Blackrock Clinic

Issue 1 | 2010

BLACKROCK

CLINIC

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14

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Freeph Enquir one yL 1800 60 ine 10 60

Your successes today create opportunities tomorrow

Along your professional journey, you have discovered that rewards come through skill and perseverance. And with every new achievement, the next goal comes into view. At Edwards Lifesciences, we value the opportunity to work with you to transform patient care. You have our admiration and support—let’s continue the journey together.

Edwards Lifesciences S.A. · Route de l’Etraz 70 · 1260 Nyon · Switzerland · Phone 41.22.787.4300 · www.edwards.com/Europe Edwards is a trademark of Edwards Lifesciences Corporation. Edwards Lifesciences and the stylized E logo are trademarks of Edwards Lifesciences Corporation and are registered in the United States Patent and Trademark Office. © 2010 Edwards Lifesciences SA. E1594/06-10/HVT

Blackrock Clinic | WELCOME

WELCOME

W

hether you are new to our work, or well-familiar with it, we hope there is something for ever yone and that you will enjoy hearing news and updates from the Clinic and its depar tments in the for thcoming pages.

Recent years have seen great improvements to our facilities: indeed, 2010 was a year of celebration. This summer, we added impressive new Day Surgery and Emergency Department facilities, the result of a €100m investment which will maintain our position at the pinnacle of private healthcare in Ireland.

As well as the three new floors added this year, we have put in place strong foundations that will enable us to make fur ther progress in the years ahead.

Today, there is a new multi-storey carpark, a 200% increase in daycare capacity and the possibility of 125 new jobs over the next five years. These are all fur ther signs that Blackrock Clinic is building on its traditions while striving for the ver y highest and most modern standards.

So without further ado, I invite you to discover the work of our expert departments, read our interview with CEO Bryan Harty, and hear the latest from Ireland’s leading private hospital at this time of great change.

Yours Sincerely, Emer MacNeice Head of Marketing

“This summer, we added impressive new Day Surgery and Emergency Department facilities, the result of a €100m investment which will maintain our position at the pinnacle of private healthcare in Ireland.”

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MSD is the world’s second largest pharmaceutical company and employs 2,300 people at operations in Carlow, Cork, Dublin, Tipperary and Wicklow. In the last four decades we have invested over €2.2bn in Ireland and our investment continues to grow, making MSD one of Ireland’s leading exporters both now and in the future.

At MSD, we work hard to keep the world well.

How? By providing people all around the globe with innovative medicines, vaccines and over the counter consumer and animal health products.

We also provide leading healthcare solutions that make a difference. We do it by listening to patients, healthcare professionals and our other partners. Our recent merger with Schering-Plough expands and strengthens our capabilities to help make the world a healthier place.

Copyright © 2010 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Whitehouse Station, NJ, USA. All Rights Reserved.

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See all we’re doing at www.msd.ie

Blackrock Clinic | CONTENTS

e Contents

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13 40

05

About Blackrock Clinic

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Investment and Progress: Interview with CEO Bryan Harty

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A Guide to Choosing Blackrock Clinic

13

New Daycare Unit

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New Emergency Department

23

Cardiology

27

Physiotherapy

31

Radiology & Diagnostics

35

Pathology

38

Quality

40

Clinical Governance

43

Technology & Expertise

46

New Freephone Enquiry Line

49

A Lifetime in Medicine: A Tribute to Maurice Neligan

53

Infection Prevention & Control

57

Financial Matters

60

General Information

Contact us Blackrock Clinic Rock Road Blackrock County Dublin Freephone: 1800 60 10 60 Phone: +353 1 283 2222 Fax: +353 1 206 4314 Web: www.blackrock-clinic.ie

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Building our Future in Healthcare Specialists in Healthcare construction Recently completed; • Blackrock Clinic Extension • Mallow Primary Care Centre (PCC) • Galway Clinic Extension • Whitfield Private Clinic • Elysian Diagnostics Clinic, Waterford

Currently constructing; • New Mater Adult Hospital • Dialysis Unit, Waterford Regional Hospital • Barchester Trim PCC • Naas Vista HSE PCC • Mountmellick PCC • ICU Our Lady’s Hospital, Crumlin

- umbrella structure for • • • • •

M.E.D. Surgical Cardiac Services Tekno Surgical Synapse Medical Eschmann have recently joined SISK Group

Tekno Surgical and Cardiac Services have developed online shopping facilities which provide access to comprehensive catalogues, visit; http://shoponline.tekno-surgical.com or http://shoponline.cardiac-services.com

Total Healthcare Solution Provider Build - Equip - Consumables Supply • • • • • • •

GP Surgeries

Primary Care Centres

Hospital Extensions

New Hospitals Retirement / Nursing Homes Healthcare Fit-Out Full Coordination - Turnkey Solutions

SISK Group - Sicon Limited is a diversified building business involved in construction, specialist stone, architectural glazing, distribution and healthcare in Ireland, UK, Europe and Middle East. The SISK Group which celebrated its 150th anniversary last year is an Irish owned family business which has its origins in Cork in 1859.The Group is one of the largest privately owned companies in Ireland. In 2009, turnover exceeded €1.4 billion with 1,600 people employed across all of its operations.

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Blackrock Clinic | ABOUT BLACKROCK CLINIC

About

BLACKROCK CLINIC O

ver 25 years ago, the Blackrock Clinic welcomed its first patients.

The brainchild of four Irish medical consultants, the Clinic was founded in an attempt to offer a new approach to private medical care, based on its founders’ international experience. It quickly became a success.

The Ireland of 1984 is not remembered fondly: amidst economic and social strife, Blackrock was the first private hospital to be built in 20 years. Nonetheless, the outpatient complex led the way, with the emphasis on the high-tech and the custom-built, never before seen in Ireland. It was soon followed by the hospital, which received its first patients in April of 1986 and proudly boasted 116 beds – 84 being single, en-suite rooms – five theatres and an ICU suite.

Our Mission Statement “We are an organisation in which the patient is the focus of all our thinking.

We strive for long term excellence in the delivery of acute surgical, medical and diagnostic services. We aim to attract and retain the best staff in a climate of continuous quality improvement.”

Our Core Values � Compassion for the patient and their family � Efficiency in all hospital activities � Teamwork to provide seamless care � Clinical excellence in all that we do � Care and respect not only for the patient but also for each other � Maintaining financial viability underpins our future � Engaging professional consultants and staff � Providing the best technology possible

Since then, the developments have come thick and fast: the Clinic also includes a Coronary Care Unit, a Daycare facility and an Oncology Day Ward. Oversight is provided by the Clinic’s Medical Advisory Committee and Clinical Trials and Medical Research Committee, both of which monitor Blackrock Clinic’s medical standards, supporting its commitment to provide the best possible environment for patients, doctors and staff. The Clinic is also associated with the Royal College of Surgeons and University College Dublin (UCD), which considerably enhances its practice and knowledge base.

Aside from proven results, the clearest expression of Blackrock Clinic’s ambition is found in its mission statement: “We are an organisation in which the patient is the focus of all our thinking. We strive for long term excellence in the deliver y of acute surgical, medical and diagnostic ser vices. We aim to attract and retain the best staff in a climate of continuous quality improvement.”

Fast forward to the present day, and the economy may be bleak once more, but the Clinic continues at the forefront. It recently opened new Daycare and Emergency units, the result of a €100m development programme. Its commitment to the latest medical technology has been proven, re-investment after re-investment. And the medical climate is different too: reforms to the insurance industry, growth in the private sector and Ireland’s emergence as a location for the pharmaceutical industry have all seen to that.

Now fully up to date for the coming decade, Blackrock Clinic faces into the future able to offer 170 beds, a multi-storey carpark, further theatres, endoscopy suites and minor procedure rooms. Not only that, but CEO Bryan Harty has revealed his ambition to expand further. Watch this space.

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Helping your patients make their life feel normal again. time with family

back to work

I can get back to my life laughing

meeting with friends

going for walks confidence

In determining remission from depression, patients consider a return to one’s usual, normal self as very important.1 CYMBALTA* (DULOXETINE). REPUBLIC OF IRELAND ABBREVIATED PRESCRIBING INFORMATION. Presentation Hard gastro-resistant capsules, 30mg or 60mg of duloxetine. Also contains sucrose. Uses Treatment of major depressive disorder. Treatment of generalised anxiety disorder. Treatment of diabetic peripheral neuropathic pain (DPNP) in adults. Dosage and Administration Major Depressive Disorder Starting and maintenance dose is 60mg once daily, with or without food.

Dosages up to a maximum dose of 120mg per day have been evaluated from a safety perspective in clinical trials. However, there is no clinical evidence suggesting that patients not responding to the initial recommended dose may benefit from dose uptitrations. Therapeutic response is usually seen after 2-4 weeks. After establishing response, it is recommended to continue treatment for several months, in order to avoid relapse. In patients responding to duloxetine, and with a history of repeated episodes of major depression, further long-term treatment at 60 to 120mg/day could be considered. Generalised Anxiety Disorder The recommended starting dose in patients with generalised anxiety disorder is 30mg once daily, with or without food. In patients with insufficient response the dose should be increased to 60 mg, which is the usual maintenance dose in most patients. In patients with co-morbid major depressive disorder, the starting and maintenance dose is 60mg once daily. Doses up to 120mg per day have been shown to be efficacious and have been evaluated from a safety perspective in clinical trials. In patients with insufficient response to 60mg, escalation up to 90mg or 120mg may therefore be considered. After consolidation of the response, it is recommended to continue treatment for several months, in order to avoid relapse.

Abrupt discontinuation should be avoided. When stopping treatment with Cymbalta the dose should be gradually reduced over at least one to two weeks to reduce the risk of withdrawal reactions. If intolerable symptoms occur following a decrease in the dose or upon discontinuation of treatment, then resuming the previously prescribed dose may be considered. Subsequently, continue decreasing the dose, but at a more gradual rate. Diabetic Peripheral Neuropathic Pain Starting and maintenance dose is 60mg daily, with or without food. Doses above 60mg/day, up to a maximum dose of 120mg/ day in evenly divided doses, have been evaluated from a safety perspective. Some patients that respond insufficiently to 60mg may benefit from a higher dose. The medicinal response should be evaluated after 2 months treatment. Additional response after this time is unlikely. The therapeutic benefit should regularly be reassessed.

Contra-indications Hypersensitivity to any of the components. Combination with MAOIs. Liver disease resulting in hepatic impairment. Use with potent inhibitors of CYP1A2, eg, fluvoxamine, ciprofloxacin, enoxacine. Severe renal impairment (creatinine clearance <30ml/min). Should be used in pregnancy only if the potential benefit justifies the potential risk to the foetus. Breast-feeding is not recommended.

Initiation in patients with uncontrolled hypertension that could expose patients to a potential risk of hypertensive crisis. Precautions Do not use in children and adolescents under the age of 18. No dosage adjustment is recommended for elderly patients solely on the basis of age. However, as with any medicine, caution should be exercised. Data on the use of Cymbalta in elderly patients with generalised anxiety disorder are limited. Use with caution in patients with a history of mania, bipolar disorder, or seizures. Caution in patients with increased intra-ocular pressure or those at risk of acute narrow-angle glaucoma. Duloxetine has been associated with an increase in blood pressure and clinically significant hypertension in some patients. In

patients with known hypertension and/or other cardiac disease, blood pressure monitoring is recommended as appropriate, especially during the first month of treatment. Use with caution in patients whose conditions could be compromised by an increased heart rate or by an increase in blood pressure. For patients who experience a sustained increase in blood pressure while receiving duloxetine, consider either dose reduction or gradual discontinuation. Caution in patients taking anticoagulants or products known to affect platelet function, and those with bleeding tendencies.

Hyponatraemia has been reported rarely, predominantly in the elderly. Caution is required in patients at increased risk for hyponatraemia, such as elderly, cirrhotic, or dehydrated patients, or patients treated with diuretics. Hyponatraemia may be due to a syndrome of inappropriate anti-diuretic hormone secretion (SIADH). Adverse reactions may be more common during concomitant use of Cymbalta and herbal preparations containing St John’s Wort. Monitor for suicidal thoughts, especially during first weeks of therapy, dose changes, and in patients under 25 years old. Since treatment may be associated with sedation and dizziness, patients should be cautioned about their ability to drive a car or operate hazardous machinery. Cases of akathisia/psychomotor restlessness have been reported for duloxetine. Duloxetine is used under different trademarks in several indications (major depressive disorder, generalised anxiety disorder, stress urinary incontinence, and diabetic neuropathic pain). The use of more than one of these products concomitantly should be avoided. Cases of liver injury, including severe elevations of liver enzymes (>10-times upper limit of normal), hepatitis, and jaundice have been reported with duloxetine. Most of them occurred during the first months of treatment. Duloxetine should be used with caution in patients with substantial alcohol use or with other drugs associated with hepatic injury. Capsules contain sucrose. Patients with rare hereditary problems of fructose intolerance, glucosegalactose malabsorption, or sucrose-isomaltase insufficiency should not take this medicine. Interactions Caution is advised when taken in combination with other centrally acting medicinal products and substances, including alcohol and sedative medicinal products; exercise caution when using in combination with antidepressants.

In rare cases, serotonin syndrome has been reported in patients using SSRIs concomitantly with serotonergic products. Caution is advisable if duloxetine is used concomitantly with serotonergic antidepressants like SSRIs, tricyclics, St John’s Wort, venlafaxine, or triptans, tramadol, pethidine, and tryptophan. Undesirable effects may be more common during use with herbal preparations containing St John’s Wort.

Effects on other drugs: Caution is advised if co-administered with products that are predominantly metabolised by CYP2D6 (risperidone, tricyclic antidepressants [TCAs], such as nortriptyline, amitriptyline, and imipramine) particularly if they have a narrow therapeutic index (such as flecainide, propafenone, and metoprolol). Anticoagulants and antiplatelet agents: Caution should be exercised when duloxetine is combined with oral anticoagulants or antiplatelet agents due to a potential increased risk of bleeding.

Increases in INR values have been reported when duloxetine was co-administered with warfarin. Undesirable Effects The majority of common adverse reactions were mild to moderate, usually starting early in therapy, and most tended to subside as therapy continued. Those observed from spontaneous reporting and in placebo-controlled clinical trials in depression, generalised anxiety disorder, and diabetic neuropathic pain at a rate of ≥1/100, or where the event is clinically relevant, are: Very common (≥1/10): Headache, somnolence, dizziness, nausea, dry mouth. Common (≥1/100 and <1/10):

Weight decrease, palpitations, tremor, paraesthesia, blurred vision, tinnitus, yawning, constipation, diarrhoea, vomiting, dyspepsia, flatulence, sweating increased, rash, musculoskeletal pain, muscle tightness, muscle spasm, decreased appetite, flushing, fatigue, abdominal pain, erectile dysfunction, insomnia, agitation, libido decreased, anxiety, orgasm abnormal, abnormal dreams. Clinical trial and spontaneous reports of anaphylactic reaction, hyperglycaemia (reported especially in diabetic patients), mania, hyponatraemia, SIADH, hallucinations, dyskinesia, serotonin syndrome, extrapyramidal symptoms, convulsions, akathisia, psychomotor restlessness, glaucoma, mydriasis, syncope, tachycardia, supra-ventricular arrhythmia (mainly atrial fibrillation), hypertension, hypertensive crisis, epistaxis, gastritis, haematochezia, dysuria, gastrointestinal haemorrhage, hepatic failure, hepatitis, acute liver injury, angioneurotic oedema, Stevens-Johnson syndrome, trismus, and gynaecological haemorrhage have been made. Cases of suicidal ideation and suicidal behaviours have been reported during duloxetine therapy or early after treatment discontinuation. Cases of aggression and anger have been reported, particularly early in treatment or after treatment discontinuation. Cases of convulsion and tinnitus have been reported after treatment discontinuation. Discontinuation of duloxetine (particularly abrupt) commonly leads to withdrawal symptoms. Dizziness, sensory disturbances (including paraesthesia), sleep disturbances (including insomnia and intense dreams), fatigue, agitation or anxiety, nausea and/or vomiting, tremor, headache, irritability, diarrhoea, hyperhydrosis, and vertigo are the most commonly reported reactions. The heart rate-corrected QT interval in duloxetine-treated patients did not differ from that seen in placebo-treated patients. No clinically significant differences were observed for QT, PR, QRS, or QTcB measurements between duloxetine-treated and placebo-treated patients. In clinical trials in patients with DPNP, small but statistically significant increases in fasting blood glucose were observed in duloxetine-treated patients compared to placebo at 12 weeks. At 52 weeks there was a small increase in fasting blood glucose and in total cholesterol in duloxetine-treated patients compared with a slight decrease in the routine care group. There was also an increase in HbA1c in both groups, but the mean increase was 0.3% greater in the duloxetine-treated group. For full details of these and other side-effects, please see the Summary of Product Characteristics, which is available at http://www.medicines.ie/ Overdose Cases of overdoses, alone or in combination with other drugs, with duloxetine doses of 5400mg have been reported.

Some fatalities have occurred, primarily with mixed overdoses, but also with duloxetine alone at a dose of approximately 1000mg. Signs and symptoms of overdose (duloxetine alone or in combination with other medicinal products) included somnolence, coma, serotonin syndrome, seizures, vomiting, and tachycardia. Legal Category POM. Marketing Authorisation Numbers and Holder EU/1/04/296/001, EU/1/04/296/002.

Eli Lilly Nederland BV, Grootslag 1-5, NL-3991 RA Houten, The Netherlands. Date of Preparation or Last Review December 2009. Full Prescribing Information is Available From Eli Lilly and Company Limited, Lilly House, Priestley Road, Basingstoke, Hampshire, RG24 9NL, Telephone: Basingstoke (01256) 315 000 or Eli Lilly and Company (Ireland) Limited, Hyde House, 65 Adelaide Road, Dublin 2, Republic of Ireland, Telephone: Dublin (01) 661 4377. *CYMBALTA (duloxetine) is a trademark of Eli Lilly and Company.

Date of Preparation June 2010.

Reference: 1. Zimmerman M, McGlinchey JB, et al. Am J Psychiatry 2006;163:148-150.

IECYM00076

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Blackrock Clinic | interview with the ceo

investment and progress A

s one of the most innovative healthcare institutions in the country, Blackrock Clinic has earned a reputation for quality care in a clean, safe environment. This had its beginnings in the 1980s, when the Clinic’s founders returned to Ireland from Europe and America to practice private healthcare on a par with the best the world had to offer.

Today, Bryan Harty, CEO of Blackrock Clinic, is continuing his forebearers’ commitment to cutting-edge healthcare by developing a system that revolves around the best interests of the patient. One of his most telling contributions since his arrival at Blackrock has been his leadership of a €100 million investment in the Clinic’s facilities and infrastructure.

