scholarly journals Patient Feedback on Pharmacist Prescribing for Minor Ailments in a Canadian Province

2017 ◽  
Vol 8 (1) ◽  
Author(s):  
Jeff G Taylor ◽  
Kerry Mansell
Keyword(s):  
Online Survey ◽  
Conflicts Of Interest ◽  
Standard Of Care ◽  
Original Research ◽  
Minor Ailment ◽  
Minor Ailments ◽  
Financial Interests ◽  
Canadian Provinces ◽  
One Year ◽  
A Minor

Background: Pharmacists have been given authority in many Canadian provinces to go beyond simply recommending over-the-counter medicines to patients with minor ailments. In Saskatchewan, they can prescribe medicines normally under the sole control of physicians for 17 conditions. An evaluation program is underway to assess the value of the program. Methods: Adults were recruited over a one-year period and were eligible for inclusion if prescribed an agent for an applicable condition. Pharmacists from 40 pharmacies participated in identifying people who received the service. Of patients agreeing to participate, a link to an online survey was provided. The survey included items on clinical improvement, care options, and patient confidence in knowing when to seek a physician for a minor ailment. Results: Forty-eight people were involved in prescribing encounters, with the majority seeking help for themselves. All but one saw their symptoms improve subsequent to pharmacist assistance, most often to a significant extent. Satisfaction with the service was high. Convenience and trust in pharmacists were primary reasons for choosing the service over medical care (rather than an issue potentially more worrisome such as not having a family physician). Had this service not been in place, 30.6% of those asking for help would have gone to a medical clinic or emergency room. Seventy-five percent were (at least) very confident in knowing when to seek a physician (rather than a pharmacist) for such conditions. Conclusion: Information on the clinical outcomes of pharmacist-led minor ailment care is starting to accrue in Saskatchewan. While the numbers are extremely low to date, what has become available suggests the service is of value to the citizens of the province, it is chosen for appropriate reasons, and is of an acceptable standard of care. Conflict of Interest We declare no conflicts of interest or financial interests that the authors or members of their immediate families have in any product or service discussed in the manuscript, including grants (pending or received), employment, gifts, stock holdings or options, honoraria, consultancies, expert testimony, patents and royalties. However, the authors are pharmacists licensed within the province and bring this perspective to this evaluation of a pharmacy-based program.   Type: Original Research

scholarly journals Community Pharmacist Attitudes on Medication Synchronization Programs

2017 ◽  
Vol 8 (2) ◽  
Author(s):  
Matthew Witry ◽  
Thao Hoang
Keyword(s):  
Community Pharmacist ◽  
Conflicts Of Interest ◽  
Positive Impact ◽  
Patient Adherence ◽  
Original Research ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Medication Therapy ◽  
Financial Interests ◽  
Significant Change

Background: Medication synchronization is a service offered by an increasing number of community pharmacies that aligns refilling of a patient’s multiple medications. Purported benefits include increased adherence and improved dispensing efficiency. Objective: To assess community pharmacist agreement with a set of declarative statements about medication synchronization programs and to identify variation related to pharmacist characteristics. Methods: In 2015, a cross-sectional survey was mailed to 1,000 pharmacists from 5 Midwestern U.S. states using 4-contacts and an online option. Respondents used a 7-point Likert scale to agree or disagree with 5 statements about medication synchronization. Demographic and workplace characteristics were collected. Data were analyzed using descriptive statistics and factor analysis. Multiple linear regression tested the relationship between pharmacist characteristics and a 4-item attitude composite. Results: There were 258 usable responses for a response rate of 28.8%. About half (45.0%) reported their pharmacy offered medication synchronization. Most pharmacists (82.6%) agreed this service has a positive impact on patient adherence but 57% agreed that a “significant change to workflow” was or would be required. Pharmacist agreement that the program provides financial benefits to the pharmacy was higher than agreement that the service provides more opportunities for patient interactions (p<0.001). In the multiple regression analysis, having a PharmD and working at a pharmacy offering Medication Therapy Management were associated with more positive scores on the medication synchronization benefits composite whereas working in a staff role (rather than a manager/owner) was lower. No demographic predictors were significantly associated with agreeing that a significant change to workflow would be required for implementation. Conclusions: Pharmacists generally were positive about medication synchronization programs, although some negative views were present, especially regarding the need for workflow change. Research is needed to understand barriers and facilitators to how medication synchronization programs are implemented and maintained and their effects on outcomes. Conflict of Interest We declare no conflicts of interest or financial interests that the authors or members of their immediate families have in any product or service discussed in the manuscript, including grants (pending or received), employment, gifts, stock holdings or options, honoraria, consultancies, expert testimony, patents and royalties.   Type: Original Research

