Trauma care in crisis: war trauma and mental health funding.

Background: Israel is currently under a state of continued unrest and state of war. There has been an influx of financial aid to treat the mental health fallout both from within Israel and abroad. Despite increased research into resilience, treatment and wide-scale interventions, there is a concern that this is not significantly influencing mental health aid allocation.Objective: This letter to the editor aims to describe the current situation and address current difficulties in regard to the relevant literature from recent conflicts and national traumatic events.Method: A consortium of national and international trauma experts pooled together their knowledge to produce a working statement based on evidence from clinical and research findings.Results: As opposed to wider, short-term psychological interventions which have limited long-term proven efficacy, lessons from previous war zones, wide-scale exposure to trauma and current war-torn countries highlight the importance of targeting and assessment, addressing barriers to care, strengthening existing systems and promoting community resilience and care.Conclusions: In addition to acute care, funding should be allocated to long-term care, enhancing treatment accessibility and community follow-up and additionally support long-term research to assess effectiveness and contribute to international knowledge.

Immediately following widescale attacks, national disasters and outbreaks of war there is a tendency for an outpouring of aid, and in recent years, mental health aid.Despite an increase in research in the field there are still significant gaps in the literature and a disconnect between the evidence and economic and philanthropic policy with short-term initiatives often favoured over long-term strategic planning.It is recommended that greater attention be paid to targeting and assessment, addressing barriers to care, strengthening existing systems and promoting community care.

How do you see me? The impact of perceived societal recognition on PTSD symptoms amongst Norwegian peacekeepers.

Background: The peacekeeper role is different to that of traditional combat, however, peacekeepers, like combat soldiers, may also be exposed to high levels of dangerous and/or potentially morally injurious events (PMIEs).Objective: It was hypothesized that given the centrality of societal approval for the peacekeeping mission, in addition to the known relevance of perceived social support, perceived societal recognition would influence PTSD symptoms (PTSS) and depression. It was hypothesized that perceived societal recognition would moderate the effect of exposure to potentially traumatic events and PMIEs on psychological outcomes.Method: 8341, predominantly male, former UNIFIL peacekeepers, almost three decades following deployment, answered a survey to determine the impact of perceived social support and perceived societal recognition, on PTSS and depression symptoms. Hierarchical regression analyses were performed for PTSS and depression separately and moderation analysis was performed for perceived societal recognition.Results: Exposure to potentially traumatic events showed the greatest predictive value for PTSS and exposure to PMIEs and potentially traumatic events were equally predictive of depression symptoms. While perceived social support presented the strongest buffer for PTSS and depression symptoms following UNIFIL deployment, perceived societal recognition also significantly contributed to the prediction of both PTSS and depression symptoms. There was a weak moderation effect of perceived societal recognition on trauma type in the development of PTSS.Conclusions: Even decades following peacekeeping deployment, military experiences have a significant impact on psychological functioning. This impact is both from the types of events experienced and from the perception of social and societal support upon return home.

Peacekeepers receive little attention in general military research and their missions are often directly influenced by public perception.The current study found that key military traumas; danger based and moral injury based events, were prevalent in the peacekeeper population and predicted PTSD symptoms and depression symptoms respectively.While there was a weak moderation effect, perceived societal recognition was a unique predictor of PTSD symptoms. Those who perceived negative levels of societal recognition of the UNIFIL mission had greater PTSD symptoms than those who perceived neutral or positive levels of societal recognition.

Exposure to combat experiences: PTSD, somatization and aggression amongst combat and non-combat veterans.

To this date, the prevalence of posttraumatic stress disorder (PTSD) and associated psychological symptom profiles amongst non-combatant community-based veterans in Israel has not been studied. Data were analysed from a web-based survey of veterans via a market research platform during September 2021 and included 522 non-combat (e.g. intelligence, office-based or education corps) veterans and 534 combat (e.g. front-line infantry) veterans. The survey assessed PTSD, depression, anxiety and somatic symptoms in addition to the prevalence of self-reported aggression. A two-way multivariate analysis of covariance indicated that higher PTSD and somatic symptoms were prevalent for those exposed to combat experiences even when not in a combatant role. A logistic regression indicated that of those who did not self-define as aggressive prior to service, those exposed to combat were three times more likely to be aggressive following their service than veterans not exposed to combat. This effect was not demonstrated for combat soldiers compared to non-combat soldiers. Results indicate that mental health outreach would be better targeted towards those who have been exposed to combat-type experiences during their service even in non-combat units. The current study highlights the effect of combat exposure on secondary PTSD symptoms; aggression and somatization.