“We’ve transformed the hospital. We have moved from a hospital that was dated 20 years old to a hospital that looks cutting edge,” he says. This transformation included the construction of a new Emergency Department, and also a new state-of-the-art daycare centre, which Harty believes to be the future of healthcare.

“At the end of the programme, every bed in the hospital will be in a single room, which is very important from an infection control perspective,” he says. “We will have state-of-the-art daycare units, which is the future, as most types of procedures – ears and throat, ophthalmic, neurology and so on – are all done on a daycare basis now.”

Quality control

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While the expansion programme is one of Harty’s proudest achievements during his tenure thus far, he is also proud of his

track record in demonstrating the quality of care at Blackrock Clinic.

“We appointed a Clinical Governance Director a few years ago, who monitors the quality of care delivered in the hospital, but we have also done other small things which are very important,” he says. “We were the first hospital in Ireland to introduce patientreported outcomes. This is where patients coming in for hip and knee replacements complete a questionnaire before coming in to measure their quality of life.

“They then have another questionnaire three and six months after their surgery, measuring their quality of life, so we are able to say that if you come into Blackrock Clinic for a hip replacement, you do get better and we can demonstrate that you get better. That’s quite an important step,” he continues.

Harty believes that Blackrock Clinic’s unwavering commitment to quality in every aspect of its business is what sets it apart from the competition. In his opinion, Blackrock Clinic has some of the best quality doctors and consultants working in the hospital, and it is the doctors and their skills that ultimately bring the patients to the hospital. “We’ve also got the quality of patient outcomes and clinical governance,” he adds. “I think people – customers, doctors, GPs and patients – want to see hospitals that publish their infection rates, cardiac surgery success rates and so on.

All of that data is available on our website.”

Another key differentiator, he believes, is customer service. When patients come into the Blackrock Clinic, they are worried, anxious and vulnerable, and his staff

recognise that above all else. “When people write to me to thank me for what’s going on in the hospital, they don’t thank me for publishing the data on our website or investing €100 million – they thank me for an episode that occurred, maybe in the middle of the night, when one of our staff sat down with someone who was upset. That differentiates us from our competitors as well,” he says.

Hurdles in healthcare There is a clear divide between public and private healthcare in Ireland, according to Harty, and he believes that operating within the private sector has helped push standards higher at Blackrock Clinic. “The public and private healthcare systems are fundamentally different… on the basis of their funding model,” he says. “Public hospitals get a grant allocation each year that – up until recently, at least – has not had any connection with activity or throughput.

“We have to earn every admission and each one we get brings with it a sum of money, which I need to pay staff. We are driven by a need to innovate, the need to deliver and measure our quality of service because if we don’t, then we fail,” he says.

While earning admissions is a daily challenge for Harty and his staff, arguably the biggest challenge facing private and public hospitals alike, in the short-term, is that of licensing. Today, hospitals are not licensed, but there are moves afoot in political circles to introduce such a system – a development ver y much welcomed by Harty.

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Blackrock Clinic | interview with the ceo

“Licensing is very important. It is important for the patient, the institution, public confidence and the industry as a whole,” he says. “Licensing will mean explicit standards being published, so instead of having a general aspiration to health and safety, we will know what we have to achieve and how it is to be measured. It will also mean external audits… and while it is yet to be defined how it is going to be audited, there will be some form of check-up. This would be a welcome development, as there isn’t enough checking up in the hospital system at the moment.”

The money trail Another major hurdle facing private healthcare organisations like Blackrock Clinic is the issue of reimbursement. Harty appreciates that Ireland, like many other western economies, is suffering from economic malaise at the moment, but this has resulted in pressure being placed on healthcare funding. Private healthcare operators are therefore being asked to do more with less.

“We are being asked to produce higher quality care for less money, and that is a challenge because it often entails changing the way you work, reinvestment, and starting some things while stopping others,” he says.

Influencing policy Healthcare provision is a complex area, and policy formulation at Government level hasn’t always hit its targets. In that context, the Independent Hospitals’ Association of Ireland – which includes all private

hospitals in Ireland – was established to impar t its members’ wisdom to the HSE, Depar tment of Health and Government ministers, with the aim of aiding informed policy formulation in both public and private healthcare.

Blackrock Clinic plays a significant role in this organisation – and rightfully so, according to Har ty, given that it dominates cer tain elements of the healthcare market such as PET/CT scanning and cardiac surger y.

However, one area where Har ty does not see eye-to-eye with the Government is its policy of creating public sector-only consultants – a move which the state seems committed to seeing through.

“The healthcare system in Ireland is essentially public and private… and the change in the consultants’ contract is going to lead to rapid growth in the number of full-time private consultants,” he says. “You’re therefore going to see a division of consultants into public-only and private-only, and I think that is a retrograde step because illness does not discriminate between public and private.

“If you get an illness, sometimes it’s appropriate for you to be treated in the private sector and sometimes it’s appropriate for you to be treated in the public sector. It would be good if the doctors covered both but if they don’t, it means that you need to be transferred from one to the other.”

Har ty also believes that vested interests in the Irish healthcare system are impeding progress, and this is something that Government will have

to weed out if the overall situation is to improve.

“We’ve done some research here that indicates that the length of stay in hospital is related to the time of week you have your operation,” he says.

“Hospitals are often organised around a five-day-week basis when they should be organised on a seven-day-week basis. The Government has recognised that and wants to extend the working day, and also introduce working across weekends – but that’s not without its challenges.”

Looking ahead While Har ty is involved in the macrohealthcare debate at a ver y high level on behalf of Blackrock Clinic, he is nonetheless keeping his focus firmly on the development of Blackrock as the benchmark for other private healthcare operators.

“My key priorities now are to build the occupancy of the hospital’s new facilities,” he says. “These include the new Daycare Unit, the Emergency Depar tment, and a new ser vice we are launching for people with medical retina difficulties.

“I am also keen to further expand the hospital if I can. There are other opportunities to build and develop the hospital in other capacities,” he continues. “Healthcare expenditure is going to move from hospitals into the community, and there are opportunities for the private sector in that area as well.”

Br yan Har ty, like the founders of Blackrock Clinic back in the 1980s, clearly isn’t one to rest on his laurels.

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Difene A4 297 x 210mm giant.pdf

1

01/06/2010

15:12

Made in Ireland

Abbreviated prescribing information for Difene.Presentations: Difene (diclofenac sodium) 25mg and 50mg capsules containing enteric coated pellets; 75mg capsules containing 25mg enteric coated pellets combined with 50mg sustained release pellets; 100mg capsules containing 25mg enteric coated pellets combined with 75mg sustained release pellets; Suppositories of 100mg; Ampoules of 75mg/3ml. Difene Spray Gel 4%; Difene Gel 1%. Indications: Capsules and suppositories: rheumatoid arthritis (including juvenile chronic arthritis for 25mg and 50mg only), osteoarthritis, ankylosing spondylitis, psoriatic arthropathy, low back pain and acute musculoskeletal disorders including periarthritis, tendinitis, tenosynovitis, bursitis, sprains, strains, dislocations and in acute gout. Post operative pain and inflammation in orthopaedic, dental and other minor surgery. 75mg and 100mg only: Relief of pain in fractures; in the management of dysmenorrhoea and associated menorrhagia. Ampoule 75mg/3ml for i.m. injection: acute exacerbation of rheumatoid arthritis and osteoarthritis, in acute back pain, acute gout, post operative pain, acute traumatic musculoskeletal disorders, fractures and renal colic. IV Infusion: Post operative pain. Difene Spray Gel 4%: local relief of pain and inflammation following acute blunt trauma of small and medium-sized joints and periarticular structures. Difene Gel 1% also includes localized forms of soft tissue rheumatism. Dosage: Adults: usual daily dose is 100 - 150mg per day. Maximum daily dose is 150mg. In elderly, dosage should be kept as low as possible.

Children over 6 years: usual total daily dose is 1 - 3mg/kg in divided doses. Difene 25mg and 50mg t.d.s; Difene 75mg Dual Release b.d.; Difene 100mg D.R. and Suppository - once daily; Ampoule: Adults: 1-2 i.m. injections daily for maximum of 2 days. IV by infusion diluted in a minimum of 300ml of normal saline over 30 minutes. A maximum of 2 doses may be given intravenously. Difene Spray Gel 4% 4-5 sprays TDS; Difene Gel 1% 2-4g qds. Contra-indications: History of GI bleeding or perforation related toprevious NSAID therapy. Active or history of recurrent peptic ulcer / haemorrhage. Use in patients hypersensitive to aspirin, diclofenac or other non-steroidal anti-inflammatory agents or any of the excipients which precipitate attacks of asthma, urticaria or acute rhinitis. Severe heart failure. Last trimester of pregnancy. Precautions and warnings: Use lowest effective dose for shortest duration possible. Avoid concomitant NSAIDs including COX-2s. GI bleeding, ulceration and perforation may occur with or without warning symptoms or previous history of GI events. Consider combination therapy with protective agents (e.g. misoprostol or proton pump inhibitors) for at risk patients. Patients with history of peptic ulcer, G.I. bleeding, hepatic, renal or cardiac insufficiency or bleeding diathesis or intestinal inflammation. All patients, particularly the elderly, on long term NSAID treatment should be kept under regular surveillance with monitoring of renal, cardiac and hepatic function and of haematological parameters. Pregnancy. Caution in patients with history of hypertension and congestive heart failure. High dose and long-term use may be associated with small increased risk of arterial thrombotic events. Careful consideration before use in longterm patients with cardiovascular disease or risk factors. Discontinue at first sign of skin rash, mucosal lesion or other sign of hypersensitivity. May impair female fertility. Topical formulations should only be administered onto intact skin, not on open wounds or diseased areas. Avoid contact with mucous membranes, eyes or oral use. Avoid excessive exposure to sunlight to prevent photosensitivity. Precaution with large areas of skin i.e. 600sqcm or prolonged use to avoid systemic side-effects (see below). Concomitant use with oral NSAIDs. Interactions: Co-administration of digoxin, lithium, acetylsalicylic acid, anti-diabetic agents, cyclosporin, methotrexate, quinolone antimicrobials, cardiac glycosides, anti-hypertensives, aminglycosides and probenacid. Activity of some diuretics may be inhibited and potassium retaining property increased. Concurrent use of systemic corticosteroid, NSAIDs, anti-coagulants, SSRIs or anti-platelet agents may increase the risk of G.I. bleeding and of ulceration. Topical formulations only theoretical risk. Side-effects: G.I. disturbances and bleeding, irritability, fluid retention, rash, dizziness, hepatitis, renal dysfunction, anaphylaxis and, rarely, blood dyscrasias, bronchospasm and erythema multiforme. Topical formulations local allergic skin reactions. Photosensitivity in isolated cases. Systemic absorption is very low but possibility of systemic side effects cannot be excluded. Packs: Blister pack of 56: 25mg (PA 1241/12/1), 50mg (PA 1241/12/2), 75mg D.R (PA 1241/12/3). Blister pack of 28: 100mg D.R. (PA 1241/12/4). Blister pack of 10: 100mg suppositories (PA 1241/12/7). Pack of 10 ampoules (PA1241/12/6). Difene Spray Gel 4% 25g bottle (PA 1241/12/8). Difene Gel 1% 50g (PA1241/12/5).

Legal Category: Prescription only medicine. Product Authorisation Holder: Astellas Pharma Co., Ltd, 25 The Courtyard, Kilcarbery Business Park, Clondalkin, Dublin 22. Full prescribing information available on request. Difene is a registered trademark. Astellas Pharma Co., Ltd. Tel: +353 1 467 1555. Date of Preparation: Oct 2008. Reference: Difene 21. Reference 1: Data on File: Astellas

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Blackrock Clinic | choosing blackrock clinic

A Guide to Choosing

BLACKROCK CLINIC T

he modern patient is not exactly stuck for choice when it comes to private healthcare: one legacy of the Celtic Tiger is a huge expansion in the private sector, with new private clinics, hospitals and practices coming onstream alongside developments in the private health insurance marketplace.

So why choose Blackrock Clinic? � Staff: Blackrock Clinic recruits the finest medical practitioners in their fields, and our support staff are selected for their quality and desire to go the extra mile for the comfort and recovery of the patient. Staff surveys indicate that those who work for us are far happier than the benchmark. � Facilities: Our purpose-built hospital and clinic buildings, belief in proven results from the latest technologies, and massive reinvestment have given the Clinic ever ything it needs to lead the market in quality private healthcare. � Environment: At Blackrock Clinic, we believe that a relaxed, positive atmosphere is an important part of the patient recovery process. We encourage

visitors, and do our best to facilitate every request. Bright spaces with remarkable views of Dublin Bay, the city and the Wicklow Mountains provide the most comfortable surroundings possible for treatment and recovery. � Heritage: From the moment we welcomed our first patients in 1984, we have built up a tradition and a reputation that continue to inspire: the Blackrock Clinic brand is now a byword for leadership within the sector. � Commitment: Innovative approaches such as publishing surgery and disease statistics online, the backup provided by our supervisory committees, and our pursuit of appropriate international standards and accreditation all point towards a dedication to the highest levels of excellence.

“At Blackrock Clinic, we believe that a relaxed, positive atmosphere is an important part of the patient recovery process.”

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New Formulation

(0.01%)

For Your Newly Diagnosed Glaucoma Patients Name: LUMIGAN® eye drop solution 0.01% Strength: 0.1mg/ml Size: 3ML Movianto code: 0916377 GMS code: 77432 LUMIGAN® (Bimatoprost Ophthalmic Solution) 0.01% Abbreviated Prescribing Information Presentation: Eye drop solution, one ml contains 0.1mg bimatoprost.

Indications: Reduction of elevated intraocular pressure (IOP) in chronic open-angle glaucoma and ocular hypertension in adults (as monotherapy or as adjunctive therapy to beta-blockers).

Dosage and Administration: Please refer to the Summary of Product Characteristics before prescribing. Recommended dose is one drop in the affected eye(s) once daily, administered in the evening.

More frequent administration may lessen the IOP lowering effect.

If more than one topical ophthalmic medicinal product is being used, each should be administered at least 5 minutes apart. Not recommended in children or adolescents (under the age of 18). Use with caution in renal or hepatic impairment.

Contraindications: Hypersensitivity to bimatoprost or any of the excipients. Patients who have had a suspected previous adverse reaction to benzalkonium chloride that has led to discontinuation.

Warnings/Precautions: Prior to treatment patients should be informed of the possibility of eyelash growth, darkening of the eyelid

skin and increased iris pigmentation. Some of these changes may be permanent and may lead to differences in appearance between the eyes when only one eye is treated. The change in iris pigmentation occurs slowly and may not be noticeable for several months or years. At 12 months there was one report of iris hyperpigmentation (incidence of 0.5%). Periorbital tissue pigmentation has been reported to be reversible in some patients. Contains the preservative benzalkonium chloride (0.2mg/ml) which may cause eye irritation and may be absorbed by and discolour soft contact lenses. Lenses should be removed before Lumigan instillation and may be reinserted 15 minutes after administration. Use with caution in dry eye patients, those where cornea may be compromised and in patients taking multiple BAK-containing drops. Monitoring required with prolonged use in such patients. Use with caution in patients with compromised respiratory function, those predisposed to low heart rate or low blood pressure or prior history of significant ocular viral infections or uveitis/ iritis. Lumigan has not been studied in patients with heart block more severe than first degree or in uncontrolled congestive heart failure; inflammatory ocular conditions, neovascular, inflammatory, angleclosure glaucoma, congenital glaucoma or narrow-angle glaucoma.

Cystoid macular oedema has been uncommonly reported (≥1/1000

to <1/100) with Lumigan 0.03% therefore Lumigan 0.01% should be used with caution in patients with known risk factors for macular oedema (e.g. aphakic patients, pseudophakic patients with a torn posterior lens capsule). Interactions: None anticipated in humans, since systemic concentrations of bimatoprost 0.03% were extremely low following ocular dosing.

Pregnancy: No adequate data from the use of bimatoprost in pregnant women. Do not use unless clearly necessary.

Lactation: Decision on whether or not to continue breast-feeding or therapy with Lumigan should be made taking into account the benefit of breast-feeding to child and Lumigan therapy to woman.

Driving/Use of Machines: Negligible influence on the ability to drive and use machines.

Adverse Effects: In a 12-month clinical study, approximately 38% of patients experienced adverse reactions, the most frequently reported of which was conjunctival hyperaemia (mostly trace-mild) which occurred in 29% patients. Approximately 4% patients discontinued due to any adverse event in the 12-month study. The following undesirable effects were reported: Nervous system disorders Uncommon (≥1/1,000 to <1/100): headache; Eye disorders Common (≥1/100 to <1/10): punctate keratitis, eye irritation, eye pruritus,

growth of eyelashes; Uncommon : asthenopia, blurred vision, conjunctival disorder, conjunctival oedema, iris hyperpigmentation, madarosis Skin and subcutaneous tissue disorders Common: eyelid erythema, eyelid pruritus, skin hyperpigmentation, hypertrichosis; Uncommon: dry skin, eyelid margin crusting, eyelid oedema, pruritus; General disorders and administration site conditions Common: instillation site irritation Please refer to Summary of Product Characteristics for full information on side effects.

Marketing Authorisation Number: EU/1/02/205/003-004.

Marketing Authorisation Holder: Allergan Pharmaceuticals Ireland, Castlebar Road, Westport, Co. Mayo, Ireland.

Legal Category: Prescription.

Date of Preparation: May 2010.

Further information is available from: Allergan Limited, Marlow International, The Parkway, Marlow, Bucks, SL7 1YL.

Allergan Ltd, Marlow International, The Parkway, Marlow, Bucks, SL7 1YL Tel: +44 (0)1628 494026 www.allergan.co.uk IR/0013/2010g Date of preparation: May 2010.

11082 IR00132010g Lumi IRE IPU blackrock_clinic_magazine.indd 12Ad A4.indd 1

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5:46:27

Blackrock Clinic | new daycare unit

New

Daycare Unit S

eptember 2010 was a watershed in the Blackrock Clinic’s histor y, as Minister for Health Mar y Harney opened our new €100m expansion. Included is a state-of-the-ar t Daycare Unit.

Located on the fifth floor, the Unit is a first for Ireland, and patients and staff benefit from glorious views across Dublin Bay, the city and the Wicklow Mountains. It is open from 7am to 8pm Monday-Friday, and 7am to 4pm Saturday.

Perhaps the foremost point about the Unit is its custom-built nature, a rarity in this countr y: it has been designed to cater for daycare surger y in the 21st centur y.

International statistics strongly suggest that upwards of 75% of elective surger y should be delivered on a daycare basis.

