Duration of sweat cyclophosphamide excretion in patients undergoing a conditioning regimen of high-dose cyclophosphamide for hematopoietic stem-cell transplantation.

PURPOSE: To investigate the duration of cyclophosphamide (CPA) excretion in the sweat after administration when receiving high-dose CPA therapy as a conditioning regimen for hematopoietic stem-cell transplantation (HSCT). METHODS: Shirts and pillowcases samples (changed once a day) from 12 patients, categorized as groups 1 (n = 6), 2 (n = 4), and 3 (n = 2), receiving high-dose CPA therapy were collected, sealed, stored at 4°C, and mailed to an analytical facility for CPA estimation using LC-MS/MS. CPA was administered intravenously at a dose of 60 mg/kg on days 1, 2 (closed-system delivery for group 3), and samples were collected during days 1-4 (groups 1,3) or days 1-9 (group 2). RESULTS: CPA was detected in all 126 shirts and pillowcases. In 9 patients, excluding 1 patient who had fever during the study period and group 3 patients, the mean (range) rate of CPA excretion in sweat was 0.03% (0.01-0.12%). The mean CPA excretion in 9 patients adjusted for body weight was 19.9 µg/kg on day 1 and 0.3 µg/kg on day 4. CONCLUSIONS: This study showed that CPA was excreted for an extended duration in the patient's sweat, receiving a high-dose CPA therapy as a conditioning regimen against HSCT.

Developing and testing a set of quality indicators for pharmacist home visit services: A mixed methods study in Japan.

OBJECTIVE: Quality indicators (QIs) are an important mechanism by which health services can be evaluated. We aimed to develop a set of QIs for pharmacist home visit services and assess their measurement properties. METHODS: A three-step procedure was applied: (1) Selection of existing content-validated QIs from the international literature and the development of QIs based on national guidelines and home healthcare professionals' opinions; (2) Expert panel consensus of a preliminary set of QIs using the RAND/UCLA Appropriateness Method; (3) Field testing to evaluate their measurement properties (feasibility, applicability, improvement potential, discriminatory capacity, sensitivity to change, acceptability and implementation issues) followed by exploratory semistructured interviews in Japan. RESULTS: Fifty-two preliminary QIs were prepared and 45 were judged as "appropriate"by the expert panel. Sixty-one community pharmacies were recruited to this study with 41 contributing QI data monthly over the 6-month period. Field testing showed that 20 QIs met six measurement properties (ie, feasibility, applicability, improvement potential, discriminatory capacity, acceptability and implementation issues). Nine of these QIs also had high sensitivity to change. Additionally, interviews identified that the main positive impact on practice of using QIs was the early detection of causes of drug-related problems but a negative impact was decrease of pharmacists' motivation. Auto extraction of QIs was seen as a major facilitator, given the time taken to manually extract QI data. CONCLUSIONS: A set of QIs for pharmacist home visit services was rigorously developed and tested. This QI set may be useful in evaluating the quality of such services.

[Advanced Pharmaceutical Management Functions in Home Pharmaceutical Care].

Patients who receive home visits by pharmacists show a wide range of diseases.The patients are mainly elderly people with chronic diseases, children with some diseases or disabilities, and cancer patients receiving palliative care.Such patients request various pharmaceutical care at home from pharmacies.Pharmacies are essentially medical facilities and they must receive prescriptions from all patients, but depending on each pharmacy, there are few cases of a pharmacy refusing to receive prescriptions.Pharmacies participating in home pharmaceutical care need to establish a system incorporating 1 ) sufficient number of pharmacists, 2 ) pharmacy aseptic unit, 3 ) stockpiling of medical narcotics, and 4 ) stockpiling of medical supplies.However, because individual pharmacies have different situations, such as the intention of the founder, size of the facility, and experience and regionality of pharmacists, it is impossible for all pharmacies to participate in home pharmaceutical care in the same way.An increasing number of home patients with high dependence on medical care is expected in the future.For these patients, pharmacists need high clinical experiences, and at the same time, the burden on pharmacies to stockpile medicines will increase.Therefore, evaluation of pharmacies for home care patients with high dependence on medical care should be considered as an advanced pharmaceutical management function.

