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Introduction: Minimal trauma fractures (MTFs) often occur in older patients with osteoporosis and may be precipitated by falls risk-increasing drugs. One category of falls risk-increasing drugs of concern are those with sedative/anticholinergic properties. Collaborative medication management services such as Australia's Home Medicine Review (HMR) can reduce patients' intake of sedative/anticholinergics and improve continuity of care. This paper describes a protocol for an randomised controlled trial to determine the efficacy of an HMR service for patients who have sustained MTF., Method and Analysis: Eligible participants are as follows: ≥65 years of age, using ≥5 medicines including at least one falls risk-increasing drug, who have sustained an MTF and under treatment in one of eight Osteoporosis Refracture Prevention clinics in Australia. Consenting participants will be randomised to control (standard care) or intervention groups. For the intervention group, medical specialists will refer to a pharmacist for HMR focused on reducing falls risk predominately through making recommendations to reduce falls risk medicines, and adherence to antiosteoporosis medicines. Twelve months from treatment allocation, comparisons between groups will be made. The main outcome measure is participants' cumulative exposure to sedative and anticholinergics, using the Drug Burden Index. Secondary outcomes include medication adherence, emergency department visits, hospitalisations, falls and mortality. Economic evaluation will compare the intervention strategy with standard care., Ethics and Dissemination: Approval was obtained via the New South Wales Research Ethics and Governance Information System (approval number: 2021/ETH12003) with site-specific approvals granted through Human Research Ethics Committees for each research site. Study outcomes will be published in peer-reviewed journals. It will provide robust insight into effectiveness of a pharmacist-based intervention on medicine-related falls risk for patients with osteoporosis. We anticipate that this study will take 2 years to fully accrue including follow-up., Trial Registration Number: ACTRN12622000261718., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: When consumers choose a service provider, they trade-off their perceptions of service quality with their perceptions of the cost of engaging with the service provider. For community pharmacy owners and managers, it is important to understand the relative impact on loyalty of providing the extra resources to improve service quality versus forsaking gross profit by discounting prices. The aim of this study was to explore the relative effects of consumers' perceptions of service quality (pSQ) and price competitiveness (pPC) on patronage loyalty (patronage history of the rated pharmacy), patronage disloyalty (patronage history at other pharmacies) and loyalty intentions., Methods: This was a cross-sectional study conducted within Australia using an online survey administered to members of a consumer marketing panel. Eligible participants were adults taking 2 or more prescription medicines and had attended a community pharmacy within the past 4 weeks. Participants were asked to rate the pharmacy they had last visited, self-report patronage history of that and other pharmacies and report the brand of pharmacy visited. Previously validated scales were used for consumers' perceptions of service quality (pSQ) and loyalty intentions. New scales were developed for pPC and self-reported patronage loyalty and disloyalty. Confirmatory Factor Analysis (CFA) was used to validate the measurement model. Structural Equation Modelling (SEM) with robust estimator (EQS) was used to test the relationships between the variables. Sensitivity analysis, in the presence of covariates were performed with multivariate regression analysis with bootstrapping., Results: Surveys were completed by 303 participants. Most consumers had visited the rated pharmacy more often than once monthly and most had visited only 1 or 2 pharmacies in the past 12 months for prescription medicines. Overall, participants rated pSQ, pPC highly and expressed high loyalty intentions. The SEM was a good fit for the data. The model predicted 12%, 15% and 69% of the variation in patronage loyalty and patronage disloyalty and loyalty intentions, respectively. The effect of pSQ on patronage was 0.38 (p < 0.05) for loyalty and -0.38 (p < 0.05) on disloyalty whereas the effect of pPC was marginal. The total effect of pSQ and pPC on loyalty intentions was 0.64 (<0.05) and 0.20 (p < 0.05) and in sensitivity analyses, no other covariate, including pharmacy brand was significant., Conclusion: In order to drive loyalty behavior and generate loyalty intentions, providing a high-quality service appears to be far more effective than creating perceptions that the pharmacy has competitive prices. This finding affords a motivation for both discount AND non-discount brand pharmacies to undertake the steps needed to improve service quality., (Crown Copyright © 2023. Published by Elsevier Inc. All rights reserved.)

Necrotizing enterocolitis (NEC) is a complex disease with a multifactorial etiology. As the leading cause of intestinal morbidity and mortality among premature infants, many resources are being dedicated to neonatal care and molecular targets in the newborn intestine. However, NEC is heavily influenced by maternal and perinatal factors as well. Given its nature, preventive approaches to NEC are more likely to improve outcomes than new treatment strategies. Therefore, this review focuses on maternal, environmental, and racial factors associated with the development of NEC, with an emphasis on those that may be modifiable to decrease the incidence of the disease., (Copyright © 2022. Published by Elsevier Inc.)

Background: Osteoporosis is a major public health concern, given that disease prevalence is expected to substantially increase due to the aging population. Community pharmacists can play a key role in the identification and management of chronic diseases., Objectives: The purpose of this systematic review was to present an overview of the literature on the role of community pharmacists in providing osteoporosis interventions to patients. The secondary objective was to assess the impact of these interventions on patient outcomes., Methods: A literature search was conducted in Embase, CINAHL, Scopus, MEDLINE, and Web of Science from database inception to March 2021. The search was limited to human studies in the English language. Primary studies were included if they described or assessed a patient-directed osteoporosis intervention conducted by community pharmacists. The following data were extracted and tabulated: citation, study location, study design, subject, number of participants, nature of intervention, classification of intervention, outcome measures, measurement methods, findings, and effect. Risk of bias was assessed using the Cochrane Risk of Bias tool for randomized trials (RoB 2) and Risk of Bias in Non-randomized Studies (ROBINS-I)., Results: Twenty-one studies were included in this review. The main interventions were education, screening, and medication management. Nineteen of these studies reported patient outcomes, all yielding positive outcomes. Outcomes included increased physician follow-up, risk factor reduction, increased osteoporosis knowledge, increased medication adherence, identification of medication-related problems, and positive patient-reported experience measures (PREMs). Three studies were considered to have a moderate risk of bias, whereas the remaining 18 studies had a high risk of bias., Conclusion: There is some evidence that pharmacist-led osteoporosis interventions have a positive impact on patient outcomes. More high-quality studies using objective outcome measures are needed to determine whether this translates into clinical outcomes such as decreased hospitalization and fractures., (Copyright © 2022 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Background: Non-prescription medicines (NPMs), while relatively safe, are responsible for a small but significant proportion of medication misadventure and inappropriate use may lead to avoidable healthcare cost. Some consumers vary their use of NPMs from the directions provided on packaging or advice from healthcare professionals. Consumers may use NPMs at lower doses or less frequently than directed because of the risk of side effects., Purpose: This study aimed to develop and validate a self-report measure for the extent to which consumers' follow directions (FDs) for NPMs. Secondly, it aimed to explore the relationship between risk perception towards NPMs and following directions., Methods: A cross-sectional study was administered online to participants who belong to an Australian agency which conducts consumer research. Participants were Australian adults who had used NPMs within the last month. Items for the FD-NPM scale were developed and validated. Exploratory factor analysis and confirmatory factor analysis were used to validate the FD-NPM scale. Structural equation modelling (SEM) was employed to explore the relationships between risk perception, covariates, and FDs., Results: There were 403 participants recruited. Less than 20% "always" or "often" self-reported following directions for dose, frequency, or duration of use. Factor analyses confirmed that there are two moderately positively correlated dimensions of FD-NPM (r = 0.46), which were named underuse and overuse. That is, consumers who self-reported underuse of non-prescription medicines were also more likely to self-report overuse. Consumers with high-risk perception towards NPMs, those who were younger and those who were more educated had a greater tendency to not follow directions., Conclusion: A new self-report measure, the FD-NPM scale was developed and validated. That people who perceives NPMs to be harmful, tend to underuse and more concerningly, overuse them, is of great interest to clinicians and policymakers who are required to manage risk communications., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Despite the growth of research in how professional services are implemented in the community pharmacy setting, there is limited evidence for which implementation strategy is more effective., Objective: The aim of this review was to assess the evidence for the comparative effectiveness of implementation strategies for pharmacist delivered professional services in the community pharmacy., Methods: Studies comparing implementation strategies published in the last 13 years in English were extracted via four databases, combining the topics of 'pharmacy', 'pharmacy services' and 'implementation'. Experimental studies with quantitative evaluation of two or more implementation strategies were included. Selected studies were screened through three internationally recognised tools, two focusing on implementation: quality of evidence (Cochrane Qualitative & Implementation Methods Group), reporting standards (Standards for Reporting Implementation Studies - StaRI), and one assessing the risk of bias (The Risk of Bias in Non-randomised Studies of Interventions)., Results: Six studies were identified, assessing the implementation of services improving use of medicines (n = 2), primary care and public health services (n = 3), and one study evaluating the implementation of services in both categories. Some form of staff training was demonstrated to be more effective (n = 4). The risk of bias ranged from moderate to critical. With respect to reporting on StaRI tool items, the mention of these was, in the majority, indirect. Items such as harms and published protocols and economic evaluation were not reported in any of the studies included in the final review, highlighting opportunities for improvement., Conclusions: Training may be superior for implementation of professional services to community pharmacies, although this finding is limited by a moderate to critical risk of bias. A recommendation to researchers is for the greater use of comparative implementation study designs that reflect recognised reporting, quality and validity tools., Registration: None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The perceived service quality scale (pSQS) is a patient-reported experience measure (PREM) previously developed for measuring perceived service quality (pSQ) in community pharmacies. While measuring pSQ is feasible, further psychometric evaluation of the pSQS is warranted. In addition, the length of the 20-item pSQS may lead to fatigue among patients. It remains to be determined whether a short form of the pSQS has acceptable psychometric properties., Objectives: The aim of this study was to psychometrically test the pSQS with a specific focus on making scoring recommendations and developing a short form pSQS with acceptable psychometric properties., Methods: Participants were recruited either in community pharmacies or via an online panel to complete a questionnaire including the pSQS. Confirmatory factor analyses (CFA) were conducted using robust statistics, including tests of factorial invariance. Alternative models were tested including a bifactor model. Spearman's correlation was used to conduct test-retest analyses on responses obtained one month apart., Results: Data were analysed from 319 participants recruited in-store and 303 participants recruited online, 86 participants providing test-retest reliability. Tests of factorial invariance indicated that the pSQS is stable across settings. The most parsimonious and best-fitting solution was obtained with a 19-item bifactor model with 5 factors plus a "general" factor. Factor scores obtained from the "general" factor explained sufficient variance and are unlikely to be excessively biased in regression models. A short-form 6-item scale (pSQ-SF6) demonstrated acceptable psychometric properties and similar predictive capacity to the original pSQS for patient loyalty intentions. Test-retest analyses indicated acceptable reliability for pSQS and PSQ-SF6., Conclusion: This study confirms that the pSQS has acceptable psychometric properties including temporal stability. It is recommended that a 19-item pSQS be used to obtain a comprehensive overview of patients' pSQ. The short-form pSQ-SF6 is suitable as a community pharmacy PREM., (Copyright © 2021. Published by Elsevier Inc.)