The daycare unit proudly contains: � Two theatres � Two endoscopy rooms � Three minor procedure rooms � 25 recovery beds � Comfortable discharge lounge � Doctors’ offices � Friendly reception lobby

In order to do that, the healthcare provider needs to have a number of things: the appropriate physical or structural environment design, good access, the correct equipment to allow appropriate minimally-invasive surger y, and the appropriate clinical pathways to allow you to deliver that ser vice. On top of that, it must be overlaid with appropriate audit and follow-up, and background facilities for patients when they go home. Blackrock Clinic is now at the cutting-edge in delivering that to the Irish healthcare market.

On arrival, patients go directly to the Unit for registration, where they will be welcomed by a “meet and greet” member of staff there to help patients settle in. Next, a nurse admits the patient, and carries out preparations for the daycare procedure if necessar y.

All medical specialties can be catered for in the daycare setting – clearly, not ever y procedure is suitable for daycare, but much elective work can be catered for in that environment – and with the exact same medical outcomes as inpatient ser vices.

The single biggest change is that the Daycare Unit is a standalone, separate theatre complex. It increases the number of operating rooms alone by over 40%. It has doubled the number of

“Perhaps the foremost point about the unit is its custom-built nature, a rarity in this country: it has been designed to cater for daycare surgery in the 21st Century.”

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PTSB_

Blackrock Clinic | new daycare unit

endoscopy rooms and minor procedure rooms, making the Unit a huge structural change within the Blackrock environment.

In addition, there’s a reorientation in the manner in which our care is delivered.

The first challenge to Blackrock has been the massive increase in the footprint of the Unit, and the increase in the number of rooms and capacity for the way in which we can treat the patient. Another challenge has been to put in appropriate pre-operative assessment and post-operative followup, to make sure that the outcome of the surger y can be benchmarked satisfactorily against international standards. That’s par t of a wider logistical project that we have been

working on and delivered over the past 18 months.

Details such as the auditing of clinical outcomes, ser vice deliver y and patient satisfaction are par t and parcel of modern daycare surger y, as are the measurements made to make sure that clinically the provider is matching up all of that. Some of the inspiration comes from the United States, where one of the team members, an exper t in daycare, spent time studying the subject at Yale University.

Delivering value for money is another motivation: as in all walks of life, costs must be given due attention. There is little doubt that healthcare is ver y expensive. If one can remove the ‘hotel’ component from the cost of healthcare, moving to a situation where patients are being treated intensively for the period of their stay before an appropriate step down – the more economical par t of their healthcare plan – then that

provides financial benefits for all. The evidence is that daycare surger y delivers better value for money to the healthcare economy than practically any other area. In addition, it’s less disruptive for patients, in that they’re not in hospital for any longer than they need to be.

Daycare treatment at the Blackrock Clinic is also advantageous when one thinks of the risk of hospital-acquired infections such as MRSA, and that is now greatly reduced – yet the clinical outcome is the equivalent of inpatient stay, and there is no price to be paid clinically for the improvement in economic outcome. For these reasons there will be and should be a greater emphasis on daycare surger y, and Depar tment of Health and HSE publications over the past number of years have highlighted the impor tance of this in the future of Irish healthcare.

The question is: will the Irish healthcare system evolve to the point where more

14 www.blackrock-clinic.com

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Blackrock clinic | nEW dayCarE uniT

and more of the procedures are directed down the daycare route? Ireland stands well below that 75% level at present.

This is part of the reason why we proportionally have so many inpatient beds and part of the reason why, in relative terms, there’s poor value around some areas of the healthcare system.

Culturally, such emphasis on daycare is new, and culture change may take place as patients who might expect inpatient ser vice discover that outpatient treatment is more suitable. This is one step towards redressing that in a major way.

Looking at the Blackrock Clinic brand and what it has tried to deliver over the past 25 years, there is an onus to be smarter with money, especially if it’s taxpayers’ or healthcare providers’ money. The new Daycare Unit is a major development along that path. Our goal is to increase the number and type of procedures going through the Unit, to get patients out of hospitals in a more timely manner, to reduce the 'hotel' component and therefore deliver better value to everybody.

Most impor tantly, the patients – who don’t want to be in hospital any longer than they have to be – are the major

cornerstone of the project. One of the most impor tant factors is to have the stepdown and follow-up facilities so that people realise that they’re still connected to the centre that looked after them.

On discharge, the patient is given instructions and advice, and may receive a convenient information booklet where relevant. Patients can avail of our new discharge lounge, where they can relax in comfor t while waiting to go home. The Blackrock Clinic is happy to book taxis on request.

A few days after the procedure, the Clinic contacts patients to ensure that they are well, understand the procedure that they have undergone, and are happy to answer any questions. Upon leaving, patients receive a discharge sheet for their GP. This includes details of their procedure and clinical condition upon discharge.

Finally, patients receive an emergency contact number. In the event of any difficulties, the 24-hour service is available and operates seven days a week. With the opening of the new Daycare Unit, the necessary stepdown and follow-up facilities can now be delivered.

Before admission, consultants will have informed patients of: � Specific information in relation to their procedure � The date and time of admission � Any fasting requirements � Patients will bring any tests or x-rays relevant to their procedure. � Patients will be forwarded a copy of the Daycare Unit Practical Information Booklet

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02/12/2010 11:44:41

CRESTOR

®

(rosuvastatin)

Now indicated for patients estimated to be at high risk of a first major CV event in conjunction with correction of other risk factors* Based on data from a post hoc analysis of high risk patients (SCORE ≥ 5% or Framingham > 20%) from the JUPITER study1

come on! you promised the doctor you’d lose some weight

hey dad, wanna go for a run?

sure didn’t she say my cholesterol was grand

but you never gave up the smokes ...remember what happened to grandad?!

honest son, i’m really trying to cut down...

enjoy your run, i’ll join you next time!

with CRESTOR† if he’s at high risk... you can now help prevent his first major cv event in conjunction with correction of his other risk factors* † NOTE: JUPITER used CRESTOR 20mg. The recommended start dose for hypercholesterolaemia is 5 or 10mg (refer to SPC) * modifiable risk factors include smoking cessation, exercise, weight loss and diet Abbreviated Prescribing Information CRESTOR® Refer to the full Summary of Product Characteristics (SPC) before prescribing Presentation: Film-coated tablets containing 5mg, 10mg, 20mg, or 40mg of rosuvastatin. Indications: In patients unresponsive to diet and other nonpharmacological measures, CRESTOR is indicated for primary hypercholesterolaemia (including heterozygous familial hypercholesterolaemia), homozygous familial hypercholesterolaemia, or mixed dyslipidaemia. Prevention of cardiovascular events in patients who are estimated to have a high risk for a first cardiovascular event as an adjunct to correction of other risk factors. Dosage: Treatment of hypercholesterolaemia: Recommended start dose is 5 or 10 mg daily (including those being switched from other statins). Choice of start dose should take into account the individual patient’s cholesterol level and future cardiovascular risk and potential risk for adverse reactions. A dose adjustment to the next dose level can be made after 4 weeks, if necessary. Maximum daily dose is 40mg. A final titration to the maximum dose of 40 mg should only be considered in patients with severe hypercholesterolaemia at high cardiovascular risk (in particular those with familial hypercholesterolaemia), who do not achieve their treatment goal on 20 mg, and in whom routine follow-up will be performed. Specialist supervision is recommended when the 40 mg dose is initiated – refer to SPC. Doses may be given at any time of the day with or without food. Elderly: A start dose of 5 mg is recommended in patients >70 years. No other dose adjustment is necessary in relation to age. Dosage in patients with renal insufficiency: Recommended start dose is 5 mg in patients with moderate renal impairment (creatinine clearance <60 ml/min). The 40 mg dose is contraindicated in patients with moderate renal impairment. The use of CRESTOR in patients with severe renal impairment is contraindicated for all doses.

Children and adolescents 10-17 years of age: Paediatric use should only be carried out by specialists – refer to SPC. In heterozygous familial hypercholesterolaemia, the usual start dose is 5mg daily, usual dose range is 5-20mg daily. The 40mg dose is not suitable for paediatric patients.

Children under 10 years: Safety and efficacy not established. Race: Increased systemic exposure in Asian subjects. Recommended starting dose 5mg. CRESTOR 40mg is contraindicated in such patients. Dosage in patients with pre-disposing factors to myopathy: The recommended start dose is 5 mg in these patients. The 40 mg dose is contraindicated in some of these patients (see Contraindications). Prevention of cardiovascular events: the dose used in the cardiovascular events risk reduction study was 20mg. Contra-indications: Hypersensitivity to any of the ingredients; active liver disease or unexplained persistent elevations in serum transaminases and any serum transaminase > 3 x upper limit of normal; severe renal impairment; myopathy; concomitant ciclosporin; pregnancy and breast-feeding; women of child-bearing potential not using contraception. In addition CRESTOR 40mg is contraindicated with concomitant fibrates, and in patients with predisposing factors for myopathy/rhabdomyolysis including patients of Asian origin (refer to SPC for more information). Warnings and precautions: Renal effects: Proteinuria which in most cases is transient or intermittent has been observed. Assessment of renal function should be considered during routine follow-up of patients treated with CRESTOR 40 mg. Muscle effects: Patients with signs and symptoms of myopathy should be asked to report their symptoms immediately and should have their creatine kinase (CK) levels monitored. CRESTOR should be discontinued if CK levels are markedly elevated or, if muscle symptoms are severe and cause daily discomfort. Risk of myositis and myopathy may increase when administered with certain other drugs (refer to SPC), combination of CRESTOR with gemfibrozil is not recommended for this reason and the benefit versus risk considered when combining CRESTOR with fibrates and niacin. Very rare cases of rhabdomyolysis have been reported with the use of ezetimibe and HMG-CoA reductase inhibitors. CRESTOR, as with other HMG-CoA reductase inhibitors, should be prescribed with caution in patients with pre-disposing factors for myopathy or rhabdomyolysis (see SPC), and if CK levels are significantly elevated at baseline, treatment should not be started. CRESTOR should not be used in patients with an acute, serious condition suggestive of myopathy or predisposing to the development of renal failure secondary to rhabdomyolysis. Rarely, rhabdomyolysis, occasionally associated with impairment of renal function has been reported with all doses and in particular doses >20mg. Liver effects: CRESTOR should be used with caution in patients with a history of liver disease and/or alcoholism. Liver function tests should be carried out, prior to, and 3 months following the initiation of treatment. CRESTOR should be discontinued or the dose reduced if the level of serum transaminases is greater than 3-times the upper limit of normal. The reporting rate of serious hepatic events is higher at the 40mg dose. Interstitial lung disease: Exceptional cases have been reported with some statins, if it is suspected that a patient has developed interstitial lung disease, statin therapy should be discontinued. Diabetes Mellitus: In Patients with fasting glucose 5.6 to 6.9 mmol/L, treatment with Crestor has been associated with an increased risk of diabetes mellitus. The concomitant use of rosuvastatin in HIV patients receiving protease inhibitors is not recommended. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency of glucose-galactose malabsorption should not take this medicine. Pregnancy and lactation: See contra-indications. Drug interactions: Also refer to contraindications. CRESTOR is neither an inhibitor nor inducer of cytochrome P450 isoenzymes. CRESTOR may potentiate the anticoagulant effect of Vitamin K antagonists (e.g. warfarin). Decrease in CRESTOR levels seen when co-administered with erythromycin or antacids containing aluminium and magnesium hydroxide. Increase in oral contraceptive level and hormone replacement therapy level is seen when co-administered with CRESTOR. Concomitant use of CRESTOR and gemifibrozil resulted in a 2-fold increase in rosuvastatin Cmax. Concomitant use of CRESTOR and ezetimibe resulted in no change in AUC or Cmax for either drug; however a pharmacodynamic interaction in terms of adverse events cannot be ruled out. Protease inhibitors. Undesirable effects: Common: headache, dizziness, constipation, nausea, abdominal pain, myalgia, asthenia and diabetes in patients with fasting glucose 5.6 to 6.9mmol/L. Uncommon: pruritus, rash and urticaria. Rare: myopathy (including myositis), rhabdomyolysis, hypersensitivity reactions including angioedema, increased hepatic transaminases, pancreatitis. Very rare: jaundice, hepatitis, haematuria, polyneuropathy and memory loss and arthralgia. Other usually transient side effects: elevation in CK levels, proteinuria. Other adverse events listed as unknown: diarrhoea, Stevens-Johnson syndrome, oedema, cough and dyspnoea. The following adverse events have been reported with some statins: depression, sleep disturbances including insomnia and nightmares, sexual dysfunction and exceptional cases of interstitial lung disease, especially with long term therapy. Legal Category: POM. Marketing Authorisation Number (s): PA 970/57/1-4. Marketing Authorisation Holder: AstraZeneca UK Ltd, 600 Capability Green, Luton, LU1 3LU, UK. Further information is available on request from: AstraZeneca Pharmaceuticals (Ireland) Ltd., College Park House, 20 Nassau Street, Dublin 2 Telephone: (01) 6097100; Updated 06/10 CRESTOR is a trademark of the AstraZeneca group of companies. Licensed from Shionogi & Co Ltd, Osaka, Japan. Date of preparation: July 2010. URN: 10/0325.

References: 1. Crestor SmPC. 2. Jones PH, Davidson MH, Stein EA et al. Am J Cardiol 2003; 92 (2): 152-160. 3. Schuster H, Barter P, Stender S et al. Am Heart J 2004; 147 (4): 705-712. 4. Ballantyne C et al. Am Heart J 2006; 151 (5):975.e1-975.e9. 5. Faergeman O et al. Atheroscler Suppl 2006; 7(3):580, Abs Th-P16394. 6. Clearfield M et al. Atheroscler Suppl 2005; 6(1), Abs W16-p-014:104. 7. Leiter LA et al. Eur Heart Journal 2005; 26(1):581 Abs P3503; 8. Blasetto JW, Stein EA, Brown WV et al. Am J Cardiol 2003; 91(Suppl): 3C-10C.

Still the most Effective Statin for Lowering LDL-C1-8

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At Pinewood Healthcare, we stand for

choice.

As the Number 1 branded generic supplier in Ireland, we are proud to offer GP’s and pharmacists throughout the country, the choice to prescribe and dispense treatments which cost a fraction of their branded counterparts. In doing so, we are working with you to help your patients benefit from quality, cost-effective medication.

With over 30 years manufacturing healthcare products in Ireland, Pinewood Healthcare is one of the largest generic employers with a workforce of over 340 people. We are always committed to providing the Irish market with quality brands at inexpensive prices.

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02/12/2010 11:44:46

6:58:40

Blackrock Clinic | new emergency department

New Emergency Department “The Emergency Department delivers rapid medical expertise and attention to patients, and is designed to meet the needs of those who value the high quality environment of a private hospitalbased clinical treatment unit – and the prompt service it can deliver.”

A

nother new arrival at the Blackrock Clinic is our Emergency Department.

Opening the facility in June 2010, our Chief Executive Bryan Harty explained that, in a nutshell, "patients will be seen within a maximum of one hour and can be reassured that they will receive a speedy diagnosis and the best possible specialist care in a relaxed and calm environment.”

The Emergency Department delivers rapid medical expertise and attention to patients, and is designed to meet the needs of those who value the high quality environment of a private hospital-based clinical treatment unit – and the prompt service it can deliver.

It’s like a public emergency department, apart from a number of notable differences. The patient population is roughly the same, except the Department does not take ambulance referrals unless previously arranged by private ambulance. It is consultant-delivered, so there are no junior doctors. Finally, there is better access to ser vices and in-house

consultants than one finds in the public ser vice.

The development is a step forward for Blackrock Clinic: traditionally seen as an elective hospital, new categories of emergency and acute medical patients can now be treated. Previously, patients would have been required to book in, and brought in several days later, or it might be difficult for a GP to get access to a consultant to bring their patient in. Now, however sameday admission can be offered.

Major accidents and critical illnesses are better dealt with by public emergency departments, and so are not catered for by the Department. We accept patients who refer themselves, or patients can be referred in by their General Practitioner.

This offers the choice of attendance to those who need immediate consultation and attention. The initial assessment fee is €120. In the event that further tests are needed, there is a cap of €500 in place – meaning that no series of tests can cost more.

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Blackrock Clinic | new emergency department

Excellent services and facilities There are seven bays within the depar tment, a waiting area, and direct access to beds in the hospital.

Relative to the public sector, that’s a great improvement, where stories of patients waiting on trolleys are familiar. In Blackrock Clinic, a decision to admit a patient can be made and the patient can go up to a ward on the same day, before close of business.

Patients are af forded easy access to radiology, CT and MRI ser vices, among all the other facilities available onsite. Treatments that are sometimes dif ficult to obtain in the public sector, such as cardiac ser vices, echo and stress tests, can be provided on the same day.

The Emergency Department maintains a consultant presence all day long, from start to close of business, as well as two nurses and a receptionist. The Clinical Director, Aidan Gleeson, is joined by Dr Stuart Carr, Consultant in Emergency Medicine, who is present four or five days a week. Dr Carr’s training has mainly been in Ireland – having qualified in 1999, he went into emergency medicine as a junior in 2000, and has been trained in the Irish system throughout, apart from a short period in Dallas on a teaching fellowship.

A great variety of cases The range of patients represents quite a mix, encompassing all age groups above 14. Dr Carr and his colleagues see acute medical problems such as pneumonia, cardiac, undif ferentiated chest pain, hear t attacks and some trauma. A number of patients have walked in with injuries and broken bones, or their treatment has been arranged by private ambulance. Head injuries, headaches and strokes are all among a large variety of cases.

In general, patients have been extremely happy: “we’ve had a lot of ‘with compliments’ cards and boxes of chocolates – we’re popular people!” repor ts Dr Carr. GPs seem to be ver y happy with the ser vice too: from their perspective, the patients’ discharge letters are sent out within 24 hours, and GPs are updated with what happens with the patients they refer in.

Patients who need to be admitted to the hospital will be fully covered by VHI Plan B (or higher), or an equivalent plan with another insurer. Supplements normally payable by members of VHI Plan B, or equivalent, will be waived. However, if the policy has an excess per claim then this will be payable by the patient. If there are any doubts about cover, the reception desk

team in the Emergency Depar tment are always happy to help.

The Emergency Depar tment is open Monday to Friday, 9am-6pm.

Patients over 14 with any ailment requiring urgent care can use the service, including:

� Acute medical and surgical emergencies

� Minor injuries - sprains, strains and wounds

� Fractures � Respiratory conditions � Gastrointestinal conditions � Chest pain

“The Emergency Department maintains a consultant presence all day long, from start to close of business, as well as two nurses and a receptionist.”

