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OBJECTIVE To identify goals for exercising among community-dwelling persons with spinal cord injury (PwSCI). DESIGN Qualitative descriptive study. SETTING Community-based exercise facility for persons with a disability. PARTICIPANTS Fifty-five PwSCI identified their exercise goals prior to participation in a community-based exercise intervention. INTERVENTIONS None. OUTCOME MEASURES A modified version of the Canadian Occupational Performance Measure was used to ask about exercise goals. The International Classification of Functioning, Disability, and Health (ICF) was used to code the goals for themes. RESULTS The participants were predominantly male (76%) and Black (56%) with thoracic-level injury (51%) and a mean age of 39.44 (standard deviation [SD] 13.62). A total of 231 goals (mean 4.2 goals per participant; SD 1.25) were identified. Participants rated their performance and satisfaction with their goals as 4.256 (SD 1.55) and 3.57 (SD 1.67), respectively. Participants most frequently reported goals related to endurance, muscle strengthening, weight loss, activities of daily living, transferring, and home and community mobility. The most commonly reported goals fell into five ICF domains: Functions of Cardiovascular, Hematological, Immunological, and Respiratory Systems; Neuromusculoskeletal and Movement-Related Functions; Structures Related to Movement; Mobility; and Self-Care. CONCLUSION PwSCI have goals they would like to achieve through participation in exercise. The goals are multifaceted and encompass improving health and fitness as well as improving performance in everyday activities such as transferring and mobility. Identifying themes of goals for PwSCI to achieve through exercise is an important step in developing programs and interventions needed to support PwSCI living in the community.

Background Opioid are currently widely used to manage chronic non-malignant pain (CNMP), but there is a growing concern about harm resulting from opioid misuse and the need for medicine optimization, in which pharmacists could potentially play a key role. Objective This study explored pharmacists' roles, barriers and determinants related to their involvement in optimizing prescribed opioids for patients with chronic pain. Setting Community pharmacies in the United Kingdom. Method Semi-structured interviews based on the Theoretical Domains Framework were conducted between January and May 2020 with 20 community pharmacists recruited through professional networks. Data were analysed thematically. Main outcome measure: Pharmacists’ perceived roles, barriers and behavioural determinants in relation to opioid therapy optimization. Result Pharmacists demonstrated desire to contribute to opioid therapy optimization. However, they described that they were often challenged by the lack of relevant knowledge, skills and training, inadequate time and resources, systemic constraints (such as lack of access to medical records and information about diagnosis), and other barriers including relationships with doctors and patients. Conclusion The contribution of community pharmacists to optimize opioid therapy in CNMP is unclear and impeded by lack of appropriate training and systemic constraints. There is a need to develop innovative practice models by addressing the barriers identified in this study to enhance the contribution of community pharmacists in optimization of opioid therapy for chronic pain.

STUDY DESIGN Descriptive study. OBJECTIVES To examine grouped and intra-individual relationships between 1) exercise intensity and heart rate (EI-HR); 2) EI and oxygen uptake (EI-VO2); 3) VO2 and HR (VO2-HR); and 4) perceived exertion and VO2 (PE-VO2) in persons with tetraplegia (C4/5-C8) during different modes of exercise. SETTING Community in Winnipeg, Canada. METHODS Participants exercised at 3 graded intensities during arm ergometry (ERG), wheeling indoors on cement (MWC), or hand-cycling outdoors (HC). EI (Watts, km/hr) and VO2, HR and PE were recorded. RESULTS 22 persons completed ERG, 14/22 also completed MWC and 5/22 completed ERG, MWC and HC. Regression analysis of grouped data showed a significant relationship between EI-VO2 but not for EI-HR or HR-VO2. Intra-individual analyses showed a strong correlation (r or ρ > 0.7) for VO2-HR for 16/22 during ERG. In the participants completing multiple exercise modes, a strong VO2-HR relationship was present in 12/14 in ERG, but in only 6/14 in MWC. The 5 persons exercising with all 3 modes had a strong HR-VO2 relationship in 5/5 for ERG, 2/5 in MWC and 1/5 in HC. A strong relationship for PE-VO2 was observed in a higher proportion of participants (versus HR-VO2) during MWC (9/14) and HC (2/4). CONCLUSION Within the same individual, the HR-VO2 relationship varies across modes, despite exercising over similar ranges of steady-state VO2. HR appears less able to predict VO2 compared to PE. Based on these new findings, systematic investigation of the HR-VO2 relationship across modes of exercise in tetraplegia is warranted.

Ammar Abdulrahman Jairoun,1,2 Sabaa Saleh Al-Hemyari,2,3 Moyad Shahwan,4,5 Faris El-Dahiyat,6 Maimona Jairoun,4 Saleh Karamah AL-Tamimi,7 Ramzi A Mothana,8 Ahmed Husham Khattab4 1Health and Safety Department, Dubai Municipality, Dubai, United Arab Emirates; 2Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, 11500, Malaysia; 3Department of Pharmacy, Ministry of Health and Prevention, Dubai, United Arab Emirates; 4Department of Clinical Sciences, College of Pharmacy and Health Sciences, Ajman University, Ajman, 346, United Arab Emirates; 5Center of Medical and Bio-allied Health Sciences Research, Ajman University, Ajman, Ajman, 346, United Arab Emirates; 6College of Pharmacy, Al Ain University, Al Ain, United Arab Emirates; 7Faculty of Pharmacy, Aden University, Aden, Yemen; 8Department of Pharmacognosy, College of Pharmacy, King Saud University, Riyadh, Saudi ArabiaCorrespondence: Ammar Abdulrahman JairounHealth and Safety Department, Dubai Municipality, Dubai, 67, United Arab EmiratesTel +971558099957Email Dr_ammar_91_@hotmail.comBackground: The flux of pharmaceutical data can have a negative impact on the complexity of a pharmacist’s decision-making process, which will demand an extensive evaluation from healthcare providers trying to choose the most suitable therapeutic plans for their patients.Objective: The current study aimed to assess the beliefs and implementations of community pharmacists in the UAE regarding evidence-based practice (EBP) and to explore the significant factors governing their EBP.Setting: Community pharmacies in Dubai and the Northern Emirates, UAE.Methods: A descriptive cross-sectional study was conducted over six months between December 2017 and June 2018. Community pharmacists who had three months’ professional experience or more and were registered with one of three regulatory bodies (Ministry of Health, Health Authority Abu Dhabi, or Dubai Health Authority) were interviewed by three trained final-year pharmacy students. Face-to-face interviews were then carried out and a structured questionnaire was used.Metrics: The average beliefs score was 36% (95% CI: [34%, 39%]) compared to an implementation score of 35% (95% CI: [33%, 37%]).Results: A total of 505 subjects participated in the study and completed the entire questionnaire. On average, participants scored higher in beliefs score than implementation score. The results of the statistical modelling showed that younger, female, higher-position pharmacists with more experience and with low percentages of full-time working, and graduates from international/regional universities were more likely to believe in and implement the concept of EBP.Conclusion: A gap was identified between the beliefs and implementation of EBP. Developing educational EBP courses in undergraduate pharmacy curricula is of high importance, not only to increase knowledge levels but also to encourage commitment in those pharmacists to strive for professionalism and to support the provided patient care with evidence.Keywords: evidence-based practice, beliefs, practice, community pharmacist

ObjectiveDoes TEN4 categorisation of bruises to the torso, ear or neck or any bruise in DesignProspective comparative longitudinal study.SettingCommunity.PatientsChildren InterventionsThe number and location of bruises compared for 2568 data collections from 328 children in the community, 1301 from 106 children with IBD and 342 abuse cases.Main outcome measuresLikelihood ratios (LRs) for the number of bruises within the TEN and non-TEN locations for pre-mobile and mobile children: abuse vs accidental injury, IBD vs accident, abuse vs IBD.ResultsAny bruise in a pre-mobile child was more likely to be from abuse/IBD than accident. The more bruises a pre-mobile child had, the higher the LR for abuse/IBD vs accident. A single bruise in a TEN location in mobile children was not supportive of abuse/IBD. For mobile children with more than one bruise, including at least one in TEN locations, the LR favouring abuse/IBD increased. Applying TEN4 to collections from abused and accidental group ConclusionsThese data support further child protection investigations of a positive TEN4 screen in any pre-mobile children with a bruise and in mobile children with more than one bruise. TEN4 did not discriminate between IBD and abuse, thus IBD needs to be excluded in these children. Estimated sensitivity and specificity of TEN4 was appreciably lower than previously reported.

