The Medical Independent 12 March 2020

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Modernising the intern year The intern year, which demarcates the transition from student to doctor, is currently the focus of a major reform programme.

Catherine Reilly reports

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Ireland in the time of Covid-19

Rural America’s healthcare problem

Three cheers for Sláintecare?

Consultant in Public Health Medicine Dr Ina Kelly outlines the importance of public health medicine in combating the spread of the new coronavirus

A shortage of doctors is creating ‘medical deserts’ across rural America, leaving millions of people without adequate healthcare, writes Bette Browne

Sláintecare is unlikely to provide the solution to the problems of the health service, according to Dr Christine O’Malley

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NEWS 1-17 ● OPINION 19 ● CLINICAL 23-30 ● LIFE DIARY 32 ● FOOD & DRINK 34 ● QUIZZES 33 ● GALLERY 35-36 ● PRODUCTS 37 ● RECRUITMENT 38-39

Audit reports identify need for consultant work practice plans

Photo: Jason Clarke

PAUL MULHOLLAND

Women working on the new children’s hospital project gathered at the 12-acre construction site of the hospital in Dublin to mark International Women’s Day (8 March). Pictured are staff from the National Paediatric Hospital Development Board, Children’s Health Ireland (CHI), the design team and contractors working on the construction of the hospital. Professionals pictured range from scaffolders, architects, health and safety officers, quantity surveyors, and engineers to consultants, nurses, HR and financial professionals, and administrators. Pictured at the front is Chief Executive of CHI, Ms Eilish Hardiman.

Figures reveal spiralling cost of HSE high-tech drugs NIAMH CAHILL HSE spending on high-tech drugs jumped by 28 per cent between 2017 and 2019, new figures obtained by the Medical Independent (MI ) reveal.

An analysis of high-tech drug wholesaler and manufacturer payments shows the Executive paid out €887 million in 2019. This is compared to €692 million in 2017 and €816 million in 2018. In January 2020 alone, the HSE spent €81 million.

The above figures do not include payments to pharmacists for dispensing high-tech drugs, it is understood. In 2019 pharmacists were paid more than €20 million in high-tech dispensing and non-dispensing fees.

High-tech medicines are usually prescribed in hospitals and are often expensive, recently-developed medicines, which offer huge patient benefit.

The HSE is attempting to increase the use of “biosimilars”, drugs that are similar to another, approved biological medicine, but are cheaper, as part of efforts to alleviate the increase in spending.

In January the HSE’s Primary Care Reimbursement Service (PCRS) wrote to prescribing consultants and pharmacists advising them of new reimbursement arrangements for “best value medicines” (BVMs) for adalimumab and etanercept.

According to the correspondence, seen by MI, from the start of February 2020, for patients who have “never been treated with adalimumab or etanercept previously under hightech arrangements, reimbursement will only be supported for the BVBs medicines (ie, Imraldi or Amgevita for adalimumab and Benepali for etanercept) in adult patients commencing such therapy”.

The move follows a recommendation by the HSE Medicines Management Programme last year that patients on a biological medicine containing a tumour necrosis factor-alpha (TNF-α) inhibitor be prescribed a BVM biological medicine for adalimumab and etanercept.

The latest advice issued relates to reimbursement and is part of HSE efforts to reduce spending on “high-

tech drugs”.

The correspondence notes that since May last year, when changes were first recommended, prescribing of the BVB medicines for adalimumab and etanercept has increased.

“As of 20 January 2020, over 3,800 patients have been prescribed one of the BVB medicines for adalimumab and etanercept.

“The HSE may identify additional BVB medicines for adalimumab and etanercept in 2020.”

The HSE National Service Plan 2020 outlines the aim to expand the range of medicines administered through the high-tech ordering and monitoring hub to encompass, on a phased basis, all therapeutic areas.

The plan notes the importance of promoting the switch to biosimilar drugs to enable continued access to high-tech and other medications by offsetting cost growth and the Department of Health-led sustainability programme on community pharmaceutical costs to enable continued access to high-tech and other medications.

The lack of complete work practice plans for consultants was criticised in reports by the HSE’s internal audit division last year, the Medical Independent can report.

In an audit of consultants’ public and private practice in University of Limerick Hospitals Group, completed in February 2019, a sample review identified work practice plans and various versions of work schedules on file for only eight of 15 consultants (53 per cent).

“Some were noted to be sketchy on detail for activities, time allocation to activity, total hours work, etc,” according to the report.

Only three of the eight documents presented a complete plan denoting allocated times for public and private practice and total weekly hours.

In another HSE internal audit report for consultant practice in Connolly Hospital, Dublin, from January 2019, it was noted that work practice plans “were not available” for eight out of the 15 consultants assessed.

The issue was also identified in another consultant public/ private report relating to Cork University Maternity Hospital conducted by the division and completed in May 2019.

According to the report, the work practice plans were “hand-written in multiple formats” and did not include the total scheduled number of weekly hours.

All three reports referenced the fact that many work practice plans were not signed off by a senior consultant or clinical director. It was recommended that complete plans are in place for all consultants to facilitate the monitoring of contractual terms and conditions.

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Full prescribing information for Ultibro Breezhaler, Seebri Breezhaler and Onbrez Breezhaler is available on request from: Novartis Ireland Ltd., Vista Building, Elm Park Business Park, Merrion Road, Dublin 4, D04A9N6 (Tel: 01 260 1255) or at www.medicines.ie Legal Category: POMs. Marketing Authorisation Holder: Novartis Europharm Limited, Vista Building, Elm Park, Merrion Road, Dublin 4, Ireland.

Date of Preparation: August 2019 IE02/PCF19-CNF015

For all that matters in medicine available in print and digital

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THE MEDICAL INDEPENDENT | 12 MARCH 2020

News Anger as GPs hit with GMS payment delays

‘Fragmented’ governance for intern year highlighted

NIAMH CAHILL

CATHERINE REILLY

The HSE has been strongly criticised by GPs after it issued a notice advising of payment delays for claims made through the GMS. In a recent email notice to GPs in parts of Dublin, the HSE Primary Care Reimbursement Service (PCRS) advised that “due to unforeseen circumstances the primary care unit is currently managing at a reduced level of resources”.

“Therefore, any claims you may have submitted to the office relating to palliative care, medical indemnity, and maternity and infant will be processed in due course, however, you may experience some delays in receiving your payments for same.”

The notice, shared on social media by Dublin GP Dr Nina Byrnes, included an apology for these delays.

Dr Byrnes told the Medical Independent (MI) that practices have staff and suppliers that cannot wait to be paid “in due course”. She said this was not the first time she had encountered payment delays.

The GP said she was still awaiting payment for maternity claims going back as far as 2017. She said she was also owed “tens of thousands” in special type consultation payments since July 2019.

According to Dr Byrnes, she had contacted the PCRS several times, but had not received a response on when the claims will be paid.

“This is very frustrating. We’re a small business with no cash reserves and we need to be paid,” she told MI. GPs on social media heavily criticised the PCRS measure, with one labelling it “appalling”.

A spokesperson for the Executive told this newspaper: “The HSE communicate with GMS GPs regularly. This email was part of a regular communication to all GMS GPs in north Dublin.

“We are working to ensure that payments are paid as promptly and effectively as possible.

“If a GP has any question about payments, we would advise them to contact our office directly, as per usual.”

The “fragmented” governance system for the intern year has compromised the Medical Council and HSE’s ability to undertake their statutory roles efficiently, according to a paper they produced.

The paper, dated September 2017 (amended in December 2019), outlined a new governance structure for the year.

The “current fragmented governance system” led to the lack of a national approach to issues “such as induction, assessment, leave (including maternity leave) policy, remediation, QA [quality assurance] of intern posts and MCI [Medical Council of Ireland] sign-off on

ONE DEVICE

completion of the year, amongst others”, according to the paper.

