“Additional pharmacist ward operations” were established by revision of the medical payment system in 2012. This new category of operations for pharmacists was established to create a preintervention system for pharmacists by proposals and planning of prescriptions, rather than the conventional system of intervention after prescriptions have been established, in order to achieve appropriate and safe drug therapy in wards. Since April of 2015, pharmacists have been assigned to positions in all wards including the ICU, NICU and GCU in Hokkaido University Hospital.
Pharmacists perform duties as part of the medical team in various fields including palliative care, infection control, nutritional support and transplantation therapy.
In order for pharmacists to sufficiently provide their expertise, not only standardization and improved efficiency of central duties and expansion of ward duties but also coordination of central, ward and medical team duties are essential. The development of next-generation team medicine (hybrid system) is important. In our hospital, we are aiming to establish a next-generation model for team medicine with a focus on the following three keywords: 1) education (establishment of an education program for newly graduated pharmacists, 2) cooperation (cooperation between ward pharmacists and the medical team), and 3) information and communication technology (efforts to establish an ICT system).
Our goal is not to give priority to ward duties but to establish a system for coordination of ward and central pharmacy duties, leading to a paradigm shift from ward duties to clinical care service.

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In recent years, Mohs chemosurgery has been reported to be beneficial for the management of bleeding and exudation by unresectable cancer skin invasion. However, Mohs paste is difficult to use because it melts by exudate. Furthermore, Mohs paste is unsuitable for long-term use because it solidifies in a few days after preparation. Thus, we developed a modified Mohs paste in order to address these problems. The composition of modified Mohs paste is Mohs paste and Zinc oxide 10% single ointment, the weight ratio is 1:1. Although modified Mohs paste has a slower tissue fixation effect than Mohs paste, the risk of injuring surrounding normal skin is less than that of Mohs paste because it does not collapse in the exudate. Furthermore, modified Mohs paste is available for use in emergency situations because it can be stored for more than 3 months in a usable form. Modified Mohs paste is useful in the management of tumor exudate.

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Vancomycin (VCM) is a first-line antibiotic used for methicillin-resistant Staphylococcus aureus (MRSA), and therapeutic drug monitoring (TDM) is recommended to minimize the risk of nephrotoxicity and ensure successful therapeutic outcomes. In Kyoto University Hospital, we have developed a new approach of pharmacist intervention in the medication with VCM, which is named “Protocol-Based Pharmacotherapy Management (PBPM).” PBPM is based on a protocol approved in a hospital committee, which mentioned that pharmacists could order TDM and propose the most appropriate treatment plans with VCM to surgeons. From April 2011 to September 2014 in Kyoto University Hospital, a total of 54 patients hospitalized for cardiovascular surgeries received VCM without the treatment of hemodialysis. Twenty-nine patients before introducing PBPM were the control group. The VCM treatment according to PBPM was applied to 25 patients (protocol group). The incidence of acute kidney injury (AKI) due to VCM therapy, the retention rates of VCM blood concentration maintained in the therapeutic range (10-20 µg/mL) and in the toxic range (over 20 µg/mL) were retrospectively surveyed. The incidence of AKI was significantly lower in the protocol group than that in the control group (8.0% vs 31.0%, P < 0.05). The retention rates maintained in the therapeutic blood concentration range and in the toxic blood concentration range were significantly different between the control group and the protocol group. These results demonstrate that pharmaceutical intervention based on PBPM for MRSA treatment is effective for maintaining VCM blood concentration in the therapeutic range, resulting in a reduction of adverse drug reactions.

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It is important for pharmacists in a medical team to take vital signs before intervention. However, there are few studies regarding the willingness for taking vital signs among pharmacy students. In this study, we conducted a questionnaire survey for 1^st-, 4^th-, and 6^th-year students at the Kyoto Pharmaceutical University, to evaluate their willingness toward taking vital signs. The question was “As a pharmacist, do you want to be able to take vital signs?” Students selected one of the following options: “yes,” “no,” or “neither.” They also wrote the reason for their selection. This was analyzed using text mining, and correspondence analysis was conducted to determine the relationship between “the combination of school grade and selected answer” and keywords. We grouped similar combinations of frequency of keywords using cluster analysis and selected the keywords that significantly developed in a provided cluster. Consequently, typical keywords provided by the 1^st- and 4^th-year students who selected “yes” were “patients,” “emergency,” and “clinical condition;” however, those provided by the 6^th-year students who selected “yes” were “homecare,” “side effect,” and “discovery.” On the other hand, the typical keywords provided by the 1^st-, 4^th-, and 6^th-year students who selected “no” or “neither” were“ specialist,” “pharmacist,” and “work.” Therefore, the recognition of taking vital signs by pharmacists may be different among 1^st-, 4^th-, and 6^th-year students. To develop education related to taking vital signs for pharmacy students, further detailed surveys regarding various factors that affect students' recognition of taking vital signs is required.

