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Therapeutic drug monitoring: an e-learning resource

Therapeutic drug monitoring: an e-learning resource Volume 2 † Number 2 † June 2009 10.1093/biohorizons/hzp013 ......................................................................................................................................................................................................................................... Research article Therapeutic drug monitoring: an e-learning resource Krupa Samani* University of Manchester, Manchester, UK. * Corresponding author: 16 Hatherleigh Road, Evington, Leicester LE5 5NR, UK. Email: krupa65@hotmail.com Supervisor: Dr Michael Hollingsworth, University of Manchester, Manchester, UK. ........................................................................................................................................................................................................................................ The main aim of this project was to produce an interactive e-learning resource explaining the pharmacokinetic principles related to therapeutic drug monitoring (TDM). The target audience for the resource were scientists at Manchester Royal Infirmary and the intended learning outcome for the users was to improve their understanding of the pharmacology behind the results they generate. The null hypothesis stated that the resource would not cause a significant improvement in the users’ understanding of pharmacokinetics. The ADDIE Instructional Design Model was applied to the learning situation. A pre-project questionnaire allowed for a needs analysis to be conducted, determining the current level of knowledge. Design and development involved production of project plans and story- boards and the entire resource was produced using Opus Professional. The resource was distributed via compact discs, along with pre- and post-resource questionnaires to permit analysis. Knowledge was compared before and after using the resource to establish the effectiveness of the resource, and the functionality of the resource was evaluated. The needs questionnaire results outlined the exist- ing level of knowledge as being varied and provided suggestions for possible concepts to include in the resource. A more precise and accurate definition of TDM, why it is carried out, and the pharmacokinetic parameters were apparent in the post-resource questionnaire results. Confidence in the understanding and interpretation of data produce was not significantly improved (Wilcoxon matched pairs signed ranks test, n ¼ 14, P ¼ 0.13), while confidence in the understanding of pharmacokinetic parameters was significantly improved (Wilcoxon matched pairs signed ranks test, n ¼ 16, P ¼ 0.01). About 81% of the audience found the resource very helpful to understand- ing TDM and all of the users found it either easy to use or very easy to use. The post-resource results showed that confidence in the understanding of pharmacokinetics was improved, indicating that the learning outcomes of the user were achieved thus allowing the null hypothesis to be rejected. However, confidence in understanding the data generated was not improved, suggesting a possible aspect to be developed if the project was to be repeated. Functionality of the resource was successful as users found the resource easy to use and navigate. Key words: therapeutic drug monitoring, e-learning resource, pharmacokinetics. ........................................................................................................................................................................................................................................ blood samples received from patients to determine the con- Introduction centration of a given drug. This concentration can then be Therapeutic drug monitoring (TDM) utilizes the principle used by a clinician to determine the success of treatment that the clinical response of a drug is directly related to its and whether sub-optimal, optimal or toxic drug concen- concentration in blood and hence monitoring is carried out trations are being achieved. to support the management of patients receiving certain It was considered that the target audience needed 1, 2 drugs. The central goal of TDM is to use drug concen- improved grounding in pharmacokinetics to strengthen tration to manage drug regimens to optimize therapy. The their comprehension of the reasoning behind the data that target group consisted of about 30 scientists who work in they generated. A resource was designed to support the the Biochemistry, Toxicology and Microbiology laboratories users’ understanding of the potential sources of pharmacoki- at the Manchester Royal Infirmary, and who carry out TDM netic variation, which can result in the varying drug concen- on a regular basis. Their key responsibility is to monitor trations they monitor in patients’ samples. ......................................................................................................................................................................................................................................... 2009 The Author(s). This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/2.0/uk/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 113 Research article Bioscience Horizons † Volume 2 † Number 2 † June 2009 ......................................................................................................................................................................................................................................... The resource followed the concept of a clinical audit for shown in Figure 1. The survey was conducted with scientists the Central Manchester and Manchester Children’s who carry out TDM as well as other biochemical tests in the University Hospitals NHS Trust (CMMC) with the Biochemistry, Toxicology and Microbiology laboratories at purpose of improving patient care and outcomes following Manchester Royal Infirmary. Pre-project questionnaires a systematic review of the TDM process through implement- were distributed to 25 out of the 29 staff used for the ing the change of improving knowledge. The process of needs questionnaire on the 3 December 2007. Staff were resource development referred to the stages of clinical audit given two weeks to complete and return them to Dr. Gwen to improve their awareness and, therefore, enhance their Ayers (co-supervisor at the hospital). The questionnaire understanding of the results which they generate. aimed to determine the background, current level of The majority of information relating to TDM can be understanding and requirements of the target group and 7–9 10 found either in textbooks or journals. However, whether there was a need to produce an e-learning resource content is often too textual and few pharmacology textbooks on TDM. describe TDM specifically, presenting more complex infor- mation than is necessary. Therefore, there was a need for a Design specific resource. The resource was based around the Development of Project Plan concept of enquiry-based learning, which describes an A detailed plan (Figure 2) was produced detailing the various environment that is driven by active learning. Active learn- components of the resource and demonstrating the links ing encourages effective learning and permits the opportu- between them, allowing for a thorough visualization of the nity for the user to reason, enabling the acquisition of format and layout and how to represent the content. The knowledge. The resource was developed as e-learning to design strategy ensured that the resource was interactive provide interactivity for the user and the advantage that and included audience participation to facilitate learning the user could pursue their studies at their own pace. The through active learning. Presentation took into account the latter was useful as the target audience consisted of pro- potential range of learning styles of the audience. fessionals who work in a busy environment and are under pressure to maintain their knowledge but are often faced Storyboard of Content with restrictions due to time or other factors. The resource An extensive storyboard was devised to delineate the full had to cater for varied levels of knowledge present in multi- content and layout of the resource (Figure 3). The content disciplinary teams. The range of learning styles present in was kept to the essential points relating to pharmacokinetics, the target audience, such as visual, auditory and kinaesthetic as the resource was designed to take approximately 30– learning styles, had to be taken into consideration. 