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Pre-Pharmacy
University of Liberia
course: Pharmacy Application course (P-101)
Instructor: James O. Beyan, PharmD ©, BPharm, Rph, Bsc,
Pharmacy – What is it?
The goal of pharmacy is to guarantee that pharmaceuticals are used
in a safe, efficient, and cost-effective manner. Pharmacy is the
science and practice of discovering, producing, preparing,
dispensing, reviewing, and monitoring medications. It connects
health sciences with pharmaceutical sciences and natural sciences,
making it a diverse field of study. Since pharmaceutical corporations
currently produce the majority of the pharmaceuticals, professional
practice is shifting toward a clinical focus. Pharmacy practice is
divided into two categories: community pharmacy and institutional
pharmacy. Clinical pharmacy is the practice of providing direct
patient care in the network of institutional pharmacies.
Continuation: Pharmacy – What is it?
The range of pharmacy profession includes more
conventional tasks like pharmaceutical manufacturing and
dispensing. Additionally, it contains more up-to-date medical
services like clinical services, assessing prescriptions for
safety and efficacy, and giving out pharmacological
information. The major health care providers who maximize
the use of medication for the benefit of patients are
pharmacists, who are experts in drug therapy.
Continuation: Pharmacy – What is it?
The phrase "pharmacy" (more prevalent in the United States) or "
chemists" (more prevalent in Great Britain, but pharmacy is also
used) refers to a location where pharmacy (in the first meaning) is
practiced. Drugstores frequently sell medications in the United
States and Canada, along with other commodities including candy,
cosmetics, office supplies, toys, hair care products, periodicals, and
on occasion refreshments and food.
The work of the apothecary can be seen as a forerunner to the
current sciences of chemistry and pharmacology in its examination
of herbal and chemical components, before the creation of the
scientific method.
Area of Practice:
Community pharmacy, infusion pharmacies, hospitals, clinics,
insurance firms, medical communication firms, research
institutions, pharmaceutical businesses, extended care
homes, mental hospitals, and regulatory agencies are just a
few of the places where pharmacists’ practice. Even
pharmacists themselves may be skilled in a particular area of
medicine.
Community pharmacy:
Community Pharmacy:
is where most pharmacists practice the profession of
pharmacy. It is the community pharmacy in which the
dichotomy of the profession exists; health professionals who
are also retailers.
Community pharmacies usually consist of a retail storefront
with a dispensary, where medications are stored and
dispensed
Hospital pharmacy:
Pharmacies within hospitals differ considerably from
community pharmacies. Some pharmacists in hospital
pharmacies may have more complex clinical medication
management issues, and pharmacists in community
pharmacies often have more complex business and customer
relations issues.
Hospital pharmacy:
Because of the complexity of medications including specific
indications, effectiveness of treatment regimens, safety of
medications (i.e., drug interactions) and patient compliance issues
(in the hospital and at home), many pharmacists practicing in
hospitals gain more education and training after pharmacy school
through a pharmacy practice residency, sometimes followed by
another residency in a specific area. Those pharmacists are often
referred to as clinical pharmacists and they often specialize in
various disciplines of pharmacy.
For example, there are pharmacists who specialize in hematology/
oncology, HIV/AIDS, infectious disease, critical care, emergency
medicine, toxicology, nuclear pharmacy, pain management,
psychiatry, anti-coagulation clinics, herbal medicine, neurology/
epilepsy management, pediatrics, neonatal pharmacists and more.
Continuation: Hospital pharmacy:
Hospital pharmacies can often be found within the premises
of the hospital. Hospital pharmacies usually stock a larger
range of medications, including more specialized
medications, than would be feasible in the community setting.
Most hospital medications are unit-dose, or a single dose of
medicine. Hospital pharmacists and trained pharmacy
technicians compound sterile products for patients including
total parenteral nutrition (TPN), and other medications are
given intravenously. That is a complex process that requires
adequate training of personnel, quality assurance of products,
and adequate facilities.
Continuation: Hospital pharmacy:
Several hospital pharmacies have decided to outsource high-
risk preparations and some other compounding functions to
companies who specialize in compounding. The high cost of
medications and drug-related technology and the potential
impact of medications and pharmacy services on patient-care
outcomes and patient safety require hospital pharmacies to
perform at the highest level possible.
Clinical pharmacy
Pharmacists provide direct patient care services that
optimize the use of medication and promotes health,
wellness, and disease prevention. Clinical pharmacists care
for patients in all health care settings, but the clinical
pharmacy movement initially began inside hospitals and
clinics. Clinical pharmacists often collaborate with physicians
Continuation: Clinical Pharmacy
They often participate in patient care rounds for drug product
selection. In the UK clinical pharmacists can also prescribe
some medications for patients on the NHS or privately, after
completing a non-medical prescriber’s course to become an
Independent Prescriber.
The clinical pharmacist's role involves creating a
comprehensive drug therapy plan for patient-specific problems,
identifying goals of therapy, and reviewing all prescribed
medications prior to dispensing and administration to the
patient. The review process often involves an evaluation of the
appropriateness of drug therapy (e.g., drug choice, dose, route,
frequency, and duration of therapy) and its efficacy.
Continuation: Clinical Pharmacy
Research shows that pharmacist led strategies reduce errors related to
medication use. The pharmacist must also consider potential drug
interactions, adverse drug reactions, and patient drug allergies while they
design and initiate a drug therapy plan
Ambulatory care pharmacy:
Since the emergence of modern clinical pharmacy,
ambulatory care pharmacy practice has emerged as a unique
pharmacy practice setting. Ambulatory care pharmacy is
based primarily on pharmacotherapy services that a
pharmacist provides in a clinic. Pharmacists in this setting
often do not dispense drugs, but rather see patients in-office
visits to manage chronic disease states.
In the U.S. federal health care system, ambulatory care
pharmacists are given full independent prescribing authority.
In some states, these pharmacist clinicians are given
collaborative prescriptive and diagnostic authority. In 2011
the board of Pharmaceutical Specialties approved ambulatory
care pharmacy practice as a separate board certification.
Compounding pharmacy/industrial
pharmacy:
Compounding involves preparing drugs in forms that are
different from the generic prescription standard. This may
include altering the strength, ingredients, or dosage form.
Compounding is a way to create custom drugs for patients
who may not be able to take the medication in its standard
form, such as due to an allergy or difficulty swallowing.