The Council has a number of legislative responsibilities regarding internship, such as approving posts and inspecting intern training sites, to ensure compliance with guidelines.

The HSE’s legal responsibilities include, among other aspects, annual assessment of the number of intern training posts required by the health service and advising the Minister for Health on development and co-ordination of specialist medical education and training.

According to the paper, medical schools are contractually obliged to develop and provide the intern training programme through service level agreements (SLAs) with the HSE.

The Council and HSE recognised that the intern year was “relatively under-funded” in comparison to postgraduate specialist medical training.

“A new governance structure will ensure that the benefits of this new investment will be reflected evenly across the intern system.”

This reformed structure, involving a medical intern board and unit, has since been taking shape.

Funding for intern training is covered in SLAs between the HSE and medical schools and is subject to a confidentiality clause.

Increased funding levels have not yet been determined, stated the HSE. See news feature, p4-5

TWO THREE POWERFUL SIMPLE INGREDIENTS1-3 STEPS1

HPRA recommendation could lead to ‘severe maternal morbidity’ – IMPS CATHERINE REILLY Implementing a recommendation approved by the Health Products Regulatory Authority (HPRA) could lead to “sub-optimal control” of hyperemesis gravidarum (HG) and “potentially severe maternal morbidity”, according to the Irish Medicines in Pregnancy Service (IMPS).

The IMPS, based at the Rotunda Hospital, noted that in late 2019 the marketing authorisation holders (MAH) for ondansetron (Zofran) wrote to healthcare professionals regarding its safety during the first trimester of pregnancy.

The communication followed recommendations from the European Medicines Agency (EMA) and HPRA, which included that ondansetron should not be used during the first trimester. This recommendation applied to ondansetron’s licensed indications, which does not include HG, noted the IMPS. HG is a complication of pregnancy characterised by severe, protracted nausea and vomiting. In its position statement, the IMPS recommended that ondansetron should remain a treatment option for women with HG, where first-line agents have not been effective. Women should be adequately counselled on benefits and potential risks.

The IMPS did not consider that available data supported the conclusion that ondansetron caused congenital anomalies.

An IMPS spokesperson said its statement offered “pragmatic recommendations from the perspective of healthcare professionals”. A HPRA spokesperson said the EMA’s safety committee examined ondansetron in its licensed uses. This followed a review of new safety data, which reported “a small but increased risk” of orofacial malformations linked to the drug’s use in the first trimester.

As ondansetron is not licensed for use in HG in the EU, the EMA committee did not conduct a benefit-risk assessment in this off-label indication.

Off-label use was a matter of clinical judgement and prescribers “can refer to clinical guidelines” if treatment with ondansetron is considered for HG, stated the HPRA spokesperson. The HPRA “fully agrees with the principle that the risks to the unborn child when taking a medicine during pregnancy have to be weighed against the risks to the mother and child of not taking the medicine”.

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Ultibro® Breezhaler® ABBREVIATED PRESCRIBING INFORMATION Please refer to Summary of Product Characteristics (SmPC) before prescribing Presentation: Ultibro Breezhaler 85mcg / 43mcg inhalation powder hard capsules containing indacaterol maleate and glycopyrronium bromide respectively and separate Ultibro Breezhaler inhaler. Indications: A maintenance bronchodilator treatment to relieve symptoms in adult patients with chronic obstructive pulmonary disease (COPD). Dosage and administration: Recommended dose is the inhalation of the content of one capsule once daily, administered at the same time of the day each day, using the Ultibro Breezhaler inhaler. Capsules must not be swallowed. No dose adjustment required in elderly patients, for patients with mild and moderate hepatic impairment or for patients with mild to moderate renal impairment. No data available for use in patients with severe hepatic impairment and should only be used in patients with severe renal impairment or end-stage renal disease requiring dialysis if the expected benefit outweighs the potential risk. No relevant use in the paediatric population. Contraindications: Hypersensitivity to the active substances or to any of the excipients. Warnings/Precautions: Not to be administered concomitantly with medicinal products containing other LABA’s or LAMA’s. Asthma: ♦ULTIBRO BREEZHALER SHOULD NOT BE USED FOR TREATMENT OF ASTHMA. Acute use: ♦Not indicated for treatment of acute episodes of bronchospasm.

Hypersensitivity: ♦Immediate hypersensitivity reactions have been reported after administration of indacaterol or glycopyrronium. If signs suggesting allergic reactions occur (in particular, angioedema, difficulties in breathing or swallowing, swelling of the tongue, lips and face, urticaria or skin rash), treatment should be discontinued immediately and alternative therapy instituted. Paradoxical bronchospasm: ♦If paradoxical bronchospasm occurs, Ultibro Breezhaler should be discontinued immediately and alternative therapy instituted. Anticholinergic effects related to glycopyrronium: ♦To be used with caution in patients with narrowangle glaucoma and in patients with urinary retention. Patients with severe renal impairment: ♦Should only be used in patients with severe renal impairment, including those with end-stage renal disease requiring dialysis, if the expected benefit outweighs the potential risk. These patients should be monitored closely for potential adverse reactions. Cardiovascular effects: ♦To be used with caution in patients with cardiovascular disorders (coronary artery disease, acute myocardial infarction, cardiac arrhythmias, hypertension), in patients with known or suspected prolongation of the QT interval or patients treated with medicinal products affecting the QT interval and in patients with unstable ischaemic heart disease, left ventricular failure, history of myocardial infarction, arrhythmia (excluding chronic stable atrial fibrillation), a history of long QT syndrome or whose QTc (Fridericia method) was prolonged. ♦LABA’s may produce a clinically significant cardiovascular effect in some patients as measured by increases in pulse rate, blood pressure, and/or symptoms, ECG changes. In case such effects occur, treatment may need to be discontinued. Hypokalaemia: ♦LABA’s may produce significant hypokalaemia in some patients, which has the potential to produce cardiovascular effects.

In patients with severe COPD, hypokalaemia may be potentiated by hypoxia and concomitant treatment which may increase the susceptibility to cardiac arrhythmias. Hyperglycaemia: ♦Inhalation of high doses of LABA’s may produce increases in plasma glucose. Upon initiation of treatment with Ultibro Breezhaler plasma glucose should be monitored more closely in diabetic patients therefore caution and appropriate monitoring are advised in such patients. ♦Ultibro Breezhaler has not been investigated in patients for

whom diabetes mellitus is not well controlled. General disorders: ♦To be used with caution in patients with convulsive disorders or thyrotoxicosis, and in patients who are unusually responsive to LABA’s. Excipients: ♦This medicinal product contains lactose. Patients with rare hereditary problems of galactose intolerance, total lactase deficiency or glucose-galactose malabsorption should not take this medicine. Pregnancy and Lactation: ♦Ultibro Breezhaler should only be used during pregnancy if the expected benefit to the patient justifies the potential risk to the foetus. ♦Not known whether indacaterol, glycopyrronium and their metabolites are excreted in human milk. Use of Ultibro Breezhaler by breast-feeding women should only be considered if the expected benefit to the woman is greater than any possible risk to the infant. Interactions: ♦Concomitant use is not recommended with beta-adrenergic blockers, anticholinergics or sympathomimetics. ♦Concomitant hypokalaemic treatment with methylxanthine derivatives, steroids, or non-potassium-sparing diuretics may potentiate the possible hypokalaemic effect of beta2-adrenergic agonists, therefore use with caution. ♦Inhibition of the key contributors of indacaterol clearance, CYP3A4 and P-gp, does not raise any safety concerns given the safety experience of treatment with indacaterol. ♦No clinically relevant drug interaction is expected when glycopyrronium is co-administered with cimetidine or other inhibitors of the organic cation transport. Adverse reactions: ♦Very common: upper respiratory tract infection. ♦Common: nasopharyngitis, urinary tract infection, sinusitis, rhinitis, hypersensitivity, hyperglycaemia and diabetes mellitus, dizziness, headache, cough, oropharyngeal pain including throat irritation, dyspepsia, dental caries, bladder obstruction and urinary retention, pyrexia, chest pain. ♦Uncommon: angioedema, insomnia, glaucoma, ischaemic heart disease, atrial fibrillation, tachycardia, palpitations, paradoxical bronchospasm, dysphonia, epistaxis, gastroenteritis, dry mouth, pruritus / rash, musculoskeletal pain, muscle spasm, myalgia, pain in extremity, oedema peripheral and fatigue. ♦Please refer to SmPC for a full list of adverse events for Ultibro Breezhaler.

