Search

Numerous investigations have established the strong clinical utility of cardiac rehabilitation, while clinical guidelines continually call for a high level of referral and participation. Historically, medical facilities have faced challenges referring eligible patients to cardiac rehabilitation, enrolling only a small portion of those receiving referral. Consequently, less than ~10% of qualifying patients receive any amount of cardiac rehabilitation. This sobering figure has prompted many efforts to identify barriers to referral as well as enrollment and accordingly propose strategies to bolster participation rates. Although reports have highlighted improvements through focused approaches, enrollment rates still lag behind the goal of reaching 70% by 2022, proposed by the Million Hearts Cardiac Rehabilitation Collaborative. An area of inquiry that has received little to no attention in this effort has been the influence of proximity between physician-driven outpatient clinics and cardiac rehabilitation facilities. In this report we outline the development and design of a clinical faculty practice aimed to maintainclose geographical proximity between our physicianclinic and the cardiac rehabilitation area. We also propose that our impressive enrollment rates of 57% within our facility and 73% when including patients that started alternative exercise programs were likely due to establishing a close proximity between the respective practices. [ABSTRACT FROM AUTHOR]

The current study explored the use of ballistic examinations and cross-border information sharing across 14 European countries. The presented data were collected using a mixed methods technique consisting of semi-structured interviews and questionnaires that were completed by participants. The results painted a very heterogeneous picture of the use of automated ballistic systems across these countries, as well as how ballistic analyses are integrated in the fight against gun-enabled crime. Three super-ordinates themes emerged from the thematic analysis: use of automated ballistic systems; Ballistic evidence recovery and analysis; knowledge exchange and best practices. The ability to draw firm conclusions regarding the value of ballistics comparison systems, either on a national or cross-border basis, is hampered by inconsistencies regarding data recording practices and definitions. Therefore, key recommendations are suggested to establish better cross border cooperation between member states and develop a better understanding of data sharing procedures. [ABSTRACT FROM AUTHOR]

Background Obesity and inflammatory bowel disease (IBD) represent chronic inflammatory conditions. Bariatric surgery improves some obesity-related co-morbidities, but the effects of bariatric surgery on IBD have not been well studied. Objectives To examine if bariatric surgery may attenuate colitis in an obese murine model of IBD and study the mechanisms underlying the postsurgical amelioration of intestinal inflammation. Setting University of California Irvine, Department of Surgery and Microbiology laboratories. Methods Obese mice were assigned to one of 2 bariatric procedures [Duodenojejunal Bypass (DJB n = 6), Sleeve Gastrectomy (SG n = 8)]. Sham-operated mice were (Sham n = 8) were used as a control. After recovering from surgery, IBD was induced by administration of 2% dextran sodium sulfate. Fecal samples were collected before and after IBD induction for microbiome analysis. Pathologic analyses and immunohistochemical staining were performed on colon. Results Survival after DJB and SG was higher relative to Sham mice. Histologically, DJB mice had significantly less intestinal inflammation. The observed improvements were not related to a difference in weight among the groups. Farnesoid X receptor staining in the colon was observed quantitatively more in DJB than in SG and sham mice. A statistically significant increase in the number of Lactobacillales was observed in the stool of mice after DJB. Conclusion These results suggest that bariatric surgery, in particular DJB, reduces the severity of colitis in a chemically-induced IBD murine model. The anticolitis effects of DJB may be associated with Farnesoid X receptor regulation and gut microbiome rearrangements. [ABSTRACT FROM AUTHOR]

• In adults, ureteral duplication is usually asymptomatic. • Ureteral anatomical varieties increase the possibility of iatrogenic injury. • Ureteral injuries may increase morbidity and even cause mortality. • If unilateral duplication is observed, bilateral duplication should be suspected. Incomplete bilateral ureteral duplication is a very rare condition. Ureteral duplication is often asymptomatic or may be associated with several urinary tract complications. We report a case of a 72- year- old Caucasian female who was referred to our clinic after she was diagnosed with FIGO IIIc ovarian cancer with peritoneal metastases. The patient underwent Cytoreductive Surgery plus Hyperthermic Intraperitoneal Chemotherapy. During the standard bilateral recognition of the ureters, intraoperatively, incomplete duplication of both of the ureters was identified. Bilaterally, the ureters were derived from a single renal parenchyma and duplication of the pyelocaliceal system in each kidney. The incomplete bilateral duplication of the ureters is a rare congenital renal abnormality. In a series of 51.880 autopsies ureteral duplication was observed in 0.66% of the cases, while in another autopsy series the ureteral duplication rate was 0.68%. Anatomical varieties of the ureter are of utmost importance for the surgeons, because they increase the possibility of iatrogenic ureteral injury. Ureteral injuries are severe complications of pelvic operations and may increase morbidity and even cause mortality. [ABSTRACT FROM AUTHOR]

