Speaker 1: Welcome to the ASHP Official Podcast, your guide to issues related to medication use, public health and the profession of pharmacy.
Dr. Lindsay Christensen:
Thanks for joining us for ASHP's Practice Journey Podcast. This podcast invites members to share their stories about their professional path, lessons learned and how their experience has shaped who and where they are today. My name is Dr. Lindsay Christensen, clinical pharmacist at UCHealth Poudre Valley Hospital and advisory group member for the ASHP New Practitioners Forum clinical practice advisory group. And I'll be your host today.
Dr. Lindsay Christensen:
With me today is Dr. Pete Johnson, professor of pharmacy practice at University of Oklahoma College of Pharmacy, adjunct professor of pediatrics at University of Oklahoma College of Medicine, PGY2 pediatric residency program director, director of clinical and translational science fellowship in pediatric pharmacotherapy and clinical pharmacy specialist in pediatric critical care at The Children's Hospital at OU Medical Center.
Dr. Lindsay Christensen:
Dr. Johnson is also a senior associate editor for the American Journal of Health-System Pharmacy and was guest editor for AJHP's 2019 special issue on pediatrics. He has served as an editorial board member for AJHP from 2009 to 2011, the Journal of Pediatric Pharmacology and Therapeutics from 2018 to 2019, and the Journal of Pediatric Intensive Care from 2018 until the present.
Dr. Lindsay Christensen:
Thanks for joining us today, Pete. Let's start talking about today's topic, manuscript mysteries: unlocking unanswered questions from an editor's perspective. So, can you tell me a little about yourself and how you became an editor?
Dr. Pete Johnson:
Sure. Thanks for having me today. I have always had a passion for writing and using that as a creative outlet to produce things to help other people explore solutions to problems, even going back to when I was in grade school. And then for a while in pharmacy, I didn't get a chance to necessarily do that until my residency program with participation in medical writing. So with original research with my PGY1 and PGY2 project, and then other opportunities that I had. So ever since completing my residency programs, I've always sought out opportunities to do that. That passion for writing and creating things has always been there.
Dr. Pete Johnson:
And in terms of how I became an editor, I like to write and have been published. But I've also been significantly involved in peer review. And so I did get some opportunities with AJHP just because I created my name for myself in terms of peer review, but also publishing with the journal.
Dr. Lindsay Christensen:
That's great. Thank you. In what ways does serving as an editor challenge you and add value to your clinical practice?
Dr. Pete Johnson:
Great question. I think I also see it as an opportunity to help create stories or solutions to problems. So in this case, I'm not the actual one writing the article, or even necessarily providing that peer review, but just orchestrating that. So helping find the best people to critically evaluate a particular article so that the creative solution to patient care problems, pharmacy practice problems are really there. So that the end product is not just some bunch of jargon on electronic media, but it's something that could be actionable at the patient's bedside. So that's why or what excites me about the editing process is helping in another way to create the end product.
Dr. Lindsay Christensen:
That's great. Let's talk a little more about becoming an editor. Do you need a certain number of publications to become an editor?
Dr. Pete Johnson:
I would say, no, you don't necessarily need a set number. I think definitely having experience in publishing, whether that's probably different types of articles, original research, review articles, case reports, having that experience doing it yourself. And then I think other requirements, not necessarily publication, is that consistent peer review process is really the things that make good training for being an editor.
Dr. Lindsay Christensen:
What's the difference in responsibilities between the different types of editors?
Dr. Pete Johnson:
Well, each journal has a little bit different editorial structure. So we'll take AJHP for example. They have Dr. Daniel Cobaugh as the main editor and then working underneath him is Dr. Maryam Mohassel, and they have underneath them several different editorial teams. I'm on one of the teams. So I'm a senior associate editor, so that means I have two associate editors working underneath me. And we have about four to five different teams.
Dr. Pete Johnson:
When AJHP gets an article, they distribute those to different teams. So we are then responsible for soliciting peer review. And then once we get the peer review back, as an editorial team, we discuss that with the senior AJHP editors to make the decision on that manuscript.
Dr. Pete Johnson:
Now, not in a role of an editor, but each journal also usually has an advisory board. So as you mentioned, I did serve on the advisory board and those advisory board members may have some responsibilities with how many peer-reviewed publications they have to review. And sometimes they're brought on for specific types of expertise, but they're not necessarily an editor. They give feedback from the journal from more of a global perspective. And so that's another extra layer of quality insurance for the success of the journal.
