NPPG Newsletter 19 - Neonatal and Paediatric Pharmacists Group

Editor: Peter Mulholland
Pharmacy Department
Southern General Hospital
1345 Govan Road
GLASGOW G51 4TF
Tel: 0141 201 1382
Fax: 0141 201 2996
Email: newsletter@nppg.demon.co.uk
www.nppg.demon.co.uk
Newsletter No 19 January 2002
Editorial
A summarised report from the conference
appeared in the UK Pharmaceutical
journal, and the Scottish chemists review,
bringing the group to a wider community
pharmacy view within the UK. The full
review will appear in the newsletter over
the next few issues. We still need some
workshops reports back – you know who
you are! The website goes from strength to
strength, with an increase in usage since
the site transferred to SHOW. We now
average 1,700 visitor sessions per month,
nearly 800 unique users each month and
over 900 documents sessions downloaded
last month. The message board continues
to grow with groups available for PICU,
NICU, Renal, SNAPP and general
discussion. If you want to join any of these
groups let me know.
The therapeutic guidelines index page is
one of the popular pages on the site – but
we need more information. Please send me
titles of your protocols.
NPPG Conference – Glasgow
September 2001
Welcoming delegates to the conference
JONATHAN BEST (Chief Executive
Yorkhill Trust) spoke of the levels of
deprivation for children in the Glasgow
area and how, in partnership with other
services, the health service in initiatives
such as free fruit for primary schools,
free swimming in all health centers for
children and oral hygiene services to
nurseries was hoping that early
intervention in child health would lead to
a reduction in adult health problems.
Dr JONATHAN COUTTS (Consultant
Neonatologist, Yorkhill Trust) spoke of
the advances in respiratory management
of premature babies. These advances
have led to a decrease in the number of
babies who develop Bronchopulmonary
Dysplasia (BPD) - defined as being
oxygen dependant at 28 days of age.
The introduction of artificial lung
surfactant has led to a decrease inn lung
disease and the main debate over it’s
use now lies in whether to use artificial
or naturally derived drug, and whether
it’s use should be prophylactic or as
rescue therapy. New ventilator
techniques, including high frequency
ventilation which optimizes lung inflation
have also been of benefit - better square
waves, shorter inspiratory times.
Treatment can optimize lung inflation,
using high pressures initially to aim for a
low (

chestiness and have subtle differences in
exercise intolerance in adulthood.
Premature babies have a high pulmonary
vascular resistance and a potential result
of this is the development of Persistent
Pulmonary Hypertension of the Newborn
(PPHN). This is a cardiopulmonary
disorder characterized by systemic
arterial hypoxemia secondary to
elevated pulmonary vascular resistance
with resultant shunting of pulmonary
blood flow to the systemic circulation.
Systemic vasodilators have side effects
and are not recommended. The
treatment of choice is inhaled nitric
oxide, which is a natural vasodilator and
only enters the ventilated alveoli. It is
inactivated by haemoglobin once it
enters the bloodstream. It is easy to give
via a ventilator and a portable system is
available for transfer of patients between
hospitals. Extracorporeal membrane
oxygenation (ECMO) is used as rescue
therapy in cases of severe respiratory
failure and is currently available in 4
centres in the UK.
complications associated with ECMO
include:
• haemhorrage (due to the need to
heparinise the blood flowing
through the circuit)
• circuit problems
• loss of the carotid artery
long term developmental studies are
awaited
drug therapy tends towards standard
doses and monitor where possible. If
ECMO is not working an alternative is
liquid ventilation using perfluorocarbons.
RSV (Respiratory Syncytial Virus) is a
common cause of bronchiolytis in babies
and young children. Healthy infants do
well (mortality < 1%) but high risk
infants can have a mortality up to 30%,
or can suffer long term respiratory
problems. Recently Palivizumab ( a
humanized murine RSV IgG monoclonal
antibody) has been launched for passive
vaccination against this illness.. Studies
have shown it to decrease hospitalisation
and ICU admissions, but treatment cost
is expensive at around £3,000 per
patient. In Greater Glasgow strict
adherence to the SPC guidance could
have resulted in an annual cost of over
£2 million. Following a review by
paediatricians and pharmacists
treatment criteria were agreed to target
the most vulnerable patients and this
was funded by the Health Board. In
addition to vaccination , in the
community parents have to be educated
to the risk of RSV, including the
prevention of cross infection. The role of
ribavirin was queried as to its
effectiveness.
