Though a change from oral morphine dosage forms to transdermal fentanyl patches achieved good pain relief in 70% of cancer patients, the remaining 30 % still showed poor pain control or fentanyl vitiation. In some cases when pain control was poor, effective pain-relief was only sustained for 3 days. This suggests that the absorption of fentanyl was being hampered in such cases. In view of these findings, we investigated the relationship between the amount of fentanyl released and plasma fentanyl concentrations. To estimate amounts of fentanyl delivered into the skin, we measured the amount of fentanyl remaining in fentanyl patches after 3 days of continuous use. Amounts of fentanyl remaining in the patches ranged from 41-58%, which was close to the design residual amount of 40%. However, the amount of fentanyl release varied between patches applied to patients at home and those applied to hospitalized patients, and the fentanyl was more steadily released from patches applied to the sides of the body or back than those applied to the chest. The fentanyl release also varied with the caregivers who were applying them. Thus, it is essential to apply patches according to the instructions to ensure steady release. In this study, we observed that plasma fentanyl concentrations rapidly decreased for some patients 3 days after patch application so in such cases, patches should be changed every 2 days.
The ability and attitude of pharmacy students in clinical communication should be assessed before their clerkship in the clinical setting. Designed for this purpose, the objective structured clinical examination (OSCE) was tried out for the first time on graduate students taking the Master's course in clinical pharmacy with the cooperation of medical faculty staff. The students took the OSCE after completing a course in communication skills. Four typical scenarios of communication between patient and pharmacist were provided to assess examinee's performance as follows : (1) patient interview, (2) explanation of how to wash hands for disinfection, (3) explanation of peak flow meter to patients with asthma, and (4) explanation of how to apply an eye drop solution. In these situations, eight examinees took the role of the pharmacist in communicating with standardized patients (SP) whose parts were played by medical faculty staff and junior students. The examiners and observers had well understood the purpose of OSCE in communication education. Many were of the opinion that students were able to understand the importance of communication with patients by performing in front of the examiners. These opinions suggest that the OSCE would make students more motivated to learn communication skills and that it would be useful in pharmacy education. OSCE which was tried by us was assessed by the questionnaires to all participants ; observers, examiners, and examinees.
When trace elements (EM) and multi vitamins (MV) are mixed into total parenteral nutrition solutions, the in-line filters sometimes become colored and blocked. We conducted an investigation to determine the causative substances and the mechanisms by which the coloring and blocking of the in-line filters occur. We first determined the coloring substance. MV and EM were mixed into the parenteral nutrition solution, which was irradiated with ultraviolet light under different conditions. The resulting solutions were filtered and then an amino acid solution, KCL with vitamin B2 (VB2) and EM were then mixed into them, and these solutions then filtered again with and without shading. The filters used this time were then analyzed for substances they contained by X-ray analytic microscopy. Secondly, we determined the mechanism of deposition of the substances using the sulfur-containing amino acid L-cysteine (Cys) and the radical-capturing agent hydroquinone was also used to confirm whether radicals were involved. Cys was decomposed by the photo-hypersensitization of VB2 generating sulfur radicals that reacted with copper to produce copper sulfide (CuS), which was precipitated. These observations indicate that the substance causing the coloring and blocking of the filters was CuS.
A general method of administering powdered medicines to infants is to add a spoonful of water to the powder to make a paste and then making the paste into small dumpling-sized balls. We investigated the optimal amount of water for making a paste for 35 kinds of powdered medicine which included fine granules, granules and dry syrups. The optimal water amount was expressed as an amount per gram of powder. Approximately 80% of the powders examined in this study required 0.2-0.4 mL of water per gram of powder to make a paste that would form small balls. Optimal water amounts were calculated for amounts of powder ranging between 0.1 and 1.5 grams by proportion and when the calculated amounts of water were added, small dumpling sized balls could be formed. In the same way, we also calculated amounts of water required for powdered mixtures of several medicines for 6 prescriptions often prescribed in our pharmacy from corrected standard volumes for each medicine in the mixture. The amounts of water added on this basis achieved the required paste state for all of the powder mixtures used. These results suggest that the optimal water amount for powdered medicines of various weights can be estimated from standard volumes of water by proportion. Thus, optimal water amounts determined by our method may be useful for the administration of mixed powdered medicines to infants.
We examined differences in adverse drug reactions reported in trials for new drug applications and those reported in early post-marketing phase vigilance (EPPV) for drugs approved between October, 2001 and July, 2003. In EPPV reports, we found that the proportion of adverse drug reactions noted from blood tests (e.g. drug-induced hepatitis, hematology adverse reactions, electrolyte metabolism disorders, and renal dysfunction) was less than that of other adverse drug reactions. We consider that this was because blood tests were not conducted regularly enough and the reason that such reactions are severe when discovered. Since EPPV is considered as phase IV of drug testing, regular blood tests are still required and we feel that it is necessary to carry out pharmacovigilance more thoroughly to ensure the safety of drugs after they have been marketed.