Compounding is necessary for these patients to still be able
to properly get the prescriptions they need.
One area of compounding is preparing drugs in new dosage
forms. For example, if a drug manufacturer only provides a
drug as a tablet, a compounding pharmacist might make a
medicated lollipop that contains the drug. Patients who have
difficulty swallowing the tablet may prefer to suck the
medicated lollipop instead.
Compounding pharmacy/industrial
pharmacy:
Another form of compounding is by mixing different strengths
(g, mg, mcg) of capsules or tablets to yield the desired
amount of medication indicated by the physician, physician
assistant, nurse practitioner, or clinical pharmacist
practitioner. This form of compounding is found at
community or hospital pharmacies or in-home administration
therapy.
Compounding pharmacies specialize in compounding,
although many also dispense the same non-compounded
drugs that patients can obtain from community pharmacies.
Consultant pharmacy:
Consultant pharmacy practice focuses more on medication regimen review (i.e. "
cognitive services") than on actual dispensing of drugs. Consultant pharmacists
most typically work in nursing homes, but are increasingly branching into other
institutions and non-institutional settings.
Traditionally consultant pharmacists were usually independent business owners,
though in the United States many now work for a large pharmacy management
company such as Omnicare, Kindred Healthcare or PharMerica.
. This trend may be gradually reversing as consultant pharmacists begin to work
directly with patients, primarily because many elderly people are now taking
numerous medications but continue to live outside of institutional settings. Some
community pharmacies employ consultant pharmacists and/or provide
consulting services.
Veterinary pharmacy:
Veterinary pharmacies, sometimes called animal pharmacies,
may fall in the category of hospital pharmacy, retail pharmacy
or mail-order pharmacy.
Veterinary pharmacies stock different varieties and different
strengths of medications to fulfill the pharmaceutical needs of
animals.
Because the needs of animals, as well as the regulations on
veterinary medicine, are often very different from those related
to people, in some jurisdictions veterinary pharmacy may be
kept separate from regular pharmacies.
Nuclear pharmacy:
Nuclear pharmacy focuses on preparing radioactive materials for
diagnostic tests and for treating certain diseases.
Nuclear pharmacists undergo additional training specific to handling
radioactive materials, and unlike in community and hospital pharmacies,
nuclear pharmacists typically do not interact directly with patients.
Military pharmacy:
Military pharmacy is a different working environment to civilian practice
because, military pharmacy technicians perform duties such as evaluating
medication orders, preparing medication orders, and dispensing medications.
This would be illegal in civilian pharmacies because these duties are required
to be performed by a licensed registered pharmacist.
Continuation: Nuclear pharmacy:
In the US military, state laws that prevent technicians from counseling patients or
doing the final medication check prior to dispensing to patients (rather than a
pharmacist solely responsible for these duties) do not apply.
Pharmacy informatics
Pharmacy informatics is the combination of pharmacy practice science and
applied information science. Pharmacy informaticists work in many practice
areas of pharmacy, however, they may also work in information technology
departments or for healthcare information technology vendor companies.
As a practice area and specialist domain, pharmacy informatics is growing
quickly to meet the needs of major national and international patient information
projects and health system interoperability goals. Pharmacists in this area are
trained to participate in medication management system development,
deployment, and optimization.
Specialty pharmacy:
Specialty pharmacies supply high-cost injectable, oral, infused,
or inhaled medications that are used for chronic and complex
disease states such as cancer, hepatitis, and rheumatoid
arthritis.
. Unlike a traditional community pharmacy where
prescriptions for any common medication can be brought in
and filled, specialty pharmacies carry novel medications that
need to be properly stored, administered, carefully monitored,
and clinically managed.
In addition to supplying these drugs, specialty pharmacies
also provide lab monitoring, adherence counseling, and assist
patients with cost-containment strategies needed to obtain
their expensive specialty drugs.
Specialty pharmacy Cont.
In the US, it is currently the fastest-growing sector of the pharmaceutical
industry with 19 of 28 newly FDA approved medications in 2013 being
specialty drugs.
Due to the demand for clinicians who can properly manage these specific
patient populations, the Specialty Pharmacy Certification Board has
developed a new certification exam to certify specialty pharmacists.
Along with the 100 questions computerized multiple-choice exam,
pharmacists must also complete 3,000 hours of specialty pharmacy
practice within the past three years as well as 30 hours of specialty
pharmacist continuing education within the past two years.
The Important Role of Pharmacy in Healthcare:
If we’re going to talk about healthcare, it’s like diving deep into a vast endless
ocean of topics disciplines, professions, knowledge.
But before we go further, we need to clear things up a little bit. We all might see or
read Health Care with two words and Healthcare with one word scattered all over
the internet, which gives a bit of confusion to Us.
Definition of Healthcare:
So, simply put according to Dr. Waldman, of the blog Medical Malprocess. “Health
care—two words—refers to provider actions. Healthcare—one word—is a system.
We need the second in order to have the first,” Health care is the specific things
that people do: see a patient or prescribe medication. Healthcare is an industry,
the system by which people get the health care they need.
Pharmacy in Healthcare:
As We already know that Healthcare is a system that is supported by
many disciplines that is important to its growth. Specifically one of
these disciplines is Pharmacy.
. Pharma is the root word of Pharmacy, which is the knowledge and
procedure of manufacturing as well as administration of drugs.
To be more specific, Pharmacy is a clinical health science that links
medical science with chemistry and it is charged with the discovery,
production, disposal, safe and effective use, and control of
medications and drugs.
Pharmacists are responsible for the preparation of the dosage forms
of drugs, such as tablets, capsules, and sterile solutions for injection.
History of Pharmacy:
Pharmacy is an ancient discipline, the art of healing as old as
time. A short history of pharmacy can be traced all over the
world, from the Greek mythology of Hygieia.
She is known as an apothecary or pharmacist of Asclepius the
Greek god of medicine. Hygieia’s duty is compounding
Asclepius’s remedies.
From ancient Greek to clay tablets record prescriptions for
medicine that was found in the 4th millennium BC in Sumeria.
. All the way to India in the form of The Sushruta Samhita, an
ancient Sanskrit text on medicine and surgery.
The Important Role of Pharmacy:
As We already discussed above, pharmacy holds a critical role in the
Healthcare system. Pharmacy’s existence is to support and sustain the
healthcare system
Including clinical services, reviewing medications for safety and
efficacy, and providing drug information.
