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Stage Hors Erasmus à Ottawa 1er octobre – 31 décembre 2010

Ottawa

Canada : Superficie : 9 976 139 km2 Population : 33 739 900 hab

France Superficie : 551 695 km2 Population : 62 793 432 hab

Ottawa : Superficie : 2797 km2 Population : 919 258 hab

Marseille Superficie : 241 km2 Population : 860 363 hab

Hôpitaux Ottawa: 5

Hôpitaux Marseille : 5

Sabine DEREY


Table of contents 1. Introduction: My Discovery of Ottawa • • • • •

Flight Accommodation Transport Phone My Schedule

2. What I have done, and what I would advise you to do • • • •

Activities in downtown Ottawa Activities outside downtown region Restaurants, pubs Places I have visited outside Ottawa

3. My placement at CHEO • • -

A few words about CHEO My projects:

Rate and occurrence of constipation in pediatric patients with acute use of opioid narcotics Therapeutic Drug Monitoring for Extended Intervl Aminoglycoside Dosing in Children or the “AG study” HIV clinic and rounds Tall Man Lettering Project Drug utilization in end of life patients Pictogram Calendar survey Time in motion study Additional tasks I have done

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My Discovery of Ottawa: Flight Direct flights from Marseille to Ottawa are quite expensive, so instead I took a plane from Marseille to Montreal. After landing, some flight companies such as Air France have buses (Greyhound company) or shuttles available to get to Ottawa. Visa You definitely have to get a visa to be able to do your internship and it takes a long time to obtain one ... It took me about 4 months to receive mine. In fact, the first answer of the Canadian authorities was that I would have to undergo a thorough medical examination and specific laboratory tests with a physician and lab recognised by the Canadian government (I had to go to Nice because there are no physicians and laboratories with a Canadian agreement in Marseille). Then you have to wait for the final response. Accommodation I lived in Sandy Hill, in a really nice neighbourhood in downtown Ottawa. So if you need to find accommodation, I would search for a place in Sandy Hill region and ask CHEO for help. Transport The OC transport buses are quite expensive (2.50 dollar + tax). Fortunately, there was a free university shuttle available for students who went daily to CHEO! And so I only walked 10 minutes to get to the university bus station. Moreover, it’s better than the city buses because the bus driver is always exactly on time... Phone The cheaper deal is to have an unlocked phone and to buy a Sim card (10 dollars with Fido). And then to just bought some cards, and unlimited text was 0.50 dollars a day. My schedule In Canada you have to work 37.5h a week, and my schedule was either from 7h00 to 15h00 or 8h00 to 16h00, but most of the time I didn’t have time to stop to eat a real lunch. I usually ate my lunch during meetings or in front of my desk after late clinic rounds. So having lunch with the others students in the cafeteria was rare but enjoyable! I had lots of work to do, but it was really interesting and it gave me the opportunity to meet great people. The project coordinator and the administrator were really nice and really helpful with all the projects I had to do…

What I have done, and what I advise you to do Activities in downtown Ottawa (varies according to the seasons…): -Go to the National Art Centre to see a ballet, or a theatre movie (very good program) 3


-Visit the Museum of civilizations. I love this place, the garden is beautiful, before winter comes you can see movie outside on a huge screen, and there is also an Imax room. -Visit the National Gallery downtown, I saw a good exhibition but I guess this is dependent on which exhibition is being presented. -Visit the Museum of War. Actually I haven’t gone to see it, but I have gotten lots of positive feedback on it. -Visit the Parliament Building (beautiful place) - Eat a Beavertail or a « queue de castor », one of Ottawa’s unique specialities - Eat a turkey for Thanksgiving - Celebrate Halloween: get a costume, welcome children who are tricking or treating around the neihbourghood and then go to a party ! Activities outdoor -Zip lining -Hike in the Gatineau Park -Cross country skiing, snowshoe hiking -Go to Bank and Glebe neighbourhoods, and go to Wakefield, there are really nice place to go for traditional shopping. -Watch your first hockey game on ice! -Go to the Canadian show “Signatures”; a market open for 2 weeks in December where you can only find things made in Canada. It’s nice if you want to buy some gifts… Restaurants, pubs: If you want sweets, and sugar beverage for very cheap go to Tim Hortons. It won’t be hard to find one, it’s everywhere !!! If you want a typical or original and good hamburger: The Works If you want to eat a good fish and chips, go to The Druid or Heart and Crown. They are good Irish pubs where you can find good beers and basic food that isn’t very expensive and also where many live bands play. But it’s very noisy. If you want a brunch: Cora’s If you like sushi, you have to go to an ‘all you can eat’ sushi restaurant! Yummy: Ken’s If you want to go a good greek restaurant: Pilos Others : Try the bagels from the market, they are definitely the best. Try Cinnabon in Rideau Center, there are always hot, yummy! I’m not a big fan of the « poutine» (french fries with brown sauce and cheese) but it’s a speciality in Quebec.