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Workshops on the use of adrenaline auto-injection (EPIPEN), reconsideration of training programs on food allergies, and an approach to increase risk awareness of food allergies are required. We investigated the current state of education of school teachers and school pharmacists in Tondabayashi City.
A total of 120 school teachers and 14 school pharmacists participated in our questionnaire. More than 90% of teachers had experience with children with allergies, and more than 95% of teachers were aware of anaphylaxis. Although most teachers were familiar with EPIPEN, they did not have detailed knowledge and were not confident in using it in an emergency. School teachers who attended EPIPEN workshops had a higher degree of confidence in using EPIPEN in an emergency than school teachers who do not attended the workshops. Attending workshops will increase the self-confidence of teachers in using EPIPEN in an emergency. The survey results indicate that it is important for school pharmacists to hold regular workshops on EPIPEN, including practical training, to develop the EPINEN skills of school teachers and enlighten them on the subject.

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Adsorption of the new generation antiepileptic drug E Keppra_® dry syrup containing 50% levetiracetam to an automated dividing and packing machine was observed after dispensing by using the machine. We examined drug loss and variation in divided weight after dispensing a pediatric dose of the dry syrup. When 1.4 g of E Keppra_® dry syrup 50% was divided into 14 packs using an automated dividing and packing machine, the drug loss per pack was 10% - 27%. The high drug loss was observed during an early stage of packaging the dry syrup. Conversely, drug loss per pack was less than 10% when 7.0 g of the dry syrup was divided into 14 packs. The variation in divided weight in 1.4 g of the dry syrup was 2.3%, which was larger than the variation in 7.0 g of the dry syrup. The drug loss and variation in divided weight were observed under the following conditions: the dry syrup particles were less than the average particle diameter of 150 μm and the humidity was less than 50%. The drug loss during division was prevented by addition of a vehicle, such as lactose, to the dry syrup. These results indicate that using the machine to divide the E Keppra_® dry syrup 50% into low doses recommended for children gives rise to inaccurate dosing.

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Case report: The 33 year-old male patient suffered from neuropathic pain on his right leg caused by metastatic retroperitoneum after surgical removal of sigmoid colon cancer. Although he was treated with a transdermal fentanyl patch, immediate release oxycodone, flurbiprofen, paracetamol, and pregabalin, his breakthrough pain and fulminant pain were not improved. Afterward, as oral medicine administration became difficult due to obstructive ileus, and the opioid was changed from transdermal fentanyl patch to fentanyl injection, but there was no improvement. Then, the ward pharmacist and palliative care team discussed an analgesic adjuvant, and decided to inject lidocaine to the patient. The injection caused the patient's condition to dramatically improve. By giving drug information to the ward team and carrying on pain assessment, the ward pharmacist contributed to lessening the patient's pain and the shift to the home medical care. The ward pharmacist joining in the team medical care widened the scope of information sharing. As a result, the medical team was able to realize medical therapy in accordance with the patients wish.

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Patients admitted in rehabilitation wards are usually older than those in general wards. Since elderly patients suffer from multiple co-morbidities thus showing a variety of symptoms, they are often at risk of polypharmacy. In the present retrospective observational study, we aimed to search for clinical characteristics of patients who were associated with factors influencing the number of drugs at discharge. One hundred and twenty-four patients (aged ≥65 years) who were admitted to rehabilitation wards in Setagaya Memorial Hospital between April and September either in 2013 and 2014 were enrolled in this study. Prescribed drugs during hospitalization, primary diseases and comorbid conditions were retrieved from the medical records of the patients. The mean age of the patients was 81 ± 8 years and 46% were men. Fifty-one patients (41%) were given polypharmacy at discharge. There was a significant reduction in the number of patients receiving non-steroidal anti-inflammatory drugs at discharge as compared admission. A multiple regression analysis revealed that the numbers of drugs prescribed at admission correlated (P < 0.05) with that prescribed at discharge. In addition, co-morbidities of heart disease and hypertension were associated with 1.2 and 0.9 more drugs at discharge, respectively. Pharmacists may intervene in the polypharmacy of patients more effectively if they take patients' clinical characteristics into account.

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