Parenthood during the COVID-19 pandemic: Post-traumatic growth amongst university students.

This study sought to investigate a positive dimension of coping with the COVID-19 pandemic, that of post-traumatic growth (PTG). This study investigated coping difficulties and PTG amongst parent and nonparent students in Israeli Universities. A total of 4022 parents (3648 Jews and 374 Palestinian-Arab Citizens [PACs]) and 14,651 nonparents (12,010 Jews and 2641 PACs) completed measures of coping, social support and PTG. Parents demonstrated significantly higher levels of coping and PTG. Amongst parents, fathers coped slightly better than mothers; however, while Jewish mothers demonstrated greater PTG than Jewish fathers, PAC fathers had significantly greater PTG than both PAC mothers and Jewish parents. These findings, while specific to COVID-19, indicate that PTG should be studied in greater depth in different ethnic and minority groups in order to develop enhanced understanding and facilitate promotion of post-traumatic growth, in addition to the prevention of COVID-19-related distress.

Environmental Health Literacy as Knowing, Feeling, and Believing: Analyzing Linkages between Race, Ethnicity, and Socioeconomic Status and Willingness to Engage in Protective Behaviors against Health Threats.

This study investigates the relationships between environmental health literacy, the characteristics of people (race, ethnicity, and socioeconomic status) associated with health disparities, and people's willingness to engage in protective behaviors against environmental health threats. Environmental health literacy is a framework for capturing the continuum between the knowledge of environmental impacts on public health, and the skills and decisions needed to take health-protective actions. We pay particular attention to three dimensions of environmental health literacy: factual knowledge (knowing the facts), knowledge sufficiency (feeling ready to decide what to do), and response efficacy (believing that protective behaviors work). In June 2020, we collected survey data from North Carolina residents on two topics: the viral infection COVID-19 and industrial contaminants called per- and polyfluoroalkyl substances (PFAS). We used their responses to test stepwise regression models with willingness to engage in protective behaviors as a dependent variable and other characteristics as independent variables, including environmental health literacy. For both topics, our results indicated that no disparities emerged according to socioeconomic factors (level of education, household income, or renting one's residence). We observed disparities in willingness according to race, comparing Black to White participants, but not when comparing White to American Indian, Alaska Native, Asian, Native Hawaiian, or Pacific Islander participants nor Hispanic to non-Hispanic participants. The disparities in willingness between Black and White participants persisted until we introduced the variables of environmental health literacy, when the difference between these groups was no longer significant in the final regression models. The findings suggest that focusing on environmental health literacy could bridge a gap in willingness to protect oneself based on factors such as race/ethnicity and socioeconomic status, which have been identified in the environmental health literature as resulting in health disparities.

Peace of mind: Promoting psychological growth and reducing the suffering of combat veterans.

The Peace of Mind (POM) program was designed to enable combat veterans in Israel to process their combat experience, address difficulties in the transition to civilian life and facilitate psychological growth as a result of their military experience. During the course of the program, 1068 participants were studied at four time points. Post-traumatic symptoms were measured using the PTSD checklist for DSM-5 (PCL-5), and post-traumatic growth (PTG) was measured using the Post Traumatic Growth Inventory (PTGI). Multilevel Modeling (MLM) was used to assess symptom and psychological trajectories for all participants and for those who began with and without PTSD symptoms, respectively. The results demonstrated that those who began the program with elevated PTSD symptoms experienced a significant reduction in PTSD symptoms following the completion of the intensive element of the program. Additionally, all participants demonstrated an increase in PTG following the intensive section of the program and this was maintained throughout follow-up. The findings indicate that the POM program is beneficial in relation to both positive and negative outcomes of traumatic military experiences though it is clear that the transition from combat to civilian life is more complex than the current measures identify and that further research needs to examine the distinct lifestyle and functional changes which occur following the program.

The Effect of Martial Arts Training on Cognitive and Psychological Functions in At-Risk Youths.