20 www.blackrock-clinic.com

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02/12/2010 11:45:02

At Johnson & Johnson we embrace research and science to bring innovative ideas, products and services to advance the health and well being of people throughout the world.

We continue to invest heavily across Ireland in our manufacturing facilities in Cork, Limerick and Cashel where we employ more than 2,200 employees working in biologics and pharmaceutical production, the manufacture of orthopaedic devices and contact lenses to name just a few. Our manufacturing presence in Ireland and its contribution to the Irish Economy has been exemplary in terms of partnership between Public and Private sectors and we remain fully committed in this regard.

ETHICON ENDO-SURGERY develops and markets advanced medical devices focusing on procedure-enabling devices for the interventional diagnosis and treatment of conditions in general and bariatric surgery, as well as gastrointestinal health, gynaecology and surgical oncology.

ETHICON a global medical device company, has been a leader in surgical sutures (stitches) for more than 100 years.

Today, we have expanded our expertise into women’s health and cardiovascular surgery.

Restoring the Joys of Motion ™ is what united the DePuy companies and drives all innovation. Their portfolio addresses a range of solutions for patients and professionals, and spans from orthopaedic to neurological care continuing from early intervention through to joint replacement and spinal fusion.

Advanced Sterilization Products, is a leading developer of innovative instrument sterilization, high-level disinfection and are decontamination technologies. ASP is dedicated to protecting patients, health care workers, and the environment with products that focus as much on safety as they do on efficacy and cost effectiveness.

Cordis Corporation is a worldwide leader in developing and manufacturing interventional vascular technology. Through the company’s innovation, research and development, physicians worldwide are better able to treat millions of patients who suffer from vascular disease Johnson & Johnson (Ireland) Limited, Airton Road , Tallaght, Dublin 24

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02/12/2010 11:45:12

The Benchmark in Neuromodulation Parkinsonâ&#x20AC;&#x2122;s disease Essential Tremor Dystonia Chronic Pain (Opioid) Chronic Pain Chronic Back Pain Syndrome Complex Regional Pain Syndrome Peripheral Vascular Disease Refractory Angina

Gastroparesis Malignant Pain Spasticity Pelvic Floor Dysfunction Overactive Bladder Non-Obstructive Retention Fecal Incontinence Constipation Bladder Pain Syndrome www.medtronic.ie www.neuroreferrals.ie

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Innovating for life.

02/12/2010 11:45:44

Blackrock clinic | CardiOLOgy

©istockphoto.com/KameleonMedia

Department of

CardiOLOgy T

he Cardiology Department at Blackrock Clinic has been under the watchful eye of Chief Cardiac Technician, Jean Grainger, for 20 years now. Having joined the Clinic in 1990, Jean has been at the Clinic long enough to not only witness the metamorphis of the Clinic from a physical perspective, she has also been at the forefront when it comes to the amazing developments in technology over the past two decades.

“We are much busier now than when I first joined the Clinic,” says Jean. “Today, we are conducting a lot more advanced testing in Cardiology. When I first came to the Clinic we were carrying out cardiac ultrasounds which were done through the chest wall. Now, however, developments in technology also allow us to carry out this procedure by passing an ultrasound probe down the patient's throat. The significant developments in the area of technology and the advancements made have enabled us to carry out more complex procedures with less difficulty, while also broadening the range of procedures that we can do and offer.”

“While the procedures are not unique to Blackrock Clinic, the waiting lists at the Clinic when compared to the public healthcare system are much shorter and access to these treatments is much faster than what one would

find in a public hospital. That is a major attraction for patients when choosing to use our ser vices.”

increased awareness It hardly comes as a surprise when Jean points out that the Cardiology Department at Blackrock Clinic is much busier today when compared with 1990. As well as having enhanced capability to carr y out more and more procedures, Jean believes that the general public is becoming ever more health conscious and rather than wait for a problem to arise, many of the Department’s patients are increasingly proactive when it comes to taking care of themselves.

“In general, people are becoming much more aware of health issues, which can directly be attributed to the increased throughput at the Cardiology Department at Blackrock Clinic,” says Jean. “We get a lot of people who have been visiting patients of the Clinic who come back to have a check-up themselves. As a result, we are seeing an improvement in people’s knowledge of health problems and risks and they tend to act much faster to these risks than perhaps they did in the past. The direct result of that, of course, is that we have seen a sharp rise in the activity of the Cardiology Department at the Clinic.”

“WE spEnd as MuCh TiME WiTh ThEM as is rEquirEd TO MaKE ThEM fEEL aT EasE and TO MaKE ThEM COMfOrTaBLE. paTiEnT CarE is aT ThE vEry hEarT Of WhaT WE dO hErE.”

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Blackrock Clinic | cardiology

©istockphoto.com/deliormanli

Patient comes first Managing the extra number of patients is part of Jean’s and her staff’s responsibility. The 14-strong team (10 full-time; four part-time) of the Cardiology Department run the Department five days per week. “Like all other departments at Blackrock Clinic, the patient is our absolute focus,” says Jean. “We spend time with all of our patients and answer any questions that they might have and explain in full any tests or procedures. It takes away any fear that a patient may have.”

“Our receptionist is the first person to meet and greet our patients. Once all of the necessary paperwork is completed, the patient is called for their procedure.

The details of the procedure are fully explained to them, particularly if they are first-time patients. Some people can get very nervous and so we spend as much time with them as is required to make them feel at ease and to make them comfortable. Patient care is at the very heart of what we do here.”

Indeed, Blackrock Clinic has developed a considerable reputation for patient care and being much more than just a healthcare facility. The Clinic’s unerring

focus on every patient that comes through the door, no matter how complicated or simplistic the procedure that is required, sets the Clinic apart in healthcare in Ireland today. The staff understand the need to be accommodating and go the extra mile to do so.

In the Cardiology Department, once the staff rota is complete and staff are allocated to each section of the department for the entire week, like other manager’s at the Clinic, Jean’s work in monitoring the progress of the entire department begins in earnest. “I work on an hour-to-hour basis and there is a huge onus on me and all of my staff to be flexible when carr ying out our duties. Ver y often we have a fully booked schedule but if a patient is admitted that has to be seen that day, then we have to accommodate that. We don’t cancel appointments just because we have extra patients on our rota – ever ybody is seen to.”

Appointments Appointments can be made by contacting the Department directly on 1800 300 200 or 01 206 4552. A referral letter from the patient’s GP or consultant is required.

“We don’t cancel appointments just because we have extra patients on our rota – everybody is seen to.”

24 www.blackrock-clinic.com

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02/12/2010 11:46:11

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02/12/2010 11:46:37

26 www.blackrock-clinic.ie

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02/12/2010 11:46:46

Blackrock clinic | physiOThErapy

©istockphoto.com/Philartphace

Department of

physiOThErapy P

“iT’s aBOuT aLLOCaTing EnOugh TiME WiTh ThE paTiEnT, MaKing ThEM fEELing COMfOrTaBLE and KEEping ThEM in ThE LOOp. Our saTisfaCTiOn COMEs frOM sEEing paTiEnTs WhO arE happy WhEn ThEy’rE LEaving us having OBTainEd MaxiMuM BEnEfiT frOM Our inpuT.”

hysiotherapy, another of Blackrock Clinic's important departments, requires solid management from the top down. At the summit is Verna Kenning who directs the operation that oversees the entire hospital’s physiotherapy patient care for both inpatients and outpatients.

“The Physiotherapy Depar tment has an outpatient ser vice but more than half of the staff gives a physiotherapist ser vice to all the hospital,” explains Verna. “That covers three areas; cardiothoracic, or thopaedic, which is post-joint replacements and back surger y, and also a medical respirator y ser vice, which covers patients who need intensive rehab post-stroke and falls.

Then there is the outpatient ser vice and as manager, together with my staff, I oversee all of activity there.”

Verna has managed Blackrock Clinic's physiotherapy team for over seven years, having previously worked here for 15 years as a senior in cardiothoracic.

She completed her training in England, describing her main interests as “major trauma and cardiothoracic intensive care work”, and began her career in the Mater Hospital before coming to Blackrock.

These days much of the team's work focuses on people with various back problems, who are referred to Blackrock Clinic by their GPs. From the initial assessment of these patients, the team can decide the best course of treatment, whether it is intensive physio, or thopaedic, consultation referral, a pains specialist, or a follow up in another area. “What we’re really doing is facilitating a return to work,” explains Verna. “A lot of our patients have fear avoidance, or they get totally deconditioned while they’re out of work. It is often something that’s quite simple like a bio-mechanical problem, or a strengthening programme that they need to get them back to work. With the programme a lot of education is done, looking at fear avoidance, we also have a stress management component for any patients who need it. If a patient must travel a long distance to get here, we generally carr y out the initial assessment and the final assessment and refer them to a physio in their area if physiotherapy is required.”

While back problems are a huge par t of the physiotherapy depar tment’s work, they see all sor ts of neuromuscular

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02/12/2010 11:46:59

helix

Blackrock Clinic | physiotherapy

Technology and research Even with so much experience to draw upon, Verna is keen to stress the importance of keeping up to date with the latest technology and research. The Outpatient Department is led by clinical

specialist, Jean Andrews, who ensures all staff are up to date in best practice.

Treatments like electro-therapy have mostly been discarded after recent research revealed poor performance. These have been replaced with techniques that have been proven to be beneficial in line with best clinical practice beginning with accurate assessment. “Constantly involving the patient in their own goals, and getting the patients to buy into how they can have a major influence into fixing their own problem is most valuable,” says Verna.

But even with the latest research and technology at her disposal, Verna is in no doubt that giving her patients the reassurance that ever ything possible will be done to improve their condition has always been of the utmost importance.

“It’s about allocating enough time with the patient, making them feel comfortable and keeping them in the loop. Our satisfaction comes from seeing patients who are happy when they’re leaving us having obtained maximum benefit from our input.”

©istockphoto.com/Rike_

problems, whether its necks, legs or any other par t of the body. To deal with any problems a patient might be suf fering from, Verna has assembled a knowledgeable team with the skills to tackle any and all issues. “Most of my physios are Master’s level so all of them are ver y experienced. One member of staf f worked for the Royal Ballet in London so is par ticularly experienced in lower limb problems.

Another of our physiotherapists with a Masters in spor ts is experienced in strengthening and conditioning patients post-injur y, and we have a physio who specialises in necks. Our highly experienced team, with areas of special clinical exper tise, allows us a breadth of experience to treat all ailments.”

“As we have physios who have specialties in certain areas, that allows us a breadth of experience to treat all ailments.”

28 www.blackrock-clinic.com

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02/12/2010 11:47:14

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02/12/2010 11:47:15

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02/12/2010 11:47:20

BLACKROCK CLINIC | RADIOLOGY & DIAGNOSTICS

RADIOLOGY

©istockphoto.com/Hirkophoto

& Diagnostics

R

“TAKING CARE OF INPATIENTS AND OUTPATIENTS ALIKE, A WIDE AND EVERDEVELOPING VARIETY OF SERVICES ARE AVAILABLE, BOTH GENERAL AND SPECIALIST-SPECIFIC.”

adiology and diagnostic ser vices form an impor tant element of Blackrock Clinic’s quality care of fering. Taking care of inpatients and outpatients alike, a wide and ever-developing variety of ser vices are available, both general and specialist-specific.

Diagnostic ser vices is quite a high-tech depar tment: on of fer are general radiography and a screening fluoroscopy room – for barium meals and barium enemas, for example. Two labs are available, where angiograms, stenting and angioplasties are among the ser vices of fered. MRI and CT are impor tant facilities, as is mammography. Finally, under the nuclear medicine bracket there is SPECT/CT, a separate gamma camera and PET/CT machiner y. “We have nice equipment,” says Nancy Manning, Head of Radiology.

The Depar tment’s offering has evolved in recent years: four years ago, cardiac CT commenced at Blackrock, an impor tant development in the Clinic’s por tfolio. This was followed by cardiac MRI in 2009, a ser vice which has become par ticularly busy. The team tries to per form about 20 a week, under the guidance of its dedicated Cardiologist, Dr Ror y O’Hanlon.

In fact, cardiac MRI is an area for fur ther growth and development Blackrock is a rarity in Ireland in that per fusion scanning can be per formed, where the hear t is deliberately stressed in a controlled manner, necessitating the presence of a Cardiologist, who is available if the need arises. The results are excellent, indicating that the ser vice will be a priority in future.

The Blackrock Clinic still does a great deal of cardiac surger y and inter ventional cardiology, with stenting and associated procedures to the forefront. Last year was one of firsts for the Depar tment: CT colonography commenced, the first vascular angioplasty was per formed in theatre, as was the first percutaneous scoliosis procedure in Ireland. The first private radioiodine ablation suite in Ireland also began its work, with a superb response.

The Blackrock Clinic’s patients are par ticularly loyal, and many are familiar faces. The radiology and diagnostic staff have actually come to recognise and know them well, leading to first-name terms and the occasional chat. This friendship becomes par t of the patients’ care: staff who build up a relationship with the patient find that the level of trust rises even more.

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Blackrock Clinic | radiology & Diagnostics

For now, though, work in the general depar tment star ts at 8am, concluding at 6pm. CT runs from 7:30am until 6pm, though the Emergency Depar tment is covered to 7pm, in case a patient arrives late. MRI runs from 7am to 7pm.

This compares well with other hospitals, both public and private, but another advantage is that the Department has flexible staff: if there is an urgent MRI – such as a cardiac MRI – that someone wants at 6am, a member of staff will be in by 6:15am to provide it.

The growth in the availability of medical technology means that infrastructure such as the CT and MRI scanner – and even, increasingly, PET/CTs – are more familiar in Ireland. The SPECT/CT, however, remains a par ticular advantage over other providers in the field. Its introduction has changed the way patients are managed, par ticularly in the fields of or thopaedics and oncology. This has, in turn, raised the profile of nuclear medicine imaging.

But there is one final, simple gauge of the quality of care provided by Blackrock Clinic's Radiology Depar tment: with same-day repor ting of results, speed of ser vice is an impor tant element of patient care, and just another example of Blackrock Clinic’s dedication to quality.

©istockphoto.com/btrenkel

Those who make Blackrock Clinic their healthcare provider of choice include oncology patients, for example, though staff are familiar with those who might suffer from more minor ailments – and say they wouldn’t dream of going to any other place. Morale is high, then, among patients and staff.

Radiology and Diagnostics has, like practically ever y other element within the Clinic, been affected by the development programme. This has increased the number of patients being admitted.

With the opening of the Emergency Depar tment, workload has increased – especially for CT. Theatre has become busier, and more patients going through that process leads to more demand for radiology: some days there are three surgeons looking for a radiographer at once. All are accommodated.

This has led to expansion: the team is welcoming a new and par ticularly knowledgeable member, who is returning after a previous stint in the Depar tment.

Possible upgrades for the more long-term future might include a hybrid theatre, or a second MRI scanner – enabling one to be dedicated to cardiac work. At a time of heavy demand, there could be work enough to do cardiac MRIs ever y day. The absence of a radiation dose to the patient is a major advantage.

“The Blackrock Clinic’s patients are particularly loyal, and many are familiar faces.

The radiology and diagnostic staff actually come to recognise and know them well, leading to firstname terms and the occasional chat.”

32 www.blackrock-clinic.com

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03/12/2010 12:43:05

dpnp_

Treat the symptoms of Diabetic Peripheral Neuropathic Pain (DPNP) Shooting Burning

Stabbing

The pain in my feet interferes with my life Decreased general activity Trouble sleeping

Effective

Tolerable

Simple

Pain symptom improvement from as early as day 3 1

Generally well tolerated 2,3

60mg once-daily dosing is simple and convenient 2

CYMBALTA* (DULOXETINE). REPUBLIC OF IRELAND ABBREVIATED PRESCRIBING INFORMATION. Presentation Hard gastro-resistant capsules, 30mg or 60mg of duloxetine. Also contains sucrose. Uses Treatment of major depressive disorder.

Treatment of generalised anxiety disorder. Treatment of diabetic peripheral neuropathic pain (DPNP) in adults. Dosage and Administration Major Depressive Disorder Starting and maintenance dose is 60mg once daily, with or without food. Dosages up to a maximum dose of 120mg per day have been evaluated from a safety perspective in clinical trials. However, there is no clinical evidence suggesting that patients not responding to the initial recommended dose may benefit from dose up-titrations.

Therapeutic response is usually seen after 2-4 weeks. After establishing response, it is recommended to continue treatment for several months, in order to avoid relapse. In patients responding to duloxetine, and with a history of repeated episodes of major depression, further long-term treatment at 60 to 120mg/day could be considered. Generalised Anxiety Disorder The recommended starting dose in patients with generalised anxiety disorder is 30mg once daily, with or without food. In patients with insufficient response the dose should be increased to 60 mg, which is the usual maintenance dose in most patients. In patients with co-morbid major depressive disorder, the starting and maintenance dose is 60mg once daily. Doses up to 120mg per day have been shown to be efficacious and have been evaluated from a safety perspective in clinical trials. In patients with insufficient response to 60mg, escalation up to 90mg or 120mg may therefore be considered. After consolidation of the response, it is recommended to continue treatment for several months, in order to avoid relapse. Abrupt discontinuation should be avoided.

When stopping treatment with Cymbalta the dose should be gradually reduced over at least one to two weeks to reduce the risk of withdrawal reactions. If intolerable symptoms occur following a decrease in the dose or upon discontinuation of treatment, then resuming the previously prescribed dose may be considered. Subsequently, continue decreasing the dose, but at a more gradual rate. Diabetic Peripheral Neuropathic Pain Starting and maintenance dose is 60mg daily, with or without food. Doses above 60mg/day, up to a maximum dose of 120mg/day in evenly divided doses, have been evaluated from a safety perspective. Some patients that respond insufficiently to 60mg may benefit from a higher dose. The medicinal response should be evaluated after 2 months treatment. Additional response after this time is unlikely. The therapeutic benefit should regularly be reassessed.