Legal Category: POM. Pack sizes: Cartons containing 10 capsules (1x10 capsule blister strips) and one Ultibro Breezhaler inhaler or 30 capsules (3x10 capsule blister strips) and one Ultibro Breezhaler inhaler. Marketing Authorisation Holder: Novartis Europharm Limited, Vista Building, Elm Park, Merrion Road, Dublin 4, Ireland.

Marketing Authorisation Numbers: EU/1/13/862/007 & 003. Full prescribing information is available on request from Novartis Ireland Ltd, Vista Building, Elm Park Business Park, Dublin 4. Tel: 01 2601255 or at www.medicines.ie Date of Revision of API Text: June 2019.

REFERENCES: 1. Ultibro Breezhaler Summary of Product Characteristics. www.medicines.ie. Accessed on January 2020. 2. Donohue JF, et al. Int COPD 2017;12:367-381. 3. Miravitlles M, et al. Clin Invest (Lond) 2014;4(12);1095-1111.

ADVERSE EVENT REPORTING Reporting suspected adverse reactions of the medicinal product is important to Novartis and the HPRA. It allows continued monitoring of the benefit/risk profile of the medicinal product. All suspected adverse reactions should be reported via www.hpra.ie or email to medsafety@hpra.ie.

Adverse events could also be reported to Novartis preferably via www.report.novartis.com or by email: drugsafety.dublin@novartis.com or by calling 01 2080 612.

Date of Preparation: January 2020 IE02/ULT19-CNF027a

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THE MEDICAL INDEPENDENT | 12 MARCH 2020

News Feature CATHERINE REILLY catherine@mindo.ie

Modernising the intern year The intern year, which demarcates the transition from student to doctor, is currently the focus of a major reform programme.

Catherine Reilly reports

C

ertain factors have limited the “effectiveness” of the intern year, a pivotal time in a doctor’s early professional development, according to a progress report on its “modernisation”.

Lack of “an effective system” to ensure comparable content and quality of education, training and experience across the six intern networks is cited. The intern year has also been “relatively under-funded” compared to postgraduate specialist medical training.

These details are outlined in Modernisation of the Intern Year Project, Progress Report, December 2018-August 2019, obtained from the HSE under Freedom of Information (FoI) law.

In his message, Prof Frank Murray, Director of HSE National Doctors Training and Planning (NDTP), wrote that the environment in which doctors practised in Ireland had changed, presenting “several extra challenges”.

“It is appropriate now to review the intern year with a view to modernisation. This project, ably led by Dr Gozie Offiah, will address many issues which impact on the intern year.”

In a separate paper, also obtained via FoI, the HSE and Medical Council stated that a “fragmented” governance system limited their ability to undertake their statutory

responsibilities efficiently, in regard to the intern year (see panel).

In 2017, with such issues in mind, the NDTP and Council established the medical intern board to develop and oversee reforms.

Prof Frank Murray

A medical intern unit was founded in May 2018 and operates under the board. It has been reviewing various aspects of the intern year with input from stakeholders.

Preparedness to practice Inconsistencies in clinical training pre-date the intern year, stated the progress report.

It cited the example of clerkships, ie, when a medical student observes the work of an intern at a hospital site.

“A report on the six medical schools in Ireland from the Medical Council describes a variation in the period of student clerkship that takes place, ranging from twoto-25 weeks,” it outlined.

“This variability requires further review and clarification as to the recommended standards and more importantly, identifying the optimum learning opportunities provided by clerkship.”

This aspect would need to be driven by the medical schools, in collaboration with the medical intern unit.

Standardising intern induction and ensuring payment were also goals of the modernisation project. During 2018, representatives of the medical intern board and NDTP met with officials from the Department of Health, which supported induction payment in principle.

Significant developments have occurred since the report was authored.

Five days’ induction pay was introduced from July 2019, against the background of claims submitted by the IMO to the Workplace Relations Commission (WRC) and potential industrial action. Issues remain in regard to interns not being paid for induction-related work outside the agreed 39-

hour week, which has prompted a further set of claims to the WRC by the IMO. Bullying The progress report did not specifically mention bullying, a concern identified in the Medical Council’s Your Training Counts and clinical site inspection reports. However, this matter has been discussed at meetings of the medical intern board, according to minutes obtained by the Medical Independent (MI).

At its meeting in September, Dr Justin Brophy, Chair of the Forum of Irish Postgraduate Medical Training Bodies, referred to reports of bullying in Your Training Counts, “and the fact that perhaps interns are not aware of how to respond to incidents appropriately”.

“It was agreed that action is required with regard to incidents of bullying and it must be communicated to interns that there is a process in place to report same.”

Intern posts The quality and quantity of intern posts are being examined as part of the modernisation project.

There was “a feeling that the current number of intern places is insufficient to match the number of graduates from Irish medical schools”.

Who governs the intern year?

The “fragmented” governance system for the intern year has compromised the ability of the Medical Council and HSE to undertake their statutory roles in an efficient manner, according to a paper they produced.

The paper by HSE NDTP and the Council, dated September 2017 (amended in December 2019), outlined the manner in which intern year governance should be reformed.

“The intern year is a new medical graduate’s first experience of working as a doctor and it takes place in a heavily supervised environment,” according to the paper. “Satisfactory completion of the year is a requirement for registration with the MCI [Medical Council of Ireland] and the legal right to independent practice.”

The HSE and Council believed the biggest issue facing the intern year was the lack of a centralised approach to ensure a comparable intern experience across all the intern networks.

“The result of the current fragmented governance system is non-comparable processes across intern networks and the absence of a national approach to issues such as induction, assessment, leave (including maternity leave) policy, remediation, QA [quality assessment] of intern posts and MCI signoff on completion of the year, amongst others. The current approach compromises the ability of both the MCI and the HSE to undertake their statutory roles in an efficient manner.”

Under the Medical Practitioners Act 2007, the Council has a number of responsibilities in regard to internship, such as approving posts and inspecting the sites where intern train-

ing is conducted, to ensure compliance with guidelines.

The HSE’s legislative responsibilities include, among other aspects, annual assessment of the number of intern training posts required by the health service.

Under an EU directive, basic medical training comprises at least six years of study or 5,500 hours of theoretical and practical training provided by (or under the supervision of) a university. To ensure that all of the medical degree programmes available in Ireland meet this criteria, the intern year is considered part of undergraduate basic medical training.

The medical schools “play an active role” in developing, managing and delivering the intern training programme in conjunction with the intern network co-ordinators, the Medical Council, HSE, postgraduate medical training bodies, intern tutors and trainers on clinical sites.

Each medical school is assigned to an intern training network and has appointed a consultant-grade intern network co-ordinator supported by the HSE. According to the HSE/Council paper, medical schools are contractually obliged to develop and provide the intern training programme through the service level agreement between the university/relevant body and the HSE. Both the Council and HSE recognised that the intern year had been “relatively under-funded” in comparison to postgraduate specialist medical training and wished to “address this imbalance”, according to the paper.

“A new governance structure will ensure that the benefits

of this new investment will be reflected evenly across the intern system.”

The governance structure, which has since been taking shape, involves a medical intern board as a central overarching body with responsibility for the governance and strategic direction of the intern year.

