The Journal of the Irish Practice Nurses AssociationIssue 4 Volume 4 July/August 2011

SuddeN cArdIAc deATh IN

The youNgHelen O’Donnell

IPNA coNfereNce – why you Need To be There

Lynn Cartwright

‘Desperately seeking’ acaDemiaKaren Canning

IPNA ClINICAl AwArd 2011Your chance to win €1000 educational bursary

The Prince STudy – PracTice nurSeS’ exPerienceSDr Dympna Casey et al

STrucTured cAre ProgrAmme for

dIAbeTIc PATIeNTSWinnie McCabe

Free Educational Seminarsfor Healthcare Professionals

PROBIOTIC SEMINARSThe Yakult science team is currently taking bookings for both primary and secondary healthcare professionals. So if your journal club, branch meeting or department would like an update on probiotic research from a member of our team (consisting of a microbiologist and nutritionists) please get in touch with us.

These seminars objectively review the scientific evidence for probiotics and can be tailored to your specific areas of interest, for example digestive health, immune benefit, elderly care, and infection control.

WHAT ATTENDEES SAY“Our November meeting was held in the Abbey Hotel Roscommon and was very well attended. The meeting was kindly hosted by Deirdre Jordan of Yakult Ireland, who gave us an amazing presentation on research done regarding the benefits of probiotics. She explained that not only do probiotics contribute to a balanced diet but that there is growing evidence that probiotics provide health benefits in a clinical setting.”

Practice nurse Roscommon Branch IPNA

THE IMPORTANCE OF STAYING UPDATEDContinuing professional development (CPD) is relevant to all healthcare professionals. CPD helps maintain, improve and broaden knowledge so that patients can be given the best quality of care. CPD is your commitment to being professional, keeping you up to date and enabling you to continuously improve skills. CPD has become progressively more important due to the rate at which scientific research is being published and the emphasis on patient-led care.

WHO WOULD BENEFIT FROM A SEMINAR?The seminars are aimed at all healthcare professionals, but may be of particular interest to dietitians, practice nurses, students and anyone interested in nutrition, infection control, gastroenterology or elderly care.

Email science@yakult.ie to enquire about a free seminar on probiotics, placing ‘Presentation’ in the subject box; alternatively you can call us on the number below. (Please note Yakult will not pass your email address to any third parties.)

Yakult Ireland, Suite 215, The Capel Building, Mary’s Abbey, Dublin 7 science@yakult.ie +353 (0)1 804 7695

Are you interested in probiotics? Would you like to know more about specific areas of research?

Then speak to the Yakult science team to find out how they canhelp you make evidence-based decisions regarding probiotics.

1

editorial

optimist or realist –the Stockdale paradox

Our incomes have been slashed, our taxes increased, our services cut, private pensions decimated, the country is broke and we have lost our economic sovereignty. We are told that ”we have brought it all on ourselves.” (Brian Cowen). We were apparently “living beyond our means.” The economic bubble has burst, and we as a people are left to nurse the hangover. Whose fault is it?

Most of us actually work very hard and squirrel away some money for the future only to find the government chipping away 0.6% of our pensions to help mend the economic crisis.

Can it get any worse?Whilst reflecting on all the doom and gloom, I came across the story of Mark Pollock. An

ordinary man with extraordinary courage. Mark trekked the South Pole last year. He was the first blind man to conquer the South Pole.

Indeed, Mark Pollock could rightfully ask the same question. “Could it get any worse”? Whilst a young healthy 22 year Mark went suddenly and completely blind. That was 12 years ago. He has since rebuilt his life, got a job, a girlfriend, won two commonwealth medals for rowing, become a motivational speaker and has written an inspirational book called, Making It Happen.

He also ran six marathons across the Gobi Desert in 2003 raising funds for Sight Savers International.

Alas, three weeks before his wedding, Mark fell from a second floor building and broke his back.

Today he finds himself on the flat of his back, not able to walk without the help of a suspension sling. His life again has collapsed. The point I am making is – he did not give up. He explains on his blog that the first step in a crisis is to start “dealing in facts.”

“But I am struggling to work out what they are, are my legs temporarily asleep or am I just in denial. If I embrace and accept that my legs are not working then will I shut off the power of the mind to fix what we do not understand?”

Pollock explains that he read a book by Jim Collins called From Good to Great. He spoke about the Stockdale Paradox in relation to long term prisoners of war. He declared that “Optimists were not the ones to survive.” This analogy left Pollock confused. Should he be super positive and say he will make a full recovery or does he risk being a “Stockdale optimist”.

Let’s go back to our ”economic crisis”. Where is the line between realism and giving up?As a nation we must never give up.Who would have imagined such a successful visit from the Queen let alone the most

powerful man in the world to walk our land, but they did. “Many of the great achievements in the world were accomplished by tired and discouraged

men who kept on working.” Anon.“If we are together nothing is impossible. If we are divided all will fail”. Winston Churchill.Recent events have shown that Ireland can perform very well on many fronts, we can bury

our heads in the sand, or we can stand united and, never give up.As for my friend Mark Pollock, optimist, realist or is he something else?I think he is something else, a total inspiration.

darina Lane

Abdominal Distension bothering your IBS patients?

The sensation of abdominal swelling (bloating) and the physical increase in girth size (distension) are troublesome features of Irritable Bowel Syndrome (IBS). Abdominal bloating is often ranked the most troublesome symptom for patients with IBS, being reported by up to 96% of patients1-6.

Abdominal Bloating & Distension in IBS patients

A number of studies have demonstrated that Activia® may help improve digestive comfort7-10. One of these studies, a randomised, controlled, double-blind, parallel study of 34 women (20-69 years) with constipation predominant IBS, who consumed 2 x 125g servings of either Activia®* (n17) or a non fermented dairy product (n17) daily for 4 weeks demonstrated the following7:

ACTIVIA® can help reduce Abdominal Distension

Figure 1: Comparison of the mean hourly abdominal distension measurements over the awake hours of the measurement after consuming the test product and control product

78% (4.1cm) reduction in maximal abdominal distension**‡

Improved colonic** and orocaecal** transit time

Overall improvement in IBS symptom severity**

‡ Measured using a recently validated technique of Abdominal Inductance Plethysmography (AIP), based on the principle that a loop of inductance wire is stitched into a soft belt, worn by the patient and this then measures changes in girth size throughout the day.* Activia is a probiotic food containing the exclusive probiotic culture Bifidobacterium lactis DN 117 010 (Bifidus ActiRegularis®) which should be consumed as part of a healthy balanced diet and lifestyle.** p=<0.05

References: 1Manning AP et al. (1978) BMJ 2, 653-654. 2Maxton DG et al. (1989) BMJ 99, 1138. 3Schmulson M et al. (1999) Am J Gastroenterol 94, 2929-2935. 4Lee O-Y et al. (2001) Am J Gastroenterol 96, 2184-2193. 5Chang L et al. (2001) Am J Gastroenterol 96, 3341-3347. 6Hungin APS et al. (2003) Aliment Pharmacol Ther 17, 643-650. 7Agrawal A et al. (2008) Aliment Pharmacol Ther 29(1), 104-114. 8Guyonnet D et al. (2009) BJN 22, 1-9. 9Guyonnet D et al. (2007) Aliment Pharmacol Ther 26(3), 475-486. 10Guyonnet D et al. (2009) J Digest Dis 10, 61-70.

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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 4 Volume 4 July/August 2011

*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

Abdominal Distension bothering your IBS patients?

The sensation of abdominal swelling (bloating) and the physical increase in girth size (distension) are troublesome features of Irritable Bowel Syndrome (IBS). Abdominal bloating is often ranked the most troublesome symptom for patients with IBS, being reported by up to 96% of patients1-6.

Abdominal Bloating & Distension in IBS patients

A number of studies have demonstrated that Activia® may help improve digestive comfort7-10. One of these studies, a randomised, controlled, double-blind, parallel study of 34 women (20-69 years) with constipation predominant IBS, who consumed 2 x 125g servings of either Activia®* (n17) or a non fermented dairy product (n17) daily for 4 weeks demonstrated the following7:

ACTIVIA® can help reduce Abdominal Distension

Figure 1: Comparison of the mean hourly abdominal distension measurements over the awake hours of the measurement after consuming the test product and control product

78% (4.1cm) reduction in maximal abdominal distension**‡

Improved colonic** and orocaecal** transit time

Overall improvement in IBS symptom severity**

‡ Measured using a recently validated technique of Abdominal Inductance Plethysmography (AIP), based on the principle that a loop of inductance wire is stitched into a soft belt, worn by the patient and this then measures changes in girth size throughout the day.* Activia is a probiotic food containing the exclusive probiotic culture Bifidobacterium lactis DN 117 010 (Bifidus ActiRegularis®) which should be consumed as part of a healthy balanced diet and lifestyle.** p=<0.05

References: 1Manning AP et al. (1978) BMJ 2, 653-654. 2Maxton DG et al. (1989) BMJ 99, 1138. 3Schmulson M et al. (1999) Am J Gastroenterol 94, 2929-2935. 4Lee O-Y et al. (2001) Am J Gastroenterol 96, 2184-2193. 5Chang L et al. (2001) Am J Gastroenterol 96, 3341-3347. 6Hungin APS et al. (2003) Aliment Pharmacol Ther 17, 643-650. 7Agrawal A et al. (2008) Aliment Pharmacol Ther 29(1), 104-114. 8Guyonnet D et al. (2009) BJN 22, 1-9. 9Guyonnet D et al. (2007) Aliment Pharmacol Ther 26(3), 475-486. 10Guyonnet D et al. (2009) J Digest Dis 10, 61-70.

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4 NewS

8 brANch NewS

revIew

9 STrucTured cAre ProgrAmme for dIAbeTIc PATIeNTS role of the practice nurse ms winnie mccabe

educATIoN

21 ‘deSPerATeLy SeekINg’ AcAdemIA ms karen canning

IPNA coNfereNce – doN’T mISS IT!

16 regISTrATIoN form

AgeNdA

17 why you ShouLd be There Lynn cartwright

20 IPNA cLINIcAL AwArd 2011 your chance to win €1000 educational bursary

revIew

27 SuddeN cArdIAc deATh IN The youNg ms helen o’donnell

reSeArch

23 The PrINce STudy – PrAcTIce NurSeS’ exPerIeNceS dr dympna casey et al

AbSTrAcTS

30 ALLergy

33 ProducTS

37 croSSword

4

news

Cervical Cancer Vaccine ‘catch-up’ programme Health Minister Dr James Reilly recently announced an extension of the cervical cancer vaccination programme to begin in September of this year. From September on, a ‘catch-up’ programme will be launched in the nation’s schools so that all girls in 6th year will be able to avail of the vaccine as well as the girls in 1st year. The HSE is making the necessary arrangements to ensure that all girls in the relevant years who wish to receive the vaccine can do so free of charge.

“The wonder of a vaccine that can prevent cancer” cannot be underestimated and the great opportunity and protection it confers should not be missed, said Dr Reilly” Minister Reilly is satisfied that the planned extension of the scheme “will save many lives over the coming years protecting our people from the scourge of cancer”. The Minister also appealed to mothers, “who are concerned about any aspects of the vaccine to discuss it with their primary care professional. While the target uptake of 80% has been reached in the relevant groups in certain parts of the country, the Minister hoped that greater numbers would take advantage of the health protection provided by the vaccine. The Minister thanked the HSE for its work in making this important catch-up scheme become a reality.

Dr Brenda Corcoran, Head of the HSE National Immunisation Office, said ‘All parents of girls who are getting the vaccine in September will receive a detailed information booklet and consent form from the HSE. These will be sent from their daughter’s school before the vaccinations begin‘ ‘In the meantime, we encourage all parents and students to visit our website www.hpv.ie, where they can read all about HPV and the vaccine, and see many links to international scientific information and evidence about the value and safety of this vaccine. Preliminary figures show very high uptakes for the three doses of vaccine given to 1st and 2nd years this year. Many parts of the country have achieved the target uptake of over 80%. This is a great credit to the work of the HSE vaccination teams.’

CervicalCheck information – available in 11 languages

The Information Sheet for Women which is offered to all women who attend for a CervicalCheck smear test has been translated into Polish, Arabic, Chinese (Mandarin), French, German, Irish, Latvian, Lithuanian, Romanian, Russian and Spanish. The sheet provides information on the screening process to ensure women can make a fully informed choice before signing their consent to have a smear test. All translated versions of the ‘Information Sheet for Women’ are available to view and download from ‘use-ful Forms and Downloads’ in the Health Professionals section of www.cervicalcheck.ie.

The National Cancer Screening Service (NCSS) is committed to ensuring both its services and information materials are as acces-sible as possible to all women, regardless of their level of literacy, ability or spoken language. The translated Information Sheet for Women will enable women to make a fully informed decision regarding their smear test and will better understand the process involved.

The NCSS works closely with the National Adult Literacy Agency (NALA) to ensure its information for women achieves the ‘Plain English’ mark. All efforts are made to ensure that simple, sensitive and easy to understand language is used in materials and on web-sites. This is done to address barriers to screening which include fear, literacy difficulties, language barriers and embarrassment.

Additional resources available for women include a loop system in all four BreastCheck static screening units and certain letters and information materials in Braille. A sign language interpreter can be made available on request at all screening units. All mobile units and screening units are fully accessible to people with dis-abilities.

Men’s heart health – SeptemberThis September the Irish Heart Foundation’s Heart Month Campaign will focus on men.

More men die from heart attack and stroke than any other cause of death. As part of Heart Month, the Irish Heart Foundation will lead out on a nationwide TV advertising campaign encouraging men to know about the signs of a heart attack and to call 999 before it’s too late.

A resource for men informing them of how they can make positive lifestyle changes and limit their risk of heart attack will be widely available.

The Irish Heart Foundation is asking you to support and promote the campaign by: • Ordering and displaying Heart Month materials• Distributing Heart Month materials to men• Including a piece on Heart Month on your organisation

website or newsletter• Hosting an event for men (and friends and family)

If you would like to order free Irish Heart Month Promotional Materials or for further information on promoting Heart Month please contact: Mairéad O’Callaghan at 01 668 5001 or heartmonth@irishheart.ie

NEC NEWS

Nec meeTINgS 2011 Wednesday 7th September 2011 – Ashling Hotel, Parkgate Street, Dublin 8.Friday 14th October 2011 – Tullamore Court Hotel, Tullamore, Co Offaly.

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 2011Valerie Mangan IPNA Loyalty Award 2011 Closing date for lists of entries from Branch Treasurers is Sunday 31ts July 2011. See Grants and Awards page of IPNA website for details.

IPNA educational bursary 2011 Closing date for entries is Sunday 31ts July 2011. See Grants and Awards page of IPNA website for details.

IPNA clinical Award 2011 (see Case Study in this issue – page 20). Closing date for entries is Sunday 11th September 2011.

For more information contact Lisa Nolan: 042-9692403 or email: admin@irishpracticenurses.ie

5

news

RTE’s Marian Finucane recently launched a range of practical resources for end-of-life care, including a redesigned Family Handover Bag, which are being introduced into Irish hospitals in an effort to enhance the dignity of dying patients and their families.

The resources, which are already in use in many hospitals countrywide, have been developed by the Hospice Friendly Hospitals (HFH) Programme, an initiative of the Irish Hospice Foundation, in partnership with the Health Service Executive and hospitals around the country.

This flagship five-year programme aims to improve the quality of end-of-life care for patients and their families by putting hospice principles into hospital practices. The initiative was launched by President Mary McAleese in 2007. Over 60 acute and community hospitals are now involved in the programme nationwide.

The Family Handover Bag was originally launched in February 2005 and has since been redesigned. It is being used in most Irish hospitals as a dignified way to return the personal possessions of a deceased patient to their family and as an alternative to the practice of returning belongings in a plastic bag.

Another key resource is the end-of-life spiral which was specially designed by the HFH Programme and is displayed whenever a person has died. It is a signal to all staff that an intensively personal and profound event has happened. The spiral is replicated in other materials that have been developed including an end-of-life door sign and a bed/trolley drape which is placed over the deceased person as s/he is transferred off the ward or out of hospital.

Other resources developed by the HFH programme include a mobile multi-denominational ward altar which can be placed at the patient’s bedside and contains articles to support spiritual and culture care before and after death of patients of different faiths.

Speaking at the launch, Ms Finucane stated: “It wasn’t that long

ago that someone would be handed a loved one’s belongings in a black plastic bag. Thankfully that is no longer the norm. However, people are still dying in public wards with TVs blaring in the background. Family members have been distressed to get no answer from staff to their enquiries about what was going to happen to their loved one who had just died. The shabby surroundings of our hospital buildings have contributed to the grief they are experiencing. These insensitive and unnecessary scenarios are all products of a system that does not recognise end-of-life care at a key mission.”

End-of-life care in hospitals launch

marian finucane holds the end-of-life spiral which was specially designed by the hospice friendly hospitals Programme – an initiative of the Irish hospice foundation and the health Service executive. The spiral is displayed when a person has died. It is a signal to all staff that an intensively personal and profound event has happened.

Dr. Fiona Lyons Consultant Genitourinary Medicine GUIDE Clinic, Dublin

GUIDE CLINIC, STI foundation course

STIF core Friday 30th September

STIF plus Saturday 1st October

Venue: William Stokes Postgraduate Centre, St. James’s Hospital, Dublin

Cost: €210 per day or €400 for both days (includes lunch and refreshments)

For more information contact: Sandra Delamere, sdelamere@stjames.ie or

guidesuper@stjames.ie

INCLUDES ATTENDANCE AT A CLINICAL SESSION AT THE GUIDE CLINIC

6

news

“Carlton Clinic’s highest priority for the last three decadeshas been providing the best quality care to our 20,000patients. We demand high quality equipment and suppliesto match the expertise of our staff. We have an excellentrelationship with Promed, who have reliably provided uswith products and services over the past 25 years.

When Promed announced the Promed Advance package,we were delighted to avail of the opportunity to review allour equipment. Niall and Paddy checked and labelled every

piece of equipment in each room and prepared a detailedAsset Register.

We identified a few pieces of equipment which we expectto replace over the coming years and set a plan in place forrenewals and maintenance. It gives me peace of mind asa practice manager to know these will be taken care of,whilst keeping well within the Practice’s equipment budget.

Perhaps the best part of the Promed Advance package isthat it encourages us to use our equipment to the full, bothbecause of the handy manuals included in our PromedAdvance pack, and also through training given when newequipment is installed on site.

We are now looking forward to producing patientinformation leaflets in conjunction with Promed, to supportour screening services and generate income – so that ourpatients as well as the practice can get the best from ourequipment.”

