Community pharmacists require additional support to develop capacity in delivering alcohol-related health information to older adults

OBJECTIVES

This qualitative study explored the barriers and enablers influencing Western Australian (WA) community pharmacists' knowledge, confidence, willingness and practice in engaging older clients (>60 years) in alcohol-related health discussions.

METHODS

Two focus groups were conducted with a total of 14 community pharmacists who had previously completed a formative quantitative survey (n = 63), and indicated willingness to participate in a follow-up focus group. Focus group questions, informed by the survey results, explored participants' perceptions about barriers and enablers to delivering health information and advice about alcohol to older clients (60+ years). Shaw and colleagues' theoretical framework was used to understand barriers and enablers in relation to role legitimacy, role adequacy and role support.

KEY FINDINGS

Participants acknowledged that providing health information about alcohol to older clients is a legitimate part of a community pharmacist's role, and most were confident performing this role in situations perceived as core to their professional practice, such as while dispensing medicines. However, many participants identified limited knowledge, skills and confidence in assisting older clients who may have alcohol issues, beyond advising them on medication and alcohol use. Structural barriers such as time and financial barriers were also identified.

CONCLUSION

Routine professional practice including dispensing medicine and home medicine reviews may provide valuable opportunities to engage older clients in alcohol-related discussions. However, limited knowledge concerning appropriate strategies to assist older clients reduce their alcohol consumption, coupled with limited skills and confidence among community pharmacists in raising sensitive alcohol-related issues with clients, suggest the need for specific alcohol-related training and support.

The influence of non-HLA gene polymorphisms and interactions on disease risk in a Western Australian multiple sclerosis cohort

Non-Human Leukocyte Antigen (HLA) genes have concomitant, although modest, effects on multiple sclerosis (MS) susceptibility; however findings have varied in different populations. Here we present the results of an association study of 16 single nucleotide polymorphisms (SNPs) in 10 non-HLA genes (IL7R, IL2RA, CLEC-16A, TYK2, CD58, IRF5, STAT3, CTLA-4, APOE, ICAM-1) in a Western Australian cohort of 350 MS patients and 498 population control subjects. Our results indicate that in this population, SNPs in IL7R, TYK2, IRF5 and APOE have modifying effects on MS susceptibility. We also found evidence of interactive protective effects between polymorphisms in the IL7R/CD58, CLEC-16A/CTLA-4, and TYK2/IRF5 genes, which in some instances are restricted within HLA- or gender-defined groups.

Prevalence and clinical features of common LRRK2 mutations in Australians with Parkinson's disease

We determined the prevalence of two common leucine-rich repeat kinase 2 (LRRK2) gene mutations in Australian patients with Parkinson's disease (PD). Of 830 affected patients, eight were heterozygous for the G2019S mutation, and two were heterozygous for the R1441H (4,322 G > A) mutation. In addition, one familial patient had a novel A1442P (4,324 G > C) mutation. Haplotype analysis showed that all LRRK2 G2019S-positive individuals carried the common founder haplotype 1 and a putative founder haplotype for the R1441H mutation carriers. Clinically, patients with LRRK2 mutations had typical levodopa responsive Parkinsonism with tremor being the commonest presenting feature. Patients with the G2019S mutation in our series had a similar age of onset of symptoms when compared with patients with other LRRK2 mutations or sporadic PD, although they were more likely to have a family history of PD (2.4% of Australian patients with familial PD and 0.3% of Australian patients with sporadic PD). Our results demonstrate that the G2019S mutation carriers share the same ancestors who migrated to Australia originally from Europe and that other LRRK2 mutations (R1441H and A1442P) can be found in this population.