The board has an independent chair with representation from the Council, HSE/NDTP, Intern Network Executive, Irish Medical Schools Council (IMSC), Forum of Irish Postgraduate Medical Training Bodies and National Lead NCHD. “The board will be housed virtually within the HSE and it is proposed that each member have a term of three years.” It reports to the Medical Council and HSE NDTP. The medical intern unit will implement strategic recommendations of the board and deliver the “operational function of the intern year”.

Prof Carmel Malone, head of the IMSC, commented: “The governance of the intern year has been reviewed and restructured at the end of 2019. This process was led and fully supported by the IMSC. There are many stakeholders within this complex year and the recent revision of governance structure has enhanced the continuum of medical education from undergraduate, through internship, to postgraduate training.

“Furthermore, regional intern co-ordinators now also sit on the curriculum committees/programme boards of each medical school to enhance emphasis on preparedness for practice.”

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THE MEDICAL INDEPENDENT | 12 MARCH 2020

Feature News “Representatives from NDTP met with personnel from the Department of Health on 3 August last year [2018] to discuss intern numbers,” stated the report.

“It was acknowledged by all stakeholders that the Fottrell Report is no longer relevant with regard to intern numbers and is considered outdated, considering workforce projections, patient safety issues and European Working Time Directives (EWTD).

“If there is capacity within the HSE and sufficient training opportunities to fund additional posts, then this should be progressed but consideration will have to be given to where the posts are located. Reports following Medical Council site visits have also referred to the need for an increase in intern numbers to ensure patient safety and comply with EWTD legislation.”

In April 2019, NDTP representatives met with Ms Anne Murphy, Senior Human Resources Lead, HSE National Acute Operations, to discuss the process with regard to increasing intern numbers and securing the necessary funding and approval.

“Cost implications will have to be considered in this regard through engagement with [the] HSE strategic planning department and a review of structures at clinical sites will be important when allocating additional posts,” according to the progress report.

Around 1,200 doctors graduate from Irish medical schools each year, but there are only 734 intern places (approximately 680 are CAO candidates).

It remains to be seen when an increase may occur. In October, the Department informed MI the current number of intern posts “more than meets the domestic demand, with limited capacity to meet demand outside of Ireland’s domestic needs”.

The HSE’s spokesperson told MI: “There will be no increase in the number of interns for 2020 — this work is ongoing with stakeholders as part of the modernisation of the intern year project.”

Meanwhile, the medical intern unit is currently reviewing elements of the intern matching process, including centile rank calculations and looking at international best practice.

On-call The progress report cited the need for guidelines in regard to interns unable to carry out full duties, to support them to successfully complete training wherever possible.

Several interns in recent times had been taken off on-call duties by occupational health due to stress. However, a significant amount of learning takes place while oncall, leading to difficulties assessing interns’ performance.

A voluntary disclosure policy was also in development. This policy would “assist students who have a long-term health condition that could, at some time during their studies, impact on their ability to learn and study effectively,” according to the report.

“The focus will be to empower students to help manage their own condition and share information with those who may need to know about it. It is anticipated that it will remove or reduce obstacles and enable more effective learning for the student.”

The resultant “health passport aids a clearly-defined and agreed process for the transfer of information with regard to any issues or difficulties a student may encounter from medical school to internship and on to postgraduate training”.

The HSE informed MI the proposed health passport “will allow interns to easily record information about any issues or difficulties they may have. The passport is for intern use only and may be shared as the intern sees fit.”

Curriculum/EPAs The Medical Council and the medical intern board have committed to the development of a national curriculum, implementation of entrustable professional activities (EPAs), and associated assessment tools.

An EPA is a “core unit of professional practice” that can be fully entrusted to a trainee as soon as they have demonstrated the necessary competence to execute the activity unsupervised.

The proposed implementation of EPAs offers the opportunity to revisit the curriculum and relevant accreditation standards in a coherent, coordinated manner, in collaboration and in partnership with intern training networks

“The proposed implementation of EPAs offers the opportunity to revisit the curriculum and relevant accreditation standards in a coherent, co-ordinated manner, in collaboration and in partnership with intern training networks. It also provides an opportunity to identify gaps in the curriculum like health disparities and cultural competence, quality improvement and patient safety issues, etc.”

Seven EPAs and one personal and professional development (PPD) were identified for interns at the end of their training.

The seven EPAs are — clerk a patient; request and interpret basic investigations; perform essential procedural skills; manage the work of inpatient care; prescribe and monitor drugs and fluids; recognise and manage the deteriorating/acutely unwell patient; and hand over and discharge a patient. The PPD is to engage in personal and professional development.

The timeline for introduction of EPAs is 12to-18 months, stated the HSE’s spokesperson.

IMO feedback Many aspects of the modernisation project intersect with industrial relations.

While interns are represented in the modernisation project, the IMO is not a party to the various groups/committees under its auspices.

According to IMO Industrial Relations Officer Mr Paul Maier, the union had requested “on numerous occasions” a formal role in this process.

Nevertheless, IMO input “has been sought out and we have provided that input.

“I think it would be great to have even more impact on that, but generally speaking, I think our voice has been heard loud and clear through the actions we have taken and through the information we have provided directly to the NDTP and representatives of the other intern networks.”

Mr Maier emphasised that the IMO was not suggesting it had a role in setting or regu-

lating educational standards.

However, “if you are setting a standard for the level of training required, that obviously impacts the number of hours that need to be discharged, and if you are setting a standard for types of rotations that need to be worked on, that may change the way that our members go from location-to-location for their employment…

“Sometimes there is an attempt to remove the IMO from decisions that have been deemed to be strictly educational in nature, and I think that poses a challenge, in that educational decisions, more often than not, always will have industrial relations aspects to them, and that engagement with the IMO is engagement with NCHDs and with members we represent.”

According to Mr Maier, EWTD compliance, bullying, workplace respect, and transfer/sharing of tasks are among the key issues facing interns and doctors in other grades.

Medical school deans Head of the Irish Medical Schools Council (IMSC), Prof Carmel Malone, said it was “very supportive” of improvements to the intern year.

“Whilst the intern year is complex, with many stakeholders, including the IMSC, NDTP and Medical Council, there has never been greater cohesion or unified sense of purpose in our commitment to improving and enhancing this important year.”

Prof Malone described as “inevitable” that an increase in intern numbers will be required to address service gaps and provide appropriate learning opportunities for interns in a supportive environment.

“One of the pieces of work in the modernisation project is to look at increased funding for intern education and training,” she noted. “Education is expensive and adequate funding is required to ensure the delivery of high-quality education, which requires resources both human and material. For example, having additional funding would allow the medical schools and intern networks to improve the delivery of training and assessment using e-learning and mobile platforms.”

MINDO NUMBERS

20,000-30,000 people in Ireland are infected with chronic hepatitis C virus (HCV), the ICGP highlighted ahead of a recent conference it organised in Dublin.

60

per cent of people with HCV remain undiagnosed, according to the College, which said GPs are playing an important part in an expanded community care programme.

€1,615

per week is the average cost of care in public residential care centres for older people in 2020, according to a HSE report.

This represents a minor increase on 2019.

3

in every 1,000 deliveries are affected by placenta accreta, stated the National Maternity Hospital and Placenta Accreta Ireland as they launched an educational resource on the rare condition.

1

-in-10 patients will not be diagnosed with placenta accreta during pregnancy and the diagnosis is only made either at the time of Caesarean section or following a vaginal delivery, they stated.

450

cases of oesophageal cancer are diagnosed in Ireland each year, according to the Oesophageal Cancer Fund, though survival rates are improving.

Prof Carmel Malone

On preparedness for practice, she said this was “at the core of all curricula in Irish medical schools”.

“Academics in all schools are engaged in constant research and review to enhance the quality of training delivered to all healthcare professionals. Irish medical schools are leaders in many areas of medical education, including healthcare simulation and human factors in patient safety. The IMSC remains committed to encouraging excellence in medical education delivery and curriculum innovation based on high-quality research.”

