Words matter: Comments in support of diagnosis education in pharmacy.

Diagnosis education is explicitly included in the Draft Accreditation Standards 2025 and should be wholeheartedly supported. To address the staggering number of diagnostic errors in the US, the National Academy of Medicine advocates for diagnosis education for all health professions. Misperceptions of pharmacists' involvement in diagnosis are exacerbated by use of implicit language and euphemisms, and it's long overdue that we provide clarity. Pharmacists are engaged in diagnosis and diagnostic reasoning in everyday practice whether realized or not. Diagnosis education is implicitly included in US pharmacy curricula in the Pharmacists' Patient Care Process, and it is time to give students the language to engage in it responsibly to be practice-ready in all states. The explicit inclusion of diagnosis in the Draft Standards 2025 has positive implications for education, practice, and graduates.

Assessing the safety of physical rehabilitation in critically ill patients: a Delphi study.

BACKGROUND: Physical rehabilitation of critically ill patients is implemented to improve physical outcomes from an intensive care stay. However, before rehabilitation is implemented, a risk assessment is essential, based on robust safety data. To develop this information, a uniform definition of relevant adverse events is required. The assessment of cardiovascular stability is particularly relevant before physical activity as there is uncertainty over when it is safe to start rehabilitation with patients receiving vasoactive drugs. METHODS: A three-stage Delphi study was carried out to (a) define adverse events for a general ICU cohort, and (b) to define which risks should be assessed before physical rehabilitation of patients receiving vasoactive drugs. An international group of intensive care clinicians and clinician researchers took part. Former ICU patients and their family members/carers were involved in generating consensus for the definition of adverse events. Round one was an open round where participants gave their suggestions of what to include. In round two, participants rated their agreements with these suggestions using a five-point Likert scale; a 70% consensus agreement threshold was used. Round three was used to re-rate suggestions that had not reached consensus, whilst viewing anonymous feedback of participant ratings from round two. RESULTS: Twenty-four multi-professional ICU clinicians and clinician researchers from 10 countries across five continents were recruited. Average duration of ICU experience was 18 years (standard deviation 8) and 61% had publications related to ICU rehabilitation. For the adverse event definition, five former ICU patients and one patient relative were recruited. The Delphi process had a 97% response rate. Firstly, 54 adverse events reached consensus; an adverse event tool was created and informed by these events. Secondly, 50 risk factors requiring assessment before physical rehabilitation of patients receiving vasoactive drugs reached consensus. A second tool was created, informed by these suggestions. CONCLUSIONS: The adverse event tool can be used in studies of physical rehabilitation to ensure uniform measurement of safety. The risk assessment tool can be used to inform clinical practise when risk assessing when to start rehabilitation with patients receiving vasoactive drugs. Trial registration This study protocol was retrospectively registered on https://www.researchregistry.com/ (researchregistry2991).

Empirical antimicrobial prescribing for pyelonephritis in patients discharged from 15 US Emergency Departments: an opportunity for improvement.

BACKGROUND: Urinary tract infections (UTIs) are commonly treated in the emergency department (ED), and unfortunately, resistance to first-line agents is increasing. OBJECTIVES: To characterize treatment of pyelonephritis in a nationally representative sample of ED patients and to identify patient- and treatment-specific factors associated with receiving initial inactive antibiotics. METHODS: We conducted a multicentre, observational cohort study utilizing the Emergency Medicine PHARMacotherapy Research NETwork (EMPHARM-NET), comprising 15 geographically diverse US EDs. All patients ≥18 years of age with a diagnosis of pyelonephritis between 2018 and 2020 were included. The primary endpoint was the proportion of patients who received initial inactive empirical antibiotic therapy and to identify predictive factors of inactive antibiotic therapy. RESULTS: Of the 3714 patients evaluated, 223 had culture-positive pyelonephritis. Median patient age was 50.1 years and patients were mostly female (78.3%). Overall, 40.4% of patients received an IV antibiotic, most commonly ceftriaxone (86.7%). The most frequently prescribed antibiotics were cefalexin (31.8%), ciprofloxacin (14.3%), cefdinir (13.5%) and trimethoprim/sulfamethoxazole (12.6%). Overall, 10.3% of patients received initial inactive therapy. After adjustment in a multivariable analysis, long-acting IV antibiotic was predictive of inactive therapy (OR 0.23, 95% CI 0.07-0.83). CONCLUSIONS: In our prospective, multicentre observational study, we found that only 40.4% of patients with pyelonephritis received empirical IV antibiotics in the ED, contributing to inactive therapy. Receipt of long-acting IV antibiotics was independently associated with a decreased rate of initial inactive therapy. This reinforces guideline recommendations to administer long-acting IV antibiotics empirically in the ED upon suspicion of pyelonephritis.

