Chronic obstructive lung disease (COPD) is one of the most serious and common chronic conditions. Patients having COPD can greatly benefit from rehabilitation initiatives. However, not all patients having COPD are referred to rehabilitation. Literature does not clearly explain why only some patients with COPD are referred to rehabilitation, and only very few successful solutions to address the complexity of cross-sectorial organisations are described. The overall objective of this research project is to ensure referral and uptake for COPD rehabilitation. We focus on detangling the processes in the cross-sectorial workflow of patients with COPD to understand why most patients are not referred to rehabilitation.Based on semi structured interviews and observations a FRAM analysis was conducted to map the referring routines from hospital to municipality.We found that the hospital and the municipality have different understandings of what rehabilitation is, they use different words and hospital staff lack knowledge of offers at the municipality.The FRAM analysis was useful to detangle factors important to cross-sectorial collaboration and resulted in a series of focus areas that were disseminated at a workshop. The municipality and the hospital agreed to initiate activities to develop and coordinate the cross-sectorial relations. Chronic obstructive lung disease (COPD) is one of the most serious and common chronic conditions . PatientTherefore, it is important to offer patients rehabilitation as soon as possible after discharge or when seen in outpatient facilities. This is also stated in the newly revised Danish clinical guideline for the rehabilitation of patients with COPD. The guideline strongly recommends referral of patients to early rehabilitation after exacerbations requiring hospitalisation and initiation of rehabilitation when COPD is detected . HoweverThe literature does not clearly explain why only some patients with COPD are referred to rehabilitation , and onlThe overall objective of this research project is to ensure referral and uptake for COPD rehabilitation. In this part of the study, we focus on detangling the processes in the cross-sectorial workflow of patients with COPD to understand why most patients are not referred to rehabilitation, and use this knowledge to improve the development, implementation and evaluation of the patient pathway across healthcare sectors.In 2016, the municipality and the hospital involved in this study formed a project group. The purpose of the group was to create improved patient pathways and to ensure that more patients were referred to rehabilitation services in the municipality. In 2017, the municipality and the hospital department requested researchers involved in the project to conduct an analysis of how the patient pathways were operating and under which conditions the collaboration between the municipality and the hospital could be optimised. Based on the theory of work-as-done (WAD) and work-as-imagined (WAI) , the pri131415In a complex system, ‘work-as-done’ will always be different from what is planned or agreed on – ‘work-as-imagined’ - because it is not possible to describe and plan the system in too much detail . TherefoA functional resonance analysis method (FRAM)  was chosIn the FRAM, the working routines are mapped as functions that are connected. Each function has six aspects:Input (I) starts the functionPreconditions (P) are conditions that have to exist before a function can startResources (R) are what is needed while the function is carried out to achieve a good outputControl (C) is what controls or regulates the functionTime (T) is how time affects the functionOutput (O) is the result of the function.Figure 1.The first five aspects derive from the output of other functions and are influenced by other functions. The functions are visualised as a hexagon, and the connections are shown as lines connecting the hexagons , as showThe figure shows different functions, and in some ways, it looks like any other task analysis that divides the process in sequences. However, during the questioning, and when drawing the model focus is on the interconnectedness and how one function interrelates with the other functions, and the lines in the figure show how the functions are connected. The visualisation is used to operationalise and manage the outcome but as any other model, it will only be a reduced picture of reality.The setting is the Danish Healthcare System, consisting of the hospital, general practitioners (GPs) and municipalities. Treatment is provided by the GPs and at the hospital. Both are financed by taxes and, therefore, free of charge for the individual patient. The municipality provides rehabilitation and care. Rehabilitation initiatives can vary from municipality to municipality but are also free of charge. The rehabilitation initiatives have gradually been moved from the hospital setting to the municipality, and from January 2018, the municipality will manage all rehabilitation and prevention initiatives for patients with COPD. In this particular case, a department for internal medicine at a hospital and the municipality where the hospital is situated are used as empirical information. Focus is on rehabilitation in the municipality after hospitalization, which in Denmark does not include care provided by the GPs, thus explaining why it is only the workflow at the hospital, and the municipality that is analysed.The clinical guidelines in Denmark recommend rehabilitation when patients with COPD are discharged from hospital. It is a national goal that all patients with COPD should be informed of the rehabilitation services on offer in the municipality . The natThe wards at the hospital have 70 beds and 7700 inpatients a year; the municipality has 75,500 inhabitants.Data for the analysis were collected through documents, observation of work-as-done and interviews of staff involved in the workflow. We conducted observations and interviews at a medium-sized hospital in the southern region of Denmark and at the municipality in adjunction to the hospital. Relevant staff and involved patients at the ward gave consent for participation.By request, the Scientific Ethics Committee of Southern Denmark stated that no ethical approval was needed for this project. The study has been approved by the Danish Data Protection Agency (file no. 15/3321 and 19/3451). All rules of storage of personal information are met according to the Danish Data Protection Agency. Data will only be reported in anonymous form. Data management will be conducted according to the rules of the region of Southern Denmark at the department of OPEN (Open Patient data Explorative Network).The FRAM is based on observations and semi-structured interviews . To condThe semi-structured interviews were designed according to the aspects in the FRAM functions, and respondents were asked about input, preconditions, resources, time, control and output in a way that made sense to them.http://functionalresonance.com/FMV/index.html).The four researchers involved in the project at that time coded the data from the interviews and observation notes and categorised them in working functions according to the six aspects in each function. It was performed as a group where all participants had the written transcripts of the interviews; from these, the coding was derived. If there were discrepancies, these were discussed to consensus. We used the FRAM Model Visualizer software to build and display the FRAM model  good relations, meaning shared goals, shared knowledge and mutual respect, and (ii) good communication, meaning frequent communication, timely communication, accurate communication and problem-solving communication . An incrBraithwaite argues that we have to accept a certain degree of uncertainty in healthcare due to complexity. We must take non-linearity and inconsistency into account, and in a complex system, we cannot expect that a certain intervention automatically leads to a predicted outcome because unpredicted circumstances within the system interfere with and affect intended actions. Methods to capture this complexity must be applied to develop quality in healthcare . By condThese factors might not have been revealed using other methodological frameworks, such as lean production , the domConsequently, we found it relevant to use the FRAM, as we were analysing a complex system.The FRAM analysis was useful to disentangle factors important to cross-sectorial collaboration and resulted in a series of focus areas that were disseminated at a workshop. The workshop resulted in a request for more knowledge and collaboration across healthcare boundaries, and a common understanding, language and approach towards the concept of rehabilitation, diagnosis and functionality. To meet the workshop results, the municipality and the hospital agreed to initiate activities to develop and coordinate the cross-sectorial relations to ensure that the hospital would refer more patients to rehabilitation and prevention initiatives at the municipality.


For years, immersive interfaces using virtual and augmented reality (AR) for molecular visualization and modeling have promised a revolution in the way how we teach, learn, communicate and work in chemistry, structural biology and related areas. However, most tools available today for immersive modeling require specialized hardware and software, and are costly and cumbersome to set up. These limitations prevent wide use of immersive technologies in education and research centers in a standardized form, which in turn prevents large-scale testing of the actual effects of such technologies on learning and thinking processes. Here, I discuss building blocks for creating marker-based AR applications that run as web pages on regular computers, and explore how they can be exploited to develop web content for handling virtual molecular systems in commodity AR with no more than a webcam- and internet-enabled computer. Examples span from displaying molecules, electron microscopy maps and molecular orbitals with minimal amounts of HTML code, to incorporation of molecular mechanics, real-time estimation of experimental observables and other interactive resources using JavaScript. These web apps provide virtual alternatives to physical, plastic-made molecular modeling kits, where the computer augments the experience with information about spatial interactions, reactivity, energetics, etc. The ideas and prototypes introduced here should serve as starting points for building active content that everybody can utilize online at minimal cost, providing novel interactive pedagogic material in such an open way that it could enable mass-testing of the effect of immersive technologies on chemistry education. For a long time it has been suggested that visual immersive analytics based in virtual reality (VR), augmented reality (AR) and other advanced forms of human-computer interactions have enormous potential in assisting thinking processes in scientific research and in education, especially in areas of science that deal with abstract objects, objects much smaller or larger than human dimensions, objects that are hard to acquire and handle due to high costs, scarcity or fragility, and very large amounts of data . Chemisthttps://autodeskresearch.com/groups/lifesciences) or Nanome (https://nanome.ai/), all with interfaces specifically tailored for VR.In the last decade several groups have been studying ways to achieve immersive environments for chemistry and structural biology using VR and AR . Such inMost of these works suffer from two severe limitations. First, all but a few exceptions require hardware such as head-mount displays  or immersive installations with large surround screens plus 3D-handheld input devices and the corresponding computer and GPU hardware. The few remarkable exceptions are prototypes using ordinary webcam-enabled smartphones  