Reconsolidation of traumatic memories protocol compared to trauma-focussed cognitive behaviour therapy for post-traumatic stress disorder in UK military veterans: a randomised controlled feasibility trial.

BACKGROUND: Post-traumatic stress disorder (PTSD) occurs more commonly in military veterans than the general population. Whilst current therapies are effective, up to half of veterans commencing treatment do not complete it. Reconsolidation of Traumatic Memories (RTM) protocol is a novel, easy to train, talking therapy with promising findings. We examine the feasibility of undertaking an efficacy trial of RTM in veterans. METHODS: A parallel group, single-centre randomised controlled feasibility trial with a post-completion qualitative interview study. Sixty military veterans were randomised 2:1 to RTM (n = 35) or Trauma Focussed Cognitive Behaviour Therapy (CBT) (n = 25). We aimed to determine the rate of recruitment and retention, understand reasons for attrition, determine data quality and size of efficacy signal. We explored veterans' perceptions of experiences of joining the trial, the research procedures and therapy, and design improvements for future veteran studies. Military veterans with a diagnosis of PTSD or complex PTSD, and clinically significant symptoms, were recruited between January 2020 and June 2021. Primary outcome was feasibility using pre-determined progression criteria alongside PTSD symptoms, with depression, recovery, and rehabilitation as secondary outcomes. Data were collected at baseline, 6, 12, and 20 weeks. Interviews (n = 15) were conducted after 20 weeks. Both therapies were delivered by trained charity sector provider therapists. RESULTS: Participants' mean age was 53 years, the mean baseline PTSD symptoms score assessed by the Post-traumatic Stress Checklist (PCL-5) was 57 (range 0-80). Fifty had complex PTSD and 39 had experienced ≥ 4 traumas. Data were analysed at 20 weeks for feasibility outcomes (n = 60) and mental health outcomes (n = 45). Seven of eight progression criteria were met. The RTM group experienced a mean 18-point reduction on the PCL-5. TFCBT group participants experienced a mean reduction of eight points. Forty-eight percent of the RTM group no longer met diagnostic criteria for PTSD compared to 16% in the TFCBT group. All veterans reported largely positive experiences of the therapy and research procedures and ways to improve them. CONCLUSION: RTM therapy remains a promising psychological intervention for the treatment of PTSD, including complex PTSD, in military veterans. With specific strengthening, the research protocol is fit for purpose in delivering an efficacy trial. TRIAL REGISTRATION: ISRCTN registration no 10314773 on 01.10.2019. Full trial protocol: available on request or downloadable at ISRCTN reg. no. 10314773.

Social and economic costs of gambling problems and related harm among UK military veterans.

INTRODUCTION: Military veterans are at heightened risk of problem gambling. Little is known about the costs of problem gambling and related harm among United Kingdom (UK) Armed Forces (AF) veterans. We investigated the social and economic costs of gambling among a large sample of veterans through differences in healthcare and social service resource use compared with age-matched and gender-matched non-veterans from the UK AF Veterans' Health and Gambling Study. METHODS: An online survey measured sociodemographic characteristics, gambling experience and problem severity, mental health and healthcare resource utilisation. Healthcare provider, personal social service and societal costs were estimated as total adjusted mean costs and utility, with cost-consequence analysis of a single timepoint. RESULTS: Veterans in our sample had higher healthcare, social service and societal costs and lower utility. Veterans had greater contacts with the criminal justice system, received more social service benefits, had more lost work hours and greater accrued debt. A cost difference of £590 (95% CI -£1016 to -£163) was evident between veterans with scores indicating problem gambling and those reporting no problems. Costs varied by problem gambling status. CONCLUSIONS: Our sample of UK AF veterans has higher healthcare, social service and societal costs than non-veterans. Veterans experiencing problem gambling are more costly but have no reduction in quality of life.

Childhood adversities in UK treatment-seeking military veterans.

