The future of allergic rhinitis management: A partnership between healthcare professionals and patients.

Allergic rhinitis (AR) is a chronic respiratory condition that internationally continues to be burdensome and impacts quality of life. Despite availability of medicines and guidelines for healthcare providers for the optimal management of AR, optimisation of its management in the community continues to be elusive. The reasons for this are multi-faceted and include both environmental and healthcare related factors. One factor that we can no longer ignore is that AR management is no longer limited to the domain of healthcare provider and that people with AR make their own choices when choosing how to manage their condition, without seeking advice from a health care provider. We must build a bridge between healthcare provider knowledge and guidelines and patient decision-making. With this commentary, we propose that a shared decision-making approach between healthcare professionals and people with AR be developed and promoted, with a focus on patient health literacy. As custodians of AR knowledge, we have a responsibility to ensure it is accessible to those that matter most-the people with AR.

The impact of implementing an allergic rhinitis clinical management pathway (AR-CMaP) in the community pharmacy.

Background: The Allergic Rhinitis Clinical Management Pathway (AR-CMaP) was developed to overcome the challenge of implementing current AR guidelines in the Australian community pharmacy practice and support pharmacists in optimally managing patients' AR. Objectives: To evaluate the impact of AR-CMaP on patients' behaviour and pharmacists' needs in managing AR in the pharmacy. Methods: This study used a cross-sectional, pre-post study design in which the primary outcome was the appropriateness of medications purchased from community pharmacies in Australia. Patient data were collected before and after the implementation of AR-CMaP. Pharmacist needs were recorded before and after AR-CMaP training. Data were analysed descriptively. Results: Six pharmacies, 19 pharmacists and a total of 416 patients were included in the study; 206 pre-AR-CMaP implementation and 210 post-AR-CMaP implementation. Pre-AR-CMaP, 22.4% of patients purchased appropriate AR medication compared with 29.0% post-AR-CMaP implementation. Over half the patient cohort (52%) consulted a pharmacist pre-AR-CMaP and 37% consulted a pharmacist post-AR-CMaP implementation. Post-AR-CMaP, pharmacists reported increased awareness of barriers such as patients' lack of time, patients' perceptions about the pharmacist's role and patient choice to self-manage. Pharmacists also rated an increased desire to interact with other health care providers (HCPs) in caring for patients with AR. Conclusions: While there was a non-statistically significant increase in the proportion of patients purchasing optimal AR medication, AR-CMaP did empower patients to self-select their own medication without further detriment. Moreover, following the implementation of AR-CMaP, pharmacists developed a greater awareness of their role in AR management, exemplified by their increased desire to be actively involved in AR management and increased interaction with other HCPs. Future research needs to explore more effective tools to support pharmacists' clinical decision-making and target patients' self-selection of AR medications. This study highlights that there is an ingrained self-reliance of AR decision-making that has become a habit for people living with AR.

Effects of immersive virtual reality for managing anxiety, nausea and vomiting among paediatric cancer patients receiving their first chemotherapy: An exploratory randomised controlled trial.

PURPOSE: To assess the feasibility and acceptability of immersive virtual reality for managing anxiety, nausea and vomiting amongst paediatric patients with cancer receiving their first chemotherapy. METHODS: An exploratory randomised control trial supplemented with qualitative interviews was conducted to enrol Chinese paediatric patients receiving their first intravenous chemotherapy. Participants were randomly assigned to intervention (three immersive virtual reality sessions) or control (standard care) groups. The main outcome measures included (1) feasibility parameters; (2) anxiety, nausea and vomiting; and (3) satisfaction with the chemotherapy procedures. Qualitative data were collected by semi-structured individual interviews with patients, parents and nurses. RESULTS: A total of 19 patients, 19 accompanying parents and 9 nurses were recruited. Results suggested that the intervention was feasible as evidenced by the high consent rate, low withdrawal rate and attrition rate. The intervention group showed significantly better improvement in anxiety at T2 [Hedges' effect size, ES = 1.25, 95% confidence interval (CI): 0.22-2.17)] and T4 [ES = 1.87, 95% CI: 0.72-2.85], as well as greater reduction in acute nausea at T4 [ES = 0.97, 95% CI: 0.02-1.87] than the control group. Qualitative data yielded three categories including positive experiences and perceived benefits of the intervention, and suggested improvements. CONCLUSIONS: This study demonstrated the potential effectiveness, feasibility and acceptability of immersive virtual reality for managing anxiety and acute nausea amongst paediatric patients with cancer receiving their first chemotherapy.