Speaking on the topic of ‘Neonatal
Surgery - size does matter' CARL DAVIS
(Consultant Neonatal Surgeon, Yorkhill
Trust) covered the range of neonatal
conditions treated surgically at Yorkhill
including congenital anomalies (often
multiple) and prematurity associated
conditions such as Necrotising
Enterocolitis (NEC). As with respiratory
problems there is a changing pattern if
the diseases to be treated. The
prevalence of neural tube defects
continues to fall, even with the lack of
publicity on the use of folic acid in
women’s press. Many other defects are
picked up ante-natally.
With respect to pain control the use of
epidural analgesia has greatly benefited
neonatal surgery, with resultant
decrease in the need for post operative
ventilation. There still remains, however,
the need to find a suitable agent to
bridge the gap between paracetamol and
morphine.
Neonatal surgery requires a multidisciplinary
team and an example of this
is in the treatment of short bowel
disease. Here the aim is to get patients
home, possibly on home TPN. The
pharmacy aseptic unit at Yorkhill
provides, on average, 400TPN days to
the neonatal surgery unit per month.
Enteral feeding is used where possible
and, as with healthy babies, ‘breast is
best’.
Congenital diaphragmatic hernia is a
long term in-utero problem which can
result in complications, even after
surgery. An option is the use of in-utero
surgery, but this is still a very emotive
area.. Treatment strategies include
ECMO, but this does not treat the
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smaller lung, only resting the respiratory
circulation. A possible treatment option
is the use of liquid ventilation with
perfluorocarbons. There have been no
trails to date, only anecdotal data and
small series reports.
At the AGM of the NPPG the decision was
taken that the group would support the
formation of a faculty of Neonatal and
Paediatric Pharmacy by the College of
Pharmacy Practice. It is expected that
the faculty will be formed later this year.
The motion was also passed, with just
one vote against, that NPPG become a
'company limited by guarantee' with
each member's liability being £1.
Four members of the committee stood
down - Malcolm Partridge, Tony Nunn,
Anne Frankish and Vicky Bradnam.
There were 4 nominations for election,
so no election was necessary. At a
subsequent committee meeting over
lunchtime the roles of new chairman and
treasurer were decided. Details of the
new committee can be found on the
committee pages
At the close of conference James Wallace
praised the contributions of both
Malcolm Partridge and Tony Nunn to
NPPG. Both had been involved in the
foundation of the group and had made
major contributions to the group over
the past 7 years.
Clinical Pearls/Research
The use of sodium benzoate in
asparaginase’s overdose
S. Roy 1 , A. Doloy 1 , S. Djoussa-Kambou 1 ,
F. Legrand 2 , F. Brion 1 , A. Rieutord 1
1Service de pharmacie-toxicologie,
²service d’hématologie, Hôpital Robert
Debré AP-HP, Paris, France
Introduction : L-asparaginase is an
enzyme that catalyses the hydrolysis of
L-asparagine to L-aspartate and
ammonium. L-asparagine is an essential
amino-acid for the multiplication of
leukemia cells. This enzyme is
prescribed with other cytotoxic drugs, to
treat acute lymphoblastic leukaemia
(ALL) and non-Hodgkin lymphomas. We
report herein the case of an
asparaginase’s overdose, treated with
sodium benzoate.
Case report : D.T. (three-year-old, 0,66
m) suffering from ALL, received a
standardised chemotherapy protocol
EORTC (dexamethasone 3 mg/m²,
vincristine 1,5 mg/m², daunorubicine 30
mg/m², asparaginase E. Coli 10000
UI/m², intrathecal injections of
methotrexate, cytarabine and
hydrocortisone).
On the day 15 of the protocol, a dose of
aspariginase E. Coli, ten times higher
than the prescribed one’s, was
administered. The clinical examination
was normal although biological
parameters showed an increase of some
amino-acids (glutamic and asparticacids)
and ammonium : 224 µmol/L
(usual value : 14-38 µmol/L).
A sodium benzoate-based treatment, i.e.
206 mg/kg/day, was started and lasted
for three days.
Discussion : The main side effect of
asparaginase is the neurotoxicity due to
the depletion of asparagine, required for
cerebral formation, and the increase of
ammonium level. Sodium benzoate,
associated with glycine, has been used
as an alternative way to favor the
nitrogen excretion, as hippuric acid.
