BCG Vaccination

           In the pediatrics ID clinic the other day we had an interesting patient that I wanted talk about because this is something that we would not see in the US. This patient is a 3 year old girl who had a keloid around the area where she had her BCG vaccination. At first, there was inflammation around the site shortly after she had the vaccination administered. However, a keloid eventually formed that would occasionally bleed when it fell off. Of course the parents were very worried and took their daughter to the pediatrics ID clinic when they noticed that the keloid had not improved in over 2 months. At the clinic, the doctor was afraid that the inflammation would develop into an active form of TB so he had the patient started on isoniazid as prophylaxis. The doctor said the normally, isoniazid would have to be taken anywhere from 1-3 months.

            The Bacillus Calmette-Guerin (BCG) vaccination is given to babies in high risk TB areas. The vaccine is prepared from a strain of the live attenuated bovine tuberculosis bacillus, Mycobacterium bovis. Tuberculosis is the leading cause of notifiable diseases in Taiwan, with an estimated 15,000 new cases every year. In Taiwan, children are given the vaccination anywhere from the day they are born to 1 month later. When children are 12 years old, they all have to have a PPD test done at their school. In case the patient does not form an immune response, then he/she will have to get another BCG vaccination. Thus it is recommended to get a PPD test checked every 15 years because the effects of the vaccination can wear off.

            Normally the BCG vaccine is administered on the arm. However, due to cosmetic reasons (since the vaccination leaves a scar on the arm), parents have been opting to have their children vaccination in other areas of their body that are not as noticeable such as the buttocks are the bottom of their foot (this only works when the child is a baby). 

          Next week I will be giving a presentation on Extracorporeal Membrane Oxygenation (ECMO) dosing adjustments in the pediatrics population. Just as a preview, I recently had the privilege of seeing a neonate being placed on ECMO! 

Pediatrics Infectious Disease Clinic

            I attend the pediatrics outpatient infectious disease clinic every Tuesday and Friday mornings from 9 AM – 12 PM. This clinic consists of a doctor, 1 or 2 nurses, a 7^th year medical intern, and a pharmacy resident. NTUH has a recently started master of pharmacy program that allows pharmacists to pursue additional clinical experience in the hospital and do more research.

            Usually patients have to schedule an appointment with the doctor before the day of clinic. Spaces often fill up quickly so patients are advised to make an appointment several days in advance. Because of Taiwan’s National Health Insurance, anyone can make an appointment to see the doctor. As you can imagine, the patient load for the day can be very large. On average, we see ~35-40 patients in a 3 hour span. That’s roughly 5 minutes for each patient encounter!  When the patient first comes in, he/she will give his/her National Health Insurance card to either the nurse or the medical intern, who will then place the card on a special machine that will open up the patient’s file. This is a very nice way to centralize all of the patient data. The doctor will then assess the patient’s symptoms and make an appropriate diagnosis.  Once the doctor has decided on a treatment plan, he/she will write down the prescription and give it to the nurse or medical intern to input the medication into the computer and have it ready for the patient in the outpatient pharmacy. Unfortunately, the pharmacy resident is only allowed to observe.

            It has definitely been interesting seeing the illnesses that the pediatric population presents with.  For one thing, it almost seems like everyone has some sort of allergy. With my doctor, he commonly prescribes the antihistamine cetirizine. From my understanding, patients prefer to have the doctor tell them what medication they should take, even if the medication is available OTC. Because of this, the doctor will write a prescription for almost all OTC medications such as acetaminophen and ibuprofen.

            Another common illness that I saw was roseola, which is a viral infection that commonly infects infants and young children. It is most common in children ages 6 months – 1 year. This viral infection is caused by the human herpesvirus 6. Common symptoms that patients present with include a runny nose, sore throat, intermittent high fevers, and a pinkish colored rash that spreads throughout the body once the fevers subside. There is no specific treatment for roseola and symptomatic relief is often used such as acetaminophen to lower the fever. 