or laptoThe purpose of this work is to demonstrate that client-side web technologies have matured enough to enable web pages for AR-based molecular visualization and modeling running just on web browsers in regular webcam-equipped computers. This enables the easy creation of immersive educational material that can be employed by students and teachers at very affordable costs and with very simple setups. All they must do is access a webpage, enable webcam activity in the browser, and show to the webcam a printed AR marker on which the molecules will be displayed. From the developer side, the code is made simple thanks to a large number of libraries; in fact visualization-only applications are achievable just with HTML code while interactivity can be incorporated through custom JavaScript.This article is organized in two parts. Part 1 provides a practical overview of the main building blocks available as of 2019 to program AR apps in web pages, with a focus on ways to achieve molecular visualization and modeling. It also briefly explores ways to handle gesture- and speech-based commands, molecular mechanics, calculation of experimental observables, concurrent collaboration through the world wide web, and other human-computer interaction technologies available in web browsers. Part 2 of the article showcases prototype web apps for specific tasks of practical utility in pedagogical and research settings. These web apps are based on open, commodity technology that requires only a modern browser “out of the box”, so educators, students and researchers are free to try out all these examples on their computers right away by following the provided links.At the core of immersive experiences are visualizations based on VR or AR methods. While VR is probably best experienced with VR goggles to suppress any side view of the real world, AR is more amenable to devices like desktop or laptop computers, tablets and smartphones, making it better suited for commodity solutions, and has the additional advantages outlined in the introduction. The methods presented in this article make use of marker-based AR in a web-based setup that functions as an “AR mirror” where the user sees him/herself with the virtual objects, here molecules, overlaid on the markers he/she holds in their hands  and 1B. https://threejs.org/) being probably the most widely used. In turn, tools like A-Frame (https://aframe.io/) provide entity component system frameworks that wrap Three.js into HTML language tags through polyfills, greatly facilitating the development of AR and VR scenes. The examples presented in Part 2 showcase either direct use of Three.js or of Three.js through A-Frame for AR. These libraries/frameworks can be used either by (i) loading pre-made models of the molecular systems in formats like Wavefront’s OBJ+MTL files exported straight out of molecular visualization programs like VMD  and its A-Frame wrap (https://jeromeetienne.github.io/AR.js/aframe/). These enable highly simplified AR/VR, even using exclusively HTML code for simple developments.The other key component required for AR and VR is a means to detect and track objects or parts of the user’s body such as his/her hands, in order to manipulate virtual objects. Applications using ad hoc hardware use sensors and cameras that track the user’s position in space and handheld controllers that the user sees as virtual tweezers or hands, to directly move objects in space. For commodity AR/VR in web browsers, solutions rely on JavaScript versions of tracking libraries that implement computer vision algorithms through the webcam feed, like ARToolKit  among otIt is important to note that in marker-based AR different viewers looking at the same physical marker receive different perspectives of it and hence of the rendered virtual object, just as if it was a real object in real space . This eahttps://www.leapmotion.com/), which includes a JavaScript library to feed positional information from the device into the web app. Unfortunately, however, there are currently no ready-to-use libraries that couple these input tools to WebGL graphics, so their use would require further developments.An alternative to traditional marker-based AR should in principle be possible by using a plain hand tracking JavaScript library like Handtracking.js. Another slightly more expensive approach but possibly better in tracking performance is using a device like the infrared-based Leap Motion Controller , an engine for simulating rigid body mechanics that integrates smoothly with Three.js and A-Frame. These engines use numerical methods to propagate motions of solid bodies connected by springs and other physical constraints in an approximate but efficient way, thus adding realistic physics to the 3D bodies of AR and VR worlds. Although these engines do not account for all the forces and phenomena of the atomic realm, such as electrostatic interactions and quantum phenomena, they are useful in certain real scenarios of molecular modeling. For example, the Integrative Modeling Platform software  includes one such kind of physics engine for molecule-molecule docking .The simplest way to achieve AR in web pages consists in displaying on the AR markers representations exported from programs like VMD  in Wavefhttps://github.com/artoolkit/jsartoolkit5), in an example where six markers arranged on the faces of a cube are coupled to drive a single object in full 3D. Lastly, combining this with direct use of Three.js to draw 3D primitives, the web app in The next level of complexity is building up scenes from 3D primitives, which brings the advantage over ready-made models that all the elements can be handled independently, thus allowing the possibility of incorporating interactivity. This can be achieved either through A-Frame with AR.js, thus requiring only HTML code for display as in the Wavefront-based examples above, or through libraries that require additional JavaScript code but in turn enable more complex functionalities. Exemplifying the former case, Web apps using A-Frame can gain interactivity through portions of JavaScript code that read atom coordinates and carry out calculations on them. −pKa) favoring protonation of the base. When 2 Å < N–O distance < 3 Å the web app displays a yellow dotted line that represents a hydrogen bond between the potential receiver heavy atom and the involved proton.A modified version of this example is also provided, incorporating a very simplistic emulation of hydrogen bond detection and proton transfer .The example in https://rrasia.altervista.org/HYL1_1-2/Hyl1_12_minima.html.The web app shown in Another example, presented in The last prototype application shows rudimentary handling of highly disordered protein regions, in this case to test how a flexible linker made of six glycine residues restricts the space available for exploration and possible docking poses of two well-folded domains –5C. EachAchieving seamless integration of immersive visualizations, haptic interfaces and chemical computation stands as one of the key “grand challenges” for the simulation of matter in the 21st century . Such inThis article introduced a minimal set of building blocks and code for developing marker-based AR applications for molecular modeling in web browsers using regular computers. Since web AR is a new and emerging technology, it is reasonable to identify some limitations. Naturally, such web apps cannot currently match the graphics quality and interfacing capabilities of programs prepared for specialized AR/VR hardware, and the use of a webcam to follow markers can result in unstable tracking under certain conditions compared to setups that use ad hoc devices. Another limitation is that support for AR in smartphones is not uniform, and varies greatly between devices. Currently, only laptops and desktop computers provide a consistent experience. Lastly, content developers must routinely verify that the web apps continue to work in major browsers after updates, and also validate them against new W3C standards, APIs and libraries. On the bright side, these web apps have some important advantages. First, all examples presented here rely only on client-side programming; therefore, applications need only be uploaded to regular webservers to become available to the world. Second, they do not require client-side plugins, so are supported “out of the box” by standard web browsers. Third, the modularity of JavaScript and the availability of several ready-to-use libraries greatly simplify development of new content. Fourth, users of these applications do not need to worry about updates, as they always receive the latest version when they reload the page. All in all, these positive features will favor adoption of browser based AR/VR for educational purposes over alternatives that require specialized software and hardware.For educational applications, the next stage would be to develop actual content of value for teachers and students. The simplest content could merely provide visualizations to explore molecular geometries, surfaces, orbitals, etc., with specific sets of demos to assist learning of key concepts such as chirality, organic molecules, metal coordination complexes and biomacromolecular structures, to mention just a few cases. By adding mechanics, more complex demos could be created where students could for example interactively explore torsion angles as in the textbook cases of probing the energy landscape of rotation around the central C–C bond of butane, or swapping between chair and boat conformations of six-member rings, exploring hydrogen bonding patterns between neighbor beta strands in a protein, etc. Importantly, every single student having a computer at hand could use these apps, not only at the school/university but also at home, therefore this could become an actual learning tool of full-time, individual use. The possibility of reaching the masses with this kind of web technologies for AR-based molecular modeling in turn opens up the opportunity of performing large-scale evaluations of their actual impact in education.As actively investigated by others, there is also a need to explore if full working programs for AR-based molecular modeling may actually become powerful enough to also assist research. Here again, web-based tools like those discussed in this article could help to carry out such tests at large scales. Some of the prototypes presented here advance possible uses in research, as in the simulation of data from protein–protein docking poses and comparison to the corresponding experimental data in real time. However, some issues should be addressed before creating fully-fledged web programs for research: (i) improving AR marker detection and tracking to stabilize inputs , (ii) deSome further directions that could be explored in the near future are fluently connecting through an AR experience users in physically distant locations, so that they can collaborate on a research project or teach/learn at a distance. Adapting future standards for commodity AR/VR in smartphones (plugged into cardboard goggles for stereoscopy) is also worth exploring as this would lead to an even more immersive experience than with the mirror-like apps proposed here. However, since smartphones are more limited in power, their use for AR molecular modeling may require coupling to external computer power. Last, pushing the limits towards fully immersive visual analytics for molecular modeling, and especially thinking about solutions useful for research, a few especially enticing additions include support for haptic devices for force feedback, AR without markers  and considering occlusion, and as described above, the capability to respond to visual or audio cues by automatically checking databases and mining literature to propose relevant pieces of information.10.7717/peerj-cs.260/supp-1Supplemental Information 1Click here for additional data file.