The day after the overdose, ammonium
level was highest, i.e. 319 µmol/L, then
decreasing quite rapidly. The child
presented no serious adverse effect and
kept receiving his chemotherapy
treatment three days after overdose.
Conclusion : No such overdose was
found in the literature except the case of
a four year old-boy who had received
4200 UI [1]. The treatment
recommended could be sodium benzoate
250 UI/kg/day but evidence for treating
patient after asparaginase’s overdose
still needs to be demonstrated. The
duration of treatment is unknown but it
could be established with respect to
ammonium level. Measurements of
ammonium, urea and amino-acids are
the key points of the monitoring.
[1] Leonard JV, Kay JD : Acute
encephalopathy and hyperammonemia
complicating treatment of acute
lymphoblastic leukaemia with
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asparaginase (letter). Lancet 1986 ; 1 :
162-3.
Practical use of area under the curve
dosing of vancomycin in endocarditis
(Naomi Warner, Alder Hey Children’s
Hospital)
AB was a 15-year-old female cardiac
patient who was admitted in April 2001
with increased temperature and rigors
having been generally unwell for six
weeks. Her previous medical history
included transposition of the great
arteries (TGA), ventricular septal defect
(VSD), pulmonary atresia, and right
ventricular outflow tract obstruction
(RVOTO). She had had a severe
postoperative sternal wound infection
and had been diagnosed with subacute
bacterial endocarditis (SBE) in 2000.
The impression made by the medical
team was that of endocarditis and she
was started on IV vancomycin bd and
teicoplanin loading then maintenance.
Following a ‘red man reaction’ to the
vancomycin her antibiotics were
subsequently changed to netilmicin tds
and teicoplanin.
Blood cultures showed growth of a
coagulase negative staphylococci, Staph
epidermidis, which was sensitive to
netilmicin and vancomycin. After
discussion with microbiology and the
cardiology team it was decided to restart
vancomycin extending the infusion time
from one hour to six hours and giving
chlorpheniramine IV pre dose.
Vancomycin was then changed to tds
dosing on the advice of the
microbiologist. On further investigation
this dosing schedule was based on a
paper written by Schentag JJ (1) which
discussed the reasons for insufficient
responses and the resistance of
organisms to vancomycin. This paper
investigated area under the inhibitory
curve (AUIC) dosing where the goal of
therapy is to cover the minimum
inhibitory curve (MIC) of the grampositive
pathogen, failure to cure and
resistance are consequences of failing to
cover the MIC. It stated that the usual
breakpoint for successful bacterial
eradication is an AUIC of >125.
In order to determine the AUIC for this
patient we needed to determine the MIC
for the organism we had, await steady
state and then take a peak sample (1hr
after the end of the infusion), and a
trough sample. Using the trapezoid rule
for area under the curve measurement
the AUIC could be calculated and the
dosing altered appropriately to maintain
therapeutic levels and ensure
eradication. All calculations were carried
out by pharmacy taking into account any
changes in renal function and CRP. IV
antibiotic treatment was continued for
six weeks, after which time blood
cultures were clear and AB was
discharged, returning twice weekly for
blood cultures and U&E’s.
REFERENCES
1) Schentag JJ 2001 Antimicrobial
management strategies for Grampositive
bacterial resistance in the
intensive care unit. Critical Care
Medicine Vol 29, No 4; 100-107
A scheme for the reporting of
adverse drug reactions in children A
Clarkson, I Choonara, Academic Division
of Child Health (University of
Nottingham), Derbyshire Children's
Hospital, Uttoxeter Road, Derby, DE22
3NE, UK
BACKGROUND- The safety of medicines
used in children is of considerable public
interest, yet available data to monitor
the safety of medicines in children is
limited.
AIMS- To raise awareness and stimulate
reporting of adverse drug reactions
(ADRs) in children in the Trent region.
METHODS- A pilot Paediatric Regional
Monitoring Centre (PRMC) was
established in October 1998 in the Trent
region. The scheme operates as an
extension of the UK's spontaneous
reporting scheme, The Yellow Card
Scheme run by the Medicines Control
Agency (MCA) and the Committee on
Safety of Medicines. Proactive
interventions including a monthly
reminder letter and presentations to
staff in the identified hospital have been
made.