Dr. Lindsay Christensen:
That's interesting to hear how it works behind-the-scenes. Are you invitedor do you apply for the position?
Dr. Pete Johnson:
I would say typically, invited. How I ended up in this role is a little bit work that I've done, but more serendipitousness.. I had reviewed and published in AJHP and my name was recommended. So sometimes it's who you know professionally by someone that is a longstanding member of ASHP, but was recommended to be a guest editor on the pediatric special issue. They saw my work there and then I got asked to serve in my current capacity as a senior associate editor.
Dr. Pete Johnson:
So it was definitely an invited position, but I guess this is a lesson that I've learned many times; sometimes how you get to where you are or where your career goes is often through professional connections that you have,. So I think the value of networking is definitely significant and I can definitely attest to that with my current role.
Dr. Lindsay Christensen:
It's definitely something good to think about as a new practitioner moving forward, the continued need for networking.
Dr. Pete Johnson:
Yes.
Dr. Lindsay Christensen:
If a new practitioner has an interest in becoming an editor someday, what advice would you provide them?
Dr. Pete Johnson:
I've probably said this ad nauseam, but participate in publishing. I think is a really good anduseful thing. Also, participating in peer review for journals and/or abstract reviews with organizations like ASHP is another layer of editing or evaluating things. Another thing that I found was helpful was serving on the advisory board, seeing that side of things. Again, that's not an editor role, but you do get to interact with some of the editors. And I think it was a helpful thing for me to have the confidence that I could participate in this type of editor type role. That's something that if you get those opportunities, definitely take them.
Dr. Lindsay Christensen:
Thanks for all that information. Let's move on to talking a little more about the actual writing. There are many types of publications for which manuscripts could be formatted. Do you have any advice on delineating a specific format?
Dr. Pete Johnson:
Yeah, definitely. There are all sorts of different type of articles that you could write. So letters to the editor and case reports, review articles, and then certainly original research manuscripts. A few key tidbits that I would suggest is I usually try to think of the end product. So in this case, case reports. I would focus on actually writing the case report, but as I'm doing it, thinking of the journal that would fit that particular manuscript.
Dr. Pete Johnson:
The reason why I think identifying a journal in the midst of actually doing it, or as you're beginning your project is so important is that the journal requirements are so significantly different amongst different journals. So for example, if you're interested in doing, let's say, a review article and you're wanting to review the literature on X topic. Well, some journals only take systematic reviews or even meta-analysis that follow the PRISMA format.
Dr. Pete Johnson:
Well, some review articles that you might work on don't really fit that framework. It might be broader, it might cover several different medications or medication classes, et cetera. So thinking of the journal that you're wanting to submit to as important from that standpoint. So I would definitely say as you're doing it, just to reiterate, looking at the author guidelines for that journal to see what fits.
Dr. Pete Johnson:
Another example I can think of that's becoming more common is a number of journals have gotten rid of case reports. They might accept a case report, but in the context of a letter to the editor. So not an actual full length body in case report. Now, AJHP still does, I'll have to put in a plug for that, but many of them may only accept case reports. So I think identifying that as you're going is really important because if you develop a full length case report manuscript and you have to switch it to, let's say, a 400 to 500 word letter to the editor, you're going to shoot yourself in the foot.
Dr. Pete Johnson:
So I think looking at those author guidelines, looking at the end results and identifying what might be the best fit is really important.
Dr. Lindsay Christensen:
That's helpful. Is there anything that as an editor stands out in a negative way when reviewing submissions? In other words, is there anything specific we should be sure not to do when preparing to submit a manuscript for consideration?
Dr. Pete Johnson:
Yeah, that's a really good question. One of the biggest things that I would say is you might have done the best study or written the best review article, but if the end result or your take home message does not fit the journal that you submit to, then it doesn't make any sense. I'll give you an example of my own experience because part of how I've learned is doing things wrong, and learning from feedback that I've gotten.
Dr. Pete Johnson:
My colleagues and I did this study that was assessing a certain withdrawal scale. I'm a pediatric critical care person, but we were evaluating the scale. We weren't evaluating outcomes. We were trying to figure out if it was the best scale to fit withdrawal in this specific pediatric population. Well, when we submitted it, we had a certain take to it, or a certain slant to it. We had submitted it to a nursing journal, and the take home message that we had for the article did not really align with that particular journal.