The important role of pharmacy can be further elaborated as below:
1. Processing of Prescriptions
The pharmacist verifies the legality, safety, and appropriateness of the
prescription order, checks the patient medication record before
dispensing the prescription.
The Important Role of Pharmacy Cont.
2. Care of patients or clinical pharmacy:
The pharmacist seeks to collect and integrate information about the
patient’s drug history, clarify the patient’s understanding of the
intended dosage regimen and method of administration, and advise
the patient of drug-related precautions.
3. Monitoring of drug utilization:
The pharmacist can participate in arrangements for monitoring the
utilization of drugs, such as practice research projects, and schemes
to analyze prescriptions for the monitoring of adverse drug reactions.
The Important Role of Pharmacy Cont.
4. Extemporaneous preparation and small-scale manufacture of
medicines:
Pharmacists everywhere continue to prepare medicines in the
pharmacy. This enables them to adapt the formulation of a medicine to
the needs of an individual patient.
5. Traditional and alternative medicines:
In some countries, pharmacists supply traditional medicines and
dispense homeopathic prescriptions
6. Responding to symptoms of minor ailments:
The pharmacist receives requests from members of the public for
advice on a variety of symptoms and when indicated, refers the
inquiries to a medical practitioner.
The Important Role of Pharmacy Cont.
7. Informing health care professionals and the public:
The pharmacist can compile and maintain information on all
medicines, and particularly on newly introduced medicines.
8. Health promotion:
The pharmacist can take part in health promotion campaigns, locally
and nationally, on a wide range of health-related topics, and particularly
on drug-related topics, for example, rational use of drugs, alcohol
abuse, tobacco use, discouragement of drug use during pregnancy,
organic solvent abuse, poison prevention.
The Important Role of Pharmacy Cont.
9. Domiciliary services:
In a number of countries, the pharmacist provides an advisory as
well as a supply service to residential homes for the elderly, and
other long-term patients.
So, now that you know a little bit better how important pharmacy’s
role is in healthcare you probably might consider yourself to be a
pharmacist. Not only it is a noble job but also has a promising future
career path.
Exploring the role of pharmacy in the primary
health care and the prevention agenda:
Community pharmacists and pharmacies have a key role to play in
supporting healthy ageing and the maintenance of good health and quality
of life across the life course.
Harnessing their widespread distribution and accessibility, their close
relationship with and knowledge of the community they serve, their long
opening hours and, in most countries, teams of highly qualified health
professionals, will allow pharmacies to play an even greater role in
developing and delivering primary health care strategies, in collaboration
with colleagues across the health care team.
Three core areas in which pharmacy plays a key role in healthy ageing and
primary health care include the effective management of non-
communicable diseases (NCDs), the promotion of vaccination and
immunization, and the support of adherence to treatments.
Prevention, screening and management of
non-communicable diseases:
NCDs, such as cardiovascular diseases, cancer, chronic respiratory
diseases and diabetes, are conditions of long duration and slow
progression, having the most significant impact on quality of life and
mortality worldwide.
Their devastating social, human, economic and public health impact is
recognized as a global burden by societies and economies across the
world.
According to the WHO, more than 36 million people die annually from
NCDs, representing more than 60% of deaths worldwide, with 15 million
people dying before the age of 70. At any one time, one in five people in
the western world are expected to have more than one chronic condition.
Incidence rates of NCDs and their complications could be reduced if
affordable, evidence-based preventative actions were implemented
Prevention, screening and management of
non-communicable diseases: Cont.
Measures include screening for and early detection of diseases;
prevention through education to promote behavioral change; a re-
evaluation of access to medicine; evidence-based therapy; disease
management to initiate and implement therapy; and fostering adherence
to treatment.
Prevention and control of NCDs require interventions that are
therapeutically cost-effective, affordable and resource-feasible for both
patients and health systems. Interventions need to be framed within
national policies and in line with NCD and risk-factor indicators.
Chosen interventions should contribute to improving equity in health
care in both targeted populations and individuals, as well as improving
health outcomes.
Prevention, screening and management of
non-communicable diseases: Cont.
Several studies have outlined the benefits of pharmacists in the therapeutic
management of patients with chronic diseases. In the past years, community
pharmacists have engaged in generating hard evidence of the benefits of
such roles, expanding the profession’s scope of practice.
A 2019 report by the International Pharmaceutical Federation (FIP) points
out that pharmacists can implement public health programs, conduct
preventive measures, screen and refer potential patients, support prescribing
and improve patients’ adherence to a safe therapeutic plan, including
pharmacological and non-pharmacological therapies.
In the context of NCDs, pharmacists use their proven expertise and new
technologies to be a valuable part of the multidisciplinary healthcare team,
making a unique contribution to the clinical results of medicines therapy and
consequently to quality of life.
Improving vaccination coverage:
As a result of population ageing, susceptibility to vaccine-preventable
diseases is growing and so are the potential complications resulting from
these diseases, as a greater share of the population has limiting
comorbidities.
Vaccine-preventable diseases, such as influenza, pneumococcal disease,
herpes zoster and pertussis, are a significant cause of morbidity, loss of
quality of life and mortality in older people.
Life-long vaccination programs and the importance of vaccination for the
elderly are often underestimated.10 It is of paramount importance to
increase the focus on vaccination throughout the life course and to
ensure access to vaccines that are relevant for each age group.
Improving vaccination coverage:
This requires new responses by health systems, and as outlined in a
recent report by FIP, pharmacists can and should be part of the solution
through a variety of roles, from providing evidence-based advice on
vaccines, to administering vaccines to keeping vaccination records.
Improving adherence to treatments:
Non-adherence to medication is a significant cause of treatment failure
and a major public health concern. The consequences of non-adherence
are greater in older people because they may require a greater number of
medicines and may have greater difficulty managing their medication due
to declines in cognitive function, memory, mobility or manual dexterity.
Improving adherence to treatments: Cont.
New medicines services, increased counselling services when a
medicine is supplied repeatedly, dosage administration aids and
reminder systems are among a list of pharmacy interventions with
evidence of improving medication adherence in elderly patients with
chronic conditions.
A recent FIP report reviewed existing knowledge of pharmacy
programs and services to improve adherence in this growing patient
population.
The Role of Pharmacist in Public health:
What is public health?
Public health can be defined as “what we in term of society do to persuade the
conditions in which people can be healthy.” It is not about medicine, but it also
“emphasizes” the prevention of disease and the needs of the population health as a
whole. What is Public Health Science?
