Friday, October 23, 2009

Thoughts on connectivism and H1N1 influenza

For a variety of reasons, including H1N1 planning, connectivism has not been my top priority recently. Having said that, my connectivism "goggles" have been on and screening my world for signs that connectivism is "true" (in as much as a theory can be true) and I keep returning to H1N1.
The H1N1 influenza pandemic is unprecedented, and I say that with the knowledge that there have been previous pandemics, but it is unprecedented with regards to the environment that it is evolving in. The state of medical knowledge, technology, and communication and collaboration world wide make it unique.
I think I am seeing many of the principles of connectivism in action, as health care professionals like myself and the lay public, "find our way" through this "complex, chaotic, and rapidly shifting situation". The thesis that "knowledge is networked and distributed across connections" and "knowledge is emergent from the connections, not contained in it" seems obvious when applied to the pandemic. Connectivism seems to fit learning during the H1N1 pandemic better than any of the other learning theories (behaviourism, cognitivism or constructivism) and I hope that the following thoughts will demonstrate why I think that.
  • No single person, agency, business or organization knows everything H1N1, connections and networks between people, ideas, and research result in emergent knowledge almost on a daily (hourly?) basis and are central to learning about this virus.
I would consider myself a "hub" in the network, not because of what I personally know about H1N1 (which is very little), but because of the various multi-directional connections I am capable of. I work in a drug information centre that takes questions from health care professionals; therefore I am capable of receiving incoming connections more frequently many other pharmacists. I am also responsible for making outgoing connections; I know the major information sources and who the major decision makers are in the province and in Canada. So, I am serving as a hub, not because of my expert knowledge about H1N1, but because of my unique connecting role. Looking at my role as a "connector" and not a "knower" has eased the stress of trying to "keep up" with the amount of information available on the topic. My priority is knowing where to go (or to connect) when I get a question, not trying to retain information for the unknown future question. I like this role and didn't realize that this is what I did, until I put my connectivism goggles on. This contrasts with my attempts to be a "knower" in the connectivism course, which is stressful and impossible to keep up with, because the "information overload" in CCK09 is very similar to the H1N1 situation. I need to remember that "learning is the capacity to construct and traverse connections" and that "knowledge is not acquired or a thing". I seem to be very successful at this in one environment but it does not seem to translate to another environment.
  • The addition of new connections to the H1N1 network results in a "ripple effect, which amplifies beyond the original connection."
Medical research is a hard science where evidence base medicine prevails, and a randomized, double blind, controlled trial is the gold standard for determining optimal treatment. In the case of a pandemic there is no time to conduct this type of study and optimal treatment is being shaped by the connections made between various entities or hubs (i.e. practitioners and centers with prior experience). The treatment of the critically ill patient in hospital today will not be the same as the patient treated in the first wave because of the knowledge transmitted via networks and hopefully the "amplification effect" results in exponentially better outcomes for those patients. It is interesting to see parallels between connectivism, a theory that was developed because of the rapid changes in learning and knowledge in a digital environment and pandemic planning, another rapidly evolving field. Based on this, one could argue that the principles of connectivism could apply in any digital or non-digital, rapidly evolving field (and I'm sure that someone has).
  • Connectivism and networked learning is "increasingly aided by technology", which in the H1N1 pandemic is both beneficial and detrimental.
Positively, most of the scientific publications on H1N1 have been published online first as early releases, allowing rapid communication of detailed information. Negatively, media reports that seasonal flu vaccine increased the risk of H1N1 were communicated before data was released by the investigator, leaving other researchers and health care professionals unable to respond. Email, blogging, and microblogging, alerting services, RSS feeds, etc allows up to the minute updates and facilitates rapid transmission of information via the "strong and weak ties" in a network. Important hubs (FDA, Health Canada, CDC, etc) are easily accessible via the internet. It is relatively easy to tap into the network, the lay public has access to a large portion of information that the average health care professional has. The announcement that the Canada H1N1 vaccine was approved for use was issued via a press release simultaneously to the public and health care professionals. In fact, the media and news networks have been just as an important source of information as the official documents from Health Canada, or other organizations.