Background: Procollagen type III N-terminal peptide (PIIINP) is a biomarker of cardiac fibrosis that is associated with heart failure prognosis in whites. Its prognostic significance in African Americans is unknown. We sought to determine whether PIIINP is associated with outcomes in African Americans with heart failure.Methods and Results: Blood was collected from 138 African Americans with heart failure for determining PIIINP and genetic ancestry, and patients were followed prospectively for death or hospitalization for heart failure. PIIINP was inversely correlated with West African ancestry (R(2) = 0.061; P = .010). PIIINP > 4.88 ng/mL was associated with all-cause mortality on univariate (hazard ratio [HR] 4.9, 95% confidence interval [CI] 2.2-11.0; P < .001) and multivariate (HR 5.8; 95% CI 1.9-17.3; P = .002) analyses over a median follow-up period of 3 years. We also observed an increased risk for the combined outcome of all-cause mortality or hospitalization for heart failure with PIIINP > 4.88 ng/mL on univariate (HR 2.6, 95% CI 1.6-5.0; P < .001) and multivariate (HR 2.4, 95% CI 1.2-4.7; P = .016) analyses.Conclusions: High circulating PIIINP is associated with poor outcomes in African Americans with chronic heart failure, suggesting that PIIINP may be useful in identifying African Americans who may benefit from additional therapy to combat fibrosis as a means of improving prognosis. [ABSTRACT FROM AUTHOR]

No strangers to the phenomenon of rail transport decline, related authorities responsible for managing the sector have lately turned their attention to exploring ways for enhancing its position in the transportation market. In the quest for identifying optimal measures that will contribute to its overall improvement, they find themselves presented with a series of options, yet have no assurances that their choices will best deal with the challenges. Starting from a detailed desktop and literature review, in order to create a consolidated knowledge base on the challenges currently faced by rail transport, and focusing on South East Europe, this paper proposes a methodological approach for the formulation of roadmaps regarding the enhancement rail passenger transport. The paper conducts a clustering of reported measures in content structures (e.g. technical options, organizational and decision making structures, etc.) and assesses them in terms of their contribution to the enhancement of rail transport. These assessments build towards the formulation of roadmaps of actions, measures, policies and strategies that should be taken to strengthen the future of rail passenger transport. The evaluation is conducted via an expert group survey, covering multiple sectors and disciplines (academia, research, industry, government). Findings are formulated in the form of roadmaps that can serve as a useful tool and basis for an improved decision-making approach for different end-users to address rail transport decline. [ABSTRACT FROM AUTHOR]