The current study assessed whether an extended program of martial arts training was a viable intervention for at-risk youths in improving cognitive and psychological functions. Adolescent boys attending specialized education facilities for at-risk youths took part in regular sport lessons or martial arts practice twice a week for 6 months. Hormonal reactivity was assessed during initial training, and measures of psychological (aggression, self-esteem) and cognitive (inhibition, flexibility, speed of processing, and attention) functions were assessed before and immediately following the intervention. Participants in the martial arts training demonstrated significant improvement in the domains of inhibition and shifting and speed of processing. Additionally, initial hormonal reactivity (oxytocin and cortisol) to the intervention predicted significant post-intervention change on several measures of cognitive and psychological functioning. Specifically, oxytocin reactivity predicted improvement in processing speed, as well as reduction of aggression, whereas cortisol reactivity predicted increases in self-esteem. This pioneering, ecologically valid study demonstrates the initial efficacy of this enjoyable, readily available, group intervention for at-risk boys and suggests potential mechanisms that may mediate the process of change.

Systematic screening for vasa previa at the 20-week anomaly scan.

INTRODUCTION: The presence of vasa previa carries a high risk for severe fetal morbidity and mortality due to fetal bleeding caused by injury to unprotected fetal vessels when rupture of membranes occurs. Previously, it has been shown that prenatal diagnosis significantly improves the outcome. However, systematic screening for vasa previa is not generally performed and clinical studies demonstrating the performance of systematic screening for vasa previa in routine clinical practice are rare. The objective of this study was to assess the performance of systematic screening for vasa previa by determining placental cord insertion at the 20-week anomaly scan. MATERIAL AND METHODS: This is a retrospective study of 6038 pregnant women between 18+0 and 24+0 gestational weeks who were prospectively screened for vasa previa by depiction of the site of placental cord insertion at the 20-week anomaly scan. Pregnancies with marginal or velamentous cord insertion underwent vaginal sonography for examination for vasa previa. In cases with succenturiate or bilobed placentas, the bridging vessels were depicted, and vaginal sonography was performed if necessary. RESULTS: There were 21 cases of vasa previa and all were diagnosed prenatally. In 18 cases, the cord insertion was marginal or velamentous. The remaining three cases had placental anomalies, which necessitated a detailed examination. All pregnancies with vasa previa were delivered at a mean of 35.2 (SD 1.8) gestational weeks by cesarean section. Among pregnancies affected by vasa previa, all fetuses survived. The median birthweight was 2390 g (range 1200-2990 g) and the mean umbilical artery pH 7.34 (SD 0.04). The median 5-min APGAR score was nine (range 7-10). None of the fetuses or neonates died or required blood transfusions. In all pregnancies of the whole cohort which were complicated by fetal or neonatal demise and in neonates with a 5-min APGAR score ≤5 and/or an umbilical artery pH ≤7.10, fetal blood loss was excluded as a cause of the poor obstetric outcome. CONCLUSIONS: Screening for vasa previa is feasible and efficient, taking into account the site of placental cord insertion in pregnancies not affected by placenta previa and bilobed and succenturiate placenta.

The Contagion of Psychopathology across Different Psychiatric Disorders: A Comparative Theoretical Analysis.

Psychopathology is often studied and treated from an individual-centered approach. However, studies have shown that psychological distress is often best understood from a contextual, environmental perspective. This paper explores the literature on emotional contagion and symptom transmission in psychopathology, i.e., the complex ways in which one person's psychological distress may yield symptoms among others in his/her close environment. We argue that emotions, cognitions, and behaviors often do not stay within the borders of the individual, but rather represent intricate dynamic experiences that are shared by individuals, as well as transmitted between them. While this claim was comprehensively studied in the context of some disorders (e.g., secondary traumatization and the "mimicking" of symptoms among those close to a trauma survivor), it was very scarcely examined in the context of others. We aim to bridge this gap in knowledge by examining the literature on symptom transmission across four distinct psychiatric disorders: PTSD, major depression, OCD, and psychosis. We first review the literature on emotional contagion in each disorder separately, and then we subsequently conduct a comparative analysis highlighting the shared and differential mechanisms underlying these processes in all four disorders. In this era of transdiagnostic conceptualizations of psychopathology, such an examination is timely, and it may carry important clinical implications.

Hormonal reactivity during martial arts practice among high-risk youths.