CPR5 cause multiple defects, including aberrant trichomes, reduced ploidy levels, reduced growth and enhanced resistance to bacterial and fungal pathogens. The pleiotropic nature of cpr5 mutations implicates that the CPR5 protein affects multiple pathways. However, little is known about the structural features that allow CPR5 to affect the different pathways.The Arabidopsis CONSTITUTIVE EXPRESSER of PATHOGENESIS-RELATED GENES 5 (CPR5) has recently been shown to play a role in gating as part of the nuclear pore complex (NPC). Mutations in metCPR5 cDNAs, in which the relevant nucleotides were changed to encode glutamine, were fused to the CPR5 native promoter and the constructs transformed to cpr5–2 plants to complement cpr5-compromised phenotypes. The control and metCPR5 constructs were able to complement all cpr5 phenotypes, although the extent of complementation depended on the specific complementing plant lines. Remarkably, plants transformed with metCPR5 constructs showed larger leaves and displayed reduced resistance when challenged to Pseudomonas syringae pv Pst DC3000, as compared to control plants. Thus, the methionine-encoding nucleotides regulate growth and resistance. We propose that structural features of the CPR5 N-terminus are implicated in selective gating of proteins involved in regulating the balance between growth and resistance.Our in silico studies suggest that in addition to three clusters of putative nuclear localization signals and four or five transmembrane domains, CPR5 contains two putative alternative translation start sites. To test the role of the methionine-encoding nucleotides implicated in those sites, Plants need to carefully balance the amount of resources used for growth and resistance. The Arabidopsis CPR5 protein regulates plant growth and immunity. Here we show that N-terminal features of CPR5 are involved in the regulation of the balance between growth and resistance. These findings may benefit efforts to improve plant yield, while maintaining optimal levels of disease resistance. In the same year, Yoshida et al. [hys1 (hypersenescence1) as a mutant with accelerated leaf senescence and hypersensitivity to sugar. Borghi et al. [cpr5–3, which showed reduced leaf K+ levels and cpr5–2 phenotypes. CPR5, OLD1 and HYS1 were all found to be the same locus and subsequent studies showed that cpr5 plants also exhibit hypersensitivity to exogenous abscisic acid (ABA), jasmonic acid (JA) and ethylene (ET) [cpr5 mutants suggests that CPR5 is a master regulator of different cellular pathways [Plants recognise attack of most pathogens and respond through the production of antimicrobial proteins and the activation of defence responses . In an ad genes1 –4 and edibility5  and muta genes1) , cpr2 anand cpr6 ) were isn attack . Later, n attack  describea et al.  reportedi et al.  isolatedene (ET) –15. The pathways .Physcomitrella patens [CPR5 gene was proposed to result in compromised immunity in cpr5 mutants. However, it is not clear how structural features of the CPR5 proteins mediate selectivity.The functional analyses of the CPR5 protein have been difficult because this protein is only found in plants and the moss, a patens . Nevertha patens , which ia patens . Recentla patens , 15, 17.cpr5–2 mutant. We found that the complementing lines changed growth and disease resistance against Pst DC3000 demonstrating that the CPR5 N-terminus is involved in the regulation of plant growth and disease resistance.In silico studies suggest that CPR5 contains three clusters of NLS-encoding residues, two clusters of Casein Kinase (CK) phosphorylation sites and a number of alternative translation start sites. Here, we mutated putative alternative translation start site-encoding residues in order to test their role in CPR5 function. The mutated genes were used to complement the CPR5 transcript possess multiple in-frame start codons at positions a, b, and c as shown in Fig. CPR5 mRNA sequence was further computationally analysed. Figure CPR5 mRNA sequence and the positions of the in-frame start codons. A closer view of the second putative site (site b) shows that it consists of three in-tandem start codons, 109 nt downstream of the first start codon. The third site occurs 187 nt downstream of the first site. Furthermore, the CPR5 coding sequence is predicted to contain four stem-loop structures in the first 190 nucleotides  was fused with the SynCPR5 coding sequence, and the whole cassette was transferred into cpr5–2 plants. Following successful SynCPR5 transformation, SynCPR5 expression of three independent homozygous complemented lines was compared with CPR5 expression in the wild type Col-0 and mutant cpr5–2 lines. Relative transcript abundance of SynCPR5, CPR5 and cpr5–2 genes was quantified using SynCPR5, CPR5 and cpr5–2 gene-specific primer sets  transcript abundances. During growth of the different transgenic and control wild-type and cpr5–2 plant lines grown under same conditions, we noted that the leaves of metCPR5 plants appeared to be bigger than those of the wild type , fourth (seventh and eighth rosette leaves) and fifth (ninth and tenth rosette leaves) leaf pairs of metCPR5b plants were significantly larger than those of wild-type and SynCPR5 lines   metCPR5, SynCPR5 and wild type plants were harvested and nuclei were extracted for ploidy analysis , we hypothesised that the larger leaves of metCPR5 plants may coincide with increased susceptibility to Pst DC3000. Thus, metCPR5 plants were grown in neutral days (12:12 light:dark) conditions. Leaves from 4- to 5-week-old plants were infiltrated with Pst DC3000, and susceptibility was scored by measuring the number of colony forming units (cfu) as described (52). As shown in Fig. metCPR5b and metCPR5bc lines displayed significantly higher susceptibility to Pst DC3000 compared to the wild type. In contrast, SynCPR5 lines displayed susceptibility to Pst DC3000 in a wild type manner except SynCPR5L2, which displayed higher susceptibility than the wild type. In conclusion, metCPR5 plants, having larger leaves than wild type, show reduced resistance to Pst DC3000 infection.Since PATHOGENESIS RELATED GENE1 (PR1) is enhanced in cpr5–2 mutants and correlates with resistance [metCPR5 lines have reduced PR1 levels. The transcript abundance of PR1 was quantified from uninfected wild type, cpr5–2, SynCPR5 and metCPR5 lines using real-time qRT-PCR. As shown in Fig. cpr5–2 plants showed greatly increased PR1 levels. However, most metCPR5 lines displayed PR1 transcript levels similar to those of the wild type. The exceptions were metCPR5bL3 and metCPR5bcL1 lines, which had lower and higher PR1 levels, respectively. Remarkably, all SynCPR5 lines exhibited increased PR1 levels compared to wild type  biosynthesis and signalling are repressed in cpr5 [Pathogenesis-Related  genes (PR1 and PR5) and Plant Defensin 1.2 (PDF1.2), the formation of HR-like lesions and the higher SA levels in cpr5 plants [cpr5 plants has been proposed to be involved in the induction of lesions and early leaf senescence [cpr5 plants to the hormones SA, JA, ABA and ET [cpr5 could be the consequence of growth defects [Plants balance their resource allocation between resistance and growth to limit negative impacts on plant growth , 27. To rasitica  is consi in cpr5 . Perhaps5 plants , 11, 14.nescence , suggestnescence . SimilarA and ET , 20 indiA and ET , which fA and ET . Neverth defects , includi defects .metCPR5 result in plants that grow larger leaves than the wild type, at the expense of resistance to Pst DC3000. The mutated base pairs, rather than mRNA abundance, appear to be critical because the phenotypes correlated with the type of mutations and not the mRNA abundance. This is also consistent with previous results where overexpression of the wild type CPR5 gene using the 35S promoter resulted in 1000-fold increase in gene expression, without similar larger leaves and decreased resistance being reported [metCPR5 mutations, leading to higher protein levels. The results are furthermore consistent with the model that CPR5 does not simply function as a repressor of disease resistance, but it regulates the balance between growth and resistance, whereby structural properties - present at the N-terminus - limit the extent by which CPR5 can favour growth over resistance.We show here that nucleotide changes in reported . This sucpr5 mutants as well: the levels of salicylic acid (SA) and jasmonic acid (JA) are higher in cpr5 plants, cpr5 plants have perturbations in SA, JA, ABA and ET signalling pathways [cpr5 plants are hypersensitive to exogenous SA, ABA, JA and ET [cpr5 mutants [cpr5 plants indicates that GA levels could be affected in cpr5 plants as well [cpr5 mutant plants. This is in line with our hypothesis that CPR5 plays a central role in regulating the balance between growth and resistance by mediating growth and resistance hormones. Recent discoveries of how CPR5 functions provides a means to propose how CPR5 controls growth and resistance: CPR5 is one of the nucleoporins which function as part of the Nuclear Pore Complex (NPC) and inhibit the activities of NPC and the cyclin-dependent kinases (CKIs) under stress-free conditions [cpr5 mutants or as a result of stress, CPR5-mediated gating is altered, allowing a number of molecules to enter the nucleus, leading to the activation of resistance genes [old1-l3 allele of CPR5 (G120D), proteins such as NPR1, JAZ1, and ABI5 were found to be aberrantly not retained in the cytoplasm [metCPR5 transcripts may affect CPR5 function in other ways: the mutations remove possible alternative translation initiation sites and different alternatively translated CPR5 proteins may affect NPC gating. Indeed, in silico analysis of the CPR5 transcript identified potential RNA secondary structures nearby putative alternative translation start sites and similar secondary structures have been shown to be important for the activity of alternative translation start sites [The mechanism of how plants regulate the balance between growth and resistance is poorly understood due to its complex nature and involvement of a large number of growth- and resistance-related genes or hormones. For example, auxins, brassinosteroids, cytokinins, gibberellins, abscisic acid, ethylene, and jasmonates, have all been shown to be involved in the regulation of plant growth and immunity , 37–43. pathways , and cprA and ET , 15. Rec mutants . Nuclear mutants . The mis as well . Taken tnditions , 15, 17.rt sites –49. AltemetCPR5 could have altered CPR5-CPR5 homodimerization and consequently CPR5-mediated NPC gating. Any structural difference(s) in the NPC complex could then affect the balance between growth and resistance by a changed gating of growth and/or resistance regulators.Taken altogether, these results led us to propose that the changed nucleotides in Arabidopsis thaliana Columbia (CPR5 and cpr5–2) seeds were the same as used in [Pseudomonas syringae bacterial infiltrations, plants were grown under short-day conditions  at 21 °C and 65% RH. used in  studies. used in  and imbihttps://imagej.nih.gov/ij/).Leaves were removed from plants grown and mounted on a glass slide. Number of appendages on each trichome was counted under a dissecting microscope. At 31 DAS (days after sowing), leaf pairs were removed from plants and fed onto a leaf area machine  for the combined measurement of both leaves. Leaves were harvested in pairs: leaf 1 and 2 were considered as leaf pair 1, leaf 3 and 4 as leaf pair 2, and so on. Leaf 3 from three different plants of the same transgenic line was imaged using a scanning electron microscope  with EDAX module) following manufacturer’s instructions at Manawatu Microscopy Imaging Centre (MMIC), Massey University, Palmerston North. The images were processed and cell areas were measured individually by ImageJ . The CPR5 gene variants, along with a 1.5 kb native CPR5 promoter fragment, were cloned into pGreen0229 by GenScript. Sequence fidelity of cloned SynCPR5 and metCPR5 constructs was confirmed by Sanger sequencing and restriction digestion analyses. Plasmids were transformed into Agrobacterium tumefaciens GV3101, which was then used to transform cpr5–2 plants using floral dipping as described [CPR5, SynCPR5 and metCPR5 transgene-specific sets of primers  and cpr5–2, were carried out using a Sysmec Cyflow cytometer  as per manufacturer’s instructions. Total RNA was isolated from plants using Quick-RNA Miniprep kit (Zymo Research) and cDNA was prepared using Transcriptor First Strand cDNA Synthesis Kit (Roche). Transcript abundance was quantified using the LightCycler 480 Real-Time PCR (Roche) system [Pseudomonas syringae pv DC3000 pathogenicity assays were carried out as described [For flow cytometry, nuclei were isolated, stained and analysed as described . Kinemat) system . Transcr) system . Pseudomescribed .Additional file 1: Figure S1: Positions of putative translation start sites and RNA stem-loop structures. Figure S2: Sequence comparison and positions of primers used for real-time qRT-PCR quantifications. Figure S3: Area of abaxial epidermal pavement cells. Table S1: List of primers.