45 min to complete in order to retain the attention of the Therefore, diagrams, keywords and a ‘hands-on’ approach user. were implemented in the resource to cater for this range of A quiz section was included to test the knowledge gained learning styles. while using the resource. The selection of an incorrect Overall, the main aim was to produce an interactive e- answer presented the option to return to the relevant page learning resource to explain the main pharmacokinetic prin- to revise the content, ensuring that the learning outcomes ciples related to TDM. The learning outcome for the user of the user were achieved. Positive feedback was given was to improve their understanding of the pharmacology for correct answers and negative feedback for incorrect behind the results that they produce. The null hypothesis answers. was that the resource did not cause a significant improvement of the users’ understanding of pharmacokinetics with respect Scientific Content Included to TDM. The key scientific points to be included in the resource were a basic introduction of TDM and indications for monitor- Materials and Methods ing, and also a precise, yet thorough explanation of the pharmacokinetic parameters affecting drug concentration. ADDIE Instructional Design Model The terms therapeutic objective and therapeutic window The ADDIE instructional design model was used as the fra- were defined to allow the user to relate the pharmacology mework for the structuring and development of the resource. to terminology that they may encounter while performing The phases of analysis, design, development, implementation TDM. Absorption was defined with reference to bio- and evaluation were applied to the learning situation. availability, first pass metabolism and the kinetics of absorption, outlining the potential sources of variation in Analysis drug absorption. Distribution was described in terms of The need for the resource and the feasibility of the project the apparent volume of distribution and potential sources were analysed through a pre-project (needs) questionnaire of variation. Metabolism was explained using diagrams to ......................................................................................................................................................................................................................................... 114 Bioscience Horizons † Volume 2 † Number 2 † June 2009 Research article ......................................................................................................................................................................................................................................... Figure 1. Pre-project (needs) questionnaire distributed to allow for the analysis phase of resource production. represent the phases of metabolism and the factors that may The colour scheme of the resource was consistent through- affect drug metabolism. Excretion of drugs was shown with out to provide continuity and avoid the resource becoming reference to clearance, the elimination rate constant and difficult to read and understand. Diagrams and flow charts half-life. were introduced to break-up large blocks of text and to make the content easier to understand and animation was used wherever appropriate. Choice of Software and Resource Distribution The software was produced in Opus Professional, which Implementation allowed for the production of an interactive resource. The completed resource was delivered on compact discs (CDs) as the target group was fairly small and to avoid pro- blems with firewalls at the Manchester Royal Infirmary, Development which may have prevented viewing the resource as a Layout and presentation were kept simple yet eye-catching webpage. to preserve the attention of the user while remaining easy to read and understand. Aspects of interaction were intro- Distribution of the Resource duced to allow the user to relate participation to motivation and instructions were clear and easy to follow where The resource was handed out individually to the target audi- required. ence of the same 29 scientists on the 15 April 2008 and staff ......................................................................................................................................................................................................................................... 115 Research article Bioscience Horizons † Volume 2 † Number 2 † June 2009 ......................................................................................................................................................................................................................................... Figure 2. Developed e-learning project plan including specific content, initial ideas and a preliminary storyboard of content. were given time until 18 April 2008 to return the question- together, and to allow for comparisons to be made naires to Dr. Gwen Ayers. between before and after using the resource. In relation to the questions regarding confidence levels of the users, SPSS Evaluation 14.0 for Windows was used to carry out a Wilcoxon matched pairs signed rank test on responses given before To determine the effectiveness of the resource, a set of ques- and after using the resource. This test was selected since tionnaires were also handed out with the CD (Figures 4 and the data was non-parametric and the difference in the 5). The questionnaires consisted of a pre- and post-resource responses to categories, before and after, were being questionnaire to allow for a before and after evaluation to examined. be performed. They contained questions related to knowl- edge of the audience before and after using the resource to allow for the effect of the resource on knowledge to be ana- lysed and also questions relating to functionality to assess the Results usability of the resource. The Resource Descriptive and analytical methods were used to evaluate the data received from the pre- and post-resource question- The completed resource can be accessed at: http:// naires. Keywords were extracted from the answers to open www.ls.manchester.ac.uk/undergraduate/courses/modules/ questions to identify similar responses, which were grouped elearning/elearningprojects/ ......................................................................................................................................................................................................................................... 116 Bioscience Horizons † Volume 2 † Number 2 † June 2009 Research article ......................................................................................................................................................................................................................................... Figure 2. Continued. Pre-Project (needs) Questionnaire performed the process from 22 to 25 years. Out of 17, 10 people carried out TDM on a daily basis though one-third Of the 29 pre-project questionnaires handed out, 17 were of the people did perform TDM only occasionally. A wide returned, providing a 59% return. The results helped to range of drugs were tested by the target audience, though define the main aim of the resource, which was to enhance lithium, phenytoin and digoxin were the drugs that were fre- the awareness of the basic pharmacokinetic principles under- quently monitored. lying the interpretation of the results generated by TDM through the production of an e-learning resource. The learn- Current Knowledge of TDM ing outcomes of the target audience were to have a greater The popular definition of TDM (10/17 respondents) was understanding of the pharmacology behind TDM on com- ‘Measuring the concentration of drugs’. There was a wider pletion of the resource. variety of answers to the open question ‘Why is TDM carried out’ with ‘Avoid toxicity’ as the most favoured but Target Audience also ‘Monitor patient compliance’, ‘Ensure efficacy’ and The majority of the audience had at least a BSc qualification, ‘Optimize dosing’ given. though a wide range of qualifications were held from A-Level The results from Question 9 and summary of the aspects to PhD and MBChB. Of the target group, 70% had been car- of TDM the target group would like to be included in the rying out TDM for up to 5 years, and only two people had e-learning resource are shown in Table 1. Responses were ......................................................................................................................................................................................................................................... 117 Research article Bioscience Horizons † Volume 2 † Number 2 † June 2009 ......................................................................................................................................................................................................................................... Figure 3. Detailed storyboard outlining the final content and layout of the resource. varied, with suggestions ranging from specific drug examples parameters following the use of the resource (Wilcoxon to including ‘everything’ relating to TDM. matched pair signed rank test, n ¼ 16, P ¼ 0.01; Figure 7). Eighty-one percent of the audience found the resource very helpful to understanding TDM (Figure 8). All of the Pre- and Post-Resource Testing Questionnaires users found the resource either easy to use or very easy to Out of the 25 questionnaire and resource packs distributed, a use (Figure 9). total of 16 were returned, a 64% return. Further Comments of the Audience on the Resource Effects on Knowledge The final question on the post-resource questionnaire allowed the target audience to express their views on the Using the resource widened and clarified the perceptions e-learning resource. Comments received included ‘Well among the audience as to the definition and purposes of presented and easy to use’ (n ¼ 7) and ‘Very informative’ TDM (Table 2). (n ¼ 4). Tables 3–6 show understanding in relation to each phar- macokinetic parameter. Again, answers to all questions were more focused and relevant following the use of the resource. Discussion Many responses closely matched the definitions given in the resource, though a range of responses was still present. Potential Bias in the Data It is necessary to be aware of potential bias resulting from the Effects on Confidence of Knowledge methodology employed. Although the return rates for the For the question relating to confidence in understanding and needs and the pre-/post-resource questionnaires were high, interpreting the data produced, no significant improvement 59% and 64%, respectively, biased samples could have was seen after using the resource (Wilcoxon matched pairs resulted. The level of educational achievement was varied, signed rank test, n ¼ 14, P ¼ 0.13; Figure 6). which could have confounded the ability to detect However, a significant improvement was seen regarding resource-induced increases in confidence in understanding confidence in the understanding of pharmacokinetic TDM data and pharmacokinetic parameters. In handling ......................................................................................................................................................................................................................................... 