Martial arts have become a popular afterschool activity for youths across the globe. Accumulating data suggest that these activities may confer substantial cognitive and psychological benefits, and recent efforts have been made to introduce martial arts training into educational and rehabilitation settings. However, few studies have examined the potential mechanisms that may underlie these benefits. The current study evaluated the reactivity of two hormones, oxytocin (OT) and cortisol (CT), thought to be respectively involved in regulating mammalian social behaviors and responsivity to stress, to a session of intensive martial arts training in samples of at high-risk and low-risk (in regular educational establishments) youths. OT and CT were measured at baseline, during peak training, and following a cool down period. Analyses revealed that high-risk youths had lower OT but similar CT baseline levels, compared to low-risk youths, prior to the martial arts session. A significant group by time interaction indicated that whereas the OT levels among low-risk youths returned to baseline levels following training, OT levels among high-risk youths remained elevated. Finally, unlike low-risk youths for whom CT levels continued to increase throughout the training session, high-risk youths showed no significant CT reactivity. This study suggests that some of the beneficial effects of martial arts may be related to hormonal processes, especially increases in OT levels, and highlights the differing effects that training may have in different populations.

Perception of Caregiving During Childhood is Related to Later Executive Functions and Antisocial Behavior in At-Risk Boys.

Executive functions are considered essential for effective navigation in the social world. Parental responsiveness is a critical ingredient for normative social development and, as such, may be connected with the development of executive functions. Disruption of this development may, in turn, lead to maladaptive and antisocial behaviors. The purpose of this study was to evaluate the nature of the connections among perceived patterns of caregiving experienced in childhood, executive functions, and antisocial behaviors in at-risk adolescents. Seventy-one adolescent boys were recruited from two high-schools for adolescents who were not deemed suitable for regular schooling due to behavioral and emotional issues. Executive functions were tested using a computer-administered neuropsychological battery (CANTAB), and maternal parenting experiences and antisocial behaviors were assessed using retrospective and current questionnaires. Structural equation modeling (SEM) approach was employed to examine whether executive functions mediated the relationship between children's perceived patterns of maternal care and subsequent development of antisocial behaviors. Although maternal care had a significant direct effect on executive function (standardized coefficient = .49, p = .03) and antisocial behavior (standardized coefficient = .53, p = .05), SEM demonstrated no mediating relationships among these variables. Instead, maternal care predicted unique variance in both executive functions (standardized coefficient = .61, p = .02) and antisocial behavior (standardized coefficient = .51, p = .05). This study suggests a link between the experience of childhood caregiving and adolescent executive functions and delinquency and highlights the importance of early parenting interventions to aid executive function development. Such early interventions could potentially enhance long-term pro-social behavior.

Non-pharmacological interventions for cognitive difficulties in ADHD: A systematic review and meta-analysis.

Attention deficit hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder in children and is associated with significant risk of educational failure, interpersonal problems, mental illness, and delinquency. Despite a number of comparative and comprehensive reviews on the effects of ADHD treatments on ADHD core symptoms, evidence synthesizing the effects of ADHD interventions on cognitive difficulties is limited. In this meta-analysis, the neuropsychological effects of non-pharmacological interventions for ADHD were examined across studies published between 1980 and 2017. Data were extracted from studies that used objective cognitive measures (either computerized or pencil-and-paper), and multiple meta-analyses were conducted to compare the effectiveness across these interventions. Publication bias was assessed, as well as quality of the evidence, using Cochrane risk of bias tool for randomized control trials studies. Our final meta-analysis included 18 studies with interventions that were categorized into four categories: neurofeedback, cognitive-behavioral therapy, cognitive training, and physical exercises. Physical exercises demonstrated the highest average effect size (Morris d = 0.93). A further evaluation of cognitive functions yielded 49 effect sizes for the five categories, including attention, inhibition, flexibility, and working memory. Analyses demonstrated a homogenous, medium to large, effect size of improvement across interventions, with inhibition demonstrating the largest average effect size (Morris d = 0.685). This study highlights the positive effect of psychological interventions on ADHD cognitive symptomology and supports the inclusion of non-pharmacological interventions in conjunction with the commonly used pharmacological treatments.

Return to Babel.

End of life and beginning of life are surprisingly similar. What can we learn about the value and nature of our lives from dementia and aging?

KCTD12 Auxiliary Proteins Modulate Kinetics of GABAB Receptor-Mediated Inhibition in Cholecystokinin-Containing Interneurons.