RESULTS- There were 442 reports at the
end of the third year which included 9
fatalities. This is an increase compared
to the 40 reports for the year 1997/98.
66% of the reports were serious The
most commonly suspected medicine was
lamotrigine and the most commonly
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suspected reaction was rash. A wide
range of medicines are suspected of
causing a wide range of reactions. 60%
of the medicines suspected were being
used in a licensed manner.
CONCLUSION- The number of ADR
reports from the Trent region has
increased considerably since the scheme
started. The results so far show that
intensive education and promotion of
ADR reporting can result in a major
increase in reporting.
INTRATHECAL DRUG DELIVERY IN
CHILDREN WITH BRAIN TUMOURS S
Conroy 1 , D Walker 2 1 Academic Division of
Child Health, (University of Nottingham),
Derbyshire Children's Hospital, Derby
2 Academic Division of Child Health,
University of Nottingham, Queen's
Medical Centre, Nottingham
Background
Intrathecal drug therapy has been shown
to be successful in treating the
leptomeningeal spread of malignancies
such as leukaemia and lymphoma. It
has rarely been explored as a treatment
for primary CNS tumours. Treatment is
currently surgical resection and
radiation. Radiation causes neurocognitive
sequelae affecting the quality
of life of survivors. Alternative means of
treating these patients to improve
survival rates and reduce toxicity is
urgently needed. Intrathecal drug
delivery may offer this alternative by
bypassing the blood brain barrier and
allowing cytotoxic drugs access to
tumour cells. The aim of this project
was to identify drugs suitable for further
investigation for intrathecal
administration based on their
physicochemical characteristics and
current knowledge of use.
Methods
Available chemotherapy agents were
identified from pharmaceutical
textbooks. Literature searches using
Medline and Embase were conducted to
identify relevant physicochemical,
efficacy and toxicity data on all drugs.
Results
30,033 citations were screened covering
111 cytotoxic drugs. 90 drugs were
excluded for a variety of reasons. These
included literature evidence of
neurotoxicity, irritant or vesicant drug,
lack of efficacy in the appropriate
tumours, pro-drug requiring hepatic
activation. The remainder were
prioritised in terms of their potential
usefulness for intrathecal administration,
based on efficacy and toxicity
information, documented experience of
intrathecal delivery and relevant
physicochemical characteristics.
Conclusion
Drugs showing potential for
administration by the intrathecal route in
children with brain tumours were
identified. Further work should
determine which drugs will be worthy of
testing in clinical trials.
The potential for administering a ten
fold overdose to neonates - a
summary (K Turner, C Newman)
Introduction
The potential for medication errors in the
area of neonatal medicine is of great
concern. There have been several
reports of fatal errors, particularly due to
ten, one hundred or even one
thousandfold errors, i.e. decimal point
errors, in prescribing, preparation or
administration. This problem is
exacerbated by the high strength of
intravenous vials, which are often
tailored to the needs of adults. The aim
of the study was to determine the
proportion of prescribed doses where the
potential existed to prepare a tenfold or
one hundredfold overdose from the vial
strength available on the ward.
Method
Over a period of 6 weeks between
January and February 2001, all IV drugs
prescribed on the neonatal unit at QMC
were recorded. Information collected
included patient details, drug, dose,
number of doses given, whether the
prescription was for an infusion or a
bolus and time of prescribing. The doses
prescribed were compared to the
strength of vial available on the ward for
each drug.
Results
A total of 336 IV prescriptions were
recorded and 1348 IV doses were given.
Of these, 104 (31%) of the prescriptions
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were less than or equal to one tenth of a
vial. This equated to 333 IV doses (25%
of doses administered). Also, 16 (4.8%)
of prescriptions were less then one
hundredth of a vial, equating to 32 IV
doses (2.4% of doses administered).
Drugs highlighted as having a high
proportion of doses in the above
categories were indomethacin, insulin,
diamorphine and frusemide. It is
concerning that these are some of the
most harmful drugs in overdose.
Discussion
Many factors have been shown to affect
the incidence of administration errors.
These include nursing shortages and
high rates of interruption during
checking and administration of drugs. As
these situations occur on every unit,
safeguards must be put in place to
reduce the possibility of an error. The
results highlight the benefits of providing
a CIVAS service and indicate the areas of
highest risk and therefore most benefit.
