The Journal of the Irish Practice Nurses AssociationIssue 2 Volume 4 March/April 2011

HeAlTH cAre sTANdArds IN

geNerAl PrAcTIceKieran Murphy

OsTeOPOrOsIs – MANAgeMeNT IN

geNerAl PrAcTIceDr Ann Manley

Q and a IPNA Chairperson

Orla Loftus-Moran

MeNTAl HeAlTH – THe deAN clINIc

Alison Lane

PeANuT AllergySally Whelan

HeArT sMArT MAyOAilish Houlihan

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1

editorial

The iron law of political oligarchy

An election has taken place at one of the most crucial junctures in the history of the State. At the time of writing this editorial it is the week before the dawning of the new political group or groups.

As healthcare providers it is recognised that the country and its people have suffered a deep wound. The carer (the government elect) needs to pay particular attention to its patients (the people of this island).

Whatever the result the practice nurse needs to push forward towards a better future given hope to the PHC arena. It is said that Mary Harney did not recognise the capabilities of the community and resources behind general practice and practice nurses. It is time now to step forward and take our resources as key people in PHC, to a higher level. As Liam Doran said there is ‘strength in solidarity’, (INMO Feb 2011).

In order to protect nursing as a whole the exploitation of student nurses needs to be addressed by colleagues, both in primary and secondary care. Remember we once walked the student avenue.

In 1911 the German Sociologist Robert Michels wrote the following statement about the ‘iron law of political oligarchy’; “They started out idealistic and democratic but eventually became dominated by a self serving group of people, who have achieved positions of power and responsibility. They became enthralled by their elite positions and more inclined to make decisions that protected their power rather than representing the will of the group they are supposed to serve.”

Dave Hughes (INMO Deputy General Secretary) cited this wonderful piece in his “beware of those who promise new politics”. The words ring out loud and familiar despite the fading ink of 100 years ago.

Indeed, politics needs to be more selfless and more people/client focused without forgetting to care for the carers. Whoever sits in the driving seat of the healthcare carriage let’s hope they don’t live up to the iron law of 1911.

darina lane

Protecting today.Growing tomorrow.

Pfizer Healthcare Ireland, 9 Riverwalk, National Digital Park, Citywest Business Campus, Dublin 24, Ireland.

Pfizer Vaccines – helping to protect children right from the start.

PRE/2010/002

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3

Issue 5 Volume 2 september / October2009

ContentsThe Journal of the Irish Practice Nurses Association

Nursing in General Practice is published by GreenCross Publishing, 7 Adelaide Court, Adelaide Road, Dublin 2. Tel: 4189799 Fax: 4789449Email: maura@greencrosspublishing.ie

EDITORMaura Henderson

CONSuLTING EDITORSDarina Lane and Ruth Morrow

COMISSIONING EDITORJudith Leavy

DESIGNERBarbara Vasic

PuBLISHERSGraham CookeMaura Henderson

DisclaimerThe views expressed in Nursing in General Practice are not necessarily those of the publishers, editor or editorial advisory board. While the publishers, editor and editorial advisory board have taken every care with regard to accuracy of editorial and advertisement contributions, they cannot be held responsible for any errors or omissions contained.

Issue 2 Volume 4 March/April 2011

1 edITOrIAl

4 News

10 yOur AssOcIATION Needs yOu Benefits of IPNA membership

12 Q ANd A IPNA chair Orla loftus-Moran

14 BrANcH News

revIew

17 MeNTAl HeAlTH – THe deAN clINIc Alison lane

20 HeArT sMArT MAyO Ailish Houlihan

27 OsTeOPOrOsIs – MANAgeMeNT ANd TreATMeNT dr Ann Manley

33 HeAlTHcAre sTANdArds IN geNerAl PrAcTIce Kieran Murphy

38 PeANuT Allergy sally whelan

41 cOMMON sKIN cONdITIONs Michelle Mcdonagh

ABsTrAcTs

44 AsTHMA

46 cOPd

47 PrOducTs

49 crOsswOrd

*GreenCross Publishing is a recently established publishing house which is jointly owned by Graham Cooke and Maura Henderson.

© Copyright GreenCross Publishing 2011The contents of Nursing in General Practice are protected by copyright. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form by any means – electronic, mechanical or photocopy recording or otherwise – whole or in part, in any form whatsoever for advertising or promotional purposes without the prior written permission of the editor or publishers

Protecting today.Growing tomorrow.

Pfizer Healthcare Ireland, 9 Riverwalk, National Digital Park, Citywest Business Campus, Dublin 24, Ireland.

Pfizer Vaccines – helping to protect children right from the start.

PRE/2010/002

Pfizer Vaccines MI Advert.indd 1 20/09/2010 14:42:08

4

news

NEC NEWS

Dublin Branch members, Lynn Cartwright Brid Buckley, and Chinenye Onohua were among a large number of medical professionals who attended an international diabetes conference held recently at Dublin’s new Convention Centre.

Hosted by TCD School of Medicine the conference heard from among others, Professor Zhangrong Xu who outlined the shocking truth of the enormity of the problem facing China, while Dr Shailaja Kale described accelerated type two diabetes in India and told delegates of the phenomenon of the ‘thin fat Indian’ (having a body mass index of 23 but 21% body fat around vital organs).

Lisa Nolan, IPNA Administrator. Tel: 042-9692403 e-mail: admin@irishpracticenurses.ie

Nec MeeTINgs 2011Ashling Hotel, Parkgate Street, Dublin 8.Wednesday 4th May 2011Wednesday 7th September 2011Friday of Conference weekend – October 2011.

IPNA weBsITeThe IPNA website, www.irishpracticenurses.ie is updated constantly, so please log-in regularly to get the latest news on study days etc.

IPNA Awards 2011The details of the awards to be offered by the IPNA this year are being finalized at present. Information, flyers and entry forms will be circulated as soon as they are ready.

MembershipNew members are always very welcome. Information and application forms can be downloaded from the Membership page of the IPNA website. To see the full list of benefits turn to page 10.

IPNA members at diabetes conference

Healthcare planners will need to consider radical changes and redesign of patient services to achieve cost efficiencies as pressure on healthcare funding increases accord-ing to Professor Paul True-man, Professor of Health Economics and Director of Health Economics Research Group at Brunel university who spoke at the Royal College of Surgeons in Ireland (RCSI) annual Faculty of Nursing and Midwifery Confer-ence in February.

Approximately 200 nurses and midwives attended the RCSI’s 30th annual inter-national conference entitled, ‘Promoting Patient Centred Care in Times of Change – the Challenge for Nurses and Midwives’. Speakers from North America, Australia, the Middle East and across Europe gave global perspectives on the challenges cur-rently facing the nursing and midwifery professions.

Professor Trueman, who delivered the keynote address, spoke about the increasing role of Health Economics in the planning and delivery of modern healthcare and the key role that nurses have to play in evaluating new treatment pathways and meth-ods of service delivery.

“Healthcare planners will need to look beyond just managing drugs and supplies budgets to achieve efficiencies. Although high calibre patient-centred care is the goal of healthcare providers, it is critical that this patient care is cost effective,’ said Professor Trueman.

‘Health Economic research to date has had limited input from the nursing community. As the primary point of contact for many patients, nursing professionals are ideally positioned to identify potential improvements and contribute to cost effectiveness studies in service delivery,’ concluded Professor Trueman.

Patient care in times of change examined at 30th Annual Nursing and Midwifery Conference

Ms edna woolhead, vice-dean of the Board of Faculty Nursing and Midwifery; Professor seamus cowman, Head of department, Faculty of Nusing and Midwifery; Professor eilis Mcgovern, President of rcsI; Ms Marie Keane, deputy ceO, Beaumont Hospital, who was awarded an Honorary Fellowship; and dr Áine colgan, dean of the Faculty of Nursing & Midwifery.

5

news

A call for greater awareness of glaucoma in Ireland was launched during World Glaucoma week 6th – 12th March 2011, as the preva-lence of the eye conditions in Ireland is expected to rise with the number of older people increasing and those with a family history are at a greater risk. The National Council for the Blind of Ireland has partnered with the Association of Optometrists Ireland, Irish College of Ophthalmologists and Pfizer Healthcare Ireland to raise greater awareness of glaucoma during World Glaucoma Week

Since vision loss is permanent, glaucoma needs to be diagnosed and appropriately treated as early as possible to prevent further damage. World Glaucoma Week aims to highlight the importance of regular eye exams and the growing impact of glaucoma on families and society.

This year’s title theme was ‘Don’t lose sight of your family’ was chosen to remind patients under treatment to tell their blood relatives to be tested for glaucoma regularly as family members have an increased risk of developing glaucoma themselves. If a parent has glaucoma, the risk of developing glaucoma is increased 5 times. If a sibling has glaucoma, the risk is increased 9 fold.

Studies have shown that glaucoma is becoming increasingly more common in older people and, with the number of people aged over 65 in Ireland predicted to increase by almost two fifths by 2016, and to treble by 2041, it is vital that these are caught early.

“Lynda Mc Givney Nolan AOI spokesperson, “The Association of Optometrists urge members of the public to attend their local independent optometrist for this free glaucoma test which our members offer every year. The test is quick and painless and could save your sight. ”

For more information on Glaucoma Awareness please contact NCBI on 1850 33 43 53, www.ncbi.ie

First HeTAc validated certificate in diabetes Nursing A group of 33 nurses recently completed a Higher Education and Training Awards Council (HETAC) validated, Certificate in Diabetes Nursing. The five day stand-alone module was delivered by the Regional Centre for Nursing and Midwifery Education (RCNME) at Connolly Hospital, Blanchardstown.

The RCNME was recently approved by HETAC as a registered provider of educational programmes. The Certificate in Diabetes Nursing is a level 8 award on the National Framework of Qualifica-tions, and is the first of such modules to be delivered nationally. It was designed to support nurses working in a variety of care set-tings as they face the major challenges posed by Diabetes Mellitus (DM), a chronic disease.

The National Cancer Control Programme (NCCP) – in partnership with the HSE Office of the Director of Nursing and Midwifery Serv-ices – launched a new Community Nurse Education Programme for Primary Care Nurses at Cork university Hospital in January.

Forty eight nurses from Cork and Kerry commenced a four week course with those involved including Practice Nurses (those nurses who work in GP practices) Public Health Nurses and regis-tered general nurses.

This education programme aimed to provide the nurses with enhanced knowledge and skills to carry out their role in promot-ing health, reducing cancer incidence, integrating cancer care and improving cancer survival among the people they see and treat.

The programme consisted of four modules which took place over four consecutive weeks. Focusing primarily on the most common cancers, it featured modules on breast disease, lung cancer, skin cancer and prostate cancer. The inaugural lectures will commence in Cork university Hospital this Thursday January 13th.

The NCCP will offer the same course to nurses through the des-ignated cancer centres in Galway and Dublin, with further plans to roll it out nationally in all eight designated cancer centres over the coming months.

According to Dr Marie Laffoy, Community Oncology Advisor with the NCCP: “Cancer is becoming increasingly common. By

the age of 75 one in three men and one in four women will have developed cancer. Primary care nurses are making an important contribution in preventing and treating illness as well as support-ing people to care for themselves and their families. This course aims to support them.”

Dr Laffoy explained that the “programme was developed following research carried out directly with primary care nurses. The nurses identified a need for additional education in cancer for the primary care service. In particular they identified the need for better communication and joint approach to managing the patient between the cancer centre and the community/primary care setting.

“The nurses also looked for greater integration with the centres and greater awareness around developments such as the NCCP GP referral guidelines which we now use to standardise how pa-tients are referred into the designated cancer centres. They also looked for information around general developments nationally and internationally on cancer care and we are obviously provid-ing this.”

While much of the course is treatment based, much focus is also on prevention – ensuring that the patients they see generally are made aware of the value of protecting their own health to ensure that they know that cancer is a very preventable disease. community and the integration between the designated cancer centres and the localised services.

Don’t lose sight of your family

The group who participated in the certificate in diabetes Nursing.

New cancer education programme for primary care nurses in Cork and Kerry

6

newscork university Hospital Nurse and Midwife graduation ceremonyThe graduation ceremony for 86 nursing and midwifery students from Cork university Hospital (CuH) took place on the 4th March 2011. The graduates had completed a four year BSc in General Nursing, BSc in Midwifery or BSc in Childrens & General Nursing (Integrated).

Niamh Fenton rcN, rgN from Midleton, grainne Heffernan rcN, rgN from Tipperary and June Twomey rcN, rgN from lisgoold.

Patricia sheehan rgB from limerick and Miriam langan rgN, rcN from limerick.

Alice cliffe rgN from lismore, student of the year, with Amanda daly rgN from Midleton, elmarie deady rgN from Banteer and Patricia sheahan rgN from limerick.

Midwives Margaret sexton Fitzpatrick from clonakilty, rosie sands from clonakilty, Orlaith Murphy from Bandon and Patricia lane from Mallow.

Orna griffin rgN, rcN from Tralee, gail condon rgN, rcN from Model Farm road and Mairead creagh from limerick.

eilish ryan rgN from limerick, Martina crowley rgN from waterfall and sheila O’connor castleisland co Kerry.

Michelle greally rgN from Fermoy and Aoife shinnick rgN from glanworth.

Midwives claire donovan from rochestown, caroline Nolan from Blackrock and Paula crowley from castletownbere.

Oral dosingsyringe

provided

A4 BabyD:Layout 1 21/1/11 16:37 Page 1

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news30th Annual International Nursing and Midwifery conference Approximately 200 nurses and midwives attended the RCSI’s 30th annual international conference entitled, ‘Promoting Patient Centred Care in Times of Change – the Challenge for Nurses and Midwives’ which took place on 23rd and 24th February 2011. Speakers from North America, Australia, The Middle East and across Europe gave global perspectives on the challenges currently facing the nursing and midwifery professions.

Kimberly Magee, longmont united Hospital, Nora scott, The children’s Hospital, Kirtley ceballos, university of colorado Hospital, susan Moran, The children’s Hospital, all from colorado, usA.

Morag Mitchell, grampian NHs, dr Patricia grocott, Kings college london, eunice chisholm, grampian NHs.

chris Huet, Mary cahill and Maeve O’dwyer.

sheila dickson President, INMO, Marie Keane, deputy ceO, Beaumont Hospital, and Annette Kennedy.

Fiona Markey, Alice griffin, Marie Kelly, Bernie Kerin,

Marie Keane, sheila Mcguinness, Mary Kelly,

Mary Heywood Jones and Bernie lynch.

catherine O’Neill, rcsI, Josephine leydon and catherine clune Mulvaney, rcsI.

Free resources onL. casei Shirota

For over 75 years, Lactobacillus casei Shirota (LcS) has been the focus of considerable research, resulting in a broad range of publications on human and mechanistic studies relevant to a range of health conditions.

From topics such as care of the elderly, to immune function or gut-related infections, it’s easy to fi nd information relevant to you.

This new resource is available online and can be found at the Yakult healthcare professional website www.yakult.ie/hcp. The website will be continually updated with new topics and new LcS research as soon as they are published.

science@yakult.ie+353 (0)1 804 7695www.yakult.ie/hcp

A useful easy-to-search resource is now available for healthcare professionals that translates the sometimes complex research

papers on Lactobacillus casei Shirota, the probiotic strain of bacteria found in Yakult, into a more concise and accessible format.

10

• Invitation to each monthly educational meeting of your local branch, which will include a speaker who has been carefully chosen by the branch committee to talk about a subject that is relevant to Practice Nursing in your area and update you on the latest guidelines / best practice.

• Invitation to the annual IPNA Educational Conference/AGM. All aspects of the conference, i.e. theme, speakers, clinical workshops, poster display area, research presentations, awards and exhibitors are specifically relevant to Practice Nurses.

• Free delivery of Nursing in General Practice, the official Journal of the Irish Practice Nurses Association, which includes clinical articles, research abstracts and relevant news.

• Free IPNA Resource Pack and Personal Portfolio – to assist you with maintaining records of your Continuing Professional Development.

• Opportunity to enter the various IPNA Educational Awards, including the “Practice Nurse of the Year” award, “IPNA Educational Bursary”, “IPNA Clinical Award”, “Valerie Mangan IPNA Loyalty Award”, and “IPNA Branch Poster” award.

• Exclusive access to the members’ area of the IPNA Website

(www.irishpracticenurses.ie ), which includes upcoming events and study days, educational programmes, Grants and Awards, research abstracts, publications, speakers’ presentations from IPNA Conferences, Discussion Boards, lists of potential sponsors & speakers for branch educational meetings, recommendations of good speakers from other members, updated pages for the Professional Development Portfolio, and other relevant documents.

• The option to receive e-mail and/or text messages about relevant issues, education, study days, etc.

• The option to receive information by post from sources outside the IPNA regarding relevant study days, courses, products etc.

• Special offers from companies, e.g. uniforms, educational books, etc.

• Some practical assistance is available to members who need to source mailing lists for the purposes of carrying out research that is relevant to Practice Nursing.

• Invaluable contact with other Practice Nurses in your area. The chance to network, share information, learn from more experienced Practice Nurses and the general peer support provided by colleagues is often cited by members as one of the most beneficial aspects of IPNA membership.

Benefits of IPNA membership

As one of the ‘Grannies’ of the IPNA, the Association has always provided excellent clinical and professional support and encouragement to grow as a Practice Nurse. Every meeting or conference you attend gives more ideas and you arrive back to the practice brimming with plans. Some developed brilliantly and some get lost in the list of appointments waiting. The most important value of being a member is belonging to a fantastic group of forward thinking determined professionals who support each other through good times and often the bad times. Some of my closest friendships have been formed through the IPNA. To keep these ideas fresh we need plenty of new blood. Come on the youngsters!

IPNA Member (East Coast)

I have found the text alerts re education … invaluable. I would never hear about these things without being a member of the IPNA. Meetings are a nice opportunity to meet other nurses and to compare the different roles we play within various

practices because as we know every place of work is different!!

IPNA member (Cork)

I joined the IPNA Louth Meath group 3 years ago when I was new to practice nursing. The support I received from networking with other practice nurses was invaluable. I have remained an active member since and look forward to our meetings which are always interesting, educational and benefit me greatly. The regular emails keep me updated to new changes in practice and new courses available to attend. I would feel very isolated as a practice nurse without the IPNA.