Objectives Methods for analyzing sleep as a dyadic behavior remain relatively unexplored. We aimed to (1) characterize how bedpartners influence each other's sleep, and (2) identify factors that predict sensitivity to wake transmission between bedpartners. Design Cross-sectional study. Setting Community members in Melbourne, Australia. Participants Fifty-five couples without sleep disorders, aged 18-72 years. Measurements Participants completed the Morningness-Eveningness Questionnaire, reduced version. Habitual sleep/wake patterns were monitored for seven nights via actigraphy and sleep diary. Epoch-by-epoch sleep/wake concordances (shared sleep/wake minutes), number of transmissions received (number of awakenings immediately preceded by bedpartner wakefulness), percent transmissions received (percentage of total awakenings that were transmissions), transmissibility (percentage of all bedpartner awakenings transmitted), and percent minutes resistant to transmission (percentage of bedpartner's wake minutes that an individual slept), were calculated. Mixed-effects modeling assessed predictors of dyadic sleep. Results We described rates of sleep concordance (M = 66.8% ± 6.8%), wake concordance (M = 6.8% ± 3.1%), number of transmissions received (M = 6.0 ± 2.7), percent transmissions received (M = 18.9% ± 7.5%), transmissibility (M = 20.0% ± 6.2%), and percent minutes resistant (M = 52.1% ± 13.6%). Average couple-level percent transmissions received were highest and percent minutes resistant lowest in couples who had similar bedtime (within 30 minutes), compared to couples with greater differences in bedtime. Conclusions Wake transmission is a useful metric of dyadic sleep, which varies according to relative bedtimes, and chronotypes of bedpartners. Higher wake transmissions for couples with similar bedtimes suggest dyadic preferences for shared bedtimes may be due to psychosocial benefits of shared sleep timing, rather than minimization of bedpartner-driven sleep disruption.

Background Complementary medicines are a popular healthcare choice among patients/consumers, and most pharmacies sell these products. Pharmacists are well-placed to advise on complementary medicines, but their training and practices for these products are not optimal. Pharmacists' professional practices for complementary medicines ought to be influenced by professional codes of ethics and standards. Objective To examine community pharmacists' perspectives on complementary medicines in New Zealand, including motivations and justifications for selling these products, and professional and ethical issues complementary medicines raise for pharmacists. Setting Community pharmacists in New Zealand. Method Qualitative, semi-structured interviews with 27 New Zealand practising community pharmacists identified through purposive and convenience sampling. Main outcome measure Participants' views, experiences, and professional practices for complementary medicines. Results Participants struggled to clearly describe products they considered complementary medicines. Perspectives towards these products ranged from strongly supportive to somewhat sceptical; none was strongly opposed. Participants had several motivations for selling complementary medicines, particularly consumer demand and profits. Participants acknowledged ethical issues concerning complementary medicines, including lack of evidence of efficacy and pharmacists' limited training/knowledge. Few referred explicitly to complementary-medicines-related statements in the Pharmacy Council of New Zealand's Code of Ethics, or indicated these guided their practice. Conclusion Participants sold complementary medicines despite having limited knowledge on these products and concerns about efficacy; participants justified this as they believe they are providing an holistic option for patients, and/or ensuring complementary medicines do no harm. Participants were mindful of ethical/professional issues regarding complementary medicines, but were not necessarily aware of, or guided by, explicit statements in the Pharmacy Council of New Zealand's Code of Ethics.

Objective:To investigate the effect of maternal depressive symptom trajectories, from 3 months to 11 years postpartum, on the offspring’s body composition at 11 years of age.Design:Data from the Pelotas 2004 Birth Cohort, from the perinatal interview and from the 3-, 12-, 24- and 48-month and 6- and 11-year follow-ups.Setting:Community-based sample from the city of Pelotas, located in southern Brazil with approximately 350 000 inhabitants. The maternal depression symptom trajectories were identified through a semi-parametric group-based modelling approach, using the Edinburgh Postnatal Depression Scale (EPDS), with data from 3 months to 11 years postpartum.Participants:A total of 3467 (81·9 % of the total cohort).Results:Five trajectory groups of EPDS scores were identified (‘Low’, ‘Moderate low’, ‘Increasing’, ‘Decreasing’ and ‘Chronic high’). A total of 170 women (4·9 %) from the sample belonged to the ‘Chronic high’ group, having scored ≥13 EPDS points at every follow-up. Mean BMI in the ‘Low’ trajectory group was 0·77 (z-score 1·4), compared with 0·56 (z-score 1·4) in the ‘Chronic high’ group. Children from mothers in the ‘Chronic high’ group had lower fat mass (FM) (–1·34 ± 0·64 kg), FM% (–2·02 ± 0·85 percentage points) and FM index (–0·57 ± 0·27 kg/m2), compared with children from mothers in the ‘Low’ trajectory group. Adjusted analyses showed that sustained or transitory maternal depressive symptoms during childhood had no effect on the offspring’s body composition indices at 11 years of age.Conclusion:Children raised by chronically depressed mothers have body composition indices at 11 years of age that are similar to those of children whose mothers have never been depressed.

Objective To compare health care expenditures between older US adults (≥50 years) with pain who were prescribed opioid medications and those who were not. Design Cross-sectional. Setting Community-based adults in the 2015 Medical Expenditure Panel Survey (MEPS). Subjects Nationally representative sample of US adults alive for the calendar year, aged 50 years or older, who reported having pain in the past four weeks. Methods Older US adults (≥50 years) with pain in the 2015 MEPS data were identified. The key independent variable was opioid prescription status (prescribed opioid vs not prescribed opioid). Hierarchical linear regression models assessed health care expenditures (inpatient, outpatient, office-based, emergency room, prescription medications, other, and total) in US dollars for opioid prescription status from a community-dwelling US population perspective, adjusting for covariates. Results The 2015 study cohort provided a national estimate of 50,898,592 noninstitutionalized US adults aged ≥50 years with pain in the past four weeks (prescribed opioid N = 16,757,516 [32.9%], not prescribed opioid N = 34,141,076 [67.1%]). After adjusting for covariates, individuals prescribed an opioid had 61% greater outpatient (β = 0.477, P 0.05). Conclusions This study raises awareness of the economic impact associated with opioid use among US older adults with pain. Future research should investigate these variables in greater depth, over longer time periods, and in additional populations.

Objective Determine whether preinjury concussion symptom factors predict postinjury concussion symptom factors. Setting Community concussion surveillance program between 2008 and 2017. Participants A total of 290 high school and collegiate-aged athletes (n = 168, aged 14-17 years; n = 122, aged 18-21 years, respectively). Design Retrospective analysis. Main measures Post-Concussion Symptom Scale scores prior to and within 7 days of sustaining a sport-related concussion. Methods Post-Concussion Symptom Scale scores were aggregated into cognitive-sensory, sleep-arousal, vestibular-somatic, and affective preinjury symptom factors. These preinjury symptom factors, in conjunction with sex and previous concussion history, underwent linear regressions to predict cognitive-migraine-fatigue, somatic, sleep, and affective postinjury symptom factors. Results The cognitive-sensory factor (P = .002) and female sex (P = .002) predicted the postinjury cognitive-migraine-fatigue factor in combined age group but not stratified age group models. Among the 14 to 17 years age group, and not the 18 to 21 years age group, the preinjury sleep-arousal symptom factor predicted postinjury somatic (P = .003) and sleep factors (P = .005). The affective preinjury factor predicted the affective factor (P = .001) and somatic factor (P = .008) in the 18 to 21 years age group. A history of previous concussions also predicted the postinjury somatic symptom factor (P = .005). Conclusion Preinjury symptom factors predicted postinjury symptom factors and age-associated differences in symptom factors may provide clinical value in prognostic models for subsequent postinjury clinical outcomes.