However, the manufacture of lower
strength vials would make preparation
on the unit safer.
Conclusion
The potential for this type of error will
remain as long as vials are
manufactured with a view to treating
adults. The way forward may be the
formation of a Neonatal Unit consortium
that would increase purchasing power.
The national demand for smaller sized
vials or pressure from the licensing
authorities may result in manufacture of
neonatal targeted products.
Paediatric Medicines and the
UK Parliament
On 16 th October 2001 Dr Evan Harris
(Oxford West and Abingdon) asked the
Secretary of State for Health
(1) what recent assessment he has
made of drugs being used for the
treatment of children which are
not licensed for that purpose;
(2) what assessment he has made of
the need for research to establish
the safety and efficacy of all
drugs used in the treatment of
children;
(3) what estimate he has made of
the number of children who (a)
died and (b) were injured as a
result of treatment with drugs not
licensed for the treatment of
children in each of the last five
years; and if he will make a
statement;
(4) what steps he is taking to ensure
that pharmaceutical companies in
the United Kingdom provide clear
dosage information for children
and adults on all drugs they
produce; and if he will make a
statement
(5) what percentage of medicines
used for treatment of children do
not have a dosage approved by
the Medicines Control Agency;
and if he will make a statement.
In response Ms Hazel Blears
(Parliamentary Under-Secretary of State
for Health) replied:
‘We recognise the critical importance of
this issue and agree that children should
have access to medicines that have been
fully evaluated to the same high
standards of safety, quality and efficacy
as those available for the adult
population. The issue is not confined to
the United Kingdom, but affects the
whole of Europe and the United States.
Medicines regulation in the UK derives
largely from European legislation and an
international approach to the issue is
therefore needed.
We have consequently raised the profile
of this issue at a European level,
including taking the lead in developing a
European guideline, adopted in 1997, to
encourage companies to undertake
appropriate clinical trials on the use of
medicines in the treatment of children.
This formed the basis for an
international guideline, which came into
operation in January in the EU, and also
applies in the USA and Japan. In
addition, the Council of the European
Union has asked the European
Commission to bring forward measures
to make sure that medicines for children
are fully adapted to their specific needs.
We are presently waiting for their
proposals. However, the Commission has
stated its intention to comply with this
request. The UK will play an active role
in the development of this initiative to
ensure that effective solutions are found.
In addition, the Committee on
Proprietary Medicinal Products (CPMP),
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the scientific advisory committee of the
European Medicines Evaluation Agency
(EMEA), recognising the importance of
this topic has announced its intention to
set up a Paediatric Expert Group to
advise the EMEA and its scientific
committees on all questions relating to
the development and use of medicinal
products in children. The UK has
nominated representatives to this
Paediatric Expert Group.
In the meantime, the UK Government
have taken important steps to address
the issue at a national level within the
existing regulatory framework. The
Committee on Safety of Medicines
(CSM), an independent expert
committee that advises the Licensing
Authority has established a Paediatric
Sub-Group to provide expert advice on
the regulatory strategy to improve the
availability of medicines licensed for use
in children. MCA now routinely asks
companies for paediatric development
plans where appropriate. Pharmaceutical
companies are required by the Licensing
Authority to provide dosage information
in the Summary of Product
Characteristics when a Marketing
Authorisation for their medicinal product
is granted or amended in the UK. This
dosage information must be supported
by the findings from clinical trials
undertaken in the relevant adult or
paediatric patient population.
The safety of all medicines whether
licensed, used outside the terms of their
licence, or unlicensed, is monitored by
the Medicines Control Agency and CSM.
Various data sources are used for
monitoring safety including: the UK
Yellow Card Scheme for reporting
suspected adverse drug reactions,
suspected adverse drug reaction reports
from abroad, the world-wide medical and
scientific literature, clinical trial reports
and periodic safety updates from
manufacturers. The UK Yellow Card
Scheme acts as an early warning system
for drug safety hazards but is not a
scheme for recording all suspected
adverse reactions that occur in the UK.
Data from the Yellow Card Scheme
cannot, therefore, provide estimates of
the incidence of adverse reactions,
including fatal adverse reactions
occurring in children. The CSM Working
Group on Paediatric Medicines also
advises on the collection of information
on adverse reactions in relation to
unlicensed use of medicines in children.
