Organisation of cross-sector collaboration and its influence on crisis management effectiveness among pharmaceutical supply chain stakeholders during the COVID-19 pandemic.

OBJECTIVES: To investigate the organisation of cross-sector collaboration and how it influenced crisis management effectiveness among pharmaceutical supply chain stakeholders in Finland during the COVID-19 pandemic. STUDY DESIGN: Qualitative semi-structured interview study. METHODS: Purposeful selection was used to obtain the study sample consisting of leaders and specialists from the pharmaceutical industry and wholesalers (n = 9), community pharmacy owners (n = 9), hospital pharmacy heads (n = 6), government agency directors and officials (n = 5) and advocacy organisation representatives (n = 2). Inductive content analysis was performed to examine the data from the semi-structured individual (n = 29) and paired (n = 2) interviews in March-May 2021. RESULTS: A new conceptual model was developed to describe the organisation of collaborative crisis management. Without a predefined crisis management organisation, cross-sector collaboration was organised based on previous collaboration structures, channels and relationships and through the establishment of issue-specific groups by government agencies as per legal mandates. Crisis dynamics and related issues guided the group formation and meeting frequency. Advocacy organisations and government agencies acted in bridging role between stakeholders. Shared knowledge among pharmaceutical supply chain stakeholders enabled anticipation and preparedness during crisis; shared resources fostered maintenance of core functions; and shared problem-solving facilitated cross-sectoral solutions. CONCLUSION: This was the first study exploring cross-sector collaboration among pharmaceutical supply chain stakeholders during a crisis. Sharing knowledge, resources and problem-solving increased the crisis management effectiveness. The study presented a new illustration of organising for collaborative crisis management and added knowledge about private-third sector collaboration and issue-specific groups to the cross-sector collaboration and crisis management literature.

An inventory of collaborative medication reviews for older adults - evolution of practices.

BACKGROUND: Collaborative medication review (CMR) practices for older adults are evolving in many countries. Development has been under way in Finland for over a decade, but no inventory of evolved practices has been conducted. The aim of this study was to identify and describe CMR practices in Finland after 10 years of developement. METHODS: An inventory of CMR practices was conducted using a snowballing approach and an open call in the Finnish Medicines Agency's website in 2015. Data were quantitatively analysed using descriptive statistics and qualitatively by inductive thematic content analysis. Clyne et al's medication review typology was applied for evaluating comprehensiveness of the practices. RESULTS: In total, 43 practices were identified, of which 22 (51%) were designed for older adults in primary care. The majority (n = 30, 70%) of the practices were clinical CMRs, with 18 (42%) of them being in routine use. A checklist with criteria was used in 19 (44%) of the practices to identify patients with polypharmacy (n = 6), falls (n = 5), and renal dysfunction (n = 5) as the most common criteria for CMR. Patients were involved in 32 (74%) of the practices, mostly as a source of information via interview (n = 27, 63%). A medication care plan was discussed with the patient in 17 practices (40%), and it was established systematically as usual care to all or selected patient groups in 11 (26%) of the practices. All or selected patients' medication lists were reconciled in 15 practices (35%). Nearly half of the practices (n = 19, 44%) lacked explicit methods for following up effects of medication changes. When reported, the effects were followed up as a routine control (n = 9, 21%) or in a follow-up appointment (n = 6, 14%). CONCLUSIONS: Different MRs in varying settings were available and in routine use, the majority being comprehensive CMRs designed for primary outpatient care and for older adults. Even though practices might benefit from national standardization, flexibility in their customization according to context, medical and patient needs, and available resources is important.

Key pharmacovigilance stakeholders' experiences of direct patient reporting of adverse drug reactions and their prospects of future development in the European Union.

OBJECTIVES: In the European Union (EU), legislation allows patients to directly report adverse drug reactions (ADRs) to competent authorities. Five years after its implementation, patient reporting is not equal in all countries. This study aimed to explore key stakeholders' perceptions of patient reporting in four EU countries. STUDY DESIGN: Qualitative study design. METHODS: Twelve representatives from national pharmacovigilance centres and/or authorities as well as national pharmaceutical industry bodies in four EU countries participated in the study. Supranational organizations were also included. Data collection was via face-semi-structured interviews. Inductive content analysis was performed thereafter, applying principles of risk management as a theoretical framework. RESULTS: Four themes (attitudes and beliefs, system maturation factors, regulatory improvements, and cultural shifts) emerged, conceptually interconnected. Participants from countries introducing patient reporting recently expressed a negative attitude. Participants highlighted the need for additional resources, both human and financial, to address patient reporting and associated advantages. CONCLUSIONS: The findings identified perceived barriers and facilitators of patient reporting. The involvement of patients, use of information, and dissemination of patient reporting are far from optimal. A better integration of the work by EU regulatory authorities is recommended.