Two major histocompatibility complex haplotypes influence susceptibility to sporadic inclusion body myositis: critical evaluation of an association with HLA-DR3

Previous studies of sporadic inclusion body myositis (sIBM) have shown a strong association with HLA-DR3 and other components of the 8.1 ancestral haplotype (AH) (HLA-A1, B8, DR3), where the susceptibility locus has been mapped to the central major histocompatibility complex (MHC) region between HLA-DR and C4. Here, the association with HLA-DR3 and other genes in the central MHC and class II region was further investigated in a group of 42 sIBM patients and in an ethnically similar control group (n = 214), using single-nucleotide polymorphisms and microsatellite screening. HLA-DR3 (marking DRB1*0301 in Caucasians) was associated with sIBM (Fisher's test). However, among HLA-DR3-positive patients and controls, carriage of HLA-DR3 without microsatellite and single-nucleotide polymorphism alleles of the 8.1AH (HLA-A1, B8, DRB3*0101, DRB1*0301, DQB1*0201) was marginally less common in patients. Patients showed no increase in carriage of the 18.2AH (HLA-A30, B18, DRB3*0202, DRB1*0301, DQB1*0201) or HLA-DR3 without the central MHC of the 8.1AH, further arguing against HLA-DRB1 as the direct cause of susceptibility. Genes between HLA-DRB1 and HOX12 require further investigation. BTL-II lies in this region and is expressed in muscle. Carriage of allele 2 (exon 6) was more common in patients. BTL-II(E6)*2 is characteristic of the 35.2AH (HLA-A3, B35, DRB1*01) in Caucasians and HLA-DR1, BTL-II(E6)*2, HOX12*2, RAGE*2 was carried by several patients. The 8.1AH and 35.2AH may confer susceptibility to sIBM independently or share a critical allele.

Mitochondrial DNA variants in inclusion body myositis

Mitochondrial DNA variants have been shown to be associated with many diseases. Mutations at mitochondrial DNA nucleotide positions 3192, 3196, 3397 and 4336 have been described in association with late-onset Alzheimer's disease. The pathological similarities between inclusion body myositis and Alzheimer's disease prompted an analysis of the relationship between the reported mutations and sporadic inclusion body myositis. The 4336G variant was not significantly increased in patients with inclusion body myositis or Alzheimer's disease when compared to controls. None of the patients with inclusion body myositis carried mutations at nucleotide positions 3192, 3196 and 3397. A transition at nucleotide position 4580 was detected in some patients with inclusion body myositis and Alzheimer's disease but was not significantly higher in frequency when compared to controls. Phylogenetic analysis showed that the 4336G and 4580A variants clustered together in their respective group. A group of patients with inclusion body myositis also clustered together on a separate branch of the phylogenetic tree. Closer investigation of this group revealed a common polymorphism at nucleotide position 16311. The frequency of the 16311C variant was higher in inclusion body myositis than in Alzheimer's disease and controls, although when only caucasian patients were considered the increased frequency was not statistically significant. Further studies will be required to determine whether this variant plays a role in the pathogenesis of inclusion body myositis.

The genetic basis for the association of the 8.1 ancestral haplotype (A1, B8, DR3) with multiple immunopathological diseases

An individual's major histocompatibility complex (MHC) ancestral haplotype (AH) is the clearest single determinant of susceptibility to MHC associated immunopathological disease, as it defines the alleles carried at all loci in the MHC. However, the direct effects of any of the 150-200 genes that constitute the MHC are difficult to determine since recombination only occurs at defined hotspots. This review concerns the 8.1 AH (HLA-A1, C7, B8, C4AQ0, C4B1, DR3, DQ2), which is carried by most Caucasians with HLA-B8. It is associated with accelerated human immunodeficiency virus (HIV) disease, and susceptibility to insulin-dependent diabetes mellitus (IDDM), systemic lupus erythematosus, dermatitis herpetiformis, common variable immunodeficiency and IgA deficiency, myasthenia gravis and several other conditions. We have mapped susceptibility genes for HIV, IDDM and myasthenia gravis to the central MHC between HLA-B and the tumour necrosis factor or complement genes. Here we consider which of the remaining 8.1-associated diseases are more closely associated with HLA-DR3 and/or DQ2. Several candidate genes in the central MHC have the potential to modulate immune or inflammatory responses in an antigen-independent manner, as is seen in studies of cultured cells from healthy carriers of the 8.1 AH. Hence these genes may act as a common co-factor in the diverse immunopathological conditions associated with the 8.1 AH.

