Carol L. Armour

Pharmacy Asthma Care Program (PACP) improves outcomes for patients in the community

Background: Despite national disease management plans, optimal asthma management remains a challenge in Australia. Community pharmacists are ideally placed to implement new strategies that aim to ensure asthma care meets current standards of best practice. The impact of the Pharmacy Asthma Care Program (PACP) on asthma control was assessed using a multi-site randomised intervention versus control repeated measures study design. Methods: Fifty Australian pharmacies were randomised into two groups: intervention pharmacies implemented the PACP (an ongoing cycle of assessment, goal setting, monitoring and review) to 191 patients over 6 months, while control pharmacies gave their usual care to 205 control patients. Both groups administered questionnaires and conducted spirometric testing at baseline and 6 months later. The main outcome measure was asthma severity/control status. Results: 186 of 205 control patients (91%) and 165 of 191 intervention patients (86%) completed the study. The intervention resulted in improved asthma control: patients receiving the intervention were 2.7 times more likely to improve from “severe” to “not severe” than control patients (OR 2.68, 95% CI 1.64 to 4.37; p<0.001). The intervention also resulted in improved adherence to preventer medication (OR 1.89, 95% CI 1.08 to 3.30; p = 0.03), decreased mean daily dose of reliever medication (difference −149.11 μg, 95% CI −283.87 to −14.36; p = 0.03), a shift in medication profile from reliever only to a combination of preventer, reliever with or without long-acting β agonist (OR 3.80, 95% CI 1.40 to 10.32; p = 0.01) and improved scores on risk of non-adherence (difference −0.44, 95% CI −0.69 to −0.18; p = 0.04), quality of life (difference −0.23, 95% CI −0.46 to 0.00; p = 0.05), asthma knowledge (difference 1.18, 95% CI 0.73 to 1.63; p<0.01) and perceived control of asthma questionnaires (difference −1.39, 95% CI −2.44 to −0.35; p<0.01). No significant change in spirometric measures occurred in either group. Conclusions: A pharmacist-delivered asthma care programme based on national guidelines improves asthma control. The sustainability and implementation of the programme within the healthcare system remains to be investigated.

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.

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

Aim  To assess the impact of a community pharmacy diabetes service model on patient outcomes in Type 2 diabetes.

RAGE and TLRs: relatives, friends or neighbours?

The innate immune system forms the first line of protection against infectious and non-infectious tissue injury. Cells of the innate immune system detect pathogen-associated molecular patterns or endogenous molecules released as a result of tissue injury or inflammation through various innate immune receptors, collectively termed pattern-recognition receptors. Members of the Toll-like receptor (TLR) family of pattern-recognition receptors have well established roles in the host immune response to infection, while the receptor for advanced glycation end products (RAGE) is a pattern-recognition receptor predominantly involved in the recognition of endogenous molecules released in the context of infection, physiological stress or chronic inflammation. RAGE and TLRs share common ligands and signaling pathways, and accumulating evidence points towards their co-operative interaction in the host immune response. At present however, little is known about the mechanisms that result in TLR versus RAGE signalling or RAGE-TLR cross-talk in response to their shared ligands. Here we review what is known in relation to the physicochemical basis of ligand interactions between TLRs and RAGE, focusing on three shared ligands of these receptors: HMGB1, S100A8/A9 and LPS. Our aim is to discuss what is known about differential ligand interactions with RAGE and TLRs and to highlight important areas for further investigation so that we may better understand the role of these receptors and their relationship in host defense.

Complementary and alternative medicine use in asthma: Who is using what?

Abstract:  Consumer interest in complementary and alternative medicine (CAM) has grown dramatically in Western countries in the past decade. However, very few patients volunteer information about CAM use unless directly questioned by their health‐care practitioner. Therefore, by being informed about the prevalence and modality of CAM use for asthma, as well as characteristics of users, health‐care practitioners may be better able to identify patients who use CAM. In turn, this may facilitate proactive discussion and optimization of the patient’s overall asthma management. This review aims to summarize the current knowledge about use of CAM by people with asthma, and to assess the applicability of the available studies to the broader asthmatic population. Computerized literature searches were conducted on Medline, Embase, Cochrane and Allied and Complementary Medicine (AMED) databases from their inception to 13 April 2005. Search terms included: complementary medicine/therapies, alternative medicine/therapies and asthma. The bibliographies of accessible articles were searched for further papers. Seventeen studies have examined the use of CAM by people with asthma. The reported level of use for adults ranged from 4% to 79%, and for children from 33% to 89%. Among the most commonly used CAMs were: breathing techniques, herbal products, homeopathy and acupuncture. There is no strong evidence for effectiveness for any of these modalities. There is little consistency among available prevalence studies making conclusions difficult. Nevertheless, the high rates of CAM use reported in some studies indicate that CAM use should be taken into account when managing patients with asthma.

Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique

OBJECTIVE To evaluate the feasibility, acceptability and effectiveness of a brief intervention about inhaler technique, delivered by community pharmacists to asthma patients. METHODS Thirty-one pharmacists received brief workshop education (Active: n=16, CONTROL: n=15). Active Group pharmacists were trained to assess and teach dry powder inhaler technique, using patient-centered educational tools including novel Inhaler Technique Labels. Interventions were delivered to patients at four visits over 6 months. RESULTS At baseline, patients (Active: 53, CONTROL: 44) demonstrated poor inhaler technique (mean+/-S.D. score out of 9, 5.7+/-1.6). At 6 months, improvement in inhaler technique score was significantly greater in Active cf. CONTROL patients (2.8+/-1.6 cf. 0.9+/-1.4, p<0.001), and asthma severity was significantly improved (p=0.015). Qualitative responses from patients and pharmacists indicated a high level of satisfaction with the intervention and educational tools, both for their effectiveness and for their impact on the patient-pharmacist relationship. CONCLUSION A simple feasible intervention in community pharmacies, incorporating daily reminders via Inhaler Technique Labels on inhalers, can lead to improvement in inhaler technique and asthma outcomes. PRACTICE IMPLICATIONS Brief training modules and simple educational tools, such as Inhaler Technique Labels, can provide a low-cost and sustainable way of changing patient behavior in asthma, using community pharmacists as educators.

Responsiveness of bronchial smooth muscle from asthmatic patients to relaxant and contractile agonists.

The mechanism underlying airway hyperresponsiveness in asthma is unknown although an abnormality in the airway smooth muscle resulting in decreased relaxation or increased contractile response has been proposed. The present study was designed to demonstrate any differences in the in vitro sensitivity of airway smooth muscle between asthmatic patients and non-asthmatic patients. Using bronchial tissue obtained by resection from mild to moderate asthmatic patients and from non-asthmatic patients, we have shown that the altered airway responsiveness seen in asthmatic patients is not reflected in airway smooth muscle sensitivity in vitro. Sensitivity of the bronchial smooth muscle to isoprenaline and aminophylline or theophylline did not differ between asthmatic patients and nonasthmatic patients, while sensitivity to carbachol and histamine was significantly reduced in tissue from asthmatic patients. These results suggest that the abnormality in asthma may not lie at the level of the airway smooth muscle.

Mast cell tryptase potentiates histamine-induced contraction in human sensitized bronchus

The mast cell plays a pivotal role in the early asthmatic response via release of mediators, which directly influence airway smooth muscle tone. Canine mast cell tryptase has been reported to potentiate the contractile response of canine isolated airways to histamine. The aim of this study was to investigate whether human mast cell tryptase potentiated contractile responses in human isolated bronchi. The effect of tryptase differed according to the sensitization status of the bronchi. In lung tissue from sensitized patients (those whose bronchial tissue contracted in response to the application of any of four common antigens) 90 ng.mL-1 of human purified lung tryptase markedly potentiated the contractile response to histamine. The maximal response as a percentage of maximal contraction to acetylcholine was 80 +/- 8% in control tissues and 119 +/- 6% in tryptase treated tissues (n = 4; p < 0.05). Tryptase, at a dose of 200 ng.mL-1, also potentiated responses but to a lesser degree, 100 +/- 5% (n = 4; p < 0.05). In nonsensitized bronchi, neither 90 nor 200 ng.mL-1 tryptase had any significant effect on histamine responses. The increased response in the presence of tryptase in sensitized tissue was inhibited by the calcium voltage-dependent channel antagonist, verapamil (10(-6) M). We have shown, for the first time, that human mast cell tryptase potentiates contraction in sensitized bronchi via a calcium-related mechanism. These findings provide a link between a mast cell derived product and in vitro human airway hyperresponsiveness.

Development, Implementation, and Evaluation of a Community Pharmacy–Based Asthma Care Model

BACKGROUND Pharmacists are uniquely placed in the healthcare system to address critical issues in asthma management in the community. Various programs have shown the benefits of a pharmacist-led asthma care program; however, no such programs have previously been evaluated in Australia. OBJECTIVE To measure the impact of a specialized asthma service provided through community pharmacies in terms of objective patient clinical, humanistic, and economic outcomes. METHODS A parallel controlled design, where 52 intervention patients and 50 control patients with asthma were recruited in 2 distinct locations, was used. In the intervention area, pharmacists were trained and delivered an asthma care model, with 3 follow-up visits over 6 months. This model was evaluated based on clinical, humanistic, and economic outcomes compared between and within groups. RESULTS There was a significant reduction in asthma severity in the intervention group, 2.6 ± 0.5 to 1.6 ± 0.7 (mean ± SD; p < 0.001) versus the control group, 2.3 ± 0.7 to 2.4 ± 0.5. In the intervention group, peak flow indices improved from 82.7% ± 8.2% at baseline to 87.4% ± 8.9% (p < 0.001) at the final visit, and there was a significant reduction in the defined daily dose of albuterol used by patients, from 374.8 ± 314.8 μg at baseline to 198.4 ± 196.9 μg at the final visit (p < 0.015). There was also a statistically significant improvement in perceived control of asthma and asthma-related knowledge scores in the intervention group compared with the control group between baseline and the final visit. Annual savings of

Sensitization alters contractile responses and calcium influx in human airway smooth muscle

132.84(AU) in medication costs per patient and