Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

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.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

O024 Prognostic value of haemodynamic parameters in predicting adverse clinical events in type B aortic dissection

Introduction

Ascertain the prognostic role of in-vivo 4D-flow magnetic resonance imaging (MRI) and computational fluid dynamics (CFD) aortic haemodynamic parameters as predictors of adverse dissection-related events in type B aortic dissection (TBAD).

Methods

A systematic literature search was conducted according to the PRISMA guidelines using electronic databases searched from 1946 to 2021 for studies reporting on the relationship between aortic haemodynamics and aortic dissection-related events defined as aortic growth, aneurysm development, false lumen thrombosis, need for surgery and aortic rupture.

Results

Fourteen studies were included; eleven studies used CFD and three studies used 4D-flow MRI. Two studies found increased FL ejection fraction (EF) significantly associated with aortic growth rate, and another study found increased FL stroke volume significantly associated with increased aortic expansion rate. Result for time-averaged wall shear stress (TAWSS) and relative residence time (RRT) are contradictory; one study found TAWSS significantly associated with aortic wall deformation, but another study found no significant difference. Five studies suggested possible associations between slow flowing regions or increased RRT and FL thrombosis, with another study finding significant associations between FL thrombosis and adverse aortic outcomes. However, one study revealed opposite findings where decreased RRT significantly correlated with aneurysm formation.

Conclusion

In-vivo aortic haemodynamic measurements such as FL EF, FL stroke volume, TAWSS and RRT show possible associations with FL and aortic expansion, as well as FL thrombosis. Larger prospective studies are now needed to determine the prognostic utility of in vivo aortic haemodynamic metrics in predicting TBAD clinical outcomes to guide management.

Take-home message

Aortic haemodynamic parameters measured by 4D-flow magnetic resonance imaging and computational fluid dynamics show promising potential as predictors of adverse dissection-related events in type B aortic dissection.

Improving sleep in a population at high risk of trauma: A pilot study examining self-reported sleep, psychological symptomology and actigraphy measured night-time sleep

Introduction

Sleep disturbances (SDs), such as insomnia or regular nightmares, are associated with multiple mental health disorders, most notably PTSD, where SDs are reported in up to 92% of cases. Examining the effect of changing sleep on psychological symptomology is essential to develop the evidence base on the contribution of sleep to mental resilience.

Objectives

To examine the effect a short skills-based sleep intervention on psychological symptomology and actigraphy measured sleep.

Methods

A 4-session sleep skills training programme was used to treat active SDs in participants likely to have experienced occupation-associated trauma, namely military and first responders.

Results

Nineteen participants were included in the study. Insomnia Severity Index (ISI) measured; difficulty sleeping, difficulty staying asleep, waking too early, sleep satisfaction, sleep interference on quality of life and total ISI insomnia score improved significantly post-treatment (M = 9.44, SE = 7.35, p <0.001). No significant difference was identified post-treatment for actigraphy-measured sleep. The severity of depression (M = 5.27, SE = 1.41, p = 0.002), anxiety (M = 5.07, SE = 1.66, p = 0.008), and PTSD symptoms among participants with likely PTSD, were significantly lower following treatment (M = 29.4, SE = 4.19, p = 0.002).

Conclusions

A short sleep skills intervention based on CBT-I was effective at reducing self-report insomnia symptoms and severity of psychological symptomology but failed to improve actigraphy sleep metrics. These findings highlight a differing contribution of night-time sleep and current insomnia symptoms to the severity of self-reported psychological symptomology.

Disclosure

No significant relationships.

A Network Analysis Study Investigating Posttraumatic Stress Disorder and Dissociation Comorbidity in a UK Armed Forces Veteran Sample

Introduction

An established body of literature has identified that PTSD and dissociation are comorbid. Furthermore, the DSM introduced a dissociative subtype of PTSD into their most recent update; DSM-5.

Objectives

The current study aimed to examine symptom-level associations between PTSD and dissociation using network analysis among UK Armed Forces veterans resident in Northern Ireland (NI) to identify if there are certain symptoms that may act as bridges between the two constructs.

Methods

A large scale cross sectional survey was conducted examining the physical and mental wellbeing of UK Armed Forces Veterans living in NI. The total eligible sample size was 619 (89.8% male), with a mean age of 55.38 years (SD = 10.41). Two networks were estimated, (1) a network consisting of 20 DSM-5 PTSD items and (2) a network consisting of 20 PTSD items and four dissociative items. Expected influence bridge centrality was calculated to examine symptoms with the most/strongest cross-domain associations (i.e. between PTSD and dissociation). The presence of meaningful clustering among symptoms was also explored.