Cell surface β2-AR density was measured by enzyme-linked immunosorbent assay (ELISA) and flow cytometry. Treatment with propranolol, carvedilol, pindolol, sotalol, or timolol did not induce any significant change in surface β2-AR density in both HEK293 cells and human lymphocytes. On the contrary, treatment with the β-AR agonist isoproterenol reduced the number of cell surface β2-ARs in the tested cell types without affecting β2-AR-mRNA levels. Isoproterenol-induced effects on receptor density were completely antagonized by β-blocker treatment. In conclusion, the agonistic activity of β-blockers does not exert an important effect on short-term regulation of β2-AR density.Altered β-adrenergic receptor (β-AR) density has been reported in cells, animals, and humans receiving β-blocker treatment. In some cases, β-AR density is upregulated, but in others, it is unaffected or even reduced. Collectively, these results would imply that changes in β-AR density and β-blockade are not related. However, it has still not been clarified whether the effects of β-blockers on receptor density are related to their ability to activate different β-AR signaling pathways. To this aim, five clinically relevant β-blockers endowed with inverse, partial or biased agonism at the β The tissue responses to catecholamines depend on their relative affinities for receptor adrenergic subtypes, their concentration at the site of the receptor as well as the adrenergic receptor density on target cells. Drugs, such as β-blockers, and clinical disorders, such as heart failure, can alter the number of β-adrenergic receptors (β-AR). Previous studies performed on both animals and humans have reported dissimilar effects of β-blocker therapy on β-AR density and sensitivity. Chronic treatment with the β-AR antagonist propranolol significantly increased the number of β-ARs in the heart, lung, and lymphocytes ,2,3,4. O density . TogetheRecent findings in the molecular biology of β-ARs show that these receptors can interact with at least two different transduction proteins in the cell membrane: G proteins and β-arrestins. Endogenous agonists of G protein-coupled receptors (GPCRs) are usually equally efficient in promoting G protein-mediated signaling and the interaction of the receptor with arrestins, which promote rapid receptor internalization and signal quenching. However, GPCR ligands, such as β-blockers, can show unequal or divergent molecular efficacies for such interactions. This phenomenon, often called biased agonism or functional ligand selectivity , indicat1-ARs, β2-ARs, and β3-ARs) belong to the GPCR superfamily and activate adenylyl cyclase following the binding with catecholamines. β-AR signaling is terminated by phosphorylation of the intracellular domains of the receptor by the family of G protein-coupled receptor kinases. Although both β1- and β2-AR couple primarily to Gαs and subsequent cyclic adenosine monophosphate (cAMP)-related pathways, they are regulated differently in response to persistent agonist stimulation. In general, the studies in cultured cells indicate that β1-AR is more resistant to agonist-mediated downregulation than β2-AR [2-ARs are distributed extensively throughout the body, wherein they mediate the response to sympathetic discharges in many organs and tissues, including immune and central nervous systems [2-AR density is lacking.β-ARs  and flow cytometry using specific antibodies. We found that propranolol, carvedilol, pindolol, sotalol, or timolol do not affect β2-AR density on their own but reverse agonist-induced β2-AR downregulation.To this aim, five clinically relevant β-blockers endowed with inverse, partial, or biased agonism at the βlleagues , were te2-AR density, we used the HEK293 cell line, stably expressing the N-terminus-FLAG-tagged β2-AR at a density of 15 pmol/mg of membrane protein as previously reported [2-AR density. Specifically, we tested pindolol, a partial agonist, sotalol, and timolol, two inverse agonists, carvedilol and propranolol, two inverse agonists that also induce ERK activation, i.e., biased agonists [2-AR density in HEK293 cells. Furthermore, although propranolol tended to increase β2-AR density no statistical difference was observed among β-blockers  for 3 h reduced β2-AR density compared to cells incubated with control medium  for another 30 min. Coincubation of the cells with isoproterenol and β-blockers  completely reversed isoproterenol-mediated β2-AR downregulation restoring surface receptor density  to assess the mRNA levels of βphocytes A. In botpression B,C. Toge2-AR were evaluated for their effects on β2-AR density in both cells expressing exogenous FLAG-β2-ARs and cells expressing endogenous β2-ARs. Changes in receptor density were evaluated by immunological techniques, such as ELISA and flow cytometry. Using these techniques and these simple cell systems, we found that this subset of β-blockers does not affect short-term regulation of β2-AR density but is able to reverse agonist-induced β2-AR downregulation.Regulation of β-AR plasma membrane density is an important process in tuning β-AR response to catecholamines. β-AR antagonists inhibit catecholamine-induced β-AR stimulation and are commonly used to treat a variety of clinical conditions ranging from heart failure to capillary hemangioma. Chronic treatment of humans, animals, or cells with β-blockers may increase, reduce, or even leave the number of β-ARs unchanged depending on the drug used ,2,3,4,5.The results of the present study are in line with those of previous studies that observed no effect of both propranolol and carvedilol on β-AR density in cultured cells. Dangel et al.  reported1, β2, and β3, which act by activating a Gs protein and adenyl cyclase. β-AR signaling is terminated by phosphorylation of the intracellular domains of the receptor by the family of G protein-coupled receptor kinases. Chronic stimulation of β2-ARs by catecholamines causes desensitization of the β-adrenergic system with internalization and reduction of the number of receptors present on the cell surface. In the present study, we found that isoproterenol, a β-AR agonist, decreases β2-AR density without affecting β2-AR-mRNA levels in three different cells. We also found that β-blocker treatment leads to recycling receptors back to the surface, restoring receptor density, regardless of the ancillary pharmacological properties of β-blockers. These findings confirm and extend previous in vitro results showing the effects of catecholamines on receptor density and the impact of the treatment with the β-blocker propranolol on agonist-induced β2-AR downregulation. Di Certo et al. [2-ARs to the β-AR agonist isoproterenol resulted in a time-dependent receptor downregulation. This effect was completely abolished by propranolol treatment.β-ARs are a family of G-protein coupled receptors comprising three subtypes, βo et al.  showed t2-AR cell surface density is a well-documented phenomenon. In contrast, little is known about the cell surface regulation of the β1-AR. Chronic stimulation of β-ARs by catecholamines causes internalization and reduction of the number of both β1- and β2-ARs present on the cell surface, with the former more resistant to agonist-mediated downregulation than the latter [1-AR density [1-AR cell surface density in cultured cells.The agonist-induced reduction of βe latter ,8,9. Pre2-AR density, we used a flow cytometry-based method utilizing a specific antibody against β2-ARs according to previously reported studies [2-AR density can also be evaluated using the biotinylated β-AR ligand alprenolol [2-AR density on blood cells, such as lymphocytes, may be useful to monitor treatment responses, disease activity, and prognosis of diseases involving changes in β-AR density, such as heart failure. Fifth, in the present study, we analyzed the effects of a subset of β-blockers with different signaling profiles on β2-AR density and found that their agonistic activity does not affect short-term regulation of β2-AR density. Since the three β-AR subtypes appear to differ in their distribution as well as their signaling properties, it remains to be determined whether the agonistic activity of β-blockers is able to regulate β1-AR and/or β3-AR cell surface density in cultured cells.Additional features of our experiments are worth commenting on. First, studies in humans and animals reported that long-term therapy with β-blockers alters receptor density. In the present study, the exposure of cells to β-AR antagonists lasted only a few hours. Although previous studies show that propranolol fails to increase receptor density after 24 h of treatment, it cannot be ruled out that very prolonged exposures (48–72 h) to β-blockers may influence the transcription and the number of β-ARs. Second, radioligand binding is a powerful and widely used method to quantitatively measure receptor surface density ,26. Howe studies ,31. Althprenolol . However2-AR density and found that no tested β-blocker affected β2-AR density on their own but reversed agonist-induced β2-AR downregulation. Collectively these results suggest that the agonistic activity of β-blockers does not exert an important effect on short-term regulation of β2-AR density.In conclusion, we evaluated the effects of a subset of β-blockers, endowed with varying degrees of G protein/β-arrestin efficacy profile, on β2 -AR antibody from Abcam . Cell culture media, fetal bovine serum, G418, and Lipofectamine were from Invitrogen .Isoproterenol, propranolol, pindolol, carvedilol, sotalol, timolol, anti-FLAG monoclonal antibody (M1 clone) and Hoechst 33,258 were from Sigma–Aldrich  while anti-βHuman embryonic kidney 293 (HEK 293) cells were grown in Dulbecco’s modified Eagle’s medium  supplemented with 10% fetal bovine serum , 100 units/mL penicillin, 100 μg/mL streptomycin sulfate, and 200 μg/mL G418  in a humidified atmosphere of 5% CO2 at 37 °C. Cultured cells were serum-starved for 2 h prior to agonist stimulation.HL-1 cardiac muscle (HL-1) cells were kindly provided by Dr. S. Nanni  and were cultured in Claycomb medium  supplemented with 10% FBS, 0.2 mM norepinephrine, 2 mM L-glutamine, 1 U/mL penicillin, and 1 μg/mL streptomycin solution  as previously described .Three healthy donors (38 ± 3.6 years of age) were recruited for this study at the Institute of Hematology, Sapienza University of Rome . Following the rules of good medical practice, the nature and purpose of the study were explained to the volunteers who then gave their informed consent. The investigation conforms to the principles outlined in the Declaration of Helsinki. Lymphocytes were isolated from the peripheral blood by centrifugation on a Ficoll/Hypaque density gradient and plastic adherence to deplete monocytes before pharmacological treatments.2-AR antibody  for 45 min, following the manufacturer’s instructions. The anti-β2-AR antibody was chosen based on previously reported data [After pharmacological treatments, HL-1 cells were washed in PBS and then stained in ice with an anti-βted data ,31. Afte2-AR agonists and antagonists on receptor density were also analyzed using flow cytometry. At the end of pharmacological treatments, human lymphocytes and cardiac HL-1 cells were fixed with 0.01% paraformaldehyde for 10 min to avoid changes in cell surface receptors. After washing in PBS, cells were stained with anti-β2-AR  for 45 min, following the manufacturer’s instructions. As mentioned above, the anti-β2-AR antibody was chosen based on previously reported data [The effects of βted data ,30. Next2-AR were incubated in the presence of vehicle (control), propranolol, carvedilol, pindolol, sotalol, timolol, or isoproterenol at the concentration of 1 μM at 37 °C per 3 h. Concentrations of β2-AR ligands were chosen based on results from previous studies [HEK293 cells stably expressing the N-terminus-FLAG-tagged β studies ,35. Isop2-AR were performed using TaqMan gene expression assays  . qRT-PCR analysis was performed using the 7500 Real-Time PCR system . The glyceraldehyde 3-phosphate dehydrogenase  gene was used as a reference gene, and the ΔCt was used for statistical analysis.Total RNA was extracted from cultured cells and ventricular tissues by using TRIzol  and purified by using an RNA purelink mini kit . The concentration and purity of the RNA solution were determined by using a NanoDrop spectrophotometer , whereas its overall quality was analyzed using the Agilent 2100 bioanalyzer with an RNA LabChip . cDNA was obtained using the High Capacity cDNA Archive kit . mRNA expression levels of the βt-test for two groups or one-way ANOVA with Bonferroni’s post hoc test to compare all pairs of columns for more than two groups. A value of p < 0.05 was considered statistically significant.Data are expressed as the mean ± SEM and analyzed using a software program . Statistical significance between different groups was determined by unpaired 2-AR were evaluated for their effects on β2-AR density in both cells expressing exogenous FLAG-tagged human β2-ARs and cells expressing endogenous β2-ARs. We found that β-blockers do not affect β2-AR density on their own but reverse isoproterenol-induced β2-AR downregulation. These results suggest that the agonistic activity of β-blockers does not exert an important effect on short-term regulation of β2-AR density.In the present study, β-blockers endowed with inverse, partial, or biased agonism at the β