Characterisation of the Australian Adult Population Living with Asthma: Severe - Exacerbation Frequency, Long-Term OCS Use and Adverse Effects.

Introduction: Asthma poses a significant burden for the Australian population. Understanding severe exacerbation rates, and steroid-related burden for adults diagnosed with asthma stands to offer insights into how this could be reduced. Methods: Electronic medical records (EMR) and questionnaires from the Optimum Patient Care Research Database Australia (OPCRDA) were utilised retrospectively. OPCRDA is a real-world database with >800,000 medical records from Australian primary care practices. Outcomes were severe asthma exacerbations in Australian adults, over a 12-month period, stratified by Global Initiative for Asthma (GINA) treatment intensity steps, and steroid associated comorbidities. Results: Of the 7868 adults treated for asthma, 19% experienced at least one severe exacerbation in the last 12-months. Severe exacerbation frequency increased with treatment intensity (≥1 severe exacerbation GINA 1 13%; GINA 4 23%; GINA 5a 33% and GINA 5b 28%). Questionnaire participants reported higher rates of severe exacerbations than suggested from their EMR (32% vs 23%) especially in steps 1, 4 and 5. Patients repeatedly exposed to steroids had an increased risk of osteoporosis (OR 1.95, 95% CI 1.43-2.66) and sleep apnoea (OR 1.78, 95% CI 1.30-2.46). Conclusion: The Australian population living with GINA 1, 4, 5a and 5b asthma have high severe exacerbation rates and steroid-related burden, especially when compared to other first world countries, with these patients needing alternative strategies or possibly specialist assessment to better manage their condition.

Qualitative Exploration of Pharmacists' Feedback Following the Implementation of an "Allergic Rhinitis Clinical Management Pathway (AR-CMaP)" in Australian Community Pharmacies.

Allergic Rhinitis (AR) is both a common and high burden disease, with the majority of AR sufferers purchasing suboptimal/inappropriate AR medication from community pharmacies. Unfortunately, it is still a challenge to translate the AR management guidelines that are available at both a global and national level into practice. This study aimed to explore the experiences and perceptions of community pharmacists with regards to the implementation of AR management guidelines in real-life everyday practice. This exploration took the form of a qualitative research study in which pharmacists were interviewed following the implementation of a guideline-driven AR management pathway in their pharmacies. Fifteen pharmacists from six pharmacies agreed to participate in a telephone interview. Five themes were identified that encompassed the sentiment of the pharmacists during the interviews: 1) impact of training on pharmacists' approach to patients and AR management recommendations; 2) patient engagement and the importance of appropriate tools; 3) patient barriers to change in practice; 4) physical, logistical, and inter-professional barriers to change within the pharmacy environment; and 5) recommendations for improvement. The results of this study indicate that, following the implementation of an AR management pathway, pharmacists believe that their interactions with patients around their AR were enhanced through the use of appropriate tools and education. However, if optimal AR management is to be delivered within the community pharmacy setting, the undertaking needs to be collaborative with both pharmacy assistants and general practitioners.

Study protocol: Development, implementation, evaluation and refinement of a translational allergic rhinitis clinical management pathway (AR-CMaP) for community pharmacies.