INTRODUCTION: The long-term consequences of adverse childhood experiences (ACEs) on adult physical and mental health are well documented in the literature. The current study sought to examine this relationship in a sample of UK treatment-seeking military veterans. METHODS: The data were collected through a cross-sectional self-report survey from military veterans who have sought help for mental health difficulties from a veteran-specific UK-based charity. The response rate was 67.2% (n=403) and the effective sample for this study consisted of 386 male veterans. Participants' history of ACEs and current mental/physical health difficulties were assessed. A latent class analysis was conducted to categorise participants into subgroups based on their ACEs and the relationship of these to the mental and physical health outcomes was examined. RESULTS: Five classes of veterans with different combinations of ACEs were identified. A total of 97% reported at least one ACE. There were minimal differences between the classes on mental and physical health outcomes, but the total number of ACEs was related to aggression, common mental health problems and post-traumatic stress disorder (PTSD). CONCLUSIONS: No combination of ACEs was specifically predictive of adverse mental/physical health difficulties in our sample. Instead, those with a higher number of ACEs may be more prone to developing problems with aggression, common mental health problems and PTSD. Assessing the history of childhood adversities in military veterans is therefore important when veterans are seeking help for mental health difficulties, as some of these may be related to childhood adversities and may need to be addressed in treatment.

Predictors of not working among treatment-seeking UK veterans: a cross-sectional study.

INTRODUCTION: Many veterans do well reintegrating to civilian life following military service. Yet, many face difficulties in finding and securing work. Veterans are more likely than civilians to experience work difficulties, but there remains little research investigating contributing factors, particularly among samples of treatment-seeking veterans. As such, the study examines predictors of not working among UK treatment-seeking veterans. DESIGN: The study employed a cross-sectional design. METHODS: Of 667 treatment-seeking UK veterans, 403 (Mage =50.94) provided information on a range of demographic variables, military-related experiences, the total number of physical health conditions and mental health outcomes. Work status was categorised as not working due to illness (Mage =48.15), not working due to other reasons (Mage =61.92) and currently working (Mage = 46.13). RESULTS: Prevalence rates of not working was 69%. Not working was predicted by a greater number of physical health problems as well as more years since leaving the military. Not working due to poor health was independently predicted by symptoms of post-traumatic stress disorder (PTSD) and younger age, while not working due to other reasons was predicted by older age. CONCLUSIONS: The study revealed that treatment-seeking veterans of younger age with a high number of physical health difficulties, symptoms of PTSD and more years since leaving the military are most at risk of not working due to ill health. The findings have important implications for identifying veterans most at risk of not working and offer the opportunity to tailor rehabilitation programmes to promote successful veteran reintegration into civilian life.

Childhood adversities and psychopathology among military veterans in the US: The mediating role of social networks.

Childhood adversities can impact negatively on psychological health across the lifespan. Many military veterans have a history of adverse childhood experiences, which when combined with deployment related traumas, can lead to high levels of psychopathology. Social networks can however be protective. The current study aimed to identify typologies of childhood adversity in U.S. military veterans (n = 3092) and explore relationships between the adversity typologies and PTSD, mood and anxiety disorders, utilising data from the National Epidemiological Survey on Alcohol and Related Conditions-III (NESARC-III). The mediating role of quality and quantity of social networks were examined. Latent class analysis identified four adversity classes; 1) baseline, 2) household dysfunction, 3) maltreatment, and 4) multi-adversity. Individuals in the adversity classes (2-4), especially those who experienced multi-adversity had higher rates of psychopathology. The quality of social networks played an important mediating role, while quantity of networks did not. Those who experienced adversity were less likely to have supportive social networks, therefore adversity had both a direct and indirect impact on psychopathology. The findings highlight the importance of developing and maintaining social networks following military life. Recommendations include interpersonal skills training and programmes which may help them engage back into the community and enhance relationships.

A latent profile analysis of PTSD symptoms among UK treatment seeking veterans.