Background: no studies have examined the impact of residential medication management review (RMMR, a 24-year government subsidised comprehensive medicines review program) in Australian residential aged care facilities (RACFs) on hospitalisation or mortality., Objective: to examine associations between RMMR provision in the 6-12 months after RACF entry and the 12-month risk of hospitalisation and mortality among older Australians in RACFs., Design: retrospective cohort study., Subjects: individuals aged 65-105 years taking at least one medicine, who entered an RACF in three Australian states between 1 January 2012 and 31 December 2015 and spent at least 6 months in the RACF (n = 57,719)., Methods: Cox regression models estimated adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) for associations between RMMR provision and mortality. Adjusted subdistribution hazard ratios were estimated for associations between RMMR provision and next (i) emergency department (ED) presentation or unplanned hospitalisation or (ii) fall-related ED presentation or hospitalisation., Results: there were 12,603 (21.8%) individuals who received an RMMR within 6-12 months of RACF entry, of whom 22.2% (95%CI 21.4-22.9) died during follow-up, compared with 23.3% (95%CI 22.9-23.7) of unexposed individuals. RMMR provision was associated with a lower risk of death due to any cause over 12-months (aHR 0.96, 95%CI 0.91-0.99), but was not associated with ED presentations or hospitalisations for unplanned events or falls., Conclusions: provision of an RMMR in the 6-12 months after RACF entry is associated with a 4.4% lower mortality risk over 12-months but was not associated with changes in hospitalisations for unplanned events or falls., (© The Author(s) 2022. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Residential Medication Management Review (RMMR) is a subsidized comprehensive medicines review program for individuals in Australian residential aged care facilities (RACFs). This study examined weekly trends in medicines use in the four months before and after an RMMR and among a comparison group of residents who did not receive an RMMR., Methods: This retrospective cohort study included individuals aged 65 to 105 years who first entered permanent care between 1/1/2012 and 31/12/2016 in South Australia, Victoria, or New South Wales, and were taking at least one medicine. Individuals with an RMMR within 12 months of RACF entry were classified into one of three groups: (i) RMMR within 0 to 3 months, (ii) 3 to 6 months, or (iii) within 6 to 12 months of RACF entry. Individuals without RMMRs were included in the comparison group. Weekly trends in the number of defined daily doses per 1000 days were determined in the four months before and after the RMMR (or assigned index date in the comparison group) for 14 medicine classes., Results: 113909 individuals from 1979 RACFs were included, of whom 55021 received an RMMR. Across all three periods examined, decreased use of statins and proton pump inhibitors was observed post-RMMR in comparison to those without RMMRs. Decreases in calcium channel blockers, benzodiazepines/zopiclone, and antidepressants were observed following RMMR provision in the 3-6 and 6-12 months after RACF entry. Negligible changes in antipsychotic use were also observed following an RMMR in the 6-12 months after RACF entry by comparison to those without RMMRs. No changes in use of opioids, ACE inhibitors/sartans, beta blockers, loop diuretics, oral anticoagulants, or medicines for osteoporosis, diabetes or the cognitive symptoms of dementia were observed post-RMMR., Conclusions: For six of the 14 medicine classes investigated, modest changes in weekly trends in use were observed after the provision of an RMMR in the 6-12 months after RACF entry compared to those without RMMRs. Findings suggest that activities such as medicines reconciliation may be prioritized when an RMMR is provided on RACF entry, with deprescribing more likely after an RMMR the longer a resident has been in the RACF., (© 2022. The Author(s).)

Purpose of Review: Despite efforts to minimize patient barriers to equitable care, health disparities persist in gynecology. This paper seeks to highlight racial and ethnic disparities in gynecologic care as represented by recent literature., Recent Findings: Disparities exist among many areas including preventive screenings, vaccination rates, contraception use, infertility, and oncologic care. These can be identified at the patient, physician, and institutional levels., Summary: As we identify these social disparities in healthcare, we gain valuable knowledge of where our efforts are lacking and where we can further improve the health of women. Future research should focus on identifying and combating such disparities with measurable changes in health outcomes., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

