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Skin Cancer

CPD

September 30, 2018

CPD credits

Accreditation Number : CAP1809D

Group 1 : 0.75 CPD credits

Group 2 : 1.5 CPD credits

This activity has been accredited for 0.75 hours of Group 1 CPD (or 0.75 CPD credits) suitable for inclusion in an individual pharmacist's CPD plan, which can be converted to 0.75 hours of Group 1 CPD (or 1.50 CPD credits) upon successful completion of relevant assessment activities.

Case scenario

David, a 71-year-old retired construction worker, had many non-melanoma skin cancers removed. These are healing well, however he would like to look after his skin from now on to prevent any further skin cancers. He has been doing some reading on the internet regarding the use of vitamin B which can prevent skin cancers. He has walked into the pharmacy today and would like to know more. He asks the pharmacist for some advice.

Learning objectives

After successful completion of this CPD activity, pharmacists should be able to:

Describe different types of skin cancer
Discuss the potential role and evidence for nicotinamide for non-melanoma skin cancer and its place in therapy
Identify counselling points that pharmacists should discuss with patients enquiring about nicotinamide for skin cancer.

Competencies (2016) addressed: 1.1.1, 1.1.3, 1.2.1, 1.3.2, 2.1.2, 2.3.1, 3.1.2, 3.2.2, 3.2.5, 3.3.1, 3.6.1.

Competencies (2010) addressed: 1.1.1, 1.1.2, 1.2.1, 1.3.1, 2.1.3, 6.1.2, 6.2.1, 6.2.2, 6.3.3, 7.1.2, 7.1.4.

Accreditation code: CA1809D

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Different types of skin cancer

There are thre

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SUBJECTIVE	Only the affected person can hear the sound (e.g. normal blood flow, sign of a tumour or blood vessel damage)
OBJECTIVE	Sound can also be heard by an examiner, not only by the individual with the symptom Sound generated inside the body by blood flow, muscle contractions, spontaneous cochlear emissions Uncommon
PULSATILE	Characterised by noise that is rhythmic and resembles the heartbeat Can be either subjective or objective More noticeable at night with fewer external sounds to mask the tinnitus
PRIMARY	No identified cause other than hearing loss if present
SECONDARY	Known specific cause
ACUTE OR RECENT ONSET	Apparent for <6 months
CHRONIC	Apparent for >6 months Rare Interferes with activities of daily living and requires the help of a healthcare professional

EXTERNAL EAR	Cerumen impaction Otitis externa
MIDDLE EAR	Otitis media Cholesteatoma
INNER EAR	Acoustic neuroma (vestibular schwannoma) – a rare non-cancerous growth that affects the cochlear (hearing) or vestibular (balance) nerve in the inner ear Meniere’s disease – causes hearing loss and vertigo (a spinning sensation) Cochleitis/neuritis Ototoxic medicines
OTHER CAUSES	Exposure to extremely loud noise (short and long-term) Vascular anomalies (can present as pulsatile tinnitus) Myoclonus, such as stapedial myoclonus Nasopharyngeal carcinoma (can cause unilateral otitis media with effusion, leading to hearing loss and tinnitus) Head injury Anaemia – a reduced number of red blood cells that can sometimes cause the blood to thin and circulate so rapidly that it produces a sound High blood pressure (hypertension) and narrowing of the arteries (atherosclerosis) Thyroid disorders Diabetes Paget’s disease – where the normal cycle of bone renewal and repair is disrupted

