Exploring Alternative Methods to Reduce Milk Flow Rate From Infant Bottle Systems: Bottle Angle, Milk Volume, and Bottle Ventilation.

PURPOSE: Modifying milk flow rate is a common pediatric dysphagia treatment. Though past investigations have demonstrated how this can be achieved using bottle nipples, little is known about the impact of other bottle modifications. The objective of this investigation is to demonstrate how bottle vent, bottle position, and volume of milk alter bottle pressures and milk flow. METHOD: A Dr. Brown's bottle filled with formula was secured to a retort stand and inverted to allow milk to free flow from a Level 1 nipple. Milk flow rate and bottle pressures were calculated under three conditions: (a) with and without a vent in place; (b) with varying volumes of milk (1-4 oz); and (c) in horizontal, semi-inverted, and completely inverted positions. Differences between flow rates under the conditions were tested using repeated-measures analysis of variance. RESULTS: Upon inversion, milk dripped from both vented and unvented bottles. Dripping continued throughout the 20-min testing period in the vented bottle; however, as air pressure and hydrostatic pressure declined (p < .01) in the unvented bottle, milk flow slowed and eventually ceased (p < .001). As angle of bottle inversion increased, hydrostatic pressure and milk flow rate had corresponding increases as well (p < .001). Hydrostatic pressure increased an average of 1.4 ± 0.12 mm Hg per additional ounce of formula that was added to the bottle, with corresponding increases in milk flow rate observed (p < .001). CONCLUSIONS: Milk flow rate can be altered by feeding conditions outside of bottle nipples alone. Future work examining the clinical significance of these modifications is warranted to determine optimal interventions.

Spatially Directed Pyrolysis via Thermally Morphing Surface Adducts.

Combustion is often difficult to spatially direct or tune associated kinetics-hence a run-away reaction. Coupling pyrolytic chemical transformation to mass transport and reaction rates (Damköhler number), however, we spatially directed ignition with concomitant switch from combustion to pyrolysis (low oxidant). A 'surface-then-core' order in ignition, with concomitant change in burning rate,is therefore established. Herein, alkysilanes grafted onto cellulose fibers are pyrolyzed into non-flammable SiO2 terminating surface ignition propagation, hence stalling flame propagating. Sustaining high temperatures, however, triggers ignition in the bulk of the fibers but under restricted gas flow (oxidant and/or waste) hence significantly low rate of ignition propagation and pyrolysis compared to open flame (Liñán's equation). This leads to inside-out thermal degradation and, with felicitous choice of conditions, formation of graphitic tubes. Given the temperature dependence, imbibing fibers with an exothermically oxidizing synthon (MnCl2 ) or a heat sink (KCl) abets or inhibits pyrolysis leading to tuneable wall thickness. We apply this approach to create magnetic, paramagnetic, or oxide containing carbon fibers. Given the surface sensitivity, we illustrate fabrication of nm- and µm-diameter tubes from appropriately sized fibers.

Understanding motivations and behaviours of our influencers: What can pharmacists learn from their leaders?

Background: There has been considerable discussion regarding the "leadership crisis" in pharmacy, with concerns that insufficient numbers of pharmacists want to take on leadership roles in their own profession. This exploratory study of leaders and influencers in pharmacy was undertaken to characterize the motivations for and behaviours of titled and untitled leaders, in order to help other pharmacists learn from their experiences. Methods: Interviews with 28 individuals who self-identified or were described by others as leaders (with or without formal titles) and influencers in pharmacy were conducted using online platforms (e.g., Zoom, Teams). A semistructured interview guide was used and refined during the interviews. Data were analyzed using a constant comparative method to identify common themes. Results: While participants in this study all described different trajectories towards leadership or influencer roles, several common themes emerged, including 1) personal characteristics that enable leadership roles/activities, 2) environmental supports and drivers that propel leadership forward, 3) positive reinforcers that maintain momentum towards leadership aspirations and 4) general predictors of success as a leader/influencer in pharmacy. Discussion: To address the "leadership crisis" in pharmacy, it will be necessary to motivate and support individuals in assuming these roles. Findings from this study have highlighted the complex and individual pathways current leaders have undertaken to achieve these roles and have signposted ways in which organizations, managers and mentors can support nascent leadership aspirations in productive ways.