Contra-indications Hypersensitivity to any of the components. Combination with MAOIs. Liver disease resulting in hepatic impairment. Use with potent inhibitors of CYP1A2, eg, fluvoxamine, ciprofloxacin, enoxacine. Severe renal impairment (creatinine clearance <30ml/min). Should be used in pregnancy only if the potential benefit justifies the potential risk to the foetus. Breastfeeding is not recommended. Initiation in patients with uncontrolled hypertension that could expose patients to a potential risk of hypertensive crisis. Precautions Do not use in children and adolescents under the age of 18. No dosage adjustment is recommended for elderly patients solely on the basis of age. However, as with any medicine, caution should be exercised. Data on the use of Cymbalta in elderly patients with generalised anxiety disorder are limited. Use with caution in patients with a history of mania, bipolar disorder, or seizures. Caution in patients with increased intra-ocular pressure or those at risk of acute narrowangle glaucoma. Duloxetine has been associated with an increase in blood pressure and clinically significant hypertension in some patients. In patients with known hypertension and/or other cardiac disease, blood pressure monitoring is recommended as appropriate, especially during the first month of treatment. Use with caution in patients whose conditions could be compromised by an increased heart rate or by an increase in blood pressure. For patients who experience a sustained increase in blood pressure while receiving duloxetine, consider either dose reduction or gradual discontinuation. Caution in patients taking anticoagulants or products known to affect platelet function, and those with bleeding tendencies. Hyponatraemia has been reported rarely, predominantly in the elderly. Caution is required in patients at increased risk for hyponatraemia, such as elderly, cirrhotic, or dehydrated patients, or patients treated with diuretics. Hyponatraemia may be due to a syndrome of inappropriate anti-diuretic hormone secretion (SIADH). Adverse reactions may be more common during concomitant use of Cymbalta and herbal preparations containing St John’s Wort. Monitor for suicidal thoughts, especially during first weeks of therapy, dose changes, and in patients under 25 years old. Since treatment may be associated with sedation and dizziness, patients should be cautioned about their ability to drive a car or operate hazardous machinery. Cases of akathisia/psychomotor restlessness have been reported for duloxetine. Duloxetine is used under different trademarks in several indications (major depressive disorder, generalised anxiety disorder, stress urinary incontinence, and diabetic neuropathic pain). The use of more than one of these products concomitantly should be avoided. Cases of liver injury, including severe elevations of liver enzymes (>10-times upper limit of normal), hepatitis, and jaundice have been reported with duloxetine. Most of them occurred during the first months of treatment. Duloxetine should be used with caution in patients with substantial alcohol use or with other drugs associated with hepatic injury. Capsules contain sucrose. Patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption, or sucrose-isomaltase insufficiency should not take this medicine. Interactions Caution is advised when taken

blackrock_clinic_magazine.indd 33 dpnp_A4_ad_clo.indd 1

in combination with other centrally acting medicinal products and substances, including alcohol and sedative medicinal products; exercise caution when using in combination with antidepressants. In rare cases, serotonin syndrome has been reported in patients using SSRIs concomitantly with serotonergic products. Caution is advisable if duloxetine is used concomitantly with serotonergic antidepressants like SSRIs, tricyclics, St John’s Wort, venlafaxine, or triptans, tramadol, pethidine, and tryptophan.

Undesirable effects may be more common during use with herbal preparations containing St John’s Wort. Effects on other drugs: Caution is advised if co-administered with products that are predominantly metabolised by CYP2D6 (risperidone, tricyclic antidepressants [TCAs], such as nortriptyline, amitriptyline, and imipramine) particularly if they have a narrow therapeutic index (such as flecainide, propafenone, and metoprolol). Anticoagulants and antiplatelet agents: Caution should be exercised when duloxetine is combined with oral anticoagulants or antiplatelet agents due to a potential increased risk of bleeding. Increases in INR values have been reported when duloxetine was co-administered with warfarin. Undesirable Effects The majority of common adverse reactions were mild to moderate, usually starting early in therapy, and most tended to subside as therapy continued. Those observed from spontaneous reporting and in placebo-controlled clinical trials in depression, generalised anxiety disorder, and diabetic neuropathic pain at a rate of ≥1/100, or where the event is clinically relevant, are: Very common (≥1/10): Headache, somnolence, dizziness, nausea, dry mouth. Common (≥1/100 and <1/10): Weight decrease, palpitations, tremor, paraesthesia, blurred vision, tinnitus, yawning, constipation, diarrhoea, vomiting, dyspepsia, flatulence, sweating increased, rash, musculoskeletal pain, muscle tightness, muscle spasm, decreased appetite, flushing, fatigue, abdominal pain, erectile dysfunction, insomnia, agitation, libido decreased, anxiety, orgasm abnormal, abnormal dreams. Clinical trial and spontaneous reports of anaphylactic reaction, hyperglycaemia (reported especially in diabetic patients), mania, hyponatraemia, SIADH, hallucinations, dyskinesia, serotonin syndrome, extra-pyramidal symptoms, convulsions, akathisia, psychomotor restlessness, glaucoma, mydriasis, syncope, tachycardia, supra-ventricular arrhythmia (mainly atrial fibrillation), hypertension, hypertensive crisis, epistaxis, gastritis, haematochezia, dysuria, gastro-intestinal haemorrhage, hepatic failure, hepatitis, acute liver injury, angioneurotic oedema, Stevens-Johnson syndrome, trismus, and gynaecological haemorrhage have been made.

Cases of suicidal ideation and suicidal behaviours have been reported during duloxetine therapy or early after treatment discontinuation. Cases of aggression and anger have been reported, particularly early in treatment or after treatment discontinuation. Cases of convulsion and tinnitus have been reported after treatment discontinuation. Discontinuation of duloxetine (particularly abrupt) commonly leads to withdrawal symptoms. Dizziness, sensory disturbances (including paraesthesia), sleep disturbances (including insomnia and intense dreams), fatigue, agitation or anxiety, nausea and/or vomiting, tremor, headache, irritability, diarrhoea, hyperhydrosis, and vertigo are the most commonly reported reactions. The heart ratecorrected QT interval in duloxetine-treated patients did not differ from that seen in placebo-treated patients. No clinically significant differences were observed for QT, PR, QRS, or QTcB measurements between duloxetine-treated and placebo-treated patients. In clinical trials in patients with DPNP, small but statistically significant increases in fasting blood glucose were observed in duloxetine-treated patients compared to placebo at 12 weeks. At 52 weeks there was a small increase in fasting blood glucose and in total cholesterol in duloxetine-treated patients compared with a slight decrease in the routine care group. There was also an increase in HbA1c in both groups, but the mean increase was 0.3% greater in the duloxetine-treated group. For full details of these and other side-effects, please see the Summary of Product Characteristics, which is available at http://www.medicines.ie/ Overdose Cases of overdoses, alone or in combination with other drugs, with duloxetine doses of 5400mg have been reported.

Some fatalities have occurred, primarily with mixed overdoses, but also with duloxetine alone at a dose of approximately 1000mg. Signs and symptoms of overdose (duloxetine alone or in combination with other medicinal products) included somnolence, coma, serotonin syndrome, seizures, vomiting, and tachycardia. Legal Category POM. Marketing Authorisation Numbers and Holder EU/1/04/296/001, EU/1/04/296/002. Eli Lilly Nederland BV, Grootslag 1-5, NL-3991 RA Houten, The Netherlands. Date of Preparation or Last Review December 2009. Full Prescribing Information is Available From Eli Lilly and Company Limited, Lilly House, Priestley Road, Basingstoke, Hampshire, RG24 9NL, Telephone: Basingstoke (01256) 315 000 or Eli Lilly and Company (Ireland) Limited, Hyde House, 65 Adelaide Road, Dublin 2, Republic of Ireland, Telephone: Dublin (01) 661 4377. *CYMBALTA (duloxetine) is a trademark of Eli Lilly and Company.

Date of Preparation April 2010.

References: 1. Pritchett YL et al. Pain Med 2007;8(5):397–409. 2. Cymbalta Summary of Product Characteristics. 3. Goldstein DJ et al. Pain 2005;116:109–118.

IECYB00045

02/12/2010 11:47:45 11/05/2010 15:13:02

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Blackrock Clinic | pathology

Department of

pathology T

One important element to Pathology’s work at Blackrock Clinic is that we are a fully-accredited laboratory across all Departments. The blood bank includes the haemovigilance side of blood transfusion; in other words checking that the patients are being given the right blood at the right time and that there are no adverse reactions. This is accredited by the Irish National Accreditation Board (INAB), and complies with the EU Blood Directive. The rest of the laboratory is accredited by Clinical Pathology Accreditation (CPA), a UK organisation. We are moving towards INAB accreditation for all departments, as is the trend across Ireland, meaning that Blackrock Clinic is in line.

The Department’s routine service is from 8am until 5:30pm, with an oncall service available after hours. In comparison with public hospitals, this is a long working day. There is also a routine service on Saturday mornings, unusual for hospitals at present.

New technology a way of life New technology is a way of life at the Blackrock Clinic, and sure enough, Pathology is updating its entire range of analysers. This can take place once the hospital’s process of updating its laboratory IT system is complete, and new analysers will be an important

©istockphoto.com/choja

he Pathology Department is another of Blackrock Clinic’s proudest facilities. Headed up by Christine Cranmer, it offers a comprehensive range of general ser vices, all under one roof.

Our duties even extend beyond the front gate of Blackrock Clinic: the Department per forms all of the histopathology and microbiology for the Hermitage Medical Clinic in Lucan, as well as for St John of God Hospital in Stillorgan.

First up is a blood transfusion department, where we cross-match blood for those who require transfusions.

There is a haematology department, which provides standard haematology, coagulation studies and blood counts.

Biochemistr y per forms full biochemistr y profiles – cardiac profiles, glucoses and standard biochemistr y tests take place, for example.

Next up is a Microbiology Department, where staff per form culturing for bacteria, including the type of organisms that cause hospital-acquired infections such as MRSA and Clostridium difficile.

The Immunology Department is mainly allergy-focused, though some rheumatology-type tests take place.

Finally, there’s histopathology, where we deal with any biopsies or tissues to be processed, and examine them for disease.

“One important element to Pathology’s work at Blackrock clinic is that we are a fully-accredited laboratory across all departments.”

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Blackrock Clinic | pathology

©istockphoto.com/choja

boost to laboratory efficiency. The new equipment is generally focused around biochemistry and haemotology, although the Department does have an analyser for antibiotic sensitivity testing in microbiology. Though not quite unique, it is an important advantage and allows the Clinic to undertake a lot more sensitivity testing, as well as look for resistant organisms very quickly and efficiently.

Much of our work depends on what goes on in the hospital itself, as we respond to the variety of patients and cases presenting. Another variable is the recent expansion of the hospital: we have already seen a new emphasis on medical cases, rather than the surgical focus that was prevalent before expansion. Though the Clinic and Pathology Department still treat surgical cases in the same way, the great increase in medical patients means a lot more microbiology: new hospital

wards and the recently-opened Emergency Department are responsible for the shift in balance.

Low infection rates key Our staff have long been familiar with identifying surgical infections, but a current trend is that other types of infections are becoming more prevalent.

As medical patients tend to stay in hospital longer, much more screening for hospital-acquired infections must take place. One of the Blackrock Clinic’s biggest selling points is that it has a very good record for low numbers of hospital acquired infections. This is partly because of the advantage afforded by private rooms, but also because all patients are screened on a regular basis: constant vigilance is maintained.

The microbiologists who work with us at the Blackrock Clinic are closely involved in

infection control – they review all patients’ results to look for any particularly resistant organisms or hospital-acquired type organisms. They also work with the infection control nurse, another factor contributing to those very low occurrences of hospital-acquired infections.

Additionally, the turnaround time is very quick, so staff get to know about these organisms very quickly. Finally, excellent communication between pathology, the nurses on the wards, and specialist nurses, such as infection control, keeps our defences co-ordinated and strong.

Another advantage is that the Department’s facilities have improved over the last two years: having moved to a new location, Pathology can now expand, upgrade its technology and improve the ser vice. This also allows for an expansion of staff in targeted areas.

As a final improvement, working hours have been changed in the past two years, remaining under review in the possibility that we may need to extend the ser vice even further.

All told, the Pathology Department at the Blackrock Clinic provides quick, comprehensive testing for patients, and makes the hospital a safer and more reliable environment by combating disease.

36 www.blackrock-clinic.com

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06400

Blackrock Clinic | Quality

©istockphoto.com/Yuri_Arcurs

Quality B

lackrock Clinic has a reputation as one of the leading and foremost private hospitals in the countr y.

This reputation is built around quality and risk management standards that have been developed and implemented. The continued commitment demonstrated by the staff ensures that the highest quality of care is provided to patients. Edel Costigan, Quality Manager since 2002, explains how the organisation maintains such exacting standards. “We have a ver y mature reporting culture in place which encourages staff to report even minor incidents and near misses. This allow us, as an organisation, to address, learn and bring about change,” she says. “These changes are aimed at reducing the likelihood of similar incidents occurring in the future."

“There is a detailed analysis and categorisation of all incidents and feedback is given to the staff,

departments and committees. This promotes awareness and communication amongst staff.”

Blackrock Clinic has attained and maintained Joint Commission International (JCI) accreditation since 2002. The standards of JCI were developed by international health care experts. As Edel explains, "JCI accreditation is one measure of the hospital's continued dedication to maintaining and developing high quality standards of care for our patients and staff."

“The Joint Commission International accreditation is a triannual audit based on 1337 measurable elements of care standards that the organisation is measured against," says Edel. "Here at Blackrock Clinic, we are continuously monitoring and improving our standards – quality and risk management is an ongoing quality improvement programme.

Delivering the highest standard of care is the centre of our ethos.

The aim of Blackrock Clinic's quality and risk management system is to be proactive in the measurement of all aspects of care. One approach to achieve this is the development and measurement of key per formance indicators (KPIs) that can be benchmarked internationally. The Hospital Board assist in the development of quality and risk management systems and play an integral role in monitoring the effectiveness of the quality provided to patients.

Other measurements of the quality and risk management system include patient and staff satisfaction sur veys and the placement of comment cards in all clinical areas.

A new initiative for 2011 sets out a policy of engaging directly with patients through means of a patient forum.

38 www.blackrock-clinic.com

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06400 Lexapro Consultants Review_06400 Lexapro Consultants Review 28/10/2010 13:05 Page 1

So many symptoms...

core

Treat the of depression with Lexapro®

The No.1 prescribed anti-depressant in Ireland

1

Abbreviated Prescribing Information: Please refer to the Summary of Product Characteristics before prescribing. Presentation: Lexapro™ tablets 5 mg, 10 mg, 15 mg and 20 mg containing escitalopram as the oxalate. Indications: Treatment of major depressive episodes. Panic disorder with or without agoraphobia. Social Anxiety Disorder. Generalised Anxiety Disorder. Obsessive Compulsive Disorder. Dosage: Treating depression: Adults: Usual dosage is 10 mg once daily. The dose may be increased to a maximum of 20 mg/day. Panic Disorder with or without agoraphobia: An initial dose of 5 mg is recommended for the first week before increasing the dose to 10 mg/day. The dose may be further increased, up to a maximum of 20 mg/day. Social Anxiety Disorder: Usual dosage is 10 mg once daily. The dose may subsequently be decreased to 5 mg or increased to a maximum of 20 mg/day. Generalised Anxiety Disorder: Initial dosage is 10 mg once daily. The dose may subsequently be increased to a maximum of 20 mg/day. Obsessive Compulsive Disorder: Initial dosage is 10 mg once daily. The dose may be increased to a maximum of 20 mg daily. In known poor metabolisers of CYP2C19, 5 mg/day Lexapro is recommended for first 2 weeks, the dose can be increased to 10 mg after assessment. Elderly (>65 yrs): Initial treatment with half the usually recommended dose and a lower maximum dose should be considered. The efficacy of Lexapro in social anxiety disorder has not been studied in elderly patients. Children and adolescents (<18 years): Not recommended. Reduced hepatic/renal function: In mild/moderately impaired hepatic function an initial dose of 5 mg/day for the first two weeks of treatment is recommended, the dose may be increased to 10 mg/day. Caution and careful dose titration advised in patients with severely reduced hepatic function. Dosage adjustment is not necessary in patients with mild or moderate renal impairment. Caution is advised in patients with severely reduced renal function (CLcr<30 ml/min). Contraindications: Hypersensitivity to escitalopram or to any of the excipients. Concomitant treatment with a nonselective, irreversible monoamine oxidase inhibitor (MAOI). Concomitant treatment with a reversible MAO-A inhibitor e.g. moclobemide or reversible non-selective MAOinhibitors e.g. linezolid. Lexapro may be started 14 days after discontinuing treatment with an irreversible MAOI. At least 7 days should elapse after discontinuing Lexapro treatment, before starting a non-selective irreversible MAOI. Pregnancy and Lactation: Lexapro should not be used during pregnancy unless clearly necessary. Neonates should be observed if maternal use of Lexapro continues into the later stages of pregnancy, particularly the third trimester. Abrupt discontinuation should be avoided during pregnancy. Use of SSRIs during pregnancy may increase the risk of persistent pulmonary hypertension (PPHN) in the newborn. Refer to the full prescribing information for a list of serotonergic or discontinuation symptoms, which may occur in the neonate after maternal SSRI/SNRI use in later stages of pregnancy. Breast-feeding is not recommended during treatment. Precautions: Patients should be cautioned about the risk to their ability to drive a car and operate machinery. No pharmacokinetic or pharmacodynamic interactions are expected with concomitant alcohol intake, however the combination is not advised. Combination with serotonergic compounds is not recommended.

Insulin and/or oral hypoglycaemic dosage may need to be readjusted in diabetics. Hyponatraemia has been observed rarely with SSRI use, caution required in patients at risk of hyponatraemia. Caution is advised with coadministration of ECT and in patients with a history of mania/hypomania. Caution advised with concomitant use of oral anticoagulants, products affecting platelet function and in patients with known bleeding tendencies. Avoid in patients with unstable epilepsy and monitor patients with controlled epilepsy. Stop treatment immediately if patient develops serotonin syndrome. Use at a low starting dose for panic disorders. Avoid abrupt discontinuation. Gradual discontinuation by dose tapering is advised. As with all SSRIs it is advisable to closely monitor patients for suicide and self-harm risk in the first few weeks of treatment and until significant remission occurs. Caution is advised in patients with coronary heart disease.