QUESTIONS	EXPLANATION/ACTION
Do you find the tinnitus bothersome or non-bothersome?	Some people find tinnitus very difficult to live with, whereas others are not bothered by it A person’s response to this question will direct management
When did the tinnitus begin?	Duration will determine whether tinnitus is acute or chronic and will help direct management such as referral for further medical assessment Onset of tinnitus can be abrupt, but it is insidious in most cases
Is the tinnitus constant or pulsatile?	Obtain a description of the sound If the tinnitus is in time with a person’s pulse, it may be of vascular origin Refer the person for further medical assessment
Is the tinnitus unilateral or bilateral?	Tinnitus is usually defined as bilateral Unilateral tinnitus may be due to an acoustic neuroma, a benign tumour that develops on the balance (vestibular) and hearing, or auditory (cochlear) nerves Refer the person for further medical assessment
Is the tinnitus associated with otological (ear) symptoms (e.g. blocked ear sensation, ear pain, and vertigo)?	Otological symptoms may be indicative of secondary tinnitus e.g. glue ear, vertigo Tinnitus may be associated with a blocked sensation in the ears; however, decongestants and antibiotics are rarely helpful Refer the person for further medical assessment
Is your hearing affected? If so, is the hearing loss sudden?	Tinnitus is often associated with hearing loss although many people are unaware of their hearing loss as it may be mild and of gradual onset Refer the person to seek medical advice including an audiological assessment to determine the extent of the hearing loss and/or if there’s an underlying cause Refer the person immediately to GP for further medical assessment if tinnitus is associated with the sudden onset of sensorineural hearing loss which may indicate that the cause lies in the inner ear, or the cochlea and associated structures, or the cranial nerve
Do you think the tinnitus is due to prolonged exposure to noise, either occupational or social?	Prolonged exposure to loud noise can lead to hearing loss and tinnitus Offer preventive strategies such as noise-cancelling earphones or buds
Are you taking any medicines?	Some medicines can lead to hearing loss and tinnitus Pharmacists should review a person’s medicines for ototoxicity if they report symptoms of hearing loss or tinnitus Refer to GP, i.e. pharmacist cannot advise patient to cease medicine without consultation with GP
How are you feeling? Depressed? Anxious?	Anxiety and depression can be associated with tinnitus Refer the person to specialised tinnitus counselling

MODIFIABLE ISCHAEMIC HEART DISEASE RISK FACTORS	NON–MODIFIABLE ISCHAEMIC HEART DISEASE RISK FACTORS
Diabetes High blood pressure High blood cholesterol levels Poor nutrition Obesity Sedentary lifestyle Smoking Excessive alcohol intake Depression	Older age Family history of cardiovascular disease Gender – at younger ages men are at higher risk compared to women, but women’s risk increases after menopause Ethnicity – Aboriginal and Torres Strait Islander peoples, South Pacific Islander peoples, Maori and people from South Asian countries are at higher risk than other ethnicities

COMMON SYMPTOMS OF ACS	LESS COMMON SYMPTOMS OF ACS
Chest pain/discomfort Shortness of breath Nausea and vomiting Sweating Dizziness, feeling light-headed or faint Feelings similar to indigestion Acute anxiety	Burning pain Pain on breathing in Upper abdominal pain

DRUG		DOSE	ROUTE	FREQUENCY
Aspirin		300 mg	Orally. Chewed or dissolved prior to swallowing if possible	Stat
Glyceryl trinitrate (GTN)	Spray	1–2 sprays (400–800 microgram)	Sublingually	Every 5 minutes as required for ongoing chest pain/discomfort, up to three doses*
Glyceryl trinitrate (GTN)	Tablet	Half to one tablet (300–600 microgram)	Sublingually	Every 5 minutes as required for ongoing chest pain/discomfort, up to three doses*
Opioid analgesic	Fentanyl	25–50 microgram	Intravenously	Every 5–10 minutes as required for ongoing chest pain/discomfort
Opioid analgesic	Morphine	2.5–5 mg	Intravenously	Every 5–10 minutes as required for ongoing chest pain/discomfort

RISK CLASSIFICATION	CLINICAL CHARACTERISTIC
Very High	Haemodynamic instability, heart failure, cardiogenic shock or mechanical complications of MI Life-threatening arrhythmias or cardiac arrest Recurrent or ongoing ischaemia (i.e. chest pain refractory to medical treatment), or recurrent dynamic ST-segment and/or T-wave changes, particularly with intermittent ST-segment elevation, de Winter T-wave changes, or Wellens’ syndrome, or widespread ST-segment elevation in two coronary territories
High	Rise and/or fall in troponin level consistent with MI Dynamic ST-segment and/or T-wave changes with or without symptoms GRACE Score >140
Intermediate	Diabetes mellitus Renal insufficiency (glomerular filtration rate <60mL/min/1.73m2) Left ventricular ejection fraction <40% Prior revascularisation: percutaneous coronary intervention or coronary artery bypass grafting GRACE score >109 and <140