Validation of Longitudinal Progression Examinations for Prediction of APPE Readiness.

OBJECTIVE: To study curricular outcomes for the purpose of holistic improvement of the curriculum. METHODS: A single-institution retrospective cohort study evaluated 3 cohorts of Doctor of Pharmacy students entering the program through performance in Advanced Pharmacy Practice Experience (APPE) rotations. Assessment scores and pass/fail outcomes were collected from the 3 examinations to use as predictors, and the numbers of "needs improvement" (NI) and "unsatisfactory" (U) ratings from preceptors during the APPE rotations served as outcome measures. RESULTS: Pharmacy mathematics competency and Milemarker 1 (MM1) examination first-time scores, but not those from Milemarker 2 (MM2), were significantly associated with NI or U scores on required APPE rotations. Significant correlations for all examinations (pharmacy mathematics competency, MM1, and MM2) were found for the Acute Care/Inpatient APPE rotation for each cohort and the combined cohorts. Significant correlations were also found between all examinations and the APPE rotation courses Advanced Hospital and Ambulatory Care, with the exception of the 2021 cohort. Performance in the Advanced Community rotation was not associated with any of the examinations. MM1 and MM2 are both reliable measures of competence in our didactic curriculum and predictive of scoring an NI or U rating in the APPE Acute Care/Inpatient rotation. CONCLUSION: The longitudinal milestone examinations used in our institution provide a mechanism to identify students likely to struggle in required APPE rotations and target them for remediation activities.

Clinician and patient perspectives on the barriers and facilitators to physical rehabilitation in intensive care: a qualitative interview study.

OBJECTIVES: The objective of this study is to explore patient, relative/carer and clinician perceptions of barriers to early physical rehabilitation in intensive care units (ICUs) within an associated group of hospitals in the UK and how they can be overcome. DESIGN: Qualitative study using semi-structured interviews and thematic framework analysis. SETTING: Four ICUs over three hospital sites in London, UK. PARTICIPANTS: Former ICU patients or their relatives/carers with personal experience of ICU rehabilitation. ICU clinicians, including doctors, nurses, physiotherapists and occupational therapists, involved in the delivery of physical rehabilitation or decisions over its initiation. PRIMARY AND SECONDARY OUTCOMES MEASURES: Views and experiences on the barriers and facilitators to ICU physical rehabilitation. RESULTS: Interviews were carried out with 11 former patients, 3 family members and 16 clinicians. The themes generated related to: safety and physiological concerns, patient participation and engagement, clinician experience and knowledge, teamwork, equipment and environment and risks and benefits of rehabilitation in intensive care. The overarching theme for overcoming barriers was a change in working model from ICU clinicians having separate responsibilities (a multidisciplinary approach) to one where all parties have a shared aim of providing patient-centred ICU physical rehabilitation (an interdisciplinary approach). CONCLUSIONS: The results have revealed barriers that can be modified to improve rehabilitation delivery in an ICU. Interdisciplinary working could overcome many of these barriers to optimise recovery from critical illness.

Interventions for improving adherence to airway clearance treatment and exercise in people with cystic fibrosis.