A recent review of missing data in pharmacy literature has highlighted that a low proportion of studies reported how missing data was handled. In this paper we discuss the concept of missing data in survey research, how missing data is classified, common techniques to account for missingness and how to report on missing data. The paper provides guidance to mitigate the occurrence of missing data through planning. Considerations include estimating expected missing data, intended vs unintended missing data, survey length, working with electronic surveys, choosing between standard and filtered form questions, forced responses and straight-lining, as well as responses that can generate missingness like "I don't know" and "Not Applicable". We introduce methods for analysing data with missing values, such as deletion, imputation and likelihood methods. The manuscript provides a framework and flow chart for choosing the appropriate analysis method based on how much missing data is observed and the type of missingness. Special circumstances involving missing data have been discussed, such as in studies with repeated or cohort measures, factor analysis or as part of data integration. Finally, a checklist of questions are provided for researchers to guide the reporting of the missing data when conducting future research., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Aim: Non-evidence-based practice and inappropriate paediatric fever management by care givers is common. The aim of this study was to survey a large sample of Australian parents and care givers utilising a validated Fever Management Tool, to determine the current knowledge, beliefs and attitudes of Australian care givers regarding fever management., Methods: This study employed a cross-sectional survey conducted via a third-party market research company. Univariate analysis of demographic factors and their influence on knowledge scores were tested. A multivariate linear regression model was specified using all available independent univariate predicators to determine the demographic factors influencing care givers fever knowledge., Results: Data from 1000 questionnaires were analysed. The participants' total knowledge scores were evenly distributed with a mean score of 15.4/29 correct answers in the True/False questionnaire, a median score of 16 and a standard deviation of 4.27. It highlighted that Australian care givers had poor knowledge in questions related to 'teething', 'physical cooling methods' and 'medication dosing'. In the multivariate analysis, 28.9% of the total variance was explained (R 2 value = 0.289, P < 0.001) with 5 of 11 factors contributing., Conclusion: Overall, this cross-sectional survey has provided a strong understanding of the current knowledge, attitude and beliefs of Australian care givers in regards to fever management in their children. Total knowledge of fever management was generally poor in Australia with many participants harbouring misconceptions and non-evidence-based practices. Future interventions improving fever management practices should be tailored to the specific weaknesses faced by Australian care givers in order to promote long term change., (© 2021 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Purpose: The Accreditation Council for Graduate Medical Education (ACGME) regulates the general surgery residency curriculum. Case volume remains a priority as recent concerns surrounding a lack of proficiency for certain surgical cases have circulated. We hypothesize that there is a significant decrease in pediatric surgery case numbers during general surgery residency despite residents meeting the minimum case requirements., Methods: We reviewed publicly available ACGME case reports for general surgery residency from 1999 to 2018. Cases are classified as Surgeon Chief or Surgeon Junior. Analyzed data included case classifications, number of residents, and number of residency programs. Simple linear regression analysis was performed., Results: We identified a significant decrease in total number of logged pediatric surgery cases over the past 20 years (p<0.001). Nearly 60% of cases were logged under a single category - inguinal/umbilical hernia. From the past five years, pyloric stenosis was the only other category with an average of greater than two cases logged (range 2.1-2.8)., Conclusion: We identified a significant decrease in total pediatric surgery case numbers during general surgery residency from 1999 to 2018. Though meeting set requirements, overall case variety was limited. With minimal number of cases required by the ACGME, graduating general surgery residents may lack proficiency in simple pediatric surgery cases., (Copyright © 2021. Published by Elsevier Inc.)

Cell-fate determination is a function of cell-intrinsic and -extrinsic signaling cues. Understanding the design principles governing fate control in multicellular systems remains difficult to understand and analyze. To address the current challenges of spatial analysis of potential signaling events, we have developed a pipeline for assessment of the neighboring cells at defined areas in the vicinity of target cells using a newly defined concept of Neighborhood Impact Factor. We have used our pipeline to interrogate cellular decision-making in a genetically derived multi-lineage liver organoid from induced pluripotent stem cells. We examined endothelial versus hepatocyte fate determination for cells with similar expression level of an engineered driver gene circuit. Our analysis suggests that the relative level of gene expression to the neighbor population can control the final fate choice in our engineered liver multicellular system.

In 2008, Apple and Android launched their Application or "App" stores. Since then, there has been a growing interest in using mobile apps for improving medication adherence. However, research on the efficacy of apps, in terms of improved medication adherence and clinical outcome and/or patient-related outcome measures (PROMs) is scarce. The objective of this research was to systematically review the impact of apps on consumers' medication adherence and to determine the effect on clinical outcome and/or PROM(s). A systematic literature search was conducted to identify publications aimed at improving medication adherence published from January 2008 to April 2018. All studies were assessed for risk of bias using either the Risk Of Bias In Non-randomized Studies-of Interventions or the revised tool for Risk of Bias in randomized trials tool, depending on study design. Eleven randomized controlled trials (RCTs) and 10 non-RCTs were included. All 11 RCTs showed improvements in adherence; however, only seven reported statistically significant improvements in at least one adherence measure. Nine RCTs also demonstrated improvements in clinical outcome/PROM(s), of which five were statistically significant, whereas two RCTs did not report on clinical outcome/PROM(s). Only two studies using non-RCT study designs showed statistically significant improvements in all measures of adherence and clinical outcome/PROM(s). The risk of bias was moderate or serious for all included studies. Even though the use of an app may improve adherence, it is difficult to draw conclusions regarding the impact of apps on medication adherence due to the high degree of heterogeneity across studies, from the methodological design to the features of the app and the measure of adherence., (© Society of Behavioral Medicine 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Pediatric foreign body ingestion remains a common reason for emergency department (ED) visits. Button battery ingestion is an established surgical emergency, requiring immediate removal. Timing of removal for other foreign bodies remains controversial. We hypothesize that there is no difference in complication rate or successful removal of esophageal foreign bodies that wait until the following morning for removal. Materials and Methods: A retrospective review for cases involving esophageal foreign body removal by pediatric surgery or pediatric gastroenterology from November 2015 to November 2019 was performed. Patients were divided into two groups based on ED arrival-daytime (05:00-16:59); nighttime (17:00-04:59). Imaging confirmed an esophageal foreign body. Data collected included basic demographics, time of presentation, time of procedure, symptoms, location of the foreign body, and complications within 30 days. Statistical analysis was performed. Results: After excluding button batteries, 273 children underwent esophageal foreign body removal. Two-thirds presented at night. A significant difference was identified in the median time from ED to the operating room when comparing daytime (194.8 minutes; interquartile range [IQR]: 108.5-347) versus nighttime groups (643 minutes; IQR: 471.5-745; P  < .001). Nine children had a complication or readmission within 30 days of their procedure and 25 patients had migration of their foreign body into the stomach, both with no significant difference ( P  = .94; P  = .98, respectively). Conclusion: We found that waiting until the following morning had minimal impact on complications or success rate when removing esophageal foreign bodies. By waiting, institutions with limited personnel can keep resources and staff available for more pressing emergencies.

Objective: Adherence to topical corticosteroids (TCS) for inflammatory skin conditions is sub-optimal. This Australian study aimed to test the hypothesis that patients who are more satisfied with the level of information they receive about TCS, are less concerned about using TCS and more adherent to healthcare professionals' instructions., Methods: Individuals who were prescribed or had used TCS in the past month were invited to complete an online cross-sectional survey. Reliability and validity of multi-item scales were tested using confirmatory factor analysis. Self-reported adherence to TCS was measured with MARS-5. Multivariate regression with mediation analyses was used to explore relationships between variables., Results: Mediation analyses of 195 survey (64.4%) responses was performed. Overall satisfaction with information about TCS action and usage (SIMS-AU) (mean = 60.7%) was higher than potential concerns (SIMS-PC) (mean = 48.2%). Analysis revealed that the SIMS subscales were highly correlated (α = 0.57, p < 0.05). Higher overall SIMS scores were predictive of stronger beliefs that TCS was beneficial, fewer concerns about TCS and better adherence., Conclusion: Being more satisfied with TCS information was associated with having more favourable disposition towards TCS and higher adherence., Practice Implications: Healthcare professionals should identity areas of dissatisfaction with medication information and tailor their counselling accordingly., (Copyright © 2019. Published by Elsevier B.V.)

Background: Consumer insights are vital to gain an understanding of service quality and enable its accurate measurement. Our team has previously developed a theory-based, qualitatively and quantitatively-informed service quality questionnaire for Australian community pharmacies with a price-focused marketing strategy (PFMS). The questionnaire assess 6 domains of service quality: Health and Medicines Advice, Non-Prescription Service, Relationship Quality, Technical Quality, Environmental Quality, and Health Outcomes., Objective: The aim of this study was to validate the questionnaire through confirmatory factor analysis (CFA) using data from customers attending pharmacies with a service-focused marketing strategy (SFMS)., Methods: A 31 item questionnaire was administered to convenience sample of customers from 3 SFMS pharmacies. The collected data was analysed using CFA. Model parameters were estimated using the full information maximum likelihood (FIML) method. The model was revised on inspection of modification indices and fit statistics and tested for construct validity, construct reliability and measurement invariance., Results: A total of 319 responses were collected for CFA. On examination of the modification indices, 4 items were deleted. The fit statistics for the final model were as follows: Satorra-Bentler scaled χ 2  = 211.4, df = 155, CFI = 0.96, TLI = 0.95, RMSEA = 0.031 (90% confidence interval = 0.016-0.042). Construct validity of all constructs was established from positive convergent and discriminant validity tests. The composite reliability values for all constructs were ≥0.7, thus confirming construct reliability. A positive test for strong invariance confirmed that the model constructs are comparable across regional and metropolitan settings, gender, age and education level., Conclusions: This study has established the validity of the questionnaire as a measure of consumer perceptions of community pharmacy service quality. The tool can be applied in Australian community pharmacies in both metropolitan and regional settings to guide improvements in aspects of service provision., (Crown Copyright © 2018. Published by Elsevier Inc. All rights reserved.)