Outcomes following anterior cruciate ligament (ACL) reconstruction are considered poor. There are many factors which may influence patient outcomes. As such, the purpose of this review was to report on the influence, barriers to and facilitators of rehabilitation adherence and participation after ACL reconstruction, providing information to help clinicians and patients make quality decisions to facilitate successful rehabilitation.A systematic search of five electronic databases was undertaken in identifying studies from inception to 18 July 2019. The search included English language articles reporting on the influence, barriers to and facilitators of adherence and participation in rehabilitation of patients who have undergone ACL reconstruction. Data extraction and synthesis of included studies were undertaken.n = 180) were assessed for eligibility following screening of titles and abstracts (n = 1967), yielding 71 studies for inclusion. Forty-four articles investigated ‘rehabilitation prescription and participation’ and 36 articles investigated ‘rehabilitation barriers and facilitators’. The results indicate that a moderately or minimally supervised rehabilitation program is at least as effective as a fully supervised high-frequency rehabilitation program, although a longer duration of supervised rehabilitation is associated with improvement in a multitude of functional outcomes. A number of psychological factors associated with rehabilitation adherence were also identified. The most commonly investigated concepts were self-motivation, athletic identity and social support. Patients perceived the therapeutic relationship, interaction with family and friends, self-motivation, fear of reinjury, organisation/lack of time and interpersonal comparison as the most common barriers to and facilitators of rehabilitation.Full text articles (A longer duration of supervised rehabilitation is associated with an increased chance of meeting functional and return to sport criteria; however, the optimal supervised rehabilitation frequency is yet to be determined. Identification of the barriers to and facilitators of adherence and participation in ACL rehabilitation provides an opportunity for further research to be conducted to address personal, environmental and treatment-related factors, with the aim to improve rehabilitation outcomes. A longer duration of supervised rehabilitation is associated with more favourable post-operative outcomes.The optimal frequency of supervised post-operative rehabilitation is unknown.Patients experience a variety of psychological, environmental, personal and treatment-related barriers to and facilitators of rehabilitation.Anterior cruciate ligament (ACL) injury occurs during rapid valgus loading and internal tibial rotation of the knee . Every yDespite significant advances in surgical technique, the outcomes following ACL reconstruction continue to be reported as poor . ResearcPotentially, the underutilisation of rehabilitation in recovery from ACL injury is contributing to the poor outcomes . GrowingTo report on the influence of rehabilitation adherence and participation on outcomes after ACL reconstructionTo report on the barriers to and facilitators of adherence and participation in ACL rehabilitationTo provide information to help clinicians and patients make quality decisions to facilitate adherence and appropriate participation in ACL rehabilitationClinicians are therefore continuing to seek guidance on the best way to structure and deliver rehabilitation to facilitate return to sport and minimise the risk of reinjury. With that in mind, this scoping review aims:A scoping review was conducted to synthesise evidence on ACL reconstruction rehabilitation adherence and participation for the clinician providing rehabilitation services to patients who have undergone ACL reconstruction. Due to the broad exploratory nature of the topic, a scoping review design and methodology was used to facilitate collation and mapping of evidence for the identification of key concepts, knowledge gaps and the types of evidence currently available .What is the reported influence of adherence and participation in ACL reconstruction rehabilitation on patient outcomes?Which factors are reported to influence adherence and participation in ACL reconstruction rehabilitation?The research questions are:https://osf.io/a7tz8/?view_only=9bc5d21c0c034f70a37202abab7330c0) prior to data extraction, on the 10 August 2019. No changes were made to the protocol from publication through to completion.A single researcher (AW) conducted the literature search to identify, screen and select studies to be included in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) . An a prA pilot search of PubMed and Embase using the medical subject headings ‘anterior cruciate ligament’ AND reconstruction AND rehabilitation AND ‘patient compliance’ (May 2019).Identified keywords and terms relating to anterior cruciate ligament reconstruction rehabilitation adherence and participation (May 2019).Execution of the final search strategy and further searching of reference lists of the selected articles, systematic reviews and narrative reviews (July 2019).The search strategy was developed through the application of the methodological frameworks proposed by Arksey and O’Malley (2005)  and Petehttps://www.endnote.com/) for selection by AW according to the PRISMA-ScR statement [A search was formulated https://wPopulation , Concept (any study reporting on the effect of adherence and participation in rehabilitation or a rehabilitation program) and Context . The following types of publications were eligible for inclusion: original research, reviews, scoping reviews, systematic reviews, meta-analysis, case series and clinical commentaries.The eligibility criteria were defined by the Exclusion criteria were (a) non-English language, (b) examined pre-operative interventions or non-operative rehabilitation intervention for ACL rupture and (c) no access to the full text. The following were also excluded from our review: conference abstracts/proceedings, opinion pieces, guidelines, magazine and newspaper articles and rehabilitation protocols.AW extracted data from publications meeting inclusion criteria into a custom Excel spreadsheet. Data extraction, categorisation and mapping were performed as per Peters et al. (2015) in an iterative process as the reviewer became more familiar with the evidence .To answer the research questions, data were narratively synthesised by the author-defined categories: (A) rehabilitation prescription and participation and (B) barriers to and facilitators of rehabilitation. Studies in category A were further categorised into 3 sub-categories: ‘supervised rehabilitation frequency’, ‘supervised rehabilitation duration’ and ‘rehabilitation adherence’. Studies in category B were further categorised into three sub-categories: ‘psychological’, ‘patient perspectives’ and ‘other factors’. Studies may be allocated to multiple groups. Results were mapped based on the population profile , study design and concepts investigated. The synthesis of qualitative data was guided by the methodological framework presented by Thomas and Harden (2008) . In linen = 2385) were removed, and exclusion based on screening of title and abstract (n = 1967) left 180 full-text articles which were retrieved and assessed for eligibility. Of these, 111 were excluded for the following reasons: 85 studies did not investigate or have outcomes related to either adherence or participation in rehabilitation; nine were of non-English language; 12 had no access to full text; four were opinion, editorial or news articles; and one article with a non-pure ACL data set (participants from multiple injuries). Seventy-one publications fulfilled the criteria and were included in the review  were selected to answer the second research question: Which factors are reported to influence adherence and participation in ACL reconstruction rehabilitation? Thirty-six articles consisting of 10 reviews and 26 original studies were included in this category. An article was categorised into ‘psychological’ if it investigated the association between a psychological variable and adherence to rehabilitation, as ‘patient perspectives’ if the study included a qualitative research methodology reporting on patients' opinions and perspectives on barriers to and facilitators of rehabilitation and as ‘other factors’ if it did not fit the first two categories.Publication dates varied from 1997 to 2019. The number of articles published increased substantially from 2015 , three prospective, one cross-sectional and one case report Table . The meaA variety of outcome measures (OMs) were used Table  with no To determine the correlation between frequency of supervised rehabilitation and rehabilitation outcome, the frequency of appointments in each intervention group was mapped based on the average number of weekly appointments across the intervention period. Patients who attended less than once per month were classified as low, between 1 and 2×/month as moderate and more than twice per month as high across the duration of their rehabilitation.The intervention period was labelled according to the stages of rehabilitation the intervention spanned; early-stage (0–3 months), mid-stage (0–6 months) and late-stage (0–6 months+). Eight studies investigated through to the late phase , 48, 49,Thirteen of the included 20 studies showed no significant difference between low, moderate or high frequency supervised rehabilitation regardless of the intervention period. The non-significant studies were all seven RCTs , 46, 48,Studies utilising a retrospective methodology found an association between higher rehabilitation utilisation and significantly higher patient reported outcomes (Knee Outcomes Survey–Activities of Daily Living (KOS-ADL) scale , 43, KneDespite significant heterogeneity between the included studies and overall poor quality of research, it is reasonable to conclude that a moderately or minimally supervised rehabilitation program is at least as effective as a fully supervised high-frequency rehabilitation program. Recent publications, however, are showing an association between higher rehabilitation utilisation improving outcomes. It remains to be seen whether there is an optimal frequency of supervised rehabilitation visits and if this varies between stages of rehabilitation. From the current research, it is unclear whether participants met an acceptable level of function for return to sport and minimisation of reinjury.Of the eight included original studies regarding supervision duration, seven studies are retrospective and one prospective in design Table . The aveSupervised rehabilitation longer than 6 months was associated with improved outcomes at all assessment time points. Specifically, associations were found