BACKGROUND: Cystic fibrosis (CF) is a life-limiting genetic disorder predominantly affecting the lungs and pancreas. Airway clearance techniques (ACTs) and exercise therapy are key components of physiotherapy, which is considered integral in managing CF; however, low adherence is well-documented. Poor physiotherapy adherence may lead to repeated respiratory infections, reduced exercise tolerance, breathlessness, reduced quality of life, malaise and reduced life expectancy, as well as increased use of pharmacology, healthcare access and hospital admission. Therefore, evidence-based strategies to inform clinical practice and improve adherence to physiotherapy may improve quality of life and reduce treatment burden. OBJECTIVES: To assess the effects of interventions to enhance adherence to airway clearance treatment and exercise therapy in people with CF and their effects on health outcomes, such as pulmonary exacerbations, exercise capacity and health-related quality of life. SEARCH METHODS: We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. Date of last search: 1 March 2023. We also searched online trials registries and the reference lists of relevant articles and reviews. Date of last search: 28 March 2023. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs of parallel design assessing any intervention aimed at enhancing adherence to physiotherapy in people with CF versus no intervention, another intervention or usual care. DATA COLLECTION AND ANALYSIS: Two review authors independently checked search results for eligible studies and independently extracted data. We used standard procedures recommended by Cochrane and assessed the certainty of evidence using the GRADE system. MAIN RESULTS: Two RCTs (77 participants with CF; age range 2 to 20 years; 44 (57%) males) met the inclusion criteria of this review. One study employed an intervention to improve adherence to exercise and the second an intervention to improve adherence to ACT. Both studies measured outcomes at baseline and at three months, but neither study formally assessed our primary outcome of adherence in terms of our planned outcome measures, and results were dependent on self-reported data. Adherence to ACTs One RCT (43 participants) assessed using specifically-composed music alongside ACTs compared to self-selected or no music (usual care). The ACT process consisted of nebuliser inhalation treatment, ACTs and relaxation or antibiotic nebuliser treatment. We graded all evidence as very low certainty. This study reported adherence to ACTs using the Morisky-Green questionnaire and also participants' perception of treatment time and enjoyment, which may influence adherence (outcome not reported specifically in this review). We are uncertain whether participants who received specifically-composed music may be more likely to adhere at six and 12 weeks compared to those who received usual care, risk ratio (RR) 1.75 (95% confidence interval (CI) 1.07 to 2.86) and RR 1.56 (95% CI 1.01 to 2.40) respectively. There may not be any difference in adherence when comparing specifically-composed music to self-selected music at six weeks, RR 1.21 (95% CI 0.87 to 1.68) or 12 weeks, RR 1.52 (95% CI 0.97 to 2.38); or self-selected music to usual care at six weeks, RR 1.44 (95% CI 0.82 to 2.52) or 12 weeks, RR 1.03 (95% CI 0.57 to 1.86). The music study also reported the number of respiratory infections requiring hospitalisation at 12 weeks, with no difference seen in the risk of hospitalisation between all groups. Adherence to exercise One RCT (24 participants) compared the provision of a manual of aerobic exercises, recommended exercise prescription plus two-weekly follow-up phone calls to reinforce exercise practice over a period of three months to verbal instructions for aerobic exercise according to the CF centre's protocol. We graded all evidence as very low certainty. We are uncertain whether an educational intervention leads to more participants in the intervention group undertaking increased regular physical activity at three months (self-report), RR 3.67 (95% CI 1.24 to 10.85), and there was no reported difference between groups in the number undertaking physical activity three times per week or undertaking at least 40 minutes of physical activity. No effect was seen on secondary outcome measures of spirometry, exercise capacity or any CF quality of life domains. This study did not report on the frequency of respiratory infections (hospitalised or not) or adverse events. AUTHORS' CONCLUSIONS: We are uncertain whether a music-based motivational intervention may increase adherence to ACTs or affect the risk of hospitalisation for a respiratory infection. We are also uncertain whether an educational intervention increases adherence to exercise or reduces the frequency of respiratory infection-related hospital admission. However, these results are largely based on self-reported data and the impact of strategies to improve adherence to ACT and exercise in children and adolescents with stable CF remains inconclusive. Given that adherence to ACT and exercise therapy are fundamental to the clinical management of people with CF, there is an urgent need for well-designed, large-scale clinical trials in this area, which should conform to the CONSORT statement for standards of reporting and use appropriate, validated outcome measures. Studies should also ensure full disclosure of data for all important clinical outcomes.