BACKGROUND: Allergic Rhinitis (AR) is a highly burdened chronic respiratory disease1-4, which affects about 40% of the world's population5. Research shows that only 15% of people with AR, in the community pharmacy setting are using optimal AR medication6. There is a clear need to better implement AR management guidelines so that more effective medication selection and an evidence-based approach to the management of AR is implemented. OBJECTIVE: This paper describes the methods that will be used to develop, implement, evaluate and refine an evidence-based, guideline informed allergic rhinitis clinical management pathway, Allergic Rhinitis Clinical Management Pathway (AR-CMaP) for community pharmacy. METHODS: AR-CMaP was developed based on the latest AR management guidelines for pharmacy7 and empirical evidence associated with patient self-management behaviours in community pharmacy15, utilising the Promoting Action on Research Implementation in Health Services implementation framework (Phase 1). AR-CMaP was then implemented in six pharmacies in the Australian Capital Territory (ACT), Australia (Phase 2). The impact of AR-CMaP on AR management in the pharmacy (AR medication management and pharmacy practice) will be evaluated in a pre-post intervention study design (Phase 3). Phase 4 will involve the refinement of AR-CMaP to ensure its generalisability and scalability; readiness for large-scale dissemination across different pharmacy locations (e.g. rural, remote, metropolitan) and different pharmacy business models. CONCLUSIONS: There is an urgent need to develop a translational AR clinical pathway, to address the wide-spread challenge of suboptimal AR management and burden of AR on individuals and society. This protocol paper describes the methods underpinning the development, implementation, evaluation and refinement of an evidence-based AR clinical pathway for community pharmacy setting, which is in line with current clinical evidence and feasible for effective implementation into the community pharmacy setting.

A qualitative investigation of the allergic rhinitis network from the perspective of the patient.

Patient self-selection of over-the-counter medicines for the management of allergic rhinitis is suboptimal. The mapping of the allergic rhinitis network demonstrates that patients' decisions with regards to their allergic rhinitis management can be influenced by up to 11 individuals/resources (alters). This study aimed to identify the role of alters within the allergic rhinitis network and identify the factors that determined their degree of influence as perceived by the patient. This research was a qualitative exploration embedded in an empirical framework and social network theory. People with allergic rhinitis were interviewed about their network and transcripts were analysed deductively and inductively. Transcripts were coded by researchers independently and then discussed until agreement was reached. Forty-one participants described the roles of 17 alters on their allergic rhinitis management. The roles of alters fell within five categories: diagnosis, medication prescription/supply/administration, medication recommendation, information about allergic rhinitis and emotional support. Participant interactions with these alters were often acute and had a long standing effect, with the participants often navigating the long-term management on their own. The significance of the influence of each alter on their allergic rhinitis management was dependent on the level of trust in their relationship, impact of the role made to the participants' day-to-day management of allergic rhinitis and/or the participant's beliefs. Allergic rhinitis management was fragmented and had opportunity to be improved by developing strategies, resources and policies to support self-management in collaboration with patients and health-care professionals.

Exploring the Asthma Network in People with Allergic Rhinitis Utilizing an Egocentric Social Network Analysis.

INTRODUCTION: Asthma and allergic rhinitis (AR) are chronic respiratory diseases of a united airway. Poor AR control is a risk factor for uncontrolled asthma. We know that people with AR feel confident in making their own treatment choices with over-the-counter therapies, yet only 16% of purchases were the optimal selection. With the high level of poor asthma control and overuse of over-the-counter, short-acting beta-agonists, we must consider whether poor AR self-management behaviours are extended to asthma management in those with both diseases. This study aims to investigate asthma management from the perspective of the patient with asthma and AR and understand the influences behind their asthma management decisions. METHODS: This study utilized a mixed methods approach based on the theoretical and analytical framework of social network theory, including mapping of the asthma network and exploring the roles and influence of those that appear within the network. RESULTS: Twenty-two people with asthma and allergic rhinitis participated in this study. General practitioners (GPs), pharmacists and respiratory physicians were the most commonly reported influences behind participants' asthma management decisions. Although non-healthcare professional (HCP) influences appear within the asthma network, they represented a smaller proportion. CONCLUSION: The asthma network of people with AR is dominated by HCP influences. This network is unique and different to other previously published asthma and AR networks. Further research on the impact of AR on asthma management patient behaviour is required.

Management of allergic rhinitis in the community pharmacy: identifying the reasons behind medication self-selection.