IPNA member (Louth/Meath)

“The IPNA is a terrific resource for new practice nurses and for those not so new. It assists me in my professional development through regular educational meetings and the email alerts keep me up to date with what’s going on. The association is invaluable in terms of peer support and

friendship as many PNs work in isolation”IPNA member (North East)

After 15yrs membership I am still attending meetings and learning all the time. Peer support and excellent clinical up-dates helped me to establish and maintain my role. Any isolation in practice that I felt initially was soon alleviated by shared experiences, depth of knowledge and generosity of spirit that was shown by all members. IPNA membership continues to be a positive and enriching experience for me.

IPNA member (North East)

As practice nurses, we often work alone amongst a team of other professionals. It is great to have the support of an organisation that is always there for advice and help. The Cork branch has been amazing and really enhances my enjoyment of the job. The journal is useful, the meetings are also useful and the clinical days the Cork branch have organised have been fantastic.

IPNA Member (Cork)

Here are just some of the many benefits of membership of the IPNA

recommendations from existing members:

It was membership renewal time recently. Some of you may have forgotten to renew your subscription so here is a list of the many benefits of IPNA membership.

11

news

The Dublin Neurological Institute at The Mater Misericordiae uni-versity Hospital recently opened its latest facility. The new patient information drop in centre marks a significant milestone in the completion of the original vision of the Institute’s founders, who sought to create a centre of excellence, whereby a multi-discipli-nary, high-quality and compassionate service would be provided to all patients’ public and private, suffering from neurological conditions throughout Ireland.

The Patient Drop-In Information Centre based in 57 Eccles Street, Dublin 7, offers a unique service whereby patients, family members and carers of those with a neurological condition can avail of this free-of-charge information facility. The centre will have all of the information and literature available so that people can educate themselves about neurological conditions. There will also be volunteers on hand to help patients to find out what services are available to them and also, nurses will be available to answer any questions people may have, which they might not necessarily have access to otherwise.

The Dublin Neurological Institute, funded by The Mater Neuro-logical Appeal and the HSE, opened in September 2008 providing a centre of information and treatment for people with neurologi-cal conditions. The facility is unique in Ireland and is designed to provide a comfortable and informal setting where all patients suf-fering from neurological conditions and their families can access information of services, counseling and gain informal support and arrange to speak to a nurse specialist. Additional complimentary services include relaxation classes with a specialist nurse to teach neurology patients the valuable skills of relaxation techniques, plus acupuncture sessions with a specialist nurse, which has been effec-tively used for the treatment of many neurological conditions.

For further information please contact The Dublin Neurological Institute, 57 Eccles Street, Dublin 7 on 01 8545038 or check out www.neurologicalinstitute.ie

dublin Neurological Institute’s patient drop-in information centre launched

Attending the eccO conference in dublin recently were Ms Maree gorman (Msd), Ms denise Keegan, Ms Nuala godwin, Ms Mary Forry and Mr Paul Kerins (Msd).

sixth congress of european crohn’s and colitis Organisation

Oestrogen-free1 Cerazette for a star performance

Primarily Inhibits

Ovulation 1

Oestrogen-FREE 1Pregnancy Protection

Comparable to a COC 1

...when Oestrogen isn’t right 1

75µg desogestrel

Cerazette® 75 microgram film-coated tablets Desogestrel AbbreviAted PresCribing informAtion (refer to summary of Product Characteristics before prescribing) PresentAtion: One sachet containing 1 strip of 28 tablets, each tablet containing 75mcg desogestrel. Uses: Contraception. dosAge: One tablet daily at about the same time. There is no pill-free week between strips. ContrAindiCAtions: Known or suspected pregnancy, active venous thromboembolic disorder, presence or history of severe hepatic disease with current abnormal liver function tests, known or suspected sex-steroid sensitive malignancies, undiagnosed vaginal bleeding, hypersensitivity to any ingredients. PreCAUtions And WArnings: Women currently using combined oral contraceptives (COCs) have a slightly increased risk of having breast cancer diagnosed. The risk in users of progestogen only pills is possibly of similar magnitude to COCs. This risk is low compared to the risk of getting breast cancer ever in life. The increased risk in COC users may be due to an earlier diagnosis, biological effects of the pill, or a combination of both. Refer to a specialist if acute or ch ronic disturbances of liver function occur. Epidemiological studies have associated the use of COCs with an increased incidence of venous thromboembolism (VTE, deep venous thrombosis and pulmonary embolism). It is unclear whether desogestrel used alone carries the same risk. Discontinue in the event of a thrombosis. Consider stopping prior to long term immobilisation due to surgery or illness. Caution patients with a history of thromboembolic disorders. Consider discontinuation if hypertension develops. Benefit/risk assessment should be made in women with liver cancer. Monitor patients with diabetes during the first months of use. Effects on bone density are unknown. Despite the fact that Cerazette consistently inhibits ovulation, ectopic pregnancy should be taken into account in the differential diagnosis if the woman gets amenorrhoea or abdominal pain. Chloasma may occasionally occur. Cerazette contains less than 65mg lactose, and therefore should not be administered to patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency, or glucose-galactose malabsorption. Use in PregnAnCY And LACtAtion: Not recommended during pregnancy. Cerazette does not influence the production or quality of breast milk. Small amounts of the metabolite etonogestrel are excreted with the milk. Limited long term follow-up data (up to 2.5 yrs) on children who were breast-fed do not indicate any differences compared to those whose mother used a copper IUD. However development and growth of the nursing infant should be carefully observed. interACtions: Interactions may lead to breakthrough bleeding and contraceptive failure. This may be seen with enzyme inducers such as hydantoins, barbiturates, primidone, carbamazepine, rifampicin, oxcarbazepine, topiramate, rifabutin, felbamate, ritonavir, nelfinavir, griseofulvin and products containing St John’s Wort. Reduced absorption of etonogestrel may be seen with medical charcoal. Hormonal contraceptives may interfere with metabolism of other drugs, and therefore increase or decrease their plasma or tissue concentrations. Adverse reACtions: Refer to SmPC for full details. Common: irregular bleeding, amenorrhoea, headache, weight gain, breast pain, nausea, acne, mood changes, decreased libido. Breast discharge may also occur. Other less common and rarely reported side effects are listed on the SmPC. overdose: No serious effects have been reported. Symptoms may include nausea, vomiting and in young girls, slight vaginal bleeding. Treatment should be symptomatic.Legal Category: Prescription Only Medicine. Product Licence number: PA 61/27/1 Product Licence Holder: Organon (Ireland) Limited, P.O. Box 2857, Drynam Road, Swords, Co. Dublin, Ireland further information is Available from: Schering-Plough Ltd, Shire Park, Welwyn Garden City, Hertfordshire, AL7 1TW, UK. Telephone +44 (0) 1707 363636 Please refer to the full smPC text before prescribing this product. Adverse events should be reported. reporting forms and information can be found at www.imb.ie Adverse events with this product should also be reported to schering-Plough drug safety department on +44 (0) 1707 363773. date of revision of Prescribing information: July 2009 Cerazette/API/1RL/07-09/1Reference 1. Cerazette Summary of Product Characteristics.

Date of preparation: September 2010

09-1

1-CE

R-20

10-IR

L-35

57-J

Pelham House, South County Business Park, Leopardstown, Dublin 18, Ireland.

2823_CZT_297x105_AD.indd 1 13/10/2010 14:51:51

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Q&A

so what’s the best thing about living in Mayo?The best thing about living in Mayo is the people. From my experience there is something special about Mayo people, they are good humored and gentle, with a strong sense of meitheal. I have great affection for my native county, it is one of the most beautiful, varied and peaceful parts of the country. Mhaigh Eo Abú!

what’s the downside?It rains a lot!

who’s your hero?Barack Obama; I think he conducts the office of president of the united States with great dignity and compassion. I particularly admire his tenacity and diplomacy in bringing the healthcare reform bill through to enactment into law this year.Ben Goldacre; Science writer, Doctor and Psychiatrist. Ben is a staunch critic of scientific inaccuracy, health scares, pseudoscience and quackery. A man after my own heart!Check him out at http://www.badscience.net/.

Nursing hero?I think all nurses are the unsung heroes on the frontline of health services. Do you know that Nurses consistently rank at the top of the Gallup Poll of the Honesty and Ethical Standards

Orla was elected National Chairperson of the IPNA in November 2008, after 18 months in the role of National Vice-Chairperson. Orla has been a Practice Nurse since 1997. She completed her Masters of Science in Women’s Health in the

RCSI in 2004 and was accredited as CNS in 2005. She won the 2007 IPNA Educational Bursary for her studies on, The Role of Practice Nurses during Clinical Encounters with Patients Requesting First Time Contraception in the Western Health Board.

Orla has worked as Course Tutor with the ICGP Cervical Screening Theory Course and represented IPNA as a member of the National Cancer Screening Service Primary Care Quality Assurance Subgroup for Cervical Screening. She is the Practice Nurse Rep on the Mayo Primary Care Implementation Steering group and Chairperson of her local Primary Care Team. Orla is a member of the Crystal Clear Health Literacy and Astellas Changing Tomorrow Awards judging panels.

Her special clinical area of interest is Women’s Health. Orla is a keen advocate of the “practice what I preach about healthy lifestyles” philosophy – putting this into practice by regular walking, running and cheering for Mayo at GAA fixtures! Her proudest moment this summer was running the Achill half marathon for the second year in a row.

Orla loftus-Moranchairperson, IPNA

13

Q&A

of Professions? This is because the nursing role is to be with patients, often working in difficult circumstances, trying to get the most from complex and ever changing treatments and adapting to changing technology. Nurses on a daily basis explain difficult diagnosis, answer the unasked questions, perceive unspoken fears and are at all times advocates for their patients. We are often so busy doing what we do that we don’t reflect on the impact we make on patients lives. who’s a villain?H1N1, Antibiotic Resistant Bacteria!

when did you decide to become a nurse?I knew I wanted to be a nurse since I was a little girl, my dad was a doctor at the local district hospital and at the weekend I would go into the hospital and wait while he did his rounds. I would watch the nursing staff in awe; they seemed so confident, kind and assured in caring for their patients. I admired them so much and realized that the work nurses did was valuable and special. So I thought I would give it a go and here I am.

where did you train?university College Hospital Galway.

what’s the best thing about practice nursing?Working in general practice is unique and special because you meet and work with patients in their own locality. Patients are often surprised and grateful for the services we provide locally such as warfarin clinics and venesection for haemochromatosis. I often feel that general practice is a cross between an outpatient’s clinic and an A&E. You never know what a day’s work will bring and I enjoy that diversity. Patient teaching; disease prevention and management is typically a large part of my work. Helping people see that small changes in their lifestyles can make a big difference to their health, is very rewarding. Currently there is eight staff (administration and healthcare professionals) working in our surgery. The ethos of mutual respect and teamwork is very strong amongst us, so we are a tight group and I enjoy being part of this team immensely.

Nurse prescribing, is it what you expected?I knew it would be tough, there is so much packed into a few months, and I suppose I expected that. But I feel nothing can really prepare you for anything until you get into the thick of it yourself. Overall I have found the course very worthwhile and have learned lots. I would recommend it to anyone who is thinking about doing it but would advise shopping around between the various colleges in relation to costs (there are differences). I have to say a big thanks to my boss Dr Diarmuid Murray for supporting me in this endeavor!

do you work on your own or part of a nursing team?I job share with my fantastic colleague Maura Gannon CNS, we work very closely together. She is a great support to me and we liaise on a daily basis in relation to issues which may arise at work (this is regardless of which of us is on duty at the time!) Of course in the wider context we are part of a primary care team and work closely with our colleagues in Public Health Nursing.

In 2007 you won the IPNA educational bursary, congratulations. what would you say to other practice nurses to encourage them to apply for the bursary?Just do it! So many PNs are doing good work on courses or within their work settings and we need to hear about it. The process of applying is not difficult and well worth the effort.

what would you change in your job if money, time and red tape were not factors?I would fill the surgery with the most cutting edge and up-to-date diagnostic equipment, and be able to enhance the range of services we offer to our patients (for example ultrasound and x-ray). I think chronic disease management and prevention services should be funded and based in General Practice.

you said at last conference that you will be stepping down as chair in October. Have you any messages for your future successor?I would tell her/him to keep the primary aims of our association to the forefront of their mind. Remember it is the members we serve and it is vitally important to encourage and support them. PNs, both professionally and personally are facing difficult times. The IPNA needs to be a strong, vocal association working with government agencies and allied professional bodies to ensure that PN interests and needs are addressed, making certain that the valuable role the PN plays in the provision of health services is recognized and supported. Also enjoy the time as Chairperson, the IPNA is a great organization and it is a great privilege to be involved at this level.

what comes next for Orla loftus-Moran?I have always found that one thing leads to another so who knows what the future will bring. I hope to reacquaint myself with my family! They are so patient with me and my ‘projects’. My colleague Maura has been such a support that I would like to think I will pull my weight a bit more and take the pressure off her!

Academic Associate

Diploma

email: info@viktorfranklinstitute.ie web: www.viktorfranklinstitute.ie

Now accepting applications for its part-time professional training programme, 2011/2012

in Logotherapy

One-Year Course. Sept-May, once weekly.

or

Intensive Summer Course. May-Sept, twice weekly.

in Logotherapy

Further one-year practitioner's Diploma. Sept-May, once weekly.

LocationLectures take place at the Jesuit Conference Centre, Milltown Park,Sandford Rd., Dublin 6

14

NEWS FOR IPNA BR ANCHES COuNTRY WIDEregional news

cAvAN/MONAgHAN PATRICIA JENKINS

We have enjoyed excellent attendances at our regional practice nurse meetings over the winter with very interesting topics and speakers.

In January, CNS Maeve Hyland, Tissue Viability Nurse for Cavan Hospital, gave us a very practical and interesting talk on wound care. She looked at the appropriate use of dressings and the do’s and don’t’s of silver and iodine type dressings. She also emphasised the importance of wound assessment and documentation. Stephen Ruane from Smith & Nephew kindly sponsored our meeting.

In February CNS Aileen Doyle, lactation nurse in Cavan Hospital, gave us a welcome insight into the many benefits of breastfeeding for mother and baby. We were shocked that Ireland has one of the worst breastfeeding rates in the world. In the uK and central Europe 76 – 98% of women breastfeed with Ireland trailing behind at 43%. Our meeting was kindly sponsored by Aptamil.

The meeting and meal in March will be sponsored by ultan Kenny from Servier Laboratories and the topic is osteoporosis and Protelos. In May, Abina O’Flynn from MSD is sponsoring our talk when Declan Campbell, Podiatrist will give us an update on assessment of the diabetic foot.

The INMO provided nurses with a welcome update on legal issues in a general practice. This day proved very popular in the past. Our next IPNA AGM will be in Tullamore Court Hotel, on 14th & 15th October. Tipperary South Branch is hosting the AGM and they

aim to promote new membership. Ruth Morrow, ANP and Prescriber, was presented with a gift as a token of our appreciation for her contribution to Cavan/

Monaghan branch while she was employed as PDC. Ruth continues to make a significant difference to our branch and is an inspiration to us all. We count ourselves very fortunate to have her as a member of the Cavan/Monaghan branch.

And lastly, the members of Cavan/Monaghan branch would like to extend our sympathy to Pascaline Hunt and her family on the untimely death of her husband John. May he rest in peace.

clAreAINE LALLY

Our first meeting of the new year got off to a good start and we were delighted with such a great turn-out of nurses. As usual it was held in the Old Ground in Ennis. At first we addressed the results of a questionnaire, kindly carried out by Anne Akamnonu, chairperson of the Clare branch. The questionnaire was to help identify Clare practice nurses’s needs and wants in relation to our monthly meetings.

We then had a most informative and helpful CPR refresher course given by Donal Twomey from Elite Ambulance Ltd in Cork. It was an excellent refresher course and we all agreed we could do with this course at least yearly in order to be fully prepared for any such emergencies in the GP surgery. It was very kindly sponsored by Declan Brouder from Eli Lily.

For our February meeting we were delighted to have a presentation by Ina Crowley, Project Officer, NMPDu, HSE West and former professional development co-ordinator for practice nurses. Ina gave a very enlightening overview and briefing on the ‘Nurse and Midwifery Prescribing Initiative’. Limerick will be added to the current list of venues for the nurse prescribers course for 2011.

This presentation was complemented by a great insight from Mary Kelly into the ‘day to day life’ of a practice nurse prescriber and how it enhances her role in holistic patient care. Mary currently works with Dr Conor Hanrahan in Ennis and has recently completed the nurse prescribers course. The members of the Clare branch would like to congratulate Mary on her wonderful achievement which required a lot of effort, organisation and personal dedication.

cOrK BrANcHELAINE GOGGIN

The Cork branch got back to business in February after our Christmas break. The meeting was very kindly sponsored by Sarah Hyde from McNeil Healthcare.

Our guest speaker was Joan O’Sullivan, Smoking Cessation Officer with the HSE South who gave a wonderful talk on motivational interviewing and techniques that we as practice nurses can use in our daily practice, not just with regard to smoking cessation but also how we can implement them in other areas e.g. diabetic care, weight loss etc.

Our March meeting is on Wednesday 9th in our usual venue of Rochestown Park Hotel. Our sponsor is Claire Forde from Pfizer Healthcare Ireland and the topic will be based on respiratory problems. Our committee has also arranged a study day for our members on Saturday 12th March on breastfeeding. This will be a practical workshop by Lorraine O’Hagan who is a very experienced lactation nurse specialist who works in National Maternity Hospital, Dublin.

Finally the NEC Officers are visiting our branch for our March meeting. We are looking forward to it and hopefully it will prove to be a very positive initiative for all involved.

15

NEWS FOR IPNA BR ANCHES COuNTRY WIDE regional news

KerryANNE EDWARDS

The Kerry branch apologies for not writing any news until now. This was down to a few teething problems encountered by myself as the new Kerry branch chairperson. So from now on it will be forward all the way.

Our January meeting was not sponsored by any drug company. It was held in the Recovery Haven, Tralee. This is a house that is used to facilitate cancer patients and their families as a support and a drop-in centre. It offers services such as a listening ear, massage therapy, relaxation and much more. Our speaker was Marion Barnes. She gave us a very informative talk and a tour of the building. So thanks again to her for the very tasty finger food and wine supplied on the night.