between longer supervised rehabilitation and functional symmetry , 51, a gIt is reasonable to conclude that a longer duration of supervised rehabilitation of at least 6 months, which includes structured agility, gym exercises, landing and on-field rehabilitation, is associated with more favourable outcomes after ACL reconstruction. It is likely that 9 or 12 months of structured supervised rehabilitation would offer further benefits. High-quality prospective randomised trials in this area are required.All three reviews evaluated adherence to clinic and home-based rehabilitation against functional and subjective outcomes Table . There iOf the four included original studies regarding adherence, three studies of prospective design compared measures of adherence to clinic and home-based rehabilitation against functional and subjective outcomes over the first 6 weeks, 8 weeks and 6 months of rehabilitation  consisting of 32 raw themes; 36 mentions as a barrier to and 46 mentions as a facilitator of rehabilitation. Personal factors were mentioned 51 times across three sub-themes , consisting of 19 raw themes; 28 mentions as a barrier and 23 mentions as a facilitator. Environmental factors were mentioned 19 times across two sub-themes , consisting of four raw themes; 11 mentions as a barrier and eight mentions as a facilitator.n = 11), interaction with family and friends (n = 9), self-motivation (n = 9), fear of reinjury or return to sport (n = 7), organisation/lack of time (n = 6), interpersonal comparison (n = 6), interaction with team and coaches (n = 5), access to facilities and equipment (n = 4), expectations (n = 4), pain, weakness or illness (n = 4), length and commitment of rehabilitation (n = 4) and enjoyment (n = 4).The most common raw themes arising in the literature as either a barrier or facilitator of rehabilitation were therapeutic relationship  or may require tailored interventions or alternative professionals to facilitate rehabilitation. Social and societal factors also play a key role but are harder to influence by the practitioner.The three included original studies investigated associations between clinician experience and qualification , graft cTo determine physiotherapist practice patterns, Greenberg et al. (2018) surveyed 1074 physiotherapists from the USA. They found clinicians with less clinical experience, higher volumes of patients post ACL reconstruction and an orthopaedic clinical specialist or sports clinical specialist certification deliver a longer overall duration of clinical care more in line with clinical recommendations .In terms of graft choice and meniscus injury, Dempsey et al. (2019) found that competitive and recreational athletes who received a BPTB graft completed more days of rehabilitation per week and had more total visits compared with patients who received an HT graft; however, meniscal procedures did not correlate with rehabilitation quantity .In a prospective study, Niven et al. (2012) found variation in the adherence levels across different sports, indicating that Gaelic football, hockey, rugby and soccer players consistently adhered well, whereas motocross participants were poor adherers . The levNewly graduated and specialty trained therapists may be more cognisant of current evidence and delivery care more in line with current recommendations. Although patients with BPTB graft attended more often, it is unclear what this may be due to and the implications for rehabilitation adherence. Finally, it is unclear as to the reasons why different sports have different levels of adherence.Participation in ACL rehabilitation is considered critical to facilitate return to sport , 51, 88.Furthermore, many factors were associated with a patient’s ability to adhere to and participate in rehabilitation. Psychological factors of self-motivation, athletic identity, stress and mood disturbance, goal setting, positive self-talk and the personality traits of optimism, agreeableness and conscientiousness were associated with rehabilitation adherence. Numerous patient-perceived barriers to and facilitators of rehabilitation were identified. The most common were the therapeutic relationship, interaction with family and friends, self-motivation, fear of reinjury and organisation/lack of time.For the researcher and clinician, the results of our scoping review highlight the need to develop appropriate rehabilitation protocols that not only develop the physical capabilities of patients but also take into account patients’ circumstances and psychology, which may pose barriers to achieving a successful outcome. Aspects of rehabilitation may need to be varied depending on the individual presenting.It would be premature to conclude that reducing rehabilitation supervision during ACL reconstruction is required. Current practice patterns in Australia reflect a decreasing frequency of supervised rehabilitation from once or twice per week in the early phases, to less frequent visitation with a focus on independent exercise with periodic review as rehabilitation progresses . The eviBased on our results, the duration of supervised rehabilitation may be more important than frequency. Supervised rehabilitation should begin shortly after surgery , continuRecent original studies have demonstrated that even with well-controlled and implemented rehabilitation, most athletes fail to meet discharge criteria . FurtherAll original studies which showed a positive relationship between supervised rehabilitation frequency and outcomes were published in the last 4 years. This fact may suggest that modern rehabilitation programs may require more guidance from a clinician. Age may also play a role in the frequency of supervision required. Younger patients, particularly under 18, may require a higher frequency to achieve successful outcomes by providing extra guidance on exercises, goals and motivation to adhere to post-operative rehabilitation , 46, 64.Clinician knowledge may also play a role in achieving a successful outcome. Clinicians familiar with current best practice who service a higher volume of patients who have undergone ACL reconstruction are more likely to provide evidence-based care, while less familiar clinicians may be at risk of prematurely discharging patients before meeting established RTS criteria . This maA final point to consider is that the increasing demand for cost-effective health care interventions is leading to the development of more unsupervised rehabilitation protocols . RehabilWhen designing future research to examine the adherence and outcome relationship, it is critical that researchers consider the definition of adherence, parameter, adherence measure and the value for acceptable adherence . The stuDespite our improved understanding of what components need to be included within an evidence-based ACL rehabilitation , little Psychological factors, particularly fear of reinjury, are the most significant contributor to not returning to sport . The resEspecially due to the long rehabilitation process, by structuring or delivering rehabilitation in a manner that supports a positive psychological state , many barriers to rehabilitation and return to sport can be overcome , 81, 85.Our results show a large number of patient-perceived barriers to and facilitators of rehabilitation. Many of the factors likely interact with each other, and by putting in place practices that either enhance facilitators or remove barriers, outcomes could be improved Fig. .Fig. 3TAs exemplified in our results, the physiotherapist plays a significant role in driving recovery by offering motivation, support, guidance, and encouragement while also providing informational support. It is also the physiotherapist’s responsibility to set realistic expectations and deliver a fun, progressive, sport-specific program for the individual with regular goal setting and reassessment. The physiotherapist can also assist in overcoming the physiological barriers to rehabilitation, such as pain and reduced health and fitness due to injury.Group-based rehabilitation has the potential to overcome many of the barriers to and enhance facilitators of rehabilitation. Studies investigating group-based therapy demonstrated positive characteristics, including an enjoyable, cost-effective, social, supportive and motivating environment , 85. ParEnvironmental factors are harder to control as they are often out of the control of the treating physiotherapist. Physiotherapists working within team environments can assist by providing coaches and teammates with the appropriate information to facilitate inclusion and interaction with the main training group. If the physiotherapist has interaction with family members and friends, positive supportive behaviours can also be reinforced. Geographic constraints that prevent access to appropriate facilities and providers pose a particular challenge. Digital health may be an area of future research to address this domain.This review is the first to address the effects of rehabilitation adherence and participation on ACL rehabilitation outcome. We were then able to provide the reader with potential influencing factors which create barriers to or facilitate rehabilitation. The review was also conducted according to recognised standards for scoping review following the development and publication of an a priori protocol.The methodological quality of the articles was not assessed as per guidelines for conducting scoping reviews , 17. ManWhen assessing the evidence for the frequency of supervised rehabilitation, it was not determined whether any cohort of patients achieved a successful outcome from their rehabilitation. Lynch et al. (2013) detailed the criteria for defining a successful outcome after ACL reconstruction. These are the absence of giving way, patient return to sport status, the absence of knee joint effusion, quadriceps muscle strength symmetry and meeting patient-reported outcome benchmarks . Due to Only articles published in English were available for inclusion, introducing a publication bias. Only one author screened, selected and extracted the data from the studies, potentially missing articles or introducing bias to data presented. The articles were categorised and analysed based on the author determined constructs. The categorisation may have been different for different authors.Considerable heterogeneity between studies in outcome measures used, rehabilitation timeframes and programs reduced the ability to compare results directly. Most studies reported on participants over the age of 25, reducing the ability to draw conclusions for patients in a younger age group who typically have higher return to sport goals. Poor reporting of activity level and sport of the included participants leads to uncertainty in identifying factors relevant to specific athletes, sports or activity levels. Studies were from a variety of countries, introducing biases into the results due to different standards of care and access to health services. However, the review provides a comprehensive analysis of the current state of knowledge and areas where further work is needed to facilitate better rehabilitation practices.This scoping review highlighted a broad spectrum of factors the clinician should consider when facilitating a patient’s rehabilitation after ACL reconstruction. Growing evidence suggests a longer duration of supervised rehabilitation involving agility, landing and gym exercises, and a supervised return to activity or sport is required to achieve functional and return to sport goals. The lack of conclusive evidence to support a specific supervised rehabilitation frequency fails to provide appropriate guidance to treating physiotherapists to deliver more optimal care.Identification of the barriers to and facilitators of adherence and participation in ACL rehabilitation provides an opportunity for further research to be conducted to address personal, environmental, and treatment-related factors. Taking these factors into account increases the likelihood of patients complying with current best evidence rehabilitation to improve outcomes such as return to sport rates and reinjury.Additional file 1. Search