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Places I have visited outside Ottawa - I went to Montreal (Greyhound bus 50 dollars for a round trip), it’s about 2 hours to go there. - I went to Quebec City (about 6 hours away) - I went to Halifax (East of Canada) - I went to NYC, it’s only 8 hours from Ottawa by car and there are only well organized tours organised. Canada is huge, so I guess if you can, you should visit a lot of places…

Mont Royal view, Montreal Peggy’s Cove , Halifax

Chateau Laurier, Québec City New York City

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October-December 2010

My bike

Sabine DEREY Student in 5th year of Pharmacy

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The different places where I worked : -

5 East, Surgical and Rehabilitation unit C19 Infectious Disease clinic Roger’s House (palliative Care centre) At my desck in the pharmacy room Roger’s House aquarium

Julie Wade Office Administrator

Régis Vaillancourt : Director of the pharmacy department

The Students !!!! John

Jean Me

Anney Mike Ahmad Lauren

My supervisor Nathalie Dayneka, Clinical Pharmacist

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A few words about CHEO… Over the past thirty-six years, CHEO has established itself as a world-class centre providing cutting-edge treatment, diagnostic and laboratory services for children and youth aged 0 the 18 years of age. CHEO houses the Provincial Centre of Excellence for Child and Youth Mental Health and the Ontario Newborn Screening Program. CHEO is an active partner in the Champlain Local Health Integration Network, providing leadership in all aspects of pediatric health and wellbeing. CHEO's large service area includes not only Ottawa, but also Eastern Ontario, Western Quebec, Nunavut and parts of Northern Ontario. CHEO is a pediatric health and research centre providing outstanding family-centered patient care, pioneering breakthrough research, and training the health care professionals of tomorrow. I appreciated the commitment to education during my experience at CHEO. I don’t know if this is the case in all the hospitals, because it was my first hospital experience, but I really enjoyed all the presentations, grand rounds, and student education presentations I could attend. Every Wednesday morning from 8:30 to 9:30 is pediatric Grand Rounds, I have attended : - Genetics of childhood obesity : specific focus on Prader-Willi syndrome (PWS) - Pediatric capacity and consent : what’s lega land what’s right - Kidney transplantation in children- the day(s) after - Current status of pediatric instestinal transplantation - Adrenal suppression what you need to know - The health and social impacts of the growing inequities in Canada and abroad. During a week called « partners against pain » there were daily a lunch and learn sessions on various topics. These included : Nutritional approaches to chronic pain, sickle cell pain management, Codeine : the good, the bad and the ugly, Ouch… don’t wind me up, sucrose : how sweet it is. Moreover, as CHEO is very involved in research, the research day was an important day with lots of lectures offered. Also, each week there was provided a therapeutic group education for Pharmacy students. The presentations were given by the pharmacist staff. Here are the topics attended: - Drug dosage and administration - Infectious disease (UTI’s, others) - Infectious disease (pneumonias) - Immunizations - Pain management - Pharmacokinetics in children - Asthma/ respiratory disorders - Cystic fibrosis - Otitis media I also had the opportunity to go to several training sessions offered by Natalie (the clinical specialist pharmacist with who I worked) and by others pharmacists who worked on specifics projects. What is specific to CHEO is that pharmacists work a lot with the physicians, and do a lot of studies try to establish treatment guidelines. And this is required for pediatric care because there is a significant lack of sudies for many drugs. The pharmacists in the HIV clinic and in the Oncology department are responsible for discerning the best dose, changing the dose (considering weight and height) and writing orders. 8