Identifying high risk medications causing potential drug-drug interactions in outpatients: A prescription database study based on an online surveillance system.

BACKGROUND: Drug-drug interactions (DDIs) are a significant cause for adverse drug events (ADEs). DDIs are often predictable and preventable, but their prevention and management require systematic service development. Most DDI studies focus on interaction rates in hospitalized patients. Less is known of DDIs in outpatients, particularly how community pharmacists could contribute to DDI management by applying their surveillance systems for identifying high-risk medications. OBJECTIVES: The study was related to the implementation of the first online DDI surveillance system in Finnish community pharmacies. The goal was to demonstrate how community pharmacies can utilize their prospective surveillance system 1) for identifying high risk medications causing potential DDIs in outpatients, 2) for collaborative service development with local physicians, and 3) for academic risk management research purposes. METHODS: All DDI alerts given by the online surveillance system were collected during a one-month period in 16 out of 17 University Pharmacy outlets in Finland, covering approximately 10% of the national outpatient prescription volume. The surveillance system was based on the FASS database, which categorizes DDIs into four classes (A-D) according to their clinical significance. RESULTS: Potential drug-drug DDIs were analyzed for 276,891 dispensed community pharmacy prescriptions. Potential DDIs were associated with 10.8%, or 31,110 of these prescriptions. Clinically significant interaction alerts categorized as FASS classes D (most severe, should be avoided) and C (clinically significant but controllable) were associated with 0.5% and 7.0% of the prescriptions, respectively. Methotrexate and warfarin had the highest risk of causing potentially serious (class D) interactions. These interaction alerts were most frequently between methotrexate and NSAIDs and warfarin and NSAIDs. In general, NSAIDs were the most commonly interacting drugs in this study. CONCLUSIONS: This study demonstrates that community pharmacies can actively contribute to DDI risk management and systematically use their surveillance systems for identifying patients having clinically significant DDIs. The findings also indicate that the majority of potentially serious interactions in outpatients involve a limited number of drugs, particularly NSAIDs, warfarin and methotrexate. Further research should focus on community pharmacists' involvement in DDI risk management in collaboration with local health care providers.

Long-term use of benzodiazepines: Definitions, prevalence and usage patterns - a systematic review of register-based studies.

BACKGROUND: Numerous treatment guidelines recommend that long-term use of benzodiazepines (BZD) should be avoided primarily due to development of tolerance and a risk for BZD dependence. Despite this, long-term BZD use remains a controversial subject in clinical patient care with "for and against" debates. However, there is no explicit understanding of what is meant by long-term BZD use in real world. The aim of this study was to assess different definitions, usage patterns, prevalence and other characteristics of long-term BZD use based on published register-based studies. Synthesis of these characteristics is essential to derive a meaningful definition of long-term BZD. METHODS: Systematic review of register-based studies on long-term BZD use published in 1994-2014. RESULTS: Fourty-one studies met our predetermined inclusion criteria. The length of BZD use defined as "long-term" varied in these studies ranging from one month to several years. The most common definition was six months or longer during a year. The prevalence of long-term BZD use in the general population was estimated to be about 3%. The relative proportion of long-term BZD users (all definitions) in adult BZD users ranged from 6% to 76% (mean 24%; 95% CL 13-36%). The estimates were higher in studies only on the elderly (47%; 95% CL 31-64%). Long-term use involved typically steady treatment with low BZD doses. However, in elderly patients long-term BZD use and exceeding recommended doses was relatively common. Several characteristics associated with long-term use were found. CONCLUSIONS: Long-term BZD use is common and a clinical reality. Uniform definitions for "long-term", which is in line with population-based evidence, is needed to have more comparable results between studies. Our systematic review suggests that duration of BZD treatment over six months, the most common definition for long-term BZD use in the included studies. As also recommended previously, it is a useful starting point for further analyses on disadvantages but also potential advantages associated with long-term BZD use.