118 Bioscience Horizons † Volume 2 † Number 2 † June 2009 Research article ......................................................................................................................................................................................................................................... Figure 4. Pre-resource questionnaire distributed with the resource to allow for initial knowledge and understanding of the target audience to be evaluated. responses to open questions, similar words/phrases were several years, they said that would benefit them by gaining grouped together and care was taken by the researcher not more information on a process which they carry out regu- to introduce bias. Notwithstanding these qualifications, larly. They listed the drugs they tested, which suggested poss- some conclusions can be drawn. ible drug examples to be included in the resource. Current Knowledge of TDM Suitability of the Resource for the Target Audience It was apparent that the audience had a general idea that Target Audience TDM involved ‘measuring the concentration of drugs’, but There was a wide range of qualifications present in the audi- many varied responses were also received. Similarly, it was ence suggesting that the resource needed to cater for varying evident that the majority of the scientists felt that TDM levels of previous knowledge. Similarly, although the was carried out to ‘avoid toxicity,’ which is an incomplete majority of the scientists had been carrying out TDM for answer. ......................................................................................................................................................................................................................................... 119 Research article Bioscience Horizons † Volume 2 † Number 2 † June 2009 ......................................................................................................................................................................................................................................... Figure 5. Post-resource questionnaire to be completed following the use of the resource to allow for evaluation of the resource. Design of the Resource to Suit the Target Audience observations supported the conclusion that the resource improved the knowledge of the user. Following from the pre-project needs analysis, it was possible Similarly, from Table 2, it is clear that the use of the to infer that a clear definition and explanation of the indi- resource widened the knowledge of the user with regards cations for TDM were necessary to be included in the to the reasons behind TDM. The pre-resource responses resource. In addition, it was decided that a clear guide to showed wide-ranging responses, though the majority of pharmacokinetics would allow the user to understand people answered that TDM is carried out to ‘avoid toxicity.’ many of the other concepts. After using the resource, more keywords from the content appeared in the answers and there was more breadth of Effectiveness of the Resource knowledge; suggesting that the resource had improved Effects on Knowledge understanding. Concerning drug absorption, pre-resource responses por- Prior to use of the resource, there was a general understand- trayed misconceptions of absorption and some thought it ing of the concept behind TDM but some incorrect was defined as ‘the entry of drug into the organism’ responses, such as ‘measurement of levels of toxicity in the (Table 3). This error was corrected following the use of the blood’, were also received. Post-resource responses resource, indicating that the resource had improved the (Tables 2–6) were more precise and focused, with many users’ understanding. Similarly, there was improved relating specifically to content from the resource. These ......................................................................................................................................................................................................................................... 120 Bioscience Horizons † Volume 2 † Number 2 † June 2009 Research article ......................................................................................................................................................................................................................................... Table 1. Responses showing what aspects of therapeutic drug understanding pharmacokinetic parameters increased signifi- monitoring (TDM) the target group would like to be included in the cantly, suggesting that the resource improved knowledge e-learning resource (Figure 7). Topic Number of responses ................................................................................................................ Functionality of the Resource Guide to pharmacokinetics 3 The majority of the users found the resource helpful and easy Time of sampling 4 to use (Figures 8 and 9). The majority of feedback received Drug–drug interactions 2 was positive. These results suggest that all of the factors Drug examples taken into consideration in the design and development Aminoglycosides 1 phases were essential and successful in creating a useful and easy-to-use resource. Glycopeptides 1 Flucytosine 1 Effectiveness of the Utilization of Active Learning Vancomycin 1 Concerning the use of e-learning and active learning in the Gentamycin 1 resource, it is apparent that many of the users found this a Everything 1 very effective way to learn. Following responses received in Therapeutic ranges 3 the post-resource questionnaire and a discussion with the Alternate names for drugs 1 audience, it became apparent that they found that the use Alternate drugs to treat patients 2 of a computer facilitated their interaction during the learning Toxicity 3 process and mentioned the advantage of being able to Interpretation of test results 2 pursue their studies in their own way, own time and places Importance of TDM 2 of choice. This has been found to be the single biggest advan- Reasons for TDM 4 tage of self-instructional e-learning materials as it allows par- ticipants to study when and where it suits them. Multiple therapies 1 Implications for the Use of the Resource Similar words/phrases were grouped together Subsequent to a discussion with the users of the resource, it knowledge and understanding of the concepts of distri- became apparent that the resource could be integrated into a bution, metabolism and excretion (Tables 4–6). number of training programmes at Manchester Royal Infirmary. The e-learning resource could be used as part of Effects on Confidence of Knowledge ‘Continuing Professional Development’ to widen and test There was no improvement in confidence and in their ability the knowledge of staff who carry out TDM. The resource to interpret results after using the resource (Figure 6). There could be ‘of use to junior laboratory staff or as part of was already a high level of confidence present in the audience nurse education.’ To avoid problems with firewalls at the and that could be a possible reason why an improvement hospital, the resource could be uploaded onto the hospital could not be detected. Conversely, the confidence in intranet to allow all users to access it. Table 2. Responses regarding the definition and purposes of therapeutic drug monitoring (TDM) before and after using the resource Answer Number of responses pre-resource Number of responses post-resource ........................................................................................................................................................................................................................................ Avoid toxicity 16 5 Determine if dose is ineffective 5 0 Manage a patients dose 5 4 Measurement of drug concentration in blood 3 12 Monitoring to allow for optimal dosage 3 4 Measurement of levels of toxicity in the blood 1 0 Provide maximal clinical outcome 0 7 Narrow therapeutic window 0 6 Monitoring of special populations 0 4 Inpatients with hepatic or renal insufficiency 0 3 Similar words/phrases were grouped together. ......................................................................................................................................................................................................................................... 