Evaluation of Enoxaparin Dosing and Monitoring in Pediatric Patients at Children's Teaching Hospital.

OBJECTIVES: The primary objective of this study was to evaluate whether empirical enoxaparin doses according to Chest guidelines resulted in therapeutic antifactor Xa concentrations in pediatric patients. Secondary objectives were to determine the median enoxaparin dose that resulted in therapeutic anticoagulation, the median time to therapeutic concentrations, and the percentage of patients who experienced major bleeding. METHODS: Patients in a tertiary medical center who were <18 years of age and received treatment doses of enoxaparin between July 2007 and June 2010 were included. Patients with <2 antifactor Xa concentrations or with only supratherapeutic concentrations and doses that were higher than recommended by the guidelines were excluded. Subgroup analysis was conducted by dividing children into 4 age groups: <2 months of age, 2 months to <1 year of age, 1 year to <3 years of age, and 3 to 17 years of age. RESULTS: Thirty-two patients were included in the study. Thirty-seven percent of the patients achieved a therapeutic drug level with empirical dosing. The therapeutic dose ranged from 1 to 1.9 mg/kg in patients <1 year old, and 0.6 to 1.5 mg/kg in those =1 year of age. Comparison of the median therapeutic doses for patients 2 months to <1 year to that for patients =1 year old using the Mann-Whitney U test showed the median doses to be significantly difierent between the 2 groups (p=0.01). The antifactor Xa level became therapeutic on day 5 (median). There were no major bleeding events. CONCLUSION: Less than 40% of patients were therapeutic with empirical dosing, which supports findings from other studies that suggest a need for modification of empirical treatment dosing of enoxaparin in children.

An introductory pharmacy practice experience based on a medication therapy management service model.

OBJECTIVE: To implement and evaluate an introductory pharmacy practice experience (IPPE) based on the medication therapy management (MTM) service model. DESIGN: Patient Care 2 is an IPPE that introduces third-year pharmacy students to the MTM service model. Students interacted with older adults to identify medication-related problems and develop recommendations using core MTM elements. Course outcome evaluations were based on number of documented medication-related problems, recommendations, and student reviews. ASSESSMENT: Fifty-seven older adults participated in the course. Students identified 52 medication-related problems and 66 medical problems, and documented 233 recommendations relating to health maintenance and wellness, pharmacotherapy, referrals, and education. Students reported having adequate experience performing core MTM elements. CONCLUSION: Patient Care 2 may serve as an experiential learning model for pharmacy schools to teach the core elements of MTM and provide patient care services to the community.

Readiness for self-directed learning and academic performance in an abilities laboratory course.

OBJECTIVE: To assess the relationship between readiness for self-directed learning, academic performance on self-directed learning activities, and resources used to prepare for an abilities laboratory course. METHODS: The Self-directed Learning Readiness Scale (SDLRS) was administered to first-year (P1) doctor of pharmacy (PharmD) candidates at the University of Maryland. Additional data collected included final course grades, quiz scores, resources used to prepare for laboratory activities, and demographics. RESULTS: The mean SDLRS score was 148.6 ± 13.8. Sixty-eight students (44%) scored > 150, indicating a high readiness for self-directed learning. These students were more likely to complete assignments before the laboratory, meet in study groups, and report postgraduation plans to enter noncommunity pharmacy. No significant association was found between academic performance and the SDLRS. CONCLUSIONS: Readiness for self-directed learning is associated with self-directed learning habits, but may not be necessary for learning foundational knowledge, provided students are given specific instructions on what to study. Whether high readiness for self-directed learning is necessary for more complex learning or for self-identification of learning needs is unknown.

Approach to the pediatric prescription in a community pharmacy.

Pediatric patients are more susceptible to medication errors for a variety of reasons including physical and social differences and the necessity for patient-specific dosing. As such, community pharmacists may feel uncomfortable in verifying or dispensing a prescription for a pediatric patient. However, the use of a systematic approach to the pediatric prescription can provide confidence to pharmacists and minimize the possibility of a medication error. The objective of this article is to provide the community pharmacist with an overview of the potential areas of medication errors in a prescription for a pediatric patient. Additionally, the article guides the community pharmacist through a pediatric prescription, highlighting common areas of medication errors.