For the full article please go to www.promed.ie/medical/news/Carlton-Clinic and for more information on PromedAdvance log onto the Promed website www.promed.ie orcall Promed on freephone 1800 619 619

Pictured: MaryToomey of TheCarlton Clinicbeing presentedwith her AssetRegister by PaddyHart, PromedService Engineer

Advance Performance - An Innovative New ServiceQuick feedback from Mary Toomey at The Carlton Clinic, Bray

Mary Toomey, Practice Manager,The Carlton Clinic, Bray, Co Wickow

AdvanceAdvertorial:Layout 1 19/05/2011 15:29 Page 1

world’s first mSc in end-of-life healthcare ethics offered in uccThe world’s first Master’s degree in end-of-life healthcare ethics has been launched by university College Cork (uCC) and begins next September.

up to 25 students will be accepted onto this multidisciplinary programme that will run on a part-time basis over two years. The course is jointly offered by the School of Nursing and Midwifery; the School of Medicine and the School of Philosophy and Sociology at uCC.

This unique MSc emerged out of a groundbreaking national project undertaken by uCC, the Royal College of Surgeons in Ireland and the IHF (through the Hospice Friendly Hospitals programme) over three years. The research, both Irish and international, had in-put from ethicists, sociologists, legal experts, theologians and clini-cians. It culminated in the development of an Ethical Framework for End-of-life Care which was launched in October 2010. The Frame-work has since been distributed to hospitals and other healthcare settings countrywide for use as an educational resource.

Course director Dr Joan McCarthy of the School of Nursing & Midwifery at uCC, stated: “Doctors and nurses face moral and ethical challenges every day in caring for dying patients and their distressed families. How do I break bad news? Is this treatment futile and should it be withdrawn? Does this individual have the mental capacity to decide on her treatment? What will I do if a patient refuses treatment e.g. ventilation, chemotherapy, medication which I believe would prolong life? Should I document a Do Not Attempt Resuscitation Order (DNAR) for this patient? What should I do if there is no DNAR order? Research has found a keen need and demand for ethics education and support for health professionals across a range of disciplines. There is also an increasing public inter-

est in Ireland and abroad in recent years on decision making at the end of life. With its unique focus, this programme will contribute to meeting these needs.”

She continued: “The programme is focused on improving clinical practice. Health professionals have been troubled by the challenges they have to meet. These ethical worries can cause personal and professional angst. International research has found that some respond by leaving their profession early or changing professions altogether. This course will counter the emotional and psycho-logical cost of dealing with ethical challenges and that feeling of being powerless while also feeling responsible. It will give people greater confidence to raise nagging doubts and uncertainties and address any concerns constructively and collaboratively. They will be equipped with the tools to find the most ethical and negotiated solutions to the ethical, professional and legal dilemmas that they may encounter.”

Dr McCarthy said that it was hoped that after their studies, the healthcare ethics graduates would be able to apply comprehen-sive and well-assimilated knowledge and critical skills to ethically challenging situations that arise in relation to death and dying. They would also act as innovators and leaders in healthcare ethics and contribute to practice development and best practice.

Meanwhile, the IHF scholarship will cover the MSc course fees over two years for the successful candidate. The scholarship applica-tion is separate from the course application but should be sent to the Course Director, Dr Joan McCarthy. Applicants must apply in writing (no more than 1,000 words) and outline how they would expect the programme to impact on patient care and how to use the course to educate and inform others in their work organisation.

7

news

“Carlton Clinic’s highest priority for the last three decadeshas been providing the best quality care to our 20,000patients. We demand high quality equipment and suppliesto match the expertise of our staff. We have an excellentrelationship with Promed, who have reliably provided uswith products and services over the past 25 years.

When Promed announced the Promed Advance package,we were delighted to avail of the opportunity to review allour equipment. Niall and Paddy checked and labelled every

piece of equipment in each room and prepared a detailedAsset Register.

We identified a few pieces of equipment which we expectto replace over the coming years and set a plan in place forrenewals and maintenance. It gives me peace of mind asa practice manager to know these will be taken care of,whilst keeping well within the Practice’s equipment budget.

Perhaps the best part of the Promed Advance package isthat it encourages us to use our equipment to the full, bothbecause of the handy manuals included in our PromedAdvance pack, and also through training given when newequipment is installed on site.

We are now looking forward to producing patientinformation leaflets in conjunction with Promed, to supportour screening services and generate income – so that ourpatients as well as the practice can get the best from ourequipment.”

For the full article please go to www.promed.ie/medical/news/Carlton-Clinic and for more information on PromedAdvance log onto the Promed website www.promed.ie orcall Promed on freephone 1800 619 619

Pictured: MaryToomey of TheCarlton Clinicbeing presentedwith her AssetRegister by PaddyHart, PromedService Engineer

Advance Performance - An Innovative New ServiceQuick feedback from Mary Toomey at The Carlton Clinic, Bray

Mary Toomey, Practice Manager,The Carlton Clinic, Bray, Co Wickow

AdvanceAdvertorial:Layout 1 19/05/2011 15:29 Page 1

New blended learning course for rheumatology professionals launchedA new blended learning course module entitled Principles of Musculoskeletal Assessment for Rheumatology Health Professionals, jointly developed by subject experts from Our Lady’s Hospice and Care Services in Harold’s Cross, Dublin and Roche Products (Ireland) Ltd was launched recently.

The course, developed to support rheumatology health professionals, combines both online eLearning modules and a formal workshop assessment (available on completion of the eLearning course). It is designed to complement clinical practice by demonstrating the correct techniques to use when conducting a musculoskeletal assessment.

Clinical Facilitator at Our Lady’s Hospice and Care Service’s Harold’s Cross, Ms Eileen Shinners, who wrote the content for the module, provided the assembled audience of nurses, doctors, occupational therapists and physiotherapists with a demonstration of the new learning tool.

Ms Shinners also explained that the overall aim of the module was to provide an increased knowledge of MSK assessment; a standardisation of assessment processes; a validation of current practice and the assessment of competence of MSK valuation skills.

The complete course is CME accredited by An Bord Altranais with accreditation sought from the Royal College of Physicians of Ireland (RCPI). This is the first course of its kind available in the rheumatology field in Ireland and was enabled through an educational grant for the development of the online modules by Roche Products (Ireland) Ltd.

The eLearning modules and details of upcoming workshops are available at http//://roche.aurionlearning.com/. Additional information can be found by visiting www.olh.ie/education.

Tackling infections in sportFour of Ireland’s best-known sporting stars joined forces recently to launch a unique health awareness campaign that aims to help all those involved in sporting activities to avoid the threat of infections in sport.

Sponsored by pharmaceutical company, sanofi pasteur MSD, the guide’s practical, easy-to-understand advice has garnered the endorsement of the IRFu, FAI, GAA and The Irish Hockey Association.

The initiative, entitled Infections in Sport...Prevention is Key, raises awareness of the many infections that can be acquired in sport. It highlights the importance of focusing on safe practices amongst athletes, their coaches and all those who practice first aid in the absence of a health care professional.

At the study day held in dublin recently were: (front row) ms bernie o’connor, mercy cork, ms rita cullen, ms fiona kavanagh, ms Sue clarke (Trainer), ms ursula caulfield, ms michele cuddihy connolly, ms bernie walshe, ms Ann o’mahony. (back row): mr enda darcy (mSd), ms geraldine fitzgibbon, ms Lindsay browne, ms fay doody, ms frances guiney, ms mary Leonard, ms carol harmon, ms Niamh o’regan, ms Johanna o’callaghan, ms Noreen donoghue, ms Jennifer cullen (mSd), ms ronnie clarke, ms olivia Lee, ms Trish gregan, ms deirdre Long, ms kate walsh, ms Sinead kaulsay, mr JJ o’connor (mSd).

Shamrock rover’s star Stephen rice, dr danny mulvihill, chairman of the gAA medical Scientific and welfare committee, Lisa mc Laughlin, marketing manager of Sanofi Pasteur mSd, fAI medial director, dr Alan byrne and dublin corner forward bernard brogan, pictured at the launch of a health awareness sports booklet entitled Infections in Sport…Prevention is Key which is sponsored by Sanofi Pasteur mSd and endorsed by the gAA, Irfu, fAI and IhA.

Allergy and anaphylaxis interactive study day

8

NEWS FOR IPNA BR ANCHES COuNTRy WIDEregional news

cAvAN/moNAghANPATRICIA JENKINS

In March ultan Kenny kindly sponsored a talk and meal in the Errigal House Hotel in Cootehill, Co. Cavan. ultan is from Servier Laboratories and promotes Prolia, a twice yearly s.c. injection for osteoporosis. Prolia has a very safe side effect profile and shows significant bone mineral build up after 12 months. This treatment ensures compliance and may well be the way forward to treating osteoporosis. In May we had a very informative talk from Declan Campbell who is a Tissue Viability Podiatrist in Diabetes. He works in the community and is attached to the ulster Hospital in Northern Ireland and also advises in Drogheda Hospital. Declan dis-cussed how to assess and manage the diabetic foot especially focusing on ulceration. This very complex area is difficult to simplify in a short time and Declan has agreed to come back and talk to us again. We look forward to that. The meeting and supper was sponsored by Ms Abina O’Flynn from MSD and was held in Errigal House Hotel, Cootehill, Co. Cavan. Abina also sponsored a very informative evening on diabetes at the Radisson Hotel in May. Dr Muthalagu and Deirdre Moyna, CNS gave a very useful update on diabetes and how they currently manage their patients under current financial restrictions. Deirdre also looked at how diabetes will impact on our health services in the future. A few practice nurses attended the one day STI course held at the Rotunda Hospi-tal by Dr Lambert. This is a very useful course on current trends and sampling of STI infections. I have to mention the fact that our INO rep meet with Primary Care Minister, Roisin Shorthall, TD last month at the INO headquarters in Dublin. Winnie McCabe along with other practice nurses and public health nurses discussed how our role has shaped primary care in recent years and the many services we provide to patients of all ages. This is a significant meeting as practice nurses rarely have the opportunity to be heard at a political level. It is very disappointing that many branches do not even send an INO representative to the practice nurse section meetings. We need this to change in the future. We wish the South Tipperary branch the very best of luck when hosting the Nation-al AGM in Tullamore Court Hotel on 14t and 15th October. Our regional AGM will be on 21st September at 7.30. Our meetings have been very well attended over the past year and I personally look forward to seeing you all again in September. Enjoy your summer.

corkELAINE GOGGIN

The Cork branch had a most interesting meeting before our summer break. We met at Blackrock Hall Medical Centre where we were brought on a guided tour by the practice nurses working there and afterwards we mingled over some tasty food. The meeting was kindly sponsored by Susan Kearney, Organon. Guest speaker on the night was Finola Tobin, Nurse Manager of the Sexual Assault Treatment unit, SIVuH and she gave a very informative talk on this area of nursing and the work involved in the unit. This was fol-lowed by Fergus Hoban, Touchstone, owner of Blackrock Hall Medical Centre, who gave a most interesting insight into his view on the future of primary care. Cork practice nurses attended the CervicalCheck update in Rochestown Park last week which was found to be very beneficial. We are looking forward to continued support from our members at the next Cork Branch meeting which takes place on September 10th. This will also coincide with our summer day out. This will be held in Fota Island Resort, guest speaker and topic yet to be confirmed, but pampering and some nice food are on the agenda and hopefully some sunshine.

gALwAyMOIRA NOONE

We have been busy over the last few months. Our March meeting was held at the Clayton Hotel sponsored by Chris Kenny, Mc-Neil HealthCare. The educational speaker was Irene O’Byrne, Smoking Cessation Officer, Galway university Hospital. This meeting welcomed members and non members to encourage and help increase membership of the IPNA. We were very happy with such a positive result and the increase in the membership. Thanks to our Chairperson, Margie Nestor for all her hard work. Our April meet-ing was held at Harbour Hotel, sponsored by Ruth O’Brien. Novartis, Dr Fiona Harney Consultant Ophthalmologist, uCHG was the speaker.

NorTh dubLINLIz HEALy

Our meeting in March was held in Bewleys Hotel on the topic of Vitamin D and Immunisations. The meeting was sponsored by Kora Healthcare, who gave a talk on Vitamin D supplementation in babies. A public health nurse and an administrator from our local immunisation office attended and a very productive discussion was held on how we could improve and assist each other. The topic for April was the Menopause. The speaker, Dr Deirdre Lundy, gave us an excellent insight into HRT and the menopause. Two topics for an upcoming meeting were announced: Smoking cessation and Pelvic Dysfunction. It was also decided that we would have a meeting in October – the committee to arrange this. Our last meeting before we took the summer break was in May. Nurses from the Healthy Ageing Clinic in St Mary’s Hospital, talked about osteoporosis and the running of the clinic. A local service that many of us didn’t know existed!! Our next meeting will be on 13th September and will be our branch AGM. It is a year now since the Dublin Branch started back up and I’d like to thank all the members for their support and attendance at meetings and also to the commit-tee members for the support they have given each other to get the branch ‘going again’ as without this it wouldn’t have happened. Let’s hope the weather improves for our summer and that we all get to meet up in October at the conference.

9

clinical review

Diabetes is a chronic condition – meaning it is a long lasting illness. One of the major consequences of a chronic condition is that over time it reduces the quality of life for many of the adults living with it, can represent substantial financial costs to patients

themselves in addition to the health and social care system, and rising cost of lost productivity to the economy. In a recent report1 it found that productivity losses associated with chronic conditions are as much as 400% greater than the cost of treating chronic disease.

Even though the population is living longer, chronic conditions have reduced the quality of the extra years that have been gained, so unless we address the growing burden of chronic conditions we may continue to add more years to our lives without adding more life to those years.

STATISTIcS: TyPe 1 ANd 2 Figures from 2007 showed that nearly 144,000 adults in the Republic (4.5% ) had diabetes. By 2020 the figure is expected to rise to over 233,000 (5.9%). This represents a 62% increase, an additional 89,000 adults, in less than 15 years.2

Diabetes is more common amongst women. This reflects the findings of the underlying population-based reference studies.3

Similarly studies from the WHO have established that while more women than men have diabetes, current rates are higher amongst males aged less than 60 years but are higher amongst women in older age groups.4

Diabetes prevalence increases with age. Approximately one in eight people aged 60 years and over have diabetes. In 2020 somewhat more of the adults with diabetes will belong in the older age groups.

Structured care programme for diabetes patients – role of the practice nurseWinnie MaCabe outlines her experience of a structured care programme delivering care to patients with type 2 diabetes in a general practice – introduced in the North East region in 2003.

mS wINNIe mccAbe, PRACTICE NuRSE, KINGSCOuRT SuRGERy, CO CAVAN

For patients not at goal on metformin aloneIn clinical studies of patients with type 2 diabetes,

Powerful and sustained HbA1c reductions over 1 year1,2

Weight loss and less hypoglycemia vs an SU* + metformin (with sitagliptin 100 mg + metformin)3

3-D Control: comprehensive mechanism of action targets 3 key defects of type 2 diabetes1

JANUMET® for powerful glucose reductions1

(sitagliptin/metformin)

Changing the course to glucose control.