The use of SSRIs/SNRIs has been associated with the development of akathisia, increasing the dose in these patients may be detrimental. Drug Interactions: MAO inhibitors (see Contraindications/ Precautions), advise caution in use with irreversible selective MAO-B inhibitors (selegiline). Caution in use with lithium, tryptophan, serotonergic medicinal products or with products capable of lowering the seizure threshold. Avoid concomitant use with St. John’s Wort. Caution is advised with co-administration of drugs metabolised by enzymes CYP2C19, CYP3A4 and CYP2D6. Co-administration with CYP2C19 inhibitors, and general enzyme inhibitors e.g. cimetidine may require reduction of the Lexapro dose. Lexapro is an inhibitor of CYP2D6, caution is advised with concomitant use of drugs (particularly those with a narrow therapeutic index) mainly metabolized by CYP2D6. Adverse Events: Adverse reactions are most frequent during the first or second week of treatment and usually decrease in intensity and frequency with continued treatment. Frequencies are not placebo-corrected. Very Common (≥1/10): Nausea. Common (≥1/100 to <1/10): Weight increased, insomnia, somnolence, dizziness, paraesthesia, tremor, sinusitis, yawning, diarrhoea, constipation, vomiting, dry mouth, sweating increased, arthralgia, myalgia, decreased and increased appetite, fatigue, pyrexia, ejaculation disorder, impotence, anxiety, restlessness, abnormal dreams, male libido decreased, female anorgasmia. Uncommon (≥1/1,000 to <1/100): weight decreased, tachycardia, taste disturbance, sleep disorder, syncope, mydriasis, visual disturbance, tinnitus, epistaxis, gastrointestinal haemorrhages (incl. rectal), urticaria, alopecia, rash, pruritus, oedema, metrorrhagia, menorrhagia, bruxism, agitation, nervousness, panic attack, confusional state. Rare (≥1/10,000 to <1/1,000): Bradycardia, serotonin syndrome, anaphylactic reaction, aggression, depersonalisation, hallucination. Not known (cannot be estimated from the available data): Liver function test abnormal, thrombocytopenia, dyskinesia, movement disorder, convulsion, urinary retention, ecchymosis, angioedemas, inappropriate ADH secretion, hyponatraemia, orthostatic hypotension, hepatitis, galactorrhoea, male priapism, mania, suicidal ideation, suicidal behaviour.

Others: psychomotor restlessness/akathisia, anorexia, QT-prolongation, discontinuation symptoms, increased risk of bone fractures (patients ≥50 years). Overdosage: Clinical data on escitalopram overdose is limited and many cases involve concomitant overdoses with other drugs. Doses between 400-800 mg of Lexapro alone have been taken without any severe symptoms. Symptoms seen in reported overdose of Lexapro mainly relate to the central nervous system, the gastrointestinal system, the cardiovascular system and electrolyte/fluid balance conditions. There is no specific antidote. Treatment is symptomatic and supportive with monitoring of cardiac and vital signs. Gastric lavage and the use of activated charcoal should be considered. Legal Category: POM. Product Licence Holder: H. Lundbeck A/S, Ottiliavej 9, DK-2500, Copenhagen – Valby, Denmark. PA Numbers: 5 mg PA805/2/1; 10 mg PA805/2/2; 15 mg PA805/2/3; 20 mg PA805/2/4. Further information is available upon request from Lundbeck (Ireland) Ltd., 7 Riverwalk, Citywest Business Campus, Citywest, Dublin 24. ‘Lexapro’ is a registered trademark ® 2002 Lundbeck Ltd. Date of preparation: September 2010 Reference: 1. Combined IMS Hospital & Retail Data (Unit Sales) YTD July 2010 LX1/9/10

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Blackrock Clinic | clinical governance

©istockphoto.com/sjlocke

CLINICAL Governance

D

edicated to delivering the very best in health care practice to its patients, Blackrock Clinic is accredited by the Joint Commission International (JCI). JCI has worked with health care organisations on a global level since 1994; their standards and evaluation methods provide quantifiable benchmarks for patient care quality as well as driving positive changes within a health care system.

In October 2008, the Clinic’s accreditation with JCI was extended for a further three years, which emphasises the intense commitment within the hospital to clinical excellence and quality in every part of its operations.

In the same year, the Board placed a sharper focus on the quality of their care initiatives when they commissioned a clinical governance audit of the Clinic. In line with this, Professor Greg Shanik was appointed to the post of Clinical Governance Director at Blackrock Clinic.

“Clinical Governance is a systematic method of maintaining and improving

quality of care within the organisation,” says Professor Shanik. Within any given health care system, there are four key areas for clinical governance, he explains.

“The first is the safety of both patients and staff. The second is the quality of care within the system.” He highlights the culture within the Clinic as the third area, i.e. a shifting paradigm from a culture that is closed to one that is open. “The patient then becomes the focus of attention in the true sense of the word.If there is an adverse incident then it is reported; a person seeing a mistake made can put their hand up.” This, he says, promotes a “just culture”. The fourth area relates to education and continued professional development. “There is also an element of education for the patients themselves. They can ask, 'Explain that to me'”.

Since taking up the role in 2008, Professor Shanik has established a Clinical Governance Committee within the hospital, the key functions being to highlight and advise on the quality of care throughout the

hospital system to the relevant parties. He is accountable to the Board and reports to the Medical Board and the Clinical Governance Committee, which monitors the Clinic's medical standards. “Clinical governance enables improvement of care by promoting and encouraging a tansparent, just and caring health system using a multidisciplinary approach to foster patient well-being.” Patients coming to the Clinic feel secure in the knowledge that they are being offered the best service possible in order to support them in their health care needs.

“Clinical Governance is a systematic method of maintaining and improving quality of care within the organisation.”

40 www.blackrock-clinic.com

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bReAking the mould A novel RA therapy to target the IL-6 receptor1 • RoACTEMRA delivers consistently high remission rates across a wide range of patient populations2-6 • RoACTEMRA has proven superiority as monotherapy over MTX*2 • RoACTEMRA delivers a combination of a rapid onset of action and an efficacy that keeps improving over time2-6 • The safety profile of RoACTEMRA has been well characterised in a comprehensive phase III clinical trial programme7

ABRIDGED PRESCRIBING INFORMATION (For full prescribing information, refer to the Summary of Product Characteristics [SmPC]) RoActemra® (Tocilizumab) 20mg/ml Concentrate for Solution for Infusion Indications: RoActemra, in combination with methotrexate (MTX), for the treatment of adult patients with moderate to severe active rheumatoid arthritis who have had an inadequate response or intolerance to one or more DMARDs or TNF antagonists. In these patients, RoActemra can be given as monotherapy in case of intolerance to MTX or where continued treatment with MTX is inappropriate. RoActemra has been shown to reduce the rate of progression of joint damage as measured by X-ray and to improve physical function when given in combination with methotrexate. Dosage and Administration: Recommended posology is 8mg/kg diluted to a final volume of 100ml, given once every 4 weeks by iv infusion over one hour. For patients weighing more than 100kg, doses exceeding 800mg per infusion are not recommended. No data on doses above 1.2g. Treatment should be initiated by healthcare professionals experienced in the diagnosis and treatment of rheumatoid arthritis and patients should be given the Patient Alert Card. Dose adjustments: Dose modifications or interruptions, are recommended in the event of raised liver enzymes, low absolute neutrophil count or low platelet count (see SmPC for details). Not recommended in children under 18 years of age due to a lack of data. Closely monitor renal function in patients with moderate to severe renal impairment as RoActemra has not been studied in these patients. No data in patients with hepatic impairment. Contraindications: Hypersensitivity to any component of the product; active, severe infections. Warnings and Precautions: Do not initiate in patients with active infection. If serious infection develops interrupt therapy until infection is controlled. Exercise caution in patients with a history of recurring/chronic infections, or other underlying conditions which may predispose patients to infection. Vigilance for the timely detection of serious infection recommended. Advise patients to contact their healthcare professional when symptoms suggestive of an infection appear. Screen for latent TB prior to starting therapy. Treat latent TB with standard anti-mycobacterial therapy before initiating RoActemra. Viral reactivation (eg hepatitis B) has been reported with biologic therapies for RA. Patients screening positive for hepatitis were excluded from clinical trials. Events of diverticular perforations as complications of diverticulitis reported uncommonly with RoActemra.

Use with caution in patients with a history of intestinal ulceration or diverticulitis. Patients with symptoms of complicated diverticulitis should be evaluated promptly. Serious hypersensitivity reactions reported- appropriate treatment should be available for immediate use in the event of an anaphylactic reaction during administration of RoActemra. Use with caution in patients with active hepatic disease or hepatic impairment. Not recommended in patients with baseline ALT or AST >5xULN; use with caution in patients with ALT or AST >1.5xULN. Monitor ALT and AST levels according to SmPC. If raised follow recommendations for dose modification. Not recommended in patients with ANC <0.5x109/l or platelet count <50x103/μl.

Use with caution in patients with low neutrophil or platelet count; monitor neutrophils and platelets according to SmPC. If reduced, follow recommendations for dose modification. Elevations in lipid parameters observed-refer to the SmPC. Lipid parameters should be assessed according to SmPC, if elevated, patients should be managed according to local guidelines for hyperlipidaemia. The potential for central demyelination with RoActemra is currently unknown; physicians should be vigilant for symptoms of new onset disease. Immunomodulatory medicines may increase the risk of malignancy. Live and live attenuated vaccines should not be given concurrently with RoActemra as safety has not been established. Rheumatoid arthritis patients should have CV risk factors managed as part of usual standard of care. Not recommended for use with other biological agents. Product contains 26.55mg sodium per 1200mg. Drug Interactions: In RA patients, levels of simvastatin (CYP3A4) were decreased by 57% one week following a single dose of tocilizumab to levels similar to or slightly higher than those observed in healthy subjects. Patients taking medicines which are individually adjusted and metabolised via CYP450 3A4, 1A2 or 2C9 should be monitored when starting or stopping RoActemra, as doses may need to be adjusted to maintain therapeutic effect. The effect of tocilizumab on CYP450 enzyme activity may persist for several weeks after stopping therapy.

Refer to the SmPC for further details on the effects of RoActemra on cytochrome CYP450. Pregnancy and Lactation: No adequate data from use in pregnant women. Animal study showed an increased risk of spontaneous abortion/embryo-foetal death at high dose. RoActemra should not be used during pregnancy unless clearly necessary. Women of childbearing potential should use effective contraception during and up to 3 months after treatment. No lactation data in humans. A decision on whether to continue/discontinue breastfeeding or RoActemra therapy should be made taking into account the relative benefits to the child and mother. Side Effects and Adverse Reactions: ADRs occurring in patients with rheumatoid arthritis receiving tocilizumab as monotherapy or in combination with MTX or other DMARDs: Very Common (≥ 1/10): upper respiratory tract infections; Common (≥ 1/100 - <1/10) - cellulitis, pneumonia, oral herpes simplex, herpes zoster, abdominal pain, mouth ulceration, gastritis, rash, pruritus, urticaria, headache, dizziness, hepatic transaminases increased, weight increased, hypertension, leucopenia, neutropenia, hypercholesterolaemia, peripheral oedema, hypersensitivity reactions, conjunctivitis, cough and dyspnoea. Refer to SmPC for a complete listing of adverse events. Legal Category: Limited to sale and supply on prescription only. Presentations and Marketing Authorisation Numbers: 80mg of tocilizumab in 4ml (20mg/ml) pack of 1 (EU/1/08/492/001); 200mg of tocilizumab in 10ml (20mg/ml) pack of 1 (EU/1/08/492/003); 400mg of tocilizumab in 20ml (20mg/ml) pack of 1 (EU/1/08/492/005). Marketing Authorisation Holder: Roche Registration Limited, 6 Falcon Way, Shire Park, Welwyn Garden City, AL7 1TW, United Kingdom. RoActemra is a registered trade mark. Further information is available from Roche Products (Ireland) Limited, 3004 Lake Drive, Citywest, Naas Road, Dublin 24. Telephone: (01) 4690700. Fax: (01) 4690791. Date of Preparation: July 2010. References: 1. Sebba et al, Am J Health Syst Pharm. 2008 Aug 1;65(15): 1413-8. 2. Jones G, et al. Ann Rheum Dis 2008.doi:10.1136/ard.2008.105197. 3. Smolen JS, et al. Lancet. 2008;371:987-97. 4. Genovese M, et al. Arthritis & Rheumatism. 2008:58:10:2968-2980. 5. Emery P, et al. Ann Rheum Dis 2008.doi:10.1136/ard.2008.092932. 6. Kremer et al. Arthritis and rheumatism [0004-3591] yr:2008 vol:58 iss:12 pg:4031. 7. RoACTEMRA Summary Of Product Characteristics 4th June 2010. *Methotrexate. Date of preparation of this item: July 2010. P28/07/10. Copyright © 2010 by Roche Products (Ireland) Ltd. All rights reserved.

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Blackrock Clinic | technology & expertise

©istockphoto.com/clu

technology & expertise

B

“Blackrock Clinic has long been known as one of the most advanced centres for medical technology in the country, with a high level of investment in the latest developments.”

lackrock Clinic has long been known as one of the most advanced centres for medical technology in the country, with a high level of investment in the latest developments.

The Engineering Department, run by Head of Engineering Michael McGowan, leads the Clinic’s drive to deliver the most modern infrastructure available. Their remit includes Blackrock’s advanced imaging hardware, located in units such as Radiology and Pathology, and helping to provide patients with the highest level of care possible. The catalogue of CT, MRI, PET/CT and SPECT/CT equipment, to name just the most high-profile pieces, is long and not for the technologically shy.

Engineering is responsible for the management of the facilities – mechanical, electrical and medical. They deal with all medical equipment onsite, from diagnostic equipment down through patient monitoring, telemetry systems, and analytical systems like the catheterisation laboratories.

The majority of the technology is maintained directly by the Department, and that is its great advantage: its clinical engineers are trained to respond, first line, to any piece of equipment. This means that downtime is minimised: when they materialise, many of the problems associated with medical equipment are

relatively minor. Able to fix them rapidly, without having to rely on outside agencies, the Blackrock Clinic can also ensure that the right quality of procedures are in place, and the result is greater uptime.

IT infrastructure All of this medical technology rests on the support of the IT Department and its infrastructure, led by John Hayes. Hayes and his team run the helpdesk five days a week, from 7am to 6pm, and operate on call seven days a week, 365 days a year. They deal with all the mainstream IT systems in the hospital, ranging from the main patient administration through the finance, HR, personnel and tax systems.

Server administration is an important part of support, and making sure they’re backed up on time is crucial. There are two computer rooms onsite. Several years ago, the Department went down the virtualisation route and built a second computer room as a recovery. Each works as a backup to the other, with virtual servers across the two rooms. If one server or room fails, the team can switch over to the other side.

Electronic patient records One of the Clinic’s strategic acts is to work towards electronic patient records.

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Blackrock Clinic | technology & expertise

The system is ver y easy to use, and will become the norm in years to come.

There may still be some way to go, but staff find that almost ever ything they do has electronic patient records in mind. Having opened a new Emergency Depar tment, it is a good time to begin to keep all of those records electronic.

They’re still paper-based, in that they must be transferred to digital when the patient is discharged, but it will become even more digital in years to come.

The paperless Clinic As in other workplaces, the paperless office is not an overnight process, and may never quite be complete: given that the consultants are self-employed, it is left to them to decide whether to adopt the technology on offer and find ways of working that suit themselves.

Increasingly, however, consultants are looking for material electronically rather than on paper – especially younger ones.

In future years, more barcoding and increased coverage by wireless networks will take hold: much of the team’s work is geared towards ensuring that when that time does come, they will be prepared. The process of integrating IT systems in better and more efficient ways continues.

©istockphoto.com/aldra

Another is telemedicine, a successful attempt to make our ser vices easier to use by patients or staff getting their information when and where they need it. Making images available throughout the hospital is hugely important. The Clinic also has online internet access for all patient test results for GPs and consultants, and was the first hospital in the countr y to provide online access to all of the images. If a patient comes to Blackrock Clinic for a scan, x-ray or PET/ CT, the GP or consultant can not only see the report, but also the images online.

In general, two applications are used – firstly, all test results (radiology, cardiology, nuclear medicine and laborator y) are delivered through our web site, MediLINK.ie. This then connects into a DICOM Image Viewer Centricity Web, which is used to display and review images both internally within the hospital and externally via MediLINK. ie. MediLINK.ie is a Blackrock Clinic application, and Centricity Web is supplied by GE, inter facing into our RIS/ CIS/PACS backend.

The whole system has been ver y well received, and used by consultants and GPs all over the countr y. For example, when staff show others how the system works, a reaction of ‘why can’t I have that for my patients as well?’ is familiar.

Blackrock Clinic is tr ying to make itself the hospital of choice for patients, consultants and GPs. This involves making it easy to do business with us, simplifying the deliver y of what patients and staff need and want – and to the highest standard. Whether patients or GPs are booking an appointment, getting access to results or dealing with the most advanced medical testing, it all comes back to quality of care, and Blackrock Clinic's levels of technology, investment and dedication are sky-high.

"it all comes back to quality of care, and Blackrock clinic's levels of technology, investment and dedication are sky-high."

44 www.blackrock-clinic.com

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your patient

our solutions

Legal Categories: POM. TREDAPTIVE: MA numbers: Tredaptive 28 tablet pack EU/1/08/459/002, Tredaptive 56 tablet pack EU/1/08/459/003. MA holder: Merck Sharp & Dohme Ltd., Hertford Road, Hoddesdon, Hertfordshire EN11 9BU, UK. INEGY: MA numbers:10/20 mg: PA 1091/4/2. 10/40 mg: PA 1091/4/3. 10/80 mg: PA 1091/4/4. EZETROL: MA numbers: PA 1091/1/1. MA holder: MSD-SP Limited, Hertford Road, Hoddesdon, Hertfordshire EN11 9BU, UK. JANUMET: MA numbers: Janumet 50mg/850mg film-coated tablets, EU/1/08/455/003. Janumet 50mg/1000mg film-coated tablets, EU/1/08/455/010. JANUVIA: MA numbers: Januvia 100 mg film-coated tablets, EU/1/07/383/013-014. MA holder: Merck Sharp & Dohme Limited, Hertford Road, Hoddesdon, Hertfordshire EN11 9BU, UK. COZAAR: MA numbers: PA1286/4/1– 12.5 mg Tablet. PA 1286/4/2 – 50 mg Tablet. PA 1286/4/3 – 100 mg Tablet. MA holder: Merck Sharp & Dohme Ireland (Human health) Limited, Pelham House, South County Business Park, Leopardstown, Dublin 18, Ireland. COZAAR COMP: MA numbers: PA 35/90/1 – 100 mg/ 25 mg Tablet, PA 35/84/1 – 50 mg/12.5 mg Tablet, PA 1286/1/1 – 100 mg/12.5 mg Tablet. MA holder: Cozaar Comp 50mg /12.5mg and 100 mg/ 25 mg: Merck Sharp & Dohme Limited, Hertford Road, Hoddesdon, Hertfordshire EN11 9BU, UK. MA holder: Cozaar Comp 100 mg/ 12.5 mg Merck Sharp & Dohme Ireland (Human Health) Limited, Pelham House, South County Business Park, Leopardstown, Dublin 18. Additional prescribing information is available on request or from www.medicines.ie

blackrock_clinic_magazine.indd 45

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

06-12-CVT-2010-IRL-3316-J

MSD—Your CardioMetabolic partner of choice

02/12/2010 11:48:46

Blackrock Clinic | New Freephone Enquiry Line

Freephone Enquiry Line N

ew buildings are not the only things being opened at Blackrock Clinic: this August saw the commencement of our new freephone enquir y line, 1800 60 10 60.

