rapihaler 50 / 3), 26 July 2012( Symbicort Rapihaler 100 / 3). Date of most recent amendment: 28 March 2017.

* Please note changes to Product Information

References: 1. Symbicort Turbuhaler Approved Product Information. 2. Symbicort Rapihaler Approved Product Information. 3. Watson J Cur Med Res Opin 1990; 11:10, 654 – 660. Australian approved product name for eformoterol is eformoterol fumarate dihydrate. Symbicort, ® Rapihaler ® and Turbuhaler ® are registered trademarks and SMART™ is a trademark of the AstraZeneca group of companies. Registered user AstraZeneca Pty Ltd. ABN 54 009 682 311. 66 Talavera Road, Macquarie Park, NSW 2113. AstraZeneca Medical Information or to report an adverse event: 1800 805 342. www. astrazeneca. com. au. AU-3078 _ 1. Date of preparation: July 2017

News Review

‘ I slipped on my own blood and fell to the floor’

In 2014, neurosurgeon DR MICHAEL WONG was stabbed 14 times by one of his former patients. Here he describes what happened and the urgent need to protect healthcare workers from violence and abuse.

THE attacker struck in the foyer of Melbourne’ s Western Hospital on an otherwise ordinary Tuesday morning.

I’ d just arrived, and had my mobile phone out to ring my registrar to ask whether I had time to nick up to the wards and see my patients, or whether I needed to go straight to the outpatient clinic.

At first, I thought I’ d been pushed in the back. Then I slipped on my own blood and fell to the floor. I was being stabbed, over and over again. I remember turning my head so a blow coming at my eye instead landed on my skull. Being a neurosurgeon, I could all too easily picture the blade piercing my brain through the eye socket.

I remember people yelling, and the tug on my clothing as I was dragged along the floor through a set of double doors to safety and along the corridors to emergency, leaving a trail of blood.

The full story of my rescue and the incredible bravery and people behind it— including nurses, an intern, a hospital technician and a leukaemia patient— only emerged much later.

I remember looking at my arms and hands; there were deep cuts. I remember being aware that I was breathless, and trying to slow my breathing— not knowing I had a punctured lung. I remember the look of absolute horror on my registrar’ s face, as I was wheeled past him on a hospital trolley on my way to surgery. I remember asking someone to call my wife.

I remember the pain of being prepped for surgery, the sting of antiseptics on open wounds, and asking the anaesthetist why they couldn’ t put me to sleep first.( They didn’ t tell me it was for fear that I would go into arrest and they wanted to wait until the full medical team was assembled.) Hazily, I remember waking with a tube in my throat and seeing my wife. Then things faded out until I woke to the moment of truth.

It was 2am and I was alone in a hospital bed. I knew where I was and what had happened. The big question, my big fear, was that I might have had a stroke as a result of the attack. I moved one side of my body, and then other. Both sides worked. It was then that I felt I would be okay in the end.

All up, I was stabbed 14 times. But I was lucky. I was fortunate that instead of being bystanders, brave people intervened to get me away from my attacker. The surgical team did an incredible job of stitching me back together, with a cardiothoracic surgeon removing part of my lung to stem bleeding and three plastic surgeons mending severed tendons and muscles in my arms and hands.

I was also lucky to have a supportive family who helped me through the process of recovery.

My arms and hands were in splints for six weeks. I couldn’ t eat without help, or get dressed. I couldn’ t wipe my own backside— at times, I had my eightyear-old son helping me in the bathroom. If that’ s not humbling, I don’ t know what is.

Ironically, there was part of me that was pleased to have some time off from the constant pressure to work more and more hours in the resource-constrained public hospital system. At the time of my recovery, [ Malaysian Airlines flight ] MH370 went missing, and I watched hours and hours of coverage on TV.

When the splints came off, I was fortunate to have a hand therapist who worked with me over the next 12 months to enable me to regain strength and movement.

I was also lucky to be able recover fully and return to work. And I’ ve been lucky that I don’ t seem to have been left psychologically scarred— other than disliking crowded areas in hospitals, and people walking behind me.

People ask how did I escape psychological damage. I think it’ s partly because in my career I’ ve seen a lot of bad things— four-year-olds with malignant brain tumours, young people smashed to pieces. I know bad things happen to good people so I didn’ t waste time asking why, instead focusing on what I needed to do to recover.

If anything, my experience has made me a better doctor— not from a technical perspective, but in terms of a deeper understanding of how it feels to be a patient, including the inconvenience and loss of control, the fear and pain. I came to understand that the essence of good care was time. For the most part, I’ ve compartmentalised the attack and put it away, and that seems to work for me.

Protecting staff I don’ t enjoy revisiting the attack, but as someone fortunate enough to have survived I speak out on my experiences to campaign for better hospital security— most recently in the wake of a fatal one punch assault on Melbourne cardiothoracic surgeon Dr Patrick Pritzwald-Stegmann. My attacker was mentally unwell. People ask me if‘ the way forward’ is better mental health care. While that would be welcome, the solutions I’ m calling for are simpler.

First, busy public areas of hospitals should have trained security guards in them. You can’ t have security guards everywhere, but I think it’ s realistic to expect they can be stationed in hospital foyers and outpatient clinics, as well as EDs. Second, fewer areas of a hospital should be public access. All wards should be accessible only via swipe card access, in the same way surgical theatres are protected today. Third, hospitals should have secure entries for staff.

Hospital staff also need to play their part by taking the time to report violent incidents— ideally, on easy-to-use streamlined forms.

Management need to take the issue seriously— there’ s a good business case for investments that reduce occupational violence. Dealing with violent patients or bystanders wastes staff time. If staff are injured, they may need to take time off work for treatment. Indirectly, occupational violence contributes to stress that can lead to burnout, psychological damage and employee turnover. There are also issues of legal liability.

A Fairfax analysis of Victorian hospital annual reports in 2015 / 2016, found there were 8627 violent incidents reported— almost one an hour— with 1166 resulting in injuries. 1 While it is commendable that annual reports in Victoria must include this data, and other states should follow suit, the true figures are probably far higher due to underreporting.

In the past year, in my own practice, I’ ve operated on two hospital employees suffering severe back pain as a result of occupational violence at the hands of patients. It’ s not just physical pain they suffered, but emotional trauma. I had a grown man weeping in my rooms.

In the wake of the attack on Dr Patrick Pritzwald-Stegmann, but before his death, the Victorian Government hit the headlines with a new advertising campaign and a doubling of funding( to $ 40 million) to the Health Service Violence Prevention Fund. Hospital administrators will be able to apply for funding for projects they believe will have the most impact.

While any funding is good funding, and gift horses shouldn’ t be looked in the mouth, this system relies on hospital administrators to be proactive and accurately judge the merit of competing proposals. Unfortunately, there are no guarantees the money will be spent to achieve the greatest possible impact across all public hospitals.

I did not know him personally, but clearly Patrick was doing valuable, lifesaving work for the Australian community when he was cut down in his prime. And of course, he wasn’ t just a surgeon, but a husband and father too. It’ s a senseless loss that no family should have to endure, and one that tragically further underlines the importance of getting hospital security right. ● References on request.

This article first appeared on the Conversation website. See: bit. ly / 2w5vgn1

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