How the pharmacists are involved at CHEO ? Here in Canada, students in pharmacy don’t have to pass a residency exam (our « internat » in France) to work in a hospital; however many pharmacists practising in hospitals gain more education and training after pharmacy school through a pharmacy practice residency or/and a doctorate. And to reach a higher position like the Director of Pharmacy it is preferable to have a doctorate. These pharmacists are often referred to as clinical pharmacists and they typically specialize in various disciplines of pharmacy. For example, here at CHEO there are pharmacists who are specialized in oncology, HIV/AIDS, infectious disease, critical care, emergency medicine, pain management, nephrology, palliative care, psychiatrie, neonatal care… The clinical pharmacists provide direct patient care services that optimize the use of medication and promote preventive healthcare. Clinical pharmacists collaborate with physicians and other healthcare professionals to improve pharmaceutical care. They work collaboratively with physicians, nurses, social workers, physiotherapists, psychologists, nutritionists depending on the department. They participate in patient care rounds and drug product selection. For example Natalie, the pharmacist in charge of me is the pharmacist in charge of the surgery, rehabilitation department, and the HIV department. Clinical pharmacists are an integral part of the interdisciplinary approach to patient care at CHEO. Potentially dangerous drugs that require close monitoring are dosed and managed by clinical pharmacists (Oncology and HIV departments). Here is the organisation of the pharmacist staff at CHEO, one pharmacist is in charge of each department except for the Pediatrics, NICU and PICU departments where several pharmacists are involved.

Vice president, patients services Director of Pharmacy Pediatrics

GATC study, Medication safety

PICU

NICU

Oncology

Psychiatry

Clinical Specialist

CF Pharmacist

Rogers’s House, Palliative Care

GATC :Genetic Approaches to Therapy in Children Cystic Fibrosis

How do they communicate ? -

-

Every month : • there is a one hour pharmacists meeting, where all the issues, new practices, and information is summarized. On the day of each meeting we receive a summary of what we were going to talk about. • there are also a one hour staff meeting, and assistant meeting • On week days there is a 15 minutes mini meeting for day distribution. Every Friday, a pharmacists’ newsletter is produced and posted. I was asked to contribute to three of them. On a regular basis every pharmacist meets with Regis, the director of pharmacy. For us, the students, we normally meet with him twice a week. These meetings were not always possible, but most of my work was done with Natalie, another pharmacist.

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What did a typical week look like ?  On Tuesday, Thursday, and Friday I came early in the morning, 6h45, in order to go on surgical rounds with Natalie. We went through the patients’ medications issues, checked the electrolytes and TPN (Total Parenteral Nutrition). We also checked to see if some patients could be eligible for the Gentamicin study… Going to care rounds and being able to see patients allowed me to be aware of what was happening with each patient. In this study it was easier for me to know whose patients will be eligible for the « opioids study ». After rounds with my daily list of patients, I went throught the charts to see which patients could be recruited fo the opioids study. If I found some, I asked Natalie to approach the parents to obtain agreement. For ethical reasons only a pharmacist can ask for consent. When consent was given I could go to the room and have the parents sign assent and consent (for each there were 2 copies, one for them, one for me) and finally do the survey ! It was not a very glamorous survey, and some patients did not feel comfortable, especially the teenagers, but most of the time it went very well ! Fortunately everyone was able to understand my English, even with my strong accent. During the morning I also had to do the other surveys in process. When I couldn’t get the patient’s chart on his last day and when I had missed some data (same for the other study I had been involved in) I went to the Medical Records where they keep all of the patients’ charts. As it is for a research study I had a special permission to see the charts. For the Aminoglycoside study, most of the information I had to collect wasn’t in the chart but in one of the CHEO programs, « Sunrise ». Using this computer program I could see all the chemistry results, lab results, and the time when the AG infusion was started and stopped. During the rest of the day I was involved with various other tasks that Regis gave me.  On Wednesday morning, I went to the HIV clinic, where we saw patients and assessed their knowledge of their drugs, if they had any side effects, if they missed some doses and any other relevant issues. When there were some issues with the dosage, I had the occasion to discuss it with Natalie and try to find a solution with her and the PharmD student she had. In this clinic the pharmacist is really involved with the choice and the change of the medications for the patients, which was really interesting. On Thursdays, I participated in the HIV one hour round with all the team (Physicians, resident, nurses, social worker, psychlogist, nutritionist, research worker) in order to talk about the issues and the patients’ specific problems. During the week between my scheduled program, I always had different meetings (staff meetings, students educational training, presentations,etc…)