Background: Significant numbers of individuals leave the military and experience symptoms of posttraumatic stress disorder (PTSD). Veterans with PTSD symptoms rarely experience them in isolation, more commonly they are co-morbid with a range of other difficulties. Objective: Latent profile analysis (LPA) was used to explore the heterogeneity of PTSD symptom presentation. Following this, regression analysis was used to examine variables that predicted membership to the identified PTSD profiles. Methods: Data on childhood adversity, socio-demographic characteristics and mental health outcomes was collected from 386 male veterans who had engaged with mental health services in the UK. Results: LPA identified a six-profile model to best describe the sample. There was a Low symptom profile, a Severe symptom profile and four Moderate symptom profiles. The Severe symptom profile was the largest one, accounting for 37.57% of the sample. Five out of the six profiles had mean PTSD scores above the cut-off for probable PTSD. Higher rates of common mental health difficulties were associated with more symptomatic profiles. Discussion: As the vast majority of veterans met criteria for probable PTSD, the finding of six different profiles differing primarily quantitatively, but to some extent also qualitatively, suggests the importance of moving away from a 'one-size fits all' approach when it comes to treatments, towards developing interventions that are tailored to meet the specific PTSD and co-morbid symptoms profiles.

Antecedentes: Un número significativo de individuos deja el servicio militar y experimenta síntomas de trastorno de estrés postraumático (TEPT). Los veteranos con síntomas de TEPT rara vez los experimentan de forma aislada, más comúnmente son comórbidos con una variedad de otras dificultades.Objetivo: Se utilizó el análisis de perfiles latentes (LPA, en sus siglas en inglés) para explorar la heterogeneidad de la presentación de síntomas del TEPT. A continuación se usó análisis de regresión para examinar variables que predijeran la pertenencia a los perfiles de TEPT identificados.Método: Se obtuvieron datos sobre la adversidad infantil, las características sociodemográficas y los resultados de salud mental de 386 veteranos varones que habían consultado en servicios de salud mental en el Reino Unido.Resultados: LPA identificó un modelo de seis perfiles que mejor describen la muestra. Hubo un perfil de síntomas bajos, un perfil de síntomas graves y cuatro perfiles de síntomas moderados. El perfil de síntomas severos fue el más grande, representando el 37.57% de la muestra. Cinco de los seis perfiles tenían puntajes promedio de TEPT por encima del puntaje de corte para probable TEPT. Tasas más altas de dificultades de salud mental comunes se asociaron con más perfiles sintomáticos.Discusión: Como la gran mayoría de los veteranos cumplieron con los criterios de probable TEPT, el hallazgo de seis perfiles diferentes que se distinguen principalmente de forma cuantitativa, pero en cierta medida también cualitativamente, sugiere la importancia de alejarse de un enfoque 'de una sola talla' para todos cuando se trata de tratamientos, hacia el desarrollo de intervenciones que se adapten a los perfiles específicos de TEPT y síntomas comórbidos.

Debunking Occam's razor: Diagnosing multiple genetic diseases in families by whole-exome sequencing.

BACKGROUND: Recent clinical whole exome sequencing (WES) cohorts have identified unanticipated multiple genetic diagnoses in single patients. However, the frequency of multiple genetic diagnoses in families is largely unknown. AIMS: We set out to identify the rate of multiple genetic diagnoses in probands and their families referred for analysis in two national research programs in Canada. MATERIALS & METHODS: We retrospectively analyzed WES results for 802 undiagnosed probands referred over the past 5 years in either the FORGE or Care4Rare Canada WES initiatives. RESULTS: Of the 802 probands, 226 (28.2%) were diagnosed based on mutations in known disease genes. Eight (3.5%) had two or more genetic diagnoses explaining their clinical phenotype, a rate in keeping with the large published studies (average 4.3%; 1.4 - 7.2%). Seven of the 8 probands had family members with one or more of the molecularly diagnosed diseases. Consanguinity and multisystem disease appeared to increase the likelihood of multiple genetic diagnoses in a family. CONCLUSION: Our findings highlight the importance of comprehensive clinical phenotyping of family members to ultimately provide accurate genetic counseling.

Medication education program for Indian children with asthma: A feasibility stud.