Our February meeting was held in the Carlton Hotel Tralee and was sponsored by Ingrid Deutrom of Kora Health Care. Our speaker was Teresa Bennett, Health Promotion Officer, HSE who gave us a very informative talk on the implementation policy of vitamin D for all babies from 0–12 months. We also had a talk from Freda Horan the community dietitian. The meeting was well attended. Our next meeting is on Wednesday 16th March.

MIdlANdsSIOBHAN RuANE

Let me start by saying that the Midland practise nurses would like to extend our deepest sympathy to our branch member, Pascaline Hunt, Kilcormack, on the sudden death of her husband Dr John Hunt. Our thoughts and prayers are with you and we hope to see you soon at our branch meetings.

Our January meeting was sponsored by Pamela O’Regan, MSD and the topic was diabetic foot/podiatry. The meeting was held in the Tullamore Court Hotel. Many thanks to Pamela.

Thanks to all who attended our February meeting, which was also held in the Tullamore Court Hotel. Thanks to our sponsor, Niamh Carol, MSD. The topic for the evening was on contraception which was given by Dr Deirdre Lundy, GP from Bray. The talk was very interesting and informative.

Our March meeting followed closely thereafter. Teva Pharma gave us a brief informative talk on the use and cost effectiveness of the Easi breathe inhaler. Thanks to all our sponsors.

NOrTH duBlINLIZ HEALY

Our February meeting at Hilton Hotel, Northern Cross, Dublin, was a huge success with nearly a 100% attendance! Our guest speaker, from the GI unit, Mater Hospital, gave a very interesting and informative talk on haemochromatosis, a condition that we are coming across more and more. I would like to thank Boehringer-Ingelheim for sponsoring the meeting.

I would also like to welcome the new members to the North Dublin branch of the IPNA. Our next meeting will be on 24th March – vitamin D and immunisation.

wexFOrdJuNE D’ARCY

Greetings from the south-east, hope this finds all members well, and looking forward to spring like conditions. We have had some very informative speakers recently, covering topics such as osteoporosis, travel vaccines and cardiovascular health in women. Our thanks to all our speakers and sponsors who have given their time and expertise to what was sometimes a very small attendance. However, we will continue to try and provide varied and relevant topics, to entice our members to come along to the meetings. We know how hard it can be, to leave your home after a hard days work, but we do encourage and appreciate your attendance.

We had our AGM in November; Monica Dowling and June D’Arcy will continue as treasurer and secretary respectively, and Catherine Enright is our new chairperson. A very big thanks to Dorothy Patel for her outstanding contribution as chairperson. Socially; we had our Xmas night out on Friday 14th January, it was a most enjoyable night, and our thanks to Deirdre Potter, Roche Diabetes, for sponsoring the night. Our next meeting is on 9th March, and the topic is hypertension and renal disease. Enjoy the season of new beginnings, brighter evenings, and warmer days.

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17

mental health series

The purpose of this article is to inform readers about the Dean Clinic, located at Mahon, Cork. It is a new exciting eommunity-based mental health clinic. To place it in context, I will first give some background detail, as the Clinic is a service of St Patrick’s

university Hospital in Dublin.

IntroductionSt Patrick’s Hospital was founded as a result of a bequest of Jonathan Swift, Dean of St Patrick’s Cathedral. More than 250 years ago he recognised the need to establish proper care, treatment and protection for sufferers of mental illness.

“He gave what little Wealth he had, To Build a house for Fools and Mad: And Shew’d by one satiric touch, No Nation wanted it so much”

Jonathan swift, founder of st Patrick’s Hospital

Today, St Patrick’s university Hospital is driven by that same combination of vision, energy and the will to provide the best and most effective treatments and services and promote and protect the rights of everyone who suffers from mental illness.

St Patrick’s is person-centred in its focus, striving to understand and meet the needs of people with mental health issues. We are keenly aware of our not-for-profit status and philanthropic purpose. The hospital is guided by the principles of its founder, Dean Swift, the values of the Mental Health Act 2001, the European Charter for Human Rights and the united Nations Principles for the protection of persons with mental illness and the improvement of mental health care. The hospital

is committed to the principles of the Government’s policy ‘Vision for Change’ and to meeting all of the Mental Health Commissions regulations and standards.

As a result, a strategy called ‘Mental Health Matters’ was developed and one of the main priorities was to increase access for people to mental health care within their own community. Five community mental health centres have been established to date: four in Dublin (Lucan, Donaghmede, Capel St and Glasnevin) and one in Cork. The Dean Clinic in Cork is the first regional centre with another due to open in Galway later this year.

dean clinic corkThe service is designed to meet the mental health needs of the community within a multi-disciplinary setting. The multi-disciplinary team is comprised of a Consultant Psychiatrist, Dr Treasa O’Sullivan, RGN, RPN, Counsellor and Psychotherapist,

St Patrick's Dean Clinic Network

Mental Health MattersAlIsON lANe RGN, RPN, DIP ADDICTION STuDIES (MIAAAC) MSC PSYCHOTHERAPY, DEAN CLINIC, CORK

This is the first in a series of articles on mental health by Alison lane. The first article is an introduction to a new service provided by the Dean Clinic, Cork.

18

mental health series

Alison Lane, and a Cognitive-Behaviour Therapist, Rita Nagle.The multi-disciplinary team operates on ‘recovery principles’

(hope, personal responsibility, education, self-advocacy and support) thus ensuring the experience of the service is one of empowerment, hope and recovery. The Dean Clinic is very committed to working closely with GPs and Practice Nurses, recognising the central role that the primary care team plays in delivering mental health care. Once a referral is made, we liaise regularly with the referring agent (either the GP or Practice Nurse) by telephone conversations and letter, regarding the development and progress of the client. It is often through this close liaison that meaningful insights develop and above all the client receives the highest quality of care.

The aim is to provide high quality mental health assessment and treatment for people over the age of 18. A wide range of mental health problems are catered for, including depression, anxiety, eating disorders, bipolar mood disorder, addiction and stress related disorders.

referral pathwayA referral is made through the GP and the clinic operates on an appointment only basis. Referral forms can be downloaded from the hospital website www.stpatrickshosp.ie. Alternatively the central referral line can be contacted on (01)2493535. All referrals go through a central pathway. An additional letter attached to the referral form with extra information is always helpful in preparing to meet the new client.

Once the referral is received, it is triaged and an appointment is sent to the client within a few days. There is a ‘bundled care’ package with a defined care plan. This means the initial assessment (1 and ½ hours) is free of charge. Some aftercare/follow-up sessions are also free of charge if in-patient treatment is required. All other therapies and consultant reviews cost €150.

Initial assessmentA detailed mental health assessment will take place with one of the members of the MDT. A full background history is taken and a collateral history from a family member if available. Information is sought on presenting problems and relevant history, risk events history, medication use (current and previous), family history, childhood history, educational background, previous and current occupations, marital history, including children, alcohol/drug use, social circumstances, finances and debt, pre-morbid personality and mental state examination.

Following this thorough initial assessment, a range of treatment options will be considered. These include ongoing mood review, medication review, general counseling, addiction counseling, psychotherapy, cognitive-behaviour therapy (CBT) and therapeutic groups. (The therapeutic groups facilitated to date are wellness groups, depression groups and mindfulness groups. There are plans to expand this range in due course).

In collaboration with the client, the multi-disciplinary team prepares an individual care plan which usually incorporates one or more of these options. The Dean Clinic, Cork also has the full support range of day and in-patient specialist services on the campus of St Patrick’s and St Edmundsbury Hospital, if required. Therefore if admission is required, it can be facilitated without undue delay.

For further information on this or any aspect of the Dean Clinic Cork, please contact Angela or Angie on 01 6477733, email admindeancork@stpatsmail.com or www.stpatrickshosp.ie

Mental health seriesup coming articles in this series will address depression, bipolar mood disorder and dual diagnosis.

* Danone Actimel is a probiotic food containing the exclusive probiotic culture Lactobacillus casei DN 114 001. Danone Actimel helps strengthen the natural defences when consumed daily as part of a healthy diet & lifestyle.

1 McFarland LV. Diarrhoea associated with antibiotic use. BMJ 2007; 335: 54-55 doi: 10.1136/bmj.39255.829120.47.2 Parkes GC, Sanderson JD and Whelan K. The mechanism and effi cacy of probiotics in the prevention of Clostridium diffi cile-associated

diarrhoea. Lancet Infect Dis 2009, 9: 237-244.3 Barbut F and Petit JG. Epidemiology of Clostridium diffi cile-associated infections. Clin Microbiol Infect 2001; 7: 404-410.4 Hickson M, Muthu N, Rogers TR, Want S, Rajkumar C, Bulpitt CJ. Use of probiotic lactobacillus preparation to prevent diarrhoea associated with antibiotics: randomised double blind placebo controlled trial. BMJ. 2007 Jul 28; 335(7612): 171.

Probiotic Support*

Antibiotic EffectsIt is well known that antibiotic intake may have an effect on the gut microfl ora leading to diarrhoea. Antibiotic Associated Diarrhoea (AAD) may develop in up to 30% of patients treated with antibiotics, and rates have been increasing due to use of broad-spectrum antibiotics1. Clostridium diffi cile Associated Diarrhoea (CDAD) accounts for up to 25% of cases of AAD, most occurring in older patients2,3.

Probiotic SupportAccording to an independent clinical trial conducted at Hammersmith hospital, London and published in the British Medical Journal, drinking Actimel twice a day while on antibiotics in hospital, signifi cantly reduces the incidence of Antibiotic Associated Diarrhoea by 22% and Clostridium diffi cile Associated Diarrhoea by 17%4 in the elderly.

For more information visit www.probioticsinpractice.ie

Diarrhoea by 17%

Antibiotic associated diarrhoea 4 C. diffi cile associated diarrhoea 4

50

10

1520253035

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e (in

day

s)

Placebo

17%-17%

0%50

10

1520253035

Actimel0

12%Tim

e (in

day

s)

Placebo

34%-22%

50

10

1520253035

Actimel0

Tim

e (in

day

s)

Placebo

17%-17%

0%50

10

1520253035

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12%Tim

e (in

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34%-22%

Incidence of Antibiotic associated diarrhoea and C. diffi cile associated diarrhoea in Actimel and Placebo Groups.

p= 0.007 p=0.001

Probiotic Support*Probiotic Support*Probiotic Support

Published in BMJ

Actimel HCP_210x297.indd 1 14/12/2010 13:30

20

healthcare programmes

Cardiovascular disease (CVD) is the single largest cause of death for both men and women in Ireland, accounting for 35% of all deaths (Central Statistics Office, 2010). Fortunately, in Ireland as in other European countries, there has been a substantial

decline in mortality rates from cardiovascular disease over recent years (Department of Health and Children, 2010). However, despite this decline death rates from cardiovascular disease remain high.

The case for preventionIt is understood that underlying atherosclerosis develops over many years and is usually advanced by the time symptoms occur. It is also accepted that the mass occurrence of cardiovascular disease relates to lifestyle and modifiable risk factors therefore signifying the importance of early detection of cardiovascular risk factors such as raised blood pressure and cholesterol. Risk factor modifications have been unequivocally shown to reduce mortality and morbidity (Bennett et al, 2006). However, recent Irish reports indicate that there is a high prevalence of cardiovascular disease risk factors among the general population (Morgan et al, 2008 and Gibson, 2008). In addition, the increase in levels of obesity and physical inactivity threaten to reverse the decline in mortality rates from cardiovascular disease in Ireland.

who should we target?Reducing the risk of recurrent disease and death among patients with established cardiovascular disease has been

a priority area for cardiovascular prevention programmes. However, the burden of this disease could be further reduced by targeting those in the community that appear healthy but are in fact at high-risk of developing cardiovascular disease because of multiple risk factors (Graham et al, 2007).

A partnership committee was established between Croí, the West of Ireland Cardiac Foundation and Mayo Primary Community and Continuing Care (PCCC), HSE West, to examine the area of cardiovascular disease prevention in Mayo. The Committee included representation from Croí, Department of Cardiology, university Hospital Galway, Mayo General Hospital, Primary Care, General Practice, Practice Nursing, Community Nutrition, Public Health Nursing, Health Promotion and Physiotherapy. To roll out the programme HSE Innovation funding was received and in January

2009, Croí in collaboration with Mayo PCCC officially launched a community-based Cardiovascular Disease Prevention Programme called ‘Heart Smart’ Mayo.

Key programme objectives• To identify and target high-risk individuals for

cardiovascular disease• To empower these individuals to take control over their

health• To adopt a multidisciplinary approach to the

implementation of ‘Heart Smart’ Mayo working with HSE primary care teams

• To increase levels of awareness of CVD risk factors among the wider community in Mayo.

AIlIsH HOulIHAN, BNS, MA (HEALTH PROMOTION) CROí HEART SMART CO-ORDINATOR. CO MAYO

In 2009 Croí, in collaboration with Mayo Primary Community and ContinuingCare, launched a community based CVD prevention programme for Co Mayo called Heart Smart Mayo. This article outlines the main findings and outcomes from that programme.

Heart smart Mayo – combatting cvd in the community

21

healthcare programmes

what is Heart smart?The Heart Smart programme was a nurse-led community based screening programme which offered a free of charge 25-minute assessment of the following:

• Cholesterol and Glucose• Blood pressure• BMI (Body Mass Index) and waist circumference• Physical activity levels• Diet

screening in actionThe three main components of the ‘Heart Smart’ cardiovascular risk assessment were as follows:

• To identify and target individuals in the community that are at high-risk of developing cardiovascular disease

• To provide a 25 minute assessment of cardiovascular disease risk factors

• To follow up all high-risk individuals at 6 months

The target population for the ‘Heart Smart’ Mayo programme included males and females over 40 years who have not had a cholesterol check in the previous 12 months with a special emphasis being placed on those from the lower socio-economic groups.

The programme, which was free of charge, provided a 25 minute assessment of cholesterol, glucose and blood pressure (BP) levels, together with body mass index, waist circumference, nutritional and physical activity assessments. The results were discussed with each participant and

lifestyle support and advice was individually tailored. Where appropriate, individuals were referred to their GP in accordance with a protocol and were followed up 6 months later for further assessment by the Heart Smart team.

results1541 individuals were assessed by the Heart Smart Mayo programme during 2009. These individuals were from various communities across Co Mayo including farming, healthcare, traveller community, and the general public. Table 1 outlines the gender, GMS status and mean age of the population.

Table 1: gender, gMs status and mean age of the population

gender Males 44% (n=678)

Females 56% (n=863)

gMs Yes 47% (n=720)

No 53% (n=821)

Age Males 57 years

Females 57 years

The Heart smart Mayo team.

22

healthcare programmes

Total ldl systolic diastolic

cholesterol Blood Pressure

30%

25%

20%

15%

10%

5%

0%

15%

12%

28%

%

23%

risk factor profileThe prevalence of risk factors was high among this population.

Total cholesterol >5mmol/l 47%LDL cholesterol >3mmol/l 40%Systolic blood pressure >140mmHg 38%Diastolic blood pressure >90mmHg 16%Physical inactivity 33%BMI>25Kg/ m² 79%Smoking 18%

79% of females were found to have a waist circumference above the recommended measurement for women (>80cm) and 77% of males had a waist circumference above the recommended measurement for men (>94cm).

referral to gPIn total, 64% of the population were referred to general practice; 7% of individuals were advised to attend within 24-48hrs for immediate review due to raised BP or raised blood glucose levels.

Cardiovascular risk of the populationThe SCORE (Systematic Coronary Risk Evaluation) system was used as a tool to estimate an individual’s risk of having a fatal cardiovascular event such as a heart attack or stroke within a 10-year period.

• 21% of the population were at high-risk (>5%)• 49% of the population had a CVD risk SCORE of between

1-4%

results at 6 months follow-upA total of 948 individuals were invited to attend for a re-assessment of their risk factors, with 748 attending, resulting in a response rate of 79%. Encouraging individuals to attend their

GP for risk factor management is a key objective of Heart Smart. This programme was successful in encouraging participants to attend their GP for review of their risk factors with a total of 61% of individuals attending their GP as advised. The majority of those who reached cholesterol and blood pressure targets had attended their GP during the six months of the programme.

Figure 1 illustrates the number of individuals who reached European target levels for cholesterol and BP at the 6-month follow-up visit. In addition, many more individuals had made improvements to their cholesterol and BP levels, despite not reaching European targets. In total 53% of the population had made reductions to their total cholesterol and 61% reduced their LDL cholesterol. Similarly 59% of individuals made improvements to their systolic BP while 69% reduced their Diastolic BP. These reductions were significant in terms of encouraging an individual to continue the lifestyle changes to further improve their cholesterol and BP levels with the ultimate aim of reducing their risk of CVD.

Furthermore, 65% of individuals made changes to their diet and 33% reported improvements to both the duration and intensity of the exercise they were taking following their attendance at the programme. Ten individuals (8%) quit smoking during the 6-month period. Six individuals (9%) were diagnosed with diabetes.

Medication treatmentThe number of people commenced on cholesterol medication during the six months of the programme increased by 5% while the number of people commenced on antihypertensive medication increased by 12%. One individual (0.2%) had their cholesterol medication dose titrated and ten individuals (2%) had their antihypertensive medication dose titrated. In addition, six individuals (9%) were commenced on oral antihyperglycaemic medication while one individual (7%) had their oral antihyperglycaemic medication dose titrated.

Figure 1: Achieving european targets for cholesterol and blood pressure

24

healthcare programmes

Impact on participantsThe programme was very well received by the public. Its informal approach of being delivered in local venues such as libraries and community centres encouraged individuals to attend, and for many it was the first time they had a cholesterol check.

‘would never have bothered to have cholesterol checked only for this service coming along – great service’

Heart Smart Mayo highlighted the importance of having risk factors such as cholesterol and BP checked. In many cases individuals were shocked to find hey had raised cholesterol and/or BP in the absence of symptoms.

‘great service – gave me the shock I needed’

‘used to going to GP when sick – not so much for prevention’

‘having this check encouraged me to go to GP to get my cholesterol down’

‘really grateful to Heart Smart for discovering diabetes’

The link between risk factor management and making lifestyle changes was the key element of the programme.