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My different projects :

Rate and occurrence of constipation in pediatric patients with acute use of opioid narcotics This study was my main and daily work during my training at CHEO. A few words about Opioid Narcotics and especially Morphine (the main opioid used after surgery to control pain): Opioids, also known as narcotic analgesics, are agonists of morphinic receptors (µ). Their main analgesic action is due to an activation of µ receptors in the central nervous system to relieve acute pain, post-operative pain and certain types of chronic pain. However, µ receptors are not only located in the central nervous system, but also all over the body, and especially in the intestinal wall. The stimulation of these receptors when a patient is treated with opioids causes a gastrointestinal transit slowdown. The stimulation of these receptors also decreases digestive secretions by inhibiting the acetylcholine release. These two mechanisms explain how opioids induce constipation by stimulating the peripheral opioid receptors.

Endorphinomimetic Agonists of Morphinic receptors (µ+++, δ, κ) Located in Central Nervous System => Therapeutic Effect : Analgesia Located in all over the body => Adverse Effects

Most Common Adverse Effects: -

GI slowdown (Constipation, Nausea, vomiting)

Proven in long term used in Pediatrics -

Not proven in pediatrics

Drowsiness and dizziness Cardio-Respiratory depression ( Bradycardia, Bradypnea, Hypotension, etc.) Myosis Urinary retention

Why this study is being done ? In children, constipation is a common and distressing problem of gastrointestinal transit, with a childhood prevalence estimated between 1 and 30%. Constipation is one of the most described sideeffect of chronic opioid narcotics

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Opioids, especially Morphine are prescribed every day in a large quantity for analgesia at CHEO and no study is available to show if opioids cause constipation during short term use in pediatrics patients : 1. A recent study by Duensing et al.(2010) found that in adult patients taking oral opioids, 63% of patients surveyed reported experiencing opioid side effects 2. When an opioid was discontinued because of side effects, the most frequent reasons for discontinuation were nausea (78%) for immediate-release opioids, and constipation (64%) for extended-release formulations. 3. Although many articles address chronic pain and cancer pain, there is a lack of published references reporting the frequency of constipation and other gastrointestinal adverse effects associated with acute (less than 7 days) use of opioid narcotics.

Objectives : The objective is to describe the prevalence of opioid-induced constipation during short term use of opioids in a pediatric population and to compare the different opioids used.

How did I recruit patients ? When I went through all the patients charts I had to make sure : •

the patient had the inclusion criteria necessary to enter the study (Children, hospitalized, with surgery, receiving opioids…)

the patient had no exclusion criteria (oncology patients…)

The data collection included : • • •

general patient informations (the longer part to collect) the group that belonged the patient (kind of surgery) an evaluation of opioid-induced constipation with the questionnaire

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This is one of the data collection sheets. For more, wait for the study to be published…

MODIFIED CONSTIPATION ASSESSMENT SCALE Not obtained (No data collected) = NDC Data collected from:

Patient

Legal guardian

Expectations: what will happen when patients have been recruited, data collected, and an article published ? The goal is to change clinical practice or to take better care of the patients in the future.  The study hopes to collect data that could be used to develop guidelines to prevent constipation. To describe the frequency of opioid-induced constipation, and also to decide if some opioids are more likely to induce constipation than others. If it appears that short-term opioid use doesn’t cause constipation, the underlying objective could be to prevent physicians from prescribing laxatives or stool softeners when a short term opioid is used ; on the contrary, if the study reveals opioids induce constipation, the underlying objective, could be to simultaneously prescribe a laxative that with an opioid order when a short term opioid is used …

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What I learned from this study ? I had the chance to approach the patient or the parents by my own, to make them signe assents and consents, and to explain our study. Being the first to start recruiting patients, I was the one who tested the data collection sheets. I had to see what didn’t work, what was missing and make the necessary modifications. It was my first experience in research and in a hospital. This study was perfect for me because I had to learn how to get the relevant information from a chart and a MAR (Medical Administration Record). It was a great opportunity to interact with patients and/or the parents. I really could start a relationship in a few days with patients, which made things easier. As I want to work in Regulatory Affairs, it was interesting to see the legal dimensions to this study (consent, different assents depending on age, the rule that pharmacist must be the first to approach the patient…) I also learnt how to create a data sheet, and how to input the data on a specific statistic program: SPSS version 18. To conclude, this was a really enriching experience, although the topic might not appear glamorous… Just to be clear I never called the study « the poo study » in front of the patient ! It was only the pharmacists’ code ! The only thing that makes me sad is not to be able to finish the study and participate in the final article, but I have only recruited 30 patients out of a goal of 200 patients… So no regrets !