Patients’ Knowledge Of Anticoagulation and Its Association With Clinical Characteristics, INR Control and Warfarin-Related Adverse Events

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 1738-1738 ◽  
Author(s):  
Poupak Rahmani ◽  
Charlotte L. Guzman ◽  
Mark D Blostein ◽  
Ashley Tabah ◽  
Alla Muladzanov ◽  
...  
Keyword(s):  
Adverse Events ◽  
Conflicts Of Interest ◽  
Tertiary Care ◽  
Mechanical Heart Valve ◽  
Standard Of Care ◽  
Patient Characteristics ◽  
Bleeding Events ◽  
Chi Square ◽  
Level Of Knowledge ◽  
One Year

Abstract Background Whether level of knowledge of anticoagulation (AC) among patients on warfarin plays a role in maintenance of therapeutic INR or in warfarin-related adverse events is controversial. Most studies conducted on this subject had small patient sample sizes and did not use validated questionnaires to assess patients’ knowledge of AC. Objectives To use the validated Oral Anticoagulation Knowledge (OAK) test (Zeolla MM, 2006) to assess knowledge of AC among patients attending a busy AC clinic, and to examine associations between level of knowledge, INR control and adverse events. We hypothesized that patients with higher OAK test scores (i.e. greater knowledge) would have better INR control (primary outcome) and fewer bleeding and thrombosis events (secondary outcomes). Methods Consecutive patients who had been followed in our AC clinic (tertiary care, university-affiliated hospital, 20,000 patient-visits per year) for at least one year and consented to participate were asked to complete the OAK test. The OAK test is a 20-question multiple-choice questionnaire that assesses patients’ knowledge of warfarin AC. A passing score is ≥15 correct responses. Patient charts were reviewed to obtain data on clinical and demographic characteristics, and information on INR values and any thrombosis or bleeding events during the preceding 1 year period. Associations between OAK scores and patient characteristics, INR control and bleeding/thrombosis events were assessed by chi-square and t-tests, as appropriate. Results Among 252 patients screened for participation, 225 met the inclusion criteria and completed the OAK test. Mean (SD) age was 70 (13.4) years, 53% were male and 75% were on warfarin for >3 years. Indications for AC were atrial fibrillation in 65%, VTE in 8%, mechanical heart valve in 10%, and other in 19%. The mean OAK score was 12/20, and 64% failed the OAK test. Predictors of a pass score on the OAK test were younger age (p= 0.01) and higher level of education (p=0.03). Over the preceding year, 57.3% of INRs were therapeutic, 25.1% subtherapeutic and 17.4% supratherapeutic, and there were 22 bleeding events and 5 thrombosis events. There was no association between OAK score and INR control, or OAK score and bleeding or thrombosis events. Conclusion To our knowledge, this is the first study to use the validated OAK test to assess patients’ AC knowledge. We found that younger and more educated patients were more likely to pass the OAK test; however, OAK test result did not predict INR control or occurrence of bleeding or thrombotic events. The OAK test may not be sensitive enough to capture the standard of care practiced in different anticoagulation clinics (e.g. differences in teaching material, frequency of INR checks in stable patients). Also, for some patients, AC knowledge among their caretakers may be more important than self-knowledge. Further research is needed to assess the relationship between AC knowledge, INR control and adverse clinical outcomes. Disclosures: No relevant conflicts of interest to declare.

scholarly journals Preceptors' Need For Support In Tutoring Pharmacy Students in Finnish Community Pharmacies

2016 ◽  
Vol 7 (4) ◽  
Author(s):  
Ulla Löfhjelm ◽  
Katja Pitkä ◽  
Sanna Passi ◽  
Marja Airaksinen
Keyword(s):  
Conflicts Of Interest ◽  
Qualitative Content Analysis ◽  
Pharmacy Practice ◽  
Original Research ◽  
Reflective Dialogue ◽  
Assessment Of Learning ◽  
Financial Interests ◽  
Care Guidelines ◽  
Need For Support ◽  
Giving Feedback