The aims of this study were to clarify the present situation of the handling (e.g. storage, administration and preparation) of injections by nurses in hospital wards and to find out what kind of drug information on injections should be provided to hospital nurses. The questionnaire survey targeted hospital nurses in Toyama Medical and Pharmaceutical University-affiliated hospitals. It consisted of multiple-choice questions on ways of shielding injections against light, the use of injection filters, selection of non-adsorptive cannulae, preparation of anti-cancer injections and necessity of drug information on injections. Nurses who filled out the questionnaire remained anonymous and their responses were analyzed for all the nurses together and by length of service as a nurse. Of the ninety-three percent of the nurses who responded to the questionnaire (264/285), 99 % paid careful attention to shielding against light during storage but more than 50% of them were not able to make a clear distinction between photo-degradability during administration as a drip and storage. Ninety-one percent of the respondents knew which injections should be filtered and which should not. Concerning injections using non-adsorptive cannulae, the proper tubing was selected by 95 % of nurses with more than 2 years of service and by 65 % of those with less than 2 years of service. Nine percent of the respondents were not concerned about the effect of exposure to anti-cancer drugs during preparation on their future health. In conclusion, our survey revealed that hospitals need to provide more information on the handling of injections to nurses as well as more drug information pertaining to injections.
The fluoropyrimidine anticancer drugs and antifungal agent, flucytosine, are designed to become active after they are metabolized into 5-fluorouracil in the body. The gimeracil in TS-1®, which consists of tegafur, gimeracil and oteracil, is included to block the catabolization of 5-fluorouracil, but an increase in the concentration of 5-fluorouracil in the body when TS-1 is used in combination with other fluoropyrimidine drugs causes serious blood and bone marrow and gastrointestinal disorders, which can be fatal. Therefore, it is important for pharmacists to check for concomitant drug use from 7 days before starting the administration of TS-1 as well as the entire medication regimen. In our hospital, this used to be done using paper records kept for each patient but with an increase in the quantity of such records, it had become very time-consuming to retrieve the data we needed. There was also the problem of the amount of space needed to store all of these records. As a solution to these problems, we developed a new computer system to keep the records electronically instead of on paper. The new system has enabled us to find patient data easily. It also allows us to rapidly carry out patient registration, check the body surface area, check for any medicines used in 7 days before starting administration of TS-1 and manage medication regimens at the same time as filling prescriptions. It also shortens the time required to input patient data for both existing patients and new patients.
Insulin glargine [rDNA origin] injection (Lantus®) was developed to provide a stable basal insulin replacement having a sustained effect over 24 hours. However, an urgent safety alert concerning overdosing with the injector used with Lantus® (OptiPen® Pro 1) has been issued, and the injector is difficult to use, which often causes problems. To investigate the problems in instructing patients on the use of this new type of insulin and its acceptance by them, we studied 62 diabetic patients (M/F= 23/39, 45 ± 14 yrs) who changed from NPH insulin to insulin glargine under intensified insulin therapy. We gave them a questionnaire to fill out and reviewed their charts. Some patients said that while the scale of the injector was large enough to see clearly, it did not return to 0 after injection. Others complained about its portability, and difficulties in replacing cartridges. However, patients also made favorable comments saying that the insulin glargine had reduced the number of injections necessary and frequency of hypoglycemic attacks, which improved their quality of life.
Admixtures of two primary corticosteroid ointments, Almeta® and Myser® ointments, were made with urea ointment and white petrolatum. The release rate of corticosteroids from the admixed ointments with urea ointment and white petrolatum to a buffer solution were significantly lower than those expected from a dilution ratio 0.5 for both Almeta® and Myser® ointments. Also, for the admixtures with urea ointment, the amount of corticosteroids penetrating into the model skin was larger than that expected from the dilution ratio, especially for Myser® ointment, while the amounts of corticosteroids penetrating into the skin from the admixtures with white petrolatum were smaller than those expected from the dilution ratio, for both primary ointments. An electron probe micro analyzer was used to observe the actual distribution profile of corticosteroid molecules in a cross section of the skin. In the case of the Myser®-urea ointment admixture, the distribution profile of difulprednate was quite homogeneous, probably due to the softening effect of urea on the skin and the affinity of difulprednate with skin tissue, though the urea ointment did not have much effect on the distribution profile of alclometasone released from the Almeta® ointment. On the other hand, difulprednate was concentrated at the surface for the admixture with white petrolatum.
The Tokyo Hospital Pharmacists Association Study Group prepared a care work sheet (WS) for liver cirrhosis patients. According to the KJ method, the making of key words and their classification, and the management of pharmacotherapy were investigated. The results of doing this were inserted into the “Front Page”, and an adverse drug reaction checklist was also made. Items related to understanding liver cirrhosis were inserted into the “Back Page”. The content of the WS was reexamined through its adoption in medical facilities and it was objectively evaluated in a workshop. Based on the results of doing all this, the final WS for liver cirrhosis patients was prepared. The results of the current study suggested that a minimum standard could be established using the WS for medication management and instruction on pharmaceutical care for liver cirrhosis patients, and that through its use, a uniform quality of care could be provided to each patient. They also suggested that there would be further improvements in the efficiency of medication management and pharmaceutical care instruction in the future. Also through understanding the process by which the WS was prepared, other hospitals could adapt it to their individual needs.
Clinical pharmacists now participate in drug therapy as members of the patient care team and play a role in the safety management of drugs. Our role is thus expanding into the realm of clinical practice and we have more chances to communicate with other medical staff. They often ask us for information on drugs and providing them with such information can have an effect on drug therapy. With this situation in mind, we investigated the nature of questions asked by medical staff and determined the differences between the information requested by doctors and that asked for by nurses, targeting questions and answers give at Kanazawa University Hospital from April through October in 2003. There were 206 questions in total consisting of 91 questions from doctors and 111 questions from nurses. We found that 27.7% of the responses we gave resulted in therapy changes such as prescription adjustment. The rate for therapy changes was higher for doctors than for nurses (41.8% versus 17.1%). In conclusion, the involvement of pharmacists helps to ensure proper drug use and leads to qualitative improvements in medical care but it is necessary to accumulate data as evidence of the useful role that pharmacists can play in this respect.