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Therapeutic Drug Monitoring for Extended Aminoglycoside Dosing in Children or the « AG study »

Interval

This is an observational, prospective, clinical study done on inpatients at CHEO that attempts to collect data.

A few words about AG… Aminoglycosides are a group of intravenous (IV) antimicrobials with bactericidal activity against gram negative bacteria. As the pharmacodynamics of aminoglycosides became better understood revealing that aminoglycosides are concentration dependent and exhibit a post antibiotic effect against gram negative bacteria, the dosing method evolved from the traditional method of a multiple daily doses to an extended interval method also referred to as the single daily dose method. Serum drug level monitoring is applied to guide dosing recommendations as the aminoglycosides have a low therapeutic index and they exhibit large interpatient variability in pharmacokinetic parameters. 

traditional method in pediatric :

With adjustment (dose and frequency) to achieve :

7.5 mg/kg/day IV divided q8h. a trough serum blood level of a peak serum blood level of

0.5 to 2 mg/L 5 to 10 mg/L.

These target levels are well established.

The literature review will help us to understand why this study was undertaken and why we want to change the guidelines… Literature Review : Since the pharmacodynamics of aminoglycosides has been elucidated, is the traditional method still the right process to follow ?  AGs are concentration dependent = more rapid bacterial kill in response to higher peak drug levels. (but no significant differences were shown in clinical or /and microbiological failure rate, although the trend did show a preference towards extended-interval method.)  One pediatric study of oncology patients with fever and neutropenia undergoing stem cell transplantation of extended-interval AG administration has shown a superior efficacy than with multiple daily dose administration.  Aminoglycosides also exhibit a significant post antibiotic effect (PAE) against gram negative bacteria which means the AGs continues to suppress bacterial growth even though its concentration at the site of infection is below the minimum inhibitory concentration (MIC) for those bacteria. Avoiding accumulation minimizes the potential toxicity in areas of the body sensitive to prolonged, high aminoglycoside concentrations such as the cochlear and vestibular hair cells in the ear and the proximal tubular cells in the renal cortex of the kidney. However, though Peak concentrations are not directly related to nephrotoxicity, the relationship between peak and auditory and vestibular toxicity has not been fully elucidated and remains unclear. In our study we have to report all the creatinine levels that have been ordered and the audiology test if one had been ordered.

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Therapeutic Drug Monitoring  Guidelines for the IV use of aminoglycosides utilizing the extended-interval dosing method are available in adult patient population. Some centres have attempted to adapt the nomogram to adjust pediatric aminoglycoside doses. This pediatric application is not evidence-based and cannot be supported at our centre.  The pharmacy and therapeutics Committee at CHEO has recommended: Pediatric patients receiving extended-interval doses of gentamicin or tobramycin IV • serum creatinine level weekly • therapeutic drug monitoring : The target is a trough level < 0.6 mg/L (level is taken just before the AG infusion)

Other Pediatric Centres (emails surveys have been done)  lack of consensus and inability to define optimal monitoring in the published literature Peak Concentration: After IV administration of an aminoglycoside, the pharmacokinetics of the aminoglycoside can be simplified into two phases. First phase = distribution, when the drug rapidly equilibrates in the blood (steady state, when distribution complete, is about 3 to 4 half-life). The distribution half-life has been shown in adults to be dependent on the size of dose given : when the size of the dose increased, the distribution half-life in adult subjects increases too. For the extended interval dosing method in an adult patient, the serum level should be taken after at least 90 to 160 minutes to avoid the distribution phase after administration. Three hours is the recommendation in the pediatric clinical trial of children with febrile neutropenia undergoing stem cell transplantation. Gent (pediatric) distribution T1/2 ≈ 5 to 10 minutes.