Objective Postoperative ischemic colitis (IC) can be a serious complication following infrarenal abdominal aortic aneurysm (AAA) repair. We sought to identify risk factors and outcomes in patients developing IC after open AAA repair and endovascular aneurysm repair (EVAR). Methods The American College of Surgeons National Surgical Quality Improvement Program database was used to examine clinical data of patients undergoing AAA repair from 2011 to 2012 who developed postoperative IC. Multivariate regression analysis was performed to identify risk factors and outcomes. Results We evaluated a cohort of 3486 patients who underwent AAA repair (11.6% open repair and 88.4% EVAR). The incidence of postoperative IC was 2.2% (5.2% for open repair and 1.8% for EVAR). Surgical treatment was needed in 49.3% of patients who developed IC. The mortality of patients with IC was higher than that of patients without IC (adjusted odds ratio [AOR], 4.23; 95% confidence interval [CI], 2.26-7.92; P < .01). The need for surgical treatment (AOR, 7.77; 95% CI, 2.08-28.98; P < .01) and age (AOR, 1.11; 95% CI, 1.01-1.22; P = .01) were mortality predictors of IC patients. Predictive factors of IC included need for intraoperative or postoperative transfusion (AOR, 6; 95% CI, 3.08-11.72; P < .01), rupture of the aneurysm before surgery (AOR, 4.07; 95% CI, 1.78-9.31; P < .01), renal failure requiring dialysis (AOR, 3.86; 95% CI, 1.18-12.62; P = .02), proximal extension of the aneurysm (AOR, 2.19; 95% CI, 1.04-4.59; P = .03), diabetes (AOR, 1.87; 95% CI, 1.01-3.46; P = .04), and female gender (AOR, 1.75; 95% CI, 1.01-3.02; P = .04). Although open AAA repair had three times higher rate of postoperative IC compared with endovascular repair, in multivariate analysis we did not find any statistically significant difference between open repair and EVAR in the development of IC (5.2% vs 1.8%; AOR, 1.25; 95% CI, 0.70-2.25; P = .43). Conclusions Postoperative IC has a rate of 2.2% after AAA repair. However, it is associated with 38.7% mortality rate. Rupture of the aneurysm before surgery, need for transfusion, proximal extension of the aneurysm, renal failure requiring dialysis, diabetes, and female gender were significant predictors of postoperative IC. AAA patients who develop IC have four times higher mortality compared with those without IC. Surgical treatment is needed in nearly 50% of IC patients and is a predictor of higher mortality. [ABSTRACT FROM AUTHOR]

Abstract: Background: Acute respiratory failure (ARF) can be a life-threatening postoperative complication after bariatric surgery and is defined as the presence of acute respiratory distress or pulmonary insufficiency. We sought to identify predictors of ARF in patients who underwent bariatric surgery. Methods: Using the Nationwide Inpatient Sample database, from 2006 to 2008, the clinical data from morbidly obese patients who underwent bariatric surgery were examined. Multivariate regression analysis was performed to identify the independent factors predictive of ARF. The factors examined included patient characteristics, co-morbidities, payer type, teaching status of hospital, surgical techniques (laparoscopic versus open), and type of bariatric operation (gastric bypass versus nongastric bypass). Results: A total of 304,515 patients underwent bariatric surgery during the 3-year period. The overall ARF rate was 1.35%. The greatest rate of ARF (4.10%) was observed after open gastric bypass surgery. The ARF rate was lower after laparoscopic than after the open surgical technique (.94% versus 3.87%, respectively; P < .01) and after nongastric bypass versus gastric bypass (.82% versus 1.54%, respectively; P < .01). Using multivariate regression analysis, congestive heart failure (adjusted odds ratio [AOR] 5.1), open surgery (AOR 3.3), chronic renal failure (AOR 2.9), gastric bypass (AOR 2.5), peripheral vascular disease (AOR 2.4), male gender (AOR 1.9), age >50 years (AOR 1.8), Medicare payer (AOR 1.8), alcohol abuse (AOR 1.8), chronic lung disease (AOR 1.6), diabetes mellitus (AOR 1.2), and smoking (AOR 1.1) were factors associated with greater rates of ARF. Compared with patients without ARF, patients with ARF had significantly greater in-hospital mortality (5.69% versus .04%, P < .01). Conclusion: We identified multiple risk factors that have an effect on the development of acute respiratory failure after bariatric surgery. Surgeons should consider these factors in surgical decision-making and inform patients of their risk of this potentially life-threatening complication. [Copyright &y& Elsevier]

Abstract: Combined movement examination (CME) is used in clinical management of spinal dysfunction. Whilst reliability of lumbar spine CME has been investigated, reliability of cervical spine CME is unclear. The aim of this study was to assess the inter-rater reliability of a CME protocol in subjects who have previously experienced a neck problem. Subjects were evaluated to identify their “side of discomfort”, “dysfunctional active prime movement (PrM)”, “prime combination of movements (PrC)” and “stretch pattern”. A secondary aim included the evaluation of a movement order effect. Inter-rater reliability of CME was evaluated in subjects (n = 25) with a history of mechanical neck problems. Through questioning and visual observation of the “functional demonstration”, raters (n = 3) had to classify subjects in anterior or posterior stretch patterns and determine movement combinations. Descriptive data for “PrC” showed moderate (67%) percentage agreement for anterior pattern and excellent (92%) for posterior pattern. AC1 values (95% Confidence Interval) were calculated for “Side” (AC1 = 0.96, CI: 0.89–1) and “Pattern” (AC1 = 0.96, CI: 0.89–1) demonstrating excellent inter-examiner reliability. “PrM” demonstrated total (100%) agreement. Establishing an order effect was unreliable (anterior pattern: 33%; posterior pattern: 38%). Results showed that a CME based protocol is a reliable assessment tool. Further research using larger samples and other clinical presentations is warranted. [Copyright &y& Elsevier]

