Antimicrobial resistance in hospitals is increasingly becoming a major problem worldwide, thus appropriate use of antimicrobial agents should be promoted. Since August 2009, our hospital has established a review system for checking prescriptions in all patients receiving antimicrobial injections according to the intervention and feedback of antimicrobial stewardship (AMS) guideline. The antimicrobial use density (AUD), duration of administration, length of hospital stay, and antimicrobial resistance in a year were compared before and after starting the intervention into AMS. Suggestions made by members of the infection control team (ICT) to the prescribers were for the major part the choice and dose elevation of antimicrobials. Most of the proposals (91%) were accepted by the prescribers. Although AUD was not changed after AMS intervention, the proportion of prolonged antimicrobial use (over 2 weeks) was significantly reduced from 5.2% to 4.1% (p=0.007), which led to the saving of costs for antibiotics (4.48 million yen/ year). The incidence of MRSA tended to decrease after AMS intervention (p=0.074). The median length of hospital stay was ultimately shortened by 1.0 day (p=0.0005), which led to an estimated saving of medical costs by 520 million yen/year. We consider that our intervention profoundly affects this cost saving. These findings suggest that the extensive intervention into AMS is effective in reducing the frequency of inappropriate use of antimicrobials, suppressing the occurrence of antimicrobial resistance, and saving medical expenses.

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Steroids are used in the treatment of patients with non-Hodgkin's lymphoma (NHL) as a one off high dose and are a key antitumor medication. Although the duration of steroid administration is short, Steroid Withdrawal Syndrome (SWS) has been documented after treatment. The aim of this retrospective study was to evaluate the prevalence of SWS and to assess the relevance of steroid tapering in 116 patients newly diagnosed with NHL. The most significant symptoms of SWS documented were fatigue in 70 patients (60.3%) and anorexia in 32 (27.6%). Four elderly patients (3.4%) suffered with serious SWS symptoms of grade 3. Of the 70 patients suffering with SWS, 22 went on to receive tapered steroid therapy during the subsequent chemotherapy treatment. The average steroid tapering period was 4.4 days and 86.4%patients reported a significant improvement of their SWS symptoms. No serious adverse events were noted. Although age did not appear to be a risk factor of SWS it was noted that elderly patients with SWS were more adversely affected.
We conclude that steroid tapering is a safe and effective treatment method. If the patient has serious symptoms of SWS we should introduce steroid tapering aggressively and early, especially in elderly patients.

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In the future, over-the-counter (OTC) drugs for chronic diseases, such as diabetes mellitus, hypertension and hyperlipidemia, may partly replace prescription drugs, and pharmacists will be required to advise patients on the proper use of these drugs. At present, the curriculum unit “Learn over the counter” is a part of the model core curriculum of the pharmacy practice externship. However, there is a gap between the general instructional objective (GIO) of this unit and the occupational ability of current pharmacists. To fill the gap, it is necessary to create a new instructional program on campus as a part of the 6-year pharmacy education program. We have developed a new approach that includes specific behavioral objectives (SBOs) for OTC, supplements and health consultation. The effectiveness of this approach was evaluated by means of a questionnaire survey and a text-mining approach based on free description. The results indicated that pharmacy students realized the importance of self-medication. In addition, they understood the responsibility of pharmacists in relation to the prevention of disease onset, the provision of advice on appropriate OTC drugs, interaction with the patient and provision of drug information. We consider that our approach will be helpful to educate pharmacists about the need to promote effective self-medication.

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A simple suspension method was employed from December 2006 for drugs prescribed from 3 of 20 departments of Fukuoka University Hospital where tablets or capsules were often grinded. After two years, this method was employed in 11 departments. To investigate the current status and problems regarding the simple suspension method, a questionnaire survey was conducted involving all nurses working at this hospital. Responses were obtained from 681 nurses (94.1%). The results showed that the drugs that should be suspended were not sufficiently disintegrated, and drugs were not sufficiently disintegrated when multiple drugs were suspended at the same time, suggesting the need for confirming the cause of insufficient disintegration at each time of drug administration. The results also showed that the conventional crushing method was preferred among nurses due to the simple procedure. We have found that these nurses do not fully understand the advantages of this method such as drug discrimination, discontinuation of drug administration, and prevention of tube clogging, suggesting the need for continuously providing drug information for nurses.