If dose increases from 2 to 7 mg/kg/dose = doubling of the distribution

half-life

Gent (pediatric) distribution T1/2 ≈ 10 to 20 minutes and steady ≈ 30 to 80 minutes. Although this means that some pediatric patients may still be in the distribution phase at 1 hour after the start of 16


infusion, the inaccuracy may be minor and must be weighed against the added value of taking the serum level at the targeted time and not requiring a pharmacist to calculate an extrapolated peak concentration from serum concentrations taken at sampling times with no assigned target values (i.e. 3 and 6 hours post dose). Trough Concentration : Traditional method (multiple daily doses)

High trough

linked to nephrotoxicity. No correlation has been established between the trough and the peak concentration with auditory or vestibular toxicity. It is difficult to model the targeted drug free interval after the duration of postantibiotic effect as the duration of postantibiotic effect is dependent on the gram negative bacteria and the drug concentration (the nomogram studied in the adult population.) Maximum duration of postATB effect : up to 16 hours =16 h suggested as the max duration for the drug free interval.

In the pediatric clinical trial (once daily dose) in febrile neutropenic patients: Drug-free (tobramycin level is less than 1 mg/L): 6 to 10 hours after the start of the aminoglycoside infusion. So any level taken more than 6 hours after the start of the infusion may not be a measurable value and therefore cannot be used for calculations such as Cmax, peak concentration, half-life and volume of distribution This study has selected an 8 hour sample in addition to the one hour peak as the majority of patients should still have a measurable level at 8 hours and it will verify that the maximal suggested duration of drug free interval of 16 hours is not exceeded. ď&#x192; 

This is also what has been decided in CHEOâ&#x20AC;&#x2122;s study.

CHEOâ&#x20AC;&#x2122;s Study : The objective of the study is to comparate the pharmacokinetic analysis of 2 serum levels in the extended interval aminoglycoside dosing method with the pharmacokinetic analysis of a single level measurement in the current multiple dosing method for pediatric patients. The primary outcome is achievement of the therapeutic range with the Aminoglycoisides post levels with a drug free interval of more than 4 hours but less than 16 hours.

So now, in practical terms, how the study is set up Recruitment The patients who were ordered intravenous aminoglycosides with a single daily dose were approached for the study Natalie, the clinical pharmacist. She explained the study to patients and their parents.

Data Collection I was involved in these dimensions of the study: -

Patients identified by an assigned study number only Documentation of the dose, duration, and time of therapy 3 serum aminoglycoside levels

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-

Recording any serum creatinine or hearing tests that are done while the patient is receiving the IV AG. Recording the microbiological cultures and clinical outcome of study patients in order to correlate these with any high serum level results.

Assessment of results The study will describe the proportion of patients that had an acceptable peak concentration and an acceptable drug free interval estimated from serum levels and what proportion of these acceptable serum levels were predicted by a single trough level post dose.

My work My involvment in this study was not as important as my involvement in the « poo study », for several reasons I will explain later. To begin with, I didn’t search for eligible patients. Natalie did this part, and if some patients were eligible, at this point I helped Natalie with completing the paperwork. In fact as we asked a favor of the nurses (to do two extra pokes) we had to write the order on the laboratory book and do as much as possible so as they will not forget to write the exact time when the infusion was started and stopped. For this study there was no interaction or contact with patients (no questions to ask), so I didn’t see the patients, and my work consisted of data collection for the data sheet (note the exact time, creatinine levels, sample labs results, microbiologic tests, and an audiology test if it was necessary).

What I learned from this study •

Pharmacokinetics can make therapeutics become complicated, especially with AG, and has to be take into account.

The recruitment of patients for research projects is not always easy

A very good relationship and positive interactions with all the healthcare partners is mandatory to make things easier and go faster. We needed the agreement of the physician and the collaboration of the nurses.

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The rate and occurrence of constipation in pediatric patients with acute use of opioid narcotics study versus the AG study I had the opportunity to work on two very different studies : o o

For one, we were able to recruit several patients each week For the other we have recruited only 6 patients in 3 monthsâ&#x20AC;Ś

Why this huge difference ? - For the poo study we asked the patient to respond to questions, which took approximatively 10 minutes. Though the subject was not glamorous it didnâ&#x20AC;&#x2122;t require more effort, even when patients were really young because the parent would answer the questions. - For the AG study we asked for two extra pokes (we know how children and even adults love to receive injections), and sometimes timing was not convenient â&#x20AC;Ś o For one study, nobody said no, and there was no obligation of time to do the survey o For the other one, lots of patients said no, and the time, a restrictive factor, prevented us from asking (examples, when the post AG samples had to be done in the night).