OBJECTIVE To compare the occurrence of falls and fall-related injuries, and the circumstances of falls among individuals with spinal cord injury (SCI) who ambulate full-time, use a wheelchair full-time and ambulate part-time. DESIGN A secondary analysis. SETTING Community. PARTICIPANTS Adults with SCI. INTERVENTION None. OUTCOME MEASURES The occurrence and circumstances of falls and fall-related injuries were tracked over six-months using a survey. Participants were grouped by mobility and fall status. A chi-square test compared the occurrence of falls and fall-related injuries, and the time and location of falls, and a negative binomial regression was used to predict the likelihood of falls by mobility status. Kaplan-Meier analysis was used to determine differences in the time to first fall based on mobility status. Group characteristics and causes of falls were described. RESULTS Data from individuals who ambulated full-time (n = 30), used a wheelchair full-time (n = 27) and ambulated part-time (n = 8) were analyzed. Mobility status was a significant predictor of falls (P

Objectives: To examine the longitudinal association between frequency of moderate physical activity (PA) and overall, physical, psychological, and social frailty among community-dwelling older adults older than 70 years. Second, we assessed the association between a 12-month change in frequency of moderate PA and frailty. Design: Longitudinal cohort study. Setting: Community settings in Spain, Greece, Croatia, the Netherlands, and the United Kingdom. Participants: A total of 1735 participants (61.1% female ; mean age = 79.6 years ; SD = 5.5 years). Measurements: The frequency of self-reported moderate PA was measured and classified into two categories: "regular frequency" and "low frequency." The 12-month change in frequency of moderate PA between baseline and follow-up was classified into four categories: "continued regular frequency, " "decreased frequency, " "continued low frequency, " and "increased frequency." The 15-item Tilburg Frailty Indicator assessed overall, physical, psychological, and social frailty. Results: Participants who undertook moderate PA with a regular frequency at baseline were less frail at 12-month follow-up than participants with a low frequency. Participants who undertook moderate PA with a continued regular frequency were least frail at baseline and at 12-month follow-up. After controlling for baseline frailty and covariates, compared with participants with a continued regular frequency, participants with a decreased frequency were significantly more overall (B = 1.31 ; 95% confidence interval [CI] = 0.99- 1.63), physically (B = 0.80 ; 95% CI = 0.58- 1.03), psychologically (B = 0.43 ; 95% CI = 0.30-0.56), and socially frail (B = 0.14 ; 95% CI = 0.04-0.23) at 12-month follow-up ; participants with a continued low frequency were significantly more overall (B = 1.16 ; 95% CI = 0.84-1.49), physically (B = 0.73 ; 95% CI = 0.51-0.96), psychologically (B = 0.42 ; 95% CI = 0.29-0.55), and socially frail (B = 0.13 ; 95% CI = 0.04-0.23) at 12-month follow-up ; the 12- month follow-up frailty level of participants who undertook moderate PA with an increased frequency was similar to those with a continued regular frequency. Conclusion: Maintaining a regular frequency of PA as well as increasing to a regular frequency of PA are associated with maintaining or improving overall, physical, psychological, and social frailty among European community- dwelling older adults older than 70 years. J Am Geriatr Soc 68:1484-1493, 2020.

Objective Examining the implementation barriers and facilitators of this service as provided by Belgian community pharmacists in collaboration with general practitioners. Setting Community pharmacies in Flanders. Method Qualitative study through interviews of pharmacists and general practitioners. Main outcome measure Opinions and experiences of pharmacists and general practitioners about type 3 medication review. Results Sixteen community pharmacists and thirteen general practitioners were interviewed and generally gave a positive assessment of the project. The general practitioners saw the pharmaceutical and pharmacotherapeutic recommendations of the pharmacists as an added value for the patients. The pharmacists indicated that performing an medication review was time-consuming, but that it improved their professional relationship with general practitioners and patients. They reported obstacles in obtaining information: cumbersome access to individual patient data (laboratory values) and difficulties in finding and choosing adequate medical information sources. Moreover, pharmacists indicated that there is a need for adequate reimbursement and additional training to make the implementation sustainable. Conclusion Both pharmacists and general practitioners were enthusiastic about medication reviews. The implementation improved the interprofessional collaboration. However, important barriers remain, such as the considerable investment of time and the difficulty in gathering all the necessary information. The sustainable implementation of type 3 medication review in Belgium requires adequate reimbursement and additional training.

BackgroundIt has been acknowledged and recognised internationally that the community pharmacy team has a major role to play in antimicrobial stewardship programmes, particularly regarding patient engagement. However, there is a paucity of published research on community pharmacy-based activities in antimicrobial stewardship, and views and perceptions of the community pharmacy team on their role in antimicrobial stewardship.ObjectiveTo explore views and experiences of community pharmacy teams across Scotland on antimicrobial stewardship, activities related to European Antibiotic Awareness Day, and a self-help guide to treating infection.SettingCommunity pharmacy, Scotland.MethodsQualitative, semi-structured in-depth telephone interviews were undertaken with a purposive sample of community pharmacy team members over a six week period between November and December in 2016. Interviews were audio-recorded, transcribed verbatim and data analysed thematically using the framework approach.Main outcome measureViews and perceptions of antimicrobial stewardship and European Antibiotic Awareness Day activities and role of the pharmacy team.ResultsTwenty-seven participants were interviewed—20 pharmacists, five pharmacy graduates completing their pre-registration year, and members of the pharmacy support team including two pharmacy technicians and one medicines counter assistant. They were working mainly in urban areas and across five regions of Scotland. Most were aware of antimicrobial stewardship but some were not familiar with the term. Participants identified roles for the community pharmacy team in antimicrobial stewardship including the importance of the pharmacy as a first port of call for self-care advice. Some participants, including pharmacists, showed lack of awareness of European Antibiotic Awareness Day; those who were aware thought it may not have the desired impact on educating the public. Most participants, irrespective of role within the team, were not familiar with the self-help guide but they perceived this as a useful resource for the pharmacy team.ConclusionThe participants recognised and identified roles for the community pharmacist within antimicrobial stewardship. However, the lack of awareness of European Antibiotic Awareness Day shows a need for European Antibiotic Awareness Day tools and other materials to be more effectively disseminated and for more training to be provided.

DESIGN Descriptive. SETTING Community, Bangladesh. OBJECTIVES To determine the costs associated with providing a community-based model of care delivered as part of the CIVIC trial to people discharged from hospital with recent spinal cord injury (SCI), and to determine the economic burden to households. METHODS Records were kept of the costs of providing a community-based model of care to participants of the CIVIC trial. Data were also collected at discharge and 2 years post discharge to capture out-of-pocket healthcare costs over the preceding 2 years, and the number of participants suffering catastrophic health expenditure and illness-induced poverty. RESULTS The mean cost of providing the community-based model of care to participants assigned to the intervention group (n = 204) was US$237 per participant. The mean out-of-pocket healthcare cost over the first 2 years post discharge was US$472 per participant (n = 410), and US$448 per control participant (n = 206). Median (IQR) equivalent annual household incomes prior to SCI and at 2 years post discharge were US$721 (US$452-1129) and US$464 (US$214-799), respectively. Of the 378 participants alive at 2 years, 324 (86%) had catastrophic health expenditure, and 161 of 212 participants who were not in poverty prior to injury (76%) were pushed into illness-induced poverty within 2 years of injury. CONCLUSION The cost of providing community-based support to people with SCI for 2 years post discharge in Bangladesh is relatively inexpensive but an overwhelming majority of households rapidly experience financial catastrophe, and most fall into poverty.

Objective To examine stressor elevations among older adults with pain, and gender and race disparities in the dual burdens of late-life pain and stressors. Design Cross-sectional. Setting Community. Subjects Participants in the Longitudinal Late-Life Health study (LLLH; N = 1,884) and the Health and Retirement Study (HRS; N = 7,704). Methods Pain and stressor measures were harmonized across the LLLH and HRS samples. Analyses of covariance were conducted to determine the effects of older adults’ pain, gender, race, and interactions between these factors, on their stressors in nine separate life domains, and in stressors overall. Results In both the LLLH and HRS samples, older adults with painful conditions (joint, back, headache, chest pain), more numerous painful conditions, more severe pain, and more pain interference had elevated stressors in all life domains, compared with older adults without or with less serious pain. Pain was more prevalent among women and nonwhites than men and whites. Stressor exposure was higher for men than women in most life domains; it was higher for nonwhites than whites in all life domains. For certain types of pain and life domains, pain and gender, as well as pain and race, interacted to predict stressor elevations. Conclusions Late-life pain is associated with elevations in stressors, and there are gender and race disparities in the dual burdens of heightened pain and elevated stressors in later life. Pain and stressors are not consistently more strongly linked among older women than older men, or among older nonwhite than older white persons.

Objectives To test a culturally tailored intervention to improve Alzheimer's disease (AD) literacy among African Americans. Design A 3-arm randomized comparative effectiveness trial. Setting Community sites in Los Angeles, CA. Participants 193 African American community-dwelling adults, ages 45 to 95 years old. Intervention All groups attended BrainWorks Live, a culturally tailored, 60-minute talk show and received standard printed educational materials on AD. From there: a) the BrainWorks Live group received no further contact until the post-test; b) one intervention group received a 1-month, culturally tailored, unidirectional, daily text-message program; and c) a second intervention group received daily text messages based on the printed educational materials that the general public would receive. AD literacy was measured at baseline and one month post intervention. Measurements Alzheimer's disease literacy and demographic and health covariates. Results At one month, participants who received culturally tailored text messages had the highest increase in AD literacy levels, followed by those in the BrainWorks Live arm. Participants who received general text messages had a lower overall increase in AD literacy levels compared to the other arms, but had higher mean AD literacy levels than the BrainWorks Live arm. There was a significantly greater increase in AD literacy levels among participants who received culturally tailored text messages compared with those who attended BrainWorks Live only. There were no other statistically significant differences between arms. Conclusions AD literacy among African Americans can be improved after only one month through culturally competent, economically feasible educational formats.