‘made me aware that changes in diet could help with blood pressure and cholesterol’

‘the explanation of the HDL and LDL was beneficial’

‘beneficial having card with all results’

For many who attended, the overall success of the programme was attributed to the 6-month follow up. The follow-up visit was viewed as a reminder and a motivator to make lifestyle changes; encouragement when changes had taken place made a difference e.g. weight or cholesterol reduction, and a fresh start for those whose risk factors may have increased since the first visit. Each person received a reminder call or text prior to their revisit appointment. This was emphasised by many individuals as being responsible for their attendance at this appointment.

IntegrationA key objective of the programme was to integrate with existing primary care services in the county. An important aspect of this integration was, therefore, effective communication about the programme with staff members in the local primary care teams. A presentation on the programme was delivered to each of the established primary care teams in Mayo. The co-ordinator also made a presentation to the Mayo branch of the IPNA in February 2009. Throughout the programme, primary care team members were involved in promoting and organising Healthy Heart Days in their areas.

raising awareness in the community The programme also involved a wider brief of increasing awareness of CVD risk factors and promoting heart health

in the local community. In achieving this, radio interviews took place and there was extensive newspaper coverage highlighting each screening including talks delivered by the programme co-ordinator, a consultant cardiologist and dietitians. The co-ordinator worked in collaboration with many community organisations such as Family Resource Centres, Community Development Projects, St Vincent de Paul, Rural Social Schemes, Traveller Support Groups and Active Retirement Groups throughout the course of the programme.

conclusionThe findings from the programme illustrate the benefits of implementing a community based CVD prevention programme. Heart Smart has proven to be an effective risk factor identification programme by identifying those most at risk in the community, encouraging high-risk individuals to attend their GP and making significant reductions to the their risk factor profile.

However, while this programme has demonstrated that it is possible to target high-risk individuals in the community and achieve lifestyle changes and risk factor reductions with a brief intervention, the prevention of CVD remains a challenge. The increase in the levels of obesity in this study once again signals the challenges that lie ahead and highlights the importance of addressing weight reduction as an integral part of all preventive cardiology programmes. In order to increase the number of individuals achieving European targets and thus reduce the mortality and morbidity in those at high-risk, we need to provide more community based preventive cardiology programmes which offer intensive risk factor modification support over a longer period of time.

referencesBennet, K., Kabir, Z., unal, B., Shelley, E., Critchley, J., Perry, I., Feely, J., Capewell, S. (2006) Explaining the recent decrease in coronary heart disease mortality rates in Ireland, 1985-2000. Journal of Epidemiology and Community Health. 60:322-7.Central Statistics Office (2010) Report on Vital Statistics 2007. Dublin: The Stationary Office. Department of Health and Children (2010) Changing Cardiovascular HealthNational Cardiovascular Health Policy 2010 – 2019. Dublin: Government Publications.Gibson, I. (2008) A Two Year Report on a Community Based Cardiovascular Disease Prevention Programme in the West of Ireland.Graham, I., Atar, D., Borch-Johnsen, K., et al (2007) European guidelines on cardiovascular disease prevention in clinical practice: fourth joint Task Force of the European Society of Cardiology and other Societies on Cardiovascular Disease Prevention in Clinical Practice. European Journal of Cardiovascular Prevention and Rehabilitation. 28: 2375-2414. Morgan, K., McGee, H., Watson, D., Perry, I., Barry, M., Shelley, E., Harrington, J., Molcho, M., Layte, R., Tully, N., Van Lente, E., Ward, M., Lutomski, J., Conroy, R., Brugha, R. (2008) SLÁN 2007: Survey of Lifestyle, Attitudes & Nutrition in Ireland.Main Report. Dublin: Department of Health and Children.

Help close the gap to LDL-C goal in one step

According to the DYSIS* Ireland Survey 48% of patients with an ESC risk ≥5% are not achieving their LDL-C goal.1

FOR PATIENTS NOT CONTROLLED BY STATIN ALONE.

In patients with hypercholesterolemia, including patients with CHD and/or diabetes

EZETROL® ezetimibeABRIDGED PRODUCT INFORMATION Refer to Summary of Product Characteristics (SPC) before PrescribingPRESENTATION 10 mg Tablet containing 10  mg of ezetimibe. USES As adjunctive therapy to diet in: Primary hypercholesterolaemia: For co-administration with an HMG-CoA reductase inhibitor (statin) for patients with primary (heterozygous familial and non-familial) hypercholesterolaemia not appropriately controlled with a statin alone. Monotherapy: For use in patients with primary (heterozygous familial and non-familial) hypercholesterolaemia in whom a statin is considered inappropriate or is not tolerated. Homozygous Familial Hypercholesterolaemia (HoFH): For co-administration with a statin, for use in patients with HoFH. Patients may also receive adjunctive treatments (e.g. LDL apheresis). Homozygous sitosterolaemia (phytosterolaemia): For use in patients with homozygous familial sitosterolaemia. A beneficial effect of Ezetrol on cardiovascular morbidity and mortality has not yet been demonstrated. DOSAGE AND ADMINISTRATION For oral administration. Put patients on an appropriate lipid-lowering diet and continue during treatment. Recommended dose is one ‘Ezetrol’ 10 mg tablet daily, administered at any time of the day, with or without food. When added to a statin, either continue with the indicated usual initial dose of that particular statin or the already established higher statin dose. Consult the statin dosage instructions. Co-administration with bile acid sequestrants: Dosing should occur either ≥2 hours before or ≥4 hours after administration of a bile acid sequestrant. Use in paediatric patients: Initiation of treatment must be performed under review of a specialist. Adolescents ≥ 10 years): no dosage adjustment is required. The clinical experience in paediatric and adolescents patient (aged 10- 17 years old) is however limited. Children < 10 years: Ezetrol is not recommended due to insufficient data on safety and efficacy. Use in hepatic impairment. No dosage adjustment is required with mild hepatic insufficiency (Child Pugh score 5 to 6). Not recommended in patients with moderate (Child Pugh score 7 to 9) or severe (Child Pugh score >9) liver dysfunction. CONTRA-INDICATIONS Hypersensitivity to any component. When co-administered with a statin, refer to the SPC for that particular medicinal product. ‘Ezetrol’ co-administered with a statin during pregnancy and lactation. ‘Ezetrol’ co-administered with a statin in patients with active liver disease or unexplained persistent elevations in serum transaminases. PRECAUTIONS Liver enzymes: When co-administered with a statin, perform liver function tests at initiation of therapy and according to the SPC for that particular medicinal product. Skeletal muscle: In post-marketing experience with ‘Ezetrol’, myopathy and rhabdomyolysis have been reported. Most patients who developed rhabdomyolysis were taking a statin concomitantly with ‘Ezetrol. However, rhabdomyolysis has been reported very rarely with ‘Ezetrol’ monotherapy and very rarely with the addition of ‘Ezetrol’ to other agents known to be associated with increased risk of rhabdomyolysis. If myopathy is suspected based on muscle symptoms or is confirmed by a creatinine phosphokinase (CPK) level >10 times the ULN, immediately discontinue ‘Ezetrol’, any statin, and any of these other agents. Advise all patients starting therapy with ‘Ezetrol’ of the risk of myopathy and to report promptly any unexplained muscle pain, tenderness or weakness Hepatic insufficiency: Not recommended in patients with moderate or severe hepatic insufficiency due to the unknown effects of the increased exposure to ‘Ezetrol’. Fibrates: The safety and efficacy of co-administration have not been established. Fibrates may increase cholesterol excretion into the bile, leading to cholelithiasis. If cholelithiasis is suspected in a patient receiving ‘Ezetrol’ and fenofibrate, gallbladder investigations are indicated and this therapy should be discontinued. Ciclosporin: Exercise caution when initiating ‘Ezetrol’ in patients taking ciclosporin and monitor ciclosporin concentrations. Warfarin, another coumarin anticoagulant or fluindione: Monitor the International Normalised Ratio (INR) if taken together with ‘Ezetrol’. Excipient: ‘Ezetrol’ tablets contain lactose: do not use in patients with rare hereditary problems of galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption. Interactions (studies have only been performed in adults): Cholestyramine: Concomitant cholestyramine administration decreased the mean AUC of total ‘Ezetrol’ approximately 55%. The incremental low-density lipoprotein cholesterol (LDL-C) reduction due to adding ‘Ezetrol’ to cholestyramine may be lessened by this interaction. Fibrates: Possible risk of cholelithiasis and gallbladder disease upon co-administration of fenofibrate with ‘Ezetrol’. Statins: No clinically significant pharmacokinetic interactions were seen upon co-administration with atorvastatin, simvastatin, pravastatin, lovastatin, fluvastatin, or rosuvastatin. Pregnancy and lactation: ‘Ezetrol’ co-administered with a statin is contra-indicated during pregnancy and lactation, refer to the SPC for that particular statin. Pregnancy: ‘Ezetrol’ should

be given to pregnant women only if clearly necessary. No clinical data are available on the use of ‘Ezetrol’ during pregnancy. Lactation: ‘Ezetrol’ is contra-indicated. Effects on ability to drive and use machines: No studies on the effects on the ability to drive and use machines have been performed. However, when driving vehicles or operating machines, it should be taken into account that dizziness has been reported. SIDE EFFECTS Refer to SPC for complete information on side effects. Clinical Studies In clinical studies where ‘Ezetrol’ was administered alone or with a statin or with fenofibrate, adverse reactions were usually mild and transient. The overall incidence of side effects was similar between ‘Ezetrol’ and placebo. Similarly, the discontinuation rate due to adverse experiences was comparable between ‘Ezetrol’ and placebo. The following common (≥1/100, <1/10) drug-related adverse experiences were reported in patients taking ‘Ezetrol’ (N=2396) and at a greater incidence than placebo (N=1159) or in patients treated with Ezetrol coadministered with a statin (N=11308) and at a greater incidence than statin administered alone (N=9361): or co-administered with fenofibrate: ‘Ezetrol’ administered alone: General disorders and administration site condition: fatigue. Gastro-intestinal disorders: abdominal pain, diarrhoea and flatulence. ‘Ezetrol’ co-administered with a statin: Investigations: ALT and/or AST increased. Nervous system disorders: headache. Musculoskeletal and connective tissue disorders: myalgia. ‘Ezetrol’ co-administered with fenofibrate: Gastrointestinal disorders: abdominal pain (common). Laboratory values. In controlled clinical monotherapy trials, the incidence of clinically important elevations in serum transaminases (ALT and/or AST ≥3 X ULN, consecutive) was similar between ‘Ezetrol’ (0.5%) and placebo (0.3%). In co-administration trials, the incidence was 1.3% for patients treated with ‘Ezetrol’ co-administered with a statin and 0.4% for patients treated with a statin alone. These elevations were generally asymptomatic, not associated with cholestasis, returning to baseline after discontinuation of therapy or with continued treatment. In clinical trials, CPK >10 X ULN was reported for 4 of 1,674 (0.2%) patients administered ‘Ezetrol’ alone vs 1 of 786 (0.1%) patients administered placebo, and for 1 of 917 (0.1%) patients co-administered ‘Ezetrol’ and a statin vs 4 of 929 (0.4%) patients administered a statin alone. There was no excess of myopathy or rhabdomyolysis associated with ‘Ezetrol’ compared with the relevant control arm (placebo or statin alone). In a study involving adolescent (10 to 17 years of age) patients with heterozygous familial hyperchlolesterolaemia (n = 248), elevations of ALT and/or AST (≥3X ULN, consecutive) were observed in 3% (4 patients) of the ezetimibe/simvastatin patients compared to 2% (2 patients) in the simvastatin monotherapy group; these figures were respectively 2% (2 patients) and 0% for elevation of CPK (≥ 10X ULN). No cases of myopathy were reported. This trial was not suited for comparison of rare adverse drug reactions. Post-marketing experience. The following additional adverse reactions have been reported in post marketing experience. Because these adverse experiences have been identified from spontaneous reports, their true frequencies are not known and cannot be estimated. Blood and lymphatic system disorders: thrombocytopaenia. Nervous system disorders: dizziness; paraesthesia. Respiratory, thoracic and mediastinal disorders: dyspnoea. Gastrointestinal disorders: pancreatitis; constipation. Skin and subcutaneous tissue disorders: erythema multiforme. Musculoskeletal and connective tissue disorders: myalgia; myopathy/rhabdomyolysis. General disorders and administration site conditions: asthenia. Immune system disorders: hypersensitivity, including rash, urticaria, anaphylaxis and angio-oedema. Hepatobiliary disorders: hepatitis; cholelithiasis; cholecystitis. Psychiatric disorders: depression. PACKAGE QUANTITIES 28 Tablets. Marketing Authorisation number: PA 1091/1/1. Marketing Authorisation holder: MSD-SP Limited, Hertford Road, Hoddesdon, Hertfordshire EN11 9BU, UK. Date of review: March 2010. ® denotes registered trademark of MSP Singapore Company, LLC © Merck Sharp & Dohme Limited, 2010 All rights reserved. Additional information is available on request or at www.medicines.ie. Legal Category: POM. API.EZE.(II/33) Reference: 1. Data on file. * DYSIS (The Dyslipidemia International Study) was a cross sectional multicentre epidemiological study of lipid levels of 22063 patients in Europe and Canada.

11-1

1-EZ

T-20

10-IR

L-38

98-J

Pelham House, South County Business Park, Leopardstown, Dublin 18, Ireland

2863_EZE_273_395_Ad_v.indd 1 31/01/2011 17:38

Convenient to take

20% more calcium than the market leader2

Calcium (as carbonate) / CholecalciferolCalcium (as carbonate) / Cholecalciferol( )

For Long Lasting Bones

ABBREVIATED PRESCRIBING INFORMATION(Please refer to Summary of Product Characteristics before prescribing)

CALTRATE* 600 mg/400 IU, fi lm-coated tabletPresentation: Each tablet contains 600 mg of calcium (as calcium carbonate) & 10 micrograms of cholecalciferol (equal to 400 IU vitamin D3). Contains sucrose & partially hydrogenated soya bean oil. Indications: Correction of combined vitamin D & calcium defi ciencies in the elderly. As an adjunct to specifi c treatments for osteoporosis, in patients where combined vitamin D & calcium defi ciencies have been diagnosed or those at high risk of defi ciency. Dosage & Administration: Adults & Elderly: One tablet twice a day (morning/evening). Pregnant women One tablet a day. Oral (Swallow with 200mls water). The elderly or patients with known diffi culties in swallowing, may break the tablet into two parts before taking with water. Do not suck or chew. Contraindications: Hypersensitivity to any ingredients including peanut or soya. Patients who now have, or have had renal failure, kidney stones, hypervitaminosis D, hypercalciuria & hypercalcaemia & diseases &/or conditions that lead to hypercalcaemia &/or hypercalciuria. Precautions: In prolonged treatment, check calcaemia & renal function, particularly in the elderly (see interactions). If renal function deteriorates, the dose must be reduced or treatment interrupted. Caution is advised in immobile patients. This product contains vitamin D; further administration of vitamin D or calcium must be medically supervised with regular monitoring of calcaemia & calciuria. Patients with sarcoidosis calcaemia & calciuria must be monitored. Risk of soft tissue calcifi cation must be considered. In severe renal insuffi ciency, vitamin D3 as cholecalciferol is not metabolised normally & other forms of vitamin D3 must be used. Cases of asphyxiation due to tablet choking have been reported. This product contains sucrose; patients with sugar intolerance should not take this medicine. Not intended for use in children & adolescents. Interactions: Thiazide diuretics & systemic corticosteroids (calcium monitoring required). Orlistat, combined ion-exchange resins (cholestyramine) or laxatives (paraffi n oil) can reduce the GI absorption of vitamin D3. Take tetracycline 2 hours before or 4 to 6 hours after taking calcium. Cardiac glycosides (monitor patients regularly with ECG check & calcaemia). Phenytoin or barbiturates (may reduce the activity of vitamin D3). Iron, zinc or strontium preparations, estramustin or thyroid hormones should be spaced at least 2 hours from calcium medicines. Bisphosphonate, sodium fl uoride or fl uoroquinolone administration, Caltrate should be spaced by at least 3 hours from these medicines. Oxalic acid (found in spinach & rhubarb) & phytic acid (found in wholegrain cereals) can inhibit calcium absorption by forming insoluble compounds with calcium ions. Patients must not take calcium containing-products in the two hours after consumption of foods rich in oxalic acid & phytic acid. Pregnancy & lactation: Caltrate may be used during pregnancy & breastfeeding. Daily intake in pregnancy should not exceed 1500mg calcium & 600IU cholecalciferol. Avoid prolonged use as hypercalcaemia can aff ect the developing foetus. Calcium & vitamin D3 pass into breast milk, this should be considered when vitamin D3 is given concomitantly to infants. Side-eff ects: Hypercalcaemia, hypercalciuria, constipation, fl atulence, nausea, abdominal pain, diarrhoea, pruritis, rash & urticaria. Legal Category: P. Pack Size: 90 tablets. PAH: Pfi zer Consumer Healthcare Ltd., Sandwich, Kent, CT13 9NJ, United Kingdom. PA number: PA172/38/1. Further information is available upon request from Pfi zer Consumer Healthcare Ltd., Citywest, Dublin 24. or look up, www.medicines.ieDate of preparation: June 2010.

Reference: 1 Based on sales (data on fi le). 2 MIMS Ireland Jan 2011, Pg 299.Artwork version Mar 11 Ref: 11 101 Med. * Trade Mark.

calcium & vitamin D3

27

clinical review

Osteoporosis is known as the silent disease, as often the first sign of a patient having the condition is when they present with a fracture. The most common osteoporosis-associated fractures are of the hip, spine and wrist; however a low trauma

fracture of any bone can be due to ‘brittle bones’ disease. Osteoporosis is a systemic metabolic bone disease that is

characterised by a decrease in the bone mass of an individual and also by a deterioration in the microstructure of the bone itself. These changes in the bone may lead to an increase in the fragility of the skeleton and to the likelihood of fracture.1

dr Ann Manley is a Board Member of the Irish Osteoporosis Society and a Committee Member of the Irish Menopause Society. She is currently completing a full time Masters in Management at uCD Smurfit Business School.