A typology of vaccine hesitancies: Results from a study of community pharmacists administering COVID-19 vaccinations during the pandemic.

Pharmacists were integral to the vaccine administration process during the first two years of the COVID-19 pandemic. As such, they encountered a variety of different forms of vaccine resistance. This qualitative study explored 33 community pharmacists (from varying geographical and practice types) responses to vaccine resistance and tactics utilized to support vaccination amongst diverse community members. A typology of 8 different variants of vaccine hesitancy emerged, each with its own root cause and potential opportunities for intervention. Pharmacists in this study described techniques to support adherence to public health guidance based on their assessment of root causes for resistance demonstrated by patients. Importantly, all pharmacists in this study described feelings of anger towards truly anti-vax patients and unwillingness to actually engage or even try to address this group in their practice.

COVID-19 vaccination in high-risk communities: Case study of Brampton, Ontario.

Background: The Peel region in Southern Ontario is among the most ethnoculturally diverse and fastest growing areas in Canada. During the COVID-19 pandemic, the multicultural community of Brampton suffered one of the highest infection rates in Canada, in part because of the demographic and socioeconomic characteristics of the community. The role of pharmacists in supporting vaccine uptake in this linguistically, ethnically and religiously diverse community has not been adequately characterized. Methods: A qualitative case study approach was used, focusing on one of the major communities in Peel (Brampton). Interviews with community pharmacists and pharmacy staff directly involved in COVID-19 vaccine administration during the pandemic were undertaken to identify common experiences and trends related to providing care and support to this high-risk community. Constant comparative coding was used to identify common themes that can inform ongoing public health supports in future pandemics. Results: A total of 29 interviews were completed. Key themes that emerged included 1) the impact of operational, organizational and logistical issues on vaccine uptake in the community; 2) the negative influence of inconsistent messaging from public health and other experts during the pandemic; and 3) the identification of an emerging typology of "vaccine hesitancies" describing different reasons/motivations for avoiding COVID-19 vaccination and approaches taken by pharmacy staff to address these within a multicultural, multilingual practice context. Discussion: The COVID-19 vaccination campaign was unprecedented in its size, scope and speed, and community pharmacists were integral in this effort. The unique needs of ethnoculturally, linguistically and socioeconomically diverse communities like Brampton require further studies to examine ways in which the pharmacy profession can positively influence greater vaccine uptake, by increasing understanding of the diverse proliferation of vaccine hesitancies that emerged.

Effectiveness and Safety Profile of Remote Pulmonary Artery Hemodynamic Monitoring in a "Real-World" Veterans Affairs Healthcare System.

Ambulatory hemodynamic monitoring has demonstrated the ability to reduce heart failure-related hospitalization, regardless of left ventricular ejection fraction; however, real-world data in a Veterans Affairs patient population are limited. The present study retrospectively reviewed 53 patients with New York Heart Association class III heart failure, regardless of left ventricular ejection fraction, implanted with a pulmonary artery pressure sensor (CardioMEMS) at our single Veterans Affairs institution. Heart failure-related hospitalizations were assessed in patients for 6 and 12 months after the implantation of the device and compared with the 6- and 12- month periods before implantation in the same patient cohort. Pulmonary arterial pressures and medication doses were also recorded at baseline, 6- months, and 12- months and procedural safety data were also assessed. Implantation of a remote pulmonary artery pressure sensor was associated with a 52% (95% confidence interval 30% to 68%, p <0.001) and a 44% (95% confidence interval 24% to 59%, p <0.001) reduction in heart failure-related hospitalization at 6 and 12 months after implant, respectively, compared with the 6- and 12-month preimplant periods. Mean pulmonary arterial pressures also demonstrated significant reductions from baseline to 6 and 12 months after implant. A total of 3 procedure-related adverse events were noted. In conclusion, pulmonary artery pressure sensor implantation is relatively safe and associated with significant reductions in heart failure-related hospitalization and decreased mean pulmonary artery pressures in patients within the Veterans Affairs system with New York Heart Association class III symptoms, regardless of ejection fraction.