OBJECTIVE: It is postulated that children with asthma who receive an interactive, comprehensive, culturally relevant education program would improve their asthma knowledge (AK), asthma control, and adherence compared with children receiving usual care. The aim of this study was to develop, implement, and evaluate the efficacy of a culturally relevant asthma education intervention for children with asthma and their parents in India. METHODS: Children with asthma (7-12 years) and their parents were recruited from an outpatient clinic in a Chest Diseases Hospital in New Delhi, and were randomly assigned to either an intervention or usual care group. At baseline, outcome data collected included pediatric asthma caregiver quality of life (PACQL, primary outcome), AK, asthma control, adherence, inhaler technique, action plan ownership, and goal achievement. These data were collected again at 1 and 6 months after baseline. Outcomes were compared within and between groups using ANOVA techniques. RESULTS: Forty parent-child pairs were recruited. Of these, 24 pairs of children with asthma and their parents received the educational intervention. The PACQL significantly improved from baseline to 6 months in the intervention (5.87 ± 0.94-7.00 ± 0.03) versus the usual care group (5.90 ± 0.52-6.34 ± 0.56) (P < 0.001). Other outcomes such as the parents' and child's AK, child's asthma control and inhaler technique were significantly improved in the intervention group across the study. All the participants possessed a written asthma action plan at the end of the intervention. Eighty-five goals were set by children with asthma across all the visits and were achieved by completion. CONCLUSION: An asthma educator delivered interactive program simultaneously involving children with asthma and their parents, improved quality of life, empowered and promoted better self-management skills.

CXCL1 is a negative regulator of mast cell chemotaxis to airway smooth muscle cell products in vitro.

BACKGROUND: Activated mast cells (MC) numbers on airway smooth muscle (ASM) are increased in eosinophilic asthma. In vitro, asthmatic cytokine-stimulated ASM cell-conditioned medium (CM) induces more MC chemotaxis than CM from nonasthmatic ASM cells. Intriguingly the nonasthmatic ASM CM inhibits MC chemotaxis to the asthmatic ASM CM. However, the inhibitory factor(s) in the nonasthmatic ASM CM is still to be identified. OBJECTIVE: To identify the factor(s) released by nonasthmatic ASM cells that inhibits MC chemotaxis. METHODS: Confluent, serum-starved ASM cells from donors with and without asthma were stimulated with IL-1ß and T-helper (Th)1 (TNFα and IFNγ) or Th2 (IL-4, IL-13) cytokines, or left unstimulated. CM samples were collected after 24 h, and a potential inhibitory factor identified using cytokine protein arrays. Its production was assessed using ELISA and RT-PCR and inhibitory role investigated in MC chemotaxis and Ca(2+) mobilization assays. RESULTS: Only CXCL1 was produced in greater amounts by nonasthmatic than asthmatic ASM cells following Th1 and Th2 cytokine stimulation. CXCL1 mRNA expression was also increased. Exogenous rh-CXCL1 significantly inhibited MC intracellular Ca(2+) mobilization and chemotaxis to either CXCL10, CXCL8 or CM collected from asthmatic ASM cells following Th1 or Th2 cytokine stimulation. Neutralizing CXCL1 in nonasthmatic ASM CM or blocking its receptor significantly promoted MC chemotaxis. CONCLUSIONS: CXCL1 was a major factor regulating MC chemotaxis in vitro. Its differential release by ASM cells may explain the differences observed in MC localization to the ASM of people with and without asthma. CLINICAL RELEVANCE: CXCL1 inhibition of MC recruitment to the ASM may lead to new targets to limit asthma pathophysiology.

Human Lung Mast Cell Products Regulate Airway Smooth Muscle CXCL10 Levels.

In asthma, the airway smooth muscle (ASM) produces CXCL10 which may attract CXCR3(+) mast/T cells to it. Our aim was to investigate the effects of mast cell products on ASM cell CXCL10 production. ASM cells from people with and without asthma were stimulated with IL-1 ß , TNF- α , and/or IFN γ and treated with histamine (1-100 µ M) ± chlorpheniramine (H1R antagonist; 1 µ M) or ranitidine (H2R antagonist; 50 µ M) or tryptase (1 nM) ± leupeptin (serine protease inhibitor; 50 µ M), heat-inactivated tryptase, or vehicle for 4 h or 24 h. Human lung mast cells (MC) were isolated and activated with IgE/anti-IgE and supernatants were collected after 2 h or 24 h. The supernatants were added to ASM cells for 48 h and ASM cell CXCL10 production detected using ELISA (protein) and real-time PCR (mRNA). Histamine reduced IL-1 ß /TNF- α -induced CXCL10 protein, but not mRNA, levels independent of H1 and H2 receptor activation, whereas tryptase and MC 2 h supernatants reduced all cytokine-induced CXCL10. Tryptase also reduced CXCL10 levels in a cell-free system. Leupeptin inhibited the effects of tryptase and MC 2 h supernatants. MC 24 h supernatants contained TNF- α and amplified IFN γ -induced ASM cell CXCL10 production. This is the first evidence that MC can regulate ASM cell CXCL10 production and its degradation. Thus MC may regulate airway myositis in asthma.