121 Research article Bioscience Horizons † Volume 2 † Number 2 † June 2009 ......................................................................................................................................................................................................................................... Table 3. Responses regarding the definition of drug absorption before and after using the resource Answer Number of responses Number of responses pre-resource post-resource ........................................................................................................................................................................................................................................ Uptake of drug by the body 4 1 How much of the administered dose is absorbed into the circulation or target organs 3 0 The movement of drug into the body 3 1 The rate at which the drug is absorbed into the bloodstream 3 0 The entry of drug into the organism 1 0 The process by which unchanged drug proceeds from the site of administration to the011 site of measurement within the blood Similar words/phrases were grouped together. Table 4. Responses regarding the definition of drug distribution before and after using the resource. Similar words/phrases were grouped together. Answer Number of responses pre-resource Number of responses post-resource ........................................................................................................................................................................................................................................ The spread to all the internal parts of the body 5 0 Transport to the correct area of the body 3 3 Process of partitioning into different compartments 3 2 The area of cells or tissues in which the drug is found 2 0 Binding to plasma proteins 1 0 The process of reversible transfer of a drug between the blood and tissues 0 5 Similar words/phrases were grouped together. Table 5. Responses regarding the definition of drug metabolism before and after using the resource Answer Number of responses Number of responses pre-resource post-resource ........................................................................................................................................................................................................................................ Breakdown by the body 4 1 A process of conversion of drug using enzymes 3 2 Process for detoxification and inactivation or activation of the parent drug 3 2 How the body changes it 3 0 The enzyme-mediated conversion of a lipophilic compound into a more 07 water-soluble one Takes place on the smooth endoplasmic reticulum of the liver 0 5 Similar words/phrases were grouped together. Table 6. Responses regarding the definition of drug elimination before and after using the resource Answer Number of responses pre-resource Number of responses post-resource ........................................................................................................................................................................................................................................ The main route of elimination of metabolites and unchanged drug 15 0 Irreversible process 1 6 The irreversible loss of drug from the body 0 6 Elimination of waste product 0 6 Elimination of drug in either a changed or unchanged form 0 2 Similar words/phrases were grouped together. ......................................................................................................................................................................................................................................... 122 Bioscience Horizons † Volume 2 † Number 2 † June 2009 Research article ......................................................................................................................................................................................................................................... Figure 9. A bar chart representing how easy the audience found the resource to use. Figure 6. A bar chart representing the responses relating to confidence in understanding and interpreting the results the audience generates before and after using the resource. Conclusions The resource met the initial aims and the learning outcomes of the target audience by providing an interactive e-learning resource to explain and widen the understanding of the phar- macokinetic principles related to TDM. The significant improvement in confidence of understanding pharmacoki- netic parameters allow the null hypothesis to be rejected. Acknowledgements I would like to thank Dr Michael Hollingsworth (Faculty of Life Sciences, Manchester University) and Dr Gwen Ayers (Biochemistry Department, Manchester Royal Infirmary) for their help and support with my project. Funding Figure 7. A bar chart representing the responses relating to confidence in The project was supported by the Faculty of Life Sciences, understanding pharmacokinetic parameters before and after using the University of Manchester, Manchester, UK. resource. References 1. Evans WE, Schentag JJ, Jusko WJ (1992) Applied Pharmacokinetics: Principles of Therapeutic Drug Monitoring, 3rd ed. PA, USA: Lippincott Williams & Wilkins. 2. Hallworth M, Capps N (1993) Therapeutic Drug Monitoring and Clinical Biochemistry. London: ACB Venture Publications. 3. Schumacher GE (1995) Therapeutic Drug Monitoring, 1st ed. London, UK: Appleton and Lange. 4. Rang HP, Dale MM, Ritter JM et al. (2003) Pharmacology, 5th ed. London, UK: Churchill Livingstone. 5. Anonymous NHS Clinical Governance Support Team (2008). http:// www.cgsupport.nhs.uk/resources/ Clinical_Audit16@Audit_Cycle_and_References.asp (accessed 7 April 2008). 6. National Institute for Clinical Excellence (2002) Principles for Best Practice in Clinical Audit. London, UK: Radcliffe Publishing. Figure 8. A bar chart representing the results relating to how helpful the 7. Hladky SB (1990) Pharmacokinetics. Manchester, UK: Manchester University target audience found the resource to understanding TDM. Press. ......................................................................................................................................................................................................................................... 123 Research article Bioscience Horizons † Volume 2 † Number 2 † June 2009 ......................................................................................................................................................................................................................................... 8. Gibaldi M, Perrier D (1982) Pharmacokinetics, 2nd ed. New York, USA: Marcel 14. Schittek M, Mattheos N, Lyon HC et al. (2001) Computer assisted learning. A Dekker. review. Eur J Dental Educ 5: 93–100. 9. Rowland M, Tozer TN (1995) Clinical Pharmacokinetics: Concepts and 15. Greenhalgh T (2001) Computer assisted learning in undergraduate medical Applications, 3rd ed. PA, USA: Lippincott Williams & Wilkins. education. Br Med J 322: 40–44. 10. Anonymous (2008) Therapeutic Drug Monitoring. PA, USA: Lippincott 16. Dark GG, Perret R (2007) Using e-learning as a tool for multidisciplinary edu- Williams & Wilkins. http://www.drug-monitoring.com/pt/re/tdm/home. cation. Eur J Cancer Care 16: 90–93. htm;jsessionid=LLlBkVQjQcHnnjzQfL1T1T2hJPPhLSFGc8npQ5f1Hy6cw9RQ9 17. Anonymous (2008) VAK Learning Styles. https://olt.qut.edu.au/it/itb116/ WD1!6707 93751!181195628!8091!-1 (accessed 24 March 2008). gen/static/vak/Index.htm (accessed 24 March 2008). 11. Hutchings B (2006) Principles of Enquiry Based Learning. Manchester, UK: 18. Anonymous (2008) The ADDIE Instructional Design Model. http:// University of Manchester. http://www.campus.manchester.ac.uk/ceebl/ www.outsource2india.com/LearningSolutions/articles/ADDIE.asp (accessed resources/general/ceeblgr002.pdf (accessed 20 July 2008). 4 March 2008). 12. Anonymous (2008) What is Enquiry-Based Learning? Manchester, UK: 19. Anonymous (2008) Digital Workshop: Opus Professional. http:// University of Manchester. http://www.campus.manchester.ac.uk/ceebl/ www.digitalworkshop.com/products/Pro.shtml (accessed 15 March 2008). ebl/ (accessed 1 April 2008). 20. Ennos AR (2006) Statistical and Data Handling Skills in Biology, 2nd ed. 13. Michael AM (2003) Allen’s Guide to e-learning: Building Interactive, Fun and England, UK: Prentice Hall. Effective Learning Programs. USA: John Wiley and Sons Inc. Author Biography Krupa Samani recently graduated from the University of Manchester with a Pharmacology BSc Honours degree. This article originates from her final year project, and shows her keen interest in pharmacokinetics and the basic drug disposition concepts underlying drug discovery, development and subsequent therapy. Throughout my degree course, Krupa gained an insight into the basic principles which are fundamental to successful drug development. She also carried out both in vitro and in vivo research which has allowed her to appreciate the effects of drugs in whole organisms. Krupa has a particular interest in research into new drugs: she hopes to build a career in research, in particular within the pharmaceutical industry. ........................................................................................................................................................................................................................................ Submitted on 1 October 2008; accepted on 18 December 2008; advance access publication 30 March 2009 ......................................................................................................................................................................................................................................... http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Bioscience Horizons Oxford University Press

Therapeutic drug monitoring: an e-learning resource

Bioscience Horizons , Volume 2 (2) – Jun 30, 2009