Background: In 2005, the American College of Cardiology/American Heart Association published performance measures to provide a standard of care for hospitalized patients with heart failure (HF). Despite increasing compliance with these measures, hospital mortality and readmission rates remain stagnant. Whether compliance with HF performance measures improves patient outcomes at the hospital level is unclear. Methods: We evaluated compliance with HF performance measures at 3,655 US hospitals. Patients admitted with a diagnosis of HF in 2008 were identified using the US Department of Health and Human Services Hospital Compare database. Compliance with 4 specific performance measures was examined: evaluation of left ventricular systolic function, administration of angiotensin-converting enzyme inhibitor I or angiotensin-receptor blocker for left ventricular systolic dysfunction, offering smoking cessation advice and counseling, and providing discharge instructions. Thirty-day mortality and readmission rate were recorded. Results: Hospitals reporting greater compliance with the 4 performance measures had significantly lower 30-day mortality rates. However, these hospitals were also located in areas of higher socioeconomic status and treated higher volumes of patients with HF. After adjusting for socioeconomic and hospital factors, only evaluation of left ventricular systolic function was associated with lower 30-day mortality, and evaluation of left ventricular systolic function and smoking cessation counseling were associated with lower readmission rates. Conclusions: We found that socioeconomic factors and hospital volume were stronger predictors of mortality than compliance with HF performance measures. After adjusting for socioeconomic factors and hospital volume, only 1 of the 4 performance measures was associated with lower 30-day mortality and 2 were associated with lower readmissions. [Copyright &y& Elsevier]

BACKGROUND: Several sets of heart failure (HF) consensus/guideline statements support the use of a flexible diuretic dosing regimen for HF outpatient management of fluid overload-related signs and symptoms. However, despite the widespread acceptance of such an approach, the evidence supporting the effectiveness of this approach in improving clinical outcomes is unknown. The primary objective of this manuscript was to summarize and review the evidence supporting the use of a flexible diuretic regimen in the management of outpatient heart failure patients. METHODS AND RESULTS: A systematic review was performed, and 9 studies were identified relevant to the question of flexible diuretic titration in the setting of chronic heart failure. Among the 9 studies, 5 were randomized. Three of the randomized trials included flexible diuretic titration as part of a broader multifaceted disease management program, and only 2 were designed to specifically evaluate the sole contribution of flexible diuretic titration. Collectively, data from all of the studies reviewed supported the idea that flexible and individualized diuretic dosing is potentially associated with reduced emergency room visits, reduced rehospitalization, and improved quality of life in HF patients with reduced ejection fraction. CONCLUSIONS: To date, only 2 randomized clinical studies were identified that were designed to determine the effects of a flexible diuretic dosing regimen in outpatient HF patients with reduced ejection fraction. Data are lacking in HF patients with preserved ejection fraction. There is a critical need to test this strategy in well designed prospective randomized clinical trials. [ABSTRACT FROM AUTHOR]

Abstract: Background: Several sets of heart failure (HF) consensus/guideline statements support the use of a flexible diuretic dosing regimen for HF outpatient management of fluid overload–related signs and symptoms. However, despite the widespread acceptance of such an approach, the evidence supporting the effectiveness of this approach in improving clinical outcomes is unknown. The primary objective of this manuscript was to summarize and review the evidence supporting the use of a flexible diuretic regimen in the management of outpatient heart failure patients. Methods and Results: A systematic review was performed, and 9 studies were identified relevant to the question of flexible diuretic titration in the setting of chronic heart failure. Among the 9 studies, 5 were randomized. Three of the randomized trials included flexible diuretic titration as part of a broader multifaceted disease management program, and only 2 were designed to specifically evaluate the sole contribution of flexible diuretic titration. Collectively, data from all of the studies reviewed supported the idea that flexible and individualized diuretic dosing is potentially associated with reduced emergency room visits, reduced rehospitalization, and improved quality of life in HF patients with reduced ejection fraction. Conclusions: To date, only 2 randomized clinical studies were identified that were designed to determine the effects of a flexible diuretic dosing regimen in outpatient HF patients with reduced ejection fraction. Data are lacking in HF patients with preserved ejection fraction. There is a critical need to test this strategy in well designed prospective randomized clinical trials. [Copyright &y& Elsevier]