[Construction of a Home-Visiting System as a Family Pharmacy].

"The Vision for Patient-centered Pharmacies," published by the Ministry of Health, Labour and Welfare(MHLW)in October 2015 specifies three functions of family pharmacies, including home medical care. In 1994, home-visits by pharmacists officially began; however, before then, we had already visited patients whose medications and life situations were of concern, at their homes. Based on that experience, as we were planning to undertake home-visits after their institutionalization, we conducted a study of a system that would promote home care using pharmacists handling various duties, including prescriptions and health consulting. Considering the pharmacists' years of experience and work shifts, efficiency/productivity, and the role of a family pharmacy, we developed a home medical care support system by allocating two pharmacists to each patient's home. Thus, we concluded that if the entire pharmacy would be involved in home-visiting services along with outpatient prescription dispensing services as part of continuous follow-up of patients from hospital visits to home care, the pharmacy would eventually serve as a family pharmacy in the community.

[Mindset for Pharmacists as an Expert of Pharmacotherapy-Case of Home-Care Rheumatoid Arthritis Patients with Multiple Diseases].

The number of older adult patients with rheumatoid arthritis(RA)is increasing. As older adult patients tend to have multiple diseases requiringmedications, they are likely to experience side effects from the decline in their physiological functioning. In addition, suppression of disease activity leads to a decline in ADL in the case of patients livingalone, even leadingto difficulties in livingat home. In the 3-years clinical course on older adult RA patients livingalone with multiple diseases, we show the mindset that community pharmacists must have for three events(namely, hypoalbuminemia, chronic heart failure, and dehydration)in which inflammation influences medicinal or side effects.

[Usual Relationship to Support Sudden Discharge-Coordination Starting from Pre-Discharge Support Considered through a Case Report of Supporting a Patient with ALS].

Due to promotion of home medical care, the number of patients who highly depend on medical care is increasing. Therefore, the role of pre-discharge conferences where a care manager is involved starting from pre-discharge support has become more important. In addition, in a usual relationship, cooperation between the hospital staff and the home care support team is crucial. Among home care workers, the word "coordination" has generally been used for a long time to prepare for the transfer of patients from a hospital to home. However, there is a considerable gap between healthcare and caregiving; consequently, it is difficult to actually create coordination between them because the terms to be used and the contents mastered by personnel in each field are different. In this paper, we report a case of successful coordination for smooth transfer of a patient with ALS from a hospital to home, by creating a homecare team in which all members work together based on the information obtained from a hospital social worker.

[Current State of Process of Dispensing Prescription for Pediatric Patients Who Need Home Visiting for Intervention for Pharmaceutical Management].

Medical advances have made it possible to save lives of children with severe refractory diseases. As a result, the number of children who need continuous medical care at home has increased. However, there are concerns that many pharmacies are not actively involved in, because the dispensing fee does not match their prescriptions, which are very complicated and contain some high-risk medicines. We analyzed the burden of dispensing prescribed medicines so that we can quantitatively discuss from prescription contents. The essence of the burden of a pharmacy regarding home medical care for children is to cover the transportation of heavy pharmaceuticals and the combination of multiple medication including high-risk medicines and lack of pediatric drug formulations with the efforts of the on-site pharmacist. It became clear that the pharmacist's objective work supports pediatric pharmacotherapy.

[Role of Pharmacists in the Care of Pediatric Patients Needing Home Visiting Intervention for Pharmaceutical Management and Their Life Depending on Medical Care].

Medical advances have made it possible to save lives of children with severe refractory diseases. As a result, the number of children who need continuous medical care at home has increased. However, currently, few medical personnel of both medical institutions and pharmacies are aware of home visiting intervention for pharmaceutical management. Home visiting intervention should be utilized more for severely impaired children who are highly dependent on medical care to effectively reduce the nursing care burden of the family and to secure pharmaceutical supply path.