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10.1093/biohorizons/hzp013
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Abstract

Volume 2 † Number 2 † June 2009 10.1093/biohorizons/hzp013 ......................................................................................................................................................................................................................................... Research article Therapeutic drug monitoring: an e-learning resource Krupa Samani* University of Manchester, Manchester, UK. * Corresponding author: 16 Hatherleigh Road, Evington, Leicester LE5 5NR, UK. Email: krupa65@hotmail.com Supervisor: Dr Michael Hollingsworth, University of Manchester, Manchester, UK. ........................................................................................................................................................................................................................................ The main aim of this project was to produce an interactive e-learning resource explaining the pharmacokinetic principles related to therapeutic drug monitoring (TDM). The target audience for the resource were scientists at Manchester Royal Infirmary and the intended learning outcome for the users was to improve their understanding of the pharmacology behind the results they generate. The null hypothesis stated that the resource would not cause a significant improvement in the users’ understanding of pharmacokinetics. The ADDIE Instructional Design Model was applied to the learning situation. A pre-project questionnaire allowed for a needs analysis to be conducted, determining the current level of knowledge. Design and development involved production of project plans and story- boards and the entire resource was produced using Opus Professional. The resource was distributed via compact discs, along with pre- and post-resource questionnaires to permit analysis. Knowledge was compared before and after using the resource to establish the effectiveness of the resource, and the functionality of the resource was evaluated. The needs questionnaire results outlined the exist- ing level of knowledge as being varied and provided suggestions for possible concepts to include in the resource. A more precise and accurate definition of TDM, why it is carried out, and the pharmacokinetic parameters were apparent in the post-resource questionnaire results. Confidence in the understanding and interpretation of data produce was not significantly improved (Wilcoxon matched pairs signed ranks test, n ¼ 14, P ¼ 0.13), while confidence in the understanding of pharmacokinetic parameters was significantly improved (Wilcoxon matched pairs signed ranks test, n ¼ 16, P ¼ 0.01). About 81% of the audience found the resource very helpful to understand- ing TDM and all of the users found it either easy to use or very easy to use. The post-resource results showed that confidence in the understanding of pharmacokinetics was improved, indicating that the learning outcomes of the user were achieved thus allowing the null hypothesis to be rejected. However, confidence in understanding the data generated was not improved, suggesting a possible aspect to be developed if the project was to be repeated. Functionality of the resource was successful as users found the resource easy to use and navigate. Key words: therapeutic drug monitoring, e-learning resource, pharmacokinetics. ........................................................................................................................................................................................................................................ blood samples received from patients to determine the con- Introduction centration of a given drug. This concentration can then be Therapeutic drug monitoring (TDM) utilizes the principle used by a clinician to determine the success of treatment that the clinical response of a drug is directly related to its and whether sub-optimal, optimal or toxic drug concen- concentration in blood and hence monitoring is carried out trations are being achieved. to support the management of patients receiving certain It was considered that the target audience needed 1, 2 drugs. The central goal of TDM is to use drug concen- improved grounding in pharmacokinetics to strengthen tration to manage drug regimens to optimize therapy. The their comprehension of the reasoning behind the data that target group consisted of about 30 scientists who work in they generated. A resource was designed to support the the Biochemistry, Toxicology and Microbiology laboratories users’ understanding of the potential sources of pharmacoki- at the Manchester Royal Infirmary, and who carry out TDM netic variation, which can result in the varying drug concen- on a regular basis. Their key responsibility is to monitor trations they monitor in patients’ samples. ......................................................................................................................................................................................................................................... 2009 The Author(s). This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/2.0/uk/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 113 Research article Bioscience Horizons † Volume 2 † Number 2 † June 2009 ......................................................................................................................................................................................................................................... The resource followed the concept of a clinical audit for shown in Figure 1. The survey was conducted with scientists the Central Manchester and Manchester Children’s who carry out TDM as well as other biochemical tests in the University Hospitals NHS Trust (CMMC) with the Biochemistry, Toxicology and Microbiology laboratories at purpose of improving patient care and outcomes following Manchester Royal Infirmary. Pre-project questionnaires a systematic review of the TDM process through implement- were distributed to 25 out of the 29 staff used for the ing the change of improving knowledge. The process of needs questionnaire on the 3 December 2007. Staff were resource development referred to the stages of clinical audit given two weeks to complete and return them to Dr. Gwen to improve their awareness and, therefore, enhance their Ayers (co-supervisor at the hospital). The questionnaire understanding of the results which they generate. aimed to determine the background, current level of The majority of information relating to TDM can be understanding and requirements of the target group and 7–9 10 found either in textbooks or journals. However, whether there was a need to produce an e-learning resource content is often too textual and few pharmacology textbooks on TDM. describe TDM specifically, presenting more complex infor- mation than is necessary. Therefore, there was a need for a Design specific resource. The resource was based around the Development of Project Plan concept of enquiry-based learning, which describes an A detailed plan (Figure 2) was produced detailing the various environment that is driven by active learning. Active learn- components of the resource and demonstrating the links ing encourages effective learning and permits the opportu- between them, allowing for a thorough visualization of the nity for the user to reason, enabling the acquisition of format and layout and how to represent the content. The knowledge. The resource was developed as e-learning to design strategy ensured that the resource was interactive provide interactivity for the user and the advantage that and included audience participation to facilitate learning the user could pursue their studies at their own pace. The through active learning. Presentation took into account the latter was useful as the target audience consisted of pro- potential range of learning styles of the audience. fessionals who work in a busy environment and are under pressure to maintain their knowledge but are often faced Storyboard of Content with restrictions due to time or other factors. The resource An extensive storyboard was devised to delineate the full had to cater for varied levels of knowledge present in multi- content and layout of the resource (Figure 3). The content disciplinary teams. The range of learning styles present in was kept to the essential points relating to pharmacokinetics, the target audience, such as visual, auditory and kinaesthetic as the resource was designed to take approximately 30– learning styles, had to be taken into consideration. 