Validating the Breathing Vigilance Questionnaire for use in dysfunctional breathing.

BACKGROUND: Dysfunctional breathing is common among people with and without primary respiratory pathology. While anxiety can contribute to dysfunctional breathing, the underpinning mechanism is unclear. One explanation is that anxiety induces conscious, vigilant monitoring of breathing, disrupting "automatic" breathing mechanics. We validated a new tool that quantifies such breathing-related "vigilance": the Breathing Vigilance Questionnaire (Breathe-VQ). METHODS: 323 healthy adults (mean (range) age 27.3 (18-71) years; 161 males) were analysed. We developed an initial Breathe-VQ (11 items, 1-5 Likert scale) based on the Pain Vigilance and Awareness Scale, using feedback from the target population and clinicians. At baseline, participants completed the Breathe-VQ, Nijmegen Questionnaire (NQ), State-Trait Anxiety Inventory form 2 and Movement-Specific Reinvestment Scale (assessing general conscious processing). 83 people repeated the Breathe-VQ 3 weeks later. RESULTS: Five items were removed based on item-level analysis. The resulting six-item Breathe-VQ questionnaire (score range 6-30) has excellent internal (α=0.892) and test-retest reliability (intraclass correlation 0.810), a minimal detectable change of 6.5 and no floor/ceiling effects. Validity was evidenced by significant positive correlations with trait anxiety and conscious processing scores (r=0.35-0.46). Participants at high risk of having dysfunctional breathing (NQ >23; n=76) had significantly higher Breathe-VQ score (mean±sd 19.1±5.0) than low-risk peers (n=225; mean±sd 13.8±5.4; p<0.001). In this "high risk of dysfunctional breathing" group, Breathe-VQ and NQ scores were significantly associated (p=0.005), even when controlling for risk factors (e.g. trait anxiety). CONCLUSIONS: The Breathe-VQ is a valid and reliable tool to measure breathing vigilance. High breathing vigilance may contribute to dysfunctional breathing and could represent a therapeutic target. Further research is warranted to test Breathe-VQ's prognostic value and assess intervention effects.

Pilot study of physiotherapist-led versus music therapist-led breathing control exercises for young adults living with breathing pattern disorder: a randomised controlled trial protocol.

INTRODUCTION: Breathing pattern disorder (BPD) is an abnormal breathing pattern associated with biochemical, biomechanical and psychophysiological changes. While physiotherapy is often offered, limited evidence-based therapies for BPD are available. Music therapy-based singing exercises have been shown to improve quality of life for individuals with respiratory conditions and may also be beneficial for individuals living with BPD. No study has previously compared these participatory interventions in the treatment of people living with BPD. METHODS AND ANALYSIS: This is a study protocol for an assessor blinded 1:1 randomised controlled trial and qualitative interview study. Forty participants aged 18-40 years who score at least 19 on the Nijmegen Questionnaire (NQ) and do not have any underlying respiratory conditions will be recruited. Participants will be randomised to receive either physiotherapy-led or music therapy-led breathing exercises for 6 weeks. The primary outcome will be between-group difference in NQ post-intervention. Semistructured interviews with a purposive sample of participants will be performed. Qualitative data will be analysed using thematic analysis to better understand participants' intervention and trial experiences. ETHICS AND DISSEMINATION: This study has received ethical approval by Brunel University London College of Health, Medicine and Life Science's Research Ethics Committee (32483-MHR-Mar/2022-38624-3). The anonymised completed dataset will be made available as an open-access file via Brunel University London Figshare and the manuscript containing anonymised patient data will be published in an open-access journal. TRIAL REGISTRATION NUMBER: This trial is registered on the Open Science Framework Registry (https://osf.io/u3ncw).