Janumet 50mg/850mg and Janumet 50mg/1000mg film-coated tablets (50 mg of sitagliptin as phosphate monohydrate and 850 mg or 1000mg of metformin hydrochloride).ABRIDGED PRODUCT INFORMATION Refer to Summary of Product Characteristics before prescribing. PRESENTATION Janumet 50mg/850mg film-coated tablets: Capsule-shaped, pink film-coated tablet with “515” debossed on one side containing 50 mg of sitagliptin as phosphate monohydrate and 850 mg of metformin hydrochloride. Janumet 50mg/1000mg film-coated tablets: Capsule-shaped, red film-coated tablet with “577” debossed on one side containing 50 mg of sitagliptin as phosphate monohydrate and 1000 mg of metformin hydrochloride. USES For patients with type 2 diabetes mellitus: Janumet is indicated as an adjunct to diet and exercise to improve glycaemic control in patients inadequately controlled on their maximal tolerated dose of metformin alone or those already being treated with the combination of sitagliptin and metformin. Janumet is indicated in combination with a sulphonylurea (i.e., triple combination therapy) as an adjunct to diet and exercise in patients inadequately controlled on their maximal tolerated dose of metformin and a sulphonylurea. Janumet is also indicated as triple combination therapy with a peroxisome proliferator-activated receptor gamma (PPARg) agonist (i.e., a thiazolidinedione) as an adjunct to diet and exercise in patients inadequately controlled on their maximal tolerated dose of metformin and a PPARg agonist. Janumet is also indi-cated as add-on to insulin (i.e., triple combination therapy) as an adjunct to diet and exercise to improve glycaemic control in patients when stable dose of insulin and metformin alone do not provide adequate glycaemic control. DOSAGE AND ADMINISTRATION Posology The dose of antihyperglycaemic therapy with Janumet should be individualised on the basis of the patient’s current regimen, effectiveness, and toler-ability while not exceeding the maximum recommended daily dose of 100 mg sitagliptin. For patients not adequately controlled on metformin alone, the usual starting dose of Janumet should provide sitagliptin dosed as 50 mg twice daily (100 mg total daily dose) plus the dose of metformin already being taken. For patients switching from co-administration of sitagliptin and metformin, Janumet should be initiated at the dose of sitagliptin and metformin already being taken. For patients inadequately controlled on dual combination therapy with the maximal tolerated dose of metformin and a sulphonylurea, the dose of Janumet should provide sitagliptin dosed as 50 mg twice daily (100 mg total daily dose) and a dose of metformin similar to the dose already being taken. When Janumet is used in combination with a sulphonylurea, a lower dose of the sulphonylurea may be required to reduce the risk of hypoglycaemia. For patients inadequately controlled on dual combina-tion therapy with the maximal tolerated dose of metformin and a PPARg agonist, the dose of Janumet should provide sitagliptin dosed as 50 mg twice daily (100 mg total daily dose) and a dose of metformin similar to the dose already being taken. For patients inadequately controlled on dual combination therapy with insulin and the maximal tolerated dose of metformin, the dose of Janumet should provide sitagliptin dosed as 50 mg twice daily (100 mg total daily dose) and a dose of metformin similar to the dose already being taken. When Janumet is used in combination with insulin, a lower dose of insulin may be required to reduce the risk of hypoglycaemia. All patients should continue their diet with an adequate distribution of carbohydrate intake during the day. Overweight patients should continue their energy-restricted diet. Spe-cial populations: Use in renal impairment: Janumet should not be used in patients with moderate or severe renal impairment (creatinine clearance < 60 ml/min). Use in hepatic impairment: Janumet should not be used in patients with hepatic impairment. Use in elderly: Janumet should be used with caution as age increases. Monitoring of renal function is necessary to aid in prevention of metformin-associated lactic acidosis. Limited safety data on sitagliptin is available in patients > 75 years of age and care should be exercised. Use in children: Not recom-mended for use in children below 18 years of age. Method of administration: ‘Janumet’ should be given twice daily with meals to reduce the gastrointestinal undesirable effects associated with metformin. CONTRAINDICATIONS -hypersensitivity to the active substances or to any of the excipients. - diabetic ketoacidosis, diabetic pre-coma. - moderate and severe renal impairment (creatinine clearance < 60 ml/min. - acute conditions with the potential to alter renal function such as: dehydration, severe infection, shock, intravascular administration of iodi-nated contrast agents. - acute or chronic disease which may cause tissue hypoxia such as: cardiac or respiratory failure recent myocardial infarction, shock. - hepatic impairment. - acute alcohol intoxication, alcoholism. - lactation. PRECAUTIONS Janumet should not be used in patients with type 1 diabetes and must not be used for the treatment of diabetic ketoacidosis. Pancreatitis In post-marketing experience there have been spontaneously reported adverse reactions of acute pancreatitis. The characteristic symptom of acute pancreatitis is per-sistent, severe abdominal pain. Resolution of pancreatitis has been observed after discontinuation of sitagliptin (with or without supportive treatment), but very rare cases of necrotizing or haemorrhagic pancreatitis and/or death have been reported. If pancreatitis is suspected, Janumet and other potentially suspect medicinal products should be discontinued. Lactic acidosis: It is a very rare serious metabolic com-plication that can occur due to metformin accumulation. Reported cases of lactic acidosis in patients on metformin have occurred primarily in diabetic patients with significant renal failure. The incidence of lactic acidosis can and should be reduced by also assessing other associ-ated risk factors. If metabolic acidosis is suspected, treatment with the medicinal product should be discontinued and the patient hospital-ised immediately. Renal function: As metformin-related lactic acidosis increases with the degree of impairment of renal function, serum creatinine concentrations should be determined at least once a year in patients with normal renal function and at least two to four times a year in patients with serum creatinine levels at or above the upper limit of normal and in elderly patients. Decreased renal function in el-derly patients is frequent and asymptomatic. Special caution should be exercised in situations where renal function may become impaired, for example when initiating antihypertensive or diuretic therapy or when starting treatment with a nonsteroidal anti-inflammatory drug (NSAID). Hypoglycaemia: Patients receiving Janumet in combination with a sulphonylurea or with insulin may be at risk for hypoglycaemia. Therefore, a reduction in the dose of the sulphonylurea or insulin may be necessary. The use of Janumet in combination with insulin has not been adequately studied. Hypersensitivity reactions: Postmarketing reports of serious hypersensitivity reactions in patients treated with sitagliptin have been reported. These reactions include anaphylaxis, angioedema, and exfoliative skin conditions including Stevens-Johnson syndrome. Onset of these reactions occurred within the first 3 months after initiation of treatment with sitagliptin, with some reports occur-ring after the first dose. If a hypersensitivity reaction is suspected, discontinue Janumet, assess for other potential causes of the event, and institute alternative treatment for diabetes. Surgery: As Janumet contains metformin hydrochloride, the treatment should be discontinued 48 hours before elective surgery with general, spinal or epidural anaesthesia. Janumet should not usually be resumed earlier than 48 hours afterwards and only after renal function has been re-evaluated and found to be normal. Administration of iodinated contrast agent: The in-travascular administration of iodinated contrast agents in radiological studies can lead to renal failure which has been associated with lactic acidosis in patients receiving metformin. Therefore, Janumet should be discontinued prior to, or at the time of the test and not reinsti-tuted until 48 hours afterwards, and only after renal function has been re-evaluated and found to be normal. Change in clinical status of pa-tients with previously controlled type 2 diabetes: A patient with type 2 diabetes previously well controlled on Janumet who develops labora-tory abnormalities or clinical illness (especially vague and poorly defined illness) should be evaluated promptly for evidence of ketoacidosis or lactic acidosis. Evaluation should include serum electrolytes and ketones, blood glucose and, if indicated, blood pH, lactate, pyruvate, and metformin levels. If acidosis of either form occurs, Janumet must be stopped immediately and other appropriate corrective measures initi-ated. Drug interactions: Co-administration of multiple doses of sitagliptin (50 mg twice daily) and metformin (1,000 mg twice daily) did not meaningfully alter the pharmacokinetics of either sitagliptin or metformin in patients with type 2 diabetes. There is increased risk of lactic acidosis in acute alcohol intoxication (particularly in the case of fasting, malnutrition or hepatic insufficiency) due to the metformin active substance of Janumet. Consumption of alcohol and medicinal products containing alcohol should be avoided. Cationic agents that are eliminated by renal tubular secretion (e.g., cimetidine) may interact with metformin by competing for common renal tubular transport sys-tems. Therefore, close monitoring of glycaemic control, dose adjustment within the recommended posology and changes in diabetic treat-ment should be considered when cationic agents that are eliminated by renal tubular secretion are co-administered. The intravascular ad-ministration of iodinated contrast agents in radiological studies may lead to renal failure, resulting in metformin accumulation and a risk of lactic acidosis. Therefore, Janumet should be discontinued prior to, or at the time of the test and not reinstituted until 48 hours afterwards, and only after renal function has been re-evaluated and found to be normal. Combination requiring precautions for use: Glucocorticoids (given by systemic and local routes) beta-2-agonists, and diuretics have intrinsic hyperglycaemic activity. The patient should be informed and more frequent blood glucose monitoring performed, especially at the beginning of treatment with such medicinal products. If necessary, the dose of the anti-hyperglycaemic medicinal product should be adjusted during therapy with the other medicinal product and on its discon-tinuation. ACE-inhibitors may decrease the blood glucose levels. If necessary, the dose of the anti-hyperglycaemic medicinal product should be adjusted during therapy with the other medicinal product and on its discontinuation. Effects of other medicinal products on sitagliptin: Clinical data described below suggest that the risk for clinically meaningful interactions following co-administration of other medicinal products is low. Cyclosporin: A study was conducted to assess the effect of cyclosporin, a potent inhibitor of p-glycoprotein, on the pharma-cokinetics of sitagliptin. Co-administration of a single 100 mg oral dose of sitagliptin and a single 600 mg oral dose of cyclosporin increased the AUC and Cmax of sitagliptin by approximately 29 % and 68 %, respectively. These changes in sitagliptin pharmacokinetics were not con-sidered to be clinically meaningful. The renal clearance of sitagliptin was not meaningfully altered. Therefore, meaningful interactions would

not be expected with other p-glycoprotein inhibitors. In vitro studies indicated that the primary enzyme responsible for the limited metabolism of sitagliptin is CYP3A4, with contribution from CYP2C8. In patients with normal renal function, metabolism, including via CYP3A4, plays only a small role in the clearance of sitagliptin. Metabolism may play a more significant role in the elimination of sitagliptin in the setting of severe renal impairment or end-stage renal-disease (ESRD). For this reason, it is possible that potent CYP3A4 inhibitors (i.e., ketoconazole, itracona-zole, ritonavir, clarithromycin) could alter the phamacokinetics of sitagliptin in patients with severe renal impairment or ESRD. The effects of potent CYP3A4 inhibitors in the setting of renal impairment has not been assessed in a clinical study. In vitro transport studies showed that sitagliptin is a substrate for p-glycoprotein and organic anion transporter-3 (OAT3). OAT3 mediated transport of sitagliptin was inhibited in vitro by probenecid, although the risk of clinically meaningful interactions is considered to be low. Concomitant administration of OAT3 in-hibitors has not been evaluated in vivo. Effects of sitagliptin on other medicinal products: In vitro data suggest that sitagliptin does not in-hibit nor induce CYP450 isoenzymes. In clinical studies, sitagliptin did not meaningfully alter the pharmacokinetics of metformin, glyburide, simvastatin, rosiglitazone, warfarin, or oral contraceptives, providing in vivo evidence of a low propensity for causing interactions with substrates of CYP3A4, CYP2C8, CYP2C9, and organic cationic transporter (OCT). Sitagliptin had a small effect on plasma digoxin concentra-tions, and may be a mild inhibitor of p-glycoprotein in vivo. Digoxin: Sitagliptin had a small effect on plasma digoxin concentrations. Following administration of 0.25 mg digoxin concomitantly with 100 mg of sitagliptin daily for 10 days, the plasma AUC of digoxin was increased on aver-age by 11 %, and the plasma Cmax on average by 18 %. No dose adjustment of digoxin is recommended. However, patients at risk of digoxin toxicity should be monitored for this when sitagliptin and digoxin are administered concomitantly. Use in fertility, pregnancy and lactation: Janumet should not be used during pregnancy or breast-feeding. Effects on ability to drive and use machines: ‘Janumet’ has no known influ-ence on the ability to drive and use machines. However, when driving or operating machines, it should be taken into account that dizziness and somnolence have been reported. Patients should be alerted to the risk of hypoglycaemia when Janumet is used in combination with other sulfonylurea agents or with insulin. SIDE EFFECTS There have been no therapeutic clinical trials conducted with Janumet tablets however bioequivalence of Janumet with co-administered sitagliptin and metformin has been demonstrated. Sitagliptin and Metformin Ad-verse reactions considered as drug related reported in excess (> 0.2 % and difference > 1 patient) of placebo and in patients receiving sitag-liptin in combination with metformin in double-blind studies are listed below. Frequencies are defined as: very common (≥ 1/10); common (≥ 1/100 to < 1/10); uncommon (≥ 1/1,000 to < 1/100); rare (≥ 1/10,000 to < 1/1,000); very rare (< 1/10,000). Sitagliptin with Metformin In a placebo-controlled 24-week study of sitagliptin 100 mg once daily added to ongoing metformin, the incidence of adverse reactions considered as drug-related in patients treated with sitagliptin added to ongoing metformin compared to treatment with placebo added to ongoing met-formin was 9.3 % and 10.1 %, respectively. Nervous system disorders Uncommon: somnolence Gastrointestinal disorders Common: nausea Uncommon: upper abdominal pain, diarrhoea Investigations Uncommon: blood glucose decreased. In a 1-year study of sitagliptin 100 mg once daily added to ongoing metformin, the incidence of adverse reactions considered as drug-related in patients treated with sitagliptin added to ongoing metformin compared to sulphonylurea added to ongoing metformin was 14.5 % and 30.3 %, respectively. In pooled studies of up to 1 year in duration comparing sitagliptin added to ongoing metformin to a sulphonylurea agent added to ongoing metformin, adverse reactions considered as drug-related reported in patients treated with sitagliptin 100 mg occurring in excess (> 0.2 % and difference > 1 patient) of that in patients receiving the sulphonylurea agent are as follows: Metabolism and nutrition disorders Uncommon: anorexia Inves-tigations Uncommon: weight decreased. Sitagliptin with Metformin and a Sulphonylurea. In this 24-week placebo-controlled study of sitag-liptin 100 mg once daily added to ongoing combination treatment with glimepiride and metformin, the overall incidence of adverse reactions considered as drug-related in patients treated with the addition of sitagliptin to the ongoing treatment with glimepiride and metformin was 18.1 % compared to treatment with the addition of placebo to the ongoing treatment with glimepiride and metformin which was 7.1 %. Me-tabolism and nutrition disorders Very common: hypoglycaemia Gastrointestinal disorders Common: constipation. Combination with a PPARg agent (rosiglitazone) and metformin. In this study of sitagliptin 100 mg once daily in combination with rosiglitazone and metformin, which continued through 54 weeks, the incidence of adverse reactions considered as drug-related in patients treated with sitagliptin combination compared to treatment with the placebo combination was 15.3 % and 10.9 %, respectively. Other drug-related adverse reactions reported in the 54-week analysis (frequency common) in patients treated with sitagliptin combination occurring in excess (> 0.2 % and difference > 1 patient) of that in patients treated with the placebo combination were: headache, cough, vomiting, hypoglycaemia, fungal skin infection, and upper respiratory tract infection. Metabolism and nutrition disorders Common: hypoglycaemia Nervous system disorders Common: head-ache Gastrointestinal disorders Common: diarrhoea, vomiting. General disorders and administration site conditions. Common: peripheral oedema. Sitagliptin with Metformin and Insulin. In this 24-week placebo-controlled study of sitagliptin 100 mg once daily as add-on to insulin and metformin, the incidence of adverse reactions considered as drug-related in patients treated with sitagliptin in combination with insulin/metformin compared to treatment with placebo in combination with insulin/metformin was 16.2 % and 9.0 %, respectively. Metabolism and nutrition disorders Very common: hypoglycaemia. Nervous system disorders Uncommon: headache Gastrointestinal disorders Uncommon: dry mouth. In a 24-week study of initial combination therapy with sitagliptin and metformin administered twice daily (sitagliptin/metformin 50 mg/500 mg or 50 mg/1,000 mg), the overall incidence of adverse reactions considered as drug-related in patients treated with the combination of sitagliptin and metformin compared to patients treated with placebo was 14.0 % and 9.7 %, respectively. The overall incidence of adverse reactions considered as drug-related in patients treated with the combination of sitagliptin and metformin was comparable to metformin alone (14.0 % each) and greater than sitagliptin alone (6.7 %), with the differences relative to sitagliptin alone primarily due to gastrointestinal adverse reactions. Additional information on the individual active substances of the fixed dose combination. Sitagliptin In addition, in mono-therapy studies of up to 24 weeks in duration of sitagliptin 100 mg once daily alone compared to placebo, adverse reactions considered as drug-related reported in patients treated with sitagliptin in excess (> 0.2 % and difference > 1 patient) of that in patients receiving placebo are headache, hypoglycaemia, constipation, and dizziness. In addition to the drug related adverse reactions described above, adverse events (reported regardless of causal relationship to medicinal product) occurring in at least 5 % and more commonly in patients treated with sitagliptin included upper respiratory tract infection and nasopharyngitis. Additional adverse events that occurred more frequently in pa-tients treated with sitagliptin (not reaching the 5 % level, but occurring with an incidence of > 0.5 % higher with sitagliptin than that in the control group) included osteoarthritis and pain in extremity. Across clinical studies, a small increase in white blood cell (WBC) count was observed due to an increase in neutrophils. This observation was seen in most but not all studies. This change in laboratory parameters is not considered to be clinically relevant. No clinically meaningful changes in vital signs or in ECG (including in QTc interval) were observed with sitagliptin treatment. Post-marketing data. Sitagliptin During post-approval use of Janumet or sitagliptin, one of the active substances of Janumet, additional adverse reactions have been reported (frequency not known). These reactions have been reported when Janumet or sitagliptin have been used alone and/or in combination with other antihyperglycaemic agents: hypersensitivity reactions including anaphy-laxis, angioedema, rash, urticaria, cutaneous vasculitis, and exfoliative skin conditions including Stevens-Johnson syndrome; acute pan-creatitis, including fatal and non-fatal haemorrhagic and necrotizing pancreatitis; impaired renal function, including acute renal failure (sometimes requiring dialysis);vomiting. Metformin Metabolism and nutrition disorders Very rare: lactic acidosis, vitamin B12 deficiency. Nervous system disorders Common: metallic taste Gastrointestinal disorders Very common: gastrointestinal symptoms Hepatobiliary disor-ders Very rare: liver function disorders, hepatitis Skin and subcutaneous tissue disorders Very rare: urticaria, erythema, pruritis. PACKAGE QUANTITIES Janumet 50mg/850mg and 50mg/1000mg film-coated tablets: 56 tablets. Legal Category: POM. Date of preparation: December 2010. Marketing Authorisation numbers: Janumet 50mg/850mg film-coated tablets: EU/1/08/455/003. Janumet 50mg/1000mg film-coated tab-lets: EU/1/08/455/010. Marketing Authorisation Holder: Merck Sharp & Dohme Limited, Hertford Road, Hoddesdon, Hertfordshire EN11 9BU, UK. © Merck Sharp & Dohme Limited 2010. All rights reserved. API.JANUMET.DEC10.IRL. Additional prescribing information available on request or from www.medicines.ie. References: 1. Data on file, MSD. 2. Goldstein BJ, Feinglos MN, Lunceford JK, et al; for the Sitagliptin 036 Study Group. Effect of initial combination with sitagliptin, a dipeptidyl peptidase-4 inhibitor, and metformin on glycemic control in patients with type 2 diabetes. Diabetes Care. 2007;30:1979–1987. 3. Nauck MA, Meininger G, Sheng D, et al; for the Sitagliptin Study Group 024. Efficacy and safety of the dipeptidyl peptidase-4 inhibitor, sitagliptin, compared with the sulfonylurea, glipizide, in patients with type 2 diabetes inade-quately controlled on metformin alone: a randomized, double-blind, non-inferiority trial. Diabetes Obes Metab. 2007;9:194–205. * SU = sulfo-nylurea; specifically glipizide. Additional prescribing information available on request or from www.medicines.ie

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

2660_JMT_395_273_0111_v.indd 1 19/01/2011 19:02

11

clinical review

High diabetes frequency rates occur across the country. Quite evidently, incidence rates are once again lowest around Dublin.

Socioeconomic circumstances affect diabetes occurrence. With both males and females, across all age groups, diabetes tends to be more prevalent amongst the socially deprived.

Efforts to reduce the burden of chronic conditions must address the causes of these uneven distributions. Effective policies such as the promotion of healthy diets and weight reduction, jointly with the workplace smoking ban, are essential to sustain the health gain.5

LIfeSTyLeLifestyle intervention especially diet and exercise is the cornerstone of type 2 diabetes management. Exercise in one form or other, be it aerobic exercise, resistance training, circuit training as well as low impact exercise – is essential to successful diabetes management. Regular physical activity, with the stress on the word ‘regular’, improves glucose control as well as improving lipids, blood pressure, cardiovascular risk and quality of life overall. Exercise also increases calorie use, contributing to weight loss and maintenance of same. Weight loss improves insulin sensitivity. Furthermore exercise improves insulin sensitivity even in the absence of weight loss. To summarise, regular exercise, even without any weight loss has been shown to significantly lower the risk of diabetes and its complications. Such complications can be prevented or delayed through adequate care in a formal and structured programme involving primary care, diabetes units and diabetes centres – in short – integrated care .

mANAgemeNT IN The NorTh eASTDiabetes Watch, a structured care programme delivering care to patients with type 2 diabetes in a general practice, was introduced in the North East region in 2003. The development of Diabetes Watch is based on recommendations included in the Department of Health & Children’s Building Healthier Hearts lDocument R.6.25. There are currently 23 practices and 1650 patients involved in the Diabetes Watch Programme.

AImS of dIAbeTIc wATchThe aim of the programme was initially to develop a model of care for people with type 2 diabetes suitable to the Irish healthcare environment based on the St Vincent declaration and best evidence. The St Vincent Declaration targets are:• cut blindness by over one third• reduce new end-stage renal failure by over one third• reduce limb amputations by over 50%• cut morbidity from coronary heart disease• improve pregnancy outcomes in women with diabetes

The second aim was to raise the overall standard of care for people with type 2 diabetes in the region through ongoing monitoring and the training of primary healthcare staff.

commuNITy cAre guIdeLINeSThe Irish College of General Practitioners Task Group Guidelines for Diabetic care in the community, the Diabetes Services Development Group Report, Diabetes Care – Securing the Future, – along with best evidence and resources available, form the structure for the management of patients on the Diabetic Watch Programme. Funding is provided for all general practitioners, practice nurses, dietitians and podiatrists taking part in the Diabetes Watch Programme to take up the Bradford distance-learning course in the management of diabetes in the community. In addition this offer has also been extended to other general practitioners, practice nurses, and community

pharmacists in the region who have an interest in diabetes but are not directly involved in Diabetes Watch. update educational days are arranged by the steering group for practices involved in the programme.