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HIV clinic and rounds with Natalie A Few words about HIV drugs â&#x20AC;Ś

NNRTI, NRTI

Raltegravir

PI

Infectious Disease (HIV) Clinic on Wednesday morning: A whole team is involved in the care of these patients. In order to limit the number of visits to CHEO, all the members of the team meet at the same time. Natalie, the pharmacist is in charge of finding which drugs and dosages are the best for the patients and if interactions may happen (lots of interactions exist with the HIV drugs.) Pharmacokinetics change a lot in the different childrenâ&#x20AC;&#x2122;s age ranges and it has an impact with NRTI drugs which are always prescribed in different combo. On entering host cells, NRTI are converted to a triphosphate by endogenous cellular enzymes. This appears to act through incorporation into growing DNA chains by viral reverse transcriptase thereby terminating viral replication. The pharmacist always has to check the dose when the patient grows up.

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Pharmacokinetic in Children : Metabolism Metabolism is reduced in neonates, increases progressively during the first 6 months of life, exceeds adult rates by the first few years for some drugs, slows during adolescence, and usually attains adult rates by late puberty. However, adult rates of metabolism for some drugs may be achieved earlier. The age of transition is defined for a few drugs. During morning rounds I helped Natalie with : -

writing orders, entering them in the centricity program, preparing the patient’s medications checking if changes in weight and height required a new dose I also went with Natalie to see patients and ask them if they know the frequency, the look, the name of their drugs, if they have missed some doses (cause for Resistance +++), if they have some adverse effects, and if they have any questions. When a patient was French speaking I could check they were all well understood.

Resistance: HIV is able to adapt itself to its environment by the selection of resistant mutants allowing its escape from drug treatments. The risk of selection of resistant viruses is not the same depending if the non compliance escape occurs with NNRTI medication or with IP medication. In the first case the risk is high, whereas the risk is weaker in the second if the esacpe is identified and taken into account rapidly. This is a real danger because adherence to the drug regimen is difficult and even more so because the patients are children or teenagers. This is why they always try to : - give as few pills as possible, - with convenient timing - avoid any side effects (such as stomach pain) which could cause the patient not to take the drugs. - Give them some tips on how not to forget any doses : have a medicine box weekly organized, take some yummy food with the drug, when the drug permits it, have an alarm clock… 

That’s why we always asked the patient and the parent how many doses have not been taken.

What is important to know in CHEO’s policy is the patients are not aware of the reason why they are taking the drugs which implies not being able to speak about HIV disease but rather Infectious disease, also not to give the medications in their original packaging., and to be very careful while talking to the patients…

Infectious Disease (HIV) Round on Thursday : This is a one hour meeting where the team meets around a table to go through all of the patients and talk about the issues arising (blood work results, resistance, changes in the therapeutic, adverse effect, a need or not to admit a patient) and the situation of any new patients if there were some approach. As different healthcare professionals are involved, it was really interesting to be there from a humanistic perspective. But, as a pharmacist and pharmacy student, we are not supposed to hear all the personal patient history. So first, it must stay very confidential, and then we don’t have to participate or comment in much of the discussion. Our role consisted of medication regimen discussion for the most part.

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What I learnt from this experience ? •

I had the opportunity to speak directly to patient, to counsel and to explain to them their regimen.

The Pharmacist has a great role to play to improve clinical practices and also to improve compliance, adherence to medication regimens. A pharmacist is really needed (the knowledge of a pharmacist is really appreciated), and even more because few guidelines exist in Pediatric patients for HIV treatment.

I learnt how a team collaborates in a specific domain to try and give the best treatment to their patients and to improve their quality of life.

It was really interesting to work in this very different specific Unit. In fact in contrary to 5 East it is outpatient and not inpatient. The way the rounds occured was totally different.