  • So, one could say that my connectivism goggles are my way of explaining what resonates with me, which is another important characteristic of networked learning.
In my short experience as an "official" adult learner (which to me means learning something as an adult that is non-medical in nature), I have found that I need to make connections to what I already know (pharmacy/medical stuff) in order for it to make sense. If I can't find or make this connection I find it very difficult to engage in the material. Now that I have linked H1N1 influenza with connectivism, they will be permanently tied together, which is probably a good thing because I am not likely to forget my H1N1 experiences!

Postscript:  I started this post with the intention of completing the first assignment, What is Connectivism? but got side tracked by my H1N1 analogy.  I am not sure if I accomplished the intended objectives of the assignment, but my connectivism goggles are hurting my eyes at this late hour, so stay tuned for futher posts.

Sunday, October 18, 2009

Drug information questions for PSL-2 in Prezi

I have finally found a good use for Prezi, a zoom presentation tool that I have posted about previously.  For the second year pharmacy student drug information lecture I created a Prezi around a drug information question.  This allowed non-linear paths through the information (cf with Powerpoint slides).  The class dictated which information to reveal next, they could not be influenced by "the instructors next slide is ____, therefore this must be the next step".  It worked quite well, and I think I will be using Prezi again.

Are clonazepam wafers available?

Is azithromycin safe in pregnancy?

Is there a drug interaction between risperidone and simvastatin?

Wednesday, October 14, 2009

Systematic Approach to Drug Information - BC DPIC

In a previous post I uploaded my Principles of Drug Information lecture for 1st year pharmacy students at the University of Manitoba.  This year, as I am preparing for the 2nd and 3rd year lectures, I came across this four part video on YouTube from BC DPIC (Drug and Poison Information Centre, Vancouver, BC).

After a quick scan, the content of these videos seems to be very similar to the lecture that I gave.  It is good to know that DI centres seem to be on the same page.  Wouldn't it be nice if everyone shared presentations like this. It doesn't make sense that there are multiple DI pharmacists creating essentially the same presentation from scratch!  Thank you DPIC.

Drug Information: Techniques for a Systematic Approach.  BC DPIC.
Part 1
Part 2
Part 3
Part 4

Saturday, October 3, 2009

Pill Identification for Canadian pills

What is the best way to identify a stray pill?

Except for the round, white, unmarked tablets; color, shape, score lines and imprint codes can assist with identification.

There are many pill identification tools online and I have been asked several times for my professional opinion on the usefulness of one or more of these programs for the identification of pills from Canada. Many of these databases are of US origin and their accuracy in identifying Canadian pills is unknown.

For a more objective comparison I decided to search for 3 different Canadian pills using 9 different ID tools available online. From my past experiences, one is more likely to identify the correct pill when searching via imprint codes alone. Addition of color and shape often leave you with no results and descriptions of color and shape are not standardized. For example the same pill could be described as oval, capsule shaped, or caplet; or a peach toned pill could be labelled as orange or pink. Also imprints codes are almost guaranteed to be unique to the product, where as there are limited colors and shapes for any pill.

I used an imprint code search for the following Canadian pills:
  • Co ciprofloxacin 500 mg tablet, made by Cobalt Pharmaceuticals, a generic manufacturer in both the US and Canada.
  • Description in the eCPS: Each white to off-white, capsule shaped, biconvex, film-coated tablet, embossed “CR 500” on one side and (embossed arrowhead or greater than sign) on the other side.
  • I searched for CR 500 (symbols can not be used in these databases)
  • Comment: It appears that this pill has the same markings in Canada and the US, therefore I would expect to find it in almost all of the databases.