LoNg Term heALTh gAINPatients enrolled in the programme benefit from the structured care provided by their general practitioner but for the most part by their practice nurse. They also have access to a designated service from a podiatrist, dietitan and annual retinopathy screening programme – all on the same site – this is primary care working efficiently. The GP must ensure that all eligible patients give informed consent to participate in the programme and informed consent for the electronic transfer in Excel format of any information from the practice to Primary Care Services. All practices and patients are allocated numbers for confidentiality and security in the Diabetic Watch Programme. If a patient is attending a hospital consultant for management of their diabetes, GPs are asked to inform the consultant/diabetes nurse specialist that the patient is enrolled on the programme. The information on the Diabetic Watch template that is transferred to primary care twice or three times depending on how stable their diabetes is during the year should include, patient number plus date of birth, gender, date of visit, systolic blood pressure, diastolic blood pressure, Hha1c, total cholesterol, LDH, HDL, weight, waist circumference, height, BMI, uKPDS score, smoking status. Medication Questions follow e.g. Insulin: yes?No, Aspirin or alternative: yes/No, Statin: yes/No, Hypertensive: yes/No, Hypoglycaemic: yes/No. In the past there was more information returned but due to increased workload, it was reviewed and the template was updated.

IdeNTIfyINg TyPe 2 PATIeNTS Various methods are used to identify suitable patients including a manual trawl of paper records, practice computer register, opportunistically, via repeat prescriptions requesting oral hypoglycemics, screening high risk groups e.g. obese patients, and those with a family history. GMS patients on oral hypoglycemics are identified through the Primary Care unit for individual practices. A register of patients with a history of impaired glucose tolerance or gestational diabetes can be kept and these patients can be screened periodically for the development of diabetes.

TArgeT guIdeLINeS for dIAbeTeS wATch ProgrAmme

• Total cholesterol less than 4.5• LDL<2.5• HDL>1.2• HbA1c <6.5• BMI <25• BP 130/85• C2H5 intake within the recommended national

guidelines • Non smoking status• Albumin creatinine ratio measured annually• Bloods are taken 3 monthly if not within target and 6

monthly if within target.

roLe of PrAcTIce NurSeThe practice nurse’s role is one of reviewing targets, reviewing monitoring of blood glucose, education/support for patients,

12

clinical review

foot examination (carried out annually if low risk ), coordinating the involvement of dietitian, podiatrist and ophthalmologist, completing electronic template and ensuring its return to primary care, running of recall system. However, the GP maintains overall responsibility for patient care within the Diabetic Watch Programme.

referrALSPodiatryEach patient enrolled in Diabetes Watch has a foot assessment carried out by the Practice Nurse. A referral form is filled in and forwarded to the podiatrist. Patients classified as medium or high risk are followed up by the podiatrist. Low risk patients continue to have their foot examination annually by the Practice Nurse unless their status changes. People with diabetes are 50% more likely to have an amputation consequently a huge financial cost to the HSE occurs. It is certainly cheaper and more forward thinking to pay a podiatrist for preventive care than to pay the huge fees that will be created by vascular and orthopaedic surgeons, or wound care and general nursing on an ongoing basis, not to mention the pain, suffering and reduced quality of life of the patient.

OphthalmologyDiabetic retinopathy (DR) is a leading cause of preventable blindness. People with diabetes are living longer and developing complications as a result. The best predictor of diabetic retinopathy is the duration of the disease.

Patients are invited for retinal screening annually which is a mobile screening service. In 2010 attendance rate for this service was 87.5%. The 2010 results were as follows: • No diabetic retinopathy 75.45%• Background DR 14.99%• 3.5% had retinopathy severe enough to require hospital

referral.• urgent referral – requiring laser treatment or intravitreal

injection 1.17%.

DieteticsThe dietitian attends the practices regularly and all patients newly diagnosed are offered a consultation and reviewed by the dietician as required. The Community Nutrition & Dietetic Department of the HSE Dublin North East run the X-PERT Programme, a structured education programme for patients with type 2 diabetes. It consists of one session per week for

6 weeks, each session lasting 2.5 hours. It is of paramount importance that people with diabetes receive ongoing, high quality diabetes education that is tailored to their needs and delivered by skilled health professionals.

merIT dIAbeTeS ProgrAmmeNovo Nordisk has developed a diabetes educational programme for primary care. The MERIT (Meeting Educational Requirements, Improving Treatment) programme aims to provide relevant, tailored training on topics such as insulin initiation and patient education to professionals working in primary care diabetes. Many practices in the North East involved in Diabetes Watch have availed of this programme.

conclusionInvolvement in Diabetes Watch has been a rewarding although a demanding experience for all concerned. The programme is successful and informal feedback from those involved, including patients, suggests that there is a high level of satisfaction with the programme. It should be rolled out nationwide as all diabetics deserve this level of care and prevention which afterall is what we in practice nursing are experts in.

references1. World Economic Forum (2008). Working Towards

Wellness: The Business Rationale. In Cooperation with PricewaterhouseCoopers. http://www.pwc.com/en_GX/gx/healthcare/pdf/wtw_business_rationale.pdf

2. Balanda, K.P., Barron, S., Fahy, L. (2010). Making Chronic Conditions Count: Hypertension, Coronary Heart Disease, Stroke, Diabetes. A systematic approach to estimating and forecasting population prevalence amongst adults on the island of Ireland. Executive Summary. Dublin: Institute of Public Health in Ireland. http://www.inispho.org/publications/makingchronicconditionscountexecutivesummary

3. Simmons et al, 1991; Chaturvidi et al, 1993; Harvey et al, 2002 cited in Balanda, K.P., Barron, S., Fahy, L. (2010). Making Chronic Conditions Count: Hypertension, Coronary Heart Disease, Stroke, Diabetes. A systematic approach to estimating and forecasting population prevalence amongst adults on the island of Ireland. Executive Summary. Dublin: Institute of Public Health in Ireland. http://www.inispho.org/publications/makingchronicconditionscountexecutivesummary

4. Wild, S., Roglic, G., Green, A., Sicree, R., King, H. (2004). Global Prevalence of Diabetes: Estimates for the year 2000 and projections for 2030. Diabetes Care, Vol 27, No 5 pp1047-1053.http://www.who.int/diabetes/facts/en/diabcare0504.pdf

5. Kabir, z., Bennett, K., Shelley, E., una, B., Critchley, J., Feely, J., Capewell, S. (2007). Life-years gained from population risk factor changes and modern cardiology treatments in Ireland. European Journal of Public Health, Vol 17, No 2, pp193–198. http://eurpub.oxfordjournals.org/cgi/reprint/17/2/193

6. D, Cooper D, O’Gorman D. Benefits of exercise and physical activity. Diabetes Professional. 2011 Spring; 7(2):15.

AcknowledgementsThe author wishes to acknowledge Dr J Smith, Ophthalmologist Diabetes Watch Programme, Norma Kierans, Podiatrist Diabetes Watch Programme, and finally Ms Celine McKenna-Croarkin, Cardiovascular Facilitator, Primary Care Services Dublin North East HSE for their contributions to this article.

Patients enrolled in the programme benefit from the structured care provided by their general practitioner but for the most part by their practice nurse.

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

d.i.g.P.

diabetes in general Practice

booking form: 4th Collaborative Diabetes Conference 2011 – “Diabetes Management in Primary Care”Wednesday 28th September 2011, 12.30-6pmThis one day Conference is aimed at Primary Care based health professionals.

Name:

Address:

Prof. discipline

contact Tel No:

email Address:

Special dietary requirements:

Yes or No(Please Indicate)

workshop choice (Please pick 2 out of 6 options to attend)

Title first workshop Title Second workshop

return by post, fax or email to: katie murphy, digP diabetes Nurse facilitator, dept of general Practice, Lancaster hall ucc, 6 Little hanover St, cork. email:k.murphy2@ucc.ie, fAx No: 021 420 1923

For further information: Contact Katie Murphy on 086 0566077Places are allocated on a first come, first served basis and are limited.

4th collaborative diabetes conference “diabetes management in Primary care”

Wednesday 28th September 201112.30-6pm

Oriel House Hotel, Ballincollig, Co.Cork

The National diabetes Programme – Integrated carekey Note Speaker: Dr Kieran Walshe – Primary Care Led Diabetes Care – the Donard Experience

workshops:1. Therapeutics Workshop2. Motivational Interviewing: Towards Concordance3. Promoting Physical Activity in Primary Care4. Dietary Management of Diabetes: Getting the Balance Right5. Diabetes and Pregnancy6. Where to start to improve Diabetes care in your Practice?

Conference Free to ParticipantsClosing Date Friday 2nd September 2011

Cialis offers your patients

CIALIS* (TADALAFIL) REPUBLIC OF IRELAND ABBREVIATED PRESCRIBING INFORMATION

Presentation Tablets 2.5mg, 5mg, 10mg, or 20mg of tadalafil. Also contains lactose. Uses Treatment of erectile dysfunction in adult males. Dosage and Administration Adult men: The recommended dose is 10mg orally, taken at least 30 minutes prior to sexual activity. In those patients in whom tadalafil 10mg does not produce an adequate effect, 20mg might be tried. Maximum dosing frequency, once per day. 10mg or 20mg tadalafil is not recommended for continuous daily use. In responder patients to an on-demand regimen, who anticipate a frequent use of Cialis (ie, at least twice weekly), a once daily regimen with the lowest doses of Cialis might be considered. The recommended dose is 5mg taken once a day at approximately the same time of day. The dose may be decreased to 2.5mg once a day based on individual tolerability. The appropriateness of continued use of the daily regimen should be reassessed periodically. Elderly: Dosage adjustment not required. Impaired renal or hepatic function: In patients with severe renal impairment the maximum recommended dose is 10mg. Once a day dosing of Cialis is not recommended in patients with severe renal impairment. In men with hepatic impairment the recommended dose is 10mg. There are no available data about the administration of doses higher than 10mg of tadalafil to patients with hepatic impairment. There is limited clinical data on the safety of Cialis in patients with severe hepatic impairment; if prescribed, a careful individual benefit/risk evaluation should be undertaken by the prescribing physician. Once a day dosing has not been evaluated in patients with hepatic impairment; therefore, if prescribed, a careful individual benefit/risk evaluation should be undertaken by the prescribing physician. Diabetes: Dosage adjustment not required. Use in children and adolescents: Cialis should not be used in individuals below 18 years of age. Not indicated for use by women. In clinical trials, Cialis demonstrated improvement in patients’ erectile function and the ability to have successful sexual intercourse up to 36 hours following dosing. Contra-indications Known hypersensitivity to any ingredient. Patients using any form of organic nitrates. In men with cardiac disease for whom sexual activity is inadvisable. Physicians should consider the potential cardiac risk of sexual activity in patients with pre-existing cardiovascular disease. Patients with myocardial infarction within the last 90 days, patients with unstable angina or angina occurring during sexual intercourse, patients with New York Heart Association class 2 or greater heart failure in the last 6 months, patients with uncontrolled arrhythmias, hypotension (<90/50mmHg), or uncontrolled hypertension, patients with a stroke within the last 6 months. Cialis is contra-indicated in patients who have loss of vision in one eye because of non-arteritic anterior ischaemic optic neuropathy (NAION), regardless of whether this episode was in connection or not with previous PDE5 inhibitor exposure. Warnings and Special Precautions Prior to any treatment for erectile dysfunction, physicians should consider the cardiovascular status of their patients, since there is a degree of cardiac risk associated with sexual activity. Tadalafil has vasodilator properties, resulting in mild and transient decreases in blood pressure. It augments the hypotensive effect of nitrates. Tadalafil (2.5mg and 5mg): In patients receiving concomitant antihypertensive medicines, tadalafil may induce a blood pressure decrease. When initiating daily treatment with tadalafil, appropriate clinical considerations should be given to a possible dose adjustment of the antihypertensive therapy. Serious cardiovascular events were reported either post-marketing and/or in clinical trials. Although most of the patients in whom these events have been observed had pre-existing cardiovascular risk factors, it is not possible to determine whether these events are related directly to these risk factors, to Cialis, to sexual activity, or to a combination of these or other factors. Visual defects and cases of NAION have been reported in connection with the intake of Cialis and other PDE5 inhibitors. In case of sudden visual defect, patients should be advised to stop taking Cialis and consult a physician immediately. Due to increased tadalafil exposure (AUC), limited clinical experience, and the lack of ability to influence clearance by dialysis, once a day dosing of Cialis is not recommended in patients with severe renal impairment. There is limited clinical data on the safety of single-dose administration of tadalafil in patients with severe hepatic insufficiency (Child-Pugh class C); if prescribed, a careful individual benefit/risk evaluation should be undertaken by the prescribing physician. Use with caution in patients who have conditions that might predispose them to priapism, or in patients with anatomical deformation of the penis. Patients who experience erections lasting 4 hours or more should be instructed to seek

medical assistance. If priapism is not treated immediately, penile tissue damage and permanent loss of potency may result. It is not known if Cialis is effective in patients who have undergone pelvic surgery or radical non-nerve-sparing prostatectomy. Cialis should not be administered to patients with hereditary problems of galactose intolerance, the Lapp lactase deficiency, or glucose-galactose malabsorption. In patients who are taking alpha1-blockers, concomitant administration of Cialis may lead to symptomatic hypotension in some patients. The combination of tadalafil and doxazosin is not recommended. Caution should be exercised when prescribing Cialis to patients using potent CYP3A4 inhibitors (ritonavir, saquinavir, ketoconazole, itraconazole, and erythromycin) as increased tadalafil exposure (AUC) has been observed if the drugs are combined. The safety and efficacy of combinations of tadalafil and other PDE5 inhibitors or other treatments for erectile dysfunction have not been studied. Patients should be informed not to take Cialis with such combinations. Pregnancy and Lactation Not indicated for use by women. There are limited data from the use of tadalafil in pregnant women. Animal studies do not indicate direct or indirect harmful effects with respect to pregnancy, embryonal/foetal development, parturition, or postnatal development. As a precautionary measure, it is preferable to avoid the use of Cialis during pregnancy. Available pharmacodynamic/toxicological data in animals have shown excretion of tadalafil in milk. A risk to the suckling child cannot be excluded. Cialis should not be used during breast-feeding. Driving, etc No studies on the effect on the ability to drive and use machines have been performed. Although the frequency of reports of dizziness in placebo and tadalafil arms in clinical trials was similar, patients should be aware of how they react to Cialis before driving or operating machinery. Undesirable Effects Very common (≥1/10), common (≥1/100 to <1/10), uncommon (≥1/1,000 to <1/100), rare (≥1/10,000 to <1/1,000), very rare (<1/10,000), and not known (events not reported in registration trials cannot be estimated from post-marketing spontaneous reports). Very common: Headache. Common: Dizziness, flushing, dyspepsia, nasal congestion, back pain, myalgia. Uncommon: Hypersensitivity reactions, blurred vision, sensations described as eye pain, tachycardia, palpitations, hypotension (more commonly reported when tadalafil is given to patients who are already taking antihypertensive agents), hypertension, abdominal pain, gastro-oesophageal reflux, rash, hyperhidrosis (sweating), chest pain(1). Rare: Stroke(1) (including haemorrhagic events), syncope, transient ischaemic attacks(1), migraine(3), visual field defect, swelling of eyelids, conjunctival hyperaemia, myocardial infarction, urticaria, Stevens-Johnson syndrome(3), exfoliative dermatitis(3), prolonged erections, priapism(3), facial oedema(3), seizures, transient amnesia, NAION(3), retinal vascular occlusion(3), sudden hearing loss(2), unstable angina pectoris(3), ventricular arrhythmia(3), epistaxis, sudden cardiac death(1,3). (1)Most of the patients in whom these events have been reported had pre-existing cardiovascular risk factors. (2)Sudden decrease or loss of hearing has been reported in a small number of post-marketing and clinical trial cases with the use of all PDE5 inhibitors, including tadalafil. (3)

Post-marketing surveillance reported adverse reactions not observed in placebo-controlled clinical trials. Adverse reactions reported with tadalafil were transient, and generally mild or moderate. Adverse reaction data are limited in patients >75 years. A slightly higher incidence of ECG abnormalities, primarily sinus bradycardia, has been reported in patients treated with tadalafil once a day as compared with placebo. Most of these ECG abnormalities were not associated with adverse reactions. For full details of these and other side-effects, please see the Summary of Product Characteristics, which is available at http://www.medicines.ie/. Legal Category POM Marketing Authorisation Numbers and Holder EU/1/02/237/001 EU/1/02/237/002 EU/1/02/237/003 EU/1/02/237/004 EU/1/02/237/005 EU/1/02/237/006 EU/1/02/237/007 EU/1/02/237/008 Eli Lilly Nederland BV, Grootslag 1-5, 3991 RA Houten, The Netherlands. Date of Preparation or Last Review September 2010 Full Prescribing Information is Available From Eli Lilly and Company Limited, Lilly House, Priestley Road, Basingstoke, Hampshire, RG24 9NL. Telephone: Basingstoke (01256) 315 000. E-mail: ukmedinfo@lilly.com or Eli Lilly and Company (Ireland) Limited, Hyde House, 65 Adelaide Road, Dublin 2, Republic of Ireland. Telephone: Dublin (01) 661 4377. E-mail: ukmedinfo@lilly.com *CIALIS (tadalafil) is a trademark of Eli Lilly and Company. Date of Preparation: September 2010. References: 1. Cialis Summary of Product Characteristics. 2. Dean, J. et al. Psychosocial outcomes and drug attributes affecting treatment choice in men receiving sildenafil citrate and tadalafil for the treatment of erectile dysfunction: Results of a multicenter, randomised, open label, crossover study. J Sex Med, 2006; 3:650-661. IECLS00137

Proven efficacy from 30 minutes up to 36 hours with sexual stimulation1

Greater sexual self-confidence and spontaneity than sildenafil2

A4 Young Couple new API SEPT 2010.indd 1 17/01/2011 17:05

16

IPNA Conference 2011

IPNA conference 2011 registration formclosing date for registration 30th September 2011

Personal details Please fill in your name and place of work as you would like them to appear on the delegate list. If you do not wish to appear on the delegate list please tick here. oPlease use bLock cAPITALS.

full Name

branch

Place of work

daytime Phone

email Address

correspondence Address

An bord Altranais Pin No.:

conference booking fees conference fee early-bird IPNA members (before friday 12th August). €80 oconference fee IPNA members: €90 oNon members €110 o

(Includes Conference material, refreshments, Gala dinner Friday, lunch Saturday).***Please ensure email address is provided for conference receipt***

conference Accommodation contact hotel: Tullamore court hotel. 057 9346689Single room 1 night single €75Double / Twin per person sharing 1 night €55ppsPlease contact the hotel directly for room bookings.