A pharmacy degree in Finland includes a six-month obligatory internship. The internship is integrated with theoretical studies and adds up to 30 European Credit Transfer and Accumulation System (ECTS) credits of the BSc (Pharm) degree. Learning is supported by reflective assignments from the university. The preceptors have an important role in organizing the internship and tutoring students successfully in community pharmacy settings. Objective: to assess whether the preceptors of University of Helsinki’s teaching pharmacies need pedagogic support in tutoring and if so, in which core pharmaceutical tasks or tutoring skills. Methods: The survey was sent to all preceptors of University of Helsinki´s teaching pharmacies (n=326) in 2011 (response rate 58%, n=190). The data was analyzed statistically using Excel (version 12.3.6). The open-ended questions were analyzed by qualitative content analysis. Results: The majority of preceptors found their skills in tutoring the students mainly good. However, assessment of learning (27% of the respondents), giving feedback (23%) and organizing the learning situations supportive for learning (23%) were the areas in which the preceptors mostly indicated a need for support. Teaching current care guidelines and pharmaceutical care (36%) and multi-professional collaboration (28%) were the areas in which the preceptors expressed that they needed to update their skills. Conclusions: The faculty should focus the support on the pedagogic skills of preceptors, particularly in improving their skills in assessment of learning and in reflective dialogue. In addition, their skills in teaching clinical and patient care aspects of pharmacy practice should be enhanced. Conflict of Interest We declare no conflicts of interest or financial interests that the authors or members of their immediate families have in any product or service discussed in the manuscript, including grants (pending or received), employment, gifts, stock holdings or options, honoraria, consultancies, expert testimony, patents and royalties   Type: Original Research  

scholarly journals Medical Spanish in U.S. Colleges and Schools of Pharmacy

2016 ◽  
Vol 7 (3) ◽  
Author(s):  
Geoffrey A Mospan ◽  
Carrie L Griffiths
Keyword(s):  
United States ◽  
Expert Testimony ◽  
Conflicts Of Interest ◽  
The United States ◽  
Pharmacy Students ◽  
Original Research ◽  
Financial Interests ◽  
Pharmacy Curriculum ◽  
Spanish Education

Objective: To determine characteristics of Medical Spanish education provided to pharmacy students in schools and colleges of pharmacy in the United States. Methods: A survey of U.S. pharmacy schools and colleges was performed to determine availability of Medical Spanish in pharmacy curriculum, course(s) containing Medical Spanish education, and characteristics of Medical Spanish courses. Additional follow-up questions were asked if a school did not offer Medical Spanish. Results: 61 out of 138 institutions completed the survey (response rate = 44%). 36% (22/61) of respondents reported Medical Spanish education was offered in their curriculum. The most common barrier to offering a Medical Spanish course included a lack of personnel to teach the course (n=21, 54%) or no room in the curriculum (n=15, 38%). Conclusion: While there is a limited number of institutions that provide Medical Spanish education to their pharmacy students, results of this survey provide a basic description of Medical Spanish education in schools and colleges of pharmacy in the United States. Data obtained from this survey can be used to refine or initiate Medical Spanish courses, including the teaching and assessment methods used. Conflict of Interest We declare no conflicts of interest or financial interests that the authors or members of their immediate families have in any product or service discussed in the manuscript, including grants (pending or received), employment, gifts, stock holdings or options, honoraria, consultancies, expert testimony, patents and royalties   Type: Original Research

scholarly journals Pharmacist Prescribing for Minor Ailments Service Development: The Experience in Ontario

Pharmacy ◽  
2021 ◽  
Vol 9 (2) ◽  
pp. 96
Author(s):  
Nardine Nakhla ◽  
Anastasia Shiamptanis
Keyword(s):  
Implementation Science ◽  
Stakeholder Engagement ◽  
Pharmacy Service ◽  
Service Development ◽  
Minor Ailment ◽  
Pharmacist Prescribing ◽  
Minor Ailments ◽  
Canadian Provinces ◽  
The Impact

To date, eight of ten Canadian provinces have authorized pharmacists to prescribe for minor ailments. Prompted by a request by the Ontario Minister of Health, draft regulations were submitted to enable this pharmacy service in Ontario. Differences exist in how jurisdictions have approached development and delivery of these programs. This paper will summarize key differences and similarities among existing programs while highlighting the multi-pronged approach utilized by Ontario. Such an approach involved broad stakeholder engagement, implementation science, and an evaluations framework to guide an assessment of the impact of this new service. These insights can be leveraged by other jurisdictions planning to initiate or evolve their minor ailment prescribing services.