Background: Recent changes within community pharmacy have seen a shift towards some pharmacies providing "value-added" services. However, providing high levels of service is resource intensive yet revenues from dispensing are declining. Of significance therefore, is how consumers perceive service quality (SQ). However, at present there are no validated and reliable instruments to measure consumers' perceptions of SQ in Australian community pharmacies., Objectives: The aim of this study was to build a theory-grounded model of service quality (SQ) in community pharmacies and to create a valid survey instrument to measure consumers' perceptions of service quality., Methods: Stage 1 dealt with item generation using theory, prior research and qualitative interviews with pharmacy consumers. Selected items were then subjected to content validity and face validity. Stages 2 and 3 included psychometric testing among English-speaking adult consumers of Australian pharmacies. Exploratory factor analysis was used for item reduction and to explain the domains of SQ., Results: In stage 1, item generation for SQ initially generated 113 items which were then refined, through content and face validity, down to 61 items. In stage 2, after subjecting the questionnaire to psychometric testing on the data from the first pharmacy (n = 374), the use of the primary dimensions of SQ was abandoned leaving 32 items representing 5 domains of SQ. In stage 3, the questionnaire was subject to further testing and item reduction in 3 other pharmacies (n = 320). SQ was best described using 23 items representing 6 domains: 'health and medicines advice', 'relationship quality', 'technical quality', 'environmental quality', 'non-prescription service', and 'health outcomes'., Conclusion: This research presents a theoretically-grounded and robust measurement scale developed for consumer perceptions of SQ in a community pharmacy., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Recent developments in synthetic biology tools and techniques are driving commercialization of a wide range of products for human health, agriculture, environmental stewardship, and other purposes. This article reviews some of the trends in synthetic biology applications as well as some of the tools enabling these and future advances. These tools and capabilities are being developed in the context of a rapidly changing industry, which may have an impact on the rate and direction of progress. Final products are subject to a regulatory framework that is being challenged by the pace, scale, and novelty of this new era of biotechnology. This article includes discussion of these factors and how they may affect product design and the types of applications that are most likely to be supported and pursued commercially. The final section provides perspective on the security implications of these advances, with a focus on US interests.

This prospective study aimed to address changes in inflammatory response between different aged populations of patients who sustained burn and inhalation injury. Plasma and bronchoalveolar lavage (BAL) samples were collected from 104 patients within 15h of their estimated time of burn injury. Clinical variables, laboratory parameters, and immune mediator profiles were examined in association with clinical outcomes. Older patients were at higher odds for death after burn injury (odds ratio (OR)=7.37 per 10years, p=0.004). In plasma collected within 15h after burn injury, significant increases in the concentrations of interleukin 1 receptor antagonist (IL-1RA), interleukin 2 (IL-2), interleukin 4 (IL-4), interleukin 6 (IL-6), granulocyte colony-stimulating factor (G-CSF), interferon-gamma-induced protein 10 (IP-10) and monocyte chemoattractant protein 1 (MCP-1) (p<0.05 for all) were observed in the ≥65 group. In the BAL fluid, MCP-1 was increased three-fold in the ≥65 group. This study suggests that changes in certain immune mediators were present in the older cohort, in association with in-hospital mortality., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Small-angle neutron scattering (SANS) and neutron spin-echo (NSE) have been used to investigate the temperature-dependent solution behaviour of highly-branched poly(N-isopropylacrylamide) (HB-PNIPAM). SANS experiments have shown that water is a good solvent for both HB-PNIPAM and a linear PNIPAM control at low temperatures where the small angle scattering is described by a single correlation length model. Increasing the temperature leads to a gradual collapse of HB-PNIPAM until above the lower critical solution temperature (LCST), at which point aggregation occurs, forming disperse spherical particles of up to 60 nm in diameter, independent of the degree of branching. However, SANS from linear PNIPAM above the LCST is described by a model that combines particulate structure and a contribution from solvated chains. NSE was used to study the internal and translational solution dynamics of HB-PNIPAM chains below the LCST. Internal HB-PNIPAM dynamics is described well by the Rouse model for non-entangled chains.

Background: Community pharmacy ownership requires engaging with marketing strategies to influence consumer behaviour. There is a plethora of information from trade journals, expert opinion, and published discussion surrounding this issue. Despite this, evidence relating to the efficacy of marketing activity within the pharmacy sector is scant., Objectives: To review how marketing activity has been conceptualised in the community pharmacy sector and to determine the evidence for the effect of marketing activity., Methods: Seven databases were systematically searched using a scoping review framework with the reporting protocol of PRISMA-P. The search yielded 33 studies that were analysed for year of publication, journal, country of focus, and framework of marketing., Results: The majority of marketing research papers focused on the United States and were published in healthcare journals. These were various marketing strategy elements, including; segmentation, targeting, differentiation, and positioning. Also evident was research regarding marketing mix, which predominately involved the "4Ps" model. Actual marketing activity comprised little of the research., Conclusions: Research into marketing activity in community pharmacy is limited, and little evidence is available to show the effects of such activities. Future research needs to demonstrate the causality for the effect of marketing activities on consumer behaviour and economic outcomes., (Copyright © 2017 Elsevier Inc. All rights reserved.)

The nanoscopic adhesive and frictional behaviour of end-grafted poly[2-(dimethyl amino)ethyl methacrylate] (PDMAEMA) films (brushes) in contact with gold- or PDMAEMA-coated atomic force microscope tips in potassium halide solutions with different concentrations up to 300 mM is a strong function of salt concentration. The conformation of the polymers in the brush layer is sensitive to salt concentration, which leads to large changes in adhesive forces and the contact mechanics at the tip-sample contact, with swollen brushes (which occur at low salt concentrations) yielding large areas of contact and friction-load plots that fit JKR behaviour, while collapsed brushes (which occur at high salt concentrations) yield sliding dominated by ploughing, with conformations in between fitting DMT mechanics. The relative effect of the different anions follows the Hofmeister series, with I - collapsing the brushes more than Br - and Cl - for the same salt concentration., (© The Author(s) 2017.)

Background: Topical corticosteroids (TCS) are key to managing chronic inflammatory dermatoses (CID). Parents/patients cite TCS phobia as an impediment to treatment adherence. Family/friends and the Internet are a source of misinformation on TCS which can negatively impact perceptions of TCS safety., Purpose: To assess information from family/friends and the Internet, as related to and reported by patients/parents using long-term TCS., Methods: A multicenter cross-sectional survey of patients (aged >18 years) and parents of patients (aged <18 years) with a history of CID requiring long-term (≥1 month) TCS use assessing messages about TCS received from family/friends and the Internet., Results: A total of 123 patients and 78 parents completed the survey (n = 201). Parents/patients were more likely to be informed by the Internet "[having] my [child's] skin condition means that [I/he/she] will need to use topical corticosteroids" (p < .001) and that "inflamed skin conditions will improve with the topical corticosteroids" (p = .007). Family/friends were more likely to recommend parents/patients "try non-prescription creams/ointments before resorting to the use of prescription topical corticosteroids" (p = .014)., Conclusions: High rates of messages about TCS "risk" from family/friends and the Internet may affect patient/parent understanding about TCS safety. This may contribute to treatment non-adherence.