  • Hyzaar 50 mg/12.5 mg (losartan 50 mg & hydrochlorothizaide 12.5 mg). Made by Merck Frost, a large brand name manufacturer in the US and Canada.
  • Description in the eCPS: Each yellow, oval shaped, film-coated tablet, marked with code 717 on one side and plain on the other.
  • I searched for 717.
  • Comment: In November 2008 Merck Frosst changed the tablet shape and imprint codes in Canada, but not the US, therefore I would expect that the US based databases will only find the US product.
  • Novamoxin 500 mg capsules, made by NovoPharm, a large generic manufacturer in Canada only.
  • Description in the eCPS: Each hard gelatin capsule with opaque scarlet cap and yellow body, size #0, printed white NOVO and 500 on opposing cap and body portions of the capsule.
  • I searched for Novo 500.
  • Comment: NovoPharm products are not available in the US, therefore I would not expect to find this drug in the US databases.

Pill identification databases searched:


  • Pillbox beta enables identification of solid dosage forms based on imprint, shape, color, size and scoring. It is currently under development by the National Library of Medicine and National Institute of Health and is not intended for clinical use (then why is it freely available online??). As of September 2009 is contains 5,693 records, but only 779 have images. Additional drug information is provided by DailyMed and the Drug Information Portal. This database is US based. I used the HMTL-based screen reader compatible version as my office computer did not allow use of the Adobe Flex version.
  • DailyMed Product Identification System is also provide by the National Library of Medicine and contains 5128 approved prescription drugs in the US. One can search via imprint, color, shape, size and scoring. Additional drug information is provided from the official FDA labels
  • Pill Identifier content is provided by Cerner Multum and Thomson-Reuter Micromedex. This website has a disclaimer that it is intended for use by consumers in the United States only. One can search for pills via imprint (mandatory), color and shape (both optional). Provides links to addition drug information from Physicians' Desk Reference, Cerner Multum, Micromedex and Wolter Kluwer Health. US based database.
  • Pill Identification Tool is another US based database that allows consumers to search for pills via imprint, color, shape, and brand/generic name. RxList is owned and operated by WebMD. I could not find what sources of drug information are used for this database.
SUBSCRIPTION DATABASES: (requires paid subscription for access)
  • Micromedex Identidex is produced by Thomson Reuters. Users can search via imprint code, color, shape or pattern. It contains more than 74,000 indexed terms to identify pharmaceuticals based on imprint codes. Micromedex Identidex is US based, but they attempt to include international products as well. Links to additional drug information (DrugDex monograph or PoisonDex, if user has subscription to these databases).
  • Facts & Comparisons 4.0 Drug Identifier is produced by Wolter Kluwer and contains more than 5,000 images. Users can search via imprint, dose form, score, shape, color 1, color 2, trade/generic name, labeler/manufacturer name, or NDC/labeler code. Once a product is found links to Drug Facts and Comparisons monograph and MedFacts/Medguide patient handouts are available. All Facts & Comparisons products are US based.
  • eCPS Product Identification Tool is the only exclusively Canadian identification tool that I am aware of. Product information and images are provided by the manufacturer. One can search via dosage form, shape, color, imprint, scored, brand name or generic name. There are no links to complete product monographs, users must return to the eCPS general search for additional information. This tool only contains brand name products, therefore it will not be able to identify generic pills. It also contains images of injections, transdermal patches, topical products, powders, inhalers, eye/ear product, suppositories, etc.
  • eCPS Advanced Search is not specifically designed as a product identification tool, but can be used as such, if one searches for imprint codes in the product information section of the monographs. This advanced search will search all monographs in the eCPS, including generic products and is a useful compliment to the Product Identification Tool.
  • Lexi-Drug ID provided by Lexi-Comp searches for pills based on imprint, dosage form, shape or colors. Links are provided to search other Lexi-Comp databases for additional drug information once product has been identified. It is a US based tool.

RESULTS: Documented whether each site found the correct drug, if the manufacturer was identified and if an image of the pill was available for verification.

Results are in Google Docs spreadsheet (as I could not figure out how to insert my original Word table here!)