Clinimetric analysis of outcome measures for airway clearance in people with cystic fibrosis: a systematic review.

BACKGROUND: Airway clearance techniques (ACTs) are integral to cystic fibrosis (CF) management. However, there is no consensus as to which outcome measures (OMs) are best for assessing ACT efficacy. OBJECTIVES: To summarise OMs that have been assessed for their clinimetric properties (including validity, feasibility, reliability, and reproducibility) within the context of ACT research in CF. DESIGN AND METHODS: A systematic review was conducted according to Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA) standards. Any parallel or cross-over randomised controlled trial (RCT) investigating outcome measures for ACT in the CF population were eligible for inclusion. The search was performed in five medical databases, clinicaltrials.gov, and abstracts from international CF conferences. The authors planned to independently assess study quality and risk of bias using the COnsensus-based Standards for the selection of health status Measurement InstrumeNts (COSMIN) risk of bias checklist with external validity assessment based upon study details (participants and study intervention). Two review authors (GS and MJ) independently screened search results against inclusion criteria, and further data extraction were planned but not required. RESULTS: No completed RCTs from the 187 studies identified met inclusion criteria for the primary or post hoc secondary objective. Two ongoing trials were identified. DISCUSSION AND CONCLUSION: This empty systematic review highlights that high-quality RCTs are urgently needed to investigate and validate the clinimetric properties of OMs used to assess ACT efficacy. With the changing demographics of CF combined with the introduction of cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies, an accurate assessment of the current benefit of ACT or the effect of ACT withdrawal is a high priority for clinical practice and future research; OMs which have been validated for this purpose are essential. REGISTRATION: This systematic review was registered on the PROSPERO database (CRD42020206033).

High prevalence of fluoroquinolone-resistant UTI among US emergency department patients diagnosed with urinary tract infection, 2018-2020.

BACKGROUND: Uropathogen resistance, fluoroquinolone-resistance (FQR), and extended spectrum beta-lactamase (ESBL), has been observed to be emerging worldwide with prevalences above recommended thresholds for routine empirical treatment. The primary aim of our study was to determine the prevalence of FQR from a geographically diverse sample of United States emergency departments (EDs). METHODS: We conducted a multi-center, observational cohort study using a network of 15 geographically diverse US EDs. All patients ≥18 years of age with the primary or secondary diagnosis of urinary tract infection (UTI) in the ED identified using International Classification of Diseases (ICD-10) diagnosis code of cystitis, pyelonephritis, or UTI from 2018 to 2020 were included. We calculated descriptive statistics for uropathogens and susceptibilities. Logistic regression analysis was used to identify antimicrobial resistance risk factors associated with FQR Escherichia coli. RESULTS: Among 3779 patients who met inclusion criteria, median age was 62.9 years (interquartile range [IQR]: 41-77.6) and 76.3% were female. The most common diagnoses were complicated (41.2%) and uncomplicated cystitis (40.3%). E. coli was the most common pathogen (63.2%), followed by Klebsiella pneumoniae (13.2%) and Enterococcus species (5.8%). Across all sites, overall E. coli FQ-resistance prevalence was 22.1%, ranging from 10.5 to 29.7% by site. The prevalence of ESBL-producing uropathogen was 7.4%, ranging from 3.6% to 11.6% by site. Previous IV or oral antimicrobial use in the past 90-days and history of a multi-drug resistant pathogen were associated with FQ-resistant E. coli (odds ratio [OR] 2.68, 95% confidence interval [CI]: 2.04-3.51, and OR 6.93, 95% CI: 4.95-9.70, respectively). Of the patients who had FQ-resistant E. coli or an ESBL-producing uropathogen isolated, 116 (37.1%) and 61 (36.7%) did not have any documented risk factors for resistance. CONCLUSION: FQ-resistant E. coli is widely prevalent across US sites highlighting the need for ongoing monitoring of antimicrobial resistance and, at some locations, modification of empirical treatments.