Background: Understanding predictors of mortality in bariatric surgery enables surgeons to use these factors for analysis of risk-adjusted mortality and aids in the surgical decision making and informed consent process. Objectives: To evaluate the effect of patient characteristics (age, gender, race, and payer type), preoperative comorbidities, and operative technique (laparoscopic versus open, gastric bypass versus gastric band) on mortality in patients who underwent bariatric operations. Methods: Using the National Inpatient Sample database, clinical data of patients with morbid obesity who underwent bariatric surgery from 2006 to 2008 were examined. Multivariate logistic regression analyses were performed to identify independent predictors of in-hospital mortality. Results: A total 304,515 patients underwent bariatric surgery over the 3-year period. The majority of patients were female (80%) and Caucasian (74%). Their mean age was 44 years and 31.6% were >50 years old. The most common payer type was private (73.5%). Laparoscopic approach was utilized in 86.2% of cases. The overall in-hospital mortality was 0.12%. Using multivariate regression analysis, male gender (adjusted odds ratio [AOR], 1.7), age >50 years (AOR, 3.8), congestive heart failure (AOR, 9.5), peripheral vascular disease (AOR, 7.4), chronic renal failure (AOR, 2.7), open procedure (AOR, 5.5), and gastric bypass operation (AOR, 1.6) were factors associated with greater mortality. Ethnicity, hypertension, diabetes, liver disease, chronic lung disease, sleep apnea, alcohol abuse, and payer type had no association with mortality in this study. Conclusion: Modifiable risk factors predictive of mortality include open surgery and gastric bypass procedure; nonmodifiable risk factors include older age, male gender, and a history of congestive heart failure, peripheral vascular disease, and chronic renal failure. Surgeons should consider these factors in selection of patients to undergo bariatric operations, providing informed consent, and selection of the procedural type. [Copyright &y& Elsevier]

Abstract: Objective: The purpose of this study was to investigate the effects of lumbar rotational manipulation and lumbar central posteroanterior mobilization on lumbar bending stiffness and flexion and extension range of motion (ROM). Methods: A same-subject, repeated-measures, crossover design was used using 32 asymptomatic subjects (16 female and 16 male; mean [SD] age, 25.5 [4.5] years; weight, 65.7 [11.8] kg; and height, 1.70 [0.08] m). Each subject received mobilization or manipulation on 2 different occasions. Bending stiffness was calculated using a 3-point bending model using an electromagnetic tracking device and a force platform; lumbar flexion and extension ROM was measured using an electromagnetic tracking device. All variables were measured pre- and postintervention. Their effect was compared using paired t tests. Results: Manipulation and mobilization did not significantly alter either bending stiffness or lumbar flexion and extension ROM (mobilization: P = .175, P = .613, and P = .535; manipulation: P = .973, P = .323, and P = .439). Bending stiffness changes were not correlated to changes in ROM (Pearson r for stiffness-flexion = −0.102, P = .586; Pearson r for stiffness-extension = 0.014, P = .941). Conclusions: Manipulation and mobilization had no significant effect on bending stiffness or flexion and extension ROM for this group of subjects. Some individual variations in effect were observed. [Copyright &y& Elsevier]

Abstract: Background: The prognostic value of the 6-minute walk test (6MWT) has been described in patients with heart failure (HF); however, limited data are available in an African-American (AA) population. We prospectively evaluated the usefulness of the 6MWT in predicting mortality and HF rehospitalization in AA patients with acute decompensated HF. Methods and Results: Two hundred AA patients (63.1% men, mean age 55.7 ± 12.9 years) with acute decompensated HF were prospectively studied. Patients were followed to assess 40-month all-cause mortality and 18-month HF rehospitalization. The median distance walked on the 6MWT was 213 m. Of the 198 patients with available mortality data, 59 patients (29.8%) died. Of the 191 patients with available rehospitalization data, 114 (59.7%) were rehospitalized for worsening HF. For patients who walked ≤200 m during the 6MWT, mortality was 41% compared with 19% in patients who walked >200 m (P = .001). For patients who walked ≤200 m during the 6MWT, HF rehospitalization was 68% compared with 52% in those who walked >200 m (P = .027). Multivariate Cox regression analysis showed that 6MWT distance ≤200 m was the strongest predictor of mortality (adjusted hazard ratio [HR], 2.14; confidence interval [CI], 1.20 to 3.81; P = .01) and HF rehospitalization (adjusted HR, 1.62; CI, 1.10 to 2.39; P = .015). Conclusions: In AA patients hospitalized with acute decompensated HF, 6MWT strongly and independently predicts long-term all-cause mortality and HF rehospitalization. [Copyright &y& Elsevier]