ESDP Conference 2001
In November 2001, I attended the 7 th
Congress of the European Society for
Developmental Pharmacology which took
place in Limassol in Cyprus. The invited
speakers and delegates included
neonatologists, paediatricians and
pharmacists all with a special interest in
paediatric clinical pharmacology. A total
of 7 pharmacists attended the Congress
this year. The delegates were from
Europe and the United States. Invited
lectures included the topics of:
• Adverse drug reactions in children
• Input of pharmacokinetics in the
design of better and safer CNS
drugs
• Detecting adverse effects in
pregnancy
• Developmental pharmacology of
pain and analgesia
• Recent developments in
prostaglandin research
• Cox inhibitors and the kidney
• Cox inhibitors and the ductus
arteriosus
• The use of NSAIDs in the
perinatal and neonatal period
• Pharmacogenetics in drug
therapy and drug development
• Pharmacogenomic implications of
cholinesterase polymorphisms
• Gene targeting
• Pharmacoeconomics in
paediatrics
• Ethical aspects of involving
children in clinical research
• The need for transparency and
public disclosure of clinical trials
in children
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• New technologies for making
vaccines
• Prevention of RSV in infants
• Potential effects of new vaccines
on the pattern of drug usage in
paediatrics
Other lectures including progress reports
on the Paediatric Pharmacology Research
Unit Network in the United States and
the European Network for Drug
Investigation in Children were also held.
The final lecture discussed the challenge
of achieving optimal paediatric
pharmacotherapy in the developing
world. In addition to these invited
lectures, there was a series of free oral
communications presented on each day.
Some excellent work was presented and
abstracts of these presentations may be
found in the next edition of Paediatric
and Perinatal Drug Therapy which is due
out in December 2001. All NPPG
members will receive a copy of this.
Poster presentations were also done
where the posters were displayed for the
duration of the Congress and, at the
poster session times, each delegate was
given 5 minutes to talk about his/her
poster and to answer any questions.
This was a very interesting meeting,
where I learnt a lot. It was very intense
and hard work, but gave me the
opportunity to meet some well known
people whose work has been published
extensively. If anyone is interested in
further details of sessions from the
Congress, please do not hesitate to
contact me.
Sharon Conroy (Lecturer in Paediatric
Clinical Pharmacy Derbyshire Children’s
Hospital
First Scandinavian Paediatric
Pharmacy Conference
In October, 21 enthusiasts gathered in
Lund, Sweden, for the first Scandinavian
Paediatric Pharmacy Conference,
arranged by SPPG. The objectives of the
conference were to get an introduction in
the paediatric pharmacy area and to
establish and find the forms for a
knowledge-based network of
Scandinavian paediatric pharmacists.
The day started with Tor Skärby, clinical
pharmacologist and paediatrician, who
introduced us to drug dosage to infants
and children. The experienced nurse in
neonatology, Mari Wahlström, gave
practical advice on how pharmacists can
help on a neonatology ward. She
emphasised the difficulties of drug
administration and intravenous access in
neonates, and the need of a devoted
pharmacist. Ingrid Grönlie, Norway, gave
a report from the NPPG congress, which
she also recommended warmly.
The afternoon was spent in workshops
with the objective to establish guidelines
for investigating paediatric pharmacy
issues. The discussions were built on
case presentations by Per Nydert,
Sweden. The workshop presentations
were summarised in a checklist on useful
paediatric literature, and information on
how to proceed the investigation that
can be downloaded from the SPPG
homepage. Other statements were the
importance of consulting more than one
literature source, to use the pharmacist
network and experience, and ensure all
necessary questions are asked before
checking the literature. The possibilities
to compile information in a Scandinavian
Medicines for Children were discussed.
At the end of the day, a formal SPPG
union was formed and the goals of NPPG
were adopted. An interim board was
formed with the members: Siri Wang
(Tönsberg, Norway), Per Nydert
(Huddinge, Sweden), Sofia Jönsson
(Lund, Sweden), Ulla Hultström
(Göteborg, Sweden) and Åsa Andersson
(Stockholm, Sweden).
The arrangers were happy to find the
conference participants representing a
broad competency: hospital pharmacy,
pharmacy laboratory, research,
pharmacokinetics as well as a broad
geographic area. We all had a very
interesting and inspiring day and we are
now looking forward to next year's
conference.
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