Use of intravesicular amikacin irrigations for the treatment and prophylaxis of urinary tract infections in a patient with spina bifida and neurogenic bladder: a case report.

This case report describes the use of intravesicular amikacin irrigations to treat and prevent urinary tract infections (UTIs) in a pediatric patient with spina bifida and neurogenic bladder. A 15 year old Hispanic female was admitted for a UTI caused by Enterobacter cloacae and multiple-drug resistant Pseudomonas aeruginosa. A 7 day course of daily intravenous amikacin and ceftazidime was initiated along with twice daily intravesicular amikacin irrigations (15 mg/30 mL) with a dwell time of 2 hours. The patient improved and was discharged on prophylactic Bactrim SS (sulfamethoxazole/trimethoprim) 1 tablet daily and intravesicular amikacin irrigations (15 mg/30 mL) once every other day. Approximately 2 months after discharge, the patient developed another UTI from multidrug resistant Escherichia coli and was treated with a 14 day course of daily intravenous ciprofloxacin accompanied by daily intravesicular amikacin irrigations. Adjunctive therapy with either once daily or twice daily intravesicular amikacin irrigations successfully treated the patient's UTI. However, prophylactic treatment with intravesicular amikacin failed to prevent future UTIs in this patient.

Scoring objective structured clinical examinations using video monitors or video recordings.

OBJECTIVE: To compare scoring methods for objective structured clinical examinations (OSCEs) using real-time observations via video monitors and observation of videotapes. METHODS: Second- (P2) and third-year (P3) doctor of pharmacy (PharmD) students completed 3-station OSCEs. Sixty encounters, 30 from each PharmD class, were selected at random, and scored by faculty investigators observing video monitors in real-time. One month later, the encounters were scored by investigators using videotapes. RESULTS: Intra-rater reliability between real-time and videotaped observation was excellent (ICC 3,1 of 0.951 for P2 students and 0.868 for P3 students). However, 13.3% of students' performance in both P2 and P3 cohorts changed in pass/fail determination from passing based on real-time observation to failing based on video observation, and 3.3% of students changed from failing real-time to passing on video. CONCLUSIONS: Despite excellent overall reliability, important differences in OSCE pass/fail determinations were found between real-time and video observations. These observation methods for scoring OSCEs are not interchangeable.

The impact of advanced pharmacy practice experiences on students' readiness for self-directed learning.

OBJECTIVE: To evaluate the impact of advanced pharmacy practice experiences (APPEs) on doctor of pharmacy (PharmD) students' readiness for self-directed learning. METHODS: The Self-Directed Learning Readiness Scale (SDLRS) was administered to students prior to and after completing their APPEs. SDLRS is a validated instrument that determines the relative degree to which students have the attitudes and motivation to engage in self-directed learning. RESULTS: Seventy-seven (64%) students completed the SDLRS prior to starting their APPEs and 80 (67%) students completed the instrument after completing their APPEs. Forty-six (38%) students completed both. Prior to starting their APPEs, 74% of students scored greater than 150 on the SDLRS, indicating a high level of readiness for self-directed learning. No significant difference was found between the mean scores of students who took the SDLRS both prior to (159 +/- 20) and after completing their APPEs (159 +/- 24; p > 0.05). CONCLUSION: Students at our institution appear to be ready for self-directed learning but APPEs had a minimal impact on their readiness for self-directed learning.

Fake bad test response bias effects on the test of variables of attention.

This study investigated the effects of faking bad (FB) on the Test of Variables of Attention (TOVA) using subjects randomly placed into two groups. Subjects in Group 1 took the TOVA under normal conditions (NC) first; they were then requested to subtly fake bad. Group 2 subjects took the TOVA under the same fake bad instructions first, then took the test under normal conditions the second time. An analysis of the effects of test order yielded non-significant differences for basic TOVA variables across all four quarters, both halves and the total score. An analysis for group mean differences between the NC and the FB instructions yielded significant differences across the basic TOVA variables across the four quarters, two halves and total score. The FB group had excessive amounts of omission and commission errors, a greater response time mean (i.e., slower to respond) and had greater variance around their mean response time. The study affirms that the professional using the TOVA needs to carefully eliminate a fake bad test-taking bias when subjects produce excessive test results.