Covid-19 ICU remote-learning course (CIRLC): Rapid ICU remote training for frontline health professionals during the COVID-19 pandemic in the UK.

Background: The unprecedented increase in critically ill patients due to the COVID-19 pandemic mandated rapid training in critical care for redeployed staff to work safely in intensive care units (ICU). Methods: The COVID-19 ICU Remote-Learning Course (CIRLC) is a remote delivery course developed in response to the pandemic. This was a one-day course focused on the fundamentals of Intensive Care. The course used blended learning with recorded lectures and interactive tutorials delivered by shielding and frontline ICU trained professionals. The course was developed within one week and piloted at three NHS Trusts. It was then made publicly available free of charge to redeployed healthcare professionals across the UK and Ireland. An iterative cycle of improvement was used to update the course content weekly. A course confidence questionnaire with quantitative and qualitative questions was used to evaluate effectiveness. Data is reported as n (%), means (SD) and thematic analysis was used for the open questions. Results: 1,269 candidates from 171 organisations completed the course, with 99 volunteer trainers. 96% of respondents rated the course as very or extremely useful. 86% rated the online platform as excellent. Overall confidence improved from 2.7/5 to 3.9/5. Qualitative data showed that the course was pitched at the appropriate level, accessible and built clinicians confidence to work in intensive care. Conclusion: This model of educational delivery with a rapid iteration cycle was a pragmatic, effective solution to knowledge-based training under social distancing measures. Whilst full course evaluation was not possible, we believe that this work demonstrates practical guidance on educational response in a pandemic as well as highlighting the altruistic nature of the critical care community.

Development of the Barriers to Error Disclosure Assessment Tool.

OBJECTIVES: An interprofessional group of health colleges' faculty created and piloted the Barriers to Error Disclosure Assessment tool as an instrument to measure barriers to medical error disclosure among health care providers. METHODS: A review of the literature guided the creation of items describing influences on the decision to disclose a medical error. Local and national experts in error disclosure used a modified Delphi process to gain consensus on the items included in the pilot. After receiving university institutional review board approval, researchers distributed the tool to a convenience sample of physicians (n = 19), pharmacists (n = 20), and nurses (n = 20) from an academic medical center. Means and SDs were used to describe the sample. Intraclass correlation coefficients were used to examine test-retest correspondence between the continuous items on the scale. Factor analysis with varimax rotation was used to determine factor loadings and examine internal consistency reliability. Cronbach α coefficients were calculated during initial and subsequent administrations to assess test-retest reliability. RESULTS: After omitting 2 items with intraclass correlation coefficient of less than 0.40, intraclass correlation coefficients ranged from 0.43 to 0.70, indicating fair to good test-retest correspondence between the continuous items on the final draft. Factor analysis revealed the following factors during the initial administration: confidence and knowledge barriers, institutional barriers, psychological barriers, and financial concern barriers to medical error disclosure. α Coefficients of 0.85 to 0.93 at time 1 and 0.82 to 0.95 at time 2 supported test-retest reliability. CONCLUSIONS: The final version of the 31-item tool can be used to measure perceptions about abilities for disclosing, impressions regarding institutional policies and climate, and specific barriers that inhibit disclosure by health care providers. Preliminary evidence supports the tool's validity and reliability for measuring disclosure variables.

Inhaled Tranexamic Acid for Massive Hemoptysis in the Setting of Oral Anticoagulation: A Case Report.

INTRODUCTION: We discuss a case of massive hemoptysis in the setting of a direct-acting oral anticoagulant (DOAC) successfully managed with nebulized tranexamic acid (TXA). CASE REPORT: Per the American College of Cardiology and the American Society of Hematology, it is recommended that significant bleeding associated with a DOAC be treated with either 4-factor prothrombin complex concentrate or andexanet alfa. However, our patient was at high risk for thrombotic complications given a recent pulmonary embolism. CONCLUSION: We demonstrate that it is reasonable to trial nebulized TXA given its low cost, ease of administration, and safety profile. Additionally, this report discusses a unique dosing strategy and a previously unreported complication associated with nebulization of undiluted TXA.