According to the HSE, the current funding for intern training is outlined in the service level agreement between each medical school and the HSE and these details are covered by a confidentiality clause.

“Increased funding levels through the modernisation of the intern year project have not yet been determined.”

90%

— the uptake for the HPV vaccine in the late Laura Brennan’s home county of Clare, “a wonderful testament to her selfless advocacy”, said Dr Lucy Jessop, Director, HSE National Immunisation Office.

74

per cent of children and adolescents with an autism spectrum disorder have unmet service needs in Ireland, according to a new study published

by NUI Galway health economists.

6

THE MEDICAL INDEPENDENT | 12 MARCH 2020

News Proposal on consultant status for occupational health being considered by DoH GP training director impasse due to be DAVID LYNCH Proposals to offer full consultant status to occupational health physicians are currently being considered by the Department of Health (DoH), although there is no indication when a final decision will be made on the matter, the Medical Independent (MI) can report. The IMO told this newspaper that it has been “pushing the HSE to push the Department” on consultant status for occupational health physicians.

A Department spokesperson confirmed to MI that alongside the HSE, it is “considering the appropriate remuneration level for the role of occupational

health physician. It is not possible at this time to indicate when a final decision might be made”.

Mr Anthony Owens, IMO Director of Industrial Relations, Consultants and NCHDs, told MI: “This is something which has been percolating away in the background for a long time. Occupational health physicians are consultants in occupational medicine.

“They are trained to consultant standards, but don’t necessarily have consultant contracts. So they perform consultant duties without the contract.

“So we have been pushing both the HSE and DoH to kind of regularise the situation, and to offer them the correct contract, which we would maintain are the consultant contracts.”

Mr Owens emphasised that occupational health physicians are trained to consultant level and provide this standard of service to the population.

“But also, there is a requirement on the HSE to recruit and maintain more of these doctors, and our position would be by offering them comparable terms and conditions to their consultant colleagues, this could be done.”

Mr Owens said that the issue had been “examined by a management consultancy firm in 2008 and their recommendation ultimately pointed in the direction of a proper consultant contract for these doctors”. He admitted, however, that the post-election uncertainty may delay the resolution of the issue.

resolved by ‘end of year’ NIAMH CAHILL

Clarity surrounding the employment status of programme directors and assistant programme directors affected by the proposed transfer of GP training to the ICGP is due by the end of 2020, according to the IMO. Terms of reference for mediation between the IMO and HSE regarding directors and assistant directors on GP training schemes will be signed shortly.

After terms have been agreed, independent mediation chaired by Ms Marguerite Bolger, Senior Counsel specialising in employment law, will commence and involve two phases.

Mr Val Moran, IMO Director of Industrial Relations, General Practice, Public and Community Health, told the Medical Independent (MI) the first phase would lead to a determination on the employment status of directors and whether they are considered contractors or HSE employees. Once this issue has been settled, a mediation process would commence examining the wishes of directors, explained Mr Moran. Some may wish to avail of redundancy packages, for instance, while others Mr Val Moran may seek transfer to the ICGP. The process directly impacts about 70 individuals.

MI understands that the majority of programme directors and assistant programme directors have employment contracts with the HSE, but a minority do not. A spokesperson for the ICGP said that the College “remains satisfied with the progress that is being made” on the issue. Efforts to complete the transfer of training have been ongoing for many years but cannot conclude until clarity is reached on the employment rights and status of programme directors and assistant programme directors.

Separately, the ICGP has said that the shortage of paediatric doctors available to GP training schemes remains a concern.

Nationally, there is a lack of adequate paediatric training posts for GP trainees due to a shortage of paediatricians in Irish hospitals. The matter has been cited as a significant impediment to increasing GP training places. A spokesperson for the College said: “This continues to be of concern. However, the HSE are liaising with the College and all efforts are being made to address this challenge”.

New geneticist roles will reduce patient waiting times — HSE NIAMH CAHILL

Date Of Preparation: January 2020 IE/20/NOR/001-00

The appointment of two consultant clinical geneticists along with two further planned senior genetics posts will lead to improvements in waiting times for genetic care, according to the HSE. The Executive has advertised the post of professor of genetics as a joint appointment with Trinity College Dublin and University College Dublin to lead on the establishment of the National Genetics and Genomics Medicine Network (NGGMN). A spokesperson for the HSE told the Medical Independent the professor would “bring together all parties within the field of genomic medicine for multidisciplinary working in a national clinical and research centre”.

“The purpose of this post is to provide clinical advice and leadership in relation to the design and development of genetics and genomics in Ireland. More importantly, to drive the implementation of a hub-and-spoke model for genetic services at all levels with the HSE and through the Hospital Groups and specifically to provide support and general leadership in genetics and genomics.”

A national diagnostics lead for genomics medicine is also being established and recruitment is underway, the spokesperson added. Two full-time consultant clinical geneticists at Children’s Health Ireland (CHI) at Crumlin will begin work this year after funding was approved in 2019. According to the HSE, the move will help to “improve outpatient waiting times to see a geneticist”.

“Many patients who are on the waiting list may have a primary diagnosis and are being treated by a primary consultant. Patients are triaged by consultants based on clinical priority. CHI at Crumlin currently have a locum consultant undertaking additional clinics to reduce waiting times.”

Only four clinical genetics specialists work in the health service nationally at present, three of whom are over the age of 55. This is against a backdrop of demand for at least 15 consultants. Irish patients are without access to genetic counselling and are faced with waiting times of between 15 and 18 months for priority cases and over two years for routine referrals.

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Prof. Gavin Blake

Dr. Usama Boles

Dr. Roger Byrne

Prof. Ivan Casserly

Dr. Helen Cooney

Eimear Dempsey CNS

Susi Gnanaraj CNS

Dr. Joseph Galvin

Dr. Saber Hassan

Dr. Hafiz Hussein

Dr. John Keaney

Dr. Edward Keelan

Dr. Mark Kennedy

Claire Howard CNS

Claire O’Donoghue CNS

Prof. Niall Mahon

Dr. Hugh McCann

Prof. Declan Sugrue

Dr. Gábor Széplaki

Dr. Albert Alonso Tello

Prof. Kevin Walsh

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Treatment Update – Antihypertensive Therapy Dr. Helen Cooney

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Chair: Prof. Robert Byrne, Prof. Declan Sugrue, Prof. Gavin Blake

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Expert Update – Atrial Fibrillation Ablation Dr. Gábor Széplaki

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8

THE MEDICAL INDEPENDENT | 12 MARCH 2020

News

Pancreas transplant programme New vaping evidence review now operational 24/7 — SVUH due next month CATHERINE REILLY The national pancreas transplant programme is now operational on a 24/7 basis, a spokesperson for St Vincent’s University Hospital (SVUH), Dublin, has stated.

As reported in the Medical Independent (MI) in September, 12 potential pancreas donations did not proceed in an eight-month period due to manpower deficits in organ donation and transplantation. In June, MI revealed that pancreas transplant surgery was only taking place Monday-to-Friday.

In November, the board of the Irish Kidney Association (IKA) wrote to SVUH CEO Ms Kay Connolly to express its “grave concern” at media reports on potential pancreas transplants not proceeding, due to the restricted hours of the service.

The correspondence was copied to outgoing Minister for Health Simon Harris and obtained from the Department under Freedom of Information law.

“Given that there are upwards of 16 patients currently on the list awaiting pancreas and kidney transplant transplants, a number of whom have been waiting for many years, this is a truly alarming situation which has caused great anxiety and adverse comment among our members,” according to the correspondence from the IKA board.

The letter outlined that the kidney, liver, heart and lung transplant programmes were 24/7 services and “we find it difficult to explain to our members why a similar situation does not obtain in respect of pancreas/kidney transplants”.

Last month, a spokesperson for SVUH said there were 22 patients

on the active list for a simultaneous pancreas and kidney transplant and one patient awaiting a pancreas transplant following a kidney transplant.

