There are several types of community pharmacies in the United States. The most common are independents, chains, and supermarket pharmacies. There are pharmacies that specialize in home healthcare supplies/devices, compounding, and infusions. Currently, there is a great shortage of pharmacists in the United States, and as a result salaries are high (2002 median salary was ¥ 9.5 million). Pharmacy rules and regulations are quite different in the United States. One “prescription” is usually one medication order. Additionally, there are no limits on the number of prescriptions one pharmacist may fill per day. Many pharmacists are starting to provide direct patient-care services. These clinical services may include cholesterol screenings, manual blood pressure measurements, hemoglobin A1C testing, blood glucose testing, osteoporosis screenings, vaccinations, and many others.
Community pharmacy practice is changing quickly in the U.S. With the current shortage of pharmacists, and large prescription volume, pharmacies will be challenged to provide for the medication needs of their patients. While direct patientcare services are increasing in community pharmacies, many challenges will need to be overcome before their provision becomes widespread.

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Our pharmacy accepted the challenge of improving management at Ehime University Hospital from the perspective of rationalizing drug use. The following 3 points were considered important and examined : increasing the rate of prescriptions dispensed at pharmacies outside the hospital, switching to generic drugs, reducing unnecessary drug use by providing information on the proper use of drugs. Information was processed on the pharmacy client terminal computer system using Microsoft ACCESS 2000, which was connected through an open database connectivity (ODBC) interface with an Oracle database. This allowed information to be retrieved from the hospital application system network.
As a result of our efforts, the Management Improvement Committee made a request to departments and doctors with low rates for prescriptions dispensed outside the hospital to cooperate in increasing them. The rate has now risen to over 90%. Nine injection drugs were switched to generics, which has reduced costs. Our investigation of the use of blood preparations (Antithrombin III drugs) revealed that it was more economical to use one particular drug in this category. Pharmaceutical kits containing antibiotics were switched to separate vials except in cases where there was concern associated with such a switch. High use of albumin preparations and G-CSF pharmaceuticals was reduced through the use of information sheets informing clinical departments and doctors about their proper use. Our contributions to management improvement enabled drug use to be reduced to about 70% of the previous level, even better than the target of about 85% versus the previous year. Our project seemed to have raised awareness of the importance of using drugs properly and drug cost control among the doctors in each clinical department.

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A list of easily mistakable injections with photographs was distributed to all wards and outpatient consulting rooms at Yamagata University Hospital to reduce the mistaken use of injections. Many of them were injections with similar names or those that look-alike. A questionnaire regarding the list was then given to all the nurses in our hospital to enable us to evaluate it and learn about other easily mistakable injections not included in the list.
More than 92% of the nurses answered that they knew of the list, and 88.1% of them refbrred to it. Unfortunately, only 12.8% answered that they knew all the injections on the list and 75.7% said that there were some that they did not know. The nurses were impressed with the list because it included photographs of the injections, and said it was useful for preventing mistakes in selecting injections as well as for educating other nurses and trainee nurses. Some injections that nurses had mistakenly used in the past were not on the list Thus the list was useful in preventing mistakes in selecting injections. However, it should be occasionally revised to include other easily mistaken injections mentioned by nurses and new injections that have recently been added; and those that are no longer available should be deleted.

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Benzylpenicillin Potassium (PCG) is effective for infectious endocarditis (IE) but it is necessary to exercise caution when prescribing it for patients. This is because one bottle of PCG contains 1.7 mEq of potassium. We investigated the use of PCG in eight patients to whom it was prescribed for IE from April 2000- October 2003 and examined the occurrence of angialgia. One patient could not be continuously administered with PCG, and the other seven patients received 12 to 20 million units for an average of 33.6 days. Following the administration of PCG, inflammation reactions subsided and no electrocardiogram abnormalities due to aggravation of kidney dysfunction or rise in serum potassium levels, or other adverse reactions were observed. Angialgia was observed in three patients, and was not relieved in two of them when the rate of medication was reduced.
Though the pH of a PCG solution does not change with its concentration, the osmotic pressure rises as the concentration increases. An increase in osmotic pressure was considered to be a cause of the angialgia. It is therefore important for the pharmacist to use concentrations of PCG that do not cause angialgia in medication plans for patients with IE, so that their quality of life may be improved.