Cytokine gene therapy or infusion as treatment for solid human cancer

In the induction of tissue-directed immune responses, cytokines tend to be released within the affected tissues. We used two strategies to expose tumor tissues to continuous high levels of cytokines: First, a vaccinia interleukin (IL)2 recombinant was injected directly intratumorally 3-weekly at 10(7) pfus/dose in six patients with the solid tumor malignant mesothelioma (MM). No virus excretion was detectable. At each cycle vaccinia-IL-2 mRNA (SQ [semi-quantitative] reverse transcription polymerase chain reaction) was maximal 24-72 h following injection reduced at 8 days and faded by 21 days. No tumor regression occurred. Second, based on the success of granulocyte macrophage colony-stimulating factor (GM-CSF) in gene transfer experiments, we conducted a study using continuous intratumoral GM-CSF infusion in eight patients with MM using a portable pump at doses of 10 micro/cg/24 h over 8 weeks. Systemic neutrophil agglutination and local catheter-related difficulties occurred. Two patients demonstrated tumor necrosis, one of whom had a marked progressive mononuclear cell infiltration of the tumor associated with a partial response (>50% reduction in tumor area). Murine studies using our MM model in CBA and BALB/C mice have demonstrated that B7-1 and allo-class I transfections induce strong tumor-specific cytotoxic T lymphocyte responses: GM-CSF, IL-12, and IL-2 induced mixed nonspecific plus specific responses, whereas B7-2 and class II transfections were not effective. We conclude that increased intratumoral cytokine concentrations can be generated using both gene transfer and cytokine infusion approaches; however, both have their limitations and, at this stage, have not produced dramatic antitumor effects in humans.

Induction and maintenance of T-cell response to a nonimmunogenic murine mesothelioma cell line requires expression of B7-1 and the capacity to upregulate class II major histocompatibility complex expression

Intratumoral expression of the T-cell costimulator B7-1 has been reported to induce tumor-specific immunity against immunogenic, but not nonimmunogenic, tumors. We transfected the B7-1 gene into a nonimmunogenic murine mesothelioma cell line that constitutively expresses high levels of class I major histocompatibility complex (MHC) and transforming growth factor-beta (TGF-beta). Tumor development by two of the four B7-1 transfectant clones was markedly delayed, although all clones eventually formed tumors. Retardation of tumor growth required both CD4+ and CD8+ T cells. Tumor-specific cytotoxic T-lymphocytes (CTLs) were elicited in response to the least (AC29-B7-6), but not the most (AC29-B7-7), tumorigenic transfectant clone. Tumor-specific CTL activity could be detected at early time points but not at the time of tumor outgrowth. This lack of responsiveness was tumor antigen specific. Differences in immunogenicity of transfectant clones did not relate to the level of expression of MHC class I, vascular cell adhesion molecule-1, or transfected B7-1, or to the level of TGF-beta secreted. Class II MHC expression was most readily inducible in those transfectant clones whose growth in vivo was most delayed. An explant cell line derived from a tumor that developed from AC29-B7-6 had a markedly reduced capacity to upregulate MHC class II expression and produced tumors in vivo at a faster rate than did the parental cell line. Thus, B7-1 expression in this nonimmunogenic tumor cell line can promote the generation of tumor-specific CTLs with consequent retardation of tumor development, and coexpression of MHC class II seems likely to play an important role in this process. This work also illustrates that clonal heterogeneity within a single tumor and the development of immunological nonresponsiveness resulting in tumor outgrowth, even in the presence of continued B7-1 expression, are potential difficulties associated with this therapeutic approach.

HLA DQA tissue typing of cadaveric eye bank donor material with polymerase chain reaction

It has been suggested that the provision of HLA matched tissue for corneal transplantation would be beneficial for graft survival especially in high risk patients. In this study we report the application of a polymerase chain reaction (PCR) based tissue typing procedure to type cadaveric donor material. Using beta-globin gene amplification as a test system we found that cornea, corneal rim, conjunctiva, sclera, rectus muscle, optic nerve and neural retina were all suitable for PCR amplification but DNA extracted from pigment epithelial cells and from the iris could not be amplified. HLA DQA typing results of 9 samples identified 5 alleles and 7 genotypes. In two cases the antigens detected by serology reflected the alleles detected by PCR. In a third case in which the class II serological typing was inconclusive we detected two DQA alleles by PCR. These alleles were consistent with those which would be predicted to be present on the basis of known linkage disequilibrium between HLA-Cw, B, DR and DQ. In this study we have shown that PCR based tissue typing is more sensitive and gives more detailed typing results than serology and would be suitable to type cadaveric donor material on a routine basis.