Medication review practices in European countries.

BACKGROUND: Medication review procedures have been developed in many countries to improve rational and safe medication use. The similarities, comprehensiveness, and effectiveness of these procedures has not been assessed, or compared. OBJECTIVE: The aim of this study was to explore medication review practices in European countries. METHODS: An online survey was sent to 32 European countries (all 28 European Union countries and 4 other European countries) by email to one person in each country known to be aware of medication review practices in their country in May 2011. The informants were identified through Pharmaceutical Group of European Union. To complement and validate the information received through Pharmaceutical Group of European Union, medication review experts involved in Pharmaceutical Care Network Europe were contacted. The survey assessed comprehensiveness of the medication review procedures classified according to 3 types in terms of settings; access to patient clinical information; patient involvement; availability of documentation and information; collaboration with the physician; quality control, and training required. RESULTS: Almost two thirds (64%) of the 25 European countries which responded (response rate 78%) indicated having at least one type of medication review procedure in their country. In the community setting prescription (type I) and adherence (type II) medication reviews were the most common (established in 9 and 11 countries, respectively). More comprehensive type III clinical medication reviews requiring access to clinical patient information were still rare, and just being established in 6 countries. CONCLUSIONS: Medication review procedures are becoming common in health care throughout Europe, however improving their comprehensiveness would require better access to patient information for those professionals conducting clinical medication reviews. In addition to benchmarking, the inventory can enhance cooperation between countries and stakeholders involved in medication review practice development nationally and internationally.

LRRTM1-deficient mice show a rare phenotype of avoiding small enclosures--a tentative mouse model for claustrophobia-like behaviour.

The LRRTM family proteins have been shown to act as synaptogenic cell adhesion molecules via interaction with presynaptic neurexins and are associated with neuropsychiatric disorders. LRRTM1-knockout mice have subtle morphological deficits in excitatory hippocampal synapses and were suggested to have impaired cognitive function. Here we report that LRRTM1-knockout mice exhibit an extraordinary phenotype of avoiding small enclosures. In the light-dark box, the knockout mice escape to dark through a standard opening as quickly as wild-type littermates but avoid escaping through a small doorway. While all wild-type mice spontaneously enter a small tube, most knockout mice do not. This apparent aversion to enter narrow space may explain other abnormalities such as increased time in open arms in the elevated plus maze and less visits through a tunnel in the IntelliCage. Moreover, LRRTM1-knockout mice show increased social interaction, reduced nest building and MK801-induced locomotion, and slower swim speed but normal water maze learning. Since LRRTM1 is predominantly expressed in thalamus, hippocampus and limbic cortex, specific synaptic defects in those areas presumably cause these behavioural abnormalities.

Determinants of mental health stigma among pharmacy students in Australia, Belgium, Estonia, Finland, India and Latvia.

BACKGROUND: Healthcare professionals commonly exhibit negative attitudes toward people with mental disorders. Few international studies have sought to investigate the determinants of stigma. OBJECTIVE: To conduct an international comparison of pharmacy students' stigma towards people with schizophrenia, and to determine whether stigma is consistently associated with stereotypical attributes of people with schizophrenia. METHOD: Students (n = 649) at eight universities in Australia, Belgium, India, Finland, Estonia and Latvia completed a seven-item Social Distance Scale (SDS) and six items related to stereotypical attributes of people with schizophrenia. RESULTS: Mean SDS scores were 19.65 (+/- 3.97) in Australia, 19.61 (+/- 2.92) in Belgium, 18.75 (+/- 3.57) in India, 18.05 (+/- 3.12) in Finland, and 20.90 (+/- 4.04) in Estonia and Latvia. Unpredictability was most strongly associated with having a high social distance in Australia (beta = -1.285), the perception that people will never recover in India (beta = - 0.881), dangerousness in Finland (beta = -1.473) and the perception of being difficult to talk to in Estonia and Latvia (beta = -2.076). Unpredictability was associated with lower social distance in Belgium (beta = 0.839). CONCLUSION: The extent to which students held stigmatizing attitudes was similar in each country, however, the determinants of stigma were different. Pharmacy education may need to be tailored to address the determinants of stigma in each country.