Public Health Science is the art of preventing disease, increasing longevity of life
and promoting health through efforts and choices made by society, public and
private organizations, the community and by individuals.
Public Health Science deals with dangers to the public health of a population,
whether small or large (i.e. populations of a continent) to improve the quality of
health and the quality of life in through detecting and preventing disease and other
physical and mental health conditions, promoting health behaviors, tracking cases
and health indicators. Public Health Science uses a multi-disciplinary method
incorporating epidemiology, biostatistics and health services.
The Role of Pharmacist in Public health: Cont.
What are public health services?
Public health services occur on two measures: the macro measures and
micro measures i.e., planning and the implementation of planning,
respectively. Macro-level public health measures target on the health of
the population as a whole.
These services include identification of health-related community
problems with community representatives, planning community health
programs and policies, administering and evaluating community health
promotion programs, educating the community about public health, and
researching and publishing facts about public health actions.
All these activities are exercised by public health professionals of
different backgrounds. Micro-level public health measures consist of the
activities necessary to execute public health plans.
The Role of Pharmacist in Public health: Cont.
These services are carried out on a “program-to-population or a provider-to-
patient basis”. For examples; the screening of diseases, tobacco-cessation
programs immunization programs, and counseling for at-risk populations.
The overall concept beneath these so many public health activities is prevention,
which can be categorized into three types: primary prevention secondary
prevention and tertiary prevention i.e., reduction of the occurrence of diseases,
decrease the progression of the disease, and treatment of disease to return the
initial state respectively.
What should be the public health activities of a
pharmacist?
In 1981, the role of the pharmacist in public health is defined by the
American Public Health Association (APHA).
This association outlined that the role of the pharmacist is now escalating
beyond the dispensation and distribution of medicines, and health supplies.
Today, the administrative, and public health functions are also included in
the services of pharmacists. Now, it becomes more patient-oriented.
A pharmacist can provide many services to public health that may include
pharmacotherapy, provide care, and prevention measures.
A pharmacist has an available resource for health and medication
information apart from dispensing medicine.
What should be the public health activities of a
pharmacist?
Due to valuable placement of pharmacists in the clinical community, the
integration of public health custom into pharmaceutical care, and
pharmacological training is indispensable.
The public health services that an individual pharmacist performs will depend
on the abilities, experience, training, and work methodology.
. APHA believes that all pharmacists can contribute to the promotion of public
health by working alone or in cooperation with health care colleagues and
administrators.
The following are the other activities where pharmacists can play an
important role to promote public health:
What should be the public health activities of a
pharmacist? Cont.
1. Population-based Care:
The Center for Advancement in Pharmaceutical Education (CAPE)
Educational Outcomes suggested that pharmacists should involve in both
patient-based and population-based care.
In the past twenty years, the health-system pharmacists can support
public health efforts using designing and providing disease management
programs.
The health-system pharmacists with their health care colleagues can
contribute to population health care using tools such as medication-use
evaluation, evidence-based disease management programs that are
planned according to the needs of the served institutions and
communities.
Health-system pharmacists can involve in quality reviews by which they
What should be the public health activities
of a pharmacist? Cont.
2. Prevention of Disease and Medication Safety:
A pharmacist can be indulged in the prevention and control of disease in many
way. They can help in the establishment of some screening programs to check
out the status of immunization, and identification of some undiagnosed
medical conditions.
The federal government’s Healthy People 2010 initiative is also outlined the role
of health-system pharmacists in medication safety and error prevention.
These practices can reduce the number of hospital admissions due to reasons
for drug therapy mismanagement and counterfeit medications. Medication
reconciliation programs are one of the vital tools with which pharmacists can
achieve these goals.
What should be the public health activities of a
pharmacist? Cont.
3. Health Education:
The development of programs on the safe and effective use of medication,
and other public health-related topics, such as exercise, healthy nutrition and
tobacco cessation, is also an important area where pharmacists play their role.
The education and training programs are beneficial for public health care if
they start at an early age, such as school health programs, which help in the
development of good health behaviors in children that can continue into
adulthood also. Pharmacists should support these types of school health
programs.
Furthermore, health-system pharmacists can educate their health care
colleagues about the safe and effective use of medication that further
improves use of medications.
The pharmacists can also educate community leaders like public office
holders, legislators, school officials, regulators, and religious leaders who
What should be the public health activities of a
pharmacist? Cont.
4. Public Health Policy:
Health-system pharmacists can participate in the development of public health
policy concerned with local boards of health as well as national programs.
Drugs are the central part of health systems. Hence, the health policy, especially
policy targeted for chronic disease, must be prepared with better consideration
of drug therapy as well as factors affecting the disease outcomes.
The role of Health-system pharmacists in emergency planning and service
delivery of specialized pharmaceuticals like antidotes, vaccines, and antibiotics
is critical.
What should be the public health activities of a
pharmacist? Cont.
5. Research and Training:
A health-system pharmacist must get adequate education and training to carry
out his responsibility in public health. Health-system pharmacists should be
expertise in pharmacoepidemiology, research methodology, and biostatistics
with their applications in decision related to public health.
He should have an understanding of the design, conduct, and interpretation of
clinical studies.
Health-system pharmacists should participate in collaborative research and
serve on data monitoring and safety committees, institutional review boards,
and expert medication advisory committees. Moreover, the research fellows
need exposure to research in public health policy, Pharmacoeconomics,
pharmacoepidemiology, and evidence-based medicine for experimental and
instructive training.
What should be the public health activities
of a pharmacist? Cont.
Future Aspects:
The revolutionary progress in biomedical sciences, including stem-cell
biology, human genomics, biomedical engineering, immunology, and
bioinformatics, open the door to provide information for the betterment of
human health.
New technology and practices such as population genetics and
pharmacogenomics will allow reduction in failures of treatment and prevent
adverse drug reactions using the proper appliance of pharmacogenetic
principles.
Health-system pharmacists will need to apply these new tools not to get
better patient-specific pharmacotherapy but to progress public health. Health
professionals, as well as the legislators, will require education and training
about the safe use of new medication delivery technologies.
Assignment:
Assignment#: 1
What was your previous idea of the Profession and the Professional area of application?
What’s the meaning of dosage forms?
Explain the difference between the following medication dosage unit: g, mg, & mcg
What are radioactive materials?
What are novel medications?
What are novel medications ?