BACKGROUND: Community pharmacists have a key role to play in the management of allergic rhinitis (AR). Their role is especially important because the majority of medications used to treat AR are available for purchase over-the-counter (OTC), allowing patients to self-select their own medications and bypass the pharmacists. Patients' self-selection often results in suboptimal treatment selection, undertreated AR and poor clinical outcomes. In order for pharmacists to optimise the care for AR patients in the pharmacy, pharmacists need to be able to identify patient cohorts who self-select and are at high risk of mismanagement. OBJECTIVES: This study aimed to compare the demographics, clinical characteristics and medication selected, between pharmacy customers who choose to self-select and those who speak with a pharmacist when purchasing medication for their AR in a community pharmacy and identify factors associated with AR patients' medication(s) self-selection behaviour. METHODS: A cross-sectional observational study was conducted in a convenience sample of community pharmacies from the Sydney metropolitan area. Demographics, pattern of AR symptoms, their impact on quality of life (QOL) and medication(s) selected, were collected. Logistic regressions were used to identify factors associated with participants' medication self-selection behaviour. RESULTS: Of the 296 recruited participants, 202 were identified with AR; 67.8% were female, 54.5% were >40 years of age, 64.9% had a doctor's diagnosis of AR, and 69.3% self-selected medication(s). Participants with AR who self-select were 4 times more likely to experience moderate-severe wheeze (OR 4.047, 95% CI 1.155-14.188) and almost 0.4 times less likely to experience an impact of AR symptoms on their QOL (OR 0.369, 95% CI 0.188-0.727). CONCLUSIONS: The factors associated with AR patients' self-selecting medication(s) are the presence of wheeze and the absence of impact on their QOL due to AR symptoms. By identifying this cohort of patients, our study highlights an opportunity for pharmacists to engage these patients and encourage discussion about their AR and asthma management.

A patient-centric analysis to identify key influences in allergic rhinitis management.

Allergic rhinitis (AR) is increasingly becoming a patient self-managed disease. Just under 70% of patients purchasing pharmacotherapy self-select their treatment with no health-care professional intervention often resulting in poor choices, leading to suboptimal management and increased burden of AR on the individual and the community. However, no decision is made without external, influencing forces. This study aims to determine the key influences driving patients' decision-making around AR management. To accomplish this aim, we utilised a social network theory framework to map the patient's AR network and identify the strength of the influences within this network. Adults who reported having AR were interviewed and completed an AR network map and AR severity and quality of life questionnaires. Forty one people with AR completed the study. The AR networks of the participants had a range of 1-11 influences (alters), with an average number of 4 and a median of 5. The larger the impact of AR on their quality of life, the greater the number of alters within their network. The three most commonly identified alters were, general practitioners, pharmacists and the participants' 'own experience'. The strength of the influence of health-care professionals (HCPs) was varied. The proportion of HCPs within the AR network increased as the impact of AR on their quality of life increased. By mapping the AR network, this study demonstrated that there are multiple influences behind patient's decisions regarding AR management but the role of the HCP cannot be dismissed.

The Burden of Rhinitis and the Impact of Medication Management within the Community Pharmacy Setting.

BACKGROUND: The burden of rhinitis is high. It is unknown to what extent this burden is related to inappropriate medication use. OBJECTIVE: This study aimed to identify the way in which people with rhinitis medicate their condition and to evaluate the appropriateness of this medication management. METHODS: Pharmacy customers who visited Sydney metropolitan community pharmacies and purchased medication for nasal symptoms were the sampling frame for this study. To determine the condition for which the participants were seeking medication and the appropriateness of their medication selection, the following data were collected with a researcher-administered questionnaire: participant's demographics, symptoms, medication selected. An expert panel of clinical researcher pharmacists and specialist respiratory physician evaluated the appropriateness of medication selection based on the Allergic Rhinitis and its Impact on Asthma international guidelines. RESULTS: Two hundred and ninety-six participants were recruited from 8 pharmacies; 63.2% had a doctor's diagnosis for the symptoms for which they were selecting treatment. Seventy percent of participants self-selected their medications. Seventy-one percent of the participants were identified as having rhinitis. Overall, 16.5% of participants who had rhinitis selected optimal medications. Sixteen percent of participants with allergic rhinitis reported wheezing (6.3% selected optimal medications). CONCLUSIONS: The majority of the participants with rhinitis selected suboptimal medications from community pharmacy highlighting the significant burden of rhinitis in community pharmacy and the contribution of medication management. Pharmacists need to take a proactive and evidence-based role in the management of rhinitis supported by clinical pathways when need to be articulated and promoted in all rhinitis guidelines.