STUDY DESIGN Questionnaire survey conducted in 2017 as part of the Swiss Spinal Cord Injury Cohort Study (SwiSCI). OBJECTIVES To elucidate the use of outpatient health care providers by individuals with chronic spinal cord injury in a situation of free choice and ample supply. SETTING Community, nationwide. METHODS The frequency of visits was compared to that of a survey conducted five years earlier. Using regression tree analysis, the characteristics of individuals with extensive use of health care providers' services were investigated. Substitution effects, where health care users replace one provider type by another, were quantified using likelihood ratios for positive outcomes. RESULTS The questionnaire was returned by 1,294 persons (response rate 33%). Participants reported visits to 14 different health care providers within the previous 12 months. Most often visited was the general practitioner (GP) by 82%. Older individuals used fewer health care providers than younger participants. Individuals with spasticity and females visited a broader variety of health care providers than the average user. The participants used fewer providers than they did five years ago. Health care users were not found to be substituting one provider type with another. CONCLUSIONS Individuals with spinal cord injury in Switzerland use a wide array of medical service providers. All providers were used complementary to each other without redundancies between providers. The use of providers is driven by health-related factors and gender. Old age was not as much a driver for high utilization as described in other settings.

The ‘disclosure problem’ continues to pose a challenge to the accounting standard setting community. To help confront this problem, in this commentary we present an exploratory approach for the review and evaluation of note disclosure standards rooted in the conceptual framework’s enhancing qualitative characteristics of comparability, verifiability, timeliness, and understandability. In our approach, note disclosure – an enhancement – is necessary and justified when it rectifies a material information deficiency in the primary financial statements. Our approach requires that the information deficiency, the traceable enhancing qualitative characteristic, and the materiality rationale, are each clearly evident in the written accounting standard. We demonstrate an application of our approach with a case study using the International Accounting Standard (IAS) 1 disclosure guidance on capital structure.

Background For a safe drug therapy, outpatients have to self-administer their medications correctly. However, these procedures are known as error-prone. In community pharmacies, the pharmaceutical staff has to recognize patients’ counseling needs and to use adequate strategies to prevent possible handling errors. Objective Assessing the experiences and opinions of pharmaceutical staff on counseling patients on practical drug handling. Setting Community pharmacies in a German city and surrounding area. Method Descriptively evaluating a self-administered questionnaire to be completed by members of the pharmaceutical staff involved in patient counseling. Main outcome measures Estimated counseling needs of patients, current counseling strategies and limitations of counseling. Results 520 staff members of 119 pharmacies (59.8%, 199 invited) participated. The majority prioritized counseling on dosage over counseling on practical drug handling. Participants saw a particular need when medication was dispensed for the first time compared to repeated use (all medication types, each p

Objectives This study aimed to assess if playing wind instruments leads to a measurable increase in middle ear pressure during note generation and to provide evidence to clinicians to advise musicians undergoing middle ear surgery. Study design An observational cohort study of 40 volunteers in 7 different wind instrument categories underwent tympanometry at rest and during note production. Setting Community. Patients Recreational musicians aged over 18 years recruited from the student body attending Birmingham University, UK. Intervention None. Main outcome measures Tympanometry is used as a noninvasive measure of middle ear pressure. The pressure at which peak compliance occurred was taken as an indirect measure of middle ear pressure. The data produced at rest and during note production was statistically analysed with paired t testing and significance set at a p value less than 0.01. Results Overall a statistically significant increase in middle ear pressure change of 0.63 mm Hg (p = 0.0001) during note production was identified. Musicians playing the oboe and trumpet demonstrate the largest increase in middle ear pressure of 1.46 mm Hg (p = 0.0053) and 0.78 mm Hg (p = 0.0005) respectively. Conclusion The data provided by this study gives evidence for the first time that playing wind instruments does increase middle ear pressure. Although the clinical significance of this is yet to be determined the authors would advise that musicians who undergo otological procedures should refrain from playing their instruments until full recovery has been achieved as advised by their clinician following direct microscopic review.

OBJECTIVE Physical inactivity is recognized as a pandemic health problem. The association of pain with physical activity, particularly when measured objectively, in older adults is unclear. This study investigates the association of number of chronic musculoskeletal pain sites and pain severity with objectively measured physical activity in community-dwelling older adults. DESIGN Observational study. SETTING Community. SUBJECTS We analyzed 267 community-dwelling older adults (mean age = 75.3 years, 67.0% women). METHODS Number of chronic musculoskeletal pain sites and pain severity were measured using a self-reported questionnaire. Mean steps per day and mean minutes of light physical activity per day and moderate to vigorous physical activity per day were measured using an accelerometer. Linear regression models were applied to analyze the association of number of chronic musculoskeletal pain sites and pain severity with physical activity. RESULTS The results suggest that a higher number of chronic musculoskeletal pain sites is associated with lower step count (beta = -333.5, 95% confidence interval = -655.9 to -11.0, P

Objective To understand the facilitators and barriers to community reintegration (CR) among injured female veterans. Design Phenomenologic qualitative design. Setting Community. Participants Community-dwelling female veterans with physical and/or psychological injury (N=13). Interventions None. Main Outcome Measures None. Results Conventional content analysis revealed 3 types of facilitators, including (1) strong social support, (2) impactful programs, and (3) protective personal beliefs. Six types of barriers included (1) inadequate services, (2) lack of access to services, (3) poor social support, (4) difficulty trusting others, (5) nonsupportive personal beliefs, and (6) injury factors. Multiple environmental and personal factors acted as facilitators and barriers to CR. Findings are relatively consistent with previous veteran and civilian community reintegration research that indicates the importance of health-related services, attitudes of others, and social support. However, women in this study reported being effected by many of these facilitators and barriers because of their sex. Conclusions This study supports the need to foster social support among injured female veterans throughout the rehabilitation process to promote CR. Long-term social support can be gained by incorporating services (eg, adjunctive therapies, recreation, other social programming) into the rehabilitation repertoire to help with CR for all veterans, particularly women.

Study Objective The primary purpose of this study was to assess the patient's satisfaction with laparoscopic radiofrequency fibroid ablation (Lap-RFA) for the treatment of symptomatic uterine fibroids. We inquired about their quality of life, health state, and overall treatment effects. Design Survey study. Setting Community-based tertiary care medical center. Patients or Participants All patients who underwent a Lap-RFA by a single surgeon between the years of 2012 and 2020. Interventions laparoscopic radiofrequency fibroid ablation (Lap-RFA). Measurements and Main Results 48 patients underwent Lap-RFA procedure by the same provider and were mailed surveys for postoperative evaluation. Twenty patients responded, yeilding a 42% response rate. The mean age of the patients was 46 (34-60) years. The average time interval from surgery to survey response was 23 months (1-50). The Uterine fibroid Symptom and Health-Related Quality of Life (UFS-QOL) and the Health State Questionnaire scores are inversely related to outcomes. The UFS-QOL score can range from 37 to 185 with 37 being the optimal outcome. The average UFS-QOL score was found to be 72 (range 37-146). In addition, the Health state questionnaire can range from 5 to 15, and the average score was 6 (range 5-9). On a scale of 1 to 10, 10 representing optimal outcome, the average health rating was 8 (range 5-10). Using the Menorrhagia Impact Questionnaire, seven patients reported improved menses, ten had no change in symptoms, one had worsening symptoms, and two were postmenopausal. Sixteen patients reported some degree of satisfaction with the procedure, while three were dissatisfied with their overall treatment outcomes. Ninety percent of patients would recommend Lap-RFA to a friend. Conclusion Lap-RFA procedure is an effective uterine-sparing treatment for symptomatic fibroids with good patient satisfaction. The Lap-RFA procedure should be considered when counseling patients about fibroid management options.