Understanding the psychology of trust between patients and their community pharmacists.

BACKGROUND: Pharmacists need patients to trust them in order to support best possible health outcomes. There has been little empirical work to test the widely stated claim that pharmacists are the "most trusted" health care professional. This study was undertaken to characterize the factors that shape public trust of individual pharmacists and the profession as a whole. METHODS: An exploratory qualitative study was undertaken. Semistructured interviews with 13 patients from 5 different community pharmacies were completed. Interview data were transcribed, coded and categorized to identify trust-enhancing and trust-diminishing factors influencing patients' perceptions of pharmacists. RESULTS: Four trust-diminishing factors were identified, including the business context within which community pharmacy is practised, lack of transparency regarding pharmacists' remuneration, lack of awareness of how pharmacists qualify and are regulated and inconsistent previous experiences with pharmacists. Four trust-enhancing factors were identified, including accessibility, affability, acknowledgement and respect. DISCUSSION: This study illustrates that trust-diminishing factors appear to be somewhat outside the day-to-day control of individual community pharmacists, while trust-enhancing factors are elements that pharmacists may have greater personal control over. Further research is required to better understand these factors and to develop a more generalizable understanding of how patients develop trust in their pharmacists. Can Pharm J (Ott) 2021;154:xx-xx.

Resilience in the time of pandemic: The experience of community pharmacists during COVID-19.

BACKGROUND: As a result of the COVID-19 pandemic, there has been a significant disruption of the practice of pharmacy. Importantly, in many parts of the world, this disruption occurred literally overnight, requiring pharmacists to demonstrate significant adaptability and resiliency in order to manage continuing and in some cases expanding needs of patients. OBJECTIVES: The objective of this research was to characterize how community pharmacy in Ontario (Canada) responded to the COVID-19 pandemic of winter/spring 2020, in particular in understanding what factors may influence or predict resiliency of individual practitioners and their workplaces. METHODS: One-on-one interviews mediated through technology (Microsoft Teams) were used, following a semi-structured interview protocol. Verbatim transcripts were produced and analyzed by two independent researchers, using an inductive coding process to identify and characterize themes. RESULTS: A total of 21 pharmacists participated in this study. Six themes were identified: a) use of and comfort with technology; b) early adoption of corporate and professional guidance; c) workplaces that emphasized task-focus rather than multi-tasking were more resilient; d) scheduling methods and practices in the workplace are important for personal resilience; e) dedicated specialty staff allowed pharmacists to focus on their work; and f) provision of personal protective equipment was essential. CONCLUSIONS: Traditionally, resilience in professional practice has been characterized as a personal, not a workplace, issue. This study suggests that personal resiliency for pharmacists requires substantial workplace support; further work in this area is required to better understand how pharmacists adapt to complex and difficult situations such as pandemics.

How do patients develop trust in community pharmacists?

BACKGROUND: Pharmacists frequently self-describe as "the most trusted health care professional" in society. Beyond the rhetoric of such self-promoting statements, there is little empirical evidence regarding how trust between pharmacists and patients is formed, nurtured, and sustained. OBJECTIVES: This exploratory qualitative study in Ontario, Canada was undertaken in early 2020 to characterize trust-enhancing factors in community pharmacy practice. METHODS: Recruitment posters/handouts in purposively-selected pharmacies using a convenience sampling of people collecting prescriptions was used to recruit 28 patient-participants. Inclusion criteria included a minimum of six conversations with a pharmacist regarding health/medication use in the previous 12 months. A semi-structured interview protocol was used to elicit descriptions from patients regarding how experiences with community pharmacists shaped or influenced trust formation in both individual pharmacists and the profession as a whole. RESULTS: A total of 28 patients were interviewed for this study. Five trust-enhancing factors were identified: i) availability; ii) affability; iii) acknowledgement; iv) respect; and v) interpersonal chemistry. Within each factor, sub-factors or facets were also identified that focused on specific behaviours of community pharmacists that helped enhance trust. This study suggests that trust-enhancing factors include a series of interpersonal communication behaviours and skills that are within the control of pharmacists; leveraging these behaviours and skills in a more consistent and effective manner may support more trusting relationships between pharmacists and patients. CONCLUSIONS: For pharmacists to truly live up to the moniker of "most trusted health care professional" it is important to better understand how trust is built and sustained, and to consider opportunities to focus on specific trust-enhancing behaviours that ultimately support better patient care and outcomes.