Aims: To investigate the impact of the method of treatment on the oncological outcomes in patients with epithelioid sarcomas managed at two international speciality sarcoma centres., Methods: The databases of two centres were used to identify patients treated for epithelioid sarcomas between 1985 and 2012. Patient, tumor, treatment and outcome data was collected., Results: There were 36 males and 18 females with a mean age of 38.3 years (range 9-79). Of 49 patients who were treated surgically, limb salvage surgery was carried out in 38 patients (78%) and limb amputation in 11 (22%). Of 49 total patients who underwent surgery for ES, 48 (98%) with ES had negative margin resection and 24 (49%) received (neo) adjuvant radiotherapy. Regional lymph node metastases developed in 5 (13%) patients. The five-year risk of local recurrence was 14%. The overall survival rate at five and ten years was 70% and 66% respectively. In multivariate analysis of patients with localized disease and negative margins, survival and risk of metastases was worse in those treated by amputation., Conclusion: This series has shown that although the rate of local recurrence is not influenced by the type of surgery, the risk of metastases is higher following amputation. This finding is likely due to patients with larger, deeper and more locally advanced tumors requiring amputation. However, we could not prove that immediate amputation was likely to affect overall survival., (Copyright © 2017 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Gene synthesis providers affiliated with the International Gene Synthesis Consortium (IGSC) voluntarily screen double-stranded DNA (dsDNA) synthesis orders over 200 bp to check for matches to regulated pathogens and to screen customers. Questions have been raised, however, about the continuing feasibility and effectiveness of screening. There are technical challenges (e.g., oligonucleotides and tracts of DNA less than 200 bp are not screened) and corporate challenges (e.g., the costs of screening are high, but other costs are dropping, so screening is an increasing portion of operating costs). In this article, we describe tangible actions that should be taken to (i) preserve the effectiveness of DNA order screening as a security tool and (ii) develop additional mechanisms to increase the safety and security of DNA synthesis technologies. Screening is not a perfect solution to DNA synthesis security challenges, but we believe it is still a valuable addition to security, and it can remain effective for some time.

Purpose: To assess pharmacist and general practitioner (GP) advice and behaviors, as related to and reported by patients and parents of patients using topical corticosteroids (TCS) on a long-term basis., Materials and Methods: Multicenter cross-sectional survey of patients (aged 18+) and parents of pediatric patients (aged <18) with a history of long-term (≥1 month) TCS use, assessing: TCS treatment adherence and reasons for non-adherence; beliefs regarding TCS use and safety; messages regarding TCS received from community pharmacists, GPs, family/friends and the Internet; and experiences of GP and pharmacist counseling regarding TCS use., Results: A total of 123 patients and 78 parents completed the survey (n = 201). 76.6% of respondents reported consistently ("Often" or "Always") receiving one or more message(s) regarding TCS "risk" from a GP and/or pharmacist (n = 192). Respondents reported being told to "try natural or complementary and alternative therapies before resorting to the use of TCS" significantly more often by pharmacists than by GPs (p = 0.039)., Conclusions: High rates of consistently delivered messages about TCS "risk" from GPs and pharmacists affect patient/parent understanding about TCS safety and may lead to treatment non-adherence. This indicates a need for reeducation of these groups on the safety of TCS use.

Background: The proximal tibia is one of the most challenging anatomic sites for extremity reconstructions after bone tumor resection. Because bone tumors are rare and large case series of reconstructions of the proximal tibia are lacking, we undertook this study to compare two major reconstructive approaches at two large sarcoma centers., Questions/purposes: The purpose of this study was to compare groups of patients treated with endoprosthetic replacement or osteoarticular allograft reconstruction for proximal tibia bone tumors in terms of (1) limb salvage reconstruction failures and risk of amputation of the limb; (2) causes of failure; and (3) functional results., Methods: Between 1990 and 2012, two oncologic centers treated 385 patients with proximal tibial resections and reconstruction. During that time, the general indications for those types of reconstruction were proximal tibia malignant tumors or bone destruction with articular surface damage or collapse. Patients who matched the inclusion criteria (age between 15 and 60 years old, diagnosis of a primary bone tumor of the proximal tibia treated with limb salvage surgery and reconstructed with endoprosthetic replacement or osteoarticular allograft) were included for analysis (n = 149). In those groups (endoprosthetic or allograft), of the patients not known to have reached an endpoint (death, reconstructive failure, or limb loss) before 2 years, 85% (88 of 104) and 100% (45 of 45) were available for followup at a minimum of 2 years. A total of 88 patients were included in the endoprosthetic group and 45 patients in the osteoarticular allograft group. Followup was at a mean of 9.5 (SD 6.72) years (range, 2-24 years) for patients with endoprosthetic reconstructions, and 7.4 (SD 5.94) years for patients treated with allografts (range, 2-21 years). The following variables were compared: limb salvage reconstruction failure rates, risk of limb amputation, type of failures according to the Henderson et al. classification, and functional results assessed by the Musculoskeletal Tumor Society system., Results: With the numbers available, after competitive risk analysis, the probability of failure for endoprosthetic replacement of the proximal tibia was 18% (95% confidence interval [CI], 10.75-27.46) at 5 years and 44% (95% CI, 31.67-55.62) at 10 years and for osteoarticular allograft reconstruction was 27% (95% CI, 14.73-40.16) at 5 years and 32% (95% CI, 18.65-46.18) at 10 years. There were no differences in terms of risk of failures at 5 years (p = 0.26) or 10 years (p = 0.20) between the two groups. Fifty-one of 88 patients (58%) with proximal tibia endoprostheses developed a reconstruction failure with mechanical causes being the most prevalent (32 of 51 patients [63%]). A total of 19 of 45 osteoarticular allograft reconstructions failed (42%) and nine of 19 (47%) of them were caused by early infection. Ten-year risk of amputation after failure for endoprosthetic reconstruction was 10% (95% CI, 5.13-18.12) and 11% (95% CI, 4.01-22.28) for osteoarticular allograft with no difference between the groups (p = 0.91). With the numbers available, there were no differences between the groups in terms of the mean Musculoskeletal Tumor Society score (26.58, SD 2.99, range, 19-30 versus 27.52, SD 1.91, range, 22-30; p = 0.13; 95% CI, -2,3 to 0.32). Mean extension lag was more severe in the endoprosthetic group than the osteoarticular allograft group: 13.56° (SD 18.73; range, 0°-80°) versus 2.41° (SD 5.76; range, 0°-30°; p < 0.001; 95% CI, 5.8-16.4)., Conclusions: Reconstruction of the proximal tibia with either endoprosthetic replacement or osteoarticular allograft appears to offer similar reconstruction failures rates. The primary cause of failure for allograft was infection and for endoprosthesis was mechanical complications. We believe that the treating surgeon should have both options available for treatment of patients with malignant or aggressive tumors of the proximal tibia. (S)he might consider an allograft in a younger patient to achieve better extensor mechanism function, whereas in an older patient or one with a poorer prognosis where return to function and ambulation quickly is desired, an endoprosthesis may be advantageous., Level of Evidence: Level III, therapeutic study.

The widespread and rapidly increasing trend of binge drinking is accompanied by a concomitant rise in the prevalence of trauma patients under the influence of alcohol at the time of their injury. Epidemiological evidence suggests up to half of all adult burn patients are intoxicated at the time of admission, and the presence of alcohol is an independent risk factor for death in the early stages post burn. As the major site of alcohol metabolism and toxicity, the liver is a critical determinant of postburn outcome, and experimental evidence implies an injury threshold exists beyond which burn-induced hepatic derangement is observed. Alcohol may lower this threshold for postburn hepatic damage through a variety of mechanisms including modulation of extrahepatic events, alteration of the gut-liver axis, and changes in signaling pathways. The direct and indirect effects of alcohol may prime the liver for the second-hit of many overlapping physiologic responses to burn injury. In an effort to gain a deeper understanding of how alcohol potentiates postburn hepatic damage, the authors summarize possible mechanisms by which alcohol modulates the postburn hepatic response., Competing Interests: The authors of this manuscript have no conflicts of interest to report.