Dr. Pete Johnson:
So when we submitted it, it didn't even make it past the initial vetting of the journal. It didn't make it out to peer review stage. I'm biased, I think it was a good article. It was eventually published, but the big lesson that I took away there is that you really have to think, does the manuscript fit the journal that you're going for? So sometimes that might mean in an article like ours, we had to change the message or the takeaway message to fit with the journal.
Dr. Pete Johnson:
We didn't have to change the outcomes, but we just had to mold it into fitting with a better take home message. So we ended up submitting that particular article to the pharmacy journal, and our point was that if we don't know how to assess withdrawal, we're not really going to know how to treat it. So we made that connect a little bit more. That's one major thing that I would say.
Dr. Pete Johnson:
Another thing that I would say is, I know I've mentioned it before, but it's following the author guidelines to at T. Some of them have a checklist, like AJHP, , so as a new writer I would definitely go through the checklist that these journals have to make sure that it fits all the specific criteria that they want it in. I wish there was a universal checklist or a universal author guidelines, but the reality is that they're not. Even within the pharmacy community, with all the different sized journals that are out there, they all have drastically different requirements.
Dr. Pete Johnson:
Another example, because this is how my mind thinks, is one time we were working on a review article. It was a systematic review and it was to a critical care journal. Well, when we read it, we understood that the word count limit is 3000 words. Well, we submitted it and it didn't pass the internal review process because little did we know, and it was in the fine print in the author guidelines that, that 3000 words included the abstract. Well, there is no way that we could cut out any more words without taking out phrases that would actually help the manuscript make sense. So we ultimately had to go to a different journal.
Dr. Pete Johnson:
So another take home message is that those author guidelines, the checklists, it might be the best thing ever, but if it doesn't fit all those criteria that the journal sets forth, then you're not going to be successful with publishing, at least in the journal that you've selected the first go around. So those are the two biggest things that stand out. Certainly grammatical errors and spelling errors don't help when you might have problems, but those are two things that really jump out to me.
Dr. Lindsay Christensen:
It sounds like really knowing where you want to publish before you start and what the requirements are will really help you in the long run.
Dr. Pete Johnson:
Or at least during the process, early on. You might not know at the beginning if you're analyzing data, but at least thinking about options while you're doing it, or at the beginning, I think is helpful. And it's easier to have options and then get rid of those options in terms of journals, than you write then doing that at the end.
Dr. Lindsay Christensen:
Thank you. So, what are some common errors made with an initial manuscript submission?
Dr. Pete Johnson:
As I mentioned, author guidelines is one. One in particular, an issue with other guidelines that it might be selected to be sent out for peer review, but it's a common mistake is references. Every journal has drastically different requirements for references. Certainly there are reference managers out there, but some of those reference managers don't have the certain requirements in them for some newer journals. So I consult the author guidelines because the reference citations are so drastically different.
Dr. Pete Johnson:
So some journals, for example, they're not super strict. They want the references in brackets and then the actual citations, they might want you to have the DOI number, not just the actual citation itself. So even though you would think that's such a minor issue, you're just happy to get words on the paper and get through the whole thing. That's something that is an error that if it's not addressed may not sit well with a reviewer. Because your article might get selected to be reviewed by a very experienced reviewer for the journal. They may like the article, but when they get to the references and they see how they're referenced and they know that they don't follow the criteria of the journal, then even subconsciously, they may not be very positive in their review. And so that's just one thing that comes to mind.
Dr. Pete Johnson:
Another one that I would say is making sure no matter the type of article that you're working on to have some general purpose statements in your background. For original research manuscript, that purpose statement makes sense, but for review articles and case reports, you definitely need to have something in there just to tease the reader as they go into the next section. And certainly, for original research manuscripts, whether that's a practice based quality improvement project or some sort of interventional study, they need to have clear objectives. So making sure that you spell those out.
Dr. Pete Johnson:
And then one last thing that I tell my trainees, this is like blood in the water for reviewers and indefinitely for editors too, is making sure your abstract matches your paper. Oftentimes I do this myself and I recommend this to trainees that they work on the abstract last, and that's great. But sometimes we get so excited on thinking from the author side of things about finishing the manuscripts that in hindsight, it doesn't actually match the wording that's in the abstract. And the first thing that a lot of reviewers see is the abstract.