Airway smooth muscle CXCR3 ligand production: regulation by JAK-STAT1 and intracellular Ca²âº.

In asthma, airway smooth muscle (ASM) chemokine (C-X-C motif) receptor 3 (CXCR3) ligand production may attract mast cells or T lymphocytes to the ASM, where they can modulate ASM functions. In ASM cells (ASMCs) from people with or without asthma, we aimed to investigate JAK-STAT1, JNK, and Ca²âº involvement in chemokine (C-X-C motif) ligand (CXCL)10 and CXCL11 production stimulated by interferon-γ, IL-1ß, and TNF-α combined (cytomix). Confluent, growth-arrested ASMC were treated with inhibitors for pan-JAK (pyridone-6), JAK2 (AG-490), JNK (SP-600125), or the sarco(endo)plasmic reticulum Ca²âºATPase (SERCA) pump (thapsigargin), Ca²âº chelator (BAPTA-AM), or vehicle before and during cytomix stimulation for up to 24 h. Signaling protein activation as well as CXCL10/CXCL11 mRNA and protein production were examined using immunoblot analysis, real-time PCR, and ELISA, respectively. Cytomix-induced STAT1 activation was lower and CXCR3 ligand mRNA production was more sensitive to pyridone-6 and AG-490 in asthmatic than nonasthmatic ASMCs, but CXCL10/CXCL11 release was inhibited by the same proportion. Neither agent caused additional inhibition of release when used in combination with the JNK inhibitor SP-600125. Conversely, p65 NF-κB activation was higher in asthmatic than nonasthmatic ASMCs. BAPTA-AM abolished early CXCL10/CXCL11 mRNA production, whereas thapsigargin reduced it in asthmatic cells and inhibited CXCL10/CXCL11 release by both ASMC types. Despite these inhibitory effects, neither Ca²âº agent affected early activation of STAT1, JNK, or p65 NF-κB. In conclusion, intracellular Ca²âº regulated CXCL10/CXCL11 production but not early activation of the signaling molecules involved. In asthma, reduced ASM STAT1-JNK activation, increased NF-κB activation, and altered Ca²âº handling may contribute to rapid CXCR3 ligand production and enhanced inflammatory cell recruitment.

Human lung mast cells modulate the functions of airway smooth muscle cells in asthma.

BACKGROUND: Activated mast cell densities are increased on the airway smooth muscle in asthma where they may modulate muscle functions and thus contribute to airway inflammation, remodelling and airflow obstruction. OBJECTIVES: To determine the effects of human lung mast cells on the secretory and proliferative functions of airway smooth muscle cells from donors with and without asthma. METHODS: Freshly isolated human lung mast cells were stimulated with IgE/anti-IgE. Culture supernatants were collected after 2 and 24 h and the mast cells lysed. The supernatants/lysates were added to serum-deprived, subconfluent airway smooth muscle cells for up to 48 h. Released chemokines and extracellular matrix were measured by ELISA, proliferation was quantified by [(3) H]-thymidine incorporation and cell counting, and intracellular signalling by phospho-arrays. RESULTS: Mast cell 2-h supernatants reduced CCL11 and increased CXCL8 and fibronectin production from both asthmatic and nonasthmatic muscle cells. Leupeptin reversed these effects. Mast cell 24-h supernatants and lysates reduced CCL11 release from both muscle cell types but increased CXCL8 release by nonasthmatic cells. The 24-h supernatants also reduced asthmatic, but not nonasthmatic, muscle cell DNA synthesis and asthmatic cell numbers over 5 days through inhibiting extracellular signal-regulated kinase (ERK) and phosphatidylinositol (PI3)-kinase pathways. However, prostaglandins, thromboxanes, IL-4 and IL-13 were not involved in reducing the proliferation. CONCLUSIONS: Mast cell proteases and newly synthesized products differentially modulated the secretory and proliferative functions of airway smooth muscle cells from donors with and without asthma. Thus, mast cells may modulate their own recruitment and airway smooth muscle functions locally in asthma.