PreveNTABle dIseAseI believe there are four reasons why we should care about osteoporosis. Firstly, osteoporosis is a preventable and treatable disease in most cases. If we can prevent a fracture, we can prevent the subsequent health implications of that fracture, which include pain, deformity, reduced quality of life and loss of independence. An individual can lose up to 16cm of height due to vertebral fractures deforming the spine. The major complication of osteoporosis is the dreaded hip fracture,2 as 20% of patients who have a hip fracture will die of complications of that fracture within a year. Half of these

Osteoporosis – management and treatment

28

clinical review

patients will be unable to care for themselves properly.3 Many will end up in nursing homes or blocking acute hospital beds. Only one third of osteoporotic vertebral fractures actually come to clinical attention. One in five post-menopausal women with a prior vertebral fracture will have another vertebral fracture within 12 months.4 Vertebral fractures have been shown to increase the morbidity and mortality of patients.5,6

The second reason why we should care about osteoporosis is that the incidence is increasing. Currently, osteoporosis affects one in two women over the age of 65 and one in five men, however, it affects adults and children of all ages. The projected number of hip fractures is estimated to triple from the year 2000’s figures worldwide and by 2050,7 the incidence of hip fracture is predicted to have increased by 135% in the Eu alone.8

Thirdly, the causes of, and risk factors for, osteoporosis are common. Osteoporosis is a complication of many medical and surgical conditions, either by the disease process itself or by the medications used to treat these conditions. Identifying the patient’s risk factors for osteoporosis is of paramount importance in the diagnosis and subsequent treatment of a patient. Some of the risk factors and causes osteoporosis are demonstrated in Figure 1.

Finally, Osteoporosis fractures pose a huge financial burden on the state, particularly hip fractures. Figures in 2000 from the International Osteoporosis Foundation showed that it cost €20 billion to treat the hip fractures that occurred worldwide that year. In 2008, the Irish Osteoporosis Society calculated that the cost of treating eight hip fractures in Ireland cost the health service €250,000.9

Thus, if we can prevent the fracture, we can prevent the suffering of the patient and the state’s coffers.

dIAgNOsIsThe Gold Standard test for diagnosing osteoporosis is the DEXA scan. This is a simple low radiation scan that takes approximately six minutes to complete and involves scanning either one or both hips and the lower spine through a patients clothing. Some DEXA machines will also allow the technician

to do a lateral vertebral assessment view to look for vertebral fractures, which as we’ve seen are less likely to come to clinical attention. The DEXA scan will demonstrate by means of a T-score if the patient has brittle bones or not. If a patient has a T-score of – 1 or greater, they have normal bone density. If it is between – 1 and – 2.5, they are in the osteopenic range (osteopenia is an early stage of osteoporosis; patients are at risk of developing osteoporosis at a later stage). If they lie below – 2.5, they have osteoporosis.12 Interestingly, more people actually fracture in the osteopenic range than in the osteoporotic range.11 If a patient with osteopenia fractures with minimal trauma, they automatically will be defined as having osteoporosis and should be treated appropriately.12

“If we can prevent a fracture, we can prevent the subsequent health implications of that fracture, which include pain, deformity, reduced quality of life and loss of independence.”

Figure 1: risk factors and causes of osteoporosis

risk Factors10 causes

Age

Previous low trauma fracture

Low BMD

Family history of fracture/osteoporosis

Low oestrogen or testosterone

Low body mass index (BMI)

Smoking

Excessive alcohol

No/excessive exercising

High fibre/high caffeine intake

Glucocorticoid use

Post-menopausal and age related causes

Malabsorption states e.g. Coeliac disease

Inflammatory conditions e.g. Crohns/ulcerative colitis, rheumatoid arthritis

Other conditions e.g. anorexia nervosa, sarcoidosis, cirrhosis, renal tubular acidosis

Endocrine abnormalities e.g. gonadal insufficiency, thyroid, pituitary, parathyroid or adrenal cortex disorders

Neoplastic disease – disease or therapy – chemo and radiation therapy

Medications e.g. steroids, methotrexate, heparin, warfarin, some anti-psychotics, anti-epilepsy drugs.

Disuse e.g. prolonged bed rest, immobility, wheelchair user/paralysis

Calcium and/or vitamin D deficiency in the elderly can lead to lossof muscle tone and increased risk of falls and osteoporotic fractures.1-5

Calcichew-D3 Forte is indicated for the treatment and prevention of calcium and vitamin D deficiency.6

CALCICHEW-D3 FORTE CHEWABLE TABLETS PRESCRIBINGINFORMATION(Please refer to full Summary of Product Characteristicswhen prescribing) Presentation: Chewable tablet containing1250mg calcium carbonate (equivalent to 500mg of elementalcalcium) plus 400IU colecalciferol (equivalent to 10 microgramsvitamin D3). Uses: Prevention and treatment of vitaminD/calcium deficiency. Supplementation of vitamin D andcalcium as an adjunct to specific therapy for osteoporosis, inpregnancy, in established vitamin D dependent osteomalaciaand in other situations requiring therapeutic supplementation ofmalnutrition. Dosage and administration: Oral (suck orchew). Adults and elderly: Two tablets daily. Children: Notintended for use in children. Hepatic impairment: No doseadjustment required. Renal impairment: Should not be used inpatients with severe renal impairment. Contraindications:Diseases and/or conditions resulting in hypercalcaemia and/orhypercalciuria, severe renal impairment, renal stones,hypervitaminosis D, hypersensitivity to ingredient(s) especiallysoybean oil and peanut. Precautions: Monitor serum calciumand creatinine levels, particularly in patients on cardiacglycosides or diuretics and in patients with high tendency tocalculus formation. Use with caution in patients with impairedrenal function. Take into account risk of soft tissue calcification.Avoid in patients with phenylketonuria or sugar intolerance.Prescribe with caution in patients with sarcoidosis. Use with

caution in immobilised patients. Additional doses of calcium orvitamin D should only be taken under close medical supervision.Interactions: Tetracyclines (take 2 hours before, or 4 to 6 hoursafter Calcichew-D3 Forte), bisphosphonates or sodium fluoride(take 3 hours before Calcichew-D3 Forte), Quinolone antibiotics(take two hours before or after), levothyroxine (take four hoursbefore or after), thiazide diuretics, corticosteroids, cardiacglycosides, ion exchange resins (cholestyramine), laxatives(paraffin oil). Calcichew-D3 Forte should not be taken within 2hours of eating foods high in oxalic acid (e.g. spinach andrhubarb) or phytic acid (e.g. whole cereals). Side effects:Hypercalcaemia, hypercalciuria, constipation, dyspepsia,flatulence, nausea, abdominal pain, diarrhoea, pruritus, rash,urticaria. Very rarely (usually only seen on overdose) milk-alkalisyndrome. Use in pregnancy and lactation: Can be used incase of calcium and vitamin D deficiency. Daily intake inpregnancy should not exceed 1500mg calcium and 600IUcolecalciferol (15 micrograms vitamin D3). Avoid overdose aspermanent hypercalcaemia affects developing foetus. Calciumand vitamin D3 pass into breast milk so consider this whengiving additional vitamin D to the child. Pharmaceuticalprecautions: Do not store above 30°C. Keep container tightlyclosed to protect from moisture. Legal category: Pharmacyproduct. Product Authorisation No: 535/1/3. ProductAuthorisation holder: Shire Pharmaceuticals Ltd., HampshireInternational Business Park, Chineham, Basingstoke, Hampshire

RG24 8EP UK. Distributed in Republic of Ireland by: Cahill MayRoberts, P.O. Box 1090, Chapelizod, Dublin 20, Republic ofIreland. Further information is available on request. Date ofrevision: November 2010CALCICHEW is a registered trademark of Shire PharmaceuticalsLtd in the Republic of Ireland.

Adverse events should be reported to thePharmacovigilance Unit at the Irish Medicines Board (IMB)(imbpharmacovigilance@imb.ie). Information aboutadverse event reporting can be found on the IMB website(www.imb.ie). Adverse events may also be reported toShire Pharmaceuticals Ltd on +44 1256 894000.

References: 1. Perez-Lopez FR. Maturitas 2007;58: 117-137.2. Dawson-Hughes B & Bischoff-Ferrari HA. J Bone Miner Res2007; 22: S2; v59-v63. 3. Lin JT & Lane JM. Phys Med RehabilClin N Am 2005; 16: 109-128. 4. Heaney RP. Endocrinol MetabClin North Am 1998; 27(2): 255-265. 5. Hunter DJ & SambrookPN. Arthritis Res 2000; 2(6): 441-445. 6. Calcichew-D3 Forte.Summary of Product Characteristics. October 2010. 7. MIMS2011.

Date of preparation: January 2011. Item Code: IRE/CDF/11/0002

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Calcichew Ad 2011 166x254:Layout 1 21/01/2011 11:11 Page 1

30

clinical review

wHO Needs A dexA scAN? When attempting to identify patients who may be affected by osteoporosis, one must consider that bone is a living tissue and needs five factors to be in balance in order for bone to function correctly. Having normal hormone levels is crucial. This means not only having the essential levels of oestrogen in women and testosterone in men, but also the correct balance of the other endocrine hormones in the body. Next, one needs to consider the patients diet, ensuring that they have adequate calories and protein, as well as looking at calcium and vitamin D intake. Finally, one must look at the level of weight bearing exercise the individual is partaking in. This should be at least 30 minutes of exercise a day that involves activities such as walking, running, skipping, dancing or hiking for example.

If one considers both the list of risk factors and the causes of osteoporosis as well as the five factors that maintain healthy bones, one can build a risk profile for a patient. To aid memory and to ensure nothing is missed, especially in a busy clinic, a questionnaire that contains a patient friendly assessment of an individual’s risk of osteoporosis could and should be used. These will also form a broader base for a diagnosis when put together with the DEXA scan result.

TreATMeNTSo, we have the questionnaire complete and we have decided the patient is at risk and we have scanned them. What now? When considering treatment for osteoporosis, one must first look at simple non pharmaceutical interventions; modifying the patient’s diet, supplementing calcium and vitamin D intake, and evaluating their exercise history. One must look at the patient’s medical history and look for the secondary causes of osteoporosis. By treating the causes, one can improve the bone mineral density in many causes. Then, after examining these reversible and modifiable components, including a falls risk assessment, one can prescribe pharmaceutical therapies.13

Most commonly used and first-line therapy for most osteoporotic patients are the class of drugs called the bisphosphonates. These come in tablet form to be taken weekly or monthly on an empty stomach. The patient must stay upright for at least half an hour to ensure absorption. They are very effective drugs in reducing the risk of fracture. They can also be given in hospital in an intravenous infusion once yearly. This form is more potent and useful in severe osteoporosis or where compliance with oral medications is an issue.

Strontium ranelate is used to treat osteoporosis also. It is a once a day oral sachet therapy that is particularly effective in reducing risk of vertebral fractures. Patients must not have calcium containing foods for two hours either side of the medication. It is useful as an alternative to bisphosphonates if a patient cannot tolerate them.

Hormone replacement therapy (HRT) is useful in the younger peri-menopausal woman for both menopausal symptoms relief and for the maintenance of bone health. A discussion and risk assessment should be undertaken with the woman prior to commencement of therapy. The Selective oEstrogen Receptor Modulators (SERMs) are also an option for some women who have no contraindications to hormone therapy and no menopausal symptoms.

Parathyroid hormone injections are reserved for the more severe osteoporosis sufferer, especially those who have a known osteoporotic vertebral fracture. This is a highly potent treatment which is licensed for two years therapy which is given daily by injection.

“Practice nurses have a unique opportunity to aid in the identification of at risk patients, most especially in patients who have recently had a low trauma fracture.”

ABRIDGED PRESCRIBING INFORMATION(For full prescribing information refer to the Summary of Product Characteristics [SmPC])Bonviva® (ibandronic acid) 150mg film-coated tabletsIndication: Treatment of osteoporosis in postmenopausal women at increased risk of fracture. A reduction in the risk of vertebral fractures has been demonstrated, efficacy on femoral neck fractures has not been established. Dosage and Administration: No relevant use in children. Not studied in the paediatric population. Not recommended where creatinine clearance <30 ml/min. Patients should receive supplemental calcium and/or Vitamin D – see SmPC. 150 mg once a month swallowed whole (the tablet should not be sucked or chewed) with plain water only (180-240 ml) whilst sitting or standing in an upright position. Take after overnight (≥6 hours) fast and one hour before the first food, drink (except water) or any other oral medicinal products or supplements (including calcium). Patients must not lie down for 1 hour after administration. Refer to SmPC for missed doses. Contraindications: Abnormalities of the oesophagus which delay oesophageal emptying such as stricture or achalasia, inability to stand or sit upright for at least 60 minutes, hypocalcaemia and hypersensitivity to any ingredient. Warnings and Precautions: Caution should be used when Bonviva is given to patients with active upper gastrointestinal problems. Risk of severe oesophageal adverse experiences appears to be greater in patients who do not comply with the dosing instruction and/or who continue to take oral bisphosphonates after developing symptoms suggestive of oesophageal irritation. Instruct patients to pay particular attention to and be able to comply with the dosing instructions. Monitor for signs or

symptoms of possible oesophageal reactions – instruct patients to discontinue therapy and seek medical attention if they develop dysphagia, odynophagia, retrosternal pain or new or worsening heartburn. Caution with concomitant administration of NSAIDs. Treat hypocalcaemia and other disturbances of bone and mineral metabolism before starting Bonviva. Ensure adequate intake of calcium and vitamin D. Osteonecrosis of the jaw reported. A dental examination with appropriate preventive dentistry should be considered prior to treatment in patients with concomitant risk factors. Avoid invasive dental procedures if possible during treatment. Refer to SmPC for full details. Not recommended if creatinine clearance <30 ml/min. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take the tablet presentation. Drug Interactions: Observe fasting requirements for food, drink and oral medicinal products/supplements. Pregnancy and Lactation: Do not use. Side Effects and Adverse Reactions: Common adverse reactions (≥1/100 to <1/10): Headache, oesophagitis, gastritis, gastro-oesophageal reflux disease, dyspepsia, diarrhoea, abdominal pain, nausea, rash, arthralgia, myalgia, musculoskeletal pain, muscle cramp, musculoskeletal stiffness and influenza-like illness. Refer to the SmPC for a full listing of adverse events including post marketing experience. Legal Category: Limited to sale and supply on prescription only. Presentation and Marketing Authorisation Numbers: 1 tablet blister pack EU/1/03/265/003. Marketing Authorisation Holder: Roche Registration Limited, 6 Falcon Way, Shire Park, Welwyn Garden City, AL7 1TW, United Kingdom. Further information is available from Roche Products (Ireland) Limited, 3004 Lake Drive, Citywest, Naas Road, Dublin 24. Telephone: (01) 4690700. Fax: (01) 4690791. Bonviva is a registered trade mark. Date of Preparation: March 2010.

Bonviva:Licensed for

the treatment of postmenopausal

osteoporosis

p11/08/10

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clinical review

The newest therapy on the market is Denosumab or Prolia. This is the first biological therapy for osteoporosis and is effective at both the hip and spine. It is given by injection every six months and is licensed for the treatment of postmenopausal osteoporosis. Its risk reduction is similar to the intravenous bisphosphonate, zolendronate.

Finally, kyphoplasty or vertebroplasty are techniques used to treat new vertebral fractures, which try to restore the height of a collapsed vertebra.

conclusionOsteoporosis is an expensive disease which is costly to the patients’ health and to our health service itself. By early risk assessment and treatment, osteoporosis is a preventable and treatable disease in most cases. Practice nurses have a unique opportunity to aid in the identification of at risk patients, most especially in patients who have recently had a low trauma fracture. In osteoporosis management treatment, prevention is better than cure so let’s beat the break!

The Irish Osteoporosis society can be contacted at:Irish Osteoporosis society12 Burlington road,garden level,Ballsbridge,dublin 4.Telephone: lo-call 1890 252 751 / 01 637 5050Fax: +353 (0)1 668 0098email: info@irishosteoporosis.ie

references:1 World Health Organisation Technical Report series 921,

Prevention and Management of Osteoporosis: Report of WHO Scientific Group, 2003.

2 Reginster J-Y and Burlet N. Bone 2006;38: S4-S9.3 Cooper, S., American Journal of Medicine 1997;103:12S-19S.4 Edwards BJ, et al. Clin Orthop Relat Res 2007;461:226-230.5 Bliuc D., et al. JAMA 2009; 301(5): 513-521.6 Center JR, et al. Lancet 1999;353:878-882.7 Johnell O and Kanis JA. Osteoporos Int. 2006;17:1726-1733.8 European Commission. Report on osteoporosis in the

European Community-action for prevention. Luxembourg Office for Official Publications of the European Communities, 1998. Available at: http://www.iofbonehealth.org/download/osteofound/filemanager/publications/pdf/eu-report-1998.pdf

9 Irish Osteoporosis Society 2008 figures looking at HSE/HIPE figures.

10 Kanis JA, et al. Osteoporosis International: 2005;16:581-589.11 Siris ES, et al. Arch Intern Med 2004;164:1108-1112.12 World Health Organization. Technical Report Series 921.

Prevention and Management of Osteoporosis: Report of a WHO Scientific Group. 2003.

13 National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis. 2008.

Amgen (Europe) GmbHDammstrasse 23, CH-6301 Zug, Switzerland.

GlaxoSmithKline,980 Great West Road, Brentford, Middlesex, TW8 9GS, UK.

Legal Category: POM. Presentation and Marketing Authorisation Number: PROLIA® 60 mg: Pack of 1 pre-filled syringe with automatic needle guard; EU/1/10/618/003. Marketing Authorisation Holder: Amgen Europe B.V., Minervum 7061, NL-4817 ZK Breda, The Netherlands. Further information is available from Amgen Limited, 240 Cambridge Science Park, Milton Road, Cambridge, CB4 0WD. Prolia® is a registered trademark of Amgen Inc.