Payment I enclose a cheque / postal order for a total of € made payable to Irish Practice Nurses Association

Please return booking form and fee to: Tracey rooney, membership Secretary, dundrockan, donaghmoyne, carrickmacross, co. monaghan Phone No: 086 2634917 e-mail membership@irishpracticenurses.ie

cancellations must be received in writing by post or email no later than friday 7th october 2011 after this date fees cannot be refunded.

frIdAy 14 th

2.00-4.00 registration & exhibition

4.00-5.30 workshopsVenesection for the treatment of haemochromatosis in primary careTeaching breast self-check techniqueECG interpretation

6.30 conference opening address

7.00 Key note speakerDr Tony Humphries, Clinical PsychologistMotivation

8.00 AwardsResearch Bursary AwardClinical Award

8.30 conference gala dinner

SATurdAy 15th

8.30 Exhibition

10.00 Dr Alan Moore Psychiatry in Primary Care

10.45 Sandra Delamare, ANP, St James’s Hospital STI – Role of the Practice Nurse

11.30-12.30 Coffee and Exhibition

12.30-1.15 Eileen Brennan PN, CNS, General PracticeNurse Prescribing in General Practice – My Experience

1.30 Valerie Mangan IPNA Loyalty Award

LuNch

2.30 Agm

conference close

NATIoNAL coNfereNce – ocTober 14th and 15th 2011 – TuLLAmore courT hoTeLProPoSed AgeNdA

17

IPNA Conference 2011

From its' humble' beginnings in the early 1990s as a small group of practice nurses who decided to meet regularly to share ideas and information, the IPNA has expanded steadily and now boasts over 700 practice nurse members nationwide, with 19 branches holding

monthly meetings. There are currently over 1,700 practice nurses in Ireland.

The first IPNA Annual Conference & AGM (a much smaller affair than today's conference) was held in Galway in 1995. By 2004 the number of members and the practicalities of organising a large conference whilst seeing patients became evident; it was decided to appoint a Conference Coordinator from within the organisation. So the IPNA Conference Coordinator post was created for a pilot period of 2 years. Grainne Lynch gallantly took up the challenge of developing the post and produced the next series of very successful conferences with a professional standard as befits our organisation.

The benefits of such a move would lead to better communication and continuity between the IPNA, the host branch and the members whilst maintaining a high quality conference with topics and themes relevant to practice nurses. In 2005 it was Louth/Meath who were the hosts and 200 members attended the Grand Hotel in Dublin.

2006 saw 1,239 practice nurses working in Ireland of which 700 were members of the IPNA. The Kildare/Carlow Branch were the hosts of the conference held at Lyrath Estate. The host branch selected a theme which would examine the future of practice nursing within the primary healthcare plans. The focus was on the health of the future generation who would ultimately be affected by these changes. The title ‘Great Expectations’ was a very apt title. 200 members attended the conference.

Income from the conference allowed for employment of part-time IPNA administrator (Lisa Nolan) without whom we could not function. The conference also allowed for the development of IPNA Branch Poster Award, Practice Nurse of the year Award and the Valerie Mangan IPNA Loyalty Award (in honour of our departed colleague). This prize is open to any IPNA member who has loyally attended all their branch meetings during the year. Valerie was devoted to IPNA loyalty and felt very strongly about branch attendance.

2007 saw Cork Branch take up the challenge. They designed

an excellent programme examining how practice nursing is ‘Bridging the Gap’ between holistic and traditional medicine. As more patients are seeking alternative and complimentary therapies, it was felt that it is vital for nurses to be well informed on these practices. Again this conference was well attended by some 200 members.

The practice nurses from the Garden County hosted the 2008 Conference and AGM in the Slieve Russell Hotel, Ballyconnell, Co Cavan on the 17th and 18th October. Over 160 practice nurses from all over the country attended. The host branch always decides the theme of the conference and our Wicklow colleagues did not disappoint with their chosen theme that year — The Changing Role of the Practice Nurse — which focused on the practicalities of our role.

Th 2008 speakers included Dr John Faul from Dublin who spoke with great enthusiasm and depth of knowledge on the subject of COPD, Ms Mary O’Connor gave a presentation on how to measure ankle brachial index. Ms Rosemary Wilson, barrister-at-law talked on legal issues. Linda Latham from Dublin — Recognising the Addict in the Practice and Mr Charles Blow demonstrated venepuncture and ECG.

2009 saw Mayo host the conference at the Castlecourt hotel in Westport. The theme chosen for that year was ‘The Challenge of Change’. The programme focused on areas in society where people (patients) had experienced negative changes since the demise of the Celtic Tiger. Great thought and discussion by the Mayo branch went into choosing the topics and selected speakers for this programme. Every effort was made to include a good balance of clinical focus with theoretical.

Friday 15th October 2010 saw practice nurses arriving in the town of Ballybofey, Co Donegal. This was the location for the 2010 Irish Practice Nurses Association Educational Conference. Exhibitors, guests and speakers joined the IPNA members at Jackson’s Hotel and were given the warmest of welcomes by the host branch, Donegal.

The Donegal Branch chose an excellent theme and title for the 2010 Conference. Sonas, Spraoí agus Sláinte (happiness, laughter and health). The title was positively received by sponsors and members alike. The programme was designed to include a good balance of clinical, topical and thought-provoking presentations. In this time of financial and social difficulties, the Donegal ladies stayed true to their traditional

Why should I go to the 2011 IPNA conference?The reasons are many – from sharing experience to making new friends to keeping up with your CPD requirements – the annual conference should be a priority for every practice nurse.

LyNN cArTwrIghT, IPNA PRO

18

IPNA Conference 2011

Cerazette® 75 microgram film-coated tabletsDesogestrelAbbreviAted 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 suspec-ted 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 ef-fects 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. date of revision of Prescribing information: July 2009. date of preparation: June 2011. Cerazette/API/1RL/07-09/1. references: 1. Cerazette Summary of Product Characteristics: www.medicines.ie 2. Data on file. Kenilworth, NJ: Schering Corporation.

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bright outlook. Jane Campion was the winner of the IPNA Educational Bursary last year, and presented the results of her research into ‘Chronic disease management and multi morbidity in the Irish primary care setting’.

you Are NoT ALoNeAt a recent meeting of the Dublin Branch the subject of introductions came up. True, practice nursing can be professionally a very lonely job. Not all of us have the luxury of having another nursing colleague. Some will have met each other on training courses. Some will have been friends a long while. Branch meetings are an excellent way of meeting others. The annual conference likewise. So, how do you pluck up courage to walk into your first local practice nurse meeting or take off on your own to beautiful Donegal to hook up with like minded souls who are in need of education but also to let your hair down, leaving husband, kids and pets to fend for themselves? How do you find out is there anyone else going from your area that might be going too?

Firstly be reassured. We’ve all been there. We’ve all taken that breath and walked through a door into a room full of strangers, feeling as though everyone is staring and that all the others know each other. There will always be a number of people attending a meeting/conference that have never been there before and we all feel just like you. So, come on in...Take a deep breath. Take a seat. Smile at your neighbour. – it is probably the first time they too have attended a conference. We are a friendly, welcoming bunch.

There is something very special about the practice nurse conference. Nurses come from across Ireland. They’re an interesting lot, with all their different experiences from the brand new to the old timers. you can gain as much from the pearls of wisdom offered by someone during the coffee breaks and meals in addition to the high quality of the main stage speakers. Energy is high and a practice nurse has a thirst for knowledge like a sponge.

General practice is an attractive place for nurses to work and not just the easy option. Be proud that we all have far more experience in all subjects than our colleagues on their single speciality wards and our way of gaininga that information is by keeping ourselves up to date at branch meetings and the national conference.

Speakers are selected based on their expertise in the chosen topic, and their relevance to practice nurses. Our colleagues here (GPs) and our counterparts across the water in the united Kingdom all have to produce proof of continuing education. The new nurses bill (2010) will mean we too have to produce proof. Attending conference is a way of maintaining relevant educational needs to enhance our practice. We do not have the luxury of hospital funding so meeting our educational needs has to be value for money which is something Conference gives us.

The 2011 IPNA Educational Conference will take place on 14th and 15th October, in the Tullamore Court Hotel. With this central location, we look forward to seeing many more members attending.

It will be hosted by the IPNA South Tipperary Branch who guarantee a warm welcome .They have promised an inspiring relevant programme and are working very hard to maintain the high professional standard set by Grainne over the past years.

19

IPNA Conference 2011

2011 IPNA conference andAgm

‘Live Long & Prosper’Hello All!

Our theme for this year’s Conference, ‘Live Long & Prosper’, is surely the perfect aspiration for both ourselves and our patients. So time to whet your appetite for the ‘new look’ Conference which will take place on Friday afternoon the 14th and Saturday the 15th of October at the Tullamore Court Hotel. Although hosted this year by the South Tipperary Branch the central venue was agreed upon in order to facilitate ease of access for everyone from Donegal to Cork and everywhere in between!

As most of you are no doubt aware the South Tipperary Branch are taking charge of all aspects of the weekend with the valued assistance of the National Executive. The conference branch committee has worked hard on developing the programme and we hope that you will all be as enthused as we are with the clinical content.

The pharmaceutical representatives are looking forward to meeting you all at their exhibition stands. The Conference could not be held without the generous support of the pharmaceutical companies so our attendance at their stands is one way of showing our appreciation.

Tea/Coffee and finger food will be available from registration.Then time to get the glad rags on and gather for the

official opening of the Conference at 6.30pm. Our keynote speaker on Friday evening will be Mr Tony Humphries, Clinical Psychologist, a motivational speaker not to be missed.

Just before and during the gala dinner the annual awards will be presented, with lots of time afterwards to mix and mingle!

Saturday will start off bright but not too early, 10.00am SHARP. The programme commences with Dr Alan Moore – Psychiatry in Primary Care, followed by Sandra Delamere ANP – STI and the role of the Practice Nurse.

Then coffee, exhibition viewing and we round off the morning with our very own Eileen Brennan PN, CNS General Practice, South Tipperary Branch who will share her experience as a registered Nurse Prescriber in General Practice.

The presentation of the Valarie Mangan IPNA Loyalty Award will be followed by lunch. The afternoon concludes with the AGM and closing address.

The cost of that amazing line-up will be €80 for IPNA members if paid up before the 12th August and €90 after that. As the Conference is open to non IPNA members this year there will be a set price of €110 for same.

So if you’re looking for a value for money Conference with great clinical content and good company then look no further. We need to make this Conference a huge success and with your support we will!

Looking forward to seeing you all in Tullamore.

South Tipp Branch Conference Committee

Date of preparation: May 2010 05-11-NUV-2010-IRL-J

Minimal Oestrogen MonthlyJust 0.015mg ethinylestradiol daily 1

References 1. NuvaRing - Summary of Product Characteristics 2. van den Heuval MW et al. Contraception 2005 Sep;72(3):168-74. 3. Milsom I et al. Hum Reprod 2006;21(9):2304-2311 4. Novak A et al. Contraception 2003;67:187-194. 5. Organon data on file.

5.5 million women years exposure to NuvaRing® worldwide 5

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

NuvaRing® provides a low and steady delivery of hormones compared to a COC 2

Neutral effect on weight – no difference vs. drospirenone 3

96% user satisfaction rate 4

Nuvaring 0.120 mg/0.015mg per 24 hours vaginal delivery system® (See SPC before Prescribing) Etonogestrel and ethinylestradiol. Presentation: Vaginal ring. Uses: Contraception. Dosage and Administration: A ring should be inserted into the vagina and left in for 3 weeks. Strictly follow insertion instructions. Contraindications: Presence/history of venous thrombosis, with/without the involvement of pulmonary embolism. Presence/history of arterial thrombosis or prodromi of a thrombosis. Known predisposition for venous/arterial thrombosis, with/without hereditary involvement or the presence of severe/multiple risk factors. History of migraine with focal neurological symptoms. Diabetes mellitus with vascular involvement. Pancreatitis or history thereof if associated with severe hypertriglyceridemia. Presence/history of severe hepatic disease if liver function values abnormal. Presence/history of liver tumors. Known/suspected sex-hormone dependent tumors. Undiagnosed vaginal bleeding. Hypersensitivity to any ingredients. Precautions and Warnings: No epidemiology data available on vaginal administration but the warnings for combined OCs (COCs) are considered applicable. Risk of breast cancer possibly similar to that associated with COCs. This may be due to earlier diagnosis in COC users, the biological effects of the COC, or a combination of both. Use of hormonal contraceptives has been associated with increased risk of venous thromboembolism (VTE, DVT, PE) and arterial thrombosis. It is unclear whether NuvaRing carries the same risk. Remove ring in event of a thrombosis and before long-term immobilisation. Council patients on symptoms of thrombosis. Increased risk of cervical cancer in long term COC users has been reported, but this may be confounded by other factors. Abnormal liver function or liver tumors. Increased risk of pancreatitis in women with hypertriglyceridemia taking hormonal contraceptives. Hypertension. Diabetes. Crohn’s disease/ulcerative colitis. Chloasma. History during pregnancy/previous use of sex steroids: jaundice and/or pruritis related to cholestasis, gallstone formation, porphyria, SLE, HUS, Sydenham’s chorea, herpes gestationis, otosclerosis. Remove ring if there is increased frequency/

severity of migraine. Increased risk of thromboembolism in the puerperium. May not be suitable for women with a prolapse or severe constipation. Consider incorrect positioning in case of cystitis. Occasional vaginitis. If ring accidentally expelled follow SPC instructions. Interactions: Possible interactions with phenytoin, phenobarbital, primidone, carbamazepine, rifampicin, oxcarbazepine, topiramate, felbamate, ritonavir, griseofulvin, penicillins, tetracyclines, ciclosporin, lamotrigine and St John’s Wort. Use of antimycotic ovules may increase the chance of ring disconnection. Pregnancy and Lactation: Not recommended. Common Undesirable effects: Vaginal infection, depression, decreased libido, headache, migraine, abdominal pain, nausea, acne, pelvic pain, breast tenderness, genital pruritis, female dysmenorrhoea, vaginal discharge, weight increased, discomfort, device expulsion. See SPC for full details of other uncommon side effects. Overdose: No reports of serious effects from overdose. Legal Category: Prescription Medicine Product Authorisation Number: PA 61/29/1. Price: NuvaRing x 1 €9.41, NuvaRing x 3 €28.23 Product Authorisation holder: Organon Ireland Limited, a part of Schering-Plough Corporation, 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 SPC text before prescribing this product. Adverse events should be reported. Reporting forms and information can be found at www.yellowcard.gov.uk (UK) and www.imb.ie (Ireland). 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: December 2008 Nuvaring/IRL/API/12-08/1

H54641 NUV Ire 375x126 v6.indd 1 18/5/10 12:25:22

20

IPNA clinical award 2011

cASe STudyMary is a 52 year old lady who is married to John who is 56 years. They have three children aged 12, 14 and 18 years. (Anna, Darren and James). James has just done his Leaving Certificate. Mary works full time in the local bank which she finds very stressful and pressurised. Her husband works in the local garden centre and works Saturdays. His job is under threat due to the recession and his salary has been dramatically cut.

Despite the fact that they both work, they are under pressure financially. Their 14 year son has ADHD and this has caused difficulties at home. Mary has struggled with her weight all her life and no longer believes she can get to a healthy weight. According to her “she has tried everything Weight Watchers, lipotrim, every diet that exists and nothing works”. They all work for a short time but she puts the weight back on and then feels even worse. She is 5 ft 4 inches, weighs 109.2 kg (17st 3 lbs). She has raised blood pressure and cholesterol and also type 2 diabetes. She often has stomach problems and constipation. She was diagnosed last year with sleep apnoea and now sleeps with a c pap machine. Over the years she has been depressed (both about her weight and things in general) and her GP put her on antidepressants but she does not think they make any difference. Her knees and hips are sore when she walks for any length of time so she does not do so. She has been advised to swim but is too embarrassed to do so. She likes to read and bake for the family (when she has some time – usually at the weekends). She gets very anxious at times and her self confidence has diminished over the years. She is tired most of the time and admits they often go for the easy option food-wise which she knows is not good but feels helpless to change this. She would really love to loose weight and knows she cannot continue the way she is.

Her medications include:Lipitor 20mgs nocteCoversyl 10mgs nocteCardura XL 4mgs bdAnafranil 75mgs sr nocteStilnoct 10mgsProtium 40mgs Gulcophage 500mgs TIDPando PRN

IPNA Clinical Award 2011 (Obesity)The IPNA and Nursing in General Practice are delighted to announce the IPNA Clinical Award 2011, kindly supported by Allen & Hanburys/GSK. This year the award focuses on obesity and the winner will receive an educational bursary of €1,000.

how To eNTerBelow is a case study accompanied by a set of questions that must be answered within the word limit of 1,000 to 1,500. Please email your completed answers, along with your name, An Bord Altranais PIN and full contact details to admin@irishpracticenurses.ie

Closing date for receipt of entries is Sunday 11th September 2011.The winner will be notified by telephone before the conference. The result will be announced and Certificate & Award will be presented to the winner at the IPNA Annual Educational Conference in Tullamore on 14th October 2011 if they are in attendance. The winner will also be announced on the IPNA website after the conference and the winning entry will be published in a later issue of Nursing in General Practice.

ruLeS• Entrants must be on the current register of An Bord Altranais in either the RGN or PHN divisions. The Bord Altranais PIN must

accompany each entry for verification.• Entrants must be a current member of the Irish Practice Nurses Association.• Entrants must answer all questions.• Word limit for entries is 1,000 to 1,500.• Entrants must submit their entry on or before the closing date.• Joint entries will not be accepted.• The judges’ decision is final and no correspondence will be entered

into.

Questions.

1. What are the medical and psychological consequences of obesity?

2. What are the specific consequences when the BMI increases from one category to another and what are the specific benefits when the patients drop from one category to another.

3. What do you consider to be Mary‘s biggest problems and what can you do to help her?

4. What are the basics elements of motivational weight management and how can you implement them to assist Mary? Outline motivational tools you can use to keep Mary moving forward.

5. Mary needs help with motivation, nutrition and lifestyle change management. Given that your time is limited, how much time would you spend on each of these elements?

6. How would you use goal setting to help Mary improve her health ?

7. What nutritional and physical activity advice would you give to Mary?

8. If Mary did achieve her health goals, what difference would this make to her life and how could you use this to help Mary?

9. What impact to you think your personal view of Mary’s weight problems can have on your treatment approach and the outcomes?