“Since the commencement of the service in 2016, one patient who was on the waiting list has died and, respecting patient confidentiality, we cannot give details of their death or its causes.

“It is important to note that patients are not transplanted in order of the sequence that they are added to the waiting list. Priority for transplant is based on clinical fitness to transplant, donor availability and donor-recipient suitability.

“No pancreas is retrieved from a donor and transplanted to a recipient without these criteria being met. Funding received and allocated to the pancreas transplant service is €1.92 million annually 2018-2020.”

Regions will facilitate physical and mental health integration — Minister DAVID LYNCH The creation of the six new health regions will help integration of mental and physical healthcare, outgoing Minister for Health Simon Harris informed the College of Psychiatrists of Ireland in correspondence.

In September, the College’s Faculty of Liaison Psychiatry raised concerns with the Minister regarding integration between services under the Sláintecare plan.

In November, Mr Matthew O’Gorman, Private Secretary at the Department of Health, replied on behalf of Minister Harris.

Mr O’Gorman’s letter stated that the Minister “shares your view that where care is truly integrated, the outcomes for patients are much better”.

The letter indicated that the creation of regional care organ-

isations “will enable a better planned and more fairly funded system with services that are more joined-up and able to provide truly integrated care”.

In its letter, the Faculty of Liaison Psychiatry stated that after publication of Sláintecare, “we were disappointed and disheartened to see little mention of integration of mental and physical healthcare in any of the key documents that followed”.

“Where care is truly integrated, the outcomes for patients are much better. Unfortunately, essential integrated mental health services are often at most an afterthought in the design of specialist services such as those for cystic fibrosis, transplantation, etc.

“We strongly recommend and call for the inclusion of essential integration of mental and physical healthcare in the scope for the implementation of Sláintecare.

“True parity of esteem of mental and physical healthcare with improved and greater outcomes and reduced cost of hospital care is not possible without this.”

Separately, in his reply on behalf of Minister Harris, Mr O’Gorman noted that the Department “will publish a refreshed national mental health policy” this year.

“The refreshed policy seeks to ensure that mental health is at the centre of healthcare provision in Ireland and aligned fully with Sláintecare. The refreshed policy will make recommendations about developing a mental health service that is population-based, supported by whole of Government and encourages interdisciplinary working.”

According to the Department, it is finalising “a revised national mental health policy”. This work is “nearing completion and will be published as soon as it can be approved by Government”.

DAVID LYNCH A review of the evidence in relation to the potential harms of e-cigarettes and their effectiveness as a smoking cessation aid is expected to be completed next month, this newspaper has been informed. A Department of Health spokesperson told the Medical Independent that the review, which is being undertaken by the Health Research Board (HRB), is due to be completed in April.

The Director of the Irish Vape Vendors Association Mr Declan Connolly wrote to outgoing Minister for Health Simon Harris in September about the “recent hysteria about vaping [that] has led to alarmist reactions, not just in the US, but also worldwide, including Ireland”. Mr Alan Kelly, Private Secretary in the Department of Health, responded on behalf of Minister of State for Health Promotion and National Drugs Strategy Catherine Byrne.

“As you are aware, the current position on e-cigarettes in Ire-

land is based on advice to the Minister for Health from the Health Information and Quality Authority (HIQA) in its 2017 health technology assessment of ‘smoking cessation products and services’,” wrote Mr Kelly.

“In relation to the safety of e-cigarettes, the HIQA assessment concluded that this remains an evolving area of research, while potentially safer than smoking, evidence of long-term safety has yet to be established.

“In relation to e-cigarettes as an aid to smoking cessation, HIQA advised the Minister for Health as follows: ‘Although the currently available research results for e-cigarettes are promising, there is insufficient evidence at present to reliably demonstrate their effectiveness as an aid to smoking cessation’.”

Mr Kelly added that the review conducted by the HRB would also influence Government advice.

“Although the HIQA assessment was published only in 2017, the evidence on e-cigarettes is rapidly evolving,” he wrote.

Steady increase in patients receiving Suboxone DAVID LYNCH There was a steady increase in the number of patients attending for opioid substitution treatment (OST) with buprenorphine/naloxone (Suboxone) in the final months of last year, according to recent figures provided to this newspaper.

New HSE figures show this number had increased to 261 by December. This compares with 203 patients, as reported in the Medical Independent (MI) in April 2019.

At the end of 2017, there were 110 patients in receipt of Suboxone, an alternative substitution treatment for opioid drug dependence. New regulations were introduced in November 2017 to provide access to certain buprenorphine-based medicinal products in the OST system on the same statutory basis as methadone. HSE figures showed that, in September, 237 patients were receiving Suboxone, 240 in

October, 249 in November and 261 in December. GPs contacted by MI last August said access to Suboxone was working well but they did not predict a major shift of patients from methadone.

In December, there were 9,713 patients attending for methadone treatment, according to the HSE. “It is the HSE’s intention to expand the availability of opioid substitution treatment (buprenorphine-based products) as appropriate,” a HSE spokesperson told MI. “Training has been delivered in HSE addiction services in relation to buprenorphine/naloxone (Suboxone) prescribing.

“Level II GPs in the community who have received training can also prescribe.

“We continue to monitor the numbers in receipt of this form of OST and encourage services to consider this option when appropriate when treating individuals with opioid dependence syndrome.”

VOX BOX We are conscious of our responsibility to protect the patients and individuals who report themselves to health authorities. We call on the media to respect patient confidentiality and understand our efforts to protect the privacy of the people we serve.”

Many service providers were aware of emerging evidence in the area of adverse childhood experiences. There is now evidence that these adverse experiences in childhood have significant negative effects on mental and physical health into adulthood.”

Chief Medical Officer Dr Tony Holohan explaining the decision not to name the secondary school in the east, which was closed for the duration of the Covid-19 incubation period, following a confirmed case.

Dr Geraldine Casey, SpR in Public Health Medicine, Department of Public Health, HSE Mid-West, speaking at the Social Determinants of Health Ireland 2020 Conference on research into the effect of homelessness on children in Limerick.

E-cigarettes are still fairly new, so we don’t yet know how safe they are and it will take some time for us to fully understand the risks and benefits. There are still questions about whether they work as stop smoking aids.”

Dr Paul Kavanagh, HSE Public Health Medicine Specialist, commenting on National No Smoking Day last month.

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10

THE MEDICAL INDEPENDENT | 12 MARCH 2020

News

HSE continues to implement Scally recommendations NIAMH CAHILL More than 100 HSE actions developed on foot of recommendations made in reports

by Dr Gabriel Scally following the CervicalCheck controversy have been completed. The HSE was given responsibility for 116 out of the 170 actions arising from 58 recommendations in Dr Scally’s reports.

To date, it has completed 105 actions, leaving 11 outstanding for completion, a HSE spokesperson told the Medical Independent.

The progress comes as the HSE prepares to introduce human papillomavirus (HPV) cervical screening at the end of March, which the Scally review noted would “significantly improve the accuracy

of the screening process, increasing the chances of more cancers being prevented due to the detection of early changes”.

The HSE says “significant resources” have been allocated to the HPV project, including communications, quality assurance, and laboratories.

But healthcare professionals have criticised the HSE for failing to increase staffing and facilities in advance of the introduction of HPV screening, a move which the Scally review said would “lead to more unnecessary referrals for further investigation”.

Under the new screening programme, at the first test women who are positive for HPV will either be tested again in 12 months’ time or referred to colposcopy for further investigation. According to a

HSE spokesperson, the CervicalCheck programme is supported directly by 37 staff working in clinical, technical, managerial and support roles in both Limerick and Dublin, up from 29 in January 2018.

HPV testing is being introduced after it was recommended in a 2017 HIQA health technology assessment. Information distributed to GPs by CervicalCheck in recent weeks states that in January, the programme ceased sending invitation letters to women to participate in the screening programme, with the exception of women who required a 12-month recall or a “failsafe” letter.