How do community pharmacies in Ontario manage drug shortage problems? Results of an exploratory qualitative study.

BACKGROUND: Pharmacists report spending a considerable amount of time dealing with drug shortages. There is no research in Canada identifying and describing the strategies and resources that pharmacists use to minimize disruption and continuity of care for patients. METHODS: An exploratory qualitative methodology was used. Community pharmacists and technicians in Ontario were interviewed using a semi-structured protocol. Verbatim transcripts were generated and coded by at least 2 independent reviewers using content analysis methods to identify management strategies. RESULTS AND DISCUSSION: A total of 14 pharmacists and 7 regulated pharmacy technicians participated in this study. The following 5 main strategies for managing drug shortages were identified: (1) using the supplier, (2) generic options, (3) brand options, (4) contacting other pharmacies and (5) switching to a different medication. CONCLUSION: The strategies identified through this research can provide pharmacists with some guidance in approaching the real-world problem of drug shortages. It also highlights opportunities for organizations, government and manufacturers to provide additional support for pharmacists to minimize disruptions for patients and to ensure current ad hoc practices do not further compound shortage issues. Can Pharm J (Ott) 2020;153:xx-xx.

COVID-19: How did community pharmacies get through the first wave?

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic of early 2020 was one of the most impactful events in living memory. As an essential service, community pharmacies remained open to provide care and service. The unprecedented nature and scale of the pandemic triggered considerable change in daily practice. In anticipation of future pandemic waves and similar mass-scale civil disruptions, it is important to understand how community pharmacies adapted and responded in the early weeks of COVID-19. METHODS: A combination of convenience, snowball and purposive sampling methods was used to recruit staff from community pharmacies across Ontario, from a variety of different practice locations and types. A semistructured focus group interview protocol was used to elicit experiences. Data gathering was undertaken until the point of saturation. Thematic analysis was used to surface common experiences and to describe how community pharmacies adapted and responded. RESULTS: A total of 39 participants (pharmacists, registered technicians and assistants) from 11 different pharmacies participated in this study. Data were coded based on 1) what happened, 2) how community pharmacies responded, and 3) what worked and did not work to support pharmacy staff in continued provision of service and care. Key findings included the collapse of provision of nondispensing remunerated services, the central role of managerial decisions in supporting resilience (e.g., change to 8-hour shifts from 12-hour shifts) and the central role of technology in supporting continuity of quality pharmacy services. DISCUSSION: With anticipated future pandemic waves, preparedness of community pharmacy will be essential. This study provides important insights based on participants' own experiences regarding ways employers can better support staff in provision of care and service to patients during times of mass-scale civil disruption. Can Pharm J (Ott) 2020;153:xx-xx.

How physicians change: Multisource feedback driven intervention improves physician leadership and teamwork.

BACKGROUND: Multisource feedback provides a method of quantitatively assessing and improving physician professionalism, interpersonal communication, teamwork, and leadership behaviors. We sought to determine whether tiered educational interventions can improve measurements of multisource feedback for physicians across specialties, and whether multisource feedback baseline measurements and improvements after intervention vary by specialty designation. METHODS: Multisource feedback assessments were performed on physicians from academic (34%) and community hospitals (66%) in the United States and Canada. PULSE 360 Survey data was obtained on 1,190 physicians from primary care (25%), surgical (46%), and other (29%) specialties. Physician respondents were 75% male and 24% female. Raters included administrators, colleagues, staff, and self-ratings with an average of 35.7 ratings per physician. A leadership teamwork index was measured before and after delivery of educational intervention. Three tiers of intervention were used depending on baseline leadership teamwork index score: (1) report only, (2) debriefing only, and (3) debriefing and development. RESULTS: Surgeons had a significantly lower baseline leadership teamwork index at 59.9, whereas primary care and specialists started with an leadership teamwork index of 67.1 and 65.9, respectively. Those who participated in a tier 3 intervention had the greatest change from an average baseline leadership teamwork index of 36.6 to 56.3 on follow-up. Surgeons experienced the largest mean increase of 9.1 leadership teamwork index points after intervention, whereas medicine specialists had a mean increase of 6.7 leadership teamwork index points. CONCLUSION: Baseline multisource feedback scores vary by specialty and improve based on feedback, goal-setting, coaching, and education. In particular, physicians who start with low scores have the greatest potential for leadership teamwork index improvement.