Aims: Extendible endoprostheses have been available for more than 30 years and have become more sophisticated with time. The latest generation is 'non-invasive' and can be lengthened with an external magnetic force. Early results have shown a worryingly high rate of complications such as infection. This study investigates the incidence of complications and the need for further surgery in a cohort of patients with a non-invasive growing endoprosthesis., Patients and Methods: Between 2003 and June 2014, 50 children (51 prostheses) had a non-invasive growing prosthesis implanted for a primary bone sarcoma. The minimum follow-up was 24 months for those who survived. Their mean age was 10.4 years (6 to 14). The incidence of complications and further surgery was documented., Results: The mean follow-up was 64 months (20 to 145). The overall survivorship of the patients was 84% at three years and 70% at five years. Revision-free survival was 81.7% at three years and 61.6% at five years with competing risk analysis. Deep infection occurred in 19.6% of implants at a mean of 12.5 months (0 to 55). Other complications were a failure of the lengthening mechanism in five prostheses (9.8%) and breakage of the implant in two (3.9%). Overall, there were 53 additional operations (0 to 5 per patient). A total of seven patients (14%) underwent amputation, three for local recurrence and four for infection. Their mean limb length discrepancy was 4.3 mm (0 to 25) and mean Musculoskeletal Tumor Society Score functional score was 26.5 (18 to 30) at the final follow-up., Conclusions: When compared with previously published early results, this mid-term series has shown continued good functional outcomes and compensation for leg-length discrepancy. Infection is still the most common complication: post-operative wound healing problems, central line infection and proximal tibial location are the main risk factors. Cite this article: Bone Joint J 2016;98-B:1697-1703., (©2016 The British Editorial Society of Bone & Joint Surgery.)

Objective. To develop and test a conceptual model that hypothesized student intention to undertake a higher degree in pharmacy practice research (PPR) would be increased by self-efficacy, outcome expectancy, and the social influence of faculty members. Methods. Cross-sectional surveys were completed by 387 final-year pharmacy undergraduates enrolled in 2012 and 2013. Structural equation modeling was used to explore relationships between variables and intention. Results. Fit indices were good. The model explained 55% of the variation in intention. As hypothesized, faculty social influence increased self-efficacy and indirectly increased outcome expectancy and intention. Conclusion. To increase pharmacy students' orientation towards a career in PPR, faculty members could use their social influence by highlighting PPR in their teaching.

Aims: The purpose of this study was to review a large cohort of patients and further assess the correlation between the histological response to chemotherapy in patients with Ewing's sarcoma with the overall (OS) and event-free survival (EFS)., Patients and Methods: All patients treated for Ewing's sarcoma between 1980 and 2012 were reviewed. Of these, 293 patients without metastases at the time of diagnosis and treated with chemotherapy and surgery were included. Patients were grouped according to the percentage of necrosis after chemotherapy: Group I: 0% to 50%, Group II: 51% to 99% and Group III: 100%., Results: The mean age at diagnosis was 16 years (1 to 62) and the mean follow-up was 9.1 years (six months to 32.6 years). The OS and EFS for the series were 75% and 65% at five years. There were significant differences in survival between the groups of necrosis: 0% to 50% (OS: 49% and EFS: 45% at five years, respectively) compared with 51% to 99% (OS: 72% and EFS: 59% at five years, respectively) and 100% (OS: 94% and EFS: 81% at five years, respectively) (p < 0.001). There were no significant differences in survival between patients treated between 1980 and 1989 compared with those treated between 1990 and 1999, and those treated between 2000 and 2012 (p = 0.55)., Conclusion: Only patients with 100% necrosis after chemotherapy should be classified as having a good response to chemotherapy because they have significantly better rates of survival compared with those with any viable tumour in the surgical specimen. Cite this article: Bone Joint J 2016;98-B:1138-44., (©2016 The British Editorial Society of Bone & Joint Surgery.)

Objectives: Informal caregivers experience daily hassles - a form of persistent stress, as a consequence of caregiving. This study aimed to develop and test a new theoretical model of health information-seeking behaviour, the Knowledge Hassles Information Seeking Model (KHISM). KHISM hypothesized that the knowledge hassles of caregivers - daily stressors experienced while dealing with tasks which require knowledge about the safety and effectiveness of the care-recipients' medicines - would influence caregivers' willingness to assist their care-recipient to use an Australian medication management service, Home Medicines Review (HMR)., Methods: A cross-sectional postal survey was conducted among 2350 members of Carers (NSW, Australia). Respondents were included in the study if they were involved in medication-related tasks for their care-recipient and were not paid as caregivers. Also, their care-recipient needed to be taking more than five medicines daily or more than 12 doses daily and had not yet experienced HMR. Structural equation modelling was used to test the model., Results: A total of 324 useable surveys were returned yielding a response rate of 14%. Respondents were quite willing to assist their care-recipient to use HMR (willingness). The model predicted 51% of the variation in willingness. Knowledge hassles increased positive outcome expectancy (β = 0.40, P < 0.05) and indirectly increased willingness., Conclusions: The more caregivers experience hassles with medication knowledge, the more they perceive HMR to be a helpful information source and the more willing they are to use it. Targeted marketing centred on HMR as an information source may increase caregivers' demand for HMR. Further exploration of the phenomenon of knowledge hassles is warranted., (© 2013 The Authors Health Expectations Published by John Wiley & Sons Ltd.)

Aims: The aim of this study was to establish what happens to patients in the long term after endoprosthetic replacement for a primary malignant tumour of bone., Patients and Methods: We conducted a retrospective analysis of a prospectively maintained database to identify all patients who had undergone an endoprosthetic replacement more than 25 years ago and who were still alive. Their outcomes were investigated with reference to their complications and need for further surgery. A total of 230 patients were identified. Their mean age at diagnosis was 20.7 years (five to 62). The most common diagnosis was osteosarcoma (132). The most common site was the distal femur (102)., Results: The mean follow-up was 29.4 years (25 to 43). A total of 610 further operations were undertaken, an average of 2.7 further operations per patient. A total of 42 patients (18%) still had the original prosthesis in place. The risk of amputation was 16% at 30 years (31 patients). Those without infection had a mean of 2.1 further operations (one to nine) while those with infection had a mean of 4.6 further operations (two to 11). The risk of infection persisted throughout the life of the prosthesis with a mean of 1% per year becoming infected. Of the 60 patients who developed an infection, 21 (35%) developed this following the primary procedure at a mean of 50 months, but another 19 developed this within a year of another surgical procedure. The risk of infection after any further surgery was 2.7%. The site with the highest risk of infection was the proximal tibia (43.3%)., Take Home Message: This study highlights the inevitable need for further surgery following first-generation endoprosthetic reconstruction, although in most cases, limb salvage is maintained. Late complications, especially infection, continue for the lifetime of the implant. Cite this article: Bone Joint J 2016;98-B:857-64., (©2016 The British Editorial Society of Bone & Joint Surgery.)

Background Confirmatory factory analysis (CFA) and structural equation modelling (SEM) are increasingly used in social pharmacy research. One of the key benefits of CFA is that it allows researchers to provide evidence for the validity of internal factor structure of measurement scales. In particular, CFA can be used to provide evidence for the validity of the assertion that a hypothesized multi-dimensional scale discriminates between sub-scales. Aim This manuscript aims to provide guidance for researchers who wish to use CFA to provide evidence for the internal factor structure of measurement scales. Methods The manuscript places discriminant validity in the context of providing overall validity evidence for measurement scales. Four examples from the recent social pharmacy literature are used to critically examine the various methods which are used to establish discriminant validity. Using a hypothetical scenario, the manuscript demonstrates how commonly used output from CFA computer programs can be used to provide evidence for separateness of sub-scales within a multi-dimensional scale. Conclusion The manuscript concludes with recommendations for the conduct and reporting of studies which use CFA to provide evidence of internal factor structure of measurement scales.

The threat of nuclear disaster makes combined radiation and burn injury (CRI) a relevant topic when discussing modern trauma, as burn injuries are likely to occur with detonation of a conventional nuclear weapon. Previous studies in a murine model have shown that there is a breakdown of the gut epithelium and subsequent bacterial translocation into mesenteric lymph nodes after CRI. This study examines the early innate immune response of the small intestine after CRI. Using a previously established murine model of 5 to 5.5 Gy total body irradiation combined with 15% TBSA burn, the injury response of the small intestine was examined at 24, 48, and 72 hours by visual assessment, myeloperoxidase, and cytokine measurement. At 24 hours, intestinal damage as measured by villus blunting, crypt debris, and decreased mitosis, was apparent in all injury groups but the derangements persisted out to 72 hours only with CRI. The prolonged intestinal damage in CRI was accompanied by a 2-fold (P < .05) elevation in myeloperoxidase activity over sham animals at 48 hours and persisted as a 3-fold (P < .05) elevation at 72 hours after injury. Corresponding levels of KC were 8-fold (P < .05) higher than sham at 48 hours with persistent elevation at 72 hours. An enhanced innate immune response, partially mediated by the influx of neutrophils into the gastrointestinal tract is contributing to the hyperinflammatory state seen after CRI. Attenuation of the local gastrointestinal inflammatory response may play a major role in managing victims after nuclear disaster.