“I am delighted to say it is proving to be a popular initiative and the phones have hardly stopped ringing since,” blogged Blackrock CEO Br yan Har ty.

“We launched the enquir y line to assist patients, families, visitors and health professionals with any queries they may have in advance of visiting the hospital.”

This may take the form of practical advice, such as directions to the hospital or details of local B&Bs, hotels, cafes and restaurants – handy for patients and families travelling from outside Dublin – and experienced staff are at the end of the phone for all manner of advice.

More medical-based information can also be sought and provided: callers can discuss details of procedures and treatments available, costs, and what health insurance covers, as well as admission procedures.

Recently, the line received a lot of calls regarding Blackrock Clinic’s Our experienced staff are dedicated to assisting patients, members of the public, healthcare professionals and everyone with enquiries relating to any aspect of Blackrock Clinic and our services.

46 www.blackrock-clinic.com

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©istockphoto.com/LockieCurrie

New

Frequently asked questions include:

� What procedures and treatments are offered?

� What are the costs and how can I pay?

� What does my health insurance cover?

� How do I get to the Clinic? � What are the admission procedures? colonoscopy ser vices, in light of the publicity regarding waiting times in the public sector. GPs can refer patients directly to our day unit for a colonoscopy procedure, which can be per formed within a week or two of initial referral.

The ser vice goes hand-in-hand with the hospital’s recently-opened Emergency Depar tment and Daycare Unit, the result of a €100m expansion programme which entailed the construction of three new floors in the main hospital. The Day Surger y Unit can cater for up to 100 patients a day, and also of fers two new operating theatres and a 40% increase in availability of theatre space.

With this new capacity, a central contact point is an invaluable resource for patients and the Clinic alike. To get all the answers to all your questions, simply call our new freephone enquir y line on 1800 60 10 60, or e-mail us at enquir y@blackrock-clinic.com.

03/12/2010 12:46:12

GlaxoSmithKline (Ireland) Limited would like to wish everyone at the Blackrock Clinic the very best in the launch of its new Emergency Department

GlaxoSmithKline (Ireland) Limited a private company limited by shares, and a member of the GlaxoSmithKline group of companies.

Stonemasons Way, Rathfarnham, Dublin 16, Ireland, Tel: 01 495 5000

blackrock_clinic_magazine.indd 47

082010GSK2803

02/12/2010 11:49:10

â&#x20AC;&#x2DC;Covidien has a 30 year manufacturing history in Ireland and in 2009 we relocated our global headquarters to Dublin. Covidien is a large Irish employer with sites located in Athlone, Galway, Tullamore and Dublin.

Additionally, we have centralized our customer service call centre for Europe to the Cherrywood Science and Technology Park, Loughlinstown, Co. Dublin. Our Cherrywood facility plays host to a wide variety of departments including customers service, technical service ,finance, contract & pricing and sales. Covidien create and deliver innovative healthcare solutions developed in collaboration with medical professionals, which enhance the quality of life for patients and improve outcomes for our customers.â&#x20AC;&#x2122;

Covidien Ireland Commercial Ltd Block G, First Floor Cherrywood Business Park Loughlinstown Co Dublin Ireland www.covidien.com 48 www.blackrock-clinic.ie

blackrock_clinic_magazine.indd 48

01 438 3000

02/12/2010 11:49:18

Blackrock Clinic | A lifetime in medicine

©istockphoto.com/ideabug

a lifetime in medicine

A tribute to Maurice Neligan

T

“He loved his patients, and put them at ease because he had a common touch with patients and staff. The manner in which he communicated with people was special.”

he death of pioneering heart surgeon Maurice Neligan, a cofounder of the Blackrock Clinic, was an occasion of great sadness for all those who knew him. Maurice, at the age of 73, died on October 8th 2010, drawing heartfelt tribute from colleagues and those in public life.

From 1971 until retirement, Maurice was Consultant Cardiac Surgeon at the Mater Hospital, also serving at Crumlin Children’s Hospital from 1974 to 2002.

He was among the four co-founders of the Blackrock Clinic in 1984. Among his achievements were the country’s first coronary artery bypass graft (1975) and first heart transplant (1985).

The reaction to his passing was warm: in The Irish Times, Dr. Muiris Houston described the Irish people’s “foremost patient advocate,” a “medical maverick” whose passion and talent for medical care was accompanied by a love of learning and a sizable personality. The Sunday Independent wrote that he was “Ireland’s best known medic,” having carried out up to 15,000 open-heart operations.

At Blackrock Clinic, the tricolour flew at half-mast in tribute. Here, he will always be remembered for his stories, humour and immense talent as a surgeon. His reputation added great weight to the Clinic, particularly in the early days, and was a considerable part in its success.

He loved his patients, and put them at ease because he had a common touch with patients and staff. The manner in which he communicated with people was special. Staff who encountered him in theatre remember him as a great teacher: encouraging, and never intimidating.

Maurice saw his patients every day and if he was on call, staff felt secure because of his competence and calmness. He had a unique manner of inspiring confidence in those working with him, and fought their corner as he did for patients.

Part of his manner was also to inspire confidence in those he cared for: on the day before an operation, he might joke that he wouldn’t have too many pints that night, or that it was the first time he’d ever performed surgery – but could do it with

www.blackrock-clinic.com 49

blackrock_clinic_magazine.indd 49

02/12/2010 11:49:22

Blackrock Clinic | a lifetime in medicine

©istockphoto.com/ddoorly

his eyes closed. Immediately, his patients would laugh and give him their trust.

On one occasion, a former colleague remembers, a patient had Mass cards at the end of their bed. Maurice waved at them, scoffed, and told the patient to “put them away, you don’t need them yet!”

No matter when you met him, Maurice would have a new story or joke to relax the patient and make them feel at ease.

Maurice’s main motivation, in the mid1980s, was that the development of private medicine would get people who would otherwise die off waiting lists, into surgery, and force the public service into providing more serious cardiac care. At that time, there was no cardiac surgery on the south side of the city, leaving huge backlogs at the Mater.

Maurice’s passing also attracted eulogies from the world of politics.

Taoiseach Brian Cowen acknowledged the affect he had on so many Irish families, adding that he knew him personally while Minister for Health. “I spoke at length to Maurice only last week,” recalled Fine Gael leader Enda Kenny. “He was the first superstar of Irish medicine following his achievements as a leading cardiac surgeon. There are many who enjoy a normal lifestyle today because of his work.

Ireland will be the poorer for his passing.”

A full life Born in Booterstown in 1937, Maurice attended Blackrock College, a continuing source of pride throughout his life – later on, at the Clinic, he insisted that his suite looked out over his alma mater and its playing fields, allowing the proud Dad to slip out and watch his children play the odd match.

At UCD, he graduated in medicine in 1962, before training as a surgeon. As his career developed, he married Pat and raised a family of seven: Maurice, John, Kate, David, Lisa, Lucy and Sara, who was tragically killed in 2007.

Maurice was a colour ful and passionate commentator on Irish healthcare, with an Irish Times health column that often overlapped into the political and the literar y. His criticisms of Minister for Health Mar y Harney and Professor Brendan Drumm were widely read and repor ted. One recent inter vention was his opposition to the Children’s Hospital at the Mater, and a constant narrative was the failure to deliver a successful public health ser vice at a time of great plenty.

For this, for the level of care he gave patients, and for many other reasons besides, he was popular with the public: a radio appearance prompted one

listener to write to the Times, hoping that he would run for president.

In retirement, golf, reading, the column and the holiday home in Glenbeigh, Co. Kerr y occupied his time. His funeral, on October 12th, was widely attended and heard fond stories of medicine and rugby. Son Maurice recalled his own path into surger y, inspired by his parents – Pat is also a doctor – and said that his father had been an impor tant par t of delivering “a world-class cardiac surgical ser vice in this countr y for adults and children.”

His voice will be sorely missed along the corridors of the Blackrock Clinic.

“Maurice was a colourful and passionate commentator on Irish healthcare, with an Irish Times health column that often overlapped into the political and the literary.”

50 www.blackrock-clinic.com

blackrock_clinic_magazine.indd 50

02/12/2010 11:49:30

Zyprexa is the number 1 prescribed antipsychotic in Ireland1 There are reasons why: ✓ Rapid symptom control in acute schizophrenia2 ✓ Longer time to treatment discontinuation compared to quetiapine3 ✓ Zyprexa is associated with low rates of rehospitalisation4 ZYPREXA* TABLETS (OLANZAPINE) REPUBLIC OF IRELAND ABBREVIATED PRESCRIBING INFORMATION ZYPREXA VELOTABS ZYPREXA INTRAMUSCULAR INJECTION. Presentations Tablets 2.5mg, 5mg, 7.5mg, 10mg, 15mg, or 20mg of olanzapine. Also contain lactose. Velotab* 5mg, 10mg, 15mg, or 20mg orodispersible tablets. Also contain gelatin, aspartame, mannitol, and parahydroxybenzoates. Powder for solution for injection, containing 10mg olanzapine. Uses Tablets and Velotabs: Schizophrenia, both as initial therapy and for maintenance. Moderate to severe manic episode; prevention of recurrence in bipolar disorder in patients whose manic episode has responded to olanzapine treatment. Injection: Rapid control of agitation and disturbed behaviours in patients with schizophrenia or manic episode, when oral therapy is not appropriate. Dosage and Administration Tablets and Velotabs: Schizophrenia: 10mg/day orally. Manic episode: 15mg/day in monotherapy; 10mg/day in combination therapy. Preventing recurrence in bipolar disorder: 10mg/day, or for patients who have been receiving olanzapine for treatment of manic episode, continue therapy for preventing recurrence at the same dose. May subsequently be adjusted to 5-20mg daily.

Injection: Intramuscular use only for a maximum of three consecutive days. Initial dose 10mg. A second injection, 5-10mg, may be administered 2 hours after. Maximum daily dose is 20mg, with not more than 3 injections in any 24-hour period. Treatment with Zyprexa Intramuscular Injection should be discontinued, and oral Zyprexa initiated, as soon as clinically appropriate. Do not administer intravenously or subcutaneously. Children: Not recommended (under 18 years). Elderly patients: Oral therapy - a lower starting dose (5mg/day) is not routinely indicated but should be considered when clinical factors warrant. Injection recommended starting dose is 2.5-5mg. Renal and/or hepatic impairment: 5mg starting dose in moderate hepatic insufficiency.

When more than one factor which might cause slower metabolism, consider a decreased starting dose. Gradual dose reduction should be considered when discontinuing olanzapine. Contra-indications Known hypersensitivity to any ingredient. Known risk of narrow-angle glaucoma. Warnings and Special Precautions Olanzapine is not approved for the treatment of dementiarelated psychosis and/or behavioural disturbances because of an increase in mortality and the risk of CVAE. Olanzapine is not indicated for use in the treatment of children and adolescents. Injection: Efficacy not established in patients with agitation and disturbed behaviours related to conditions other than schizophrenia or manic episode. Should not be administered to patients with unstable medical conditions (see Summary of Product Characteristics [SPC]). Safety and efficacy have not been evaluated in patients with alcohol or drug intoxication. Patients should be closely observed for hypotension, including postural hypotension, bradyarrhythmia, and/or hypoventilation (see SPC). Simultaneous injection with parenteral benzodiazepine is not recommended. Use to treat drug-induced psychosis with Parkinson’s disease is not recommended. Caution in patients: • who receive other medicinal products having haemodynamic properties similar to those of Zyprexa Intramuscular Injection. • with prostatic hypertrophy, or paralytic ileus and related conditions. • with elevated ALT and/or AST, hepatic impairment, limited hepatic functional reserve, and in patients treated with hepatotoxic drugs. If hepatitis is diagnosed, discontinue Zyprexa. • with low leucocyte and/or neutrophil counts, bone marrow depression, in patients receiving medicines known to cause neutropenia, and in patients with hypereosinophilic conditions or with myeloproliferative disease. • who have a history of seizures or are subject to factors which may lower the seizure threshold. • using other centrally acting drugs and alcohol. As with other antipsychotics, caution should be exercised when olanzapine is prescribed with medicines known to increase QTc interval. As with other atypical antipsychotics, sudden cardiac death has been reported in patients taking olanzapine. Discontinue if signs and symptoms indicative of NMS, or unexplained high fever. If tardive dyskinesia appears, consider dose reduction or discontinuation. Appropriate clinical monitoring for hyperglycaemia is advisable in accordance with utilised antipsychotic guidelines. Patients treated with any antipsychotic agents, including Zyprexa, should be observed for signs and symptoms of hyperglycaemia (such as polydipsia, polyuria, polyphagia, and weakness) and patients with diabetes mellitus or with risk factors for diabetes mellitus should be monitored regularly for worsening of glucose control. Weight should be monitored regularly. Blood pressure should be measured periodically in patients over 65 years. Patients treated with any antipsychotic agents, including Zyprexa, should be monitored regularly for lipids in accordance with utilised antipsychotic guidelines. May antagonise effects of dopamine agonists. Phenylalanine: Velotabs contain aspartame - a source of phenylalanine. Sodium methyl parahydroxybenzoate and sodium propyl parahydroxybenzoate: Contained in Velotabs; known to cause urticaria, contact dermatitis, and, rarely, immediate reactions with bronchospasm. Interactions Metabolism may be affected by substances that can specifically induce (eg, concomitant smoking or carbamazepine) or inhibit (eg, fluvoxamine) the isoenzyme P450-CYP1A2

blackrock_clinic_magazine.indd 51

which metabolises olanzapine. Activated charcoal reduces the bioavailability of oral olanzapine. Olanzapine may antagonise the effects of direct and indirect dopamine agonists. Olanzapine showed no interaction when co-administered with lithium or biperiden. Zyprexa Intramuscular Injection 5mg, administered 1 hour before lorazepam 2mg, added to the somnolence observed with either drug alone. Pregnancy and Lactation Should be used in pregnancy only if the potential benefit justifies the potential risk to the foetus. Patients should be advised not to breast-feed an infant if they are taking Zyprexa. Driving, etc May cause somnolence or dizziness. Patients should be cautioned about operating hazardous machinery, including motor vehicles. Undesirable Effects Those observed from spontaneous reporting and in clinical trials at a rate of ≥1%, or where the event is clinically relevant, are: Clinical Trial Adverse Event Reporting and Investigations, and Post-Marketing Spontaneous Reporting with Oral Zyprexa. Very common (>10%): Weight gain1, somnolence1, elevated plasma prolactin levels. Common (110%): Eosinophilia, increased appetite1, elevated glucose levels, elevated triglyceride levels1, elevated cholesterol levels1, glycosuria, dizziness, akathisia, parkinsonism, dyskinesia, orthostatic hypotension, mild transient anticholinergic effects, including constipation and dry mouth1, transient asymptomatic elevations of ALT and AST1, asthenia, fatigue, oedema, rash.

Uncommon (0.1-1%): Bradycardia, QTc prolongation, leucopenia, neutropenia, photosensitivity reaction, alopecia, urinary incontinence, high creatinine phosphokinase, increased total bilirubin. Not known: Thrombocytopenia, allergic reaction, development or exacerbation of diabetes occasionally associated with ketoacidosis or coma, including some fatal cases, hypothermia, seizures where in most cases a history of seizures or risk factors for seizures were reported, neuroleptic malignant syndrome, dystonia, tardive dyskinesia, discontinuation symptoms, ventricular tachycardia/fibrillation, sudden death, thromboembolism, pancreatitis, hepatitis, rhabdomyolysis, urinary hesitation, priapism, increased alkaline phosphatase. In clinical trials of elderly patients with dementia, olanzapine was associated with a higher incidence of death and cerebrovascular adverse events compared to placebo. Very common (>10%) undesirable effects in this patient group were abnormal gait and falls. Pneumonia, increased body temperature, lethargy, erythema, visual hallucinations, and urinary incontinence were observed commonly (1-10%). 1Adverse events in adolescents (13-17 years) with different frequency to adults. Additional Clinical Trial Adverse Event Reporting and Investigations with Zyprexa Intramuscular Injection. Common (1-10%): Bradycardia, with or without hypotension or syncope, tachycardia. Injection site discomfort, somnolence, postural hypotension, hypotension.

Uncommon (0.1-1%): Sinus pause, hypotension. Post-Marketing Spontaneous Events with Zyprexa Intramuscular Injection.

Temporal association in cases of respiratory depression, hypotension, or bradycardia, and death reported very rarely, mostly with concomitant use of benzodiazepines and/or other antipsychotic drugs, or use of olanzapine in excess of recommended dose. 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/1/96/022/002, EU/1/96/022/004, EU/1/96/022/006, EU/1/96/022/009, EU/1/96/022/010, EU/1/96/022/012, EU/1/96/022/014, EU/1/96/022/016, EU/1/99/125/001, EU/1/99/125/002, EU/1/99/125/003, EU/1/99/125/004. Eli Lilly Nederland BV, Grootslag 1-5, 3991 RA Houten, The Netherlands. Date of Preparation or Last Review December 2009 Full Prescribing Information is Available From Eli Lilly and Company Limited, Lilly House, Priestley Road, Basingstoke, Hampshire, RG24 9NL. Telephone: Basingstoke (01256) 315 000 or Eli Lilly and Company (Ireland) Limited, Hyde House, 65 Adelaide Road, Dublin 2, Republic of Ireland. Telephone: Dublin (01) 661 4377. *ZYPREXA (olanzapine) and VELOTAB are trademarks of Eli Lilly and Company.

References: 1. IMS Data, March 2010. 2. Kinon BJ et al. Effective resolution with olanzapine of acute presentation of behavioral agitation and positive symptoms in schizophrenia. J Clin Psych 2001;62(Suppl 2):17-21. 3. Kahn et al. Effectiveness of antipsychotic drugs in first-episode schizophrenia and schizophreniform disorder: an open randomised clinical trial. Lancet 2008;371:1085-1097. 4. Tiihonen J et al. Effectiveness of antipsychotic treatments in a nationwide cohort of patients in community care after first hospitalisation due to schizophrenia and schizoaffective disorder: observational follow-up study BMJ, 2006;333(7561):224-229 IEZYP00232 Date of preparation: May 2010.

Zyprexa is manufactured in Cork.

02/12/2010 11:49:32

A Smooth Passage

New to Ireland.....Molaxole (Macrogol 3350) Clinically proven as the most reliable laxative available

34/35 Block A, Dunboyne Business Park, Dunboyne, Co Meath

W: www.meda.ie

PRESCRIBING INFORMATION PRESENTATION Powder for oral solution. A white powder. THERAPEUTIC INDICATIONS For the treatment of chronic constipation and resolving faecal impaction which is defined as refractory constipation with faecal loading of the rectum and/or colon confirmed by physical examination of the abdomen and rectum. Posology and method of administration Chronic constipation: Adults: 1-3 sachets daily in divided doses, according to individual response. A course of treatment for constipation does not normally exceed two weeks, although this can be repeated if required. For extended use, the dose can be adjusted down to 1 or 2 sachets daily. Faecal impaction: Adults: 8 sachets daily, all of which should be consumed within a 6 hour period. A course of treatment for faecal impaction does not normally exceed 3 days.