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Our present objective was to clarify the necessary pharmaceutical care for patients in a community pharmacy located in the town of Nagi, Okayama, Japan, using a simple questionnaire survey. The subjects included 925 regular adult patients who were dispensed prescriptions at the Nagi Branch of the Muscat Pharmacy more than two times from January 1, 2007 to March 31, 2007. Out of these patients, 213 respondents were interviewed by the pharmacist. The questionnaire consisted of questions regarding the following points: 1) missed doses, 2) unused medications, 3) patients' own methods to help take medications properly, and 4) concerns about taking medications.
The respondents (74.5 (±9.6) years old, 71% female) were mostly characterized as elderly females suffering from chronic diseases such as hypertension, heart disease, hyperlipidemia and diabetes complicated with gastric disorders, arthralgia and dermatological or ophthalmic problems. The number of medications (7.8 (±4.6)/patient) was approximately 1.5-2 times higher than that of other reports, and increased with age.
The present questionnaire survey was used to characterize the patients, thus showing that the rates of patients who missed doses, had unused medicine, devised a way to make sure they take their medicine, and had concerns about their own medications were 38.5%, 47.4%, 70.4% and 14.1%, respectively. After obtaining information about the background of each patient, such as their age, lifestyle, and anxiety about medications, the community pharmacists need to check for individual problems disturbing the adherence of patients and to then provide proper pharmaceutical care.

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At the Emergency and Critical Care Center, a pharmacist has been required to participate in initial treatment for 24 hours a day. And this study was performed to evaluate the necessity. Patients taken to the centre between August 1, 2009 and December 31, 2009 were classified into 3 groups according to the time they arrived (from 9:00 to 17:00 [group 9-17], from 17:00 to 1:00 [group 17-1], and from 1:00 to 9:00 [group 1-9]). The number of all patients, intoxicated patients, the rate of the number and types of used injection drugs were investigated. Also the number of cases of drug information pharmacists gave to physicians or nurses whether orally or in writing was investigated. In this study the proportion of intoxicated patients to all patients was 25 (6.7%) in group 9-17, 27 (8.4%) in group 17-1, and 28 (14.1%) in group 1-9, indicating group 1-9 was significantly higher than group 9-17. The majority (73 cases (54%)) of information supplied in the initial treatment was about intoxication. In emergency and critical care, patients are admitted at anytime. Furthermore, intoxicated patients are more likely to be admitted at nighttime. Moreover, drug information about intoxication, drug dose and effects are needed. Therefore, it is suggested that pharmacists 24-hour participation in initial treatment is necessary and pharmacists are required to participate more in emergency and critical care.

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During the 6-year pharmacy program, students receive clinically oriented pharmacy education that develops their expertise in effectively and safely managing patients' drug use. In our university, pre-hospital clinical training (PHCT) has been conducted during the 4th year in order to prepare students for practical clinical training in hospital and community pharmacies in the 5th year. In addition to the core curriculum, the following six categories of advanced training are performed during PHCT: (1) basic life support based on the American Heart Association guidelines for cardiopulmonary resuscitation; (2) evaluation of vital signs using an emergency care simulator; (3) evaluation of drug adverse effects (acute and chronic); (4) clinical case analysis and presentation; (5) blood pressure measurement using auscultation and neurological examinations; and (6) simulation as a clinical research coordinator receiving informed consent. Students (N=22) were administered questionnaires regarding their evaluations of PHCT and their hopes for the future. The results of the questionnaire on PHCT revealed positive evaluations for the practical usefulness of the advanced training categories (1), (3) and (5). However, the other advanced training categories were not evaluated highly because students found them difficult to understand within a limited period. Analysis of the students' future hopes revealed that approximately half of the students would like to work in hospitals as a pharmacy specialist. Furthermore, they want to study basic skills during the 5th year. In conclusion, administering questionnaires on students' opinions and their study needs was useful for objectively evaluating our program.

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Gefitinib and erlotinib are small-molecule tyrosine kinase inhibitors (TKIs) of the epidermal growth factor receptor (EGFR), and have an effect on advanced non-small-cell lung cancer (NSCLC) with mutated EGFR genes. We report the case of a patient with NSCLC harboring an EGFR mutation. His disease had remained stable on daily 250 mg of gefitinib for 13 months until brain metastases developed. After the discontinuation of gefitinib therapy, erlotinib was subsequently administered at a dose of 150 mg a day, which brought about marked shrinkage of the brain metastases while the other lesions remained stable.
Gefitinib is thought to poorly penetrate into the brain due to the presence of the blood-brain barrier. As a result, cancer cells in the brain might remain sensitive to EGFR-TKIs even if those in other lesions eventually acquire resistance to gefitinib. In contrast, erlotinib confers much higher serum concentrations than gefitinib because of the difference of dose setting. Thus, we speculate that erlotinib was able to cross the blood-brain barrier and elicited response on the brain metastases in this case.

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