To review my infectious disease courses was not a bad thing…

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Tall Man Lettering Project What are Tall Man Letters ? Medication errors commonly involve confusion between drug names that look or sound alike. One possible method of reducing these errors is to print sections of the names in “Tall Man” (capital) letters, in order to emphasize differences between similar products. My work From the centricity catalogue list of CHEO, I made a list of the drugs used at CHEO containing the Tall Man Letters. I also did exactly the same thing with the pediatric drugs on Lexicomp, then I made a comparison between CHEO, Lexicomp and the recommandations. ISMP updated its list of drug name pairs with TALL man letters, including FDA approved list of Tall Man Letters. Comment : The update appeared November 11, 2010 for the oncology drugs, the day after I started to find those used at CHEO. Then on November 18 a list appeared for the others drugs, so I reviewed ma first version… CHEO is fast !

clonazePAM cloNIDine

-

CLONazepam cloNIDine

clonazePAM cloNIDine cloZAPine

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Completing data for a study : Drug Utilization in End Of Life Patients What is it About, what has been done? Comparing drugs administered to EOL patients at RH versus those at CHEO (during the 7 days prior to death) For each day ( 0* to -7 ): - List of drugs given and for each drug: route of admin, dose, number of doses/day, total mg/kg/day - Level of hydration - Comfort score and scale used for each day

What is Roger’s House ? A place which offers : Respite, End of Life, Pain & Symptom Management, Transition to Home The role of pharmacists there is to : - Provide pharmacy service for staff and patients residing at Roger’s House - Relay patient concerns/updates - Drug validation for every patient

My Work 1. For all the patients who went to Roger’s House I had to find on Sunrise Acute Care how long they have been at CHEO before, within 60 days before death, in order to have a total length of stay (CHEO + Roger’s House) 2. Hydration at the end of life : We want to know if the patients received, within their 60 days before death, some hydration. Either by IV or Gtube (gastric feeding tube) and how much. 3. Collect and input the data on SPSS Stat program.

What I learned ? -

How Roger’s House works (general survey) How patients received hydration (It’s not something I have been aware of or something I have learned before) How the patient information is collected in RH’s chart

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Pictogram Calendar survey The study Health literacy levels vary throughout the world, thereby making it possible that some patients will take their medications incorrectly. Through the International Pharmaceutical Federation (FIP), a series of pictograms have been developed to help low-literacy patients better understand their drug therapy. The current study aims to gather feedback from healthcare professionals (nursing + pharmacy) to guide the design and layout of a pictographic medication reference table.

My work I helped a studentâ&#x20AC;&#x2122;s project by doing some surveys with different health care professionals: Pharmasists (of course), technicians, nurses â&#x20AC;Ś

Last version

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Time in motion study The study To determine the length of time taken from when a medication is ordered, to when the patient receives the medication. Also examined are the durations of many steps of this process. The purpose of this data collection is for accreditation purposes.

My work : Pharmacy time capture After incorporating the time stamp into the pharmacy workflow, it was possible to retrospectively examine medication orders from all units in the hospital to determine the length of time between when the order was received in pharmacy, to when the medication was ready for pickup at the porter window. Using this data, pharmacy times were calculated for orders from all units from September 28, 2010 to October 18, 2010, and median times were calculated. Times for IV orders and non-IV orders were analyzed separately, as it was expected that IV orders would take longer to prepare in pharmacy.

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Additional tasks I have done -

Methadone Project Review. I was supposed to work on this project but the protocol had not been approved by the REB yet.

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I had to find some literature about all the interactions that have been seen with Methadone especially those due to CYP2D6

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French translations of different text for the students who worked with me and didnâ&#x20AC;&#x2122;t speak french : The International Pharmaceutical Federation (FIP side effect pictograms), a French article about resin used in milkâ&#x20AC;Ś

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Summary of what is used in alternative medicine in palliative care patients (adults and pediatric) and assessment of potential drug or disease interaction from literature reviewed

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Review of the professional role of the pharmacist (self care and self medication), statement adopted by the Council of the International Pharmaceutical Federation (FIP) and summarize all the studentsâ&#x20AC;&#x2122; feedback.

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Review of the Discrepant Black Box Warning Labeling for Same-Class Drugs

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Finding some literature on how to manage some malodorant issues (parosmia, digueusie) in an end of life patient with cancer. Treatment choice : topical cocaine HCl (can temporarily block most distortions by anesthetizing the neurons)

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Others help in studies : name and number of dose of Fluid collected from all the electronic MAR, for one day, name of the different drugs with their route prepared by the pharmacy in one day.

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Rapport Erasmus OTTAWA  

Rappoort de Stage Erasmus fait par Sabine Derrey

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