Treatment Trade-Offs in Myeloma: a Survey of Consecutive Patients

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 2059-2059
Author(s):  
Brian L. Burnette ◽  
Angela Dispenzieri ◽  
Shaji Kumar ◽  
Jeff Sloan ◽  
Jon Tilburt ◽  
...  
Keyword(s):  
Conflicts Of Interest ◽  
Financial Burden ◽  
Progression Free Survival ◽  
Standard Of Care ◽  
Maintenance Cost ◽  
Trade Offs ◽  
One Year ◽  
The Cost ◽  
First Time ◽  
Mild Toxicity

Abstract Abstract 2059 Introduction: Two randomized trials have demonstrated a benefit in progression free survival (PFS) of 18–20 mofor maintenance treatment with lenalidomide after auto-PBSCT for multiple myeloma (MM). Although results on survival benefit are conflicting and quality of life (QOL) data is lacking, some have begun to recommend maintenance. No study has evaluated patient perceptions of maintenance. We conducted a systematic survey of MM patients (pts) regarding what constitutes a meaningful benefit that would make burdens of maintenance (toxicity and cost) acceptable. Methods: We mailed a brief self-administered survey in 3 waves to 1159 consecutive living pts evaluated at Mayo Clinic. The survey provided background on the standard of care for MM in transplant eligible pts and data on maintenance. Pts were asked to estimate the magnitude of OS benefit that would be acceptable for varying degrees of toxicity and cost. Results: Of the 1159 surveys sent, 886 pts (83.2%) responded, including 150 notifying us of a decision not to participate. 736 pts returned a completed survey (66% raw response rate). (56%) male, 407 (55%) had undergone auto-PBSCT, 467 (63%) had discussed maintenance with a physician, and 9 (1%) pts had received no treatment. 10% of pts had MM for 3–12 mo, 14% for 1–2 yr, 13% for 2–3 yr, 20% for 3–5 yr, 44% for 5 yr or more. Pt age: 4% 18–49 yr, 24% 50–59 yr, 40% 60–69 yr, 27% 70–79 yr, and 6% >80 yrs. The most worrisome potential toxicity was identified as peripheral neuropathy by 27% of pts, cytopenias by 24%, LE DVT 20%, fatigue 15%, nausea 8%, diarrhea/constipation 7%. In response to a question about whether they would choose maintenance if there was a PFS benefit but no improvement in OS, 92% would opt for maintenance if it were known to cause mild toxicity, while 77% would opt for maintenance despite moderate toxicity. Subsequent questions included cost and toxicity considerations and required pts to identify minimum acceptable duration of OS benefit to estimate more precisely a meaningful clinical benefit. If treatment was free, had no toxicity, and the OS benefit was 1 yr or less, 49% would choose maintenance (see Figure). In the same scenario, if toxicities were mild, the proportion of pts who choose maintenance was similar (46%). If pts experienced moderate toxicity, 42% choose maintenance. With rising financial burden (out-of-pocket) and toxicity, the proportion of pts who choose maintenance declined (see Table). For example, if the cost was $25/mo, mild toxicity experienced, and the OS benefit was one year or less, 46% would choose maintenance, while 39% of pts would choose maintenance if it cost $250/month and there was moderate toxicity. If maintenance cost $10,000/mo and was associated with mild or moderate toxicity, 18% and 17% of pts would choose treatment, respectively. Conclusions: For the first time, we have described the broad range of patient perspectives regarding trade-offs in the treatment of MM with maintenance therapy. We found that willingness to be treated with maintenance declined when actual benefits were provided in concrete numeric terms compared with a general statement of PFS benefit. The discrepancy between the 92% of pts choosing to undergo maintenance if free and mild toxicity when there is a PFS benefit but no OS benefit, compared to 49% of pts choosing maintenance if free, mild toxicity, and associated with an OS benefit of 1 yror less; suggests pts have difficulty understanding the concept of PFS. We also found that the magnitude of benefit required to consider maintenance was affected by cost and toxicity. In our experience, pts typically incur a cost of approximately $25/mo and experience mild toxicity. In this study, nearly half (46%) of such pts would opt for maintenance if the OS benefit was 1 year or less while only 33% of pts would opt for maintenance if the OS benefit was 6 months or less. Our data implies that good care in MM requires detailed conversations about each and every patient's priorities and expectations prior to making recommendations for or against such treatments. Disclosures: No relevant conflicts of interest to declare.