45 min to complete in order to retain the attention of the Therefore, diagrams, keywords and a ‘hands-on’ approach user. were implemented in the resource to cater for this range of A quiz section was included to test the knowledge gained learning styles. while using the resource. The selection of an incorrect Overall, the main aim was to produce an interactive e- answer presented the option to return to the relevant page learning resource to explain the main pharmacokinetic prin- to revise the content, ensuring that the learning outcomes ciples related to TDM. The learning outcome for the user of the user were achieved. Positive feedback was given was to improve their understanding of the pharmacology for correct answers and negative feedback for incorrect behind the results that they produce. The null hypothesis answers. was that the resource did not cause a significant improvement of the users’ understanding of pharmacokinetics with respect Scientific Content Included to TDM. The key scientific points to be included in the resource were a basic introduction of TDM and indications for monitor- Materials and Methods ing, and also a precise, yet thorough explanation of the pharmacokinetic parameters affecting drug concentration. ADDIE Instructional Design Model The terms therapeutic objective and therapeutic window The ADDIE instructional design model was used as the fra- were defined to allow the user to relate the pharmacology mework for the structuring and development of the resource. to terminology that they may encounter while performing The phases of analysis, design, development, implementation TDM. Absorption was defined with reference to bio- and evaluation were applied to the learning situation. availability, first pass metabolism and the kinetics of absorption, outlining the potential sources of variation in Analysis drug absorption. Distribution was described in terms of The need for the resource and the feasibility of the project the apparent volume of distribution and potential sources were analysed through a pre-project (needs) questionnaire of variation. Metabolism was explained using diagrams to ......................................................................................................................................................................................................................................... 114 Bioscience Horizons † Volume 2 † Number 2 † June 2009 Research article ......................................................................................................................................................................................................................................... Figure 1. Pre-project (needs) questionnaire distributed to allow for the analysis phase of resource production. represent the phases of metabolism and the factors that may The colour scheme of the resource was consistent through- affect drug metabolism. Excretion of drugs was shown with out to provide continuity and avoid the resource becoming reference to clearance, the elimination rate constant and difficult to read and understand. Diagrams and flow charts half-life. were introduced to break-up large blocks of text and to make the content easier to understand and animation was used wherever appropriate. Choice of Software and Resource Distribution The software was produced in Opus Professional, which Implementation allowed for the production of an interactive resource. The completed resource was delivered on compact discs (CDs) as the target group was fairly small and to avoid pro- blems with firewalls at the Manchester Royal Infirmary, Development which may have prevented viewing the resource as a Layout and presentation were kept simple yet eye-catching webpage. to preserve the attention of the user while remaining easy to read and understand. Aspects of interaction were intro- Distribution of the Resource duced to allow the user to relate participation to motivation and instructions were clear and easy to follow where The resource was handed out individually to the target audi- required. ence of the same 29 scientists on the 15 April 2008 and staff ......................................................................................................................................................................................................................................... 115 Research article Bioscience Horizons † Volume 2 † Number 2 † June 2009 ......................................................................................................................................................................................................................................... Figure 2. Developed e-learning project plan including specific content, initial ideas and a preliminary storyboard of content. were given time until 18 April 2008 to return the question- together, and to allow for comparisons to be made naires to Dr. Gwen Ayers. between before and after using the resource. In relation to the questions regarding confidence levels of the users, SPSS Evaluation 14.0 for Windows was used to carry out a Wilcoxon matched pairs signed rank test on responses given before To determine the effectiveness of the resource, a set of ques- and after using the resource. This test was selected since tionnaires were also handed out with the CD (Figures 4 and the data was non-parametric and the difference in the 5). The questionnaires consisted of a pre- and post-resource responses to categories, before and after, were being questionnaire to allow for a before and after evaluation to examined. be performed. They contained questions related to knowl- edge of the audience before and after using the resource to allow for the effect of the resource on knowledge to be ana- lysed and also questions relating to functionality to assess the Results usability of the resource. The Resource Descriptive and analytical methods were used to evaluate the data received from the pre- and post-resource question- The completed resource can be accessed at: http:// naires. Keywords were extracted from the answers to open www.ls.manchester.ac.uk/undergraduate/courses/modules/ questions to identify similar responses, which were grouped elearning/elearningprojects/ ......................................................................................................................................................................................................................................... 116 Bioscience Horizons † Volume 2 † Number 2 † June 2009 Research article ......................................................................................................................................................................................................................................... Figure 2. Continued. Pre-Project (needs) Questionnaire performed the process from 22 to 25 years. Out of 17, 10 people carried out TDM on a daily basis though one-third Of the 29 pre-project questionnaires handed out, 17 were of the people did perform TDM only occasionally. A wide returned, providing a 59% return. The results helped to range of drugs were tested by the target audience, though define the main aim of the resource, which was to enhance lithium, phenytoin and digoxin were the drugs that were fre- the awareness of the basic pharmacokinetic principles under- quently monitored. lying the interpretation of the results generated by TDM through the production of an e-learning resource. The learn- Current Knowledge of TDM ing outcomes of the target audience were to have a greater The popular definition of TDM (10/17 respondents) was understanding of the pharmacology behind TDM on com- ‘Measuring the concentration of drugs’. There was a wider pletion of the resource. variety of answers to the open question ‘Why is TDM carried out’ with ‘Avoid toxicity’ as the most favoured but Target Audience also ‘Monitor patient compliance’, ‘Ensure efficacy’ and The majority of the audience had at least a BSc qualification, ‘Optimize dosing’ given. though a wide range of qualifications were held from A-Level The results from Question 9 and summary of the aspects to PhD and MBChB. Of the target group, 70% had been car- of TDM the target group would like to be included in the rying out TDM for up to 5 years, and only two people had e-learning resource are shown in Table 1. Responses were ......................................................................................................................................................................................................................................... 117 Research article Bioscience Horizons † Volume 2 † Number 2 † June 2009 ......................................................................................................................................................................................................................................... Figure 3. Detailed storyboard outlining the final content and layout of the resource. varied, with suggestions ranging from specific drug examples parameters following the use of the resource (Wilcoxon to including ‘everything’ relating to TDM. matched pair signed rank test, n ¼ 16, P ¼ 0.01; Figure 7). Eighty-one percent of the audience found the resource very helpful to understanding TDM (Figure 8). All of the Pre- and Post-Resource Testing Questionnaires users found the resource either easy to use or very easy to Out of the 25 questionnaire and resource packs distributed, a use (Figure 9). total of 16 were returned, a 64% return. Further Comments of the Audience on the Resource Effects on Knowledge The final question on the post-resource questionnaire allowed the target audience to express their views on the Using the resource widened and clarified the perceptions e-learning resource. Comments received included ‘Well among the audience as to the definition and purposes of presented and easy to use’ (n ¼ 7) and ‘Very informative’ TDM (Table 2). (n ¼ 4). Tables 3–6 show understanding in relation to each phar- macokinetic parameter. Again, answers to all questions were more focused and relevant following the use of the resource. Discussion Many responses closely matched the definitions given in the resource, though a range of responses was still present. Potential Bias in the Data It is necessary to be aware of potential bias resulting from the Effects on Confidence of Knowledge methodology employed. Although the return rates for the For the question relating to confidence in understanding and needs and the pre-/post-resource questionnaires were high, interpreting the data produced, no significant improvement 59% and 64%, respectively, biased samples could have was seen after using the resource (Wilcoxon matched pairs resulted. The level of educational achievement was varied, signed rank test, n ¼ 14, P ¼ 0.13; Figure 6). which could have confounded the ability to detect However, a significant improvement was seen regarding resource-induced increases in confidence in understanding confidence in the understanding of pharmacokinetic TDM data and pharmacokinetic parameters. In handling ......................................................................................................................................................................................................................................... 