List three examples of radioactive materials in the practice of Pharmacy
Discuss the following : Primary, Secondary, and tertiary levels in public health service
delivery
Assignment#: 2
Has this course in anyway impacted your decision to pursue your career as a Doctor of
Pharmacy ? If Yes, how? If No, why not ? Explain in 250 words

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Pharmacy Application Pdf.pdf

  • 1. Pre-Pharmacy University of Liberia course: Pharmacy Application course (P-101) Instructor: James O. Beyan, PharmD ©, BPharm, Rph, Bsc,
  • 2. Pharmacy – What is it? The goal of pharmacy is to guarantee that pharmaceuticals are used in a safe, efficient, and cost-effective manner. Pharmacy is the science and practice of discovering, producing, preparing, dispensing, reviewing, and monitoring medications. It connects health sciences with pharmaceutical sciences and natural sciences, making it a diverse field of study. Since pharmaceutical corporations currently produce the majority of the pharmaceuticals, professional practice is shifting toward a clinical focus. Pharmacy practice is divided into two categories: community pharmacy and institutional pharmacy. Clinical pharmacy is the practice of providing direct patient care in the network of institutional pharmacies.
  • 3. Continuation: Pharmacy – What is it? The range of pharmacy profession includes more conventional tasks like pharmaceutical manufacturing and dispensing. Additionally, it contains more up-to-date medical services like clinical services, assessing prescriptions for safety and efficacy, and giving out pharmacological information. The major health care providers who maximize the use of medication for the benefit of patients are pharmacists, who are experts in drug therapy.
  • 4. Continuation: Pharmacy – What is it? The phrase "pharmacy" (more prevalent in the United States) or " chemists" (more prevalent in Great Britain, but pharmacy is also used) refers to a location where pharmacy (in the first meaning) is practiced. Drugstores frequently sell medications in the United States and Canada, along with other commodities including candy, cosmetics, office supplies, toys, hair care products, periodicals, and on occasion refreshments and food. The work of the apothecary can be seen as a forerunner to the current sciences of chemistry and pharmacology in its examination of herbal and chemical components, before the creation of the scientific method.
  • 5. Area of Practice: Community pharmacy, infusion pharmacies, hospitals, clinics, insurance firms, medical communication firms, research institutions, pharmaceutical businesses, extended care homes, mental hospitals, and regulatory agencies are just a few of the places where pharmacists’ practice. Even pharmacists themselves may be skilled in a particular area of medicine.
  • 6. Community pharmacy: Community Pharmacy: is where most pharmacists practice the profession of pharmacy. It is the community pharmacy in which the dichotomy of the profession exists; health professionals who are also retailers. Community pharmacies usually consist of a retail storefront with a dispensary, where medications are stored and dispensed
  • 7. Hospital pharmacy: Pharmacies within hospitals differ considerably from community pharmacies. Some pharmacists in hospital pharmacies may have more complex clinical medication management issues, and pharmacists in community pharmacies often have more complex business and customer relations issues.
  • 8. Hospital pharmacy: Because of the complexity of medications including specific indications, effectiveness of treatment regimens, safety of medications (i.e., drug interactions) and patient compliance issues (in the hospital and at home), many pharmacists practicing in hospitals gain more education and training after pharmacy school through a pharmacy practice residency, sometimes followed by another residency in a specific area. Those pharmacists are often referred to as clinical pharmacists and they often specialize in various disciplines of pharmacy. For example, there are pharmacists who specialize in hematology/ oncology, HIV/AIDS, infectious disease, critical care, emergency medicine, toxicology, nuclear pharmacy, pain management, psychiatry, anti-coagulation clinics, herbal medicine, neurology/ epilepsy management, pediatrics, neonatal pharmacists and more.
  • 9. Continuation: Hospital pharmacy: Hospital pharmacies can often be found within the premises of the hospital. Hospital pharmacies usually stock a larger range of medications, including more specialized medications, than would be feasible in the community setting. Most hospital medications are unit-dose, or a single dose of medicine. Hospital pharmacists and trained pharmacy technicians compound sterile products for patients including total parenteral nutrition (TPN), and other medications are given intravenously. That is a complex process that requires adequate training of personnel, quality assurance of products, and adequate facilities.
  • 10. Continuation: Hospital pharmacy: Several hospital pharmacies have decided to outsource high- risk preparations and some other compounding functions to companies who specialize in compounding. The high cost of medications and drug-related technology and the potential impact of medications and pharmacy services on patient-care outcomes and patient safety require hospital pharmacies to perform at the highest level possible. Clinical pharmacy Pharmacists provide direct patient care services that optimize the use of medication and promotes health, wellness, and disease prevention. Clinical pharmacists care for patients in all health care settings, but the clinical pharmacy movement initially began inside hospitals and clinics. Clinical pharmacists often collaborate with physicians
  • 11. Continuation: Clinical Pharmacy They often participate in patient care rounds for drug product selection. In the UK clinical pharmacists can also prescribe some medications for patients on the NHS or privately, after completing a non-medical prescriber’s course to become an Independent Prescriber. The clinical pharmacist's role involves creating a comprehensive drug therapy plan for patient-specific problems, identifying goals of therapy, and reviewing all prescribed medications prior to dispensing and administration to the patient. The review process often involves an evaluation of the appropriateness of drug therapy (e.g., drug choice, dose, route, frequency, and duration of therapy) and its efficacy.
  • 12. Continuation: Clinical Pharmacy Research shows that pharmacist led strategies reduce errors related to medication use. The pharmacist must also consider potential drug interactions, adverse drug reactions, and patient drug allergies while they design and initiate a drug therapy plan
  • 13. Ambulatory care pharmacy: Since the emergence of modern clinical pharmacy, ambulatory care pharmacy practice has emerged as a unique pharmacy practice setting. Ambulatory care pharmacy is based primarily on pharmacotherapy services that a pharmacist provides in a clinic. Pharmacists in this setting often do not dispense drugs, but rather see patients in-office visits to manage chronic disease states. In the U.S. federal health care system, ambulatory care pharmacists are given full independent prescribing authority. In some states, these pharmacist clinicians are given collaborative prescriptive and diagnostic authority. In 2011 the board of Pharmaceutical Specialties approved ambulatory care pharmacy practice as a separate board certification.