Pharmacist-Pharmacy Technician Intraprofessional Collaboration and Workplace Integration: Implications for Educators.

Globally, concerns have been expressed regarding the impact of regulation of pharmacy technicians. After more than a decade of experience with technician regulation in Ontario, Canada, uptake of the full scope of practice for technicians has been sporadic at best. The objective of this study was to examine barriers and facilitators to intraprofessional collaboration between pharmacists and pharmacy technicians for the purpose of identifying possible curricular or educational interventions to enhance workplace integration. A qualitative, interview-based study of 24 pharmacists, technicians, educators, pharmacy managers, and owners was undertaken using a semi-structured interview guide. Key findings of this research include: i) Confirmation of suboptimal utilization of regulated technicians in practice; ii) identification of crucial knowledge and skills gaps for both pharmacists and technicians; and iii) proposals for undergraduate education and training, and continuing professional development learning opportunities to address these gaps. In order to achieve the promise and potential of regulation of pharmacy technicians, system-wide change management-beginning with education-will be required and will benefit from multiple stakeholder engagement and involvement.

Community pharmacists' perceptions of leadership.

BACKGROUND: Concerns have been expressed regarding a "leadership crisis" in pharmacy. Previous research has identified potential barriers to pharmacists assuming leadership roles and signposted opportunities for further exploration of leadership issues in the profession related to psychological comfort with use of power. OBJECTIVES: This study explored community pharmacists' perceptions of the effectiveness and impact of power leveraged by formal and informal pharmacy leaders. METHODS: A theoretical framework based on Raven's 7 Sources of Power model was used to guide this research. Semi-structured interviews with community pharmacists in Ontario, Canada were undertaken, and data were coded and categorized using this framework. FINDINGS: 29 pharmacists participated in this study. Participants in this study highlighted over-reliance on charismatic power, underuse of rewards and punishments, and general lack of effectiveness or impact in use of informational, expertise, positional, and relational powers amongst pharmacy leaders. Opportunities to broaden the power repertoire of pharmacy leaders, including leadership education, were identified as potentially valuable for individual leaders and the profession as a whole. CONCLUSIONS: Effectively leveraging power is important for leaders. This study has highlighted patterns of power use amongst community pharmacy leaders and identified opportunities for further research in this area and for continuing professional development for leaders.

Professional identity formation: The experience of regulated pharmacy technicians in Ontario.

BACKGROUND: Despite being regulated and spoken about as professionals, there is little formal research examining professional identity formation among regulated pharmacy technicians. METHODS: A semistructured interview protocol was generated, based on Holden et al.'s typology of professional identity formation (PIF). Regulated pharmacy technicians in Ontario with a minimum of 2 years' experience working a minimum of 32 hours/week were recruited to participate. Interviews were transcribed, coded and analyzed based on professional identity formation. RESULTS: A total of 15 regulated pharmacy technicians from southern Ontario participated in this study. Regardless of demographic background, most participants demonstrated identity splinting as the dominant form of professional identity formation. Issues related to social valuing of the role of the technician and environmental opportunities to develop and grow were highlighted as significant barriers. INTERPRETATION: These findings suggest regulated pharmacy technicians have incomplete professional identities due in part to reasons linked to pharmacists and the pharmacy profession. The type of professional identity expressed by participants in this study may limit opportunities for full and optimal expression of their role. CONCLUSIONS: Further work is necessary to better understand the professional identity formation of regulated pharmacy technicians, to help support the evolution of this role. Can Pharm J (Ott) 2020;153:xx-xx.