A view of the pediatrics ID clinic. 

The examination bed for the children

Compounding

            Today I had the opportunity to spend the afternoon in the compounding pharmacy. The use of powdered formulations was influenced by traditional Chinese medicine. The pediatric population often takes their medication in a powder form because it is easier to taken than tablets. Also, because many of the medications are dosed based on weight, smaller patients will likely need a dosage that is less than the tablet it is available in.

            There are three conditions that the compounding pharmacy strictly enforces. The first rule is that you need to check the medication to make sure that it’s correct. In the compounding pharmacy, there is an automation system that helps individually package the powder formulation into the correct dosage. It is important to only use one medication at a time with this machine to prevent any cross contamination. Second, the correct dose must be used. No modifications can be made in the middle of making the powder formulation. Third, the correct quantity must be used.

            When working in this environment, one must take note of special precautions to prevent contamination. You must wear a gown, a cap, and a special mask that prevents small particles from entering. You also have to wash your hands twice, making sure to pay special attention to the nail beds and the knuckles, which are areas that tend to have more germs. There is a special brush available as well to help get rid of the dead skin. When you are done, you can spray 75% ethyl alcohol on your hands before putting on your gloves.  You are now ready to start compounding.

            Our goal that afternoon was to make urso at three different strengths (16.7 mg, 25 mg, and 33.3 mg) using a 100 mg tablet. Urso is often used to treat small gallstones or to treat primary biliary cirrhosis. The first ingredient we work with is lactose monohydrate. This is somewhat equivalent to the syrup that we have in the US that is used to make liquid formulations. The purpose of the lactose is to make the medication taste better and to also increase the volume (which is important for medications where we’re only using a small fraction).

How to create a powder formulation

       1) Accurately measure out how much lactose you need. 

       2) Add the appropriate amount of tablets for your medication into the blender.

       3) For medications that are likely to stick to the blender (such as urso), add a little bit of  

       the lactose in as well.

       4) After blending the lactose and the medication, pour the contents into the mortar. 

       5) Make sure that you use the brush to get the remaining powder in the blender.

       6) Add the lactose and use the pestle to mix the powder.

       7) After you have made 60-80 rotations (both clockwise and counterclockwise), pour the  

       contents onto wax paper. 

       8) Use a brush to get the remaining powder in the mortar and pestle

       9) Add the contents into the automatic machine to separate the medication into unit dose  

       packaging. 

            Overall I had a great time compounding the urso tablets into a power formulation. While this can be somewhat of a labor intensive process, it is definitely help in creating a formulation that is appropriate for the pediatric population.

Pediatric ICU

            For the next 3 weeks, I will be at the pediatric ICU in the Children’s Hospital at NTUH. The Children’s Hospital consists of 700 beds, with ~300-400 of the beds being for the pediatric population. Due to spacing issues, women’s health (primarily breast/ovarian cancer patients and gynecology) is located at the Children’s Hospital as well. All children are treated in this hospital unless they are undergoing transplantation or are on the orthopedic service (mainly because this is a relatively small subset of the pediatric population), in which they will be treated in the main hospital.

            My first day was more of an orientation. Since this is my first pediatric rotation, my preceptors wanted me to be more familiar with the pediatric population so I spent part of my day reading the pediatric sections in Koda Kimble’s “Applied Therapeutics.” At NTUH, they use many of the resources that we reference to such as DiPiro’s “Pharmacology” and Lexi-Comp’s “Pediatric and Neonatal Dosage Handbook.”  

            From what I’ve heard it seems like medication dispensing is similar throughout the different pharmacy services. All of the pharmacists dispense and verify the medications. There is also no automation so this can prove to be a labor-intensive process in comparison to the United States. However, the inpatient pharmacy does have an automatic chemo dispenser which allows for a safe and closed system when working with chemotherapy.