LRRTM1 on chromosome 2p12 is a maternally suppressed gene that is associated paternally with handedness and schizophrenia.

Left-right asymmetrical brain function underlies much of human cognition, behavior and emotion. Abnormalities of cerebral asymmetry are associated with schizophrenia and other neuropsychiatric disorders. The molecular, developmental and evolutionary origins of human brain asymmetry are unknown. We found significant association of a haplotype upstream of the gene LRRTM1 (Leucine-rich repeat transmembrane neuronal 1) with a quantitative measure of human handedness in a set of dyslexic siblings, when the haplotype was inherited paternally (P=0.00002). While we were unable to find this effect in an epidemiological set of twin-based sibships, we did find that the same haplotype is overtransmitted paternally to individuals with schizophrenia/schizoaffective disorder in a study of 1002 affected families (P=0.0014). We then found direct confirmatory evidence that LRRTM1 is an imprinted gene in humans that shows a variable pattern of maternal downregulation. We also showed that LRRTM1 is expressed during the development of specific forebrain structures, and thus could influence neuronal differentiation and connectivity. This is the first potential genetic influence on human handedness to be identified, and the first putative genetic effect on variability in human brain asymmetry. LRRTM1 is a candidate gene for involvement in several common neurodevelopmental disorders, and may have played a role in human cognitive and behavioral evolution.

Ample use of physician-prescribed medications in Finnish elite athletes.

The present study aimed at determining the use of physician-prescribed medication in a large number of elite athletes compared with a representative control sample of the general population. Of all the athletes (N = 494) financially supported by the National Olympic Committee, 446 completed a structured questionnaire (response rate 90.3 %) in 2002. A control group (N = 1503, response rate 80.1 %) comprised an age-matched sample from the population-based study collected by the National Public Health Institute. Any prescribed medication was used by 34.5 % of the athletes and 24.9 % of the controls during the past seven days. The most frequently reported physician-prescribed medications among athletes during the previous seven days were anti-allergic medicines (12.6 % of the respondents), non-steroidal anti-inflammatory drugs (NSAIDs; 8.1 %), anti-asthmatic medicines (7.0 %), and oral antibiotics (2.7 %). The adjusted odds ratios (95 % CI) for the physician-prescribed medications used during the previous seven days was 2.42 (1.69 - 3.46), 3.63 (2.25 - 5.84), 3.42 (2.05 - 5.70), and 2.15 (1.03 - 4.45) for use of anti-allergic medication, NSAIDs, anti-asthmatic medication, and oral antibiotics, respectively, in the athletes compared with controls. Every fifth athlete reported some NSAID-related adverse effect. In conclusion, the athletes used NSAIDs, antibiotics, anti-asthmatic and anti-allergic medication significantly more often than a representative sample of age-matched controls. All these medicines have potential adverse effects that may have a deleterious impact on the maximum exercise performance of elite athletes. Adverse effects were commonly reported in connection with NSAID use.

Fungal spore transport through a building structure.

The study carried out laboratory measurements with a full-scale timber frame structure to determine penetration of inert particles with size distribution from 0.6 to 4 microm and spores of Penicillium and Cladosporium through the structure. Pressure difference over and air leakage through the structure were varied. Measurements at moderate pressure differences resulted in the penetration factors within the range of 0.05-0.2 for inert particles, and indicated also the penetration of fungal spores through the structure. The measurements showed that the penetration was highly dependent on pressure difference over the structure but not on holes in surface boards of the structure. The results show that surface contacts between the frames and mineral wool may have a significant effect on penetration. The penetration was approximately constant within particle size rage of 0.6-2.5 microm, but particles with diameter of 4.0 microm did not penetrate through the structure at all even at a higher-pressure difference of 20 Pa, except in the case of direct flow-path through the structure. Results have important consequences for practical design showing that penetration of fungal spores through the building envelope is difficult to prevent by sealing. The only effective way to prevent penetration seems to be balancing or pressurizing the building. In cold climates, moisture condensation risk should be taken into account if pressure is higher indoors than outdoors. Determined penetration factors were highly dependent on the pressure difference. Mechanical exhaust ventilation needs a special consideration as de-pressurizing the building may cause health risk if there is hazardous contamination in the building envelope exists.