Influence of biological response modifiers of bacterial origin on disease progression in the MRL-lpr model of systemic lupus erythematosus

Murine models of systemic lupus erythematosus exhibit some, but not all of the characteristics of human disease. Disease progression in the animal models is related to autoantibodies, genetics, and inflammatory processes. In this report the effects of two bacterial biological response modifiers (BRM) on disease progression in the MRL-lpr model were investigated. The two BRM tested were C. parvum and Bacillus-Calmette-Guerin (BCG), both of which are stimulators of the reticuloendothelial system and both of which have been shown by others to influence disease progression in NZB/W mice. Treatment of 10-week-old mice with C. parvum led to transient alterations in hepatosplenomegaly and plasma proteinase regulation, which then returned to control values. Treatment with BCG led to even more transient effects on the mice. Neither BRM appeared to impact on disease-associated alterations in autoantibody titres, hepatosplenomegaly, or elevations in plasma proteinase activity. Likewise, treatment of 17-week-old MRL-lpr mice with C. parvum did not influence disease progression as evidenced by survival, autoantibody production, or hepatosplenomegaly. Therefore, in contrast to the NZB/W strain, treatment of the MRL-lpr strain with these BRM does not appear to impact on disease progression. This difference may be due to the influence of the lpr accelerator gene in this model.

Plasma proteinase regulation during disease progression in murine models of SLE

Analysis of plasma proteinase during disease progression in murine models of systemic lupus erythematosus revealed three different patterns of regulation. Female NZB/W mice exhibited no age-dependent alterations in plasma proteinase activity from 3-9 months of age. Animals at nine months of age exhibited splenomegaly, high titers of serum autoantibodies and evidence of kidney disease, but no disruption of plasma proteinase activity. Male BxSB mice exhibited elevations in plasma proteinase activity as a late-onset (greater than 20 weeks of age) feature of the disease process. The onset of proteinase dysregulation occurred after significant mortality was evident and therefore variables associated with the induction of elevated levels of plasma proteinase activity are not related to early mortality factors. In contrast, female MRL-lpr mice exhibited age-dependent induction of elevated plasma proteinase activity which correlated temporally with the onset of mortality and the previously described reticuloendothelial system activation (Hart, J. Clin. Lab. Immunol., 26, 129). Interestingly, male MRL-lpr mice, which live slightly longer than female mice of the same strain, exhibited a delayed onset of plasma proteinase dysregulation. These results indicate that induction of changes in plasma proteinase regulation during the natural course of disease varies between these three murine models of SLE. Assessment of plasma proteinase regulation in human disease may reveal subpopulations of patients with features analogous to the murine models, which in turn could influence the choice of therapeutic modalities in disease management.

Extractable nuclear antigen autoantibodies and their association with other autoantibodies and thymoma in myasthenia gravis

The presence of autoantibodies to Extractable Nuclear Antigens (ENA) in myasthenia gravis (MG) was evaluated. These antibodies represent a subset of antinuclear antibodies (ANA), with ENA consisting of RNA and nucleoprotein. ENA autoantibodies had a prevalence of 44% in MG when tested by an

Disease associations with complotypes, supratypes and haplotypes

We have used the term supratype to describe combinations of alleles and have examined associations with disease. In RA and insulin-dependent diabetes one or more supratypes appear to be important but their functional significance remains obscure. In MG and SLE the HLA supratype may contain loci involved in immunoregulation, complement synthesis and hormone metabolism. MG induced by D-Pen is associated with Bw35/DR1 rather than A1, B8, DR3. In contrast there is no evidence of a supratype in AS. We have proposed a model for the pathogenesis of sacroiliitis and AS and have postulated two non-linked genes which act stepwise upon HLA-B27. There are cogent reasons for examining the functional effects of known loci within the MHC and particularly those involved in the expression of complement components.

Antibodies to the acetylcholine receptor in myasthenic dogs

Antibodies to the AChR and anti-striational antibodies have been detected in dogs suffering from myasthenia gravis. The detection of these antibodies adds to the known similarities between the human and canine disease. This animal model will facilitate investigation of agents involved in the induction of spontaneous myasthenia gravis.