Results

The PTSD symptoms ‘concentration problems’, ‘flashbacks’ and ‘negative emotional state’ had the highest relative bridge expected influence centrality. Of the four dissociative items, ‘gaps in awareness’ had the highest relative bridge expected influence centrality, followed by ‘cognitive-behavioural re-experiencing’. A community structure of five clusters was detected. Four clusters reflected each subscale of the PCL-5 PTSD items and the final cluster reflected the dissociation items.

Conclusions

This study extends our understanding of PTSD and disociation comorbidity by investigating symptom level relationships; potentially informing future treatments and interventions.

Disclosure

No significant relationships.

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 (M_age =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 (M_age =48.15), not working due to other reasons (M_age =61.92) and currently working (M_age = 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 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.

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.

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.

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.

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.

Pharmacy diabetes care program: analysis of two screening methods for undiagnosed type 2 diabetes in Australian community pharmacy

OBJECTIVE

To compare the efficacy and cost-effectiveness of two methods of screening for undiagnosed type 2 diabetes in Australian community pharmacy.

METHODS

A random sample of 30 pharmacies were allocated into two groups: (i) tick test only (TTO); or (ii) sequential screening (SS) method. Both methods used the same initial risk assessment for type 2 diabetes. Subjects with one or more risk factors in the TTO group were offered a referral to their general practitioner (GP). Under the SS method, patients with risk factors were offered a capillary blood glucose test and those identified as being at risk referred to a GP. The effectiveness and cost-effectiveness of these approaches was assessed.

RESULTS

A total of 1286 people were screened over a period of 3 months. The rate of diagnosis of diabetes was significantly higher for SS compared with the TTO method (1.7% versus 0.2%; p=0.008). The SS method resulted in fewer referrals to the GP and a higher uptake of referrals than the TTO method and so was the more cost-effective screening method.

CONCLUSIONS

SS is the superior method from a cost and efficacy perspective. It should be considered as the preferred option for screening by community based pharmacists in Australia.

Cell-cell interaction modulates myoD-induced skeletal myogenesis of pluripotent P19 cells in vitro

P19 embryonal carcinoma cells can be induced to differentiate in culture to develop into a wide variety of cell types that include skeletal muscle. Skeletal myogenesis is controlled by transcription factors of the bHLH class, such as myoD. Expression of myoD from transfected genes did not induce significant amounts of myogenesis in P19 cells and it was possible to establish lines of undifferentiated P19[myoD] cells that express high levels of myoD mRNA. These P19[myoD] cells remained undifferentiated when cultured on solid surfaces but when allowed to aggregate, P19[myoD] cells differentiated efficiently into skeletal muscle. Aggregation did not increase the amount of myoD mRNA or the amount of myoD protein in P19[myoD] cells. The myoD protein was present in the nucleus in cells grown as attached or aggregated cultures and, in both culture conditions, the myoD protein was associated with transcription factors of the E2A family and was able to bind DNA at E-box sequences. Thus, the aggregation-induced myogenesis of P19[myoD] cells occurs in the absence of change in the myoD protein, suggesting that the cell-cell contact achieved in aggregates may result in the induction of an activity that increases accessibility of the myoD transcription factor to muscle-specific genes in chromatin.

Effect of dietary intake of omega-3 and omega-6 fatty acids on severity of asthma in children

We assessed the clinical and biochemical effects in asthmatic children of fish oil supplementation and a diet that increases omega-3 and reduces omega-6 fatty acids. Thirty nine asthmatic children aged 8-12 yrs participated in a double-blind, randomized, controlled trial for 6 months during which they received fish oil capsules plus canola oil and margarine (omega-3 group) or safflower oil capsules plus sunflower oil and margarine (omega-6 group). Plasma fatty acids, stimulated tumour necrosis factor alpha (TNFalpha) production, circulating eosinophil numbers and lung function were measured at baseline and after 3 and 6 months of dietary modification. Day and night symptoms, peak flow rates and medication use were recorded for 1 week prior to laboratory visits. Plasma phospholipid omega-3 fatty acids were significantly greater in the omega-3 group at 3 and 6 months compared to the omega-6 group (p<0.001). In the omega-3 group TNFalpha production fell significantly compared with baseline (p=0.026), but the magnitude of change between groups did not reach significance (p=0.075). There were no significant changes in clinical outcome measures. Dietary enrichment of omega-3 fatty acids over 6 months increased plasma levels of these fatty acids, reduced stimulated tumour necrosis factor alpha production, but had no effect on the clinical severity of asthma in these children.