Dr. Pete Johnson:
Some reviewers look at the abstract before they go into the paper, just to make sure they know what they're supposed to get out of it. Some again, they might go through the manuscript and then go back to the abstract. But regardless, if there's incongruency, that's definitely a significant issue that I've seen with initial manuscript submissions.
Dr. Lindsay Christensen:
That's all really helpful advice. Thank you. So, what's your opinion on sending an author query to a journal to determine if an article would be appropriate for that specific journal?
Dr. Pete Johnson:
Yeah. An author query is, I think, definitely a good idea, especially if it's something that is maybe controversial or a little bit cutting edge. Or maybe you're just trying to figure out, does my take home message in my article that I'm working on, does it really match the interest of the readership for that journal? So I think submitting a query to the editors is definitely a good idea. It's definitely not a threatening experience.
Dr. Pete Johnson:
They're not going to be upset by saying yes or no. They may always have a stipulation about, they can't say anything for sure, whether it would be accepted to be sent out for peer review or not without seeing the final project. But at least you could get some initial information. Some journals have it set up where you can fill out an author query online, other journals, they may just provide the editor's contact information or the journals contact information. So certainly, I think just emailing them would be a start. Even if a journal provided the senior editors, that might be another capacity as well to just contact them and see what fits.
Dr. Pete Johnson:
In my mind, from some of my own experiences, it was really helpful because some of the journals definitely said, no, this wouldn't really be a good fit. And I didn't waste time trying to make sure the article followed all of the author guidelines, or went through the steps. It really helped be as time efficient as possible. So I think that's really a great idea to consider.
Dr. Lindsay Christensen:
If they only provide an email instead of a form, what are some key things you should include in the communication?
Dr. Pete Johnson:
Sure. I think a description of obviously what it is, what article, whether it's a review article, original manuscript. I think your main objective and then maybe some key findings. So if it's a case report, you could describe maybe it's a novel adverse event that's not been published before. Or if it's an original research manuscript, what your main findings were.
Dr. Pete Johnson:
You definitely don't have to include the abstract. And in fact, they may not want to see that. But I think just a few key sentences about the nature of the project, what your objective was and then what you found I think are super helpful.
Dr. Lindsay Christensen:
Thank you. So we've submitted our article. Could you provide us an editor's perspective on the manuscript review process and timeline?
Dr. Pete Johnson:
Yeah, definitely. And again, each journal is a little bit different. Let's take an example of a more robust journal like AJHP.
Dr. Pete Johnson:
It goes to the editorial staff and they do initial screening of the articles. So some articles might not even make it to those different editor teams just because it might not fit for a variety of reasons, for the scope of the readership, et cetera. But let's say that it passes that initial screening. They follow the author guidelines. They weren't like me and had a manuscript that had too many words. It wasn't going to be sent out for peer review, but basically in that case, the editors then would be in charge of finding peer reviewers.
Dr. Pete Johnson:
So, what I do from an editor's perspective is I look at the scope of the article. I'm a pediatrics person, but the reality is that I'm not in charge of overseeing just pediatric papers. So sometimes I'll have to read the article myself, the abstract, and figure out, what's the best fit in terms of a reviewer that would provide the best review? So if it's diabetes, again, that's a little bit outside my wheelhouse being a peds critical care person, but finding through the journal system good reviewers for diabetes or endocrine topics.
Dr. Pete Johnson:
Then from there, there also might be a need if your project is heavy in qualitative research, or heavy in biostatistics to get an additional biostatistician or someone that's experienced in qualitative methodology for research to also review. So they wouldn't be responsible for reviewing the content, but more for the analysis side of things. So what happens from there is that it might take us several times to find reviewers. Sometimes if you notice that there's a delay and like, "I haven't heard anything from the journal," well, part of the problem might be that we might have problems trying to find the best reviewers.
Dr. Pete Johnson:
At AJHP, we like to have at least three reviewers. Sometimes we might like to have additional ones, like I said, if it's heavy in biostats or qualitative research. Some journals also have as many as six. I'm familiar with one particular journal in the pharmacy realmthat likes to have lots of reviewers. So the reason why that becomes important is that, that can further delay when you receive the peer review feedback.