Children: Not recommended for children below 12 years old. Administration Each sachet should be dissolved in 125 ml water. For use in faecal impaction 8 sachets may be dissolved in 1 litre of water. INTERACTION WITH OTHER MEDICINAL PRODUCTS AND OTHER FORMS OF INTERACTION No clinical interactions with other medicinal products have been reported. Macrogol raises the solubility of lipid soluble drugs. There is therefore a theoretical possibility that the absorption of such drugs could be transiently reduced, if taken within 1 hour before Molaxole. PREGNANCY AND LACTATION pregnancy There is no experience of the use of Molaxole during pregnancy and lactation and it should only be used if considered essential by the physician. FFECTS ON ABILITY TO DRIVE AND USE MACHINES There is no effect on the ability to drive and use machines. SPECIAL PRECAUTIONS FOR STORAGE Store in the original package in order to protect from moisture. Prescribers should consult the summary of product characteristics for further information. Marketing Authorisation Holder; MEDA Health Sales. 34/35 Block A, Dunboyne Business Park, Dunboyne, Co Meath. Phone (01) 8026624 Fax (01) 8026629 Web: www.meda.ie.

A.Menarini Pharmaceuticals Ireland Ltd, Healthcare for Life with our continued support and best wishes for the Blackrock Clinic

Castlecourt | Monkstown Farm | Monkstown | Co. Dublin Tel: 01 284 6744

blackrock_clinic_magazine.indd 52

02/12/2010 11:49:37

Blackrock Clinic | infection prevention & control

©istockphoto.com/nyul

Infection

Prevention & Control Infection Prevention and Control

I

nfection prevention and control (IP&C) is the responsibility of all healthcare workers and is included into everyday practice. The objective is to engage staff at all levels in order to maintain a culture that supports IP&C practices across the entire hospital.

The IP&C programme has a multifaceted role in preventing the transmission of disease, which includes sur veillance of healthcare associated infections and resistant organisms, prevention of infection and control of existing infection.

Infection Prevention and Control Committee The Hospital Chief Executive Officer is responsible for the prevention and control of infection in Blackrock Clinic.

The Infection Prevention and Control

Committee (IPCC) is chaired by the Director of Nursing and the CEO also sits on the committee. The committee is responsible for providing an infection control strategy in Blackrock Clinic.

The Consultant Microbiologist is available for their exper t advice for patients that require Antibiotic treatment. For other cases please refer to the Antimicrobial guideline.

Education and Training Education is a key component of IP&C. All new staff starting in the hospital receive IP&C education as part of their orientation programme. Nursing staff receive a more extensive orientation covering standard precautions, asepsis and wound care.

Hand Hygiene There has been a clear focus on Hand Hygiene education and awareness throughout the hospital. No hand and

“A programme of activities to embrace national initiatives and to reduce infection rates has been developed and implemented.”

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02/12/2010 11:49:41

Blackrock Clinic | nfection prevention & control

Surveillance A critical function of IP&C nurse specialist is Sur veillance of Infections.

The objectives of sur veillance are to provide rates of healthcare associated infections in the Clinic. This allows the Infection prevention and control team to recognise trends in infection and carr y out audits or advise on changes where necessar y.

Surgical site infections (SSI) are identified by development of infection at the site of surger y within 30 days of surger y. Rates are available from

©istockphoto.com/mitchellpictures

wrist jeweller y, apart from a wedding band, may be worn by clinical staff. Hand Hygiene education stands are set up at hospital and clinic reception areas to display hand gel and information leaflets for staff and visitors.

The hospital is par t of the World Health Organisation (WHO) 2009 initiative – ‘WHO SAVE LIVES: Clean Your Hands’ – a global programme to encourage and improve the safety of our patients by employing best practices in hand hygiene.

the Infection Prevention and Control nurse specialist

MRSA Bacteraemia There have been no cases of MRSA bacteraemia since 2007. This was achieved by implementing an intervention programme to prevent MRSA and other infections which consisted of: � An active programme of education and training for clinical and non-clinical staff. This includes orientation staff training. � A zero tolerance approach to poor hand hygiene. � Weekly screening of patients in high risk areas for colonised MRSA. � Staff screening for MRSA. � Strict isolation of patients with MRSA. � Prophylactic topical treatment for high risk surgical patients on which no information on MRSA carrier status was available before surgery. � Mandatory education in Intravenous device care for all nurses in BRC. The IP&C committee would like to thank all the staff in Blackrock Clinic for their help and support.

“The hospital is part of the World Health Organisation (WHO) 2009 global initiative to encourage and improve the safety of our patients by employing best practices in hand hygiene. ”

54 www.blackrock-clinic.com

blackrock_clinic_magazine.indd 54

02/12/2010 11:49:44

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Intraveno Healthcare Unitech House Magna Business Park Citywest Dublin 24 Tel: 01-4048330 Fax: 01-4597169 Customer.service.intraveno@united-drug.ie

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02/12/2010 11:51:19

Blackrock Clinic | financial matters

©istockphoto.com/AdamRadosavljevic

Financial Matters

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“From doctors to housekeeping, full-time to parttime, the total staff is around 650, with several hundred more selfemployed and with secretaries in the consultants’ block.”

lackrock Clinic, at the forefront of private medicine, is a large organisation. From doctors to housekeeping, full-time to par t-time, the total staff is around 650, with several hundred more self-employed including consultants and their secretaries in the consultants’ block.

All of this requires careful oversight.

Keeping the show on the road is the Clinic’s Head of Finance, James O’Donoghue. The vast bulk of patients here are privately insured, and Blackrock Clinic also does quite an amount of work for the National Treatment Purchase Fund. Self-payers are few and far between in the client base, though there are some. The past decade has changed the picture enormously: ten years ago, the VHI held a monopoly.

The picture is ver y different now: the Clinic is seeing an increase in patients from Quinn and Aviva, but nowhere near the level of the VHI, which has an older customer profile.

The inpatient side of pricing is led by the insurance industr y: they tell providers what prices they’re prepared to pay, although there is some negotiation. They drive a hard bargain: the prices at which they sell insurance are ver y low, compared to the UK, US and other countries. It is a picture that

will probably not change any time soon: the VHI is by far the dominant player, but with the purchasing power that all insurers have, they can demand keen prices.

Competitive environment It is not just the insurance industry driving competition in the marketplace. On the outpatient side, a hospital has to be competitive with a) other hospitals, and b) with stand-alone units. At Blackrock Clinic, we believe we have a different offering, although we’re competitive with pricing: patients get a different product here at Blackrock Clinic. One example of the level of care is that we have onsite radiologists with sub-specialties.

The market, then, is hugely competitive. Blackrock Clinic's strategy for keeping above the waterline is quality, which will win out in the end.

The Clinic puts a lot of effor t into features such as sophisticated clinical governance, ver y low infection rates and good measures of outcomes in key specialties.

Medical inflation is another occupational hazard of financial control: despite the recession, costs have galloped ahead in healthcare globally. There is a constant demand for more, newer, and more expensive

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02/12/2010 11:51:46

Victoz

Blackrock Clinic | financial matters

Building for the future The routines of the finance department have been somewhat expanded in recent years, as the Clinic’s €100m, five-year development project progressed.

The scheme was challenging to oversee: the job itself, from a construction perspective, was a difficult one.

Essentially, the Clinic put another hospital on top of the existing hospital without affecting its running. Now complete, the new floors offer a distinct advantage and the finances continue to make sense.

The Clinic was in a good financial state before building commenced, and has not overextended its resources.

The expansion may open up more avenues for revenue in future, but there’s more to it than just capacity. One of

the key aims – linking into the Clinic’s drive for quality and outcomes – is that although most rooms were private prior to expansion, there were some semi-private rooms too.

It was decided to have all-private rooms only, at the end of the expansion, and this could not be achieved within the parameters of the existing building – it would have significantly reduced capacity.

It was a quality-over-quantity choice, and the only way to make rooms all-private was to expand.

There are demographic reasons, too. It is reported that in 20 years time, the over65 population in the greater Dublin region will have doubled: we are all living longer due to improvements in medicine. While that’s to be celebrated, it also needs to be planned for, and expansion in capacity is an important element. At Blackrock Clinic, that has taken place early.

But for now, the Finance Depar tment’s focus returns to the nitty gritty of financial control. Between inpatients and day cases, the Clinic sees about 20,000 patients a year. Expansion complete, more patients can be treated, and better.

©istockphoto.com/nyul

consumables, more drugs being used and developed, as well as improvements in technology. This coincides with the insurance companies’ need to keep a lid on prices. Private clinics such as Blackrock Clinic are caught in the middle, eager to supply all demand, but with an eye on competitive pricing.

“The routines of the finance department have been somewhat expanded in recent years, as the Clinic’s €100m, five-year development project progressed.”

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02/12/2010 11:52:25

Victoza A4 10(1):Layout 1 20/05/2010 09:07 Page 1

Once-daily Victoza® (liraglutide), in combination with metformin, impacts on multiple factors associated with type 2 diabetes providing, from baseline:1,2

Reductions in HbA1c: up to 1.30%1,2 Reductions in weight: up to 2.8kg1,2 Reductions in systolic blood pressure1,2 Improvements in beta-cell function1,2

Abbreviated Prescribing Information Victoza® 6 mg/ml solution for injection in pre-filled pen (liraglutide). Please refer to the Summary of Product Characteristics for full information. Victoza® 2 x 3 ml pre-filled pens. Victoza® 3 x 3 ml pre-filled pens. 1 ml of solution contains 6 mg of liraglutide. Indication: Treatment of adults with type 2 diabetes mellitus in combination with metformin or a sulphonylurea, in patients with insufficient glycaemic control despite maximal tolerated dose of metformin or sulphonylurea monotherapy; or in combination with metformin and a sulphonylurea, or metformin and a thiazolidinedione in patients with insufficient glycaemic control despite dual therapy. Dosage: Victoza® is administered once daily by subcutaneous injection and can be administered at any time independent of meals however, it is preferable that Victoza® is injected around the same time of the day. Victoza® should not be administered intravenously or intramuscularly.

Recommended starting dose is 0.6 mg daily. After at least one week, the dose should be increased to a maintenance dose of 1.2 mg. Based on clinical response, after at least one week the dose can be increased to 1.8 mg to further improve glycaemic control in some patients. Daily doses higher than 1.8 mg are not recommended. When used with existing metformin therapy or in combination with metformin and thiazolidinedione therapy, the current dose of metformin and thiazolidinedione can continue unchanged. When added to existing sulphonylurea therapy or in combination with metformin and sulphonylureas, a reduction in the dose of sulphonylurea may be necessary to reduce the risk of hypoglycaemia. Victoza® can be used in the elderly (>65 years old) without dose adjustment but therapeutic experience in patients ≥75 years of age is limited.

No dose adjustment is required for patients with mild renal impairment (creatinine clearance ≤60-90 ml/min). Due to lack of therapeutic experience Victoza® is not to be recommended for use in patients with moderate (creatinine clearance of 30-59 ml/min) and severe renal impairment (creatinine clearance below 30 ml/min), patients with end stage renal disease, patients with hepatic impairment and children below 18 years of age. Contraindications:

Hypersensitivity to the active substance or any of the excipients. Warnings and Precautions for use: Victoza® should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis. Limited experience in patients with congestive heart failure New York Heart Association (NYHA) class I-II and no experience in patients with NYHA class III-IV. Due to limited experience Victoza® is not recommended for patients with inflammatory bowel disease and diabetic gastroparesis. Victoza® is associated with transient gastrointestinal adverse reactions, including nausea, vomiting and diarrhoea.

Other GLP-1 analogues have been associated with pancreatitis; patients should be informed of symptoms of acute pancreatitis: persistent, severe abdominal pain. If pancreatitis suspected, Victoza® and other suspect medicinal products should be discontinued. Thyroid adverse events, including increased blood calcitonin, goitre and thyroid neoplasm reported in clinical trials particularly in patients with pre-existing thyroid disease. Risk of hypoglycaemia in combination with sulphonylureas; lowered by dose reduction of sulphonylurea. No studies on the effects on the ability to drive and use machines performed. Patients should be advised to take precautions to avoid hypoglycaemia while driving and using machines, in particular when Victoza® is used in combination with a sulphonylurea. Substances added to Victoza® may cause degradation; in the absence of compatibility studies Victoza® must not be mixed with other medicinal products. Pregnancy and lactation: Victoza® should not be used during pregnancy or during breast-feeding. If a patient wishes to become pregnant, or pregnancy occurs, treatment with Victoza® should be discontinued; use of insulin is recommended instead. Undesirable effects: During clinical trials with Victoza® the most frequently observed adverse reactions which varied according to the combination used (sulphonylurea, metformin or a thiazolidinedione) were: Very common: nausea, diarrhoea, hypoglycaemia when used in combination with metformin and a sulphonylurea and headache when used in combination with metformin; Common: hypoglycaemia when used in combination with a thiazolidinedione, vomiting, constipation, abdominal pain, discomfort and

References: 1. Victoza® Summary of Product Characteristics.

2. Nauck M et al; for the LEAD-2 Study Group. Efficacy and safety comparison of liraglutide, glimepiride, and placebo, all in combination with metformin, in type 2 diabetes: the LEAD (liraglutide effect and action in diabetes)-2 study. Diabetes Care 2009;32(1):84-90.

Victoza® is a trademark owned by Novo Nordisk A/S. Date of preparation: April 2010. IR/LR/0410/0014

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distension, dyspepsia, gastritis, flatulence, gastroesophageal reflux disease, gastroenteritis viral, toothache, headache, dizziness, nasopharyngitis, bronchitis, anorexia, appetite decreased, fatigue and pyrexia. Gastrointestinal adverse reactions are more frequent at start of therapy but are usually transient. Very few hypoglycaemic episodes observed other than with sulphonylureas. Patients >70 years or with mild renal impairment (creatinine clearance ≤ 60-90 ml/min) may experience more gastrointestinal effects. Consistent with medicinal products containing proteins/peptides, patients may develop anti-liraglutide antibodies following treatment but this has not been associated with reduced efficacy of Victoza®. Few cases reported of angioedema (0.05%), acute pancreatitis (<0.2%) and injection site reactions (approx. 2%). Injection site reactions usually mild. Causal relationship between Victoza® and pancreatitis can neither be established nor excluded. Thyroid neoplasms, increased blood calcitonin and goitres are the most frequent thyroid adverse events and were reported in 0.5%, 1% and 0.8% of patients respectively. The Summary of Product Characteristics should be consulted for a full list of side effects. Overdose: In the event of overdose, appropriate supportive treatment should be initiated according to the patient’s clinical signs and symptoms. MA numbers: Victoza® 2 x 3ml pre-filled pens EU/1/09/529/002. Victoza® 3 x 3ml pre-filled pens EU/1/09/529/003. Legal Category: POM. For complete prescribing information please refer to The Summary of Product Characteristics which is available on www.medicines.ie or by email from info@novonordisk.ie or from Medical department, Novo Nordisk Limited, 3-4 Upper Pembroke Street, Dublin 2, Ireland; www.novonordisk.ie.

Date created: July 2009.

Information about adverse event reporting is available at www.imb.ie.

Adverse events should be reported to the Novo Nordisk Medical department: Tel: 1850 665 665.

Further Information is available from: Novo Nordisk Limited 3/4 Upper Pembroke Street Dublin 2, Ireland Tel: 01 678 5989 Fax: 01 676 3259 Lo Call: 1850 665 665 www.novonordisk.ie

02/12/2010 11:52:30

Blackrock Clinic | GENERAL INFORMATION

GENERAL INFORMATION Further facilities Visiting hours are flexible, and generally extend from 10:30am to 9pm.

Mealtimes are at 7:30am, 12:30pm and 5:30pm – there is also a hospital restaurant on the ground floor.

The shop is located in the main hospital reception, and stocks newspapers, fresh flowers, fruit, reading material, confectionery, toiletries, gifts, stationery and postal stamps, among other items. A hairdressing service can also be arranged by nurses or ward managers.

Regular Roman Catholic, Church of Ireland and Presbyterian chaplain services are available, and those of other denominations can be arranged.

Location

By Car – If travelling to the Clinic from the city direction, right turns are permitted except between the hours of 4pm and 7pm, when access to the Clinic is only permitted from the south.

If travelling to the Clinic during the hours of 4pm - 7pm, and approaching the Clinic from the city direction, use

the N11, otherwise known as the Stillorgan Dual Carriageway. Turn left on to Mount Merrion Avenue, bringing you back to the Rock Road, where you can access the Clinic.

If travelling to the Clinic from the Blackrock direction towards the city, you may experience some traffic delays as all traffic is down to one lane.

If travelling to the Clinic from the M50, take the Sandyford exit at junction 14 and drive towards the N11/Stillorgan Dual Carriageway. Turn left onto the dual carriageway and take a right turn down Mount Merrion Avenue. Take a left turn at the bottom of Mount Merrion Avenue, bringing you on to the Rock Road, where you can access the Clinic from this direction.

By Bus – The Clinic is served by Dublin Bus routes 5, 7, 7a, 8 and 45.

By DART/Train – Alight at Blackrock Station, where a 10-minute walk will take you through Blackrock village, turning right onto the Rock Road towards the City Centre. The Clinic is located on the left.

Contact us Blackrock Clinic Rock Road Blackrock County Dublin Freephone: 1800 60 10 60 Phone: +353 1 283 2222 Fax: +353 1 206 4314 Web: www.blackrock-clinic.com

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03/12/2010 13:00:14

MSD is the world’s second largest pharmaceutical company and employs 2,300 people at operations in Carlow, Cork, Dublin, Tipperary and Wicklow. In the last four decades we have invested over €2.2bn in Ireland and our investment continues to grow, making MSD one of Ireland’s leading exporters both now and in the future.

At MSD, we work hard to keep the world well.

How? By providing people all around the globe with innovative medicines, vaccines and over the counter consumer and animal health products.

We also provide leading healthcare solutions that make a difference. We do it by listening to patients, healthcare professionals and our other partners. Our recent merger with Schering-Plough expands and strengthens our capabilities to help make the world a healthier place.

Copyright © 2010 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Whitehouse Station, NJ, USA. All Rights Reserved.

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06-11-MSD-2010-IRL-3319-J

See all we’re doing at www.msd.ie

02/12/2010 11:43:53