10. How would you measure Mary s success?

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education

When I attend a Dublin IPNA meeting, I look around and realise that I am one of the ‘Mammies’, or probably more like one of the ‘Grannies’!

The younger members all have nursing degrees, many with diplomas, as do some of the older members.

When I began general nurse training over 30 years ago and midwifery more than 25 years ago in St Laurence’s Hospital (the Richmond) and the Rotunda, there were no degrees or diplomas being awarded! But I still consider we were extremely well trained.

In 2006, DCu/Connolly Hospital, Blanchardstown, I began level 8 stand alone CVD, respiratory and diabetes modules. As I have a special interest in type 2 diabetes, I was lucky to receive a place on the diabetes module in 2007. This was my introduction to the world of academic writing! Still a daunting experience, but the study bug bit!

In 2008 I began to think: “am I being left behind academically despite attending regular updates at the IPNA monthly meetings, pharmaceutical company-funded meetings, Tallaght-Clondalkin regular meetings organised by Rita Lawlor, PDC and DFI conferences/meetings?”

At the diabetes module a few of us ‘oldies’ were in the same boat, but it was a great module and we came out the other end having learnt a lot about diabetes, and also how to use a college library on-line, Harvard referencing (ugh!), cite papers etc.

One night in June 2008, following an IPNA meeting, Rita Lawlor (an amazing and supportive PDC) and I were just chatting about the module and I mentioned that I’d love to get some kind of an academic qualification, but that it was extremely unlikely at my age.

Rita recommended the Postgraduate Diploma in Primary Care in NuI Galway, which is module based.

INTeLLecTuAL dISAbILITy cAmPAIgNerBeing the mother of a young man, Kealan, with a severe intellectual disability, I’d spent years lobbying and campaigning for rights and better services for people with an intellectual disability. I was on local and national committees (and I am still PRO of the National Parents and Siblings Alliance) and also contested the 2002 General Election in Dublin South. My son is now living happily with other young adults in a house in the care of St Michael’s House.

So I felt that perhaps it was time after 22 years to do something just for me! Perhaps this sounds a bit selfish, but we only have one life. This is it, and it is no dress rehearsal!! My other two children Ódhran and Aoibheann are both teenagers, so quite independent.

I went home that night quite excited after talking to Rita and discussed my options with my husband. Then I searched the NuIG website. Luckily the application date had been extended until the end of June. One has to apply to NuIG via the Postgraduate Applica-tions Centre which is similar to the CAO, but instructions are clear.

There are two Postgraduate Diplomas in Health Sciences, one in Primary Care and the other in Clinical Primary Care. They are taught through a combination of e-learning via blackboard and face to face sessions in NuI Galway. The student chooses 6 modules.

If anyone is considering a research Masters in the future, the Health Research module is compulsory.

The Primary Care modules are: • Concepts and Principles of Primary Care • Evidence Based Primary Care • Health Research Methods • Teambuilding and Communication Skills • Health Promotion • Health Economics • Healthcare Ethics • Psychology for Primary Care • Sociology of Health and Illness

'Desperately seeking' academia Karen Canning talks about the challenges of the Post Graduate Diploma in Primary Care

mS kAreN cANNINgPRACTICE NuRSE, RGN, RM, PGDIP HSC.

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In Clinical Primary Care there are 3 choices: One can take a single module

• Postgraduate Certificate = any 3 modules, at least 2 clinical• Postgraduate Diploma = any 6 modules, at least 3 clinical. • Modules can be accumulated over up to five years (or one

year) as you wish.

The Clinical Primary Care modules are:Clinical Modules

• Infectious Disease in Primary Care (trimester 1) • Minor Surgery and Related Dermatology in Primary Care

(trimester 1) • Diabetes in Primary Care (trimester 2) • Cardiovascular Disease in Primary Care (trimester 2) • Women's Health in Primary Care (trimester 3) • Respiratory Disease in Primary Care (trimester 3)

Non-Clinical Modules • Concepts and Principles of Primary Care (trimester 1) • Evidence Based Primary Care (trimester 1) • Clinical Teaching Methods (trimester 2) • Health Research Methods (trimester 2)

http://www.nuigalway.ie/courses/taught-postgraduate-courses/clinical-primary-care.html

My choice of modules were 5 clinical and 1 non-clinical:• Infectious Disease, Minor Surgery (Sept-Dec)• CVD, Diabetes and Research Methods (Jan-Mar)• Women’s Health (Apr-June).

Dr Mary Byrne, Dept of General Practice NuIG, is the course facilitator and nothing appears to be too much trouble for her. Initially I phoned her often when considering applying and then throughout the course. She has untold patience and is extremely professional and helpful at all times. Mary gave me tremendous support during the postgraduate diploma and continues to do so.

I would strongly recommend the Postgraduate Diploma in Health Sciences (Clinical Primary Care) NuIG to my practice nurse colleagues.

Graduation day was a wonderful and memorable experience. It was my first time in a cap and gown!

I met two other women at the conferring who had complet-ed the Postgraduate Diploma in Primary Care and the three of us are the only students now doing the 1 year Masters in Health Sciences (Primary Care) which is a research Masters.

As many of you are aware, if you received a postal question-naire, mine is a quantitative, cross-sectional, observational study on the feasibility of insulin initiation for patients with type 2 diabetes mellitus in general practice from a practice nurse perspective and also looking at current diabetic care in general practice.

To all the practice nurses who have returned the question-naire – a Big Thank you!

If any of you still have the questionnaires, could I please ask you to return them. Thanking you in advance.

Visit us at www.abbottnutrition.ie

More Taste, Less Waste.Ensure Plus –It’s the taste we love!

Ensure Plus -The preferred supplement1

Largest‡ ONS+ compliance studyn>1,700SUSTAIN study*

‡ No larger published study was identifi ed through literature reviews.

Largest ever blinded and randomised study investigating sensory factors, taste and compliance in oral nutritional supplements.+ Oral nutritional supplements.

* Study to improve Understanding of Sensory factors and Taste And their Impact on compliance with Nutritional drinks.

Reference available on request.

Abbott Laboratories Ltd., 4051 Kingswood Drive, Citywest Business Campus, Dublin 24Tel: (01) 4691500. Fax: (01) 4691501. Email: abbott_nutrition_irl@abbott.comDate of Preparation: June 2011 ANI/SIP/2011/021

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research

Visit us at www.abbottnutrition.ie

More Taste, Less Waste.Ensure Plus –It’s the taste we love!

Ensure Plus -The preferred supplement1

Largest‡ ONS+ compliance studyn>1,700SUSTAIN study*

‡ No larger published study was identifi ed through literature reviews.

Largest ever blinded and randomised study investigating sensory factors, taste and compliance in oral nutritional supplements.+ Oral nutritional supplements.

* Study to improve Understanding of Sensory factors and Taste And their Impact on compliance with Nutritional drinks.

Reference available on request.

Abbott Laboratories Ltd., 4051 Kingswood Drive, Citywest Business Campus, Dublin 24Tel: (01) 4691500. Fax: (01) 4691501. Email: abbott_nutrition_irl@abbott.comDate of Preparation: June 2011 ANI/SIP/2011/021

bAckgrouNdChronic obstructive pulmonary disease (COPD) results in persistent and progressive breathlessness which has a negative impact on a person’s ability to lead a normal life. The evidence also suggests that the prevalence of COPD worldwide is on the increase (Mathers & Loncar 2006). In Ireland, given the absence of COPD registers, details concerning the prevalence of COPD are unclear. However, in the uK the rate of COPD is estimated to range from 2-4% (CHAI 2006). COPD therefore has a significant impact on patients and on healthcare systems. Identifying and using strategies that can delay disease progression and prevent acute exacerbations are therefore vital.

Pulmonary rehabilitation (PR) programmes have been identified as a key strategy in improving the health of people with COPD (Troosters et al. 2005, Lacasse et al. 2006; Effing et al. 2007). These programmes normally consist of a patient assessment, exercise training, education and psychosocial

support (Nici et al. 2006). until recently in Ireland most PR programmes were hospital based, however, best practice guidelines for COPD emphasise the need for patients to have access to these programmes across all healthcare settings and in particular within the primary care context. (DOHC 2001; NICE 2004; GOLD 2008 NICE 2010; DH 2010). However, the extent to which PR programmes delivered in the primary care context are effective in enhancing clients self management skills and the practice nurses role in facilitating such programmes is relatively unknown.

The TrIALPRINCE (Pulmonary Rehabilitation in Nurse led Community Environments) is a two-armed, single blind cluster randomised trial conducted in Irish primary care settings. The main aim of the study was to evaluate the effectiveness of a structured education pulmonary rehabilitation programme (SEPRP),

Practice nurses experiences of a structured education pulmonary rehabilitation programme: the PRINCE studyThe authors present the results of a the study to evaluate the effectiveness of a structured education pulmonary rehabilitation programme (SEPRP) delivered in general practice on the health status of people with COPD.

dr dymPNA cASey, ProfeSSor kAThy murPhy, dr AdeLINe cooNey, mS LorrAINe mee, mS coLLeTTe kIrwAN, mS broNA mooNey ANd mS AgNeS TuLLy

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delivered at the level of the general practice, on the health status of people with COPD (Murphy et al. 2011). The SEPRP was developed based on best practice guidelines identified by NICE (2003) and (DH 2005). It consisted of a structured written 8 week curriculum designed to be nurse led, delivered in the primary healthcare setting, two hours per week over an 8 week period. The content of this programme is presented in Table 1. The practice nurse had overall responsibility for delivering the SEPRP and was assisted by a physiotherapist who focused on delivering the exercise component of the programme. This paper presents an account of practice nurses’ experiences of facilitating the PRINCE SEPRP and the factors that facilitated and hindered delivery.

PrAcTIce NurSeS exPerIeNceS of fAcILITATINg A SePrP All 16 practice nurses received a three day training programme to: • deliver the SEPRP consistently• work in an empowering way with clients and • work effectively with groups.

These training sessions were interactive and geared towards meeting facilitators learning goals and needs. The first two-days concentrated on informing nurses about the PRINCE study, its aims and expectations, how to deliver the programme, rationale and approach and familiarisation with programme content. On the third day, held a week later, practice nurses delivered to their peers an assigned element of the SEPRP. The research team observed these sessions and fed back to each participant on their performance. Furthermore, as

part of the quality assurance for the programme members of the research team observed the nurse facilitate one session.

Following delivery of the SEPRP, practice nurses were interviewed via telephone to capture their experiences of facilitating the programme and in particular to identify factors that helped or hindered facilitation. This paper describes practice nurses accounts of facilitating the PRINCE SEPRP.

All practice nurses reported that they were initially apprehensive at the prospect of delivering the SEPRP. This apprehension mainly related to the perception that they lacked specific knowledge concerning respiratory illnesses and group facilitation skills. However, they reported that the training programme gave them the knowledge and confidence to facilitate the programme. Although they admitted that they had been somewhat reluctant to undertake this mock session, they commented that conducting a mock session of the SEPRP, as part of the training programme, enhanced their confidence.

…I think even in as much as people don’t want to do a practice run it was probably very useful…because I suppose we kind of got a flavour for…different sessions. So it helped when we were actually going to deliver it ourselves…It wasn’t something you looked forward to, but I think it’s something that you actually needed to do.

All practice nurses were highly motivated and committed to facilitating the SEPRP and most reported that they would be pleased to facilitate the programme again. They felt that they empowered and motivated their clients. This increased their job satisfaction as they felt they were making a real difference in people’s lives. In particular they felt great satisfaction when they saw their clients health improving. They reported that the content and structure of the SEPRP manual was easy to follow which also enhanced facilitation. However they felt that there was a need for a follow up maintenance programme to be put in place. Some of the nurses were so convinced as to the value of the programme that at the end of SEPRP they were exploring how they could continue the programme.

fAcTorS AffecTINg fAcILITATIoN Practice nurses reported that the key factors that helped them to facilitate the programme included the structure and lay-out of the SEPRP manuals, having support from other practice nurses involved in PRINCE, the co-hesiveness of their client group, and having a prior relationship with their clients.

Table 1: content of the PrINce SePrP

week content educator

week 1 Setting the scene Practice Nurse

Introduction to exercise Physiotherapist

week 2 Managing medications Practice Nurse

Exercise programme Physiotherapist

week 3 Exercise programme Physiotherapist

Exercise programme Physiotherapist

week 4 Managing breathlessness Practice Nurse

Exercise programme Physiotherapist

week 5 Knowing and managing your symptoms

Practice Nurse

Exercise programme Physiotherapist

week 6 Recognising and managing acute exacerbations

Practice Nurse

Exercise programme Physiotherapist

week 7 Exercise programme Physiotherapist

Managing stress and anxiety

Practice Nurse

week 8 Exercise programme Physiotherapist

Where to now? Practice Nurse

many practice nurses reported that their experience of participating in PrINce had also helped them to get to know their clients better.

• 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

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In particular they emphasised the value of ‘being known’ or ‘familiar’ to their clients as this engendered trust and being available locally in the practice allowed them to provide additional support as needed.

Many practice nurses reported that their experience of participating in PRINCE had also helped them to get to know their clients better. They also felt that they now had a more real sense of the difficulties clients have managing a chronic illness on a day-to-day basis. It also highlighted the need to continually educate and re-educate clients in self management skills.

We see a patient, and they’re in for a 10 minute appointment, and then they’re away. One of the patients swas on home oxygen for…18 hours a day, and never really thinking about that…what a huge obstacle for her everyday…just realising the impact…the way we send people away and they get their inhalers, and everybody thinks that that’s grand, and it probably made me realise how we actually need to revisit that much more often…not assuming that anybody fully understands what they’re taking, and why they’re taking it.

Practice nurses also reported that the knowledge acquired from participating in PRINCE was not just having an effect on the client participants in the study but that they were using the knowledge and skills gained to help other COPD clients who attended their practice.

I found that I learnt a lot. I can now automatically feedback to our own patients with COPD.

The main barriers that hindered practice nurses in their facilitation of the SEPRP was lack of time and how busy the practice was. This was partly due to the fact that, simultaneously, as they facilitated the SEPRP the practice workload increased due to the vaccination campaign for H1N1. This was very difficult for the practice nurses who felt under pressure from colleagues to help more in the practice yet they were also committed to delivering the SEPRP. While GP practices had been reimbursed to replace practice nurses, this was not always possible and few practice nurses reported that this had occurred. In reality they facilitated the SEPRP in addition to completing their other routine duties.

… I had…my workload before I went…it was just…time that was my biggest constraint…Nobody was actually brought in to cover the workload as such…so I came in, and I worked from 9 to 10…and then I…[facilitated the SEPRP]…So by the time I got back here [to the practice] and then I was finishing off from the morning work…. So it was only it was me that was playing catch up. It didn’t have any effect on the surgery but on me it did.

In conclusion it is clear that the experience of participating in the PRINCE study and facilitating the SEPRP was a positive experience for practice nurses. Furthermore, it has expanded their expertise and knowledge. They are now more knowledgeable regarding COPD and in developing clients self management skills. In addition they are now trained to deliver a SEPRP programme and have the necessary skills to effectively work with groups of clients, rather than just with individuals. Most importantly the skills and the knowledge that they have gained will remain in the general practice, enhancing capacity in primary care in relation to disease prevention and rehabilitation – ultimately creating sustainable health (DOHC 2001).

references1. CHAI (2006) Commission for Health Care Audit and Inspection:

A National Study of Chronic Obstructive Pulmonary Disease London:uK.

2. DOHC (2001) Primary Care A New Direction. Department of Health and Children, Dublin Stationery Office, Dublin.

3. DH (2005) Department of health Structured patient education in diabetes: Report from the Patient Education Working Group Department of Health; Diabetes uK. Crown

4. DH (2010) Department of Health Consultation on a Strategy for Services for Chronic Obstructive Pulmonary Disease (COPD) in England Crown: uK.

5. Effing T, Monninkhof EEM, van der Valk PP, zielhuis GGA, Walters EH, van der Palen JJ, zwerink M. (2007) Self-management education for patients with chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD002990.

6. Global Initiative for Chronic Obstructive Lung Disease: Global Strategy for Diagnosis, Management and Prevention of COPD: update 2008. Global Initiative for Chronic Obstructive Lung Disease 2008.

7. Lacasse, y. Goldstein, R. Lasserson, T. & Martin, S. (2006) Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews, 49.

8. Mathers C, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Medicine, 2006, e442.

9. Murphy, K. Casey, D. Devane, D. Cooney, A. McCarthy B. Mee, L. Nichulain M. Murphy, AW. Newell, J. and and O’ Shea, E. (2011) A cluster randomised controlled trial evaluating the effectiveness of a structured pulmonary rehabilitation education programme for improving the health status of people with chronic obstructive pulmonary disease (COPD): The PRINCE Study protocol. BMC Pulmonary Medicine 11:4 (18 January 2011) Available at http://www.biomedcentral.com/1471-2466/11/4

10. NICE :National Institute for the Health and Clinical Excellence NICE: Guidance on the use of patient-education models for diabetes.(2003). Technology Appraisal 60. National Institute for Clinical Excellence; uK

11. NICE: National Institute for Health and Clinical Excellence: Chronic Obstructive Pulmonary Disease: Management of chronic obstructive disease in adults in primary and secondary care (2004). National Collaborating Centre for Chronic Conditions NHS: UK .

12. NICE: National Institute for Health and Clinical Excellence: Chronic Obstructive Pulmonary Disease: Management of chronic obstructive disease in adults in primary and secondary care (2010). National Collaborating Centre for Chronic Conditions NHS: UK .

13. Nici L, Donner C, Wouters E, zuwallack R, Ambrosino N, Bourbeau J, Carone M, Celli B, Engelen M, Fahy B, Garvey C, Goldstein R, Gosselink R, Lareau S, MacIntyre N, Maltais F, Morgan M, O’Donnell D, Prefault C, Reardon J, Rochester C, Schols A, Singh S, Troosters T; ATS/ERS Pulmonary Rehabilitation Writing Committee (2006). American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med. Jun 15;173(12):1390-413.

14. Troosters, T. Casaburi, R. Gosselink, R. & Decramer, M. (2005) Pulmonary Rehabilitation in Chronic Obstructive Pulmonary Disease. American Journal of Respiratory and Critical Care Medicine. 172: 19-38.

27

clinical review

Sudden cardiac death (SCD) is defined as ‘death due to natural causes within an hour of the onset of symptoms, in the absence of any other cause, and assumed or proven to have a cardiac cause.1 When a young person dies it has catastrophic effects on the

family. Post mortem results of SCD in the young have shown a number of underlying conditions, such as cardiomyopathy, myocarditis and coronary heart disease.1 There are also many unexplained deaths (approximately 20-30%) in people under 35years of age where there is no structural abnormality found at post mortem1 and these are classed as sudden arrhythmic death syndrome (SADS).

The annual incidence of SCD in the general population is estimated to be less than 1 in 1000.