Investigating outcome measures for assessing airway clearance techniques in adults with cystic fibrosis: protocol of a single-centre randomised controlled crossover trial.

INTRODUCTION: Airway clearance techniques (ACTs) are a gold standard of cystic fibrosis management; however, the majority of research evidence for their efficacy is of low standard; often attributed to the lack of sensitivity from outcome measures (OMs) used historically. This randomised controlled trial (RCT) investigates these standard OMs (sputum weight, forced expiratory volume in 1 s) and new OMs (electrical impedance tomography (EIT), multiple breath washout (MBW) and impulse oscillometry (IOS)) to determine the most useful measures of ACT. METHODS AND ANALYSIS: This is a single-centre RCT with crossover design. Participants perform MBW, IOS and spirometry, and then are randomised to either rest or supervised ACT lasting 30-60 min. MBW, IOS and spirometry are repeated immediately afterwards. EIT and sputum are collected during rest/ACT. On a separate day, the OMs are performed with the other intervention. Primary endpoint is difference in change in OMs before and after ACT/rest. Sample size was calculated with 80% power and significance of 5% for each OM (target n=64). ETHICS AND DISSEMINATION: Ethics approval was gained from the London-Chelsea Research Ethics Committee (reference 16/LO/0995, project ID 154635). Dissemination will involve scientific conference presentation and publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBERS: ISRCTN11220163 and NCT02721498.

Making Diagnostic Instruction Explicit in US Pharmacy Education.

The profession of pharmacy and standards directing the education of student pharmacists are constantly evolving. The profession continues to emphasize patient-centered practice as a model for the future. The US health care system is faced with an impending shortage of primary care providers, which will affect the ability of patients to access the health care system. The pharmacy profession should position itself to contribute to meeting this need. The explicit instruction of differential diagnosis within Doctor of Pharmacy degree programs is a critical consideration in advancing pharmacy practice and potential contributions to the primary care gap.

Individual and Team-Based Medical Error Disclosure: Dialectical Tensions Among Health Care Providers.

Researchers from disciplines of education, health communication, law and risk management, medicine, nursing, and pharmacy examined communication tensions among interprofessional (IP) health care providers regarding medical error disclosure utilizing patient simulation. Using relational dialectics theory, we examined how communication tensions manifested in both individual-provided medical error disclosure and IP team-based disclosure. Two dialectical tensions that health care providers experienced in disclosure conversations were identified: (a) leadership and support, and (b) transparency and protectionism. Whereas these tensions were identified in an IP education setting using simulation, findings support the need for future research in clinical practice, which may inform best practices for various disclosure models. Identifying dialectical tensions in disclosure conversations may enable health communication experts to effectively engage health care providers, risk management, and patient care teams in terms of support and education related to communicating about medical errors.

Dysfunctional breathing: what do we know?

Dysfunctional breathing (DB) is a respiratory condition characterized by irregular breathing patterns that occur either in the absence of concurrent diseases or secondary to cardiopulmonary diseases. Although the primary symptom is often dyspnea or "air hunger", DB is also associated with nonrespiratory symptoms such as dizziness and palpitations. DB has been identified across all ages. Its prevalence among adults in primary care in the United Kingdom is approximately 9.5%. In addition, among individuals with asthma, a positive diagnosis of DB is found in a third of women and a fifth of men. Although DB has been investigated for decades, it remains poorly understood because of a paucity of high-quality clinical trials and validated outcome measures specific to this population. Accordingly, DB is often underdiagnosed or misdiagnosed, given the similarity of its associated symptoms (dyspnea, tachycardia, and dizziness) to those of other common cardiopulmonary diseases such as COPD and asthma. The high rates of misdiagnosis of DB suggest that health care professionals do not fully understand this condition and may therefore fail to provide patients with an appropriate treatment. Given the multifarious, psychophysiological nature of DB, a holistic, multidimensional assessment would seem the most appropriate way to enhance understanding and diagnostic accuracy. The present narrative review was developed as a means of summarizing the available evidence about DB, as well as improving understanding of the condition by researchers and practitioners.