DMB-IRL-AMG-177-2010IE/DNB/0001a/10Date of preparation: Nov 2010

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in practice

Since 2001 a key policy aim of government has been to deliver high quality services that are based on evidence-supported best practice.1 More recently this agenda has been re-energised by a number of factors. Firstly, patients are now demanding and

expecting excellent service.2 Secondly, there has been public concern over high profile lapses in healthcare, in particular concerns raised following the investigation into practice at Our Lady of Lourdes Hospital.3 Thirdly, there is evidence of widespread errors in public healthcare facilities. In 2009 the Clinical Indemnity Scheme received over 83,000 reports of clinical errors in public healthcare providers.4 It was in this context that the Commission on Patient Safety and Quality Assurance5 recommended the introduction of national standards of quality and safety and a licensing system for healthcare providers. The Draft National Standards for Safer Better Healthcare6 have been designed and will be monitored by the Health Information and Quality Authority (HIQA). Once finalised these standards will form the basis of a licensing system which will apply across all publicly funded healthcare facilities. This article will explore the implications for general practice of the introduction of these Standards.

wHAT Is HIQA? HIQA was established by the Health Act of 20077 with the object of promoting safety and quality in the provision of health and personal social services for the benefit of the health and welfare of the public. HIQA has a number of statutory functions including:

Healthcare standards in general practice

• To set standards on safety and quality in relation to services provided by the Health Services Executive

• To monitor compliance with the standards. • To undertake investigations. • To operate accreditation programmes • To evaluate the clinical and cost effectiveness of health

technologies

KIerAN MurPHy, RISK MANAGER, MERCY HOSPITAL, CORK

“The future ain’t what it used to be” Yogi Berra, former catcher and manager of the New York Yankees.

In order for a healthcare facility to go through the licensing process the practice will be required to demonstrate their ability, or capability, to meet at least minimum standards whilst aiming for excellence.

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HIQA is perhaps best known for its thematic reviews of particular kinds of healthcare and service provision in nursing homes and residential care centres and also for its unannounced visits in relation to hygiene in acute public hospitals. However, its remit also extends to investigations of services where there are reasonable grounds for believing there is a serious risk to the health and welfare of a person receiving those services.8 The most well-known of these investigations related to Mrs Rebecca O’Malley and the pathology services in CuH and Limerick Regional Hospital.9

Specifically in relation to general practice HIQA has recently extended its mandate to issuing guidance on: • Standardising Patient Referral Information from GPs

(December 2010).10 This is in response to the incident relating to unreported radiology films and unprocessed GP referral letters in the Adelaide and Meath Hospital.

• General Practice Messaging Standard (September 2010).11 This is intended to standardise the electronic transmission of messages between general practices and secondary care and out of hours care.

drAFT NATIONAl sTANdArds According to the Commission on Patient Safety “Standards communicate the levels of performance that are expected from regulated organisations”.12 Standards help to ensure that regulatory processes are transparent and fair by explicitly describing the criteria on which organisations will be judged.

The standards which are currently being implemented in Ireland, and which are monitored by HIQA are listed in Figure 1.

The Draft National Standards for Safer Better Healthcare (Draft Standards) are generic standards to be applied across all publicly funded healthcare providers from general practice to an acute general hospital and everything in between.

The Draft Standards consist of eight main components, known as themes. Each theme identifies the key topics for quality and safety which are addressed by the standards. The eight themes are Person-Centred Care, Leadership, Governance and Management, Effective Care, Safe Care, Workforce, use of Resources, use of Information and Promoting Better Health (See Figure 2). These themes are divided into 20 standards which are further subdivided into 123 criteria.

Each standard consists of:• standard statement which describes the high level outcome

required to contribute to quality and safety • criteria that, taken together, will enable progress towards

achieving the standard • why is this important – an explanation of why the standard

and criteria are important for service users and service providers

• what this means for you as a service user – guidance for service users on what each standard will mean for them

• Illustrative examples of steps service providers may take towards meeting the standard but it will be very much left up to each organisation to provide the evidence of compliance with the standard. It is envisaged that initially this will be general guidance and some guidance for specific service types will be developed, which the ICGP feel is required.

The standards are currently in draft format and HIQA undertook a comprehensive consultation process with over 200 submissions received. Once the submissions have been considered it is envisaged that the Draft Standards will be submitted to the Minister for Health for approval. However, because of the volatile political situation at present this may take some time.

lIceNse TO PrAcTIce The Draft Standards once approved will form the basis of a licensing scheme for all healthcare providers including general practice but how the licensing system will operate is still not clear. In other countries licensing systems have either adopted many of the features of accreditation programmes or have begun to use accreditation programmes to assess quality.13 If this accreditation type system were introduced it would basically mean that each general practice would assess itself against the Draft Standards and submit its assessment to HIQA. There would then be periodic inspections of the practice to see if the Draft Standards were indeed being met. It has been

Figure 2

HIQA standards

Draft National Standards for Safer Better Healthcare

Standards for Residential and Foster Care Services for Children and Young People

National Standards for Prevention and Control of Healthcare Associated Infections

Hygiene Standards

Standards for Residential Care Settings for Older People

Standards for the Assessment of Need

National Quality Assurance Standards for Symptomatic Breast Disease Services

National Quality Standards: Residential Services for People with Disabilities

Figure 1

35

in practice

recommended that the license would last for three years.14 A licensing system for nursing homes is already being monitored by HIQA with an additional feature being the publication of the inspection reports. This feature could be problematic for, as Hamblin (2008) has pointed out, the publication of such information allows comparisons of performance and quality to be made.15

HIQA will most likely have enforcement powers so the implications for healthcare providers are significant. In England the Care Quality Commission has a number of enforcement measures ranging from warning notices to prosecution.16

A number of features of HIQA as regulator are worth commenting on.17 First of all its reporting arrangements are designed to ensure independence as it reports directly to the Minister for Health and not the Department of Health and the HSE. However the recent announcement of an inspection of Mallow General Hospital led to accusations that HIQA has become an implementation arm for HSE policy.18 The second feature is that unlike private accreditation systems (e.g. Joint Commission International (JCI)) HIQA does not have any commercial imperative to implement the standards and is not reliant on the services it is monitoring to provide an income stream. The third feature is that HIQA will have a dual role as it has responsibility for setting the standards but also is the organisation that will inspect against the standards. It has been observed that this dual role may risk a conflict of interest by, for example, influencing decisions about standards compliance.19

standards help to ensure that regulatory processes are transparent and fair by explicitly describing the criteria on which organisations will be judged.

IMPlIcATIONs FOr geNerAl PrAcTIce Since 2001 health policy in Ireland has aimed to increase the focus on primary care, moving treatment away from hospitals into the community.20 By the end of 2009, 27% of GPs in Ireland (755) were participating in 184 Primary Care Teams.21

Project1:Layout 1 04/03/2011 16:44 Page 1

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in practice

The landscape of regulation, audit and inspection in Ireland is evolving rapidly, with an increasing focus on the citizen’s experience of health and social care services, in particular their quality and safety as can be seen in Figure 3.22

In order for a healthcare facility to go through the licensing process the practice will be required to demonstrate their ability, or capability, to meet at least minimum standards whilst aiming for excellence.23 The practical challenge for Practice Nurses is that each general ractice will have to go through each of the eight themes, each of the twenty standards and each of the 123 criteria and provide evidence that will show compliance with the Draft Standards. For each criterion the practice will have to examine what structures they have in place, what processes they have in place (policies, procedures and guidelines, etc) and any relevant outcome indicators (audits, annual reviews, implementing reports, best practice). This will generate a huge amount of data collection and recording with time and resource impications.

The future indeed ain’t what it used to be.

references1. Department of Health and Children (2001) “Quality and

Fairness, A Health System for You”, Government Publications, Dublin

2. Grimes F (2003) The measurement of patient satisfaction with acute services in Ireland. www.hsnpf.ie )

3. Clark MH (2006) An Inquiry into peripartum hysterectomy at Our Lady of Lourdes Hospital Drogheda, Government Publications Dublin

4. tate Claims Agency (2009) STARS WEB statistics 2009 http://www.stateclaims.ie/ClinicalIndemnityScheme/publications/2009/STARSWebStats2009.pdf (Accessed 14th January 2011)

5. Department of Health and Children (2008) Building a Culture of Patient Safety, Report of the Commission on Patient Safety and Quality Assurance Government Publications, Dublin

6. Health Information and Quality Authority (2010). Draft National Standards for Safer Better Healthcare. Health Information and Quality Authority Dublin:

7. Health Act 2007. Dublin: The Stationery Office; 2007. 8. Section 9 Health Act 20079. Health Information and Quality Authority (2008) Report

of the investigation into the circumstances surrounding the provision of care to Rebecca O’Malley, in relation to her symptomatic breast disease, the Pathology Services at

Cork university Hospital and Symptomatic Breast Disease Services at the Mid Western Regional Hospital, Limerick, Health Information and Quality Authority Dublin

10. Health Information and Quality Authority (2010) Standardising Patient Referral Information from General Practitioners. Health Information and Quality Authority Dublin:

11. Health Information and Quality Authority (2010). General Practice Messaging Standard. Health Information and Quality Authority; Dublin

12. Department of Health and Children (2008) Building a Culture of Patient Safety, Report of the Commission on Patient Safety and Quality Assurance Government Publications, Dublin at page 108

13. Scrivens & Skelton (2008) The role of organizational licensing in healthcare Journal Royal Society for Promotion of Health 2008;128(6):299-305

14. Department of Health and Children (2008) Building a Culture of Patient Safety, Report of the Commission on Patient Safety and Quality Assurance Government Publications, Dublin

15. Hamblin (2008) Regulation, measurements and incentives Journal Royal Society for Promotion of Health 2008;128(6):291-298

16. Health and Social Care Act 2008, Crown Publication Service 17. Hamblin (2008) Regulation, measurements and

incentives Journal Royal Society for Promotion of Health 2008;128(6):291-298

18. Irish Times August 18 2010 Letters to the Editor “HIQA inquiry into Mallow Hospital”

19. Australian Commission on Quality and Safety in Health Care. Discussion paper. National safety and quality accreditation standards. http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/(accessed Mar 2007).

20. Department of Health and Childre (2001) Primary Care a New Direction Govenrment Publications, Dublin

21. Purcell & McHugh (2010) Competition in Primary Care in Ireland http://www.tca.ie accessed 14th January 2011

22. Jewell and Wilkinson (2008) Health and social care regulation in Wales: an integrated system of political, corporate and professional governance for improving public health The Journal of the Royal Society for the Promotion of Health 2008 128: 306

23. Buetow and Wellingham (2003) Accreditation of general practices: challenges and lessons Qual Saf Health Care 2003 12: 129-135

Figure 3

legIslATION Data Protection Acts 2003Safety Health and Welfare at Work Act 2005 Health Act 2007 Medical Practitioners Act 2007 Nurses Act 1985

regulATION Department of Health and ChildrenMedical Council Irish College of General PractitionersAn Bord Altranais Health and Safety Executive

lIceNsINg ?Health Information Quality Authority

sTANdArd seTTINg Draft National Standards for Safer Better HealthcareStandardising Patient Referral Information from General PractitionersGeneral Practice Messaging Standard

general Practice

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clinical review

I recently met a 20 year old man who had just returned from the uS where he had been visiting his girlfriend’s parents for the first time. In their house he had eaten a bite of a biscuit which unbeknownst to him, contained peanuts. This caused a severe anaphylactic reaction and it took three

doses of adrenaline for him to be stable enough for ambulance transfer to hospital. What was meant to be a relaxing enjoyable trip turned into a nightmare and a struggle for life. He was hospitalised for 3 days receiving steroids, waiting for oedema to resolve. Finally he was discharged, a person changed forever by this traumatic experience.

During our consultation we talked about how he was feeling and I then asked him what had caused him to let down his guard and make the mistake of eating food containing peanut. He had known he was severely allergic to them. He said he’d been distracted at the time as he was nervous meeting his girlfriend’s parents. Feeling awkward socially he couldn’t find the words to mention his allergy, instead he had taken a risk.

I have a severe nut allergy myself and have been trying to avoid these allergens and anaphylactic reactions for many years now so I was able to understand the man’s situation. I have made mistakes and on occasion have had a near miss, which I have learnt from. I also have a child with severe food allergies. (Sorry about those genes son!) Below are my top ten tips for living safely and avoiding my enemies, peanuts and almonds. Some of the principles are applicable to other food allergens.

sAlly wHelAN, RGN, RHV, BA (HONS), MA, PRACTICE NuRSE, GALWAY

Teenagers call a kiss which causes them an allergic reaction ‘being peanutted’. There should be an ‘I have a nut allergy talk’ even before a date.

for dealing with severe peanut allergy

Ten tips

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1. Know what you’re up againstAnaphylaxis is a potentially life-threatening, rapid onset, hypersensitivity reaction to an allergen. Symptoms can include nausea, abdominal pain, severe wheezing, urticaria, angiooedema, laryngeal oedema, hypotension, a sense of impending doom and collapse. t can be biphasic, as symptoms may return again after initial treatment appears successful.

6-8% of children under 4 and 3.7% of adults have a food allergy (uS Report 2006). Peanuts are responsible for 80% of all food allergy fatalities, (Perry 2004) and the prevalence of peanut and food allergies increased by 18% between 1997 and 2007 (Branum 2008). Approximately 20 people die from anaphylaxis, per year, in the uK (Pumphrey 2004).

2. read the small print Thoroughly examine all labels on food products, medicines, cosmetics and toiletries, before you use them. Expect the unexpected, as the peanut allergen lurks in surprising places. Be sure to examine the ingredient lists and the potential cross-contamination warnings i.e. ‘may contain traces of nuts’

It is simpler and safer to avoid all nuts. This is because some people also react to tree nuts and there is a high risk of cross-contamination in factories when different nuts are processed alongside each other.

It is easy to recognise a packet of peanuts, but it can be tricky finding nuts in disguise as many different words describe them e.g. groundnuts, arachus oil, almond oil, nutmeat, monkey nuts, marzipan, nougat etc. Basic rule is if you’re not sure, don’t risk it.

Refined peanut oil (without any fragments of peanuts in it) is theoretically safe. unrefined peanut oil isn’t. However, it is much more practical and prudent to simply avoid all peanut oil and all nut oils.

Not all medicines will make you better. The following are examples of those which contain peanuts: Cerumol, Abidec multivitamins, Naseptin cream, Calogen supplement, Hedrin. It is also surprising that manufacturers of products designed for people with allergies sometimes put nut oils in them. Given that food allergy sufferers are more likely than other children to be atopic (CDCP 2008)(3), why does Dermovate (a potent topical steroid cream used for difficult eczema) contain arachus oil? This is also the case for Siopel barrier cream, zinc and castor oil ointment, calamine oily lotion. This is wrong in my opinion and may well sensitise susceptible individuals to developing a nut allergy in the first place. (Lack 2003)

Be careful with all spa treatments and when visiting the hairdresser. Massages with a nut containing product will not make you relaxed.

Anaphylaxis Ireland (see resources below) can help by sending out contamination warnings, whenever a product has been inadvertently contaminated by a common allergen during manufacture.

3. develop self-confidence and involve family and friendsThe following is a situation encountered by allergy sufferers: you see a bowl of peanuts at a social gathering. People in the room have touched the nuts, eaten them, they may touch you, breathe on you, or transmit peanut dust onto surfaces, which you then touch. How do you handle this without insulting the host. There are no right answers, just a lot of difficult choices, all of which require you to be decisive and assertive.

To help build your self confidence in such situations practice the words you might use. Role playing might help young children develop the ability to speak up for themselves.

The social support of sharing information with other allergy sufferers will help everyone, especially teenagers who find it particularly difficult drawing attention to themselves. There are some excellent online forums offering peer group support for teenagers, to help them with this and other related issues. (see below).

It is of course much easier if family or friends intervene on your behalf and by alerting you if there are nuts available in a particular situation.

Parents of young children have to ensure people in loco parentis understand the condition and how to protect their child. Documents citing day to day precautionary measures and sample guidance for schools are available at www.irishanaphylax.org.

4. Be careful who you kissTeenagers call a kiss which causes them an allergic reaction ‘being peanutted’. There should be an ‘I have a nut allergy talk’ even before a date. The rule for anyone wanting to kiss a nut allergy sufferer is that after nuts have been eaten, they must eat a peanut-free meal, brush their teeth and wait at least 4 hours before kissing. Brushing teeth is not enough to reduce the risk of peanutting someone, as traces of the allergen remain in the saliva or in the mouth for up to four hours post ingestion. (Maloney 2006)

5. restaurantsEating outside the home can be a risky business, trying to avoid ingestion of nuts in foods or cross contamination, where very small traces of nuts may be on other foods, utensils, hands or surfaces used in food preparation. It is best to ring restaurants before going out, to see if they are able to provide a totally

39

clinical review

nut free meal with very careful preparation. Some restaurant managers and chefs are more helpful than others.

Develop a healthy sense of scepticism about people who might not understand about the severity of the allergy. This is important when ordering food in restaurants. Look the waiter in the eye, make sure they are listening, speak clearly, and be aware that English may not be their first language. Try to make them understand, and then make a judgement about whether you can trust. If not, ask to speak to the manager, or walk away and eat elsewhere.

One golden rule about eating out is never to go to a restaurant if you are very hungry. Non nut allergy sufferers will think this quite mad advice, but it is important. Many risks are taken when very hungry. For example, it is so easy to chance eating the non nut bread, which may or may not have been touching the nut bread, if you have to wait a long time for your food to arrive. This is especially so if the wine has been opened!

Be prepared for a rocky road at times, develop a thick skin and don’t take anything personally as your needs in a restaurant may not be dealt with discretely and sensitively. Recently in a well known Galway restaurant my meal was brought out to me by the waiter, who announced loudly, “who is the nut allergy?”

It is almost impossible to find a restaurant able to assure you desserts will be totally safe.

6. Accept some people won’t understand and others may lie Some people will play down the seriousness of your allergy and others may not want to hear what you are saying. One woman told a mother that her child who had been diagnosed with a severe nut allergy had more chance of being struck by lightening than having a serious reaction to food.

You’ll also meet people like Father Ted’s Mrs Doyle, who will insist repeatedly you eat something they offer you, even though you have explained you can’t.

7. Anaphylactic reaction – be preparedCarry 2 adrenaline auto injectors (Anapens or Epipens) everywhere and know how to use them. A laminated card or bracelet can be helpful for children to explain the allergy, what to do and who to contact in an emergency.

Trainer pens, available on prescription from pharmacies are useful for practising the use of an Anapen or Epipen. Adrenaline should be given through clothes, into the thigh, but be careful to avoid seams and pockets and remember to hold the injector against the thigh for 10 seconds to allow the pen to fully discharge.

Pens are expensive so when they are supplied by the pharmacist check they have expiry dates a long way into the future.

Doses for adult pens contain 300ui of adrenaline. This dose is only intended to help you until you obtain emergency medical help and is not a full adult dose of adrenaline as would be administered by medical professionals.