Tell me about your hay fever: a qualitative investigation of allergic rhinitis management from the perspective of the patient.

Allergic rhinitis (AR) is sub-optimally managed in the community and is responsible for a significant health and economic burden. Uncontrolled AR increases the risk of poorly controlled asthma and presents an increased susceptibility to thunderstorm asthma. With the availability of treatments over-the-counter, bypassing the health care professional (HCP), the role of the patient is paramount. Research on the role of the patient in AR management in the current environment is limited. This study aims to explore the patient perspective of AR management and understand why it is sub-optimally managed in the community. Patient perspectives of AR management were explored utilizing a qualitative, phenomenological approach. Adults with AR were included in the study and interviewed. Transcripts were analyzed for recurrent themes and emergent concepts. Forty-seven participants with AR were interviewed about their experiences. Patient reports of delayed diagnosis, treatment fatigue and confidence in the ability to manage their AR themselves, heavily influenced their management preferences. Patients also described barriers associated with AR management including financial expense as well as being mistaken for having an infectious disease. Patients described examples of the impact on their quality of life caused by their AR, yet they strongly believed they could manage it themselves. This belief that AR is a condition that should be entirely self-managed, contributes to its burden. It amplifies patients' separation from HCPs and having access to guidelines aimed at optimizing their AR control.

Lack of asthma and rhinitis control in general practitioner-managed patients prescribed fixed-dose combination therapy in Australia.

OBJECTIVES: The first aim of the study (i) assess the current asthma status of general-practitioner-managed patients receiving regular fixed-dose combination inhaled corticosteroid and long-acting beta2 agonist (FDC ICS/LABA) therapy and (ii) explore patients' perceptions of asthma control and attitudes/behaviors regarding preventer inhaler use. METHODS: A cross-sectional observational study of Australian adults with a current physician diagnosis of asthma receiving ≥2 prescriptions of FDC ICS/LABA therapy in the previous year, who were recruited through general practice to receive a structured in-depth asthma review between May 2012 and January 2014. Descriptive statistics and Chi-Square tests for independence were used for associations across asthma control levels. RESULTS: Only 11.5% of the patients had controlled asthma based on guideline-defined criteria. Contrarily, 66.5% of the patients considered their asthma to be well controlled. Incidence of acute asthma exacerbations in the previous year was 26.5% and 45.6% of the patients were without a diagnosis of rhinitis. Asthma medication use and inhaler technique were sub-optimal; only 41.0% of the preventer users reported everyday use. The side effects of medication were common and more frequently reported among uncontrolled and partially controlled patients. CONCLUSIONS: The study revealed the extent to which asthma management needs to be improved in this patient cohort and the numerous unmet needs regarding the current state of asthma care. Not only there is a need for continuous education of patients, but also education of health care practitioners to better understand the way in which patient's perceptions impact on asthma management practices, incorporating these findings into clinical decision making.

Identifying the hidden burden of allergic rhinitis (AR) in community pharmacy: a global phenomenon.

BACKGROUND: Patients with allergic rhinitis often trivialise their condition, self-manage inappropriately, and would benefit from health care intervention. The primary point of health care contact for these self-managing allergic rhinitis patients is the community pharmacy. With the majority of allergic rhinitis treatments being available for purchase over the counter, without health care professional contact, we know little about how the patients self-manage. This study aims to identify the burden of allergic rhinitis in the community pharmacy and to identify key opportunity for intervention. METHODS: Pharmacy customers, who purchased nasal treatment in a community pharmacy, were approached with a research-administered questionnaire that collected data on medical history, symptoms and products purchased for the treatment of nasal symptoms. RESULTS: Of the 296 participants, 69.9% self-managed with over-the-counter medications; with 68% experiencing allergic rhinitis symptoms and only 44.3% of this subgroup had a doctor's diagnosis. Nasal congestion (73.6%) was most commonly experienced and oral antihistamines were most commonly purchased (44.3%), indicating a pattern of suboptimal management. A third of participants (36.5%) experienced moderate-severe symptoms, persistently, which impacted on their daily living. Medication selection was mainly based on pharmacy customers' perceptions of medication effectiveness (47.6%). CONCLUSION: A majority of participants that self-selected over-the-counter medications have symptoms consistent with allergic rhinitis, with almost half not having received a diagnosis. Medication purchasing patterns suggest that sub-optimal therapeutic decisions made by participants, even when they are experiencing significant symptoms. This study uncovers the hidden burden of allergic rhinitis in the community pharmacy and a missed opportunity to intervene and refer if necessary. Patients need to be guided through appropriate treatment as this study showed that many should be referred to a medical practitioner.