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. Allergic Rhinitis (AR) is a chronic respiratory condition affecting 19% of Australians, with a prevalence rate in the Australian Capital Territory (ACT) as high as 29% . The ramIn Australia, AR can potentially be managed and controlled entirely with pharmacotherapy available to purchase over the counter in community pharmacies without the need to consult a pharmacist. These products are often displayed on shelves which may not be in arm’s reach of the pharmacists but, by regulation, may be in area of the pharmacy which is at a distance from the pharmacist. However, when people with AR do not consult a health care professional (HCP), AR control is rarely achieved . While iResearch has consistently identified that there is a high proportion of people with AR that self-select their medication, with up to 85% making a suboptimal choice ,2,3,9. TThe implementation of clinical guidelines in healthcare settings is of universal concern and has led to the development of several implementation frameworks, including the “Promoting Action on Research Implementation in Health Services (PARIHS)” framework, designed to ensure the optimal implementation of evidence-based guidelines in healthcare settings ,14. The The aim of this study was to explore the experiences and perceptions of community pharmacists with regards to the implementation of AR management guidelines in real-life everyday practice.The ethical aspects of this study have been approved by the Human Research Ethics Committee (HREC) of the University of Sydney (2018/658). It was conducted between October 2019 and November 2019 and all the pharmacist participants signed informed consent prior to enrolment in the study.Community pharmacists from the ACT, Australia, were recruited through a list of pharmacies collaborating with the University of Canberra to participate in a research project titled the AR-CMaP project. Their involvement in this project required pharmacists to implement the AR-CMaP in their community pharmacy. AR-CMaP is an AR education and management pathway for community pharmacies designed to support pharmacists in translating AR management guidelines into practice in order to ensure that people with AR in community pharmacies are optimally managed. The AR-CMaP is based on empirical evidence ,17,18,19The semi-structured interview guide  was deveData collection and analysis was conducted by members of the research team—RT, BC, LC, and SBA. BC conducted the pharmacist interviews, which were audio recorded and transcribed verbatim by a professional transcription service. RT checked each transcript to ensure transcription fidelity and that any identifying references were removed to ensure all data were de-identified. BC read each interview three times to ensure familiarity prior to the commencement of analysis. BC then conducted line by line observational coding for each interview. The codebook from the observational coding was shared with SBA, RT, and LC for an independent analysis and identification of themes. BC gathered the thematic analysis provided by SBA, RT, LC and BC’s own thematic coding and identified similarities and uniqueness. BC and SBA met to discuss the combined thematic analysis and came to an agreement on five overarching themes that best represented the content of the interviews. These themes were electronically shared with LC and RT, who agreed that these themes represented their individual analysis and the pharmacists’ sentiments.In total, 19 community pharmacists implemented the AR-CMaP in six pharmacies and of those, 15 pharmacists  from six pharmacies were interviewed at the end of the project. All interviews were conducted over the telephone during business hours while the pharmacists were working but able to take a short break. The interview duration varied from 4 min to 14 min (median 10 min). Of the pharmacists who were interviewed, two were proprietors and practicing pharmacists and thirteen were employee practicing pharmacists. There was a minimum of one pharmacist interviewed from each of the pharmacies involved in the implementation of the AR program. The interviews occurred during late October and early November 2019.The following themes best represent the pharmacists’ responses.1. Impact of training on pharmacists’ approach to patients and AR management recommendations.Pharmacists acknowledged they found benefit in receiving more advanced training in AR management. While some reported that the training re-enforced their existing knowledge, most said they welcomed something “new”. In particular, they reported gaining further insights into AR as it related to the high level of burden associated with AR, the skills required to evaluate AR severity, the importance of highlighting the association with asthma to their patients, the broad safety profile of intranasal corticosteroids (INCS), and the steps associated with correct intranasal inhaler technique.“I’m going for [INCS] first and having more in-depth conversations with people, having conversations about asthma and asthma management as well”PH#7As a result of this new knowledge, the pharmacists reported a change in the content, nature, and frequency of their counselling. Pharmacists said they were more proactive in speaking to patients self-selecting AR medications; they included more discussion about intranasal inhaler technique and spoke to their patients with coexisting-asthma about the importance of managing their AR. Counselling often included the evaluation of AR severity while using the VAS ruler. Pharmacists felt more confident in recommending INCS and giving patients better treatment options other than oral antihistamines (OAH). The pharmacists reported positive feedback from their patients following this in-depth counselling.Some pharmacists used their new knowledge to educate their pharmacy assistants to ensure AR management strategies included all staff within the pharmacy. Educating the pharmacy assistants raised the awareness of the importance of optimal AR management with all the staff, ensuring that people with AR were more likely to get referred to the pharmacist more frequently.“We always do debrief after we’ve had a training so that we can pass on that information maybe in a slightly simplified version, in a simplified way to them so that they can also use it properly.”PH#92. Patient engagement and the importance of tools.Pharmacists said that one of the hardest things to do in AR management was to engage patients who chose to self-select and who have been using the same medication for a long period of time. This is where the use of new tools in counselling were important and enabled pharmacists to open up new topics of discussion to engage these patients.The VAS rulers were particularly well received. Pharmacists reported that the ruler was a useful objective measure that allowed patients to assess the burden/severity of their AR. This provided pharmacists with the opportunity to review the patient’s treatment. Most patients discovered through this process that their AR symptoms were more burdensome than they had realized. Pharmacists reported that this tool made it much easier to convince the patient to consider alternative treatment. However, the difficulty associated with the use of the VAS ruler included keeping a VAS ruler with them all the time so that it was accessible to them when patients were in a rush.“Being able to show a patient visually [using VAS ruler], if you’re suffering more than a few times a week, then you’re actually needing this treatment in particular, using that format was probably a lot better than what I was doing previously. Yeah, so that definitely helped, and also making sure that patients were a little bit more educated about what it is that’s actually affecting them, rather than just watching the adverts on TV that says, take an oral antihistamine every day. So yeah, I did feel that it has had an impact in a positive way.”PH#3Pharmacist’s perspectives on the use of posters elicited mixed responses. Some pharmacists said they initiated conversations about AR between patients and pharmacists, particularly with respect to intranasal inhaler technique. Others said they had no impact because patients were overwhelmed visually and did not take the time to look around their surroundings when selecting a product. Pharmacists also highlighted that they were specifically trying to minimize visual clutter in the pharmacy, especially with large format posters. The posters were useful in some pharmacies, where they prompted patients to ask for the pharmacist and strengthened pharmacists’ counselling message.“They’ve been quite good. We’ve had some of the posters up on our little promo stand, where we have the allergy stuff, which is really good. A lot of customers are engaging in it and having a good read, so that’s things like the technique of the nasal spray and a bit more about the allergies and that”PH#1“The posters and the A4 pages, they don’t work in pharmacy, because… you’ve got very limited space to put things on shelves”PH#14The pharmacists reported limited uptake of the MASK-Air app by patients. While they felt that younger patients were more receptive to hearing about it, there was limited download and use of the app overall.“So the app is a good tool to recommend to patients, however, it doesn’t suit all patients. For example, those who are elderly don’t really know—aren’t that tech savvy—don’t get me wrong, we still told them, but most of them weren’t interested. So depending on what patients you are talking to, depended on whether that was a good tool or not.”PH#33. Patient barriers to change in practice.Pharmacists regularly cited the patient as a barrier to their ability to improve AR management. Patient beliefs, expectations, and perceptions with respects to their AR were a common concern expressed by pharmacists. While pharmacists appreciated the burden associated with AR and the importance of controlling the symptoms, they felt that patients did not feel the same way and that AR continues to be viewed as a trivial or nuisance condition by the patient. Consequently, patients would frequently rush in and out when visiting the pharmacy to purchase AR medication and appeared to have limited time to speak to the pharmacist. Pharmacists felt that the patients had no expectations of interacting with a pharmacist at that time and did not allow for time to do so. Similarly, pharmacists perceived that patients wanted AR treatments that were convenient and fit seamlessly into their busy lifestyles, such as OAH, preferring them over what pharmacists described as a “dislike” for intranasal medication. Patients’ specific requests for medicines that were sub-optimal were also difficult for the pharmacist to manage. Pharmacists did not want the patient to feel they were disagreeing with them and often used a gentle approach which was not necessarily effective. “Most of them just trivialise it. So they’re just like, oh, it’s just hay fever. It’s fine, I don’t need to have a conversation about it. So I think that would be the other biggest barrier. So time and the patients just don’t think that it’s a serious sort of condition.”PH#4While pharmacists reported that time is a challenge for many patients, the timing of the season and the severity of their symptoms sometimes made them more open to a conversation with the pharmacist. Patients were more willing to listen to what the pharmacist had to say when their symptoms were most severe and could possibly change their mindset/attitude/perception of AR and its management.“I think, especially now than when we first did the training, not so much but now that we are getting into allergy season and people are having more severe symptoms that they are being more receptive to the nasal sprays”PH#12However, pharmacists reported that the cost of prescription medication was a barrier for some patients when purchasing treatments for their AR, specifically prescription INCS sprays, in which case they chose not to have dispensed and asked for a less expensive alternative.