8. Make friends with your local allergist and gPLiving with allergies can be time consuming, expensive, debilitating, and stressful, so it is important to deal only with people who are knowledgeable and helpful. A good GP can help make sense of your symptoms, diagnose your allergy and assist you in formulating a plan of action.

Keep your asthma well under control and you have a better chance of surviving anaphylaxis. (Colver 2005)

See a consultant allergist, at least every 5 years, more often if necessary. This can ‘move you on’ as new treatments develop all the time.

9. safe Journey! If travelling by plane tell the airline about your allergy when booking your ticket. Carry your medication in hand-luggage. Cards explaining your allergy translated into different languages are helpful and are available from the anaphylaxis association. Have a snack with you in case there is nothing safe to eat.

10. Know when you are likely to break your own rulesWe are only human and at times we take risks when we know we shouldn’t. The chance of this happening increases when you are very hungry, happy, relaxed, sad, distracted, or busy. Basically, whenever you are feeling any emotion strongly. The possibility of risk taking behaviour is exacerbated if alcohol is added to the mix.

conclusionEven with painstaking avoidance of known allergens, every year 1 in 4 people have accidental exposure to the allergen they are allergic to, leading to a food induced reaction, (uS Report 2006).

Acknowledgement To Mark, who inspired this piece of work. God bless. May your life be long and happy.

references:1. Amy M. Branum, Susan L. Lukacs, Food Allergy Among u.S.

Children: Trends in Prevalence and Hospitalizations (2008) www.cdc.gov/nchs/data/databriefs/db10.pdf accessed 18th Feb, 2010

2. Colver A.F, Neventaus H, Macdougall C.F., Cant A.J. Severe food-allergic reactions in children across the uK and Ireland, 1998-2000. Acta Paediatr. (2005) 94(6): p. 689-95

3. Lack G., Fox D., Northstone K., Golding J. Factors associated with the development of peanut allergy in childhood. New Engl J Med (2003) 348(11): p. 977-85

4. Maloney J.M., Chapman M.D., Sicherer S.H. Peanut allergen exposure through saliva: assessment and interventions to reduce exposure. J Allergy Clin Immunol. (2006) 118(3): p. 719-24

5. Perry T., Conover-Walker M., Pomes A., Chapman M., Wood R. Distribution of peanut allergen in the environment. (2004) Journal of Allergy and Clinical Immunology 113: p. 973-976.

6. Pumphry R. Anaphylaxis: can we tell who is at risk of a fatal reaction? Curr Opin Allergy Clin Immunol. (2004) 4: p. 285-90

7. Report of the National Institute of Health Expert Panel on food Allergy Research. ( 2006) www.niaid.nih.gov/topics/foodallergy/documents/foodallergyexpertreport.pdf accessed 18th Feb, 2010

There is an Anaphylaxis Ireland support group meeting for patients with anaphylaxis on Saturday 9th April, 3-5pm, at the Community Meeting Rooms (beside Joyce’s Supermarket ) Knocknaccarra, Galway. All Welcome.

www.yourmedicines.ieNew site lists all leading Irish non-prescription medicines

First Irish online reference site devoted to promoting self care

Site also contains information about illnesses and the proper use of OTC medicines available for their treatment.

Edited by Dr Martin Henman, the site not only acts as a reference guide for pharmacists and other healthcare professionals, it also aims to encourage the public in the correct approach to self-medication.

YourMedicinesA4ad.indd 4 24/02/2011 20:26

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clinical review

Skin conditions like psoriasis and eczema are the fourth most common reason for GP visits in Ireland with between 25% and 33% of the Irish population suffering from a dermatological condition at any one time1.

As well as being at times physically disabling, painful and intensely irritating, conditions such as psoriasis, eczema, acne and rosacea often result in lack of self-esteem, depression and disturbed body image. While these conditions are not fatal, chronic skin disorders significantly impact on the quality of life of many sufferers. This is one area where you can make a real difference to the lives of patients by providing practical, up-to-date advice on the daily management of their skin condition. As well as advising on the many over-the-counter preparations now available to treat common skin conditions and dealing with queries regarding prescription medicines, patients need to be educated about self-care measures to reduce itching, discomfort and pain and to improve the appearance of their skin.

eczemaAtopic dermatitis, more commonly known as eczema, is an itchy inflammation of the skin most often seen in infants and children, but it may continue into adulthood. This chronic condition may be accompanied by asthma or hayfever and although it can affect any area of the body, it classically appears on the arms and behind the knees.

Eczema is now 30% more common than it was in the 1980s, affecting one in five children under the age of seven and one in 12 adults in Ireland.1 With this inflammatory disease, the skin barrier is disrupted and the skin becomes dry and prone to infection. The causes of atopic eczema are still not fully understood but it is thought that it may be the result of a malfunction in the immune system. It is hereditary but research into the genetic causes is still in its infancy.

Signs and symptoms of eczema include itching, which may be severe, especially at night; small, raised bumps, which may leak fluid and crust over when scratched; thickened, cracked or scaly skin and raw, sensitive skin from scratching.

Although it cannot be cured, there are many ways of controlling eczema and most children improve as they get older. It is vital that patients are given good advice on self-care measures, such as avoiding soaps or other irritants and applying creams or ointments correctly.

common skin conditionsMIcHelle McdONAgH

Treatments for eczema aim to reduce inflammation, relieve itching and prevent future flare-ups. These include corticosteroid creams or ointments. which help to ease scaling and relieve itching. Patients should be warned of the side effects of long-term or repeated use of these creams which can include skin irritation and thinning.

Antibiotics may be needed in the case of a bacterial skin infection or an open sore or fissure caused by scratching. Oral antihistamines can be prescribed for severe itching and for more severe cases, a short-course of oral corticosteroids, such as prednisone, may be required to reduce inflammation and to control symptoms. Light therapy can help to control eczema, but patients should be warned about the risks of overexposure to ultraviolet light.

Many parents need support and advice for parents in helping to manage their child’s eczema symptoms. They may need advice on the correct types of moisturisers, soaps and washing powders to use and on how to protect their child against triggers that can cause flare-ups such as fragranced body washes and soaps, hot baths and clothing and bedding made from rough or synthetic fabrics and bedding. Moisturisers help keep skin soft and flexible. They prevent skin cracks and further flare-ups. Avoid moisturisers with fragrances (perfume) and a lot of extra ingredients. One of the most effective moisturisers on the market is Lipikar.

Parents should be informed about the most commonly known foods that trigger eczema flare-ups which include eggs, dairy, wheat, gluten, nuts, citrus fruits, tomatoes and chocolate. In addition, inflammatory foods such as caffeine, sugar, spicy foods, and alcohol have also been found to contribute to flare-ups.

New research has shown that Aveeno Baby Eczema Therapy Moisturising Cream improved symptoms and reduced itching in infants with mild to moderate atopic dermatitis.2 And another study has found that mothers who drank milk with a probiotic supplement during and after pregnancy were able to cut the incidence of eczema in their children by almost half3.

Psoriasis Psoriasis is a very common skin condition with a strong genetic basis that causes skin redness and irritation. The disorder may affect people of any age, but it most commonly begins between ages 15 and 35. The exact cause of psoriasis is unknown although it is thought to be due to abnormally fast

When it comes to common chronic skin disorders there is a wealth of practical, up-to-date advice on the daily management of such conditions which can be given to patients.

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growing and shedding skin cells. Though not contagious, the condition is hereditary. Psoriasis is often recurrent and occurs in varying severities. The main symptoms are thick, red irritated patches of flaky silver-white scales most often seen on the elbows, knees, and trunk, but which can appear anywhere on the body. up to 30% of people with psoriasis may also have a painful condition known as psoriatic arthritis which can result in significant joint pain, stiffness and deformity. Individuals with psoriasis appear to have an increased risk of depression, anxiety and suicidality.4

Factors that may trigger psoriasis include infections such as strep throat or thrush; injury to the skin, such as a cut or scrape, bug bite, or a severe sunburn; stress; cold weather; smoking; heavy alcohol consumption and certain medications – including lithium, beta blockers, antimalarial drugs and iodides.

There is no cure for psoriasis, but there are effective cream and lotion treatments to control the symptoms of mild psoriasis. For mild-to-moderate psoriasis, topical treatments are often effective. Options include corticosteroids or retinoids to reduce inflammation; vitamin D analogs to slow skin growth and tar, to reduce scaling, itching and inflammation. Calcineurin inhibitors (tacrolimus and pimecrolimus) can help reduce inflammation and skin cell build-up.

In addition, ultraviolet light slows the rapid growth of skin cells and uV light therapy may be used alone or in combination with other treatments. Several systemic medications are used for severe forms of psoriasis, though these options pose the risk of serious side effects.

Patients should be advised on self help and homecare measures to help prevent or manage symptoms. A daily bath removes scales and calms inflamed skin and adding bath oil, colloidal oatmeal, Epsom salts or Dead Sea salts can offer additional relief. After bathing, applying a thick moisturising cream or ointment, such as petroleum jelly, can be helpful. During cold, dry weather, it’s beneficial to apply moisturiser several times a day. Short sessions in sunlight three or more times a week can improve psoriasis, as can avoiding known triggers such as smoking and alcohol.

Patients should be advised to avoid harsh products that can irritate skin even more, such as lotions containing alcohol, deodorant soaps, and even some washing powders. Scratchy, rough clothes can also aggravate the skin, so they should be advised to try switching to softer, less irritating cotton-based clothing. And of course, difficult as it can be, they should try to stop scratching their skin as this can make the condition even worse. Studies have found that people with chronic psoriasis who consumed 150g of oily fish a day were able to reduce the use of steroidal creams without experiencing a decline in their condition.5

AcneAnother very common skin condition, acne is a disorder of the hair follicles and sebaceous glands. With acne, the sebaceous glands are clogged, which leads to pimples and cysts. It usually affects people aged between 12 and 25, but some older and younger people are affected. Acne usually affects the face but may also affect the back, neck, and chest and it can range from mild to severe.

Causes of acne include rising hormone levels during puberty, hormonal level changes during the menstrual cycle in women and certain drugs (such as corticosteroids, lithium, and barbiturates). Acne can be aggravated by squeezing the pimples or by scrubbing the skin too hard.

There is currently no treatment that can completely cure acne. The goal of existing acne treatments is to minimise

scarring and improve appearance. Treatment for acne will include topical or systemic drug therapy. Depending upon the severity of acne, topical or systemic medications may be prescribed and in some cases, a combination of both. Over-the-counter topical lotions are generally mild and contain benzoyl peroxide, sulfur, resorcinol, salicylic acid or lactic acid as their active ingredient. These products can be helpful for very mild acne. For acne that does not respond to OTC medication, a stronger prescription treatment such as Tetralysal (Lymecycline) may be required. A once daily capsule, Tetralysal is marketed as a ‘teen friendly acne antiobiotic’.

Systemic antibiotics are often prescribed to treat moderate to severe acne, and may include doxycycline, erythromycin and tetracycline. Isotretinoin (Roaccutane) may be prescribed for individuals with severe, cystic, or inflammatory acne that cannot be effectively treated by other methods to prevent extensive scarring. This medicine is reserved for the most severe forms of acne due to the possibility of severe side effects. Oral contraceptives can improve acne in women.

Research suggests that OTC gels containing 5 percent tea tree oil may be an effective treatment option for mild to moderate acne. Other studies suggest that taking the supplements zinc, guggul or Brewer’s yeast may help treat acne.

Patients should be advised that with most prescription acne treatments, they may not see results for four to eight weeks, and their skin may get worse before it gets better. Younger patients in particular should be advised on good basic skin care routines to try to avoid and control acne.

rosaceaRosacea is a chronic, inflammatory skin condition that usually only affects the face and eyes. Characterised by redness, pimples, and broken blood vessels, rosacea tends to begin after middle age (between the ages of 30 and 60) and is more common in fair-skinned people. Its cause is unknown. Rosacea often begins with easy blushing and flushing of the facial skin.

Eventually, redness will persist around the nose area, extending to the rest of the face. Left untreated, rosacea tends to be progressive, however, in most people the condition is cyclic. Besides acne, rosacea can be mistaken for other skin problems, such as skin allergy or eczema.

Though the exact causes of rosacea are unknown, a number of factors can aggravate rosacea or make it worse by increasing blood flow to the surface of the skin. These include hot or spicy foods and beverages, alcohol, temperature extremes, sunlight, stress or embarrassment, strenuous exercise, hot baths, corticosteroids and drugs that dilate blood.

Again although there is no cure for rosacea, many options exist for the treatment of rosacea, including topical and systemic therapies, laser and light-based therapies, and surgical procedures. Treatment may include diet modifications, topical and oral antibiotics, glycolic acid peels, cortisone cream, laser therapy and dermabrasion.

Patients should be counselled on the triggers of rosacea, proper skin care, photoprotection, and camouflaging cosmetic options. Topical therapy is usually first line, but in moderate-to-severe cases, or those with ocular involvement, systemic therapy may be required. Laser or light-based treatments and surgical procedures can offer added benefit. Many topical agents are available for the treatment of rosacea, and the erythematotelangiectatic and papulopustular variants usually respond most favourably.

references on request.

Heel Balm

To receive trial products, samples and further information, please email Irelandinfo@flexitol.com

Laderma Health (UK) Ltd. www.flexitol.com

n Contains 25% Urea in a highly concentrated, moisturising and emollient base

n Clinically tested to be more effective than creams containing 10% or less Urea 1

n Suitable for general and diabetic foot care in adults

n Effective treatment widely recommended by healthcare practitioners, including Podiatrists, Diabetes Specialists, Dermatologists GP’s and Nurses because it works!

1 Baird S.A., Skinner C.M., Trail S., Frankis J.S., 2002, ‘A study to compare the efficacy of the use of 10% Urea cream and 25% Urea cream on the control of Anhydrosis in the diabetic foot’, Glasgow Caledonian University, Glasgow.

The Medically Proven Treatment for Dry, Cracked Feet

BEFORE AFTER

LHINT Flexitol Ireland Heel Balm Nursing in General Practice Ad A4 P IRHBN-1.indd 1 15/03/11 1:07 PM

44

abstracts

Diagnosing asthma in general practice with portable exhaled nitric oxide measurement – results of a prospective diagnostic study

schneider A, et al.

Department of General Practice and Health

Services Research, university Hospital,

university of Heidelberg, Heidelberg,

Germany

To evaluate the sensitivity, specificity and predictive values of fractional exhaled nitric oxide (FENO) for the diagnosis of asthma in general practice.

Prospective diagnostic study with 160 patients attending 10 general practices for the first time with complaints suspicious of obstructive airway disease (OAD). Patients were referred to a lung function laboratory for diagnostic investigation. The index test was FENO measured with a portable FENO analyser based on electrochemical sensor. The reference standard was the Tiffeneau ratio (FEV1/VC) as received by spirometric manoeuvre and/or results of bronchial provocation. Bronchial provocation with methacholine was performed to determine bronchial hyper-responsiveness (BHR) in the event of inconclusive spirometric results.

88 (55%) were female; their average age was 43.9 years. 75 (46.9%) patients had asthma, 25 (15.6%) had COPD, 8 (5.0%) had an overlap of COPD and asthma, and 52 (32.5%) had no OAD. At a cut-off level of 46 parts per billion (ppb) (n = 30; 18.8%), sensitivity was 32% (95%CI 23–43%), specificity 93% (95%CI 85–97%), positive predictive value (PPV) 80% (95%CI 63–91%), negative predictive value (NPV) 61% (95%CI 52–69%) when compared with a 20% fall in FEV1 from the baseline value (PC20) after inhaling methacholine concentration ≤ 16 mg/ml. At 76 ppb (n = 11; 6.9%) specificity was 100% (95%CI 96–100%) and PPV was 100% (95%CI 72–100). At a cut-off level of 12 ppb (n = 34; 21.3%), sensitivity was 90% (95%CI 79–95%), specificity 25% (95%CI 17–34%), PPV 40% (95%CI 32–50), NPV 81% (95%CI 64–91%) when compared with a 20% fall of FEV1 after inhaling methacholine concentration ≤ 4 mg/ml. Three patients with unsuspicious spirometric results have to be tested with FENO to save one bronchial provocation test.

Asthma could be ruled in with FENO > 46 ppb. Mild and moderate to severe asthma could be ruled out with FENO ≤ 12 ppb. FENO measurement with an electrochemical sensor might be reasonable with respect to the time consuming procedure of bronchial provocation, which carries also some risk of severe bronchospasm. Further research is necessary to evaluate the effectiveness of this dual diagnostic strategy. The number needed to diagnose might be improved when the diagnostic precision could be enhanced by future technical developments.

Successful respiratory control test in preschool-aged children

chipps B, Zeiger rs, Murphy K

et al. Longitudinal

validation of the test for respiratory and

asthma control in kids in pediatric practices.

Pediatrics 2011; 127(3): 737 – 747

A recent study extends the validity and reliability of Test for Respiratory and Asthma Control in Kids (TRACK) by demonstrating its responsiveness to change in respiratory-control status over time in preschool-aged children with symptoms consistent with asthma.

The five item, caregiver-completed Test for Respiratory and Asthma Control in Kids (TRACK) was developed and validated primarily in asthma-specialist practices to monitor respiratory control in preschool-aged children. This longitudinal study in children treated by pediatricians evaluated the responsiveness of TRACK to changes in respiratory – and asthma-control status over time and further assessed TRACK’s reliability and validity.

Caregivers of children younger than five years with symptoms consistent with asthma within the past year (N = 438) completed TRACK at two clinic visits separated by four to six weeks. Physicians were blinded to caregiver assessment, completed a guidelines-based respiratory-control survey at both visits, and were asked whether the visit resulted in a change in therapy. Responsiveness of TRACK to change in respiratory-control status over time was evaluated; reliability and discriminant validity were assessed.

Mean changes in TRACK scores from the initial to follow-up visits differed in the expected direction in subsets of children whose clinical status improved, remained unchanged, or worsened based on physicians’ and caregivers’ assessments (P < 0.001). Mean TRACK scores also differed significantly (P < 0.001) across patient subsets, with lower scores (indicating poorer control) in children classified as very poorly controlled, in those who required a step-up in therapy, and in those who had four or more episodes or attacks of wheezing, coughing, or shortness of breath per week in the past three months.