Dysfunctional breathing: what do we know? / Disfunção respiratória: o que sabemos?

ABSTRACT Dysfunctional breathing (DB) is a respiratory condition characterized by irregular breathing patterns that occur either in the absence of concurrent diseases or secondary to cardiopulmonary diseases. Although the primary symptom is often dyspnea or "air hunger", DB is also associated with nonrespiratory symptoms such as dizziness and palpitations. DB has been identified across all ages. Its prevalence among adults in primary care in the United Kingdom is approximately 9.5%. In addition, among individuals with asthma, a positive diagnosis of DB is found in a third of women and a fifth of men. Although DB has been investigated for decades, it remains poorly understood because of a paucity of high-quality clinical trials and validated outcome measures specific to this population. Accordingly, DB is often underdiagnosed or misdiagnosed, given the similarity of its associated symptoms (dyspnea, tachycardia, and dizziness) to those of other common cardiopulmonary diseases such as COPD and asthma. The high rates of misdiagnosis of DB suggest that health care professionals do not fully understand this condition and may therefore fail to provide patients with an appropriate treatment. Given the multifarious, psychophysiological nature of DB, a holistic, multidimensional assessment would seem the most appropriate way to enhance understanding and diagnostic accuracy. The present narrative review was developed as a means of summarizing the available evidence about DB, as well as improving understanding of the condition by researchers and practitioners.

RESUMO A disfunção respiratória (DR) é um quadro respiratório caracterizado por padrões respiratórios irregulares que ocorrem na ausência de doenças concomitantes ou secundariamente a doenças cardiopulmonares. Embora o principal sintoma seja frequentemente dispneia ou "fome por ar", a DR também está associada a sintomas não respiratórios, como vertigem e palpitações. A DR pode ser identificada em todas as idades. Sua prevalência entre adultos na atenção primária no Reino Unido é de aproximadamente 9,5%. Além disso, entre indivíduos com asma, um diagnóstico positivo de DR é encontrado em um terço das mulheres e um quinto dos homens. Embora a DR tenha sido investigada por décadas, ela permanece pouco compreendida devido a uma escassez de ensaios clínicos de alta qualidade e de variáveis de desfecho validadas especificamente para essa população. Assim, a DR é frequentemente subdiagnosticada ou diagnosticada incorretamente, devido à similaridade de seus sintomas associados (dispneia, taquicardia e vertigem) aos de outras doenças cardiopulmonares comuns, como DPOC e asma. As altas taxas de diagnóstico incorreto de DR sugerem que os profissionais de saúde não entendam completamente esse quadro e possam, portanto, não fornecer aos pacientes um tratamento adequado. Dada à natureza multifatorial e psicofisiológica da DR, uma avaliação holística e multidimensional parece ser a maneira mais apropriada de melhorar a compreensão e a precisão do diagnóstico. A presente revisão foi desenvolvida como um meio de resumir as evidências disponíveis sobre DB, bem como de melhorar a compreensão do quadro por pesquisadores e profissionais.

Findings from a mixed-methods study of an interprofessional faculty development program.

Forty faculty members from eight schools participated in a year-long National Faculty Development Program (NFDP) conducted in 2012-2013, aimed at developing faculty knowledge and skills for interprofessional education (IPE). The NFDP included two live conferences. Between conferences, faculty teams implemented self-selected IPE projects at their home institutions and participated in coaching and peer-support conference calls. This paper describes program outcomes. A mixed methods approach was adopted. Data were gathered through online surveys and semi-structured interviews. The study explored whether faculty were satisfied with the program, believed the program was effective in developing knowledge and skills in designing, implementing, and evaluating IPE, and planned to continue newly-implemented IPE and faculty development (FD). Peer support and networking were two of the greatest perceived benefits. Further, this multi-institutional program appears to have facilitated early organizational change by bringing greater contextual understanding to assumptions made at the local level that in turn could influence hidden curricula and networking. These findings may guide program planning for future FD to support IPE.