In response to the COVID-19 pandemic, research institutions across the globe have modified their operations in ways that have limited or eliminated the amount of permissible in-person research interaction. In order to prevent the loss of important developmentally-timed data during the pandemic, researchers have quickly pivoted and developed innovative methods for remote assessment of research participants. In this manuscript, we describe methods developed for remote assessment of a parent child cohort with a focus on examining the perinatal environment, behavioral and biological indicators of child neurobehavioral development, parent-child interaction, as well as parent and child mental and physical health. We include recommendations relevant to adapting in-laboratory assessments for remote data collection and conclude with a description of the successful dissemination of the methods to eight research sites across the United States, each of whom are involved in Phase 1 of the HEALthy Brain and Child Development (HBCD) Study. These remote methods were born out of pandemic-related necessity; however, they have much wider applicability and may offer advantages over in-laboratory neurodevelopmental assessments. • Novel methods for remote assessment of infant neurobehavior are described. • Methodology for remote collection of biospecimens are detailed. • Measures of caregiver behavior and maternal perinatal biology are also addressed. • These methods have been successfully disseminated across the US as part of HBCD. [ABSTRACT FROM AUTHOR]

Minimally invasive esophagectomy is a feasible and safe alternative to open esophagectomy. The stomach is the preferred conduit for gastrointestinal reconstruction after esophagogastrectomy; however, if the stomach is not usable, the colon can be interposed as an alternative conduit. We describe the technique of minimally invasive Ivor Lewis esophagogastrectomy in a patient with a gastric cardia cancer involving the gastric body and distal esophagus. Laparoscopic colonic interposition using the right colon based on the middle colic vessels was used to restore gastrointestinal continuity. [Copyright &y& Elsevier]

Roux-en-Y gastric bypass is a commonly performed procedure for the treatment of morbid obesity. Esophagectomy in patients with a history of Roux-en-Y gastric bypass presents a difficult technical challenge for the surgeon. In this report we describe a technique of minimally invasive Ivor Lewis esophagogastrectomy in a patient who had had an open Roux-en-Y gastric bypass. Minimally invasive esophagectomy was performed with resection of the Roux limb using the gastric remnant as the conduit for gastrointestinal reconstruction. [Copyright &y& Elsevier]

Flash floods are one of the most catastrophic natural hazards in many areas of the world, inducing significant losses on a yearly basis. Transportation and its infrastructure remain particularly vulnerable to such events despite their crucial role in many socioeconomic activities and commuter safety. Despite the adverse climate change projections, there is limited research providing a holistic and quantified overview of the impact of rare, extreme flash floods on the transportation of affected areas both in terms of infrastructure and circulation. The research team surveyed the effects of an extreme flash flood at Mandra, Greece, aiming to provide a systematic overview of the extent and typology of its impacts on transportation. The study quantifies the effects on different elements of transportation infrastructure, as well as vehicle circulation disturbances using floating car data. Results show an extensive impact with approximately 40% of the road network inundated or inaccessible and over 80% of river crossings (bridges, fords, and culverts) suffering damages, debris deposition and/or flooding, while critical cross-sections of the drainage network were diminished. Circulation was affected heavily with significant vehicle speed drops, travel times and distances increasing in and around the affected area. The findings indicate a considerably higher degree of impacts in comparison with less rare flash floods, implying that transportation systems may require extensive adaptation to address the increase of extreme events' frequency induced by climate change. [ABSTRACT FROM AUTHOR]

Comments on how pharmacists can be proactive and bring about change in the pharmaceutical industry in a positive way. Keys to change; Ways in which pharmacists can support the organizational efforts to improve the practice of pharmacy; Suggestions on how pharmacists can practice professionalism in their work.