ObjectivesThis qualitative study explored how to optimise a couples-focused intervention to promote couples HIV testing and counselling (CHTC).SettingCommunity setting in Kwa-Zulu Natal, South Africa.ParticipantsQualitative interviews were conducted with 20 couples who had participated in a couples-focused intervention and five staff members delivering the intervention. Partners were interviewed individually by researchers of the same gender.InterventionA couples-focused intervention comprised of two group sessions and four couples counselling sessions was previously shown to significantly increase uptake to CHTC in Kwa-Zulu Natal, South Africa. However, more than half of couples participating in the intervention still chose not to test together during follow-up.AnalysisThe transcripts were analysed using the table of changes from the person-based approach. Proposed optimisations were discussed with a community group to ensure the intervention was as persuasive and acceptable as possible.ResultsMany couples found it challenging to discuss CHTC with their partner due to an implied lack of trust. Optimisations to the intervention were identified to increase readiness to discuss CHTC, including education about serodiscordance, discussions about CHTC by peer mentors and open discussion of personal barriers to CHTC during couples’ counselling sessions. Additional training for staff in open questioning techniques could help them feel more comfortable to explore couples’ perceived barriers to CHTC, rather than advising couples to test. A logic model was developed to show anticipated mechanisms through which the optimised intervention would increase uptake to CHTC, including increasing knowledge, increasing positive outcome beliefs and managing negative emotions.ConclusionsIn-depth qualitative research informed optimisations to a couples-focused intervention for further evaluation in South Africa to encourage uptake to CHTC. Suggestions are made for optimal methods to gain open feedback on intervention experiences where participants may be reluctant to share negative views.

Research Objectives To determine anxiety trajectories across the first 10 years after traumatic brain injury (TBI), and to identify predictors of the longitudinal course of anxiety. Design Longitudinal cohort study. Setting Community. Participants 2836 participants with moderate to severe TBI enrolled in the Traumatic Brain Injury Model Systems (TBIMS) National Database who had anxiety outcomes for ≥2 data collection points over a 10-year follow-up period. Interventions N/A. Main Outcome Measures Generalized Anxiety Disorder-7 (GAD-7) at 1, 2, 5, and 10-year follow-ups. Relationships were examined with demographic variables, indicators of TBI severity, number of TBIs in addition to the index TBI, pre-morbid mental health, and substance abuse history. Results A latent class mixed model identified three anxiety trajectories: low-stable (n=2195), increasing (n=289), and decreasing (n=352). Higher GAD-7 scores were significantly associated with Black race, having public insurance, premorbid mental health problems, experiencing ≥2 additional TBIs with loss of consciousness (LOC), and increased years post-TBI. An interaction between follow-up year and age was also related to GAD-7 scores (p=.001). Conclusions Most individuals in the sample had low anxiety that was stable over time (77%). Smaller percentages of individuals had higher levels of anxiety, that either increased (10%) or decreased (13%) as time progressed. Multiple TBI's with LOC were related to greater anxiety up to 10 years after injury. Systemic economic and racial inequities likely contribute to long-term anxiety, as evidenced by greater anxiety in those who had public insurance and/or identified as Black. Younger individuals were more likely to experience an increase in their anxiety over time, suggesting a need for long-term anxiety surveillance, particularly for patients whose TBI occurred at an earlier stage in life. Author(s) Disclosures None.

Objectives To examine the relationship between polypharmacy and gait performance during simple (normal walk (NW)) and complex (walking while talking (WWT)) locomotion. Design Cross-sectional. Setting Community. Participants Community-dwelling older adults (N = 482). Measurements Polypharmacy, defined as use of five or more medications and a cohort-specific alternate definition of eight or more medications, was examined. Velocity (cm/s) measured quantitatively during NW and WWT conditions. Results The 164 participants (34%) with polypharmacy of five or more medications were older (77.0 ± 6.6 vs 76.0 ± 6.4) and more likely to have hypertension, congestive heart failure, diabetes mellitus, myocardial infarction, and higher body mass index (BMI) and to have fallen within the last year than the remaining 318 without polypharmacy and walked 6 cm/s slower (P = .004) during NW and 4 cm/s slower during WWT (P = .07), adjusting for age, sex, and education. Group differences were not statistically significant after adjusting for comorbidities. Prevalence of polypharmacy of eight or more medications was 10%. This group walked 11 cm/s slower during NW (P < .001) and 8.6 cm/s slower during WWT (P = .01) than those without polypharmacy, adjusted for age, sex, and education. Participants taking eight or more medications had slower NW (8.5 cm/s; P = .01), and WWT (6.9 cm/s; P = .07), compared to those without polypharmacy, adjusting for comorbidities. Adjustments for BMI, high-risk drugs, falls, and comorbidities yielded slower NW (9.4 cm/s, P = .005) and WWT (7.9 cm/s, P = .04 among those with polypharmacy compared to those without polypharmacy). Conclusion These results suggest an association between polypharmacy and locomotion that medical comorbidities only partly explained.

Objective To explore community pharmacists’ continuing education, counseling and communication practices, attitudes and barriers in relation to pediatric asthma management. Setting Community pharmacies in Michigan, United States. Methods Between July and September 2015 a convenience sample of community pharmacists was recruited from southeastern Michigan and asked to complete a structured, self-reported questionnaire. The questionnaire elucidated information on 4 general domains relating to pharmacists’ pediatric asthma management including: (1) guidelines and continuing education (CE); (2) counseling and medicines; (3) communication and self-management practices; (4) attitudes and barriers to practice. Regression analyses were conducted to determine predictors towards pharmacists’ confidence/frequency of use of communication/counseling strategies. Main outcome measure Confidence in counseling skills around asthma. Results 105 pharmacists completed the study questionnaire. Fifty-four percent of pharmacists reported participating in asthma related CE in the past year. Over 70% of pharmacists reported confidence in general communication skills, while a lower portion reported confidence in engaging in higher order self-management activities that involved tailoring the regimen (58%), decision-making (50%) and setting short-term (47%) and long-term goals (47%) with the patient and caregiver for managing asthma at home. Pharmacists who reported greater use of recommended communication/self-management strategies were more likely to report confidence in implementing these communication/self-management strategies when counseling caregivers and children with asthma [Beta (B) Estimate 0.58 SE (0.08), p

Objectives (1) Describe longitudinal trends in annual prevalence of hospital admission for pediatric acute otitis media (AOM) and complications of AOM (CAOM) since introduction of pneumococcal vaccination in 2000 and (2) describe the longitudinal trend of prevalence of hospital admission for pneumococcal meningitis in children with AOM-related diagnoses in the postvaccination era. Study Design Retrospective analysis of Kids' Inpatient Database from 2000 to 2012. Setting Community, nonrehabilitation hospitals. Subjects and Methods To determine annual prevalence of admission for AOM/CAOM, nationally weighted frequencies of children aged

Objective:The study of predeath grief is hampered by measures that are often lengthy and not clearly differentiated from other caregiving outcomes, most notably burden. We aimed to validate a new 11-item Caregiver Grief Questionnaire (CGQ) assessing two dimensions of predeath grief, namely relational deprivation and emotional pain.Design:Cross-sectional survey.Setting:Community and psychogeriatric clinics.Participants:173 Alzheimer (AD) caregivers who cared for relatives with different degrees of severity (63 mild, 60 moderate, and 50 severe).Measurements:Besides the CGQ, measures of caregiver burden and depressive symptoms, and care-recipients’ neuropsychiatric symptoms and functional impairment were assessed.Results:Confirmatory factor analysis supported the hypothesized 2-factor over the 1-factor model, and both subscales were only moderately correlated with burden. Two-week test-retest reliabilities were excellent. Caregivers for mild AD reported less grief than those caring for more severe relatives. Z tests revealed significantly different correlational patterns for the two dimensions, with emotional pain more related to global burden and depressive symptoms, and relational deprivation more related to care-recipients’ functional impairment. Both dimensions were mildly correlated with neuropsychiatric symptoms (especially disruptive behaviors and psychotic symptoms) of the care-recipient.Conclusions:Results supported the reliability and validity of the two-dimensional measure of predeath grief. As a brief measure, it can be readily added to research instruments to facilitate study of this important phenomenon along with other caregiving outcomes.