The present study authors conclude that the validity and reliability of TRACK has been proved by demonstrating its responsiveness to change in respiratory-control status over time in preschool-aged children with symptoms consistent with asthma.

FocuS on: aSthma

• Superior Bronchodilation

versus tiotropium1,2,*

• 5 minute rapid onset of action3

A new first line once daily maintenance treatment for COPD

1

Onbrez® Breezhaler®

Please refer to Summary of Product Characteristics (SmPC) before prescribing. Presentation: Onbrez Breezhaler 150mcg and 300mcg inhalation powder hard capsules containing indacaterol maleate, and separate Onbrez Breezhaler inhaler. Indications: For maintenance bronchodilator treatment of airflow obstruction in adult patients with chronic obstructive pulmonary disease (COPD). Dosage and administration: Recommended dose is the inhalation of the content of one 150mcg capsule once a day, administered at the same time of the day each day, using the Onbrez Breezhaler inhaler. Capsules must not be swallowed. Dose should only be increased on medical advice. The inhalation of the content of one 300mcg capsule once a day has been shown to provide additional clinical benefit with regard to breathlessness, particularly for patients with severe COPD. Maximum dose is 300mcg once daily. No dose adjustment required in elderly patients, for patients with mild and moderate hepatic impairment or for patients with renal impairment. No data available for use in patients with severe hepatic impairment. No relevant use in the paediatric population. Contraindications: Hypersensitivity to the active substance, to lactose or to any of the other excipients. Warnings/Precautions: Asthma: ◆ONBREZ BREEZHALER SHOULD NOT BE USED IN ASTHMA. Paradoxical bronchospasm: ◆If paradoxical bronchospasm occurs Onbrez Breezhaler should be discontinued immediately and alternative therapy substituted. Deterioration of disease: ◆Not indicated for treatment of acute episodes of bronchospasm, i.e. as rescue therapy. Systemic effects: ◆Indacaterol should be used with caution in patients with cardiovascular disorders (coronary artery disease, acute myocardial infarction, cardiac arrhythmias, hypertension), in patients with convulsive disorders or thyrotoxicosis, and in patients who are unusually responsive to beta2-adrenergic agonists. Cardiovascular effects: ◆Indacaterol may produce a clinically significant cardiovascular effect in some patients as measured by increases in pulse rate, blood pressure, and/or symptoms, ECG changes. In case such effects occur, treatment may need to be discontinued. Hypokalaemia: ◆ Beta2-adrenergic agonists may produce significant hypokalaemia in some patients, which has the potential to produce cardiovascular effects. In patients with severe COPD, hypokalaemia may be potentiated by hypoxia and concomitant treatment which may increase the susceptibility to cardiac arrhythmias. Hyperglycaemia: ◆Inhalation of high doses of beta2-adrenergic agonists may produce increases in plasma glucose. Upon initiation of treatment with Onbrez Breezhaler plasma glucose should be monitored more closely in diabetic patients. ◆During clinical studies, clinically notable changes in blood glucose were generally more frequent by 1-2% on Onbrez Breezhaler at the recommended doses than on placebo. Onbrez Breezhaler has not been investigated in patients with not well controlled diabetes mellitus. Pregnancy and Lactation: ◆No data available from the use of indacaterol in pregnant women. Onbrez Breezhaler should only be used during pregnancy if the expected benefits outweigh the potential risks. ◆Not known whether indacaterol / metabolites are excreted in human milk. A decision must be made whether to discontinue breast-feeding or discontinue Onbrez Breezhaler therapy, taking into account the benefit of breast-feeding for the child and the benefit of therapy for the woman. Interactions: ◆Concomitant administration of other sympathomimetic agents may potentiate the undesirable effects of Onbrez Breezhaler. Onbrez Breezhaler should not be used in conjunction with other long-acting beta2-adrenergic agonists or medicinal products containing long-acting beta2-adrenergic agonists. ◆Concomitant hypokalaemic treatment with methylxanthine derivatives, steroids, or non-potassium-sparing diuretics may potentiate the possible hypokalaemic effect of beta2-adrenergic agonists, therefore use with caution. ◆Indacaterol should not be given together with beta-adrenergic blockers (including eye drops) as these may weaken or antagonise the effect of beta2-adrenergic agonists. Where required, cardioselective beta-adrenergic blockers should be preferred, although they should be administered with caution. ◆Inhibition of the key contributors of indacaterol clearance, CYP3A4 and P-gp, does not raise any safety concerns given the safety experience of treatment with Onbrez Breezhaler. ◆Indacaterol has not been shown to cause interactions with co-medications. Adverse reactions: ◆The most common adverse reactions with Onbrez Breezhaler are: nasopharyngitis, upper respiratory tract infection, sinusitis, diabetes mellitus and hyperglycaemia, headache, ischaemic heart disease, cough, pharyngolaryngeal pain, rhinnorrhoea, respiratory tract congestion, muscle spasm, peripheral oedema. ◆Uncommon: paraesthenia, atrial fibrillation and non-cardiac chest pain. ◆Please refer to SmPC for a full list of adverse events for Onbrez Breezhaler. Legal Category: POM Pack sizes: Carton containing 30 capsules (3x10 capsule blister strips) and one Onbrez Breezhaler inhaler. Marketing Authorisation Holder: Novartis Europharm Limited, Wimblehurst Road, Horsham, West Sussex, RH12 5AB, United Kingdom. Marketing Authorisation Numbers: EU/1/09/593/002 & 007. Full prescribing information is available on request from Novartis Ireland Ltd, Beech Hill Office Campus, Clonskeagh, Dublin 4. Tel: 01 2601255 or at www.medicines.ie Date of Creation of API Text: Jan 2010 Date of Preparation: July 2010 NO0610286 References: 1. Onbrez Breezhaler SmPC. 2. Donohue JF, Fogarty C, Lotvall J, Mahler DA, Worth H, Yorgancioglu A, Iqbal A, Swales J, Owen R, Higgins M, Kramer B. Once daily Bronchodilators for Chronic Obstructive Lung Disease: Indacaterol versus Tiotropium. Am J Crit Care Med. June 2010 3. Balint et al. Fast onset of bronchodilation with indacaterol in patients with COPD (ERS Poster) 2009. * INHANCE Study comparitor was open label Tiotropium

ABBREVIATED PRESCRIBING INFORMATION

Project3 16/11/2010 17:17 Page 1

46

abstractsFocuS on: coPD

adherence to recommendations of long-acting bronchodilator use was predicted by agreement with guideline recommendations and self-efficacy

salinas gd, williamson Jc, Kalhan r et al.

Barriers to adherence to chronic obstructive

pulmonary disease guidelines by primary

care physicians. International Journal

of Chronic Obstructive Pulmonary Disease 2011;

2011(6): 171 – 179.

Research from the uS has shown that increasing guideline familiarity alone may have limited patient outcomes, as other barriers, such as low confidence and outcome expectancy, are more likely to impact guideline adherence.

Even with the dissemination of several clinical guidelines, chronic obstructive pulmonary disease (COPD) remains underdiagnosed and mismanaged by many primary care physicians (PCPs). The objective of this study was to elucidate barriers to consistent implementation of COPD guidelines.

A cross-sectional study implemented in July 2008 was designed to assess attitudes and barriers to COPD guideline usage.

Five hundred uS PCPs (309 family medicine physicians, 191 internists) were included in the analysis. Overall, 23.6 per cent of the surveyed PCPs reported adherence to spirometry guidelines over 90 per cent of the time; 25.8 per cent reported adherence to guidelines related to long-acting bronchodilator (LABD) use in COPD patients. In general, physicians were only somewhat familiar with COPD guidelines, and internal medicine physicians were significantly more familiar than family physicians (P < 0.05). In a multivariate model controlling for demographics and barriers to guideline adherence, we found significant associations with two tested guideline components. Adherence to spirometry guidelines was associated with agreement with guidelines, confidence in interpreting data, ambivalence to outcome expectancy, and ability to incorporate spirometry into patient flow. Adherence to LABD therapy guidelines was associated with agreement with guidelines and confidence in gauging pharmacologic response.

The study authors concluded that adherence to guideline recommendations of spirometry use was predicted by agreement with the recommendations, self-efficacy, perceived outcome expectancy if recommendations were adhered to, and resource availability. Adherence to recommendations of LABD use was predicted by agreement with guideline recommendations and self-efficacy. Increasing guideline familiarity alone may have limited patient outcomes, as other barriers, such as low confidence and outcome expectancy, are more likely to impact guideline adherence.

high-intensity exercise training improves heart rate variability at rest and during orthostatic stimulus in patients with coPD

camillo cA, de Moraes laburu v,

gonçalves Ns et al.

Improvement of heart rate variability after

exercise training and its predictors in COPD.

Respiratory Medicine 2011: doi:10.1016/j.rmed.2011.01.014.

According to a recent study better baseline total heart rate variability (HRV), muscle force and daily physical activity level are predictors of HRV improvements after the training program.

Current literature lacks solid evidence on the improvement of heart rate variability (HRV) after exercise training in patients with COPD.

The authors aimed to investigate changes in HRV after two exercise training programs in patients with COPD and to investigate the determinants of these eventual changes.

Forty patients with COPD (FEV1 39 ± 13 per cent pred) were randomised into high (n = 20) or low (n = 20) intensity exercise training ( three month duration), and had their HRV assessed by the head-up tilt test before and after either protocols. Baseline spirometry, level of daily physical activity, exercise capacity, body composition, functional status, health-related quality of life and muscle force were also assessed to investigate the determinants of improvement in HRV after the training program.

There was a significant improvement in HRV only after the high-intensity protocol (pre versus post; SDNN 29 ± 15 ms versus 36 ± 19 ms; rMSSD 22 ± 14 ms versus 28 ± 22 ms; p < 0.05 for both). Higher values of biceps brachialis strength, time spent walking in daily life and SDNN at baseline were determinants of improvement in HRV after the training program.

High-intensity exercise training improves HRV at rest and during orthostatic stimulus in patients with COPD. Better baseline total HRV, muscle force and daily physical activity level are predictors of HRV improvements after the training program.

47

product news

Lick 'dry mouth' with BioXtra

Research suggests that as many as one in five people suffer from dry mouth or Xerostomia.

Saliva plays an essential role in maintaining oral health and quality of life. A persistent alteration to the salivary gland function may cause a decrease in the quantity or quality of saliva causing ‘dry mouth’ which can lead to difficulty in tasting, chewing and swallowing. untreated, Dry Mouth can also increase your chance of developing dental

decay, infections in the mouth and even difficulty speaking.Dry Mouth can be caused by a variety of factors such as

smoking, mouth breathing, stress, depression, hormones and head and neck radiotherapy. Dry Mouth can cause many different and distressing side effects; including a constant need for moisture, bad breath, altered taste, burning tongue, tooth decay and loss, gum inflammation and disease, pain and discomfort, digestive problems, problems with dentures and in some cases, even malnutrition.

BioXtra has proven to be effective to ease the symptoms of dry mouth. In recent double blind tests on patients suffering

In March 2011, Nutricia Medical is launching a new, enhanced version of its tube nutrition range. For the first wave of the launch the composition of the following products will change:

- Nutrison- Nutrison Multi Fibre- Nutrison Energy- Nutrison Energy Multi FibreOther variants in the Nutrison product

portfolio will follow from 2012 onwards.These products have been reformulated

to extend their tolerance related benefits and to comply with the latest leading international nutritional guidelines.

Nutrison has always led the field in tolerance standards with its clinically proven MF6™ Multi Fibre mix and carotenoids, which are proven to reduce oxidative stress. New Nutrison builds on these benefits and targets both upper and lower digestive complications with:

A whey enriched protein blendImproved amino acid profileThe addition of Omega 3 fatty acids & MCTsIncreased Vitamin D levels

with post-radiotherapy dry mouth, symptoms of dryness, chewing difficulties, swallowing difficulties, speech difficulties, taste problems and burning sensations were all greatly reduced.

unlike other similar products for dry mouth, BioXtra works on both the outer and inner layers of biofilm. BioXtra mimics saliva’s natural protective activity.

The BioXtra range comprises six products; a gel, spray gel, mouthrinse, toothpaste, chewing gum and sucking tablets. used daily, the advanced formulation in BioXtra products gently eases the symptoms of dry mouth, helps to reduce unwanted bacteria and leaves the mouth feeling fresh and comfortable.

Nutricia Medical launches new nutrison, the most clinically advanced tube nutrition

For further information on New Nutrison contact Nutricia Medical on Freephone 1800 923 404 or visit our website, www.nutricia.ie

48

product news

Janssen receives marketing rights for cancer medication CAELYX

Janssen recently announced, that it has assumed marketing rights for the cancer medicine CAELYX (pegylated liposomal doxorubicin hydrochloride) in Ireland.

The marketing and other product rights were transferred to Janssen as part of a 1996 distribution agreement between the product’s originator, which is an affiliate of Janssen, and an affiliate of MSD. In addition to Ireland, Janssen has assumed marketing responsibilities in Europe and associated countries, Canada, Latin America, the Middle East and Asia-Pacific (excluding Japan). Prior to 1 January, 2011, Janssen affiliates already marketed the product in the united States, Japan and Israel, under the trade name DOXIL. Combined, CAELYX and DOXIL are marketed in more than 80 countries.

Adrian Fenlon, Business unit Manager at Janssen, comments, “It is satisfying that CAELYX is now a core part of the Janssen portfolio. We are very excited to begin discussing CAELYX with clinicians and it is a great addition to our growing oncology portfolio that also includes VELCADE and EPREX.”

MSD and its affiliates have worked with Janssen and its affiliates in Ireland to implement a smooth transtion and to ensure that there is no interruption to supply of treatment for patients.

The medication will continue to be sold as CAELYX in markets outside the united States, Japan and Israel, where it will continue to be sold as DOXIL. CAELYX branding and packaging will be refreshed in early 2011.

CAELYX is a long-circulating pegylated liposomal formulation of doxorubicin hydrochloride, a widely used cytotoxic agent.

Rosaliac – skin perfecting moisturiser

La Roche-Posay Rosaliac is a skin perfecting moisturiser that offsets and neutralises redness in reactive sensitive skin. Rosaliac is also available with uV protection, Rosaliac uV and Rosaliac uV Riche, which has SPF15 – UVA7 & SPF15 – UVA8 respectively, to protect the skin from uV rays which can further damage the skin. uV rays are considered by dermatologists as a worsening factor of redness as exposure further weakens the blood vessels.

Rosaliac uses two vitamins with complementary action to diffuse the onset of redness. With Vitamin B3, natural defences are stimulated to protect skin and calm redness. Vitamin CG strengthens fragile or weakened blood vessels and diminishes their reactivity. Rosaliac neutralises redness at the source, hydrates and fortifies the skin.

Rosaliac by La Roche-Posay soothes sensations of discomfort. The core ingredient of Rosaliac is La Roche-Posay Thermal Spring Water which supplies anti-free radical, soothing and decongesting properties. The Rosaliac formula, rich in glycerine, has been specially developed to supply long-lasting hydration. Rosaliac has a fine, green tinted, smooth texture which naturally offsets redness, contains no perfume and provides an excellent make-up base.

Day after day the skin is transformed, has a more luminous and unified complexion with long-lasting comfort.

Risontel (Risedronic Acid) 35mg Once a Week Film-coated Tablets for osteoporosis

Clonmel Healthcare have launched Risontel (Risedronic Acid) 35mg Once a Week Film-coated Tablets. This product will join our other medicine product listings within the Ethical Prescription Division of Clonmel Healthcare.

Risontel is for the treatment of postmenopausal osteoporosis, to reduce the risk of vertebral fractures and hip fractures. It is also used to treat osteoporosis in men at high risk of fractures.

Risontel (Risedronic Acid) 35mg Once a Week Film-coated Tablets are 28% cheaper than the brand leader.

Risontel 35mg Once a Week Film-coated tablets are available on the GMS from 1st January 2011.

The GMS code for Risontel 35mg Once a Week Film-coated Tablets is -50703:

Full prescribing information is available on request or go to www.clonmel-health.ie .

49

crossword

Name:

Address:

Email:

Congratulations to the winner of last month’s crossword, Peggy O’Halloran, C/O Dr Halkett’s Surgery, 71 Churchstreet, Listowel, Co Kerry.Please send your answers to the Editor, Nursing in General Practice, GreenCross Publishing, 7 Adelaide Court, Adeliade Road, Dublin 2. Closing date for entries: May 2nd 2011.Winner will receive v50. Please note: the winners’ cheques will be sent out within 45 days.

Caltrate is a trademark. PA 172/38/1. Full prescribing information available from Wyeth Consumer Healthcare, Plaza 254, Ballycoolin, Dublin 15 or from www.medicines.ie

AcrOss1 Would a raised spot on the skin unexpectedly

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arrest (7)10 Mac’s intricate swindle (4)11 Ms. Campbell (5)14 A lot of thought goes into this organ (5)16 Ingests various teas (4)18 Can a broken bidet be the cause of low water?

(3,4)20 A fishy way to pay a midwife? (3)21 Car for hire! (4)22 A disorganised battle is a hard pill to swallow

(6)

dOwN1 Large American cat (4)2 A canape, when blended, is a cure for all ills (7)3 Colum comes around for a replacement (5)5 See a Hawaiian garland in leisure (3)6 I clued the father of geometry mistakenly (6)7 Fe, in periodic table, for a golf club (4) 12 The kind of illusion that one sees differently (7)13 A thing to oppose! (6)15 You’ve got it at your fingertip (4)16 Colonic irrigation (5)17 Prepare a varied diet for publication (4)19 Chest punch? (3)

ANswers TO lAsT MONTH’s crOsswOrdACROSS 5 ovary 6 niacin 8 inch 9 trachoma 10 antenna 12 home 13 peer 15 pharaoah 17 fracture 20 lima 21 charge 22 cometDOWN 1 cornea 2 catheter 3 cyst 4 rash 6 niagara 7 in mem 11 neptune 12 headlamp 14 earth 16 humpty 18 cork 19 etch

1 2 3 4 5 6

7

8 9

10 11 12

13

14 15 16

22

17

18 19

21

20

For samples or further information call Nutricia on 1800 923 404

Nutricia Medical, Block 1, Deansgrange Business Park, Deansgrange, Co. Dublin. Email: support.ireland@nutricia.com

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Forticreme A4 Advert Update.indd 1 03/09/2010 15:02:12