  • 14. Compounding pharmacy/industrial pharmacy: Compounding involves preparing drugs in forms that are different from the generic prescription standard. This may include altering the strength, ingredients, or dosage form. Compounding is a way to create custom drugs for patients who may not be able to take the medication in its standard form, such as due to an allergy or difficulty swallowing. Compounding is necessary for these patients to still be able to properly get the prescriptions they need. One area of compounding is preparing drugs in new dosage forms. For example, if a drug manufacturer only provides a drug as a tablet, a compounding pharmacist might make a medicated lollipop that contains the drug. Patients who have difficulty swallowing the tablet may prefer to suck the medicated lollipop instead.
  • 15. Compounding pharmacy/industrial pharmacy: Another form of compounding is by mixing different strengths (g, mg, mcg) of capsules or tablets to yield the desired amount of medication indicated by the physician, physician assistant, nurse practitioner, or clinical pharmacist practitioner. This form of compounding is found at community or hospital pharmacies or in-home administration therapy. Compounding pharmacies specialize in compounding, although many also dispense the same non-compounded drugs that patients can obtain from community pharmacies.
  • 16. Consultant pharmacy: Consultant pharmacy practice focuses more on medication regimen review (i.e. " cognitive services") than on actual dispensing of drugs. Consultant pharmacists most typically work in nursing homes, but are increasingly branching into other institutions and non-institutional settings. Traditionally consultant pharmacists were usually independent business owners, though in the United States many now work for a large pharmacy management company such as Omnicare, Kindred Healthcare or PharMerica. . This trend may be gradually reversing as consultant pharmacists begin to work directly with patients, primarily because many elderly people are now taking numerous medications but continue to live outside of institutional settings. Some community pharmacies employ consultant pharmacists and/or provide consulting services.
  • 17. Veterinary pharmacy: Veterinary pharmacies, sometimes called animal pharmacies, may fall in the category of hospital pharmacy, retail pharmacy or mail-order pharmacy. Veterinary pharmacies stock different varieties and different strengths of medications to fulfill the pharmaceutical needs of animals. Because the needs of animals, as well as the regulations on veterinary medicine, are often very different from those related to people, in some jurisdictions veterinary pharmacy may be kept separate from regular pharmacies.
  • 18. Nuclear pharmacy: Nuclear pharmacy focuses on preparing radioactive materials for diagnostic tests and for treating certain diseases. Nuclear pharmacists undergo additional training specific to handling radioactive materials, and unlike in community and hospital pharmacies, nuclear pharmacists typically do not interact directly with patients. Military pharmacy: Military pharmacy is a different working environment to civilian practice because, military pharmacy technicians perform duties such as evaluating medication orders, preparing medication orders, and dispensing medications. This would be illegal in civilian pharmacies because these duties are required to be performed by a licensed registered pharmacist.
  • 19. Continuation: Nuclear pharmacy: In the US military, state laws that prevent technicians from counseling patients or doing the final medication check prior to dispensing to patients (rather than a pharmacist solely responsible for these duties) do not apply. Pharmacy informatics Pharmacy informatics is the combination of pharmacy practice science and applied information science. Pharmacy informaticists work in many practice areas of pharmacy, however, they may also work in information technology departments or for healthcare information technology vendor companies. As a practice area and specialist domain, pharmacy informatics is growing quickly to meet the needs of major national and international patient information projects and health system interoperability goals. Pharmacists in this area are trained to participate in medication management system development, deployment, and optimization.
  • 20. Specialty pharmacy: Specialty pharmacies supply high-cost injectable, oral, infused, or inhaled medications that are used for chronic and complex disease states such as cancer, hepatitis, and rheumatoid arthritis. . Unlike a traditional community pharmacy where prescriptions for any common medication can be brought in and filled, specialty pharmacies carry novel medications that need to be properly stored, administered, carefully monitored, and clinically managed. In addition to supplying these drugs, specialty pharmacies also provide lab monitoring, adherence counseling, and assist patients with cost-containment strategies needed to obtain their expensive specialty drugs.
  • 21. Specialty pharmacy Cont. In the US, it is currently the fastest-growing sector of the pharmaceutical industry with 19 of 28 newly FDA approved medications in 2013 being specialty drugs. Due to the demand for clinicians who can properly manage these specific patient populations, the Specialty Pharmacy Certification Board has developed a new certification exam to certify specialty pharmacists. Along with the 100 questions computerized multiple-choice exam, pharmacists must also complete 3,000 hours of specialty pharmacy practice within the past three years as well as 30 hours of specialty pharmacist continuing education within the past two years.
  • 22. The Important Role of Pharmacy in Healthcare: If we’re going to talk about healthcare, it’s like diving deep into a vast endless ocean of topics disciplines, professions, knowledge. But before we go further, we need to clear things up a little bit. We all might see or read Health Care with two words and Healthcare with one word scattered all over the internet, which gives a bit of confusion to Us. Definition of Healthcare: So, simply put according to Dr. Waldman, of the blog Medical Malprocess. “Health care—two words—refers to provider actions. Healthcare—one word—is a system. We need the second in order to have the first,” Health care is the specific things that people do: see a patient or prescribe medication. Healthcare is an industry, the system by which people get the health care they need.
  • 23. Pharmacy in Healthcare: As We already know that Healthcare is a system that is supported by many disciplines that is important to its growth. Specifically one of these disciplines is Pharmacy. . Pharma is the root word of Pharmacy, which is the knowledge and procedure of manufacturing as well as administration of drugs. To be more specific, Pharmacy is a clinical health science that links medical science with chemistry and it is charged with the discovery, production, disposal, safe and effective use, and control of medications and drugs. Pharmacists are responsible for the preparation of the dosage forms of drugs, such as tablets, capsules, and sterile solutions for injection.
  • 24. History of Pharmacy: Pharmacy is an ancient discipline, the art of healing as old as time. A short history of pharmacy can be traced all over the world, from the Greek mythology of Hygieia. She is known as an apothecary or pharmacist of Asclepius the Greek god of medicine. Hygieia’s duty is compounding Asclepius’s remedies. From ancient Greek to clay tablets record prescriptions for medicine that was found in the 4th millennium BC in Sumeria. . All the way to India in the form of The Sushruta Samhita, an ancient Sanskrit text on medicine and surgery.