Over 5,000 people suffer sudden cardiac death in Ireland each year, of which 60 to 80 are under the age of 35 years. Review of Irish post mortem data suggests that SCD in a population of 14-35 years occurs in 3 to 4 per 100,000, with males being 7 times more likely to be affected. It also suggests that in up to 50% of cases of SCD in the young, the cause may be inherited.3

high risk sub-groupsSince prospective cardiac assessment of the general population is not currently feasible, the initial focus is to target high-risk subgroups • History of sudden death in close family member with

suspected cardiac cause or unknown cause • Family history of inherited cardiac disease• Signs and symptoms that may indicate cardiac cause

Signs and symptoms

• Chest pain with activity that limits completion of activity• SOB on exertion that happens repeatedly on less than

maximal exertion• Dizziness syncope – especially on exercise• Exercise intolerance• Sometimes no symptoms – could be found during

routine medical examination• unexplained/uncontrolled seizure-like episodes

Sudden cardiac death in the young The annual incidence of SCD in the general population is estimated to be less than 1 in 1000 but it is devastating for those left behind.

mS heLeN o’doNNeLL, CNM 2, CARDIAC RISK IN yOuNGER PERSONS (CRyP) CENTRE, TALLAGHT HOSPITAL

28

clinical review

figure 1 – family pedigree with 4 generations

Conditions that can be detected on cardiac testing include:• Cardiomyopathy: dilated cardiomyopathy (DCM),

Hypertrophic cardiomyopathy (HCM), arrhythmogenic right ventricular cardiomyopathy (ARVC).

• Long QT syndrome (LQT)• Brugada syndrome• Catacholaminergic polymorphic ventricular tachycardia

(CPVT)• Wolf Parkinson White syndrome (WPW)• Connective tissue disorders (e.g. Marfans).

hypertrophic cardiomyopathyHypertrophic cardiomyopathy (HCM) is a genetic disease associated with a risk of ventricular tachyarrhythmias and sudden death, especially in young patients.7 The heart muscle becomes thick and fibres are arranged haphazardly increasing

the risk of fatal arrhythmias. The thickened muscle interferes with the heart’s normal contraction and relaxing, which results in reduced cardiac output. 25-30% of patients have the ‘obstructive’ form with relative obstruction to blood flow from the left ventricle to the aorta.

LQTLong QT syndrome is an association of cardiac rhythm disorders and QT prolongation or abnormal T waves on ECG.4 Abnormal corrected QT measurements are defined as being >440ms in men and >460ms in women for a diagnosis to be made.5 Some medications may increase the risk of arrhythmia in LQT syndrome.8 A patient’s resting ECG is not always abnormal in LQT patients.

brugada syndromeBrugada syndrome was first reported in 1992 by Josep and Pedro Brugada. It is an arrhythmogenic disease that is characterised by ST elevation in the right precordial leads (V1 – V3) with incomplete or complete right bundle branch block (RBBB) pattern on the ECG. It is associated with a high incidence of syncope and sudden death in patients with a structurally normal heart.2 The patients resting ECG is often significantly abnormal in patients at high risk of arrhythmia. Gene carriers of Brugada syndrome may be unmasked during Ajmaline provocation testing.

cPvTCatecholaminergic polymorphic ventricular tachycardia is an arrhythmogenic disorder of the heart characterized by a reproducible form of polymorphic ventricular tachycardia induced by physical activity, stress, or catecholamine infusion, which can deteriorate into ventricular fibrillation.6 Resting ECG is normal or near-normal in patients with CPVT. Diagnosis is made on exercise testing and epinephrine provocation testing.

wolff-Parkinson-white syndromeWolff-Parkinson-White (WPW) syndrome is a heart condition in which there is an extra electrical pathway (circuit) in the heart which can lead to tachycardia. Resting ECG is usually abnormal in patients with WPW.

hypertrophic cardiomyopathy (hcm) is a genetic disease associated with a risk of ventricular tachyarrhythmias and sudden death, especially in young patients.

Symbol definitions

clear symbol

Affected

29

clinical review

If a person is at risk they can be treated with either medication or an internal cardiac defibrillator.

evaluation• Detailed family pedigree (minimum 3 generations) (Figure 1)• Routine examination• Detailed history• ECG and ECHO is recommended for all 1st degree relatives • EST• Holter monitor.

TreatmentNot everyone who inherits these conditions will die suddenly. If a person is diagnosed with the condition they will be assessed according to their risk. If a person is at risk they can be treated with either medication or an internal cardiac defibrillator (ICD).9

SportExercise can increase the risk of sudden death only in those who have the conditions.

It is also possible for a young person who has one of these conditions to die suddenly doing normal activities or during sleep.

The cardiac risk in younger Persons centre The CRyP centre opened in November 2008 and it aims to see 1500 people a year.

A referral is to be sent from a GP or consultant and these are assessed in order of priority by a specialist cardiologist. The reasons for referrals are due to a family history or a patient having unexplained cardiac symptoms. There is no charge to patients and all tests and results are done on the same day.

The aims of the centre are:• Evaluation of families of victims of SCD to assist in preventing

further loss

• Evaluation of young persons who have symptoms• Support for families during their tests and counselling

service provided if required• Referral for genetic testing if required.

conclusionSCD in the young occurs in Ireland approximately once a week and for the families it is devastating. Post mortems will reveal any structural abnormalities within the heart but electrical conditions cannot be detected after death and are known as ‘SADS’. The nurse can play an important role in educating and counselling individuals and family members during this difficult period.

Acknowledgements: Many thanks to Dr Deirdre Ward, Consultant Cardiologist, AMNCH, for all her help with this article.

references1. Task Force for Sudden Cardiac Death, 2004 2. Brugada P. and Brugada J. (1992) Right bundle branch

block, persistent ST – segment elevation and sudden cardiac death: a distinct clinical and electrocardiographic syndrome. Journal Am Coll Cardiology 20, 1391-1396.

3. Morris V.B., keelan T., Leen E., Keating J., Magee H., O Neill J., and Galvin J., (2009). Sudden Cardiac death in the young: a 1 year post mortem analysis in the Republic of Ireland. Irish Journal of Medical Science. 178 (3). 257-261.

4. Khan I A, Long QT syndrome: Diagnosis and management, American Heart Journal, 2002; 143: 7 – 14.

5. R oden D.M., (2008) Long-QT Syndrome, The New England Journal of Medicine, 358: 169-176.

6. Bhuiyan z.A.,Van den Berg M.P., J. Van Tintelen P., Bink-Boelkens M.T., Wiesfeld A.C., Alders M., Postma A.V., Van Langen I., Mannens M., and Wilde A., (2007) Expanding Spectrum of Human RyR2-Related Disease. New Electrocardiographic, Structural, and Genetic Features. Circulation (116)000-000.

7. Maron B.J., Shen W., Link, M.S., Epstein A.E., Almquist A.K., Daubert J.P., Bardy G.H., Savale S., Rea R., Boriani G., Estes M and Spirito P., (2000). Efficacy of Implantable Cardioverter Defibrillators for the prevention of sudden death in patients with Hypertrophic cardiomyopathy. The New England Journal of Medicine. 342 (6) 265-273.

8. http://www.azcert.org/9. Priori S.G., Schwartz P.J.,Napolitano C.,.Bloise R., Ronchetti

E., Grillo M., Vicentini A., Spazzolini C., Nastoli N., Bottelli G., Folli R., Cappelletti D., (2003) Risk stratification in Long-QT syndrome. New England Journal of Medicine. 348: 1866-1874.

30

abstractsManagement of allergic and non-allergic rhinitis: a primary care summary of the BSACI guideline

Angier e, willington J,

Scadding g, holmes S, walker S;

British Society for Allergy & Clinical

Immunology (BSACI) Standards

of Care Committee., Department of

Immunology and Allergy, Northern General Hospital,

Sheffield, uK.

Rhinitis is a common problem in primary care which is often managed sub-optimally. It causes considerable morbidity and has been shown to have a detrimental impact on people’s ability to concentrate at school and at work. Rhinitis and asthma often present together, and symptomatic rhinitis can be associated with poor asthma control and increased risk of exacerbations. There is therefore a clear need to recognise and treat rhinitis according to guideline recommendations. This article is a primary care summary of the British Society for Allergy & Clinical Immunology (BSACI) Standards of Care Committee guideline on the management of rhinitis, written by a multi-disciplinary group of clinicians. It takes into account the time restrictions on assessment and the tests and equipment available in primary care, as well as the need for practical, clear and intuitive strategies for investigation and management. It recommends a stepwise approach to treatment, and highlights the relevance of less frequently prescribed treatments, including nasal douching leukotriene receptor antagonists and anticholinergics. Red flag symptoms are identified, together with indicators for referral. As with many other long term conditions, good communication between primary and secondary care in terms of timely and appropriate referral is a key factor for success.

Is physician-diagnosed allergic rhinitis a risk factor for the development of asthma?van den Nieuwenhof L,

Schermer T, bosch y,

bousquet J, heijdra y,

bor h, van den bosch w,

van weel c., Department of Primary

and Community Care, Radboud university

Nijmegen Medical Centre, Nijmegen,

the Netherlands

There is strong evidence that there is a relationship between allergic rhinitis (AR) and asthma, but it is unclear whether there is a causal relation between AR and asthma. The aim of this study was to assess prospectively whether AR is a risk factor for the diagnosis of asthma in a large primary care population.

We performed a historic cohort study of life-time morbidity that had been recorded prospectively since 1967 in four general practices. Two groups of subjects were selected: (i) patients with diagnosis of AR, (ii) a control group matched using propensity scores. We assessed the risk of physician-diagnosed asthma in patients with physician-diagnosed AR compared to subjects without a diagnosis of AR (controls).

The study population consisted of 6491 subjects (n = 2081 patients with AR). Average study follow-up was 8.4 years. In patients with AR, the frequency of newly diagnosed asthma was 7.6% (n = 158) compared to 1.6% (n = 70) in controls (P < 0.001). After adjusting the effect of AR on asthma diagnosis for registration time, age, gender, eczema and socioeconomic status, having AR was a statistically significant risk factor for asthma (hazard ratio: 4.86, P < 0.001, 95% confidence interval: 3.50-6.73, controls as reference).

A diagnosis of AR was an independent risk factor for asthma in our primary care study population. Having physician-diagnosed AR increased the risk almost fivefold for a future asthma diagnosis.

Changing prevalence of allergic rhinitis and asthmaSly rm,

Section of Allergy and Immunology,

Children’s National Medical Center,

Washington, DC uS.

This review will enable the reader to discuss prevalence, risk factors, and prognosis of allergic rhinitis and asthma.

A MEDLINE (PubMed) search using the terms allergic rhinitis, asthma, prevalence, risk factors was conducted of human studies published in the English language since 1978, especially studies of relatively large populations in the united States, Great Britain, Australia, and New zealand, with cross referencing to earlier relevant studies.

The current prevalence of allergic rhinitis at 16 years of age in cohorts of British children born in 1958 and 1970 increased from 12% in the earlier cohort to 23% and in the later cohort. Local surveys of allergic rhinitis at approximately 18 years of age in the uS in 1962 to 1965 disclosed prevalence of 15% to 28%, while the national survey of 1976 to 1980 disclosed a prevalence of 26%. Thus, it is uncertain whether prevalence of allergic rhinitis has changed in the united States based on these limited data. Data from several sources indicate worldwide increases in prevalence of asthma. Annual Health Interview surveys indicate increases in prevalence of asthma in the uS from 3.1% in 1980 to 5.4% in 1994, but prevalence among impoverished inner city children has been much higher. Combined prevalence of diagnosed and undiagnosed asthma among inner city children has been 26% and 27% at 9 to 12 years of age in Detroit and San Diego. Positive family history and allergy are important risk factors for allergic rhinitis and asthma. Prognosis is guarded; allergic rhinitis resolves in only 10% to 20% of children within 10 years, and at least 25% of young adults who have had asthma during early childhood are symptomatic as adults.

The author concludes that increases in prevalence remain unexplained, but avoidance of recognized allergens should reduce the prevalence of allergic rhinitis and asthma.

FoCuS on: ALLERGY

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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

32

abstractsDevelopment of allergies and asthma in infants and young children with atopic dermatitis – a prospective follow-up to 7 years of age

gustafsson d, Sjöberg o, foucard T.

Department of Paediatrics,

Orebro Medical Centre Hospital,

Sweden.

The prognosis of atopic dermatitis is usually good, but the risk of developing asthma and allergic rhinitis is very high. The aim of this study was to follow children with atopic eczema up to school age to chart the course of sensitization and development of clinical allergy, as well as to study risk factors of sensitization.

Ninety-four children with atopic dermatitis were followed up to 7 years of age. The children were examined twice a year up to 3 years of age, and thereafter once yearly. At each visit, a clinical examination was performed, and a blood sample was taken. After 3 years of age, skin prick tests (SPTs) with inhalation allergens were performed at each visit. Information was obtained about atopy in the family, feeding patterns during infancy, symptoms of atopic disease, infections, and environmental factors.

During the follow-up, the eczema improved in 82 of the 94 children, but 43% developed asthma and 45% allergic rhinitis. The risk of developing asthma was higher in children with a heredity of eczema. Presence of severe eczema at the time of inclusion in the study was associated with an increased tendency to produce food-specific IgE. An early onset of eczema was associated with an increased risk of sensitization to inhalant allergens, and development of urticaria. Early allergic reactions to food were associated with later reactions to food, allergic rhinitis, urticaria, and sensitization to both food and inhalant allergens. Early feeding patterns, time of weaning, and introduction of solid food did not influence the risk of development of allergic symptoms. A large number of periods or days with fever during the follow-up was associated with an increased risk of developing allergic rhinitis and urticaria.

Our results confirm the good prognosis for the dermatitis and the increased risk of developing asthma and allergic rhinitis. Development of other allergic symptoms or sensitization was associated with the following factors: a family history of eczema, age at onset of eczema and its severity, early adverse reactions to foods, and proneness to infections.

Timing of solid food introduction in relation to eczema, asthma, allergic rhinitis, and food and inhalant sensitization at the age of 6 years: results from the prospective birth cohort study LISA

Zutavern A, brockow I, Schaaf b,

von berg A, diez u, borte m, kraemer u,

herbarth o, behrendt h, wichmann he,

heinrich J; LISA Study group.

GSF-National Research Center for

Environment and Health,

Institute of Epidemiology,

85764 Neuherberg, Germany.

Current prophylactic feeding guidelines recommend a delayed introduction of solids for the prevention of atopic diseases. This study investigates whether a delayed introduction of solids (past 4 or 6 months) is protective against the development of eczema, asthma, allergic rhinitis, and food or inhalant sensitization at the age of 6 years.

Data from 2073 children in the ongoing LISA birth cohort study were analyzed at 6 years of age. Multivariate logistic regression analyses were performed for all children and for children without skin or allergic symptoms within the first 6 months of life to take into account reverse causality.

A delayed introduction of solids (past 4 or 6 months) was not associated with decreased odds for asthma, allergic rhinitis, or sensitization against food or inhalant allergens at 6 years of age. On the contrary, food sensitization was more frequent in children who were introduced to solids later. The relationship between the timing of solid food introduction and eczema was not clear. There was no protective effect of a late introduction of solids or a less diverse diet within the first 4 months of life. However, in children without early skin or allergic symptoms were considered, eczema was significantly more frequent in children who received a more diverse diet within the first 4 months.

This study found no evidence supporting a delayed introduction of solids beyond 4 or 6 months for the prevention of asthma, allergic rhinitis, and food or inhalant sensitization at the age of 6 years. For eczema, the results were conflicting, and a protective effect of a delayed introduction of solids cannot be excluded. Positive associations between late introduction of solids and food sensitization have to be interpreted with caution. A true protective effect of a delayed introduction of solids on food sensitization seems unlikely.

FoCuS on: ALLERGY

33

product news

Fosavance (alendronate sodium plus vitamin D3) improves vitamin D levels in postmenopausal women with osteoporosis

MSD have announced that new data from FOCuS D (FOSAVANCE vs. Standard Care – use and Study of Vitamin D) presented at the European Congress on Osteoporosis and Osteoarthritis (ECCEO11-IOF) demonstrated that the combination tablet alendronate 70 mg/vitamin D3 5600 Iu weekly improved the levels of vitamin D among postmenopausal women with osteoporosis and low vita-min D levels defined as 25-hydroxyvitamin D level <20 ng/mL (50 nmol/L), compared to patients in the referred care arm of the study who were prescribed osteoporosis therapies by their personal phy-sicians. After 26 weeks of treatment, the proportion of women with low vitamin D levels, defined as 25-hydroxyvitamin D level <20 ng/mL (50 nmol/L), was significantly lower in patients given the combination tablet alendronate 70 mg/vitamin D3 5600 Iu, group compared to those in the referred care group (8.6% compared to 31.0%, p<0.001). Data from an extension of the study showed that the same effect on 25-hydroxyvitamin D levels was sustained after 52 weeks of treatment (11.3% compared to 36.9%; p<0.001).

“In postmenopausal women with osteoporosis, ensuring adequate vitamin D levels is an essential part of the therapy, yet many patients do not receive the necessary intake as part of their standard care,” said Prof. J Bernard Walsh a lead clinician in one of the participating centres in Ireland. Our study found that at the end of one year nearly 90 percent of patients with osteoporosis and low vitamin D levels who were treated with the alendronate 70 mg /vitamin D3 5600 Iu combination tablet were no longer vitamin D insufficient compared to 63 percent of those in the referred care group.”

Vitamin D plays an important role in maintaining bone strength and health, and is crucial to the absorption of calcium and normal bone formation. Supplemental vitamin D helps patients with oste-oporosis, who may not get enough vitamin D through diet or expo-sure to natural sunlight, to absorb calcium and build bone mass.

Novartis announces the launch of Tasigna (nilotinib) 150mg in Ireland for the first-line treatment of adult patients with newly diagnosed Philadelphia chromosome-positive chronic myeloid leukemia (Ph+ CML) in chronic phase.

Tasigna is derived from Glivec (imatinib), also manufactured by Novartis. The availability of the 150mg formulation in Ireland reflects Tasigna’s superior efficacy to its ground-breaking parent, in achieving molecular and cytogenetic response and delaying cancer progression in Ph+ CML1. This superiority has resulted in Tasigna becoming the fastest drug ever in terms of moving from chemical synthesis to receiving FDA approval. Tasigna has been licensed for the second line treatment of Ph+ CML for Glivec resistant or intolerant patients since 2008.

The recommended dose of Tasigna for the first-line treatment of newly diagnosed Ph+ CML patients in chronic phase is 300mg bid.

In laboratory studies, Tasigna has been shown to be aa potent and selective inhibitor of the Bcr-Abl protein that causes production of cancer cells in Ph+ CML3. It is also active against a broad spectrum of Bcr-Abl mutations associated with resistance to Glivec5.