scholarly journals Injudicious Provision of Subtherapeutic Doses of Antibiotics in Community Pharmacies

2017 ◽  
Vol 8 (1) ◽  
Author(s):  
Mohamed E Amin ◽  
Amira Amine ◽  
Mohammad Shoukry Newegy
Keyword(s):  
Conflict Of Interest ◽  
Expert Testimony ◽  
Conflicts Of Interest ◽  
Original Research ◽  
Community Pharmacies ◽  
Beta Lactam ◽  
Pharmacy Staff ◽  
Beta Lactam Antibiotics ◽  
Financial Interests ◽  
Group A

Background: Egyptian pharmacists routinely provide antibiotics without a prescription. A few pills of common cold products are offered under the name “cold group”. A cold group may contain one or more pills of antibiotics. This study aimed to estimate the proportion of pharmacies that provide subtherapeutic doses of antibiotics in community pharmacies as part of a CG or upon direct request from a simulated client. Methods: A probability sample of community pharmacies in Alexandria, Egypt was selected. A simulated client approached pharmacy staff using a standardized scenario. He initially requested a cold group and followed by requesting two antibiotic pills.Results: The simulated client visited 104 pharmacies and was sold an antibiotic at 68 pharmacies in total. A cold group with one or more antibiotic pills was provided in 31 pharmacies. Upon request for two antibiotic pills, 2-8 antibiotic pills were provided in 30 pharmacies whereas an antibiotic carton was provided in three pharmacies. In four pharmacies, the simulated client was sold a cold group containing an antibiotic as well as another antibiotic upon request. Beta-lactam antibiotics comprised 76% of antibiotics provided. In five encounters, the simulated client was told that the cold group contained an antibiotic when, in fact, it did not. Conclusions: Subtherapeutic doses of antibiotics are provided at dangerous rates in Alexandria’s community pharmacies. Interventions are urgently needed to tackle different factors contributing to this dangerous practice. Conflict of Interest We declare no conflicts of interest or financial interests that the authors or members of their immediate families have in any product or service discussed in the manuscript, including grants (pending or received), employment, gifts, stock holdings or options, honoraria, consultancies, expert testimony, patents and royalties   Type: Original Research

scholarly journals A Qualitative Analysis of Student Pharmacists’ Response after an Auditory Hallucination Simulation

2017 ◽  
Vol 8 (3) ◽  
pp. 4
Author(s):  
Genevieve L Ness ◽  
J. Michael McGuire ◽  
Prisca Taylor
Keyword(s):  
Qualitative Analysis ◽  
Expert Testimony ◽  
Conflicts Of Interest ◽  
Auditory Hallucination ◽  
Daily Basis ◽  
Pharmacy Students ◽  
Original Research ◽  
Faith Based ◽  
Financial Interests ◽  
Question Prompt

Objectives: The goal of this research was to evaluate pharmacy students’ experiences and reactions when exposed to an auditory hallucination simulator. Methods: A convenient sample of 16 pharmacy students enrolled in the Advanced Psychiatry Elective at a private, faith-based university in the southeastern United States was selected. Students participated in an activity in which they listened to an auditory hallucination simulator from their personal laptop computers and completed a variety of tasks. Following the conclusion of the simulator, students composed a reflection guided by a five-question prompt. Qualitative analysis of the reflections was then completed to identify and categorize overarching themes. Results: The overarching themes identified included: 1) students mentioned strategies they used to overcome the distraction; 2) students discussed how the voices affected their ability to complete the activities; 3) students discussed the mental/physical toll they experienced; 4) students identified methods to assist patients with schizophrenia; 5) students mentioned an increase in their empathy for patients; 6) students reported their reactions to the voices; 7) students recognized how schizophrenia could affect the lives of these patients; and 8) students expressed how their initial expectations and reactions to the voices changed throughout the course of the simulation. Overall, the use of this simulator as a teaching aid was well received by students. Summary: In conclusion, pharmacy students were impacted by the hallucination simulator and expressed an increased awareness of the challenges faced by these patients on a daily basis. Conflict of Interest We declare no conflicts of interest or financial interests that the authors or members of their immediate families have in any product or service discussed in the manuscript, including grants (pending or received), employment, gifts, stock holdings or options, honoraria, consultancies, expert testimony, patents and royalties.   Type: Original Research

scholarly journals Multiple Bosses: Challenges and suggestions to improve organizational environments in academic settings.