A novel prolactin-like protein (PRL-L) gene in chickens and zebrafish: cloning and characterization of its tissue expression.

In this study, a full-length cDNA encoding a prolactin-like protein (PRL-L) was cloned from chicken brain tissues using RT-PCR. This putative PRL-L precursor has 225 amino acids in length and shares 30-35% amino acid sequence identity with prolactin (PRL) of chicken, zebrafish, Xenopus, rat and human. Using RT-PCR, the mRNA expression of PRL-L in chicken tissues was further examined. Unlike the predominant expression of PRL in pituitary, PRL-L was found to be widely expressed in adult chicken extra-pituitary tissues with only minimal expression detected in pituitary. In day-7 chicken embryos, the expression of PRL-L, but not PRL, was also detected in all extra-pituitary tissues examined. In line with this finding, the 5'-flanking region of chicken PRL-L (cPRL-L) gene, but not PRL gene, displayed a strong promoter activity in cultured DF-1 cell (a chicken embryo fibroblast cell line), suggesting that the basal expression of PRL-L gene is controlled by a transcriptional regulatory mechanism different from that of PRL gene. As the same findings in chickens, PRL-like protein(s), which share high amino acid sequence (42-86%) identity with chicken PRL-L, was identified in several non-mammalian vertebrate species including zebra finch, tiger puffer, green puffer and zebrafish. RT-PCR assay demonstrated that zebrafish PRL-L, similar to chicken PRL-L, is expressed in extra-pituitary tissues including brain, gill, muscle, ovary and testis. Taken together, these findings strongly suggest that a novel PRL-like protein exists in some non-mammalian vertebrates and may play an important role in target tissues, such as extra-pituitary tissues of chickens and zebrafish.

Epidermal growth factor (EGF) receptor ligands in the chicken ovary: I. Evidence for heparin-binding EGF-like growth factor (HB-EGF) as a potential oocyte-derived signal to control granulosa cell proliferation and HB-EGF and kit ligand expression.

There is increasing evidence that epidermal growth factor (EGF) receptor (EGFR) ligand and Kit ligand (KL) play critical roles in controlling follicular development in mammals. Because little is known about their expressions in the ovary of nonmammalian vertebrate, our study aimed to examine the expression, hormonal regulation, and interaction of HB-EGF and KL in the chicken ovary. Using semiquantitative RT-PCR, we demonstrated that ovarian HB-EGF expression increased dramatically with the posthatching ovarian growth. In line with this finding, HB-EGF was shown to be produced primarily by the growing oocytes and capable of stimulating the proliferation of granulosa cells in prehierarchal (3 mm) and preovulatory follicles (F5 and F1). Although HB-EGF expression is mainly restricted to the oocytes, its expression in cultured granulosa cells could be transiently yet strongly induced by HB-EGF and other EGFR ligands including EGF and TGF-alpha. And the inducing effect of HB-EGF was completely abolished by AG1478 (10 microM) or PD98059 (100 microM), indicating that the action of HB-EGF is mediated by EGFR and intracellular MAPK/ERK signaling pathway. Unlike mammals, only KL-1, not the other three isoforms identified (KL-2, -3, and -4), was detected to be predominantly expressed in the chicken ovary. Interestingly, KL expression in undifferentiated and differentiated granulosa cells could be transiently down-regulated by HB-EGF, implying an intrafollicular communication between growing oocyte and surrounding granulosa cells through the interplay of EGFR ligand and KL. Collectively, our data suggest that HB-EGF is likely a paracrine signal from the oocyte to regulate granulosa cell proliferation and HB-EGF and KL expression during ovarian follicular development.