Background Atopic dermatitis affects 10–20% of the children worldwide. Unfortunately not all patients who receive treatment have optimal treatment outcomes. Objective To assess the view of parents and pharmacy staff in order to optimize pharmaceutical care for young atopic dermatitis patients. Setting Community pharmacies in the Netherlands. Method We first held an expert panel meeting to determine experts’ views on treatment of atopic dermatitis and their suggestions for areas of improvement. This input was used to develop the interview guide. We conducted telephone interviews with parents of children (aged 0–12 years) with atopic dermatitis and face-to-face interviews with pharmacy staff members. All interviews were audiotaped and transcribed verbatim. Transcripts were coded using qualitative data analysis software. Codes were used to identify themes. Main outcome measure Perspectives of parents of young atopic dermatitis patients and pharmacy staff about treatment. Results We interviewed 29 parents and 18 pharmacy staff members. Many parents mentioned fear of steroid adverse effects, with intentional nonadherence as a consequence, and difficulties with the application of topical treatment. Pharmacy employees also mentioned to encounter these issues. Some employees themselves expressed concerns towards use of steroids. Most parents were satisfied with the information they received; however, they need more practical lifestyle advices, e.g. about bathing or clothing. Both pharmacists and pharmacy technicians mentioned that technicians often lack knowledge to support patients optimally in correct medication use. Conclusion Parents’ perceptions about topical corticosteroids might negatively influence treatment outcomes. Pharmacy staff has an important role to inform parents of children with eczema on the appropriate use of topical corticosteroids and emollients. Counseling should not be influenced by their own prejudices about topical corticosteroids. Close collaboration between primary care providers should ensure that parents receive uniform messages. Electronic supplementary material The online version of this article (10.1007/s11096-019-00827-1) contains supplementary material, which is available to authorized users.

Objective To understand the processes that couples navigate as they cope with maternal postpartum depression (PPD) in early parenthood. Design Qualitative, interpretive phenomenological study. Setting Community setting in the western United States. Participants A convenience sample of 10 couples (N = 20, 10 mothers and 10 fathers) who indicated they had maternal diagnoses of PPD after the births of their first children within the last 3 years. Methods Couples were interviewed together and then individually with the use of a semistructured interview guide. Narrative and thematic analyses were used to understand couples' lived experiences of PPD. Results Participants cocreated their experiences of maternal PPD. Three primary phases in the pattern of coping with PPD were identified: Dismissal (couples attempted to normalize their experiences and protect the mother from judgment), Acknowledgment (couples revealed their concerns, the first step in the process of seeking help), and Accommodation (process of trial and error used to find a way to meet the needs of the mother). Conclusion Our findings suggest that practitioners must support the needs of the entire family, including fathers, when mothers have a diagnosis of PPD. Fathers support mothers during this difficult experience but not without an increased burden of stress to themselves.

Objectives To understand the perspectives of both patients and the person who would make medical decisions for them if they were unable (surrogates) on their participation in advance care planning (ACP). Design Qualitative cross-sectional study. Setting Community. Participants Thirty-one veterans age 55 years and older and their surrogates. Measurements In interviews conducted with both the veteran and surrogate, they were asked to discuss their participation in four ACP activities: communication about life-sustaining treatment, communication about views on quality of life, completion of a living will, and appointment of a healthcare proxy. They were asked about barriers to and facilitators of ACP engagement. When they did not agree about engagement, they each provided their perspective on what they believed had or had not occurred. Results Many of the same barriers to and facilitators of engagement were discussed by both patients and surrogates. These included difficulty thinking about dying, differences in values, and experiences with others that demonstrated the ability of ACP to decrease burden or avoid conflict. Reasons for disagreements in perceptions about whether communication had occurred included surrogates’ need for more detailed information, surrogates’ lack of readiness to hear what the patient was saying, and surrogates’ reliance on what they know about the patient. For some dyads, participation in the study prompted additional communication, resulting in a better shared understanding of ACP engagement. Conclusion Surrogates can both impede and facilitate engagement in ACP, and they can hold different perceptions from patients regarding this engagement. Efforts to promote ACP may be most successful if they assess and address both patients’ and surrogates’ attitudes and help to facilitate clear communication between them.

Background Medicine shortages are an ongoing global problem. The Therapeutic Goods Administration (TGA) dedicated a website for monitoring of medicine shortages in Australia in May 2014, as part of the Medicine Shortage Information Initiative. This study aimed to explore the views of pharmacists regarding medicine shortages in the community setting and the impact of the TGA website in Australia. Setting Community pharmacies in New South Wales, Australia. Method Twenty semi-structured interviews were conducted with community pharmacists. Data collected were analysed thematically utilising the framework analysis method. Main outcome measure Qualitative analysis conducted using the framework approach. Results Findings clearly indicated that medicine shortages were experienced on a regular basis, but most participants were unaware of the TGA website. Medicine shortages reportedly impacted both pharmacists and consumers; and various workarounds were undertaken to manage the issue. The "price disclosure policy" was found to be a prominent contributing factor in emerging shortages. Suggestions were made for ways to improve the growing occurrence of shortages. Conclusion Overall, the study found that there was a lack of familiarity with the TGA website, despite experiencing regular shortages of medicines in practice. Also highlighted, was the importance of pharmacists prioritising patient care over business decisions. To reduce prescribing of out-of-stock medicines notifying doctors about shortages was also considered important, to allow for early action to be taken at higher levels of the supply chain. Findings of this study may help direct future policy-making around the world, as medicine shortages is a problem shared by healthcare providers in most countries around the world.

Study Objective Compilation of tips and tricks to enhance successful completion of the manual skills component of the Fundamentals of Laparoscopic Surgery (FLS) exam. Design Video demonstration of tips and tricks of the five laparoscopic tasks for the FLS Program. Setting Community-based residency program. Patients or Participants PGY1 to PGY4 OB/Gyne residents. Interventions Video demonstration of several tips and tricks to proficiently complete the five FLS skills tasks. Measurements and Main Results Since the five FLS skills tasks are timed, this video will serve to improve the residents’ efficiency and time for completion. Conclusion This educational video enhances the residents' procedural efficiency and skill development in laparoscopic techniques. Establishing an FLS program that includes a video on tips and tricks provides a useful, practical, and effective training tool for teaching laparoscopy.

Study Objective To examine whether utilizing a salaried surgical first assistant or a physician as an assistant during gynecologic robotic cases affects surgical variables. Design Retrospective chart review. Setting Community Practice Setting in Las Vegas, Nevada. Patients or Participants Female patients undergoing robotic surgical intervention for any gynecologic reason from 2005-2018 by a single gynecologic oncologist(n=1,690). Interventions N/A Measurements and Main Results A high volume gynecologic oncologist's robotic case data spanning fourteen years (2005-2018) was analyzed. We separated the cases based on the type of assistant used, either an employed surgical first assist or another physician. The assisting physicians were either members of the same practice or general gynecologists in the community. The two groups were compared for operative time and estimated blood loss. We controlled for patient Body Mass Index, uterine weight, use of the fourth robotic arm, benign versus cancer pathology, and a subjective estimate of the difficulty of the case using a conventional laparoscopic versus robotic approach. Cases with an employed surgical assist had a mean adjusted robotic console time that was 0.32hrs(19.2min) faster than cases with a physician as the assist (95% CI 0.26hrs to 0.37hrs faster, p Conclusion The use of an employed surgical assist was associated with a faster console time and lower blood loss compared to using an available physician even adjusting for confounding factors. This deserves further exploration, particularly in regards to complication rates, operating room efficiency, utilization of health care personnel, and cost.

Objectives To address the competing risk of death in longitudinal studies of older persons, we demonstrate sensitivity analyses that evaluate robustness of associations between exposures and three outcome types: dichotomous, count, and time to event. Design A secondary analysis of data from a prospective cohort study. Setting Community‐based data from the Precipitating Events Project in New Haven, CT. Participants Persons 70 years and older who were initially community dwelling and without disability in the four basic activities of daily living (N = 754). Measurements Missing outcome values from decedents were multiply imputed under different scenarios. Three outcomes were examined: dichotomous fall‐related hospitalization (FRH); a count (0‐13) of total disability in each of the 6 months after discharge; and days to functional recovery among those whose disability worsened in the hospital. Each outcome had a different exposure: for dichotomous, indicators of being overweight or obese; for count, frailty from the Fried phenotype (0‐5, where not frail = 0, prefrail = 1‐2, and frail = 3‐5); for days to recovery, vision impairment. Results For FRH, being overweight or obese lost significance when decedents were kept in the risk pool without outcome events for over 10 years. For disability count and time to recovery, with follow‐up of 6 months, exposures only lost significance under highly implausible clinical scenarios. Conclusion This method facilitates evaluation of potential bias from the competing risk of death in longitudinal studies for nondeath outcomes that are not necessarily time to event. Results suggest that death introduces substantive bias when long‐term follow‐up results in cumulatively high levels of mortality. J Am Geriatr Soc 67:357–362, 2019.