Neurturin signalling via GFRalpha2 is essential for innervation of glandular but not muscle targets of sacral parasympathetic ganglion neurons.

Neurturin, a member of the glial cell-derived neurotrophic factor familys of ligands, is important for development of many cranial parasympathetic ganglion neurons. We have investigated the sacral component of the parasympathetic nervous system in mice with gene deletions for neurturin or its preferred receptor, GFRalpha2. Disruption of neurturin signalling decreased cholinergic VIP innervation to the mucosa of the reproductive organs, but not to the smooth muscle layers of these organs or to the urinary bladder. Thus, neurturin and its receptor are involved in parasympathetic innervation of a select group of pelvic visceral tissues. In contrast, noradrenergic innervation was not affected by the gene ablations. The epithelium of reproductive organs from knockout animals was atrophied, indicating that cholinergic innervation may be important for the maintenance of normal structure. Cholinergic neurons express GFRalpha2 on their terminals and somata, indicating they can respond to neurotrophic support, and their somata are smaller when neurturin signalling is disrupted. Colocalisation studies showed that many peripheral glia express GFRalpha2 although its role in these cells is yet to be determined. Our results indicate that neurturin, acting through GFRalpha2, is essential for parasympathetic innervation of the mucosae of reproductive organs, as well as for maintenance of a broader group of sacral parasympathetic neurons.

Microbial contamination of indoor air due to leakages from crawl space: a field study.

Mechanical exhaust ventilation system is typical in apartment buildings in Finland. In most buildings the base floor between the first floor apartments and crawl space is not air tight. As the apartments have lower pressure than the crawl space due to ventilation, contaminated air may flow from the crawl space to the apartments. The object of this study was to find out whether a potential air flow from crawl space has an influence on the indoor air quality. The results show that in most cases the concentration of fungal spores was clearly higher in the crawl space than inside the building. The size distribution of fungal spores depended on the fungal species. Correlation between the fungal spores in the crawl space and indoors varied with microbial species. Some species have sources inside the building, which confounds the possible relation between crawl pace and indoor concentrations. Some species, such as Acremonium, do not normally have a source indoors, but its concentration in the crawl space was elevated; our measurements showed also elevated concentrations of Acremonium in the air of the apartments. This consistent finding shows a clear linkage between fungal spores in the indoor air and crawl space. We conclude that a building with a crawl space and pressure difference over the base floor could be a potential risk for indoor air quality in the first floor apartments.

Chromosomal localization of SLC12A5/Slc12a5, the human and mouse genes for the neuron-specific K(+)-Cl(-) cotransporter (KCC2) defines a new region of conserved homology.

K(+)-Cl(-) cotransporters (KCCs) constitute a branch of the cation-chloride cotransporter (CCC) family. To date, four KCC isoforms (KCC1-KCC4) have been identified and they all mediate obligatorily coupled, electroneutral transmembrane movement of K(+) and Cl(-) ions. KCC2 (gene symbol SLC12A5) is expressed exclusively in neurons within the central nervous system and abnormalities in its expression have been proposed to play a role in pathological conditions such as epilepsy and neuronal trauma. Here we have determined chromosome location of both the human and the mouse genes encoding KCC2, which may assist in future efforts to determine the contribution of KCC2 to inherited human disorders. We assigned human SLC12A5 to 20q12-->q13.1 and its murine homolog, Slc12a5, to 5G2-G3 by fluorescence in situ hybridization (FISH). These mapping data are contradictory to the previously reported human-mouse conserved synteny relationships disrupting an exceptionally well-conserved homology segment between human Chr 20 and mouse Chr 2. We hence suggest the first region of conserved homology between human Chr 20 and mouse Chr 5.

Stroke induces widespread changes of gene expression for glial cell line-derived neurotrophic factor family receptors in the adult rat brain.