Diabetes management in an Australian primary care population.

WHAT IS KNOWN AND OBJECTIVE: Worldwide studies have shown that significant proportions of patients with type 2 diabetes (T2DM) do not meet targets for glycaemic control, blood pressure (BP) and lipids, putting them at higher risk of developing complications. However, little is known about medicines management in Australian primary care populations with T2DM. The aim of this study was to (i) describe the management of a large group of patients in primary care, (ii) identify areas for improvement in management and (iii) determine any relationship between adherence and glycaemic, BP and lipid control. METHODS: This was a retrospective, epidemiological study of primary care patients with T2DM diabetes, with HbA(1c) of >7%, recruited in 90 Australian community pharmacies. Data collected included demographic details, diabetes history, current medication regimen, height, weight, BP, physical activity and smoking status. RESULTS AND DISCUSSION: Of the 430 patients, 98% used antidiabetics, 80% antihypertensives, 73% lipid lowering drugs and 38% aspirin. BP and all lipid targets were met by only 21% and 14% of the treated patients and 21% and 12% of the untreated patients respectively. Medication adherence was related to better glycaemic control (P = 0.04). WHAT IS NEW AND CONCLUSIONS: An evidence-base prescribing practice gap was seen in this Australian primary care population of T2DM patients. Patients were undertreated with antihypertensive and lipid lowering medication, and several subgroups with co-morbidities were not receiving the recommended pharmacotherapy. Interventions are required to redress the current evidence-base prescribing practice gap in disease management in primary care.

Diabetes Medication Assistance Service Stage 1: impact and sustainability of glycaemic and lipids control in patients with Type 2 diabetes.

AIMS: To investigate (i) optimal intensity (four visits vs. six visits) and duration (6 vs. 12 months) of the Diabetes Medication Assistance Service in community pharmacy and (ii) sustainability of improvements in patients' diabetes control associated with differing intensities of intervention. METHODS: A national quota sample of 90 community pharmacies in Australia were randomly assigned into group 1 (6-month Diabetes Medication Assistance Service) or group 2 (12-month Diabetes Medication Assistance Service) and subsequently recruited a total of 524 patients. A wide range of clinical (HbA(1c) , blood pressure, lipids) and quality-of-life outcome measures were assessed. RESULTS: The 6- and 12-month Diabetes Medication Assistance Service resulted in significant and similar reductions in HbA(1c) (-0.9 mmol/mol; 95% CI -0.7 to -1.1) -, total cholesterol (-0.3 mmol/l; 95% CI -0.1 to -0.4) and triglycerides (-0.3 mmol/l; 95% CI -0.1 to -0.5). There was also a significant reduction in the number of patients who were at risk of having a cardiovascular event in the next 10 years. For the subset of patients for whom data were available at baseline, completion and 18 months, improvements in HbA(1c) and total cholesterol were sustained at 18 months and triglycerides showed a further improvement at 18 months. CONCLUSIONS: The Diabetes Medication Assistance Service resulted in significant improvements in diabetes control that were independent of intensity and duration of the service and showed evidence of being sustained at 18 months. The extent and sustainability of clinical improvements achieved by the Diabetes Medication Assistance Service, together with the resulting reduction in cardiovascular risk, should translate into future cost savings to healthcare systems by delaying and reducing diabetes-related complications.

Role of community pharmacists in asthma - Australian research highlighting pathways for future primary care models.