Mediators on human airway smooth muscle

1. Bronchial hyperresponsiveness in asthma may be due to several abnormalities, but must include alterations in the airway smooth muscle responsiveness and/or volume. 2. Increased responsiveness of airway smooth muscle in vitro can be induced by certain inflammatory cell products and by induction of sensitization (atopy). 3. Increased airway smooth muscle growth can also be induced by inflammatory cell products and atopic serum. 4. Mast cell numbers are increased in the airways of asthmatics and, in our studies, in airway smooth muscle that is sensitized and hyperresponsive. 5. We propose that there is a relationship between mast cells and airway smooth muscle cells which, once an allergic process has been initiated, results in the development of critical features in the lungs in asthma.

Distribution of substance P receptors in rabbit airways, functional and autoradiographic studies

We have studied systematically the distribution of receptors for substance P in the airway smooth muscle of the rabbit using both functional studies and light-microscopic autoradiography. Four areas of the respiratory tract were examined: the midtrachea (T1) and proximal, middle and distal portions of the right main bronchus (B1, B2 and B3, respectively). The magnitude of the contractile response to substance P in preparations from six to eight animals was location-dependent, increasing significantly from proximal to distal areas. Maximal tension expressed as a function of tissue weight +/- S.E.M. was 24.8 +/- 3 for T1, 39 +/- 10 for B1, 108 +/- 31 for B2 and 160 +/- 42 for B3. The potency of substance P in B2 and B3 was significantly greater (EC50 = 4.8 x 10(-7) M; 2.8 x 10(-7) M, respectively) than that in T1 (2.5 x 10(-6) M). After inhibition of endogenous enkephalinase by phosphoramidon there was an increase in sensitivity to substance P in both T1 (EC50 = 2.3 x 10(-7) M, n = 5) and B3 (2.6 x 10(-9) M, n = 5). There was remarkable agreement in the results obtained with autoradiography. No binding sites (0) were visualized to Bolton Hunter substance P in T1. Sparse but specific binding (+) was seen in B1, whereas it was marked ( ) in B2 and very dense ( ++) in B3. Thus, our results have shown that receptors for substance P are more numerous in the distal than proximal airways of the rabbit. This may indicate a physiological role for substance P in the regulation of airway smooth muscle tone in the distal airways.

The calcium dependence of histamine, carbachol and potassium chloride-induced contraction in human airways in vitro

The effect of depletion of calcium from the Krebs Henseleit (KH) solution and the addition of EDTA (1 mM) on contraction of human isolated bronchus by histamine, carbachol and potassium chloride (KCl) was examined. Contractions to histamine and carbachol were almost totally abolished in calcium free KH in the presence of 1 mM EDTA which only reduced KCl responses to 76% of control values. Verapamil (10(-6), 10(-5), 10(-4) M) decreased histamine and KCl contractile responses in a dose-related manner while having no significant effect on carbachol-induced tension. The intracellular calcium antagonist TMB8 10(-4) M caused a slight but significant decrease in histamine contraction but was without effect on the maximal response of the other two agonists. TMB8 decreased the potency of both histamine and carbachol. These results suggest that histamine, carbachol and KCl utilise different pools of calcium for contraction, that only part of the calcium entry for all agonists occurs via voltage-dependent calcium channels and that intracellular calcium stores may play a small role in contraction to these agonists.

The modification by ketotifen of respiratory responses to histamine and antigen in guinea-pigs

Aerosolized solutions of histamine or ovalbumin were administered to control or ovalbumin-sensitized guinea-pigs. The time to onset of respiratory distress (preconvulsion time) during challenge with these agents was measured using a force-displacement transducer on the animal's back. The preconvulsion time for each guinea-pig was compared with and without ketotifen pretreatment. Ketotifen administered both by aerosol and intraperitoneal injection (i.p.) significantly protected (p less than 0.001) each guinea-pig from the effects of aerosol challenge with histamine. Ovalbumin-sensitized animals were also protected from the effects of antigen aerosol challenge by ketotifen pretreatment. Sodium cromoglycate (DSCG), administered as an aerosol, did not protect sensitized animals from ovalbumin challenge. The Konzett-Rössler technique was used to measure the response to the intravenous injection (i.v.) of histamine in anaesthetized artificially ventilated guinea-pigs. Ketotifen was three times more potent than mepyramine in inhibiting the histamine-induced increase in air overflow volume.