Gene expression for glial cell line-derived neurotrophic factor (GDNF) family ligands and receptors was analyzed with in situ hybridization after two focal ischemic insults of different severities. Focal ischemia was induced in rats by either 30 min or 2 h of middle cerebral artery occlusion (MCAO), causing damage to the striatum only, or involving also the parietal cortex, respectively. We found modest, transient elevation of GDNF mRNA in the dentate granule cell layer. In addition, the number of GDNF mRNA-expressing cells increased in the cortex and striatum after 2 h or 30 min of MCAO, respectively. No changes of neurturin or persephin mRNA expression were detected. Both c-Ret and GFRalpha1 mRNA levels were markedly increased in the ipsilateral cortex outside the ischemic lesion at 6-24 h after the 2-h insult, whereas GFRalpha2 expression was decreased in cortical areas both within and outside the lesion. Similar increases of c-Ret and GFRalpha1 mRNA levels were detected in the striatum, and to a lesser extent, in the cortex following 30 min of MCAO. The 2-h insult also gave rise to transient increases of c-Ret and GFRalpha1 mRNA in hippocampal subregions. Thirty minutes and 2 h of MCAO lead to elevated c-Ret, and GFRalpha1 or GFRalpha2 mRNA expression, respectively, in the ipsilateral ventroposterolateral thalamic nucleus. Both insults induced increased levels of GFRalpha1 mRNA in the subventricular zone of the lateral ventricle. Our data indicate major changes of GDNF family signaling in the forebrain, regulated mainly through altered receptor levels, in the post-ischemic phase. These changes could enhance neuroprotective and neuroregenerative responses both to endogenous and exogenous GDNF ligands.

The effects of a pharmacy-based intervention on the knowledge and attitudes of asthma patients.

The effects of a pharmacy-based intervention on the knowledge and attitudes of asthma patients was studied with a small convenience sample in four Finnish community pharmacies. The intervention consisted of patient education, counselling and outcomes monitoring according to Therapeutic Outcomes Monitoring (TOM) concept. Twenty-eight patients aged 20-64 years suffering from asthma and having problems in asthma management were involved. Measurements were done at baseline, immediately after the intervention (12 months) and 1 year after the intervention (24 months) using a pre/post-test design, with the patients being their own controls. Both knowledge about and attitudes towards asthma as a disease improved significantly during the intervention. Also knowledge about medication improved significantly during the intervention, though the patients' attitudes towards the medication remained unchanged. The negative correlation between knowledge about and attitudes towards asthma (-0.35) at baseline disappeared after the intervention (0.21). There was a positive correlation between knowledge about and attitudes towards medication at 12 months (0.40, P=0.04) which was still significant 1 year after the intervention (0.40, P=0.04).

Construction of gene-targeting vectors: a rapid Mu in vitro DNA transposition-based strategy generating null, potentially hypomorphic, and conditional alleles.

Gene targeting into mammalian genomes by means of homologous recombination is a powerful technique for analyzing gene function through generation of transgenic animals. Hundreds of mouse strains carrying targeted alleles have already been created and recent modifications of the technology, in particular generation of conditional alleles, have extended the usefulness of the methodology for a variety of special purposes. Even though the standard protocols, including the construction of gene-targeting vector plasmids, are relatively straightforward, they typically involve time-consuming and laborious gene mapping and/or sequencing steps. To produce various types of gene-targeting constructions rapidly and with minimum effort, we developed a strategy, that utilizes a highly efficient in vitro transposition reaction of phage Mu, and tested it in a targeting of the mouse Kcc2 gene locus. A vast number and different types of targeting constructions can be generated simultaneously with little or no prior sequence knowledge of the gene locus of interest. This quick and efficient general strategy will facilitate easy generation of null, potentially hypomorphic, and conditional alleles. Especially useful it will be in the cases when effects of several exons within a given gene are to be studied, a task that necessarily will involve generation of multiple constructions. The strategy extends the use of diverse recombination reactions for advanced genome engineering and complements existing recombination-based approaches for generation of gene-targeting constructions.

Human glial cell line-derived neurotrophic factor receptor alpha 4 is the receptor for persephin and is predominantly expressed in normal and malignant thyroid medullary cells.