[Team Collaboration in Home Medical Care to Support Patients at the End-of-Life - Review of Service Personnel Meeting on Discharge Day].

Due to the rising number of patients at the terminal stage or with high dependence on medical care, the cooperation of 2 teams, the hospital discharge support team and the home support team, has become very important. The recent spread of the Internet has enabled both patients and their families who have chosen home care to obtain a wide range of information about home services, as well as diseases, and form a picture of what will happen. However, there are actually many cases in which patients and families find that things are not as they imagined, and they are uneasy and unsure of what to do. Here, we report a case in which the mismatch between the patient's and family's expectations created an unsatisfactory care situation.

[Efforts of Deprescribing Drugs and Its Achievements in Institutionalized Individuals].

Recently, the combined use of multiple drugs for coexisting multiple diseases in elderly patients has become a problem. In facilities for elderly persons, pharmacists contribute to the intervention and optimization of prescriptions. However, the procedures have been conducted smoothly in only a few facilities. We established five procedures for prescription intervention by pharmacists and implemented these interventions in 80 institutionalized individuals. The total results over 2 years(January 1, 2015 to December 31, 2016)revealed 118 cases of prescription proposals from pharmacists and a reduction of 2,411,937 yen in medical expense. The purpose of prescription proposals from pharmacists is to reduce burden on patients by optimizing prescriptions, but not to reduce the number or dose of drug. In doing so, it was important to hear patients' opinions on medical care. Patient-centered prescription proposals from pharmacists are considered to have improved the quality of medical care and may enable the promotion of prescription intervention.

[Introduction of PBPM and Its Effects for a Home Care Support Clinic].

Medical teams have been promoted in home care. It is possible for pharmacists who are part of a multidisciplinary team to maintain safety and improve the quality of medical care. Protocol-based pharmacotherapy management(PBPM)is recommended for cooperation between the pharmacist and the doctor in the management of pharmacotherapy. In order to introduce PBPM, it is necessary for the pharmacist and the doctor to cooperate and to extract the problems in community medicine. In this study, the clinic pharmacist examined the problem of unnecessary inquiries and proposed PBPM. He suggested that to smoothly introduce PBPM, a protocol creation committee should be set up and an explanation of PBPM should be provided to the Community Pharmacist Association. As a pilot study, we created 5 protocols at Doctor GON Kamakura Clinic with the cooperation of 8 pharmacies. As a result, it became possible to reduce unnecessary inquiries by 46%. Careful coordination is necessary in order to introduce PBPM at clinics and community pharmacies. Moreover, a clinic pharmacist is able to facilitate the introduction of PBPM in the role of coordinator.

[Methods of Training for Pharmacists Involved in Home Care - Cultivation of a Medical Professional Mindset of Not Selecting the Patient, Time, or Place].

Home visits by pharmacists for home care patients initiated when dispensing the"home care patient drug management guidance fee(550 points)"were established in Japan in 1994. At that time, the home-visit activities of pharmacists for home care patients were not generally recognized by patients, medical doctors, or nurses. With the subsequent introduction of long-term care insurance in 2000, pharmacists became more actively involved in home visits for home care patients. However, with the increasing number of patients with dementia and in the acute stage of diseases requiring home care, an evaluation of pharmacist qualifications and skills, pharmacy functions, and the dispensing fee system now requires consideration. In particular, providing opportunities for multidisciplinary lifelong learning is essential to ensure the qualifications and skills of pharmacists involved in home care. This study explores the methods of training for pharmacists involved in home care.

[A Case of HPN, In Which QOL Improvement Was Achieved by Combining Continuous Infusion with Once-Weekly Intermittent Infusion - Contribution of Pharmacists to Health Promotion among Home Patients Receiving Infusion Therapy].