2016 ◽  
Vol 7 (2) ◽  
Author(s):  
Agnes Ann Feemster ◽  
T. Joseph Mattingly
Keyword(s):  
Conflicts Of Interest ◽  
Pharmacy Practice ◽  
Job Dissatisfaction ◽  
Additional Stress ◽  
Original Research ◽  
Organizational Environments ◽  
Academic Settings ◽  
Financial Interests ◽  
Reporting Structure ◽  
Teaching Responsibilities

Practice faculty members are often supervised by more than one individual, creating a reporting structure that mirrors a matrix organization. They are tasked with balancing administrative and teaching responsibilities established by the school with expectations of maintaining a pharmacy practice site. A matrix reporting structure offers opportunities for enhanced development, but risks of additional stress from the organizational complexity must be mitigated to reduce job dissatisfaction. Frequent and consistent communication, mutual agreement and alignment of expectations and priorities, and the ability to manage conflict and adapt to change will aid pharmacy practice faculty in managing the relationship between their primary employer (the school) and the contracted entity. Conflict of Interest We declare no conflicts of interest or financial interests that the authors or members of their immediate families have in any product or service discussed in the manuscript, including grants (pending or received), employment, gifts, stock holdings or options, honoraria, consultancies, expert testimony, patents and royalties.   Type: Original Research

scholarly journals Comparison of Reading Levels of Pharmacy Students and Reading Level of Primary Literature

2016 ◽  
Vol 7 (3) ◽  
Author(s):  
Cathy H Ficzere ◽  
Angela Hagan ◽  
Genevieve Lynn Ness ◽  
Elisa M. Greene ◽  
Kayla Hill
Keyword(s):  
Second Language ◽  
Grade Level ◽  
Conflicts Of Interest ◽  
Demographic Data ◽  
Reading Level ◽  
Pharmacy Students ◽  
Original Research ◽  
Reading Levels ◽  
Primary Literature ◽  
Financial Interests

Objectives: The project purpose was to evaluate pharmacy students’ reading levels using the Nelson-Denney Reading Test (NDRT) and compare these results with the reading level of primary literature to investigate incongruities between student’s comprehension ability and the readability level of assigned reading in the curriculum. Methods: The NDRT was administered to first- through third-year student pharmacists to determine grade equivalents (GE) for vocabulary and reading comprehension. Twenty articles previously identified as Patient-Oriented Evidence that Matters (POEMs) were analyzed to determine the Flesch-Kincaid Grade Level and Gunning-Fog Score. Student demographics, information regarding language spoken, and reading habits, were also assessed. Pearson product moment correlations, t-tests, ANOVA, and descriptive statistics were used to assess relationships between demographic data and NDRT scores. Results: One hundred students participated. The mean NDRT total grade equivalent (±SD) was 16.95 ± 2.1 (median = 17.3). NDRT grade equivalents were statistically different for students with different racial or ethnic backgrounds (t(98)=3.74, p=0.026), English as a second language (ESL) students (t(98)=5.19, p=0.021), and students that read works of fiction for pleasure (t(98)=4.31, p=0.002). The average Gunning-Fog Score for all primary literature articles was 11.48, with the introduction section being the most complex. The average Flesch-Kincaid Grade Level was 17.04, with the results section scoring the lowest average grade level. Implications: While the overall reading grade level of our pharmacy students suggests that they are capable of comprehending reading assigned in the pharmacy curriculum, minority students and students for whom English is a second language may struggle with comprehending complex text. Conflict of Interest We declare no conflicts of interest or financial interests that the authors or members of their immediate families have in any product or service discussed in the manuscript, including grants (pending or received), employment, gifts, stock holdings or options, honoraria, consultancies, expert testimony, patents and royalties.   Type: Original Research

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