Glial cell line-derived neurotrophic factor (GDNF) family ligands signal through receptor complex consisting of a glycosylphosphatidylinositol-linked GDNF family receptor (GFR) alpha subunit and the transmembrane receptor tyrosine kinase RET. The inherited cancer syndrome multiple endocrine neoplasia type 2 (MEN2), associated with different mutations in RET, is characterized by medullary thyroid carcinoma. GDNF signals via GFRalpha1, neurturin via GFRalpha2, artemin via GFRalpha3, whereas the mammalian GFRalpha receptor for persephin (PSPN) is unknown. Here we characterize the human GFRalpha4 as the ligand-binding subunit required together with RET for PSPN signaling. Human and mouse GFRalpha4 lack the first Cys-rich domain characteristic of other GFRalpha receptors. Unlabeled PSPN displaces (125)I-PSPN from GFRA4-transfected cells, which express endogenous Ret. PSPN can be specifically cross-linked to mammalian GFRalpha4 and Ret, and is able to promote autophosphorylation of Ret in GFRA4-transfected cells. PSPN, but not other GDNF family ligands, promotes the survival of cultured sympathetic neurons microinjected with GFRA4. We identified different splice forms of human GFRA4 mRNA encoding for two glycosylphosphatidylinositol-linked and one putative soluble isoform that were predominantly expressed in the thyroid gland. Overlapping expression of RET and GFRA4 but not other GFRA mRNAs in normal and malignant thyroid medullary cells suggests that GFRalpha4 may restrict the MEN2 syndrome to these cells.

Do asthma patients receive sufficient information to monitor their disease--a nationwide survey in Finland.

OBJECTIVES: The aim of this study was to assess to what extent the principles of asthma monitoring are implemented among Finnish asthma patients and if the patients have received sufficient information to adjust their medication according to asthma symptoms. SETTING: All Finnish asthma patients receiving asthma medication from Finnish community pharmacies during two days in June 1998. MAIN OUTCOME MEASURES: The proportions of asthma patients who monitor their asthma status according to the national guidelines and have received specific instructions on how and when to adjust their asthma medication. RESULTS: Eighty-six per cent of the respondents (86%) monitored their asthma status on a method recommended by the national guidelines. They made Peak Expiratory Flow (PEF) measurements (39% of the respondents), they monitored their symptoms (34%) or both (13%). A smaller proportion of the respondents (58%) were instructed on adjusting their medication according to symptoms. The lowest rates for monitoring the asthma status was found among the elderly (65 years or more) and among those who reported that they had been on medication for longer than 5 years (17% and 13% of the subgroup populations, respectively). The lowest rates for having received specific instructions on adjusting their asthma medication according to symptoms were found among the elderly (36%), among those who reported that they had been on asthma medication less than one year (44%), and among males (54%). CONCLUSIONS: Pharmacists and other health care professionals need to enhance their education activities and their co-operation in training asthma patients to monitor their disease, especially principles of adjusting medication according to symptoms. In this process, especially the training needs of the elderly patients and those who have been using asthma medicines for a long time need to be taken into account.

Distinct roles for GFRalpha1 and GFRalpha2 signalling in different cranial parasympathetic ganglia in vivo.

Neurturin (NRTN), signalling via the GDNF family receptor alpha2 (GFRalpha2) and Ret tyrosine kinase, has recently been identified as an essential target-derived factor for many parasympathetic neurons. NRTN is expressed in salivary and lacrimal glands, while GFRalpha2 and Ret are expressed in the corresponding submandibular, otic and sphenopalatine ganglia. Here, we have characterized in more detail the role of GDNF and NRTN signalling in the development of cranial parasympathetic neurons and their target innervation. Gfra1 mRNA was expressed at E12 but not in newborn cranial parasympathetic ganglia, while Gfra2 mRNA and protein were strongly expressed in newborn and adult cranial parasympathetic neurons and their projections, respectively. In newborn GFRalpha1- or Ret-deficient mice, where many submandibular ganglion neurons were still present, the otic and sphenopalatine ganglia were completely missing. In contrast, in newborn GFRalpha2-deficient mice, most neurons in all these ganglia were present. In these mice, the loss and atrophy of the submandibular and otic neurons were amplified postnatally, accompanied by complete loss of innervation in some target regions and preservation in others. Surprisingly, GFRalpha2-deficient sphenopalatine neurons, whose targets were completely uninnervated, were not reduced in number and only slightly atrophied. Thus, GDNF signalling via GFRalpha1/Ret is essential in the early gangliogenesis of some, but not all, cranial parasympathetic neurons, whereas NRTN signalling through GFRalpha2/Ret is essential for the development and maintenance of parasympathetic target innervation. These results indicate that GDNF and NRTN have distinct functions in developing parasympathetic neurons, and suggest heterogeneity among and within different parasympathetic ganglia.