            Only NTUH patients can use outpatient pharmacy to fill their medications. The pharmacy does not use telephone refills and the wait time is around 20-30 minutes. After the doctor enters the prescription into the computer via CPOE, the prescription is then printed out. In order to save time, the medication order is not verified first before it is filled. Instead the pharmacist will dispense and verify the medication before giving it to the patient. I will explain a little later how this is different in the inpatient pharmacy. Also, as opposed to the US who fill their medications in vials, in Taiwan they either use individual clear plastic bags or use blister packs that are already pre-packaged. No patient information is placed on the medication. The medication is then placed in another bag with the patient’s name on it. As you can imagine, this could lead to medication errors if the incorrect medication is placed in the patient’s bag. Another interesting aspect about the outpatient pharmacy is that the pharmacists teach patients how to reconstitute medications into liquid solutions using water. This is very prevalent in the pediatrics population. This is mainly done to help save time. However, if for whatever reason the adult is unable to reconstitute the medication (for example a grandparent who may have dexterity issues), then the pharmacist will do it in the pharmacy.

            The inpatient pharmacy also utilized CPOE. Like the US, the medication orders are verified first (as opposed to in the outpatient pharmacy). The medications are organized by alphabetical order by the brand name. In Taiwan, only one company is allowed to manufacture each drug so there is no confusion in terms of the brand name. Medication cassettes are also used to deliver medications to the wards. These cassettes are restocked and brought up to the floors once a day. All of the medications are pre packaged as a daily dose instead of a unit dose. Each cassette does have a divider available if the medication needs to be dosed more than once a day. When speaking with my preceptor, she acknowledged that one of the downfalls with their medication dispensing system is that they currently do not use a barcoding system. This can definitely lead to medication errors. She explained that this was partially because it is difficult to barcode all of the medications when the drugs are purchased from many countries. However, this is an area that NTUH’s pharmacy is working on to implement to help ensure quality assurance.              

The Children's Hospital at NTUH

The Children's Hospital has many hallways that are designed for the pediatric population. Here's an example of one of them!

Medication carts for the inpatient pharmacy

An example of how medications are packaged in Taiwan

Day 1 at NTUH

           Hello from Taipei, Taiwan! Today was my first day at the National Taiwan University Hospital (NTUH) for my international APPE experience. I will first be doing a 3 week rotation in the Pediatric ICU (PICU), followed by a 3 week rotation in family medicine. My classmate Johnny and I arrived early yesterday morning and checked into the NTU Faculty Alumni House. This housing is available for foreign exchange students at the hospital. My roommate is a medical student from Korea who is currently doing a 4-week rotation in the anesthesiology department. This has been great because I get to learn a little about how the medical school programs abroad.
            This next morning Johnny and I met with one of the assistants named Wen Chi, who is currently replacing our main contact Yu Chen while she is on maternity leave. After filling out paperwork, getting our IDs made, and meeting several faculty and  pharmacists in the School of Pharmacy, we headed off to our respective departments.
           The National Taiwan University Hospital (NTUH) was opened in 1885 and has been one of the leading medical centers in Taiwan.  Taiwan has a national health insurance system in which ~99% of the population is covered. Their department of pharmacy consists of different services such as:
            -Outpatient Pharmacy Services
            -Inpatient Pharmacy Services
            -Emergency Room Pharmacy Services
            -Oncology Pharmacy Services
            -Pareneteral Nutrition Services
            -Sections of Inventory Control
            -Drug Information Services
            -NTU Children’s Hospital Pharmacy Services
            The outpatient pharmacy dispenses 20,000 prescriptions per day. Unlike in the United States, pharmacies in Taiwan do not have technicians. Instead, all pharmacists are responsible for filling and verifying the prescriptions.
            The role of the pharmacist in the inpatient pharmacy is similar that in the United States. Pharmacists are responsible for filling and verifying prescriptions, ensuring the accuracy of medications dispensed, rounding with the medical team and applying clinical pharmacy services to help optimize patient care.
            Stay tuned for my next post in which I go into more detail about the NTUH Children’s Hospital!

Ready for our first day at NTUH!