Monthly Archives: July 2011

Didactics

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We spent the last two weeks at different hospitals reinforcing our knowledge of pharmacokinetics and critical appraisal. Even though I took pharmacokinetics course with Dr. Ensom at UBC in Spring 2011, there were parts of which I had no recollection of. I guess, if you don’t use it, you lose it! During my SPEP rotation, I employed by pharmacokinetics skills for only couple of patients on phenytoin and vancomycin. However, the refresher crash course on pharmacokinetics was essential and useful. I have been told that I would get to apply this knowledge starting during my clinical orientation rotation with Dr. Dillon and of course during my time on the ward afterwards.

During the second week, we focused on critical appraisal. I am glad we started from the basics and built our way up. Having spent 4 weeks with Dr. Tejani on my Pharmacotherapy Evaluation and Optimization rotation, he had exposed me to some areas of critical appraisal already. I believe every pharmacy student should have exposure to concepts of critical appraisal and evidence based medicine during first year of pharmacy school. I remember receiving few of lectures on the topic every year, but we never really got a chance to employ the skills in real setting. But I believe that this would not be the case during my residency and future tenure as a hospital pharmacist.

Initially, I had a perception that the way Dr. McCormack and Dr. Tejani appraise articles, we always end up concluding that the intervention does not work. However, after a discussion with Dr. Tejani my opinion has changed. The goal of critical appraisal is not to render every trial or an intervention as useless, rather providing us with a tool to determine the appropriateness of the trial and inclusion of all the required information. The key is not to believe everything that is presented, but use our critical skills to find the truth and establish if the results are applicable to my patient. Even a bad trial has some valuable information to offer. Earlier, I was under the illusion that industry funded trials are more biased and cannot be trusted. However, it was a surprise to find out that industry funded trials are actually more organized and well thought-out versus independent trials which are not funded properly.

We discussed the issues surrounding conflict of interest and pharmaceutical industry. Aaron and I had discussed this topic during my PEO rotation as well, and it was interesting to know that the size of the gift doesn’t matter even though when receiving the gift we might not think so. There is a reason why companies invest in marketing and gaining the favor and trust of healthcare workers.

As more and more trials being conducted are randomized controlled trials and focus is shifting towards evidence based medicine practice, analyzing the impact of an intervention is becoming more accessible.

After one week of didactics on critical appraisal, I am familiar with an approach to evaluate systematic reviews, meta-analysis and clinical trials. This knowledge would be solidified more during my 2 weeks of evidence based medicine rotation. We also gained appreciation for different ways to keep up to date with ever evolving world of pharmacy literature and engage in life-long learning. One of my goals is to become more timely in reading and assessing primary literature, therefore, I have signed up for Feed Reader and I am finding pharmacy sites that syndicate content and adding their RSS feed to my list. It is a great medium for information dissemination and exchange.

The assignment at the end of the week summed up most of the lectures as we incorporated different skills and knowledge in answering our clinical question. The skills used include: formulating our clinical question, conducting search, analyze the information presented, interpret statistical parameters and applying the information to answer the clinical question. I am looking forward to incorporate the skills and principles learnt in decision making process.

Final week

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I spent the last week collecting data for the directed studies project. This step reinforced the fact that data collection is the hardest task of conducting research as it involves hours and hours of looking up patient charts and collecting information. I also got more practice critically appraising an article. I would be exposed to this more during my Evidence based medicine rotation with Dr. Aaron Tejani. The skills acquired would be very helpful when practicing as a health care professional as I learnt that I do not have to believe all the information that is presented to me, rather look at all the sections carefully and analyze it critically. I gained knowledge about some key terms used in research reports and articles, for example intention to treat analysis, double dummy study etc.

Even though I never picked this rotation as an elective, I am glad I was assigned this rotation as I gained a lot of knowledge about the responsibilities of a Drug Use Evaluation Pharmacist. I believe that presence of a DUE pharmacist in a hospital or health care authority is essential as the system can analyze the drug use patterns and advice the physicians on prescribing patterns so that system’s resources are not misused.

I am looking forward to two weeks of Didactics and reinforcing my knowledge of pharmacokinetics acquired during the course taken at UBC with Dr. Ensom.

PEO Project

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Currently, I am working on a directed studies project with a 4th year pharmacy student under the guidance of Dr. Aaron Tejani. We read articles on the inappropriate use of IV PPIs and are in the process of developing a protocol. This is my first time writing a protocol. During undergrad, I always thought it was a daunting task. I am glad I am getting exposed to it now as it would be very helpful when I start writing protocol for my residency project. Until last week I was unfamiliar of the different processes and steps involved in conducing an internal audit and research. For example, for our internal audit we had to submit Fraser Health -Data Access Application and Agreement. Any kind of research or audit requires a lot of planning and paperwork completion. It is a learning process and participating in the directed studies project and residency project is providing me with first hand experience.

I also got a chance to attend a presentation by Dr. Tejani focusing on the risks of proton pump inhibitors. Preparing for PEBCs, I came across fracture risk with use of PPIs, but association of PPIs with risk of Clostridium difficile infection, pneumonia risk and possible risk of acute interstitial nephritis is something I was unaware of. Aaron introduced us to different resources where we can look up generation information on PPIs: http://www.cadth.ca >> COMPUS reports>>Proton pump inhibitor therapy

Oregon Health Sciences University DERP Proton Pump Inhibitor class review

Cochrane Databases

It was interesting and surprising to find out that risk of C.difficile infection is 3 times more even if PPI was used within the past 90 days. Studies have found that use of H2RAs is associated with both Community-acquired pneumonia and Hospital acquired pneumonia whereas PPIs are only associated with community acquired pneumonia.

On Wednesday, we attended Academic Half-Day focusing on Introduction to Infectious Diseases. It was a good review of some concepts and also introduced me to new concepts like non-specific findings, organ/system-specific findings and identification and characterization of pathogen. For example, I was unaware of Kernig’s sign and Brudzinski’s sign (signs and symptoms of meningitis).

On Friday, I got a chance to meet my mentor Anna Yuen, in regards to learning how to use Electronic Medical Records and how to pull reports. We discussed the project and she asked me questions which stimulated me to think of some concepts that I probably won’t have on my own.

I am also working on creating a presentation to introduce other health care professionals to Health-Evidence.ca website.