Background and aims The United States Food and Drug Administration has proposed regulation to require that cigarettes contain very low nicotine content (VLNC). In contrast, reducing the number of cigarettes per day (CPD) is the most common current method to reduce nicotine. This trial aims to explore whether gradually transitioning to VLNC cigarettes plus nicotine patch or reducing CPD plus nicotine patch is more effective at decreasing nicotine dependence. Design A two-arm, individually randomized open-label trial. Setting Community setting, Vermont, USA. Participants Sixty-eight adult daily smokers (40% female) of ≥ 10 cigarettes/day who were not planning to quit in the next 30 days. Interventions All participants smoked study cigarettes with a nicotine yield similar to most commercial cigarettes ad libitum for 1 week (baseline). Participants then gradually reduced to 70, 35, 15 and 3% of baseline nicotine over 4 weeks by either (a) transitioning to lower nicotine content cigarettes (n = 36) or (b) reducing the number of full nicotine cigarettes (n = 32). All participants received nicotine patches. Measurements The primary outcome was change in nicotine dependence assessed at baseline and weekly during the intervention with the Nicotine Dependence Syndrome Scale. Findings Dependence declined over time for both VLNC and CPD participants, but declined more for VLNC (mean decrease in Z-score of 1.0) than CPD (mean decrease in Z-score of 0.5) participants over time (interaction P = 0.018). Conclusions Transitioning to very low nicotine content cigarettes reduced nicotine dependence over a 4-week period to a greater extent than reducing cigarettes per day when both conditions were aided by nicotine patch.

Background Codeine is the most commonly used opioid worldwide, and is available over-the-counter (OTC) in many countries. There is continual debate regarding the risk:benefit profile for OTC codeine. In Australia, codeine containing analgesics became 'prescription only medicine' from February 2018. However, there is currently limited knowledge on the views of community pharmacists on this upscheduling and the perceived impacts on clinical practice. Objective To investigate the views of community pharmacists on the recent codeine upscheduling in Australia. Setting Community pharmacists in Australia, predominately recruited from Victoria. Method A descriptive cross-sectional study was conducted using a pre-tested customised anonymous self-administered online questionnaire between March and May 2018. To capture a broad range of demographics, pharmacists were recruited via local industry contacts and the Pharmaceutical Society newsletter, with further recruitment through snowball sampling. Main outcome measure Pharmacists' opinions to targeted questions regarding the perceived advantages and disadvantages of the recent 2018 codeine rescheduling from both their perspectives and their perceived impact on patients. Results A total of 113 pharmacists completed the survey. Approximately 43% of pharmacists agreed/strongly agreed that they believed upscheduling will positively impact their ability to manage pain; while 30% were neutral. Approximately 54% of pharmacists agreed/strongly agreed that they believed upscheduling will positively benefit their patients; while 25% were neutral. Perceived advantages for codeine upscheduling included: increased pharmacist/patient engagement, and less codeine use leading to better overall risk:benefit outcome; while disadvantages included: fewer analgesic options, and increased burden for patients, General Practitioners, and the health system. Conclusion This study showed that the current views on the recent codeine upscheduling are quite mixed, with both advantages and disadvantages perceived. Improving education and up-skilling in this space is essential.

Background Oral rehydration salt (ORS) is an affordable and effective intervention for the management of acute watery diarrhoea (AWD), especially in children under 5 years. A knowledge/practice gap exists among community pharmacists (CPs) in Lagos, Nigeria, and in many low to middle income countries. This gap results in underutilization of ORS for diarrhoea management. Objective The objective was to explore CPs’ views of the barriers and facilitators to the use of ORS in practice. Setting Community pharmacy practices, Lagos, Nigeria. Methods Qualitative methods were used to explore pharmacists’ views. Recruitment of participants were mainly at zonal meetings. A total of ten CPs participated based on maximum variation and snowballing sampling. Semi-structured interviews conducted covered knowledge, experiences and contextual issues. Interviews were audiorecorded, transcribed and analysed using framework approach to thematic analysis. Main outcome measure Pharmacists’ views of barriers and facilitators to the use of ORS. Results Barriers to the use of ORS include caregivers’ expectation for an antimicrobial, which was often explicitly and specifically for metronidazole. Also, CPs seemed to doubt applicability of ORS alone, therefore, responded to caregivers’ complaints about ORS, by dispensing metronidazole. These barriers appeared to have normalised metronidazole for AWD treatment in this setting. Current facilitators include the caregivers’ improved awareness of ORS and access to primary health centers that often resulted in increased demand for ORS in pharmacies. Conclusion CPs’ views showed that caregivers’ expectations for an antimicrobial may be the main barrier to the use of ORS in their practices.

Background Under-reporting of adverse drug reactions (ADRs) by healthcare professionals is prevalent worldwide. Community pharmacists are the most frequently visited healthcare professional and are well placed to document ADRs as a part of their routine practice. Objective To measure community pharmacists’ knowledge and perspectives towards ADR reporting and their reporting practices. Setting Community pharmacists in the New South Wales, Queensland, Victoria and Tasmania, Australia. Method A survey tool consisting of 28 items was developed, piloted and validated by a panel of expert reviewers. The final anonymised survey was distributed online to community pharmacists. Exploratory factor analysis and Cronbach’s alpha were used to measure the validity and reliability of the tool, respectively. Non-parametric statistical tests were used to analyse knowledge, perspectives and ADR reporting practices. Main outcome measures: Knowledge, perceived importance, enablers and barriers to reporting ADRs. Results The survey tool showed acceptable validity and reliability. A total of 232 respondents completed the survey. The median knowledge score was 5 out of 10 (interquartile range, 2). Less than a third of respondents (31.0%) reported sufficient knowledge and training on ADR reporting. Only 35.3% of pharmacists reported at least one ADR in the previous 12 months. Non-reporting pharmacists were more likely to report lack of time as a barrier (P P = 0.007). Conclusion Under-reporting of ADRs by community pharmacists is highly prevalent. Initiatives to educate and train them on ADR reporting and simplifying the reporting process may improve reporting practices.

Background Little is known about long-term consequences of recurrent urinary tract infections although 60% of women develop urinary tract infection during their lifetime and 20–40% of them have a recurrence. Objective To study the role of recurrent urinary tract infections in mortality or development of kidney dysfunction or hypertension in women. Design Retrospective analysis of prospective, population-based 20-year follow-up study. Setting Community. Subjects A birth cohort of 764 older females living in the defined geographical area in Southwestern Finland who were 70 years old at baseline. Methods The participants were examined and interviewed to assess health history, health behaviors, cardiovascular risk factors, morbidity and physical, social and psychocognitive functioning at the age of 70, 80, 85 and 90 years between 1991–2011. Results Recurrent urinary tract infections in females were not associated with increased mortality, development of hypertension or kidney dysfunction. Urinary incontinence predisposed females to receive antimicrobial treatment for recurrent urinary tract infections. Conclusions The results indicate that recurrent urinary tract infection in females is a benign disease in the absence of abnormalities of the urinary tract even in the older population.

Objectives The purpose of this article was to present results of cases using a subcutaneous bone pouch technique and to assess the potential "autosterilization" effect that occurs when these contaminated free bone fragments are placed in nontraumatized tissue. Design Retrospective review of prospectively collected data. Setting Community-Based Level 1 Trauma Center. Patients/participants Eight patients were consented for the described technique, and data were collected over an 8-year period. Intervention Placement of fragments into a surgically created subcutaneous pouch in a nontraumatized tissue zone, followed by delayed, cultured, and attempted reimplantation at the initial injury site. Main outcome measurements Culture results after extraction of bone fragments from subcutaneous bone pouch and clinical outcomes after reimplantation into initial open fracture site. Results All 8 cases undergoing this technique resulted in healing of the subcutaneous bone pouch without signs or symptoms of infection at the time of attempted reimplantation or fragment removal. Four of the 8 cases had successful reimplantation and union at the open fracture site. Conclusions Preserving devascularized bone fragments in a subcutaneous pouch in a region of nontraumatized tissue appears to be a safe procedure that allows for an "autosterilization" type of process to occur. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

To estimate the prevalence of wheeled mobility device (WhMD) ramp-related incidents while boarding/alighting a public transit bus and to determine whether the frequency of incidents is less when the ramp slope meets the proposed Americans with Disabilities Act (ADA) maximum allowable limit of ≤9.5°.Observational study.Community public transportation.WhMD users (N=414) accessing a public transit bus equipped with an instrumented ramp.Not applicable.Prevalence of boarding/alighting incidents involving WhMD users and associated ramp slopes; factors affecting incidents.A total of 4.6% (n=35) of WhMD users experienced an incident while boarding/alighting a transit bus. Significantly more incidents occurred during boarding (6.3%, n=26) than during alighting (2.2%, n=9) (P.01), and when the ramp was deployed to street level (mean slope=11.4°) compared with sidewalk level (mean slope=4.2°) (P=.01). The odds ratio for experiencing an incident when the ramp slope exceeded the proposed ADA maximum allowable ramp slope was 5.4 (95% confidence interval, 2.4-12.2; P.01). The odds ratio for assistance being rendered to board/alight when the ramp slope exceeded the proposed ADA maximum allowable ramp slope was 5.1 (95% confidence interval, 2.9-9.0; P.01).The findings of this study support the proposed ADA maximum allowable ramp slope of 9.5°. Ramp slopes9.5° and ramps deployed to street level are associated with a higher frequency of incidents and provision of assistance. Transit agencies should increase awareness among bus operators of the effect kneeling and deployment location (street/sidewalk) have on the ramp slope. In addition, ramp components and the built environment may contribute to incidents. When prescribing WhMDs, skills training must include ascending/descending ramps at slopes encountered during boarding/alighting to ensure safe and independent access to public transit buses.