Dr. Pete Johnson:
So we send those solicitations for peer review and then generally, reviewers are given a period of weeks to review an article, but they may ask for extensions. That's just a part of that process. But as I like to call it, the gestational age of an article, going to be completed, that gestational age can take place from anywhere at this point from a few weeks up until the longest I've had personally is about six months, which is a little bit ridiculous and definitely not something that you would see with AJHP.
Dr. Pete Johnson:
But then when the comments come back, it goes to the editor team. So the associate editor shares their feedback that they've gotten, they share their recommendation and then we discuss it with the senior associate editors with, in this case, AJHP. And then pretty soon after that, you would get notification on the decision of the article. That's a long process, but my key take home notes is that every journal is a little bit different. They have different number of reviewers required, and the more reviewers that are required, the longer it's probably going to take to get it back to you.
Dr. Lindsay Christensen:
Great. That's very interesting. Thank you. What is a good way to format our responses to reviewers' suggestions that would facilitate an efficient review and quick turnaround for revisions?
Dr. Pete Johnson:
I think addressing them line by line. So what I would recommend is when you get the reviewer comments, I just copied them. Well, the first thing I do is look at them and don't look at them, because you might be upset. You might say some expletives. Drink whatever makes you happy, if that's harder beverages or Coke or coffee, whatever. But come back to it because you might have a different perspective. We all take things personally sometimes. But anyway, I would take all the comments, put them in a document and address them line by line.
Dr. Pete Johnson:
I'd also pay attention, specifically to what the editor says. In some cases, the editors may say they want you to pay specific attention to this reviewer's comments or not. Sometimes they don't say that, and if they don't give you specific guidance, then you basically address everything. But what I do is either some journals would request you do track changes, or what I do is when I make changes in a revised manuscript, it's highlighted in yellow. That's my personal preference. I love to hate track changes. I like to highlight it and then spell it out in my response to the reviewer.
Dr. Pete Johnson:
So I try to revise it as I go, line by line. That doesn't always work, but that's my general approach. What I would also recommend is try to be as diplomatic and politically correct as you can. A reviewer might say something that's really strong and they may have missed something. And so use this as an opportunity to maybe clarify things that maybe weren't as clear as they could be during your initial submission.
Dr. Pete Johnson:
Also, you don't have to accept all the reviewers' comments. This is something that I have to teach my trainees, that just because a reviewer says you have to do something that does not have to be the case. So I would recommend discussing it with your team. If you have a group of people that you worked on, bounce that idea off of them. But typically, it's the corresponding author that's doing a lot of these changes, but bounce that off of them.
Dr. Pete Johnson:
If you're working with people that are more experienced, they may be able to weigh in and say, this reviewer has a really good comment, but that's really another study. Or that's really another review article that really doesn't fit with what we did here. Or I just reviewed seven million patient care records, I can't logistically review three million more. So those types of things I think are ways that I would approach it.
Dr. Pete Johnson:
Just keep in mind, address line by line and you don't have to accept everything. And last thing, taking a break when you initially get those comments and doing whatever makes you as much at peace as possible.
Dr. Lindsay Christensen:
That's good advice. Thank you. What advice do you have related to determining authorship credit and author order?
Dr. Pete Johnson:
This one can be a little bit dicey, especially if some of the people that you're working with have maybe academic appointments or are heavily involved in research, because the author order can impact promotion. It can also impact the ability to obtain extramural funding. So author order, it can be a very dicey thing. What I would recommend is this should be decided at the very beginning. No matter if it's original research, a manuscript or a case report, review article, decide this in the beginning.
Dr. Pete Johnson:
So the general approach that I take on author order is that the first person is the corresponding author, they're usually the lead person. And that the last author is usually the most senior, maybe in this case a mentor to the corresponding author or the first author. And then everybody in between has descending level of activity. So basically, the second author would be the next most senior person or next most person that's done the most work on the project or the manuscript.
Dr. Pete Johnson:
But these orders of different authors, like I said, can be a very big thing. So for example, in academia, usually to be promoted from, let's say, the associate to assistant or assistant to associate level, you have to be the primary author, the first author so many times. Well, to get promoted to professor, you have to be the last author. And so that's why author order when you're working with different people can be so important.