Cholecystokinin-expressing interneurons (CCK-INs) mediate behavior state-dependent inhibition in cortical circuits and themselves receive strong GABAergic input. However, it remains unclear to what extent GABAB receptors (GABABRs) contribute to their inhibitory control. Using immunoelectron microscopy, we found that CCK-INs in the rat hippocampus possessed high levels of dendritic GABABRs and KCTD12 auxiliary proteins, whereas postsynaptic effector Kir3 channels were present at lower levels. Consistently, whole-cell recordings revealed slow GABABR-mediated inhibitory postsynaptic currents (IPSCs) in most CCK-INs. In spite of the higher surface density of GABABRs in CCK-INs than in CA1 principal cells, the amplitudes of IPSCs were comparable, suggesting that the expression of Kir3 channels is the limiting factor for the GABABR currents in these INs. Morphological analysis showed that CCK-INs were diverse, comprising perisomatic-targeting basket cells (BCs), as well as dendrite-targeting (DT) interneurons, including a previously undescribed DT type. GABABR-mediated IPSCs in CCK-INs were large in BCs, but small in DT subtypes. In response to prolonged activation, GABABR-mediated currents displayed strong desensitization, which was absent in KCTD12-deficient mice. This study highlights that GABABRs differentially control CCK-IN subtypes, and the kinetics and desensitization of GABABR-mediated currents are modulated by KCTD12 proteins.

Changes of locoregional skin temperature in neonates undergoing laser needle acupuncture at the acupuncture point large intestine 4.

Laser acupuncture bears a potential risk for the skin surface, especially in neonates whose skin has histological and physiological peculiarities. We evaluated thermal changes of skin temperature in neonates during laser acupuncture by using a thermal camera (Flir i5, Flir Systems Inc., Portland, USA). Laserneedles (Laserneedle GmbH, Glienicke/Nordbahn, Germany) were fixed to the skin at Large Intestine 4 (LI 4, Hegu), bilaterally. Before application of laser acupuncture (685 nm, 15 mW, 500 µm), as well as after 1, 5, and 10 min, thermographic pictures of both hands were taken. The measuring was carried out on the 23rd day after birth (20 neonates, mean postmenstrual gestational age 38 + 2, mean weight 2604 g). Compared to the initial temperature of 34.2°C on the right hand, the skin temperature had increased to 35.3°C (P < 0.05) after 5 min and up to 36.1°C (P < 0.05) after 10 min of stimulation. Equally, on the left hand, an increase of the skin temperature from 34.5°C to 35.9°C (P < 0.05) and 35.9°C (P < 0.05) was measured. The highest measured skin temperature after 10 min of stimulation amounted to 38.7°C, without any clinically visible changes on the skin surface.

Differential GABAB-receptor-mediated effects in perisomatic- and dendrite-targeting parvalbumin interneurons.

Inhibitory parvalbumin-containing interneurons (PVIs) control neuronal discharge and support the generation of theta- and gamma-frequency oscillations in cortical networks. Fast GABAergic input onto PVIs is crucial for their synchronization and oscillatory entrainment, but the role of metabotropic GABA(B) receptors (GABA(B)Rs) in mediating slow presynaptic and postsynaptic inhibition remains unknown. In this study, we have combined high-resolution immunoelectron microscopy, whole-cell patch-clamp recording, and computational modeling to investigate the subcellular distribution and effects of GABA(B)Rs and their postsynaptic effector Kir3 channels in rat hippocampal PVIs. Pre-embedding immunogold labeling revealed that the receptors and channels localize at high levels to the extrasynaptic membrane of parvalbumin-immunoreactive dendrites. Immunoreactivity for GABA(B)Rs was also present at lower levels on PVI axon terminals. Whole-cell recordings further showed that synaptically released GABA in response to extracellular stimulation evokes large GABA(B)R-mediated slow IPSCs in perisomatic-targeting (PT) PVIs, but only small or no currents in dendrite-targeting (DT) PVIs. In contrast, paired recordings demonstrated that GABA(B)R activation results in presynaptic inhibition at the output synapses of both PT and DT PVIs, but more strongly in the latter. Finally, computational analysis indicated that GABA(B) IPSCs can phasically modulate the discharge of PT interneurons at theta frequencies. In summary, our results show that GABA(B)Rs differentially mediate slow presynaptic and postsynaptic inhibition in PVIs and can contribute to the dynamic modulation of their activity during oscillations. Furthermore, these data provide evidence for a compartment-specific molecular divergence of hippocampal PVI subtypes, suggesting that activation of GABA(B)Rs may shift the balance between perisomatic and dendritic inhibition.