118 Bioscience Horizons † Volume 2 † Number 2 † June 2009 Research article ......................................................................................................................................................................................................................................... Figure 4. Pre-resource questionnaire distributed with the resource to allow for initial knowledge and understanding of the target audience to be evaluated. responses to open questions, similar words/phrases were several years, they said that would benefit them by gaining grouped together and care was taken by the researcher not more information on a process which they carry out regu- to introduce bias. Notwithstanding these qualifications, larly. They listed the drugs they tested, which suggested poss- some conclusions can be drawn. ible drug examples to be included in the resource. Current Knowledge of TDM Suitability of the Resource for the Target Audience It was apparent that the audience had a general idea that Target Audience TDM involved ‘measuring the concentration of drugs’, but There was a wide range of qualifications present in the audi- many varied responses were also received. Similarly, it was ence suggesting that the resource needed to cater for varying evident that the majority of the scientists felt that TDM levels of previous knowledge. Similarly, although the was carried out to ‘avoid toxicity,’ which is an incomplete majority of the scientists had been carrying out TDM for answer. ......................................................................................................................................................................................................................................... 119 Research article Bioscience Horizons † Volume 2 † Number 2 † June 2009 ......................................................................................................................................................................................................................................... Figure 5. Post-resource questionnaire to be completed following the use of the resource to allow for evaluation of the resource. Design of the Resource to Suit the Target Audience observations supported the conclusion that the resource improved the knowledge of the user. Following from the pre-project needs analysis, it was possible Similarly, from Table 2, it is clear that the use of the to infer that a clear definition and explanation of the indi- resource widened the knowledge of the user with regards cations for TDM were necessary to be included in the to the reasons behind TDM. The pre-resource responses resource. In addition, it was decided that a clear guide to showed wide-ranging responses, though the majority of pharmacokinetics would allow the user to understand people answered that TDM is carried out to ‘avoid toxicity.’ many of the other concepts. After using the resource, more keywords from the content appeared in the answers and there was more breadth of Effectiveness of the Resource knowledge; suggesting that the resource had improved Effects on Knowledge understanding. Concerning drug absorption, pre-resource responses por- Prior to use of the resource, there was a general understand- trayed misconceptions of absorption and some thought it ing of the concept behind TDM but some incorrect was defined as ‘the entry of drug into the organism’ responses, such as ‘measurement of levels of toxicity in the (Table 3). This error was corrected following the use of the blood’, were also received. Post-resource responses resource, indicating that the resource had improved the (Tables 2–6) were more precise and focused, with many users’ understanding. Similarly, there was improved relating specifically to content from the resource. These ......................................................................................................................................................................................................................................... 120 Bioscience Horizons † Volume 2 † Number 2 † June 2009 Research article ......................................................................................................................................................................................................................................... Table 1. Responses showing what aspects of therapeutic drug understanding pharmacokinetic parameters increased signifi- monitoring (TDM) the target group would like to be included in the cantly, suggesting that the resource improved knowledge e-learning resource (Figure 7). Topic Number of responses ................................................................................................................ Functionality of the Resource Guide to pharmacokinetics 3 The majority of the users found the resource helpful and easy Time of sampling 4 to use (Figures 8 and 9). The majority of feedback received Drug–drug interactions 2 was positive. These results suggest that all of the factors Drug examples taken into consideration in the design and development Aminoglycosides 1 phases were essential and successful in creating a useful and easy-to-use resource. Glycopeptides 1 Flucytosine 1 Effectiveness of the Utilization of Active Learning Vancomycin 1 Concerning the use of e-learning and active learning in the Gentamycin 1 resource, it is apparent that many of the users found this a Everything 1 very effective way to learn. Following responses received in Therapeutic ranges 3 the post-resource questionnaire and a discussion with the Alternate names for drugs 1 audience, it became apparent that they found that the use Alternate drugs to treat patients 2 of a computer facilitated their interaction during the learning Toxicity 3 process and mentioned the advantage of being able to Interpretation of test results 2 pursue their studies in their own way, own time and places Importance of TDM 2 of choice. This has been found to be the single biggest advan- Reasons for TDM 4 tage of self-instructional e-learning materials as it allows par- ticipants to study when and where it suits them. Multiple therapies 1 Implications for the Use of the Resource Similar words/phrases were grouped together Subsequent to a discussion with the users of the resource, it knowledge and understanding of the concepts of distri- became apparent that the resource could be integrated into a bution, metabolism and excretion (Tables 4–6). number of training programmes at Manchester Royal Infirmary. The e-learning resource could be used as part of Effects on Confidence of Knowledge ‘Continuing Professional Development’ to widen and test There was no improvement in confidence and in their ability the knowledge of staff who carry out TDM. The resource to interpret results after using the resource (Figure 6). There could be ‘of use to junior laboratory staff or as part of was already a high level of confidence present in the audience nurse education.’ To avoid problems with firewalls at the and that could be a possible reason why an improvement hospital, the resource could be uploaded onto the hospital could not be detected. Conversely, the confidence in intranet to allow all users to access it. Table 2. Responses regarding the definition and purposes of therapeutic drug monitoring (TDM) before and after using the resource Answer Number of responses pre-resource Number of responses post-resource ........................................................................................................................................................................................................................................ Avoid toxicity 16 5 Determine if dose is ineffective 5 0 Manage a patients dose 5 4 Measurement of drug concentration in blood 3 12 Monitoring to allow for optimal dosage 3 4 Measurement of levels of toxicity in the blood 1 0 Provide maximal clinical outcome 0 7 Narrow therapeutic window 0 6 Monitoring of special populations 0 4 Inpatients with hepatic or renal insufficiency 0 3 Similar words/phrases were grouped together. ......................................................................................................................................................................................................................................... 