IntroductionWarfarin sodium is characterized by a narrow therapeutic range (eg, an international normalized ratio [INR]) of 2.0-3.0), a marked interindividual variation in dosing requirements, and an increased risk of adverse events when the dose is too high or low. 1,2 To minimize the high incidence of such events, [3][4][5] particularly during the first few weeks of initiating therapy, 1,6 most guidelines recommend prescribing warfarin at or near the anticipated maintenance dose and then adjusting the dose by trial and error. 1,7,8 While algorithms for predicting this maintenance dose a priori have improved, [9][10][11][12][13][14][15][16] there remains little guidance on how this starting dose should be adjusted a posteriori based on the subsequent INR values. We hypothesized that use of genetic markers could help optimize these dose refinements.Two common single nucleotide polymorphisms (SNPs) in the cytochrome P450 (CYP) 2C9 system are associated with impaired metabolism of warfarin, [3][4][5][6]11,17 while SNPs in the gene for vitamin K epoxide reductase complex 1 (VKORC1) correlate with warfarin sensitivity and resistance. 2,[18][19][20] No prior study has examined the impact of these SNPs on warfarin-dose adjustments. Given the current knowledge about these markers, we hypothesize that for a given INR, a patient who is a slow metabolizer of warfarin may need a more cautious adjustment in their dose than a similar patient who is a normal metabolizer. Failure to tailor dose refinements during warfarin induction in poor metabolizers may have contributed to the 3-fold increased risk of (laboratory or clinical) adverse events among poor metabolizers in our initial prospective study of pharmacogenetic-based warfarin therapy. 4 The purpose of this study was to develop a dose-refinement nomogram to guide clinicians in adjusting warfarin doses. This nomogram would be similar to prior algorithms, 21,22 but will have 2 advantages: (1) it will allow for, but not require, a first dose that is tailored to clinical and/or genetic factors and (2) it will incorporate genetics and clinical factors that are independent predictors of how much the dose should be refined. 1,11 If successful, the proposed warfarin nomogram would simplify and standardize warfarin initiation. Patients, materials, and methodsThe study was a retrospective analysis of 2 cohorts of orthopedic surgery patients who had participated in 2 prospective studies of pharmacogeneticbased warfarin therapy. The Human Research Protection Office at Washington University Medical Center approved these studies. PatientsFor patients in both cohorts, we offered participation if they were scheduled for primary or revision total knee or hip arthroplasty at Washington University Medical Center and if they were 18 years or older. We excluded patients who had previously taken warfarin or who had contraindications to warfarin treatment. To allow time for genotyping, we also excluded patients scheduled for surgery fewer than 7 days following referral to our anticoagulation s...

No abstract

Students' use of health literacy communication tools during encounters with independent-living senior residents can result in greater patient understanding and empowerment, which may in turn help improve medication adherence.

Objective: To evaluate the results of a prospectively developed plan for using multiple choice questions (MCQs) developed at defined Bloom's levels to assess student performance across a Therapeutics sequence. Methods: Faculty were prospectively instructed to prepare a specific number of MCQs for exams in a Therapeutics sequence. Questions were distributed into one of three cognitive levels based on a modified Bloom's taxonomy, including recall, application, and analysis. Student performance on MCQs was compared between and within each Bloom's level throughout the Therapeutics sequence. In addition, correlations between MCQ performance and case performance were assessed. Results:A total of 168 pharmacy students were prospectively followed in a Therapeutics sequence over two years. The overall average MCQ score on 10 exams was 68.8%. A significant difference in student performance was observed between recall, application, and analysis domain averages (73.1%, 70.2% and 60.1%; p Conclusions: As students progress through the curriculum, faculty may need to find ways to promote recall knowledge for more advanced topics while continuing to develop their ability to apply and analyze information. Exams with well-designed MCQs that prospectively target various cognitive levels can facilitate assessment of student performance.   Type: Original Research