Asthma is one of the most common chronic conditions affecting the Australian population. Amongst primary healthcare professionals, pharmacists are the most accessible and this places pharmacists in an excellent position to play a role in the management of asthma. Globally, trials of many community pharmacy-based asthma care models have provided evidence that pharmacist delivered interventions can improve clinical, humanistic and economic outcomes for asthma patients. In Australia, a decade of coordinated research efforts, in various aspects of asthma care, has culminated in the implementation trial of the Pharmacy Asthma Management Service (PAMS), a comprehensive disease management model.There has been research investigating asthma medication adherence through data mining, ways in which usual asthma care can be improved. Our research has focused on self-management education, inhaler technique interventions, spirometry trials, interprofessional models of care, and regional trials addressing the particular needs of rural communities. We have determined that inhaler technique education is a necessity and should be repeated if correct technique is to be maintained. We have identified this effectiveness of health promotion and health education, conducted within and outside the confines of the pharmacy, in public for a and settings such as schools, and established that this outreach role is particularly well received and increases the opportunity for people with asthma to engage in their asthma management.Our research has identified that asthma patients have needs which pharmacists delivering specialized models of care, can address. There is a lot of evidence for the effectiveness of asthma care by pharmacists, the future must involve integration of this role into primary care.

Healthcare professional versus patient goal setting in intermittent allergic rhinitis.

OBJECTIVE: To examine the impact of healthcare professional versus patient goal setting for the self-management of intermittent allergic rhinitis (AR) on symptom severity and quality of life. METHODS: This was a 6 week, parallel group study. Group A participants, with pharmacist facilitation, nominated personally relevant goals and strategies relating to their AR. Group B participants had their goals and strategies set by the pharmacist. The main outcome measures used included perceived symptom severity and quality of life. In addition, goals and strategies data from participants of both groups were collected and analysed. RESULTS: Both groups demonstrated significant improvements in symptom severity and quality of life scores however Group B symptom severity scores improved more. Group B set a greater number of goals and strategies which were better structured and more task specific. CONCLUSION: This is the first study to investigate the impact of goal setting on patient behaviour in a chronic yet episodic illness. Our results suggest that self-management goals set by the healthcare professional which are clinically indicated but tailored to the patient's nominated symptoms yields better outcomes than goals nominated by the patient. PRACTICE IMPLICATIONS: A brief, structured intervention, tailored to patient symptoms, can enhance self-management of intermittent allergic rhinitis.

Further delineation of cardio-facio-cutaneous syndrome: clinical features of 38 individuals with proven mutations.

BACKGROUND: Cardio-facio-cutaneous syndrome (CFC) is a multiple congenital anomaly/mental retardation syndrome named because of a characteristic facies, cardiac anomalies, and ectodermal abnormalities. While considerable literature describes the main features, few studies have documented the frequencies of less common features allowing a greater appreciation of the full phenotype. METHODS: We have analysed clinical data on 38 individuals with CFC and a confirmed mutation in one of the genes known to cause the condition. We provide data on well-established features, and those that are less often described. RESULTS: Polyhydramnios (77%) and prematurity (49%) were common perinatal issues. 71% of individuals had a cardiac anomaly, the most common being pulmonary valve stenosis (42%), hypertrophic cardiomyopathy (39%), and atrial septal defect (28%). Hair anomalies were also typical: 92% had curly hair, 84% sparse hair, and 86% absent or sparse eyebrows. The most frequent cutaneous features were keratosis pilaris (73%), hyperkeratosis (61%) and nevi (76%). Significant and long lived gastrointestinal dysmotility (71%), seizures (49%), optic nerve hypoplasia (30%) and renal anomalies, chiefly hydronephrosis (20%), were among the less well known issues reported. CONCLUSION: This study reports a broad range of clinical issues in a large cohort of individuals with molecular confirmation of CFC.

The development and evaluation of written medicines information for type 2 diabetes.