Human mesenchymal stem cell proliferation and osteogenic differentiation during long-term ex vivo cultivation is not age dependent.

Mesenchymal stem cells (MSCs) are of major clinical interest for the development of cell-based strategies to treat musculoskeletal diseases including critical-size bone defects caused by trauma, degenerative disorders, or infections. Elderly people mainly suffer from critical-size bone defects from the rising incidence of trauma, osteoporosis, and arthroplasties. In this study we investigated the influence of donor age on proliferation and osteogenic differentiation in long-term ex vivo cultures of primary human MSCs from patients in different age groups. Fifteen patients (8 men/7 women) comprised three age groups: (I) <50 years, (II) 50-65 years, and (III) >65 years. MSCs harvested from bone marrow derived from routine surgical procedures were isolated and cultured in standard medium over eight passages. Osteogenic differentiation was induced by dexamethasone (10 nM), ascorbic acid (300 µM), and ß-glycerophosphate (3.5 mM). Osteogenic differentiation capacity of MSCs was quantified by alkaline phosphatase (ALP) activity, fluorescence-activated cell sorting (FACS) analysis of the surface markers CD9, CD90, CD54, CD166, CD105, CD44, and CD73, and RT-PCR for Coll I and II, Cbfa 1, ALP, OC, BSP1, and GAPDH genes characterized the phenotypic changes during monolayer expansion. In vitro chondrogenic differentiation was analyzed by immunohistochemistry and RT-PCR. Progenitor cells could be expanded in the long term from all bone marrow donations. FACS single staining analysis from MSCs showed no significant difference between the age groups. The surface antigen CD166 was predominantly found in all cell cultures independently of differentiation stage. Comparison of expanded and differentiated MSCs within a single age group showed that undifferentiated MSCs had higher CD44 levels. Osteogenic stimulation of MSCs was confirmed by measuring ALP activity. The highest ALP activity was found in probands of the age group >65 years. Additionally, we observed a tendency toward male-specific ALP increase during differentiation. Osteogenic marker gene expression in MSCs was detected by RT-PCR. No significant expression differences were detected between the three donor age groups. Micromass culture of MSCs resulted histologically and immunohistologically in a chondrogenic phenotype. Elderly osteoprogenitor cell donors are a highly clinically relevant patient population. In summary, cultivation leads to a reduced osteogenic differentiation capacity regardless of age. Because donor age does not affect osteogenic differentiation potential, it should not be used as an exclusion criterion for autologous transplantation of human adult MSCs.

The RHINASTHMA GAV scores without SLIT, at the beginning and at the end of seasonal SLIT.

BACKGROUND: The impact of treatments for allergic rhinitis on health-related quality of life (HRQL) becomes more and more important in the view of patients, physicians and payers, but not much is known about the effect of sublingual immunotherapy (SLIT) on this outcome parameter. METHODS: In a prospective observational study, health-related quality of life was assessed with the German adapted version of a new specific questionnaire (RHINASTHMA GAV) in patients with allergic rhinitis with or without mild to moderate asthma due to grass, cereal, and/or rye pollen who were treated with seasonal high-dose SLIT with standardized allergen extracts. RESULTS: 358 patients aged 5 - 68 years, mean +/- SD disease duration of 8.8 +/- 9.2 years were evaluated. During SLIT, the mean total score and all 5 mean sub-scale scores were substantially reduced by 36% to 55%. Subgroup analyses did not reveal any clinically relevant deviations from the results in the total study population. At the end of SLIT, mean total score and sub-scale scores were virtually identical to those scores assessed during the validation procedure of RHINASTHMA GAV in healthy subjects without rhinitis, conjunctivitis, or asthma. These improvements in HRQL during SLIT were paralleled by substantially reduced disease-related burden, in terms of symptom scores and health-related impairment in daily life and at work. CONCLUSION: The improvement in HRQL during seasonal SLIT was clinically relevant and reached scores close to normal already in the first pollen season.