Once HPV screening gets underway on 30 March, CervicalCheck will recommence issuing invitation letters.

Yes we can

Minister sought late changes to HSE service plan DAVID LYNCH The HSE National Service Plan 2020 was subject to late changes with new funding, including winter capacity measures, approved just days before publication on 17 December.

In correspondence to Chair of the HSE board Mr Ciarán Devane on 22 November, Minister for Health Simon Harris indicated his approval for the draft plan, subject to “a small number of amendments”.

Mr Devane replied on 29 November advising that the HSE board accepted these amendments and re-submitted the updated plan to the Minister However, on 13 December, Minister Harris wrote to Mr Devane seeking a number of new amendments following meetings with cabinet colleagues.

“In considering the revised plan, I have consulted with colleagues and I am very happy to inform you that the Minister for Finance and Public Expenditure and Reform has now advised me of a commitment to provide additional funding to the Health Vote of €50 million in the Revised Estimates Volumes of 2020,” wrote Minister Harris.

The Minister outlined the extra funding, which included €26 million to the nursing homes support scheme (NHSS), €5 million “to enhance disability services” and €13.8 million for “additional winter capacity, including egress measures such as additional home care packages and transitional care”.

“Given the increased services that can be provided, it is important that the commitment to additional funding, as outlined above, be reflected in the national service plan.”

In his response, also on 13 December, Mr Devane welcomed the Minister’s letter and stated that “the plan has been amended to reflect increases in activity levels of disability services, NHSS and transitional care services”.

The letters were seen by the Medical Independent following a Freedom of Information request.

HSE in ‘regular’ meetings with Irish Water following boil water notice DAVID LYNCH

✓ IBUGEL has been proven to be as effective as 400 mg ibuprofen tablets t.i.d. (1200mg) in soft tissue injuries.1 ✓ IBUGEL has been shown to achieve up to 4 times greater skin penetration compared to other contemporary 5% ibuprofen gel formulations.2

Prescribe IBUGEL by name.

Ibuprofen 5.0% w/w.

Uses: For backache, rheumatic and muscular pain, sprains, strains and neuralgia. Also for relief of pain due to non-serious arthritic conditions.

Directions: Adults, the elderly and children (only on medical advice if under 12 years): Gently massage into and around the affected areas until absorbed, up to 3 times daily.

Contra-indications, warnings, side effects etc: Please refer to SPC for full details before prescribing. Do not use on broken skin, during pregnancy or lactation, or if sensitive to any of the ingredients, particularly in patients with asthma or allergic disease known to be hypersensitive to such painkillers. Keep away from eyes and mucous membranes. This product should not be used with occlusive dressings. Occasionally mild skin rashes, itching or irritation may occur at the site of application.

Concurrent use of NSAID tablets including aspirin may increase possibility of side-effects.

Further information is available from the MA holder: Dermal Laboratories, Tatmore Place, Gosmore, Hitchin, Herts, SG4 7QR, UK. Date of preparation: July 2018.

‘Ibugel’ is a trademark.

Adverse events should be reported to Dermal and the HPRA at www.hpra.ie.

References: 1. Whitefield M. et al. Comparative efficacy of a proprietary topical ibuprofen gel and oral ibuprofen in acute soft tissue injuries: a randomized, double-blind study. Journal of Clinical Pharmacy and Therapeutics; Vol 27, No. 6, December 2002. 2. Hadgraft J, Whitefield M, Rosher P.H. Skin penetration of topical formulations of ibuprofen 5%: An in vitro comparative study. Skin Pharmacology and Applied Skin Physiology. 2003; 16: 137-142.

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The HSE remains in “regular tripartite meetings” with Irish Water and the Environmental Protection Agency (EPA) about issues of water quality from the water treatment plant in Leixlip, Co Kildare, this newspaper has been told.

“In relation to the two boil water notices in the greater Dublin area last October and November (applied to areas served by Leixlip treatment plant), there was extensive regular communication and interaction between Irish Water and the HSE,” an Irish Water spokesperson told the Medical Independent (MI).

“Since the lifting of the second notice [in November], there have been regular tripartite meetings between Irish Water, the HSE, and the EPA in relation to Leixlip, where any potential risks are discussed and reviewed.”

The HSE signed-off on “health aspects” of the Irish Water press release published at the beginning of the major boiled water notice that was issued for much of Dublin city and county in October. According to correspondence seen

by MI following a Freedom of Information request, the HSE worked closely with Irish Water in relation to the two boil water notices.

A one-page report, prepared for the HSE for the Minister for Health regarding the October boil water notice stated, “Irish Water informed the HSE and EPA at 11am on Tuesday 22 October of a mechanical failure at Leixlip water treatment plant.”

A subsequent meeting between the EPA, the HSE and Irish Water that same day led to the issuing of the notice.

“The HSE agreed the health aspects of the Irish Water press release and issued a further two press releases, one dealing with issues for the public and patients, and a separate one for food manufactures and providers. The HSE also contacted all affected hospitals and other premises on Tuesday evening.”

An Irish Water spokesperson told this newspaper: “The HSE is a statutory consultee to Irish Water in matters of public health and drinking water. Under this regulation, Irish Water must consult with the HSE and agree whether the drinking water in a supply poses a risk to public health (ie, following an incident), and if so, determine what advice must be issued immediately to all affected consumers.”

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tiotropium & olodaterol Prescribing Information (Ireland) SPIRIVA® RESPIMAT® (tiotropium) Inhalation solution containing 2.5 microgram tiotropium (as bromide monohydrate) per puff. Indication: COPD: Tiotropium is indicated as a maintenance bronchodilator treatment to relieve symptoms of patients with chronic obstructive pulmonary disease (COPD). Asthma: Spiriva Respimat is indicated as add-on maintenance bronchodilator treatment in patients aged 6 years and older with severe asthma who experienced one or more severe asthma exacerbations in the preceding year. Dose and Administration: COPD Adults only age 18 years or over: 5 microgram tiotropium given as two puffs from the Respimat inhaler once daily, at the same time of the day. Asthma Adults and patients 6 to 17 years of age: 5 microgram tiotropium given as two puffs from the Respimat inhaler once daily, at the same time of the day. In adult patients with severe asthma, tiotropium should be used in addition to inhaled corticosteroids (≥ 800 µg budesonide/day or equivalent) and at least one controller. In adolescents (12 - 17 years) with severe asthma, tiotropium should be used in addition to inhaled corticosteroids (> 800 - 1600 µg budesonide/day or equivalent) and one controller or in addition to inhaled corticosteroids (400 - 800 µg budesonide/day or equivalent) with two controllers. For children (6 - 11 years) with severe asthma, tiotropium should be used in addition to inhaled corticosteroids (> 400 µg budesonide/day or equivalent) and one controller or in addition to inhaled corticosteroids (200 - 400 µg budesonide/day or equivalent) with two controllers. Contraindications: Hypersensitivity to tiotropium bromide, atropine or its derivatives, e.g. ipratropium or oxitropium or to any of the excipients; benzalkonium chloride, disodium edetate, purified water, hydrochloric acid 3.6 % (for pH adjustment). Warnings and Precautions: Benzalkonium chloride may cause wheezing and breathing difficulties; patients with asthma are at an increased risk for these adverse events. Not for the initial treatment of acute episodes of bronchospasm or for the relief of acute symptoms.