Written Medicines Information (WMI) is regarded as a key component in diabetes consumer education. In Australia, there is a paucity of WMI that specifically tailors to the extensive array of medicines used for the lifelong management of Type 2 diabetes. This research project aimed to employ a novel framework, the 'Consumer Involvement Cycle', to investigate consumer perspectives and needs of medicines information for Type 2 diabetes and develop appropriate WMI for the Type 2 diabetes population. The Consumer Involvement Cycle involved people with Type 2 diabetes and health professionals (HPs) working in partnership to design a series of WMI, incorporating a range of consumer-conceived ideas and concepts with professional evaluation from an expert panel of reviewing HPs. A total of 12 leaflets were developed. The Flesch-Kincaid Grade Level Score for the leaflets was approximately 8.0, which is considered to be 'fairly easy', in other words easily understood by a large proportion of the general public. The Consumer Involvement Cycle was validated as a useful framework in developing and evaluating appropriate consumer information. Consumer perspectives should be sought and well incorporated throughout the process of designing and assessing educational materials intended for consumer use.

The Pharmacy Diabetes Care Program: assessment of a community pharmacy diabetes service model in Australia.

AIM: To assess the impact of a community pharmacy diabetes service model on patient outcomes in Type 2 diabetes. METHODS: The study utilized a multisite, control vs. intervention, repeated-measures design within four states in Australia. Fifty-six community pharmacies, 28 intervention and 28 control, were randomly selected from a representative sample of urban and rural areas. Intervention pharmacies delivered a diabetes service to patients with Type 2 diabetes, which comprised an ongoing cycle of assessment, management and review, provided at regular intervals over 6 months in the pharmacy. These services included support for self monitoring of blood glucose, education, adherence support, and reminders of checks for diabetes complications. Control pharmacists assessed patients at 0 and 6 months and delivered no intervention. RESULTS: A total of 289 subjects (149 intervention and 140 control) completed the study. For the intervention subjects, the mean blood glucose level decreased over the 6-month study from 9.4 to 8.5 mmol/l (P < 0.01). Furthermore, significantly greater improvements in glycaemic control were seen in the intervention group compared with the control: the mean reduction in HbA(1c) in the intervention group was -0.97% (95% CI: -0.8, -1.14) compared with -0.27% (95% CI: -0.15, -0.39) in the control group. Improvements were also seen in blood pressure control and quality of life in the intervention group. CONCLUSION: A pharmacy diabetes service model resulted in significant improvements in clinical and humanistic outcomes. Thus, community pharmacists can contribute significantly to improving care and health outcomes for patients with Type 2 diabetes. Future research should focus on clarifying the most effective elements of the service model.

Histamine and tryptase modulate asthmatic airway smooth muscle GM-CSF and RANTES release.

Degranulating mast cells are increased in the airway smooth muscle (ASM) of asthmatics, where they may influence ASM function. The aim of the present study was to determine whether histamine and tryptase modulate ASM cell granulocyte-macrophage colony-stimulating factor (GM-CSF) and RANTES (regulated on activation, normal T-cell expressed and secreted) release and also to examine which receptors are involved in this release. Confluent, quiescent ASM cells from asthmatic and nonasthmatic donors were treated with histamine (1 microM-100 microM) with and without histamine receptor antagonist pre-treatment, or the protease-activated receptor (PAR)-2 agonists tryptase (0.5-5 nM) and SLIGKV (100 and 400 microM). The cells were then stimulated with interleukin (IL)-1beta and/or tumour necrosis factor (TNF)-alpha (10 ng.mL(-1)) or left unstimulated for 24 h. Release of GM-CSF and RANTES was determined by ELISA and prostaglandin (PG)E(2) measured by enzyme immunoassay. Neither histamine nor tryptase induced ASM GM-CSF or RANTES secretion. However, histamine increased IL-1beta-induced GM-CSF release and markedly reduced TNF-alpha-induced RANTES release by both asthmatic and nonasthmatic cells to a similar extent, but did not modulate PGE(2) release. All changes involved activation of the histamine H1 receptor as they were partially or fully blocked by chlorpheniramine, but not ranitidine. Tryptase, via its proteolytic activity, also potentiated GM-CSF, but not RANTES, release from asthmatic and nonasthmatic ASM cells induced by both cytokines. PAR-2 involvement in the tryptase potentiation was unlikely because SLIGKV had no effect. In conclusion, mast cells, through histamine and tryptase, may locally modulate airway smooth muscle-induced inflammation in asthma.