DRUG	REGIMEN
Tenecteplase	30–50 mg (6,000–10,000 units) intravenous bolus^a,b
Reteplase	10 units intravenous bolus, repeat once after 30 min
Alteplase	15g intravenous bolus, followed by intravenous infusion: 50 mg over 30 min (or 0.75 mg/kg if 65 kg or less) then 35 mg over 60 min (or 0.5mg/kg if 65 kg or less)

DRUG	FIRST DOSE	REGULAR DOSE
Aspirin	300 mg orally (unless already administered as part of the management of chest pain of possible cardiac cause)	100–150 mg orally daily
PLUS (where indicated)
Ticagrelor^a	180 mg orally	90 mg orally twice daily
OR
Prasugrel^b	60 mg orally	10 mg orally daily
OR
Clopidogrel^c	STEMI: 600 mg orally STEMI and afibrinolysis: 300 mg orally NSTEACS: 300–600 mg orally	75 mg orally daily

Australian pharmacists at FIP

Educating future pharmacists

Improving burns care

Free interpretation service

Providing medicines education

Focus on patient education

Stakeholder response

Challenges for pharmacists

What can pharmacists do?

Reducing over-reliance on SABAs

Other treatment changes

Information for pharmacists

Lessons for pharmacists

Case scenario

Learning objectives

Introduction

Types of tinnitus

TABLE 1 – Types of tinnitus

Causes

TABLE 2 – Common secondary causes of tinnitus

Figure 1. The membranous labyrinth of the vestibular system

Diagnosis and management

Hearing aids

Counselling

Sound therapy

Massage therapy

Sleep

Lifestyle

Medicines and supplements

Preventive strategies

Role of the pharmacist

TABLE 3 – Assessment questions for tinnitus symptoms

Case scenario continued

Conclusion

Key points

Further resources

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Pathophysiology

FIGURE 1 – Classification of acute coronary syndrome (ACS)

Risk factors and primary prevention

TABLE 1 – Examples of risk factors for cardiovascular disease

Presentation and acute management

TABLE 2 – Symptoms of ACS

Initial management of chest pain of possible cardiac cause

TABLE 3 – Initial pharmacotherapy for chest pain of possible cardiac causeas recommended in Australian Guidelines

TABLE 4 – Markers of increased risk of mortality and recurrent events among patients with confirmed ACS

TABLE 5 – Fibrinolytic regimens for treatment of STEMI according to Australian guidelines

TABLE 6 – Antiplatelet dosing in acute phase of ACS from Australian guidelines

TABLE 7 – Standard anticoagulation for acute phase ACS

Long term management and secondary prevention

Pharmacotherapy

TABLE 8 – Key medicines for secondary prevention post-ACS

Role of the pharmacist

Conclusion

Key points

Case scenario

Learning objectives

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Introduction

What are fungal infections?

What are the causes of fungal infections?

What are the clinical features of tinea at different sites?

FIGURE 1 – Tinea corporis

FIGURE 2 – Tinea capitis

FIGURE 3 – Tinea cruris

FIGURE 4 – Tinea manuum

FIGURE 5 – Tinea pedis

FIGURE 6 – Tinea unguium

What is currently recommended for the treatment of fungal infections?

TABLE 1 – Application instructions of terbinafine products for adults and children aged 12 years and older with various tinea infections

What are other treatment options?

What are the common adverse effects/precautions to consider for these medicines?

When should fungal infections be referred to the doctor?

How can fungal infections be prevented?

Where can I find further information?

Case scenario continued

Conclusion

Key points

Case scenario

Learning objectives