Objective To investigate changes and differences in patient outcomes over time for 6, 7 and 8 week pulmonary rehabilitation programmes in order to identify optimal duration. Setting Community based pulmonary rehabilitation programmes in the East of England. Participants In total 363 participants completed one of the three pulmonary rehabilitation programmes. Patients with a chronic respiratory condition showing a commitment to the pulmonary rehabilitation programme and no contraindications to exercise were included. Intervention Pulmonary rehabilitation twice a week for 6, 7 or 8 weeks. Main outcome measures St Georges Respiratory Questionnaire (SGRQ), Clinical COPD Questionnaire (CCQ), Hospital Anxiety and Depression Scale (HADS) and Incremental Shuttle Walk Test (ISWT). Results All programmes showed improvements in ISWT post rehabilitation, with the 8 week programme showing the greatest improvement. Conclusion Findings show that greatest improvements in terms of exercise capacity may be seen from 8 week pulmonary rehabilitation programmes, but that improvement for the ISWT can be obtained from 6, 7 or 8 week programmes.

Study design The primary study design was a pretest and posttest study performed in a single session with subjects as their own control. We summarize three integrated and sequential studies. Objective The objective of this study was to investigate whether commercially available cushioned shorts would add skin protection when used in adaptive sports equipment (AE). Setting Community in Tacoma Washington, USA. Methods TekScan Pressure Mapping System for recording average (AP) and peak (PP) seating pressures.Part 1. Pretest/posttest design, subjects as own control. Eight adults with SCI (C5-T6) mapped in daily wheelchair and AE with and without bicycle shorts.Part 2. Sixteen able-bodied subjects were mapped with and without an impact short and full-coverage short in a hand-cycle.Part 3. One individual with T5 SCI was mapped with and without a full-coverage short in personal basketball chair and mountain hand-cycle. Results Part 1. Significant differences between the daily wheelchair and AE in the static condition for AP and PP and AP in the dynamic condition. Bicycle shorts showed no significance.Part 2. Impact shorts increased static PP and AP. The full-coverage short decreased static AP.Part 3. The full-coverage short increased AP and PP in the basketball chair. In the mountain hand-cycle, AP decreased but PP increased. Conclusion Athletes who are static in their AE may be at greater risk of tissue breakdown than those actively playing. Cushioned shorts had highly variable effects on seated pressure in adaptive equipment. Pressure mapping is recommended prior to using any cushioning in AE by the SCI population.

Objectives To determine whether transcranial Doppler ultrasound (TCD) measures of mean blood flow velocity (MBFV) in the major cerebral arteries are associated with measures of lower extremity function in community-dwelling older adults. Design Cross-sectional study. Setting Community sample. Participants Individuals aged 70 and older (mean 79.5, 54% female) without dementia participating in the Einstein Aging Study (N = 200). Measurements All participants underwent TCD assessments and tests of lower extremity function at an annual clinic visit. Average MBFV for anterior (left and right anterior and middle cerebral arteries (MCAs)) and posterior (vertebral (VA) and basilar (BA) artery) circulation was measured using a standardized TCD protocol. Lower extremity function was characterized according to gait speed (cm/s) measured using an instrumented walkway, balance according to unipedal stance time (UPST, seconds), and lower extremity strength according to timed repeated chair rise (seconds). Results Multiple regression models adjusted for age, sex, race, education, and medical comorbidities showed that lower MBFV in the MCA was associated with slower gait speed and chair rise time but not with UPST. Ordinal regression models showed that lower MBFV in the VA and BA is associated with shorter UPST. Conclusion Low MBFV in the anterior and posterior cerebral circulation was associated with worse lower extremity function and balance in older adults. This might be indicative of the importance of age-related changes in cerebral hemodynamics in the function of brain regions involved in specific aspects of physical performance.

Background Adherence to treatment is important to achieve target outcomes, particularly for those with type 2 diabetes. Pharmacists are well placed to enhance adherence, however evidence of the impact on clinical outcomes is not well known. Objective To determine the impact of an adherence support service on adherence scores and subsequent clinical biomarkers (HbA1c). Setting Community pharmacies providing a Medicines Use Review (MUR) Service in a New Zealand locality. Methods Records of patients receiving MURs between 2007 and 2012 were obtained from a single locality. Data extraction included: individual characteristics, the adherence score assigned at every consultation, pathology records. Patients receiving oral hypoglycaemic medications (n = 86) were included in the final analysis using generalised estimating equations to explore change in HbA1c over time, and whether this was related to the adherence score. Main Outcome Measures (a) change in adherence scores and (b) association between adherence sores and HbA1c. Results A total of 350 records were obtained, of those, 115 of 350 people had follow up MUR visit/s and could be analysed for changes in adherence. Most people (110/115) showed sustained or improved adherence scores with follow up visits. For those receiving oral hypoglycaemic medications (n = 86); where poor adherence scores were recorded, their HbA1c levels were higher and continued to increase by ~ 0.1% (1 mmol/mol) every 10 weeks, B = 0.11, p = 0.009. Conversely, those with high adherence scores showed an overall decrease in HbA1c levels. Conclusion MURs may positively influence medication adherence. This improved adherence shows a measurable decline in HbA1c levels.

Purpose/objectives To describe oncology nurses' experiences discussing clinical trials with their patients, and to assess barriers to these discussions. . Research approach A qualitative study designed to elicit narratives from oncology nurses. . Setting Community- and academic-based oncology clinics throughout the United States. . Participants 33 oncology nurses involved in direct patient care in community-based and large hospital-based settings. The sample was drawn from members of the Oncology Nursing Society. . Methodologic approach In-depth interviews were conducted and analyzed using a immersion/crystallization approach to identify themes and patterns. The analyses highlight specific issues, examples, and contexts that present challenges to clinical trial discussions with patients. . Findings Oncology nurses view their roles as patient educators and advocates to be inclusive of discussion of clinical trials. Barriers to such discussions include lack of knowledge and strategies for addressing patients' common misconceptions and uncertainty about the timing of discussions. . Interpretation These data indicate that enabling nurses to actively engage patients in discussions of clinical trials requires educational interventions to build self-efficacy and close knowledge gaps. . Implications for nursing Oncology nurses can play a critical role in advancing cancer care by supporting patients in decision making about clinical trial participation. This will require training and education to build their knowledge, reduce barriers, and increase their self-efficacy to fulfill this responsibility in various clinical settings.

Purpose. To examine attitudes toward smoke-free policies and perceptions of e-cigarette use among homeless adults. Approach. A cross-sectional qualitative study was conducted. Setting. Study setting comprised seven transitional homeless shelters with indoor smoke-free policies in San Diego County; facilities differed in outdoor restrictions on smoking. Participants. Sixty-six current or former smokers were the study participants. Method. Participants completed a questionnaire on smoking behaviors, perceived antitobacco norms, and attitudes toward smoke-free policies, and attended a focus group interview that explored these topics. We used a directed content analysis approach to analyze the focus group transcripts. Results. Clients in facilities with outdoor restrictions on smoking had stronger perceived antitobacco norms than those in facilities without such restrictions. We identified the following major themes: attitudes toward smoke-free policies, the use of e-cigarettes, the addictive potential of cigarettes, vulnerability to tobacco industry marketing, and interest in smoking cessation. The consensus was that smoke-free policies were important because they limited secondhand smoke exposure to nonsmokers and children. All were curious about e-cigarettes, particularly if they could be smoked in areas where smoking was prohibited and/or used as a cessation aid. Conclusion. In this study of homeless adults, there was strong support for indoor and outdoor smoke-free policies. However, misperceptions that e-cigarettes could be used indoors could threaten antitobacco norms, highlighting opportunities to educate about the potential risks of e-cigarette use among homeless individuals.