“I think the drawback with both of those is the cost to them. So if people can’t afford that cost then that’s when I would say, oh but we can give you this one it’s not as potent but, it’s worth a go and it’s worth the cost. It costs less.”PH#12An additional patient factor that pharmacists reported in AR management was the inability of pharmacists to follow up and monitor their patients. While pharmacists told their patients to come back for a follow up consultation, they very rarely saw the same patient again. Pharmacists in larger pharmacies expected that they may not see the same patient again for follow up but were happy to follow up patients on behalf of other pharmacists. Pharmacists from small pharmacies stated that it was helpful to have regular patients, as it made the follow up of their treatment recommendations a lot easier.“I always ask them to come back. I don’t always remember if they’re the same person that I recommended something to, but I try and ask them if this doesn’t work in the next few days, please come back and tell me so I can point you in the next direction. Some of our regular customers. Who I do know very well, they do come back. Others? I honestly can’t remember. They might come back. I might not be around.”PH#94. Physical, logistical, and inter-professional barriers to change within the pharmacy environment.A significant challenge reported by pharmacists was the absence of collaboration and inconsistency in the messages delivered by doctors working within a shared pharmacy and medical center premises. Pharmacists found it difficult to challenge the appropriateness of doctors’ recommendations when they felt it was inappropriate. For example, they reported that many people with AR came from the doctor with a doctor’s note or a prescription for an OAH. Upon review of the patient, pharmacists determined that this was not necessarily an optimal treatment for the patient, however they felt it was not appropriate to challenge the general practitioner’s (GP) recommendations.“We can’t change the perspective if the doctors are writing script for [OAH], if I say, no you just take intranasal corticosteroid, that’s not good.”PH#8The physical layout of the pharmacy also presented a challenge to some pharmacists. Some pharmacies had no comfortable space in between shelves or a private counselling area, and pharmacists felt this limited their ability to deliver effective counselling to their AR patients. Pharmacists with limited free space in their pharmacies also cited the location of the AR medicines as a barrier to the placement of posters and access to VAS rulers when needed.“We found it a bit tricky to actually get the [posters] directly at the allergy section within the pharmacy, only because of where it’s actually situated in the pharmacy.”PH#5“The hay fever section needs to be easily accessible for the pharmacists. The pharmacist needs to be having conversations in that space. I think that the—and obviously, if you’re in the dispensary, you need to have—it needs to be within eye-view of that section at least”PH#7While the AR-CMaP program expected all pharmacists within a pharmacy to have participated, some pharmacies experienced logistical challenges and were not able to enroll all pharmacists in the program. These pharmacies subsequently experienced difficulties in ensuring a consistent message was being delivered within the pharmacy about AR management. “I was the only one who actually did the official training, in the webinar, and I just did a condensed version—like a verbal condensed version—to the other pharmacists that work here. I did send them the material to do but they didn’t end up doing it because it was… …fairly time-consuming. So I’d say if you could condense that, that would help”PH#145. Recommendations for improvement.Many pharmacists felt that the implementation of AR management guidelines into real-life everyday practice should be collaborative, with the AR-CMaP program broadened to include pharmacy assistants and GPs. Most pharmacists tried to share the main AR management learnings with pharmacy staff (including pharmacy assistants) during staff meetings. However, they felt strongly that if pharmacy assistants attended the same training as the pharmacists or were provided specific pharmacy assistant education, it would have been beneficial. Similarly, the pharmacists stated that if their neighboring GP colleagues were provided with the same training at the same time, it would ensure a consistent message was delivered to their common patient community and would re-enforce the recommended AR management pathways.“We probably didn’t train them [pharmacy assistants] as well as we could’ve”PH#3“I spoke to the [pharmacy assistants] after I had done the training, and I filled them in on what the training was, what the guidelines and treatments were for the different levels of various symptoms, et cetera. They were interested to know about that because they didn’t necessarily know that that was the right thing. So they were quite surprised to find out about the oral antihistamines, and how they’re fairly ineffective for most”PH#14Improvements to patient tools and resources were also suggested. Pharmacists felt that paper resources such as posters were outdated and were not modern forms of communication. Pharmacists recommended adopting technology and social media to raise awareness of AR and its burden. Pharmacists believed that by employing social media to engage patients, they would be more receptive to the information, rather than when they were in a rush in the pharmacy. Social media was recommended as a platform to raise awareness of the importance of speaking to a pharmacist about AR. Pharmacists also recommended that technology be used in an interactive way in the pharmacy. Suggestions included the digitalization of the VAS ruler and its placement near AR medicines to encourage patient interaction. It was felt that by using an interactive tool, patients would be motivated to speak to the pharmacist about their AR treatment. Alternatively, pharmacists suggested reducing the size of the posters and VAS ruler so that they can be attached to the pharmacy shelves to grab the attention of the patients.“[The patient will] be sitting at home after dinner, or in front of the TV with their phone skimming through stuff and they’ll see an interesting post on allergic rhinitis and think, oh, that sounds like what I’ve got. Read into it and then find, through their own investigation, maybe there’s a better treatment available”PH#2Pharmacists suggested that in order to maximize participation and minimize logistical issues, a shorter pharmacist education component would have been beneficial. Although they understood extensive education was required to meet Continuing Professional Development (CPD) requirements, they felt a more concise program would be more impactful as it would be accessed by more pharmacists. The length of the webinar also meant that in some circumstances, it had to be completed outside of working hours. In some circumstances, this resulted in pharmacists being paid by their employers to complete the training after hours.“The webinar one was interesting. It was probably a little bit too long. I understand it probably needs all those bits in there. But that was a little bit long.”PH#12Pharmacists reported that the timing of the delivery of the implementation program was a factor that required improvement. The pharmacists felt that they were not given enough time to mentally and physically prepare for the implementation prior to the peak of AR season. Preparations would ideally have begun approximately three months prior to spring to ensure enough time for all staff to be engaged and physical changes to the pharmacy environment to be made.“I think there were some timelines and deadlines that had to be met, coming up to the allergy season, so I think it will kind of add constraints there but yeah probably just maybe starting maybe a month earlier, get in the training—the outline of the training and what needs to be done, just to get everyone prepared”PH#5This study, to our knowledge, is the first to explore pharmacists’ feedback following the implementation of an AR clinical management pathway designed to translate AR management guidelines into practice and optimize AR management within the community pharmacy setting. Several key areas for consideration were identified, however it was clear that optimal AR management requires a multi-pronged approach which goes beyond the pharmacist. It was evident from the research that AR management must be a collaborative effort between pharmacists, GPs, pharmacy assistants, and their patients, and pharmacists must be equipped with comprehensive tools and strategies to communicate with and engage patients about optimizing their AR treatment.While the community pharmacy is central to AR management and pharmacists clearly are able to improve AR outcomes, very few pharmacist/pharmacy-centered AR interventions have been explored ,23,24. APharmacists embraced the new knowledge they had gained to engage with patients that would otherwise have chosen not to interact with a pharmacist. The pharmacists welcomed the tools provided such as the MASK-air app, VAS ruler, and AR posters as items that also sparked opportunity for new conversations with patients that would otherwise have been missed. This study also suggests that pharmacists are not accustomed to having conversations with patients around AR severity or the disease itself, and any tool or objective measure of AR severity is desperately needed within the pharmacy setting. A further reason why pharmacists may not be used to having conversations with patients around their AR is that they may perceive that their patients may not need to speak to them. A recent study found that patients feel confident in self-managing their AR and they do not see the need to speak to the pharmacist , propagaPharmacists believed that addressing the issue of AR management needed to be a whole pharmacy approach including pharmacy assistants, as well as a collaborative approach across the health care system. Pharmacists reported difficulty when inappropriate AR treatments were being recommended by neighboring GPs to patients. To improve AR management within the community pharmacy setting, the pharmacists recommended collaborative AR training with GPs to ensure a consistent message is delivered to AR sufferers that is consistent with ARIA guidelines, incorporating these values into an integrated care approach . AlthougThe pharmacy environment, technology, and support tools were highlighted as areas requiring improvement; however, it appears that a systemic change may be required to improve AR management in the community pharmacy. The location of the medications was clearly a barrier—i.e., the location was highly important when it came to the opportunity to counsel patients about their AR. Therefore, perhaps AR medications, despite being available for purchase without a prescription and without interaction with the pharmacist, should be located in a position which makes them difficult to access without pharmacist interaction.The principles of AR management also need to promote the follow up and review of AR patients. Other chronic respiratory conditions such as asthma and chronic obstructive pulmonaru disease (COPD)have systems in place to support patient self-management and follow up with a HCP , which iAlthough this study is limited by its small sample size, it is valuable in its methodology and the unique location chosen for its high AR prevalence. AR pathways are traditionally evaluated by the changes in clinical outcomes that they generate . HoweverThis study demonstrates that AR management within the community pharmacy is complex and several barriers need to be addressed in order to implement a clinical AR management pathway for pharmacists. To optimize AR management, a collaborative approach must be adopted within the primary care setting, and pharmacists need to be provided with resources to support self-management among their patients with AR.