Patients receiving parenteral nutrition at home have the following two options: 24-h continuous or intermittent infusion. To date, for patients with impaired glucose tolerance and/or other metabolic disorders or for those with decreased cardiac/ pulmonary/renal function, it is desirable to opt for continuous infusion to minimize the variance in the body's metabolic rate as much as possible. Furthermore, it should be noted that continuous infusion evokes a stronger feeling among patients of being constrained because it restricts their everyday activities. This case witnesses collaborations among the patient's doctor, dispensary's pharmacy, and patient's family. Because ofthe use ofintermittent infusion more or less once per week in addition to continuous infusion, significant improvement in quality of life was achieved, and the patient was able to enjoy taking a short trip. To assist a home patient receiving infusion therapy, it is essential that the pharmacist be equipped with skills to manage risks associated with infusion therapy and have knowledge about insurance to cover incidents concerning infusion fluids or medical materials. It will certainly depend on the degree ofindependence ofpatients and the level ofcare their families can provide; however, should we manage to use a similar medical procedure in at least a few cases in the future, we may be able to contribute to "joie de vivre" in home patients receiving infusion therapy.

[Empathy to be Shown by Pharmacists toward Home Patients - Initiatives Undertaken by Pharmacists to Promote the Proper Use of Pharmaceutical Products].

Separation of medical and dispensary services has taken root in Japan as a healthcare system;8 00 million prescriptions have been issued, and 70% of medical institutions now participate in this practice. Additionally, discussions are ongoing regarding patient-oriented family pharmacies from a"back-to-basics"perspective of the separation drug dispensing from medical practice. Through a series of such discussions, the Ministry of Health, Labour and Welfare published a paper entitled"Vision for Pharmacies Working for Patients"with a focus on 3 functions to be implemented by family pharmacists and pharmacies. In home healthcare, there have been cases so far, as shown in the Vision paper, of suggestions from and initiatives taken by pharmacists that have helped improve patient home care services. This paper explores home care-related initiatives undertaken by our pharmacy, including 2 cases in which our pharmacists intervened to prevent duplicate prescriptions and promoted adherence to a medication regimen, having noticed a change in a patient's physical abilities caused by the presence of drug residues. Our pharmacists will inform other relevant professionals about this issue. The study discusses our experience, which may help provide insight on the ideal roles of pharmacists in this time of partnerships among professionals.

[Case Study - A Successful Cooperation of Clinic Pharmacist and Pharmacies in Home Palliative Care with PCA Pump].

To make a good end at home and provide good palliative care for patients with cancer are urgent issues in Setagaya ward, as shown by certain statistics. Medical opioids are greatly needed for palliative care; as patient controlled analgesia(PCA) develops, it can lead to decisions by patients and their families to receive end-of-life care at home because the patient can choose to receive the same advanced palliative care received at the hospital. With in-home palliative care, given the rapid change in the medical condition of the patient and the sentiment of the family, the role of pharmacists is to quickly and reliably supply the pharmaceuticals and medical equipment that doctors need. The following are important in order to enable this; 1 ) a pharmacy stocked with medicalopioids in accordance with needs, 2 ) a pharmacy with a system that can provide support quickly, 3 ) the presence of people who understand the area of resources, and 4 ) a constant face-to-face relationship. The "Sakura-HOPPS(Sakurashinmachi Homecare Pharmacists PartnershipS)"is a group intended to provide exchange and cooperation of pharmacists beyond the framework of organizationalaffil iation, and authors hope to encourage the participation of increasingly more pharmacists to develop a close-cooperation system of acute care hospitals and community medical/home care.

[Promoting Appropriate Pharmacotherapy for Home Care Patients: Coordination between Regional Comprehensive Support Centers and Pharmacies].