121 Research article Bioscience Horizons † Volume 2 † Number 2 † June 2009 ......................................................................................................................................................................................................................................... Table 3. Responses regarding the definition of drug absorption before and after using the resource Answer Number of responses Number of responses pre-resource post-resource ........................................................................................................................................................................................................................................ Uptake of drug by the body 4 1 How much of the administered dose is absorbed into the circulation or target organs 3 0 The movement of drug into the body 3 1 The rate at which the drug is absorbed into the bloodstream 3 0 The entry of drug into the organism 1 0 The process by which unchanged drug proceeds from the site of administration to the011 site of measurement within the blood Similar words/phrases were grouped together. Table 4. Responses regarding the definition of drug distribution before and after using the resource. Similar words/phrases were grouped together. Answer Number of responses pre-resource Number of responses post-resource ........................................................................................................................................................................................................................................ The spread to all the internal parts of the body 5 0 Transport to the correct area of the body 3 3 Process of partitioning into different compartments 3 2 The area of cells or tissues in which the drug is found 2 0 Binding to plasma proteins 1 0 The process of reversible transfer of a drug between the blood and tissues 0 5 Similar words/phrases were grouped together. Table 5. Responses regarding the definition of drug metabolism before and after using the resource Answer Number of responses Number of responses pre-resource post-resource ........................................................................................................................................................................................................................................ Breakdown by the body 4 1 A process of conversion of drug using enzymes 3 2 Process for detoxification and inactivation or activation of the parent drug 3 2 How the body changes it 3 0 The enzyme-mediated conversion of a lipophilic compound into a more 07 water-soluble one Takes place on the smooth endoplasmic reticulum of the liver 0 5 Similar words/phrases were grouped together. Table 6. Responses regarding the definition of drug elimination before and after using the resource Answer Number of responses pre-resource Number of responses post-resource ........................................................................................................................................................................................................................................ The main route of elimination of metabolites and unchanged drug 15 0 Irreversible process 1 6 The irreversible loss of drug from the body 0 6 Elimination of waste product 0 6 Elimination of drug in either a changed or unchanged form 0 2 Similar words/phrases were grouped together. ......................................................................................................................................................................................................................................... 122 Bioscience Horizons † Volume 2 † Number 2 † June 2009 Research article ......................................................................................................................................................................................................................................... Figure 9. A bar chart representing how easy the audience found the resource to use. Figure 6. A bar chart representing the responses relating to confidence in understanding and interpreting the results the audience generates before and after using the resource. Conclusions The resource met the initial aims and the learning outcomes of the target audience by providing an interactive e-learning resource to explain and widen the understanding of the phar- macokinetic principles related to TDM. The significant improvement in confidence of understanding pharmacoki- netic parameters allow the null hypothesis to be rejected. Acknowledgements I would like to thank Dr Michael Hollingsworth (Faculty of Life Sciences, Manchester University) and Dr Gwen Ayers (Biochemistry Department, Manchester Royal Infirmary) for their help and support with my project. Funding Figure 7. A bar chart representing the responses relating to confidence in The project was supported by the Faculty of Life Sciences, understanding pharmacokinetic parameters before and after using the University of Manchester, Manchester, UK. resource. References 1. Evans WE, Schentag JJ, Jusko WJ (1992) Applied Pharmacokinetics: Principles of Therapeutic Drug Monitoring, 3rd ed. PA, USA: Lippincott Williams & Wilkins. 2. Hallworth M, Capps N (1993) Therapeutic Drug Monitoring and Clinical Biochemistry. London: ACB Venture Publications. 3. Schumacher GE (1995) Therapeutic Drug Monitoring, 1st ed. London, UK: Appleton and Lange. 4. Rang HP, Dale MM, Ritter JM et al. (2003) Pharmacology, 5th ed. London, UK: Churchill Livingstone. 5. Anonymous NHS Clinical Governance Support Team (2008). http:// www.cgsupport.nhs.uk/resources/ Clinical_Audit16@Audit_Cycle_and_References.asp (accessed 7 April 2008). 6. National Institute for Clinical Excellence (2002) Principles for Best Practice in Clinical Audit. London, UK: Radcliffe Publishing. Figure 8. A bar chart representing the results relating to how helpful the 7. Hladky SB (1990) Pharmacokinetics. Manchester, UK: Manchester University target audience found the resource to understanding TDM. Press. ......................................................................................................................................................................................................................................... 123 Research article Bioscience Horizons † Volume 2 † Number 2 † June 2009 ......................................................................................................................................................................................................................................... 8. Gibaldi M, Perrier D (1982) Pharmacokinetics, 2nd ed. New York, USA: Marcel 14. Schittek M, Mattheos N, Lyon HC et al. (2001) Computer assisted learning. A Dekker. review. Eur J Dental Educ 5: 93–100. 9. Rowland M, Tozer TN (1995) Clinical Pharmacokinetics: Concepts and 15. Greenhalgh T (2001) Computer assisted learning in undergraduate medical Applications, 3rd ed. PA, USA: Lippincott Williams & Wilkins. education. Br Med J 322: 40–44. 10. Anonymous (2008) Therapeutic Drug Monitoring. PA, USA: Lippincott 16. Dark GG, Perret R (2007) Using e-learning as a tool for multidisciplinary edu- Williams & Wilkins. http://www.drug-monitoring.com/pt/re/tdm/home. cation. Eur J Cancer Care 16: 90–93. htm;jsessionid=LLlBkVQjQcHnnjzQfL1T1T2hJPPhLSFGc8npQ5f1Hy6cw9RQ9 17. Anonymous (2008) VAK Learning Styles. https://olt.qut.edu.au/it/itb116/ WD1!6707 93751!181195628!8091!-1 (accessed 24 March 2008). gen/static/vak/Index.htm (accessed 24 March 2008). 11. Hutchings B (2006) Principles of Enquiry Based Learning. Manchester, UK: 18. Anonymous (2008) The ADDIE Instructional Design Model. http:// University of Manchester. http://www.campus.manchester.ac.uk/ceebl/ www.outsource2india.com/LearningSolutions/articles/ADDIE.asp (accessed resources/general/ceeblgr002.pdf (accessed 20 July 2008). 4 March 2008). 12. Anonymous (2008) What is Enquiry-Based Learning? Manchester, UK: 19. Anonymous (2008) Digital Workshop: Opus Professional. http:// University of Manchester. http://www.campus.manchester.ac.uk/ceebl/ www.digitalworkshop.com/products/Pro.shtml (accessed 15 March 2008). ebl/ (accessed 1 April 2008). 20. Ennos AR (2006) Statistical and Data Handling Skills in Biology, 2nd ed. 13. Michael AM (2003) Allen’s Guide to e-learning: Building Interactive, Fun and England, UK: Prentice Hall. Effective Learning Programs. USA: John Wiley and Sons Inc. Author Biography Krupa Samani recently graduated from the University of Manchester with a Pharmacology BSc Honours degree. This article originates from her final year project, and shows her keen interest in pharmacokinetics and the basic drug disposition concepts underlying drug discovery, development and subsequent therapy. Throughout my degree course, Krupa gained an insight into the basic principles which are fundamental to successful drug development. She also carried out both in vitro and in vivo research which has allowed her to appreciate the effects of drugs in whole organisms. Krupa has a particular interest in research into new drugs: she hopes to build a career in research, in particular within the pharmaceutical industry. ........................................................................................................................................................................................................................................ Submitted on 1 October 2008; accepted on 18 December 2008; advance access publication 30 March 2009 .........................................................................................................................................................................................................................................

Journal

Bioscience HorizonsOxford University Press

Published: Jun 30, 2009

Keywords: Key words therapeutic drug monitoring e-learning resource pharmacokinetics

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