No single pill identification database found all three pills via imprint codes. Micromedex Identidex and the eCPS Advanced Search identified 2 out of the 3 pills. The eCPS Product Identification Tool was the only database that provided an image to confirm the identity of a pill (Hyzaar). The free US based databases did not find any of the Canadian pills.

Several databases identified Co ciprofloxacin 500 mg because the US and Canadian products have the exact same imprint codes, but this would not necessarily be known to the searcher and not all manufacturers use the same imprint codes for US and Canadian products.

Hyzaar 50 mg/12.5 mg was only identified by the eCPS, all of the other databases found the US product which is also imprinted with 717, but after the November 2008 manufacturing change, this would not be helpful for identifying the Canadian product. Searching only for 717 resulted in numerous results on several of the websites, in this case narrowing by color or shape would have helped to decreased the number of results.

Novamoxin, the exclusively Canadian product was only identified by Micromedex. The eCPS Product Identification Tool only includes brand name products, and the Advanced Search function found 500+ results when searching for Novo 500. No results were found the other databases.

LIMITATIONS: Results only apply to identification of Canadian pills, as the majority of the databases were US in origin, one would expect better results when attempting to identify US pills. Databases were selected based on familiarity and accesibility, therefore other important pill identification databases may have been excluded. The three pills were selected with the knowledge that many of the databases were US based, this may have biased the results against the US databases. Use of the subscription databases are restricted to paid users, which limits their usefulness for those who do not have access.

DISCUSSION: There are a couple other methods for identification of Canadian pills. The easiest method is to ask a dispensing pharmacist or technician who see these products on a daily basis, in many cases they can identify the pill with a quick glance.

Most Canadian provinces attempt to control drug costs by using generic products, therefore many requests for pill identification will be from a Canadian generic manufacturer. Companies like Apotex, NovoPharm, Pharmascience, GenPharm (now Mylan), and Cobalt use distinct and easily recognized imprint codes (Apotex =APO; Novopharm = NOVO, Pharmascience = P or PMS, etc). Each of these companies websites maintain a product directory with product images, therefore once the pill manufacutrer is identified, the website can used for confirmation. These sites do not allow imprint code searching, therefore probably would not be useful to the non-pharmacist, but this is the method that I use to identify generic products in Canada.

Other Canadian databases that are not useful for identification of pills from imprint codes, shape or color include the Drug Product Database (DPD) from Health Canada. This website allows searching via DIN (Drug Identification Number), ATC (Anatomical Therapeutic Classification), Company, Product Name (brand), Active Ingredient (generic), and Active Ingredient Group Number). Some of the entries have links to the complete Canadian product monograph, therefore DPD could be used for confirmation after a pill is identified, but at the moment is not useful for inital searching. This database probably has the most potential for development into a pill ID tool. for Canadian consumers is produced by MediResource provides Canadian drug information, but is only searchable via DIN or drug name.

Ident-a-drug from Therapeutic Research Center (publishers of Pharmacists' Letter and Natural Medicines Comprehensive Database, two of my favorites) allows searching via imprint code, US NDC or Canadian DIN or advanced searching. This is a subscription database that I do not have access to, therefore I could not include it, but it appears promising.

CONCLUSION: The best pill identification websites for identification of Canadian pills via imprint codes are the eCPS (Product Identification Tool and Advanced Search) and Micromedex Identidex. As expected the US based databases failed to identify Canadian products, except when the imprint codes were exactly the same in both countries (Co ciprofloxacin). Even then, confirmation with a Canadian resource is require to confirm this, as some pills have different imprint codes in the US and Canada (Hyzaar). Pills from exclusively Canadian manufacturers (Novamoxin) will not be found in US databases.

There is a need for a comprehensive Canadian pill identification tool as reliance on US based databases is inappropriate and inadequate. Pharmacists currently must work with several sources (eCPS, Micromedex, generic manufacturer websites) when attempting to identify pills via imprint codes and there are no freely available pill ID sites for Canadian consumers. In my opinion organizations such as Health Canada or the Canadian Pharmacists Association (publisher of the CPS) are in the best position to develop such a tool.