Objective: Patient safety education is a key strategy to minimise harm, and is increasingly being introduced into junior pharmacy curricula. However, currently there is no valid and reliable survey tool to measure the patient safety attitudes of pharmacy students. This study aimed to validate a modified survey tool, originally developed by Madigosky et al, to evaluate patient safety attitudes of junior pharmacy students., Design: A 23-item cross-sectional patient safety survey tool was utilised to evaluate first and second year pharmacy students' attitudes during May 2013 with both exploratory and confirmatory factor analyses performed to understand the psychometric properties of the survey tool and to establish construct validity., Setting: Undergraduate university students in Sydney, Australia, Participants: 245 first year and 201 second year students enrolled in the Bachelor of Pharmacy Programme at The University of Sydney, Australia in May 2013., Results: After exploratory factor analysis on first year student responses (55.76% variance explained) and confirmatory factor analysis on second year responses, a 5-factor model consisting of 14 items was obtained with satisfactory model fit (χ(2) (66)=112.83, p<0.001, RMSEA=0.06, CFI=0.91) and nesting between year groups (Δχ(2)(7)=3.079, p=0.878). The five factors measured students' attitudes towards: (1) being quality improvement focused, (2) internalising errors regardless of harm, (3) value of contextual learning, (4) acceptability of questioning more senior healthcare professionals' behaviour and (5) attitude towards open disclosure., Conclusions: This study has established the reliability and validity of a modified survey tool to evaluate patient safety attitudes of pharmacy students, with the potential for use in course development and evaluation., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Sarcomas are rare tumours and particularly rarer in the foot and ankle region. The complex anatomy of the foot and ankle makes it unique and hence poses a challenge to the surgeon for limb salvage surgery. Other lesions found in the foot and ankle region are benign bone and soft tissue tumours, metastasis and infection. The purpose of this article is to discuss the relevance of the complex anatomy of the foot and ankle in relation to tumours, clinical features, their general management principles and further discussion about some of the more common bone and soft tissue lesions. Discussion of every single bone and soft tissue lesion in the foot and ankle region is beyond the scope of this article., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Purpose: The aim of the study was to report overall survival, local recurrence and development of metastasis in a group of patients with femur chondrosarcoma that presented with or without a pathological fracture., Methods: A retrospective review was performed, and 182 patients (39 pathological fractures) that had been treated by oncologic surgery for femoral chondrosarcoma were included. The mean age of the series was 50 years (range, eight to 90) and 114 patients were male (63%). Mean follow-up was 113 months (range, three to 216). Cancer-specific overall survival, development of metastasis and local recurrence were analysed, grouping patients by grade (grade I / grade 2-3 / dedifferentiated)., Results: Disease-specific survival in the entire group of chondrosarcoma of the femur was 69% (CI95% 63-76) at 5 years. Five-year disease-specific survival in the fracture group was 49% lower than in the control group 75% (p = 0.0001). Survival of patients with grade 1 chondrosarcoma with fracture was significantly less than those without fracture (p = 0.02) but there was no difference in those with grade 2-3 (p = 0.49) and dedifferentiated tumours (p = 0.09). The local recurrence rate of the entire series was 27%. Only dedifferentiated chondrosarcomas with an associated pathological fracture had a significantly higher rate of local recurrence. There was no relationship between development of metastases and fracture., Conclusion: A pathological fracture of the femur has a negative prognostic influence in grade 1 chondrosarcoma and increases the risk of local recurrence in dedifferentiated femur chondrosarcomas.

Background: Research has shown that consumers prefer a pharmacist who is skilled in communication and pays particular attention to friendliness, empathy and attentiveness. Medication management interviews tend to be more time consuming than other patient-pharmacist interactions. The extra time for these interviews provides patients with an opportunity to evaluate the quality of interpersonal care provided by the pharmacist. Patient evaluations of pharmacists may influence their intentions to use medication management services. In previous studies, a conceptual model based on information-seeking theory was developed and used to explain a significant amount of the variation in consumers' and caregivers' willingness to use Australia's Home Medicines Review (HMR) service., Objective: The aim of this paper was to extend the conceptual model to include the influence of patients' evaluation of interpersonal care provided. We aimed to test the hypothesis that patients' perceptions of how well the pharmacist listened to them during their most recent HMR interview (Listening) would increase their willingness to re-use HMR (Willingness)., Methods: Patients (N = 595) who had experienced Australia's Home Medicines Review (HMR) within the previous 6 months completed questionnaires. Exploratory and confirmatory factor analyzes were used to validate the measurement scales. Structural equation modeling was used to test the model., Results: The structural model provided a reasonable fit to the data and explained 53% of the variation in Willingness. The structural model revealed that Listening increased patients' perceptions that the HMR provided positive outcomes (Outcomes) (β = 0.37, P < 0.05) and directly and indirectly increased Willingness (β = 0.61, P < 0.05)., Conclusion: These results suggest that patients' willingness to use a medication management service in the future is strongly influenced by their perceptions of how well the pharmacist listened to them during their last medication review interview. Improving pharmacist listening skills may be explored as a strategy for improving patient engagement with pharmacy services., (Crown Copyright © 2015. Published by Elsevier Inc. All rights reserved.)

Aims: To investigate whether the oncological outcomes of patients with osteosarcomas in the upper distal extremity are similar to other sites and assess if limb-salvage surgery is safe in this location., Methods: The centre database was used to identify all patients with osteosarcomas in the lower humerus and distally between 1985 and 2012. Patient, tumor, treatment and outcome data was collected., Results: Twenty-six patients were included in this study. There were 9 males and 17 females with a mean age of 33 years (9-90). Seventeen osteosarcomas were located in the forearm bones (65%), six in the distal humerus (23%), and three (12%) in the hand. The three most common sub-diagnoses were parosteal 7/21 (33%), fibroblastic 4/21 (19%) and osteoblastic osteosarcomas 3/21 (14%). 2 patients (8%) had Paget's disease and 19 patients (73%) had high-grade tumors. Local excision was carried out in 12 patients (48%), 4 patients underwent endoprosthetic replacement (16%) and 9 underwent amputation (36%). The overall risk of local recurrence was 4% in our series. The five-year overall survival rate was 67%, with low tumor grade and parosteal type of osteosarcoma being positive predictors of survival., Conclusion: This series has shown that patients with high-grade osteosarcomas of the upper distal extremities have a higher amputation risk than other limb sites but have favorable outcomes with limb-salvage surgery, comparable to other anatomical sites. Parosteal osteosarcomas in particular have a good prognosis., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

We conducted a case-control study to examine the merit of silver-coated tumour prostheses. We reviewed 85 patients with Agluna-treated (silver-coated) tumour implants treated between 2006 and 2011 and matched them with 85 control patients treated between 2001 and 2011 with identical, but uncoated, tumour prostheses. In all, 106 men and 64 women with a mean age of 42.2 years (18.4 to 90.4) were included in the study. There were 50 primary reconstructions (29.4%); 79 one-stage revisions (46.5%) and 41 two-stage revisions for infection (24.1%). The overall post-operative infection rate of the silver-coated group was 11.8% compared with 22.4% for the control group (p = 0.033, chi-square test). A total of seven of the ten infected prostheses in the silver-coated group were treated successfully with debridement, antibiotics, and implant retention compared with only six of the 19 patients (31.6%) in the control group (p = 0.048, chi-square test). Three patients in the silver-coated group (3.5%) and 13 controls (15.3%) had chronic periprosthetic infection (p = 0.009, chi-square test). The overall success rates in controlling infection by two-stage revision in the silver-coated group was 85% (17/20) compared with 57.1% (12/21) in the control group (p = 0.05, chi-square test). The Agluna-treated endoprostheses were associated with a lower rate of early periprosthetic infection. These silver-treated implants were particularly useful in two-stage revisions for infection and in those patients with incidental positive cultures at the time of implantation of the prosthesis. Debridement with antibiotic treatment and retention of the implant appeared to be more successful with silver-coated implants., (©2015 The British Editorial Society of Bone & Joint Surgery.)