  • 25. The Important Role of Pharmacy: As We already discussed above, pharmacy holds a critical role in the Healthcare system. Pharmacy’s existence is to support and sustain the healthcare system Including clinical services, reviewing medications for safety and efficacy, and providing drug information. The important role of pharmacy can be further elaborated as below: 1. Processing of Prescriptions The pharmacist verifies the legality, safety, and appropriateness of the prescription order, checks the patient medication record before dispensing the prescription.
  • 26. The Important Role of Pharmacy Cont. 2. Care of patients or clinical pharmacy: The pharmacist seeks to collect and integrate information about the patient’s drug history, clarify the patient’s understanding of the intended dosage regimen and method of administration, and advise the patient of drug-related precautions. 3. Monitoring of drug utilization: The pharmacist can participate in arrangements for monitoring the utilization of drugs, such as practice research projects, and schemes to analyze prescriptions for the monitoring of adverse drug reactions.
  • 27. The Important Role of Pharmacy Cont. 4. Extemporaneous preparation and small-scale manufacture of medicines: Pharmacists everywhere continue to prepare medicines in the pharmacy. This enables them to adapt the formulation of a medicine to the needs of an individual patient. 5. Traditional and alternative medicines: In some countries, pharmacists supply traditional medicines and dispense homeopathic prescriptions 6. Responding to symptoms of minor ailments: The pharmacist receives requests from members of the public for advice on a variety of symptoms and when indicated, refers the inquiries to a medical practitioner.
  • 28. The Important Role of Pharmacy Cont. 7. Informing health care professionals and the public: The pharmacist can compile and maintain information on all medicines, and particularly on newly introduced medicines. 8. Health promotion: The pharmacist can take part in health promotion campaigns, locally and nationally, on a wide range of health-related topics, and particularly on drug-related topics, for example, rational use of drugs, alcohol abuse, tobacco use, discouragement of drug use during pregnancy, organic solvent abuse, poison prevention.
  • 29. The Important Role of Pharmacy Cont. 9. Domiciliary services: In a number of countries, the pharmacist provides an advisory as well as a supply service to residential homes for the elderly, and other long-term patients. So, now that you know a little bit better how important pharmacy’s role is in healthcare you probably might consider yourself to be a pharmacist. Not only it is a noble job but also has a promising future career path.
  • 30. Exploring the role of pharmacy in the primary health care and the prevention agenda: Community pharmacists and pharmacies have a key role to play in supporting healthy ageing and the maintenance of good health and quality of life across the life course. Harnessing their widespread distribution and accessibility, their close relationship with and knowledge of the community they serve, their long opening hours and, in most countries, teams of highly qualified health professionals, will allow pharmacies to play an even greater role in developing and delivering primary health care strategies, in collaboration with colleagues across the health care team. Three core areas in which pharmacy plays a key role in healthy ageing and primary health care include the effective management of non- communicable diseases (NCDs), the promotion of vaccination and immunization, and the support of adherence to treatments.
  • 31. Prevention, screening and management of non-communicable diseases: NCDs, such as cardiovascular diseases, cancer, chronic respiratory diseases and diabetes, are conditions of long duration and slow progression, having the most significant impact on quality of life and mortality worldwide. Their devastating social, human, economic and public health impact is recognized as a global burden by societies and economies across the world. According to the WHO, more than 36 million people die annually from NCDs, representing more than 60% of deaths worldwide, with 15 million people dying before the age of 70. At any one time, one in five people in the western world are expected to have more than one chronic condition. Incidence rates of NCDs and their complications could be reduced if affordable, evidence-based preventative actions were implemented
  • 32. Prevention, screening and management of non-communicable diseases: Cont. Measures include screening for and early detection of diseases; prevention through education to promote behavioral change; a re- evaluation of access to medicine; evidence-based therapy; disease management to initiate and implement therapy; and fostering adherence to treatment. Prevention and control of NCDs require interventions that are therapeutically cost-effective, affordable and resource-feasible for both patients and health systems. Interventions need to be framed within national policies and in line with NCD and risk-factor indicators. Chosen interventions should contribute to improving equity in health care in both targeted populations and individuals, as well as improving health outcomes.
  • 33. Prevention, screening and management of non-communicable diseases: Cont. Several studies have outlined the benefits of pharmacists in the therapeutic management of patients with chronic diseases. In the past years, community pharmacists have engaged in generating hard evidence of the benefits of such roles, expanding the profession’s scope of practice. A 2019 report by the International Pharmaceutical Federation (FIP) points out that pharmacists can implement public health programs, conduct preventive measures, screen and refer potential patients, support prescribing and improve patients’ adherence to a safe therapeutic plan, including pharmacological and non-pharmacological therapies. In the context of NCDs, pharmacists use their proven expertise and new technologies to be a valuable part of the multidisciplinary healthcare team, making a unique contribution to the clinical results of medicines therapy and consequently to quality of life.
  • 34. Improving vaccination coverage: As a result of population ageing, susceptibility to vaccine-preventable diseases is growing and so are the potential complications resulting from these diseases, as a greater share of the population has limiting comorbidities. Vaccine-preventable diseases, such as influenza, pneumococcal disease, herpes zoster and pertussis, are a significant cause of morbidity, loss of quality of life and mortality in older people. Life-long vaccination programs and the importance of vaccination for the elderly are often underestimated.10 It is of paramount importance to increase the focus on vaccination throughout the life course and to ensure access to vaccines that are relevant for each age group.
  • 35. Improving vaccination coverage: This requires new responses by health systems, and as outlined in a recent report by FIP, pharmacists can and should be part of the solution through a variety of roles, from providing evidence-based advice on vaccines, to administering vaccines to keeping vaccination records. Improving adherence to treatments: Non-adherence to medication is a significant cause of treatment failure and a major public health concern. The consequences of non-adherence are greater in older people because they may require a greater number of medicines and may have greater difficulty managing their medication due to declines in cognitive function, memory, mobility or manual dexterity.
  • 36. Improving adherence to treatments: Cont. New medicines services, increased counselling services when a medicine is supplied repeatedly, dosage administration aids and reminder systems are among a list of pharmacy interventions with evidence of improving medication adherence in elderly patients with chronic conditions. A recent FIP report reviewed existing knowledge of pharmacy programs and services to improve adherence in this growing patient population.