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To improve the communication skills of our students, training involving the participation of simulated patients (SPs) was introduced into the curriculum of the Master' s Clinical Pharmacy Course in the graduate school of Kyoto Pharmaceutical University. In 2002, we carried out this training for the first-year graduate students.
The training was initiated under the direction of a facilitator, who set up role-plays between patients and pharmacists in specific scenarios. Next, all the students played the role of either patient or pharmacist with each other and then four students role-played with two SPs for 10 minutes in turn. After the role playing had finished, SPs gave their feedback concerning their impressions of the pharmacists and how they had felt in the role-plays.
We also had students fill out questionnaires anonymously before and immediately after the training to obtain their views on communication skill training using SPs. The responses were used to evaluate the effectiveness of the training and clarify the problems.
Among the 22 participating students, 19 had some idea about SPs beforehand, suggesting that there was interest in improving communication in the clinical situation. Afterwards, all of the students felt that it was important to have such training and that it had been useful to them. Some students said that they had become aware of the difficulty in communication between patients and pharmacists and the gap between them. Thus, we were able to confirm that training using SPs was very useful for developing the communication skills of pharmacists in the clinical setting.

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We investigated the characteristics of hypolipidemic drug use at hospitals in Okinawa. We constructed a drug information database for prescriptions issued by 5 hospitals with over 300 beds in Okinawa (Okinawa Hokubu Hospital, Okinawa Chubu Hospital, Urasoe General Hospital, University of the Ryukyus Hospital and Okinawa Kyodo Hospital). A total of 16, 250 prescriptions was issued by the 5 hospitals from June 1 to 7, 1999 and among them 999 (6.1%) were for hypolipidemic drugs.
Hypolipidemic drugs comprised the highest proportion of prescriptions in the 65-74 years age group and in the 45-84 years age group they accounted for 92.9% of the total. By chemical structure, HMG-CoA reductase inhibitors were prescribed the most among hypolipidemic drugs and nicotinic acid derivatives came second, followed by fibrates and probucol. In terms of individual drugs, pravastatin sodium was most prescribed and then came simvastatin, tocopherol, nicotinate, bezafibrate and probucol in that order. These five drugs accounted for more than 95% of all prescriptions. As for prescriptions for combinations of hypolipidemic drugs, the combination of HMG-CoA reductase inhibitors and fibrates accounted for about 25%. Since such combinations are contraindicated in principle, particular attention should be paid to adverse effects. Looking at combinations of hypolipidemic drugs and other drugs, the most frequently prescribed other drug type was vasodilators, followed by antipyretic analgesics, antihypertensive agents, peptic ulcer drugs, and antidiabetic drugs.

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The aim of the present study was to ascertain the factors of post-operative infection in gastrectomy patients employing clinical pathways. We examined 157 patients who underwent surgery for gastric cancer at the First Department of Surgery of our hospital. Significant correlations were observed between age, sex, operative time, blood loss during operation and post-operative infection. However, preoperative complications, antibiotics administered for prevention of post-operative infection and stage of gastric cancer had no bearing on post-operative infection. These findings indicate that age, sex, operative time and blood loss during operation are major factors influencing the likelihood post-operative infection in gastrectomy patients. We also found that post-operative infection resulted in extended hospitalization following gastrectomy.

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Acyclovir is a drug that is mainly eliminated via the renal route so its pharmacokinetics are affected by renal function. In cases of renal failure, the dosage must thus be adjusted to avoid neurotoxicity. We report on two cases of neurotoxicity caused by valacyclovir, a prodrug of acyclovir, in patients with end-stage renal disease who were undergoing maintenance hemodialysis (HD). In both cases, neurotoxicity occurred even though the dose of valacyclovir had been reduced and the elimination half-lives were the same as those reported in other HD patients (about 20hours). Therefore, individual variation in elimination did not appear to be the cause of the neurotoxicity, but there was still the possibility that it was due to the dosage being too high. So for the hext patient, the dose of valacyclovir given after each HD treatment was further reduced to 500mg. This dosage was well tolerated and still effective against herpes zoster. It is therefore necessary to re-examine the administration of valacyclovir for patients undergoing HD from the standpoint of safety and our recommended dosage for the prevention of herpes zoster infection following HD is 500mg.

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The aim of our study was to survey consumers' awareness of the serious side effects that may occur with nonprescription drugs. The results showed most of consumers had little knowledge of such serious side effects of non-prescription drugs. As a particular finding, 94% of respondents had never heard of the Stevens-Johnson syndrome. In this regard, the survey found that most people had no desire to buy non-prescription drugs having the potential to cause the Stevens-Johnson syndrome from convenience stores suggesting that safety was a more important consideration than convenience in the purchase of non-prescription drugs.

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