Japan is rapidly developing into an aged society, and its construction of a regional comprehensive care system is urgently needed for the baby boomer generation, who will reach 75 years of age in 2025. As part of providing medical care and longterm caregiving in a regional comprehensive care system, ordinary citizens will be supported in their local neighborhoods by multidisciplinary care, team medicine, and information sharing. However, pharmacists visit only once or twice per month; therefore, it can be difficult for them to grasp the overall status of patients' lifestyles. For pharmacies to support ordinary citizens, information on local residents must be shared, and coordination with regional comprehensive support centers is essential. This paper discusses a case where a pharmacy was able to promote appropriate pharmacotherapy through coordination with a regional comprehensive support center.

[Collaboration of Hospitals and Home Care Providers - Lessons to be Learned from an Actual Case to Enable Patients to Keep Living at Home by Their Own Values].

The aging society has arrived, and home care options are being promoted. To date, because of an increase in the number of patients with higher disability levels in greater need of medical help and senior people living alone or in senior-person households, more patients are in need of discharge support. Many medical institutions cannot consider the option of staying at home and receiving home care services for such patients, and such patients often give up on going home. In the case of service recipients suffering from incurable diseases or disabilities and undergoing age-related changes, it is necessary that they decide on their own"where and how they want to live."For their decision to be respected, a key is collaboration with those who support patient discharge from the hospital and those who support patient home care. This paper explores a patient appropriate for level-3 care with brain hemorrhage and paralysis of the left half of the body. This patient required supportive and adaptive devices, a cane for walking, and constant observation. In consideration of the wishes of the patient and his family, he was allowed to go home.

[Significance of Allowing Pharmacy Students to Attend Visits to Home Care Patients].

In 2006, with the admission of a new batch of students, pharmaceutical education became a 6-year course. This was a result of the urgent need to train a new generation of pharmacists to respond to increasingly advanced and intricate medical care as well as the specific need to coordinate with multiple occupational categories. Meanwhile, with Japan becoming an aged society, medical care has undergone functional differentiation, and home care is now being promoted. As part of an 11- week practical course for 5th-year practical training, students attended visits to home care patients from an early stage, making it possible for them to be present at multiple visits. This was highly significant because it allowed students to experience various disease states of different patients and increase their practical knowledge of pharmaceuticals. This study explores the case example of proposals made by pharmacy students for improving medication-related problems in home care patients during 5th-year practical training.

[Supporting Patients with Disease Living at Home].

In daily life, many are not familiar with progressive intractable disease. It is often the case that the patient's family confronts a rare progressive disease only once a diagnosis is made. In recent years, the internet has made it possible for families to learn about diseases in detail, and they can more or less predict the likely course of nursing care required by the patient in the days to come. Yet families often lack understanding of terms related to a disease and how to respond to disease progression. It is desirable that, when a patient confronts a disease and home health care is going to be provided, a care provider be able to show empathy for the patient and the family and build a trust relationship with them. Under the theme of"living at home with disease,"this study examines the case of a patient who copes with the diagnosis of a specified disease and who remains at home. This paper highlights the importance of ongoing collaboration between community medicine and home health care service.

[Consideration of the Work Content of the Clinic Pharmacist and Its Usefulness].

"Medical teams"have been promoted in the home care setting. For the pharmacist, it is possible to maintain the safety and improve the quality of medical care by working with a multidisciplinary team. The arrangement of the pharmacist with the clinic is specified in Article 18 of the Medical Care Law, but there is no medical treatment fee for the clinic pharmacist. We examined the work content and usefulness of the clinic pharmacist. The work content was to participate in visiting consultation, introduce pharmacotherapy management based on the clinic pharmacist's working protocol, propose prescriptions, provide drug information service, and cooperate with insurance pharmacy pharmacists. Because the pharmacist was working in the clinic, he or she was able to actively intervene in drug treatment. Intervention in medication requires organizing and gathering information, which is difficult in the position of the insurance pharmacy pharmacist. The fact that the clinic pharmacist assumes this role and works with insurance pharmacy pharmacists makes it possible to maintain the safety and improve the quality of medical care.