Cutaneous wound healing is a complex physiological process. This process can be altered by multiple physiological and pathological factors. Multiple pathophysiological disturbances act to impair resolution of cutaneous wound injury, including obesity, diabetes, peripheral vascular disease, and advanced age. As our longevity increases without a concomitant increase in healthy living years, it is plausible to assume that problematic wound closure will continue to consume a large portion of our health care resources. Furthermore, advanced age is associated with numerous alterations in the innate and adaptive immune responses that complicate outcomes following cutaneous injury, trauma, or infection. Thus, models that examine the impact of advanced age on cutaneous wound repair will be of great benefit to the development of potential therapeutics that target age-related aberrancies in tissue repair. Herein, we detail two animal models of tissue injury, excisional wound injury and burn injury, that can be used to evaluate wound healing in the context of advanced age. We also describe modifications of these methods to examine wound infection following either excisional or burn injury. Lastly, we discuss methods of subsequent tissue analysis following injury. Models described below can be further adapted to genetically engineered murine strains to study the effects of aging and other co-morbidities on wound healing.

A poor response to chemotherapy (≤ 90% necrosis) for osteosarcomas leads to poorer survival and an increased risk of local recurrence, particularly if there is a close margin of excision. We evaluated whether amputation confers any survival benefit over limb salvage surgery (LSS) with narrow margins in patients who respond poorly to chemotherapy. We only analysed patients with an osteosarcoma of the limb, a poor response to chemotherapy and close margins on LSS (marginal/intralesional) or primary amputation: 360 patients (36 LSS (intralesional margins), 197 LSS (marginal margins) and 127 amputations) were included. Local recurrence developed in 13 (36%) following LSS with intralesional margins, and 39 (20%) following LSS with marginal margins. There was no local recurrence in patients who underwent amputation. The five-year survival for all patients was 41% (95% confidence interval (CI) 35 to 46), but for those treated by LSS with marginal margins was 46.2% (95% CI 38 to 53), 36.3% (95% CI 27 to 45) for those treated by amputation, and 28% (95 CI 14 to 44) for those treated by LSS with intralesional margins. Patients who had LSS and then developed local recurrence as a first event had the same survival as those who had primary amputation without local recurrence. Prophylactic adjuvant radiotherapy was used in 40 patients but had no discernible effect in preventing local recurrence. Although amputation offered better local control, it conferred no clear survival benefit over LSS with marginal margins in these patients with a poor overall prognosis., (©2015 The British Editorial Society of Bone & Joint Surgery.)

The aim of this study was to evaluate the functional and oncological outcome of extracorporeally irradiated autografts used to reconstruct the pelvis after a P1/2 internal hemipelvectomy. The study included 18 patients with a primary malignant bone tumour of the pelvis. There were 13 males and five females with a mean age of 24.8 years (8 to 62). Of these, seven had an osteogenic sarcoma, six a Ewing's sarcoma, and five a chondrosarcoma. At a mean follow-up of 51.6 months (4 to 185), nine patients had died with metastatic disease while nine were free from disease. Local recurrence occurred in three patients all of whom eventually died of their disease. Deep infection occurred in three patients and required removal of their graft in two while the third underwent a hindquarter amputation for extensive flap necrosis. The mean Musculoskeletal Tumor Society functional score of the 16 patients who could be followed-up for at least 12 months was 77% (50 to 90). Those 15 patients who completed the Toronto Extremity Salvage Score questionnaire had a mean score of 71% (53 to 85). Extracorporeal irradiation and re-implantation of bone is a valid method of reconstruction after an internal hemipelvectomy. It has an acceptable morbidity and a functional outcome that compares favourably with other available reconstructive techniques., (©2014 The British Editorial Society of Bone & Joint Surgery.)

Aims: The aim of this study was to clarify the clinical features and outcomes of diaphyseal osteosarcoma., Methods: Patients with newly-diagnosed high-grade osteosarcoma occurring in the long bone were eligible for this retrospective study. Clinicopathological information was collected from our database and compared with 36 diaphyseal, 405 proximal and 519 distal metaphyseal, and 14 whole bone osteosarcoma patients. Additionally, case-control study matching by age, gender, site, and metastatic status at diagnosis with 1:3 ratio of 36 diaphyseal to 108 metaphyseal osteosarcomas patients was also conducted., Results: Five-year overall survival and metastasis-free survival of the three groups including diaphyseal, metaphyseal, and whole bone osteosarcoma patients showed significant difference (P = .029 and P = .013, respectively), although there is no difference for the survivals between proximal and distal metaphyseal osteosarcoma patients. Case-control study showed that patients with diaphyseal osteosarcomas had a significantly larger tumour (mean 13.5 cm vs 10 cm, P = .026), and demonstrated higher pathologic fracture rate (28% vs 12%, P = .033), superior 5-year metastasis-free survival (74% vs 40%, P = .0068), and slightly better 5-year overall survival (68% vs 46%, P = .074). Prognostic factor analysis showed that a pathologic fracture significantly decreased the survival of the patients with diaphyseal osteosarcoma., Conclusions: The current study showed that diaphyseal osteosarcoma has distinct clinical features from metaphyseal osteosarcoma having an increased risk of pathologic fractures but with favorable survival outcome., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Primary aneurysmal bone cysts (ABCs) are benign, expansile bone lesions commonly treated with aggressive curettage with or without adjuvants such as cryotherapy, methacrylate cement, or phenol. It has been reported that occasionally these lesions heal spontaneously or after a pathologic fracture, and we observed that some ABCs treated at our center healed after biopsy alone. Because of this, we introduced a novel biopsy technique we call "curopsy," which is a percutaneous limited curettage at the time of biopsy, obtaining the lining membrane from various quadrants of the cyst leading to consolidation (curopsy = biopsy with intention to cure)., Questions/purposes: We asked whether (1) a curopsy results in comparable likelihood of healing of the ABC compared with more aggressive approaches involving curettage, (2) the two approaches differ in terms of the likelihood of recurrence after treatment, and (3) the two approaches differ in terms of complications after surgery., Methods: Between January 1, 1999 and June 30, 2012, 221 patients with a diagnosis of primary ABC were registered in our oncology database. Patients presenting with a pathologic fracture and those seeking a second opinion were excluded. One hundred ninety patients were included in the study. One hundred two (54%) were treated with curopsy and 88 (46%) were treated with curettage after a core needle biopsy. Complete followups were available for 88% (90 of 102) and 93% (80 of 88) of patients in those groups, respectively. During that period, a curopsy was performed for all patients with benign bone lesions with imaging suggestive of classic primary ABCs and for whom the core needle biopsy simply showed blood with no solid component. Curettage after a core needle biopsy was reserved for histologically confirmed primary ABCs, lesions with impending fractures, large lesions, if the ABC was thought to be a secondary disorder, and patients for whom the curopsy failed. All patients were followed up until consolidation of the lesion (mean, 9.6 weeks, range, 3-25 weeks, 95% CI, 8.32-10.9 for curopsy; mean, 11.4 weeks, range, 8-32 weeks, 95% CI, 10.6-12.3 for curettage). The median followup for all patients was 14 months (range, 6-36 months)., Results: Of the 102 patients who had curopsy and observation, 83 (81%) required no additional treatment and the lesion resolved. Of the 88 patients who underwent curettage (with or without adjuvant therapy) after core needle biopsy, the success rate was 90% (79 of 88). Local recurrences in both groups (curopsy or curettage) were treated successfully with additional curettage in all but one case. Curopsy in comparison to curettage provided a mean shorter healing time (9.6 versus 11.4, p = 0.01) but there was a higher local recurrence and need for additional intervention rate (18.6% versus 10.2%, p = 0.04). There were no differences in the complications between the treatment groups., Conclusions: A curopsy is a novel biopsy technique that was successful in resolving ABCs in 81% of the patients in our study. Curopsy, as a biopsy technique, for ABCs needs consideration as it potentially minimizes the number of patients needing a second procedure (a core needle biopsy being the first) as is the current practice. Furthermore, it does not disadvantage the patient or surgeon should additional intervention be needed in the form of curettage with or without adjuvants., Level of Evidence: Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.