In its pivotal head-to-head trial, ENESTnd (Evaluating Nilotinib Efficacy and Safety in Clinical Trials of Newly Diagnosed Ph+ CML Patients), Tasigna surpassed Glivec in key measures of treatment

efficacy. As has been reported in the New England Journal of Medicine, Tasigna eliminated Bcr-Abl faster and more deeply than Glivec and resulted in lower rates of cancer progression after 12 months of therapy. Major molecular response (MMR), a measure of deep reduction in Bcr-Abl, is considered to be a critical therapeutic milestone associated with good long-term outcomes for patients with Ph+ CML in chronic phase. Treatment with Tasigna led to higher rates of both MMR and complete cytogenetic response (CCyR) (undetectable levels of the Philadelphia chromosome that is the hallmark of this cancer) compared with Glivec.

ENESTnd, the randomized, open-label, multicenter trial, compared the efficacy and safety of Tasigna versus Glivec in adult patients with newly diagnosed Ph+ CML in chronic phase1. It is the largest global randomized comparison of two oral therapies ever conducted in newly diagnosed Ph+ CML patients in chronic phase.

Irish researchers Professor Michael O’Dwyer of NuIG, Dr Eibhlin Conneally of Trinity College Dublin and Professor Frank Giles, Professor of Cancer Therapeutics at the National university of Ireland and Trinity College Dublin, have played a major role in both the development of the drug and in the international clinical trials which subsequently established its superiority to Glivec.

Gilenya – first oral multiple sclerosis treatment for use in the EU

The European Commission has granted Novartis approval for Gilenya (fingolimod) 0.5 mg daily as a disease modifying therapy in patients with highly active relapsing-remitting multiple sclerosis (RRMS) despite treatment with beta interferon, or in patients with rapidly evolving severe RRMS.

“This is an important step in the way we manage this chronic, debilitating disease” said Professor Orla Hardiman, Dept. of Neurol-ogy, Beaumont Hospital and Trinity College Dublin. “Gilenya is the first oral therapy for MS, and a welcome addition to our treatment options”

The approval was based on the largest clinical trial programme submitted to date for a new MS drug, and included data from clini-cal studies showing significant efficacy in reducing relapses, the risk of disability progression, and the number of brain lesions detected by magnetic resonance imaging (MRI), a measure of disease activ-ity’́ ”

Gilenya is the first in a new class of drugs called sphingosine 1-phosphate receptor (S1PR) modulators. In MS, the immune system damages the covering that protects nerve fibres in the central nerv-ous system (CNS), which includes the brain and spinal cord. The nov-el mechanism of Gilenya is thought to work by reducing the im-mune system’s attack on the CNS by retaining certain white blood cells (lymphocytes) in the lymph nodes. This prevents the white blood cells from reaching the CNS, where they could potentially attack the protective covering around the nerve fibres, resulting in less inflammatory damage to the nerve cells. The white blood cell retention is reversible if Gilenya treatment is stopped.

Data from a two-year placebo-controlled study showed a reduc-tion in the risk of disability progression among Gilenya patients (30% reduction confirmed at three-month follow-up visit p=0.02, compared with placebo) ”. In Clinical studies, treatment with Gilenya also resulted in statistically significant reductions in brain lesion activity as measures by MRI.

Tasigna 150mg – first line treatment of chronic myeloid leukemia

34

product news

30 second intervention from a healthcare professional could double a smoker’s chances of quitting

The majority of smokers want to quit yet new research reveals many smokers view smoking as part of their everyday lifestyle rather than a chronic, relapsing condition.

With 24% of smokers from Ireland viewing their smoking as ‘more of a habit than an addiction’, the data from the Ipsos Mori Extreme Smoking Report shows many are failing to recognise the seriousness of their condition or the need for medical support. As a result, these smokers are overlooking their best chance of quit success – evidence-based support and treatment. This highlights the need for healthcare professionals (HCPs) to take the important first step in helping smokers quit successfully via a simple brief intervention.

The new findings, from research commissioned by Pfizer among 1,000 smokers in Ireland, reveal that 60% of smokers who have tried to quit unsuccessfully at least three times have never sought medical help. In addition, many smokers see their doctor as a port of call solely for illness and do not consider nicotine and smoking addiction as an illness.

While smokers in Ireland view doctors as one of the most credible sources of smoking cessation advice – suggesting they would welcome proactive help from HCPs – the research reveals the most common quit method in Ireland is willpower. However, 97% of smokers who try to quit by themselves will be smoking again within one year and the majority relapse in as little as eight days.

Prof. Luke Clancy of the Tobacco Free Research Institute says, “By seeing smoking as only a habit or lifestyle choice rather than an addiction or medical condition, many smokers are ruling out seeking medical help, thinking that they must give up by themselves. But the addictive effects of nicotine and the psychological rituals and associations linked with smoking make quitting a major challenge for most smokers. It is essential that they know that help is available.

“Even a brief conversation can help double a smoker’s chances of long-term quit success so it is essential we create opportunities to discuss a patient’s best course of action to smoking cessation. By taking the short time needed, as little as 30 seconds, we can not only help smokers quit, but also lower the risk of specific diseases and premature death, and help increase life expectancy.”

A new report, Europe Quitting: Progress and Pathways (EQuIPP)focuses specifically on supporting the implementation of Article 14 of the FCTC, which demands action to promote cessation of tobacco use and provide adequate treatment for tobacco dependence. The report reveals the views of 60 European smoking cessation experts and has been commissioned by Pfizer and endorsed by the European Respiratory Society, the European Network for Smoking and Tobacco Prevention and The German Society for Pneumology.

Prof. Luke Clancy says, “It is extremely encouraging to see that, at a policy level, concerted efforts are being made to drive down tobacco dependence and we believe that the EQuIPP Report offers a much-needed roadmap for improving our smoking cessation services and infrastructure in Ireland. However, if we are to see a significant reduction in the number of smokers and smoking-related illnesses in Ireland it is vital that, as clinicians, we are also taking immediate action in our clinics. Smoking cessation is one of the most important preventative interventions we can make. Offering brief advice not only helps patients understand why they should quit, but, more importantly, how they can do so, which can be potentially life-saving.”

‘Sun Safe at Sea’ talks

Sanofi and leading French dermo-cosmetic brand, Eau Thermale Avène, have announced the roll-out of a series of talks aimed at keeping sailors and water sports enthusiasts in the Dublin bay area ‘sun safe’ while they are on the water. The talks will be delivered by Dr Mark Wheeler, of the Edenpark Surgery in Raheny and they will take in three clubs in Dun Laoghaire Harbour – the National, Irish and George yacht Clubs over the coming weeks.

Dr Wheeler, who has a special interest in skincare, said:“I am very pleased that the sailing clubs and the Bray Sea

Scouts have been willing to get involved. These groups subject themselves to a lot of sun exposure on the water, so this is about giving them the facts about sun protection so they can stay ‘Sun Safe’ while enjoying their favourite pastime.”

“People often describe a sun tan as a ‘healthy glow’, but the appearance of a tan means your skin is reacting to damage done by the sun’s uV rays. As well as that, most people apply their sunscreens at one third of the thickness used for testing, so these talks will help to dispel some of the myths that exist about sun care and sun protection.”

The talks are being sponsored by leading French dermo-cosmetic brand, Eau Thermale Avène. said:

“Sailing and watersports are a good fit for our brand, which is photostable for 4 hours and very water resistant. We are already helping one of the Dun Laoghaire yacht Clubs with their Junior Regatta and in mid July, and we will sponsor the Bray Sea Scouts to complete their Bray-Wicklow Challenge. We also have further plans for July and August. With an innovative, patented formula, the Eau Thermale Avène range of sun care products is suitable for every skin type. The range is paraben and alcohol free and has organic, chemical and mineral sunscreens, so no matter what the sensitivity of your skin, there’s something suitable for you to use.”

Dovonex Scalp Solution 60ml discontinued

LEO Pharma has announced that Dovonex®Scalp Solution 60ml will be discontinued from July 2011. This discontinuation is not due to any safety or quality issues with Dovonex, therefore pharmacists and patients may continue to dispense or use any pack presentations of Dovonex that they currently have. Please note that Dovonex Cream 120g will continue to be available.

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product news

Stelara – for moderate to severe plaque psoriasis – safety profile

MedCoat – revolutionary new tablet coating system

New findings presented today from pooled analyses of the Stelara (ustekinumab) psoriasis clinical development programme showed that the safety profile of Stelara and rates of adverse events remained consistent and stable over time in adults with moderate to severe plaque psoriasis receiving up to four years of treatment.1

“These findings are promising and support a favorable benefit-to-risk profile for Stelara with up to four years of treatment,” said Professor Kristian Reich, MD, Department of Dermatology of Dermatolgikum, Hamburg, Germany, and lead trial investigator for the PHOENIX 2 study. “Ongoing studies in psoriasis and psoriatic arthritis will continue to define the safety profile of Stelara in the psoriatic population.”

The four year safety analysis of the Stelara Phase 2, PHOENIX 1, PHOENIX 2 and ACCEPT trials evaluated the largest psoriasis-focused clinical trial safety database for a biologic reported to date, with more than 1100 patients who have had at least three years of treatment with Stelara and more than 600 patients treated for four or more years for a total of nearly 6800 patient years (Py).

The pooled safety data, from a total of 3117 patients, showed rates of adverse events (AEs) to be generally stable over time through up to four years of treatment with Stelara. The most commonly reported AEs [greater than 5 per 100 Py] included nasopharyngitis, upper respiratory tract infection, arthralgia, sinusitis, headache and back pain and influenza. Observed

occurrences of AEs of interest, including serious infections (0.8 and 1.32 for 45 mg and 90 mg Stelara patient groups, respectively, per 100 Py), non-melanoma skin cancer (0.70; 0.53 per 100 Py, respectively), other malignancies (0.63; 0.61 per 100 Py, respectively) and major adverse cardiovascular events (MACE) (0.42; 0.36 per 100 Py, respectively) remained generally stable during the time periods evaluated.

Furthermore, the observed rate of malignancies (excluding non-melanoma skin cancers) was consistent with that expected in the general uS population, derived from the Surveillance, Epidemiology and End Results (SEER) Database. Rate of non-fatal myocardial infarction (MI) or stroke was consistent with or lower than that expected in the general uS population and psoriasis populations, derived from the Framingham Database and General Practice Research Database (GPRD), respectively.

“Biological therapies are a valuable advancement in the treatment of moderate-to-severe psoriasis. To support dermatologists in their decision-making about the most suitable treatment option for patients, it is important to have long-term data on available therapies,” comments Professor Christopher Griffiths, university of Manchester, uK, and lead trial investigator for the ACCEPT study. “This pooled 4-year safety data provides a growing and significant body of evidence about the role ustekinumab can play in the management of this chronic, life-long condition.”

MedCoat is an important new healthcare innovation, which makes medicines 98% easier to swallow. MedCoat is a patented, tablet-coating system enabling patients to easily apply a special coating to their pills or tablets. The coating both masks the tablet’s original taste and also makes it slippery, making them much easier to swallow. Independent studies conducted by MedCoat have shown that the majority of people using Medcoat find it much easier to take their meds. Because Medcoat contains food ingredients, it is not a medicine and therefore will not react or interfere with a medicine either.

MedCoat has significant implications for improving patient compliance. It is estimated that more than 50% of patients do not comply with dosing instructions due to poor taste and difficulty in administration. If medication has a poor taste, the likelihood of non-compliance increases. MedCoat coats tablets with a pleasant citrus flavour, making tablets far more palatable. Approximately 1/3 of patients have difficulty swallowing tablets or capsules. Non-compliance is especially significant amongst geriatric and paediatric patients. A common solution to a patient’s problem swallowing tablets is to advise crushing or opening of capsules. However, this practice carries significant risks.

MedCoat was invented by a Swedish Engineer, Fredrik Lilieblad. While studying Engineering at the Royal Institute of Technology in Stockholm, Fredrik wanted to find an easier way to take his daily Vitamin C – the resulting invention, MedCoat has won several awards.

MedCoat represents a significant advance in helping patients who experience difficulties in swallowing tablets. MedCoat Research shows that more than 25%³ of the general population find it difficult to swallow a tablet.

MedCoat has particularly important implications for improving compliance amongst children and the elderly where tablet swallowing poses greater problems. MedCoat also makes medication more palatable for children over four years of age and is also suitable for patients suffering from medical conditions such as dysphagia, a condition causing swallowing difficulties and xerostomia or dry mouth.

MedCoat is not a medicine, as it only contains substances classified as foodstuffs. Coating a tablet with Medcoat is an easy and rapid procedure too. One Medcoat package contains 10 films and with one film you can mask 1-2 tablets, depending on its size.

The design of the device makes it possible to apply coatings to most tablets, capsules and pills. Even broken tablets (halves or quarters) can be coated. The coating dissolves in the stomach in seconds and contains only food ingredients that are not known to interact with drugs or have any side effects. MedCoat is distributed in Ireland by Pamex Ltd.

36

product news

Neulasta (pegfilgrastim) and Aranesp (darbepoetin alfa) – improving needle safety for healthcare professionals

Amgen recentlyannounced the introduction of an automatic needle guard (ANG) for Neulasta (pegfilgrastim) and Aranesp (darbepoetin alfa) prefilled syringes. The ANG will replace the current classic prefilled syringe for Neulasta indicated for the reduction in the duration of neutropenia and the incidence of febrile neutropenia in patients treated with cytotoxic chemotherapy for malignancy (with the exception of chronic myeloid leukaemia and myelodysplastic syndromes), and Aranesp for the treatment of symptomatic anaemia associated with chronic renal failure (CRF) in adults and paediatric patients, and the treatment of symptomatic anaemia in adult cancer patients with non-myeloid malignancies receiving chemotherapy.

According to the Health Information and Quality Authority (HIQA), an estimated 6,000 needle-stick injuries occur per year in Ireland, with up to 70% of these going unreported.1 It is anticipated that the introduction of the ANG to these products will reduce the risk of needle stick injuries for doctors, nursing staff and patients.

The transition to ANG commenced at the end of May 2011 however please note the ANG will only become available once all stocks of classic prefilled syringes have been depleted. unfortunately, Amgen cannot accept the return of cold chain products, however in order to prevent any product wastage, Amgen is working closely with all wholesalers during this transition phase.

The Aranesp 10μg pre-filled syringe is unchanged and all strengths of Aranesp SureClick have an existing automatic needle guard and therefore remain unchanged. This wide range of Aranesp presentations allows healthcare professionals to select the best option for their needs and those of their patients.

For further information please contact Amgen Ireland Ltd on 01-8527400. For medical queries, please contact the Medical Information department on 1800 88 29 61.

Novartis introduce patient outcomes reimbursement programme for Xolair

New Irish data shows that Xolair delivers a 67% reduction in hospitals and a 61% reduction in exacerbations for severe allergic asthma patients.

Novartis Ireland offer a new outcomes based reimbursement programme where hospitals only pay for patients who respond to treatment.

Xolair delivers a saving of 12 hospital bed days for every patient treated for a 6 month period.

A recently published clinical paper shows that Xolair significantly reduces asthma, hospitalisations and hospital bed days for Irish patients.

Xolair (Omalizumab) is a humanized monoclonal antibody that is unique in blocking the action of immunoglobulin E (lgE) – a root cause of the allergy inflammatory cascade that is triggered by allergens in the air in patients with severe persistent allergic asthma. Xolair is recommended in the Global Initiative for Asthma (GINA), as an add-on treatment for patients with severe persistent allergic asthma that is inadequately controlled by standard clinical options. More than 120,000 patients worldwide have been treated with Xolair, 190 of whom are Irish patients.

A study of Irish Xolair patients has just been completed and the data published in the Irish Journal of Medical Science. The study compared patients outcomes for 6 month pre treatment and 6 month post treatment in 5 respiratory centres in Ireland. The results of the audit are listed below.

• 67% reduction in hospitalisations (p<0.0001)

• 68% reduction in bed days (p<0.0001) (Saving of 12 bed days per 6 months per patient)

• 61% reduction in exacerbations (p<0.0001)

• 62% reduction in courses of oral corticosteroids (p<0.0001)

• 90% reduction in work days lost (p<0.0001)“For the small number of severe allergic asthma patients in

Ireland (450), the benefits these patients have received from Xolair is very impressive. The patients have significantly reduced the frequency and length of their hospitalisations and the treatment has allowed them to return to work and lead a normal life as seen by the improvement in work days.” Said Prof Costello, Principle investigator.

The study also proves that Xolair is cost effective to the health system for the 77% of patients who respond to treatment. This cost saving is driven from a sharp reduction in hospitalisations and bed days used. The study has shown a saving of 12 hospital bed days per patient over a 6 month period.

The figures for the study show that 77% of patients who started Xolair responded to treatment, with the remaining 23% discontinued at the 16 week evaluation point. To ensure the Xolair is cost effective for every patient and every hospital, Novartis Ireland will introduce the Xolair Patient Outcomes Reimbursement programme which will now refund any stock used on a patient who does not respond to treatment at the 16 week evaluation. We hope that this innovative approach will ensure that patients have access to this groundbreaking treatment during this time of austerity.

37

crossword

Name:

Address:

Email:

Congratulations to the winner of last month’s crossword, Siobhán Connolly, Camayo, Garbally Drive, Ballinasloe, Co Galway

Please send your answers to the Editor, Nursing in General Practice, GreenCross Publishing, 7 Adelaide Court, Adeliade Road, Dublin 2. Closing date for entries: 1st September 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 and 9 across. Rub Ella together for 2 down (6,7)4 Crypt raided by Lara Croft (4)8 Spider’s Internet address? (3)9 See 1 across (7)10 Bloody idiot? (4)11 I believe in Latin! (5)14 Prize for a sick-room? (5)16 The incredible one burst his shirt on T.V. (4)18 Evil sec conceals small blister (7)20 A cushy residence? (3)21 Frothy kind of opera? (4)22 Merriment of a Dublin theatre (6)

dowN1 G now changes dress (4)2 Measly complaint of German origin, perhaps

(7)3 Let in and confess (5)5 Lubricant found in boiler (3)6 Chess piece presiding over diocese, possibly

(6)7 White powder discovered in metal canister! (4)12 See about clip! It could turn day into night (7)13 Birth-mark confuses a Venus (6)15 No score for Donald or Daffy! (4)16 A laughing scavenger (5)17 The sixth of June (1,3)19 Health resort in Spain (3)

ANSwerS To LAST moNTh’S croSSwordAcross: 1 Emetic 4 Chef 8 Ear 9 Amnesia 10 Ache 11 Lucan 14 Tress 16 Stye 18 Timpani 20 Nee 21 Sots 22 OedemaDown: 1 Eden 2 Earache 3 Image 5 HMS 6 Flaunt 12 Cayenne 13 States 15 Swab 16 Spice 17 Beta 19 Mot

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