Randomized Linear Algebra Approaches to Estimate the Von Neumann Entropy of Density Matrices.

The von Neumann entropy, named after John von Neumann, is an extension of the classical concept of entropy to the field of quantum mechanics. From a numerical perspective, von Neumann entropy can be computed simply by computing all eigenvalues of a density matrix, an operation that could be prohibitively expensive for large-scale density matrices. We present and analyze three randomized algorithms to approximate von Neumann entropy of real density matrices: our algorithms leverage recent developments in the Randomized Numerical Linear Algebra (RandNLA) literature, such as randomized trace estimators, provable bounds for the power method, and the use of random projections to approximate the eigenvalues of a matrix. All three algorithms come with provable accuracy guarantees and our experimental evaluations support our theoretical findings showing considerable speedup with small loss in accuracy.

Understanding psychological engagement and flow in community pharmacy practice.

BACKGROUND: Psychological engagement in work has been identified as a crucial predictor of peak performance and enhanced productivity. A theoretical framework for understanding engagement as the peak of a continuum including satisfaction, commitment, motivation, and flow describes the various states of psychological relationship that exists between individuals and their work/profession. Application of this theoretical framework and these constructs to the pharmacy profession has not been fully described previously. OBJECTIVES: To characterize, describe, and gain greater insight into engagement by pharmacists in community pharmacy practice. METHODS: A purposeful recruitment method was used to invite exemplary Canadian pharmacists who had won prestigious awards to participate in interviews exploring their engagement with their profession. A psychotherapeutic appreciative inquiry research method using techniques proposed by Kratochwill and Levin was used to guide data collection; data analysis was undertaken using the theoretical framework. RESULTS: Thirteen award winning community pharmacists participated in this study. These exemplary pharmacists rarely described engagement and instead more frequently described flow in their practice. Common determinants of flow in community pharmacy described by participants included: i) autonomy; ii) altruism; iii) admiration; iv) agreement/acceptance; v) alignment; and vi) aspiration. CONCLUSIONS: Engagement as conceptualized in management literature did not feature prominently for these award winning pharmacists. Further research is required to better understand how peak performance in community pharmacy practice manifests and is sustained.

Learning Needs of Pharmacists for an Evolving Scope of Practice.

Around the world, changes in scope of practice regulations for pharmacists have been used as a tool to advance practice and promote change. Regulatory change does not automatically trigger practice change; the extent and speed of uptake of new roles and responsibilities has been slower than anticipated. A recent study identified 9 pre-requisites to practice change (the 9Ps of Practice Change). The objective of this study was to describe how educationalists could best apply these 9Ps to the design and delivery of continuing professional development for pharmacists. Twenty community pharmacists participated in semi-structured interviews designed to elicit their learning needs for scope of practice change. Seven supportive educational techniques were identified as being most helpful to promote practice change: (i) a coaching/mentoring approach; (ii) practice-based experiential learning; (iii) a longitudinal approach to instructional design; (iv) active demonstration of how to implement practice change; v) increased focus on soft-skills development; (vi) opportunities for practice/rehearsal of new skills; and (vii) use of a 360-degree feedback model. Further work is required to determine how these techniques can be best applied and implemented to support practice change in pharmacy.

Obstructive sleep apnoea in a patient with chronic lymphocytic leukaemia.

A 69-year-old Caucasian woman presented with chronic lymphocytic leukaemia (CLL; stage 1-Rai System), significant oropharyngeal lymphoid enlargement, snoring and fatigue. Overnight polysomnography revealed moderately severe obstructive sleep apnoea (OSA), which was managed successfully with oral appliance therapy with resolution of snoring and daytime fatigue. Structural abnormalities of the upper airways are known to cause OSA. Airway narrowing can result from bony structural abnormalities, nasopharyngeal growth, soft tissue redundancy, macroglossia, malignant and benign growth of the upper aero-digestive tract, and adenotonsilar enlargement. Clinicians should be encouraged to consider a diagnosis of OSA in patients with CLL when they present with symptoms of worsening fatigue.