Dr. Pete Johnson:
The same thing too with grants. If you're wanting to get extramural grants, the more times you're either the first or the last author helps strategically for the. So that's why author order can be a very dicey thing, and people can have conflict over that. So my advice would be discuss that early and make sure everybody's okay with that.
Dr. Pete Johnson:
This is also a good reminder to say that any time an article is submitted or even an abstract is submitted, make sure you have the approval by those authors. Because you don't want something to be submitted and maybe there is a fatal flaw when you have the expert on whatever that fatal flaw was to address that. Because if that gets sent out for peer review, then that person, people can say, "Oh my gosh, Pete was on this. They should have known." So I think this is a good reminder that with author order, making sure everybody is on board and approves it is a really important thing.
Dr. Lindsay Christensen:
Is there any specific guideline available to help facilitate this process?
Dr. Pete Johnson:
Yeah, there's a few different resources that are out there from AAP, ICMJE that give responsibilities to the role of the authors and how authorship should be established. Certainly, some journals have policies about ghost authorship, so putting somebody's name just because it might help it get published, that's definitely a no-no. And some of them may ask you when you submit it to actually spell out what each author did. Did they analyze the data? Did they collect the data?
Dr. Pete Johnson:
So I think some of those resources are helpful, but then also, each journal, when you submit it may have a different way of capturing what each author did to make sure that they actually participated. And there's usually language when you actually submit it that you check off as the corresponding author saying, everybody has read and approved it. So obviously, to be as ethical as we can, you have to only check that if that is a true case.
Dr. Pete Johnson:
There are still some journals that will send out after you submit it, an email notification that authors have to sign-off on, but that's a little bit less common. A couple of different medical journals do that, but that's not quite as common as the corresponding author verifying that for everyone.
Dr. Lindsay Christensen:
That's helpful. Thank you. Well, that's all the time we have today. I want to thank Dr. Pete Johnson for joining us today to discuss manuscript development. Join us here every Thursday where we will be talking with ASHP member contact matter experts on a variety of clinical topics.
Speaker 1: Thank you for listening to ASHP Official, the voice of pharmacists advancing healthcare. Be sure to visit ashp.org/podcast to discover more great episodes, access show notes and download the episode transcript. If you love the episode and want to hear more, be sure to subscribe, rate or leave a review. Join us next time on ASHP official.
Lindsay Nicole Christensen, PharmD, BCPS, is an Inpatient Clinical Pharmacist at UCHealth Poudre Valley Hospital in Fort Collins, Colorado. Dr. Lindsay Christensen earned her Doctor of Pharmacy from the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences in Aurora, Colorado in 2017. She completed a PGY1 pharmacy practice residency at the VA Eastern Colorado Health Care System in Denver, Colorado in 2018. She has been an active member of ASHP since she was a student and currently serves as a member of the New Practitioners Forum (NPF) Clinical Practice Advisory Group (CPAG). Her areas of interest include internal medicine and rural health. 
Peter N. Johnson, Pharm.D., BCPS, BCPPS, FPPA, FCCM, is a Professor of Pharmacy Practice at the OU College of Pharmacy (OUCOP) and Adjunct Professor of Pediatrics at the OU College of Medicine. Dr. Johnson also maintains an active practice site in the Cardiovascular Pediatric ICU (PICU) and PICU at The Children’s Hospital at OU Medical Center (CHO) in Oklahoma City precepting pharmacy residents and students. Dr. Johnson serves as the Residency Program Director for the PGY2 Pediatric Pharmacy Residency and Director of the Clinical and Translational Science Fellowship in Pediatric Pharmacotherapy at the OUCOP. He is active among many professional organizations including ASHP. Currently, he is the Chair of the Pediatric Section Advisory Group (SAG) of the Section of Clinical Specialists and Scientists, serves as member ASHP’s Pediatric Pharmacy Board Certification Exam Review Course Faculty, and serves as a Senior Associate Editor of the American Journal of Health-System Pharmacy. Dr. Johnson is board certified in pharmacotherapy and pediatric pharmacy. He is a fellow of the American College of Critical Care Medicine (FCCM) and the Pediatric Pharmacy Association (FPPA). His research/scholarship focuses in pain management and sedation in children, pharmacokinetic alterations in critically ill children, and student and resident education and training in pediatric pharmacy. 