  • 37. The Role of Pharmacist in Public health: What is public health? Public health can be defined as “what we in term of society do to persuade the conditions in which people can be healthy.” It is not about medicine, but it also “emphasizes” the prevention of disease and the needs of the population health as a whole. What is Public Health Science? Public Health Science is the art of preventing disease, increasing longevity of life and promoting health through efforts and choices made by society, public and private organizations, the community and by individuals. Public Health Science deals with dangers to the public health of a population, whether small or large (i.e. populations of a continent) to improve the quality of health and the quality of life in through detecting and preventing disease and other physical and mental health conditions, promoting health behaviors, tracking cases and health indicators. Public Health Science uses a multi-disciplinary method incorporating epidemiology, biostatistics and health services.
  • 38. The Role of Pharmacist in Public health: Cont. What are public health services? Public health services occur on two measures: the macro measures and micro measures i.e., planning and the implementation of planning, respectively. Macro-level public health measures target on the health of the population as a whole. These services include identification of health-related community problems with community representatives, planning community health programs and policies, administering and evaluating community health promotion programs, educating the community about public health, and researching and publishing facts about public health actions. All these activities are exercised by public health professionals of different backgrounds. Micro-level public health measures consist of the activities necessary to execute public health plans.
  • 39. The Role of Pharmacist in Public health: Cont. These services are carried out on a “program-to-population or a provider-to- patient basis”. For examples; the screening of diseases, tobacco-cessation programs immunization programs, and counseling for at-risk populations. The overall concept beneath these so many public health activities is prevention, which can be categorized into three types: primary prevention secondary prevention and tertiary prevention i.e., reduction of the occurrence of diseases, decrease the progression of the disease, and treatment of disease to return the initial state respectively.
  • 40. What should be the public health activities of a pharmacist? In 1981, the role of the pharmacist in public health is defined by the American Public Health Association (APHA). This association outlined that the role of the pharmacist is now escalating beyond the dispensation and distribution of medicines, and health supplies. Today, the administrative, and public health functions are also included in the services of pharmacists. Now, it becomes more patient-oriented. A pharmacist can provide many services to public health that may include pharmacotherapy, provide care, and prevention measures. A pharmacist has an available resource for health and medication information apart from dispensing medicine.
  • 41. What should be the public health activities of a pharmacist? Due to valuable placement of pharmacists in the clinical community, the integration of public health custom into pharmaceutical care, and pharmacological training is indispensable. The public health services that an individual pharmacist performs will depend on the abilities, experience, training, and work methodology. . APHA believes that all pharmacists can contribute to the promotion of public health by working alone or in cooperation with health care colleagues and administrators. The following are the other activities where pharmacists can play an important role to promote public health:
  • 42. What should be the public health activities of a pharmacist? Cont. 1. Population-based Care: The Center for Advancement in Pharmaceutical Education (CAPE) Educational Outcomes suggested that pharmacists should involve in both patient-based and population-based care. In the past twenty years, the health-system pharmacists can support public health efforts using designing and providing disease management programs. The health-system pharmacists with their health care colleagues can contribute to population health care using tools such as medication-use evaluation, evidence-based disease management programs that are planned according to the needs of the served institutions and communities. Health-system pharmacists can involve in quality reviews by which they
  • 43. What should be the public health activities of a pharmacist? Cont. 2. Prevention of Disease and Medication Safety: A pharmacist can be indulged in the prevention and control of disease in many way. They can help in the establishment of some screening programs to check out the status of immunization, and identification of some undiagnosed medical conditions. The federal government’s Healthy People 2010 initiative is also outlined the role of health-system pharmacists in medication safety and error prevention. These practices can reduce the number of hospital admissions due to reasons for drug therapy mismanagement and counterfeit medications. Medication reconciliation programs are one of the vital tools with which pharmacists can achieve these goals.
  • 44. What should be the public health activities of a pharmacist? Cont. 3. Health Education: The development of programs on the safe and effective use of medication, and other public health-related topics, such as exercise, healthy nutrition and tobacco cessation, is also an important area where pharmacists play their role. The education and training programs are beneficial for public health care if they start at an early age, such as school health programs, which help in the development of good health behaviors in children that can continue into adulthood also. Pharmacists should support these types of school health programs. Furthermore, health-system pharmacists can educate their health care colleagues about the safe and effective use of medication that further improves use of medications. The pharmacists can also educate community leaders like public office holders, legislators, school officials, regulators, and religious leaders who
  • 45. What should be the public health activities of a pharmacist? Cont. 4. Public Health Policy: Health-system pharmacists can participate in the development of public health policy concerned with local boards of health as well as national programs. Drugs are the central part of health systems. Hence, the health policy, especially policy targeted for chronic disease, must be prepared with better consideration of drug therapy as well as factors affecting the disease outcomes. The role of Health-system pharmacists in emergency planning and service delivery of specialized pharmaceuticals like antidotes, vaccines, and antibiotics is critical.
  • 46. What should be the public health activities of a pharmacist? Cont. 5. Research and Training: A health-system pharmacist must get adequate education and training to carry out his responsibility in public health. Health-system pharmacists should be expertise in pharmacoepidemiology, research methodology, and biostatistics with their applications in decision related to public health. He should have an understanding of the design, conduct, and interpretation of clinical studies. Health-system pharmacists should participate in collaborative research and serve on data monitoring and safety committees, institutional review boards, and expert medication advisory committees. Moreover, the research fellows need exposure to research in public health policy, Pharmacoeconomics, pharmacoepidemiology, and evidence-based medicine for experimental and instructive training.
  • 47. What should be the public health activities of a pharmacist? Cont. Future Aspects: The revolutionary progress in biomedical sciences, including stem-cell biology, human genomics, biomedical engineering, immunology, and bioinformatics, open the door to provide information for the betterment of human health. New technology and practices such as population genetics and pharmacogenomics will allow reduction in failures of treatment and prevent adverse drug reactions using the proper appliance of pharmacogenetic principles. Health-system pharmacists will need to apply these new tools not to get better patient-specific pharmacotherapy but to progress public health. Health professionals, as well as the legislators, will require education and training about the safe use of new medication delivery technologies.
  • 48. Assignment: Assignment#: 1 What was your previous idea of the Profession and the Professional area of application? What’s the meaning of dosage forms? Explain the difference between the following medication dosage unit: g, mg, & mcg What are radioactive materials? What are novel medications? What are novel medications ? List three examples of radioactive materials in the practice of Pharmacy Discuss the following : Primary, Secondary, and tertiary levels in public health service delivery Assignment#: 2 Has this course in anyway impacted your decision to pursue your career as a Doctor of Pharmacy ? If Yes, how? If No, why not ? Explain in 250 words