Spiriva Respimat should not be used as monotherapy for asthma. Asthma patients must be advised to continue taking antiinflammatory therapy, i.e. inhaled corticosteroids, unchanged after the introduction of Spiriva Respimat, even when their symptoms improve. Immediate hypersensitivity reactions may occur after administration of tiotropium bromide inhalation solution. Caution in patients with narrow-angle glaucoma, prostatic hyperplasia or bladder-neck obstruction. Inhaled medicines may cause inhalation-induced bronchospasm. Tiotropium should be used with caution in patients with recent Prescribing Information (Ireland)

myocardial infarction < 6 months; any unstable or life threatening cardiac arrhythmia or cardiac arrhythmia requiring intervention or a change in drug therapy in the past year; hospitalisation of heart failure (NYHA Class III or IV) within the past year. These patients were excluded from the clinical trials and these conditions may be affected by the anticholinergic mechanism of action. In patients with moderate to severe renal impairment (creatinine clearance ≤ 50 ml/min) tiotropium bromide should be used only if the expected benefit outweighs the potential risk. Patients should be cautioned to avoid getting the spray into their eyes. They should be advised that this may result in precipitation or worsening of narrowangle glaucoma, eye pain or discomfort, temporary blurring of vision, visual halos or coloured images in association with red eyes from conjunctival congestion and corneal oedema. Should any combination of these eye symptoms develop, patients should stop using tiotropium bromide and consult a specialist immediately. Tiotropium bromide should not be used more frequently than once a day. Interactions: Although no formal drug interaction studies have been performed, tiotropium bromide has been used concomitantly with other drugs commonly used in the treatment of COPD and asthma, including sympathomimetic bronchodilators, methylxanthines, oral and inhaled steroids, antihistamines, mucolytics, leukotriene modifiers, cromones, anti-IgE treatment without clinical evidence of drug interactions. Use of LABA or ICS was not found to alter the exposure to tiotropium. The co-administration of tiotropium bromide with other anticholinergiccontaining drugs has not been studied and is therefore not recommended. Fertility, Pregnancy and Lactation: Very limited amount of data in pregnant women. Avoid the use of Spiriva Respimat during pregnancy. It is unknown whether tiotropium bromide is excreted in human breast milk. Use of Spiriva Respimat during breast feeding is not recommended.

A decision on whether to continue/discontinue breast feeding or therapy with Spiriva Respimat should be made taking into account the benefit of breast feeding to the child and the benefit of Spiriva Respimat therapy to the woman. Clinical data on fertility are not available for tiotropium. Effects on ability to drive and use machines: No studies have been performed. The occurrence of dizziness or blurred vision may influence the ability to drive and use machinery. Undesirable effects: COPD: Common (≥ 1/100 to < 1/10) Dry mouth. Uncommon (≥ 1/1,000 to < 1/100) Dizziness, headache, cough,

pharyngitis, dysphonia, constipation, oropharyngeal candidiasis, rash, pruritus, urinary retention, dysuria. Rare (≥1/10,000 to <1/1,000): Insomnia, glaucoma, intraocular pressure increased, vision blurred, atrial fibrillation, palpitations, supraventricular tachycardia, tachycardia, epistaxis, bronchospasm, laryngitis, dysphagia, gastrooesophageal reflux disease, dental caries, gingivitis, glossitis, angioneurotic oedema, urticaria, skin infection/skin ulcer, dry skin, urinary tract infection. Not known (cannot be estimated from the available data): Dehydration, sinusitis, stomatitis, intestinal obstruction including ileus paralytic, nausea, hypersensitivity (including immediate reactions), anaphylactic reaction, joint swelling.

Asthma: Uncommon (≥ 1/1,000 to < 1/100) Dizziness, headache, insomnia, palpitations, cough, pharyngitis, dysphonia, bronchospasm, dry mouth, oropharyngeal candidiasis, rash. Rare (≥1/10,000 to <1/1,000): Epistaxis, constipation, gingivitis, stomatitis, pruritus, angioneurotic oedema, urticaria, hypersensitivity (including immediate reactions), urinary tract infection. Not known (cannot be estimated from the available data): Dehydration, glaucoma, intraocular pressure increased, vision blurred, atrial fibrillation, supraventricular tachycardia, tachycardia, laryngitis, sinusitis, dysphagia, gastrooesophageal reflux disease, dental caries, glossitis, intestinal obstruction including ileus paralytic, nausea, skin infection/skin ulcer, dry skin, anaphylactic reaction, joint swelling, urinary retention, dysuria. Serious undesirable effects consistent with anticholinergic effects: glaucoma, constipation, intestinal obstruction including ileus paralytic and urinary retention. An increase in anticholinergic effects may occur with increasing age. Prescribers should consult the Summary of Product Characteristics for further information on undesirable effects. Pack sizes: Single pack: 1 Respimat re-usable inhaler and 1 cartridge providing 60 puffs (30 medicinal doses); Single refill pack: 1 cartridge providing 60 puffs (30 medicinal doses). Legal category: POM. MA number: PA 775/2/2. Marketing Authorisation Holder: Boehringer Ingelheim International GmbH, D-55216 Ingelheim am Rhein, Germany. Prescribers should consult the Summary of Product Characteristics for full prescribing information. Additional information is available on request from Boehringer Ingelheim Ireland Ltd, The Crescent Building, Northwood, Santry, Dublin 9. Prepared in October 2019.

hypertension, and aneurysm; convulsive disorders or thyrotoxicosis; known or suspected prolongation of the QT interval (e.g. QT>0.44 s); patients unusually responsive to sympathomimetic amines; in some patients beta2-agonists may produce significant hypokalaemia; increases in plasma glucose after inhalation of high doses. Caution in planned operations with halogenated hydrocarbon anaesthetics due to increased susceptibility of adverse cardiac effects.

Should not be used in conjunction with any other long-acting beta2-adrenergic agonists. Immediate hypersensitivity reactions may occur after administration. Should not be used more frequently than once daily. Benzalkonium chloride may cause wheezing and breathing difficulties; patients with asthma are at an increased risk for these adverse events. Interactions: Although no formal in vivo drug interaction studies have been performed, inhaled Spiolto Respimat has been used concomitantly with other COPD medicinal products, including short acting sympathomimetic bronchodilators and inhaled corticosteroids without clinical evidence of drug interactions. The co-administration of the component tiotropium with other anticholinergic containing drugs has not been studied and therefore is not recommended. Concomitant administration of other adrenergic agents (alone or as part of combination therapy) may potentiate the undesirable effects of Spiolto Respimat. Concomitant treatment with xanthine derivatives, steroids, or nonpotassium sparing diuretics may potentiate any hypokalaemic effect of adrenergic agonists. Beta-adrenergic blockers may weaken or antagonise the effect of olodaterol. Cardioselective beta-blockers could be considered, although they should be administered with caution. MAO inhibitors, tricyclic antidepressants or other drugs known to prolong the QTc interval may potentiate the action of Spiolto Respimat on the cardiovascular system. Fertility, pregnancy and lactation: There is a very limited amount of data from the use of tiotropium in pregnant women. For olodaterol no clinical data on exposed pregnancies are available. As a precautionary measure, avoid the use of Spiolto Respimat during pregnancy. Like other beta2-adrenergic agonists, olodaterol may inhibit labour due to a relaxant effect on uterine smooth muscle. It is not known whether tiotropium and/or olodaterol pass into human breast milk. A decision on whether to continue/discontinue breast-feeding or to continue/

discontinue therapy with Spiolto Respimat should be made taking into account the benefit of breast-feeding to the child and the benefit of therapy for the woman. Clinical data on fertility are not available for tiotropium or olodaterol or the combination of both components. Effects on ability to drive and use machines: No studies have been performed. The occurrence of dizziness or blurred vision may influence the ability to drive and use machinery. Undesirable effects: Uncommon (≥ 1/1,000 to <1/100): Dizziness, headache, tachycardia, cough, dysphonia, dry mouth. Rare (≥ 1/10,000 to <1/1,000): Insomnia, vision blurred, atrial fibrillation, palpitations, supraventricular tachycardia, hypertension, laryngitis, pharyngitis, epistaxis, bronchospasm, constipation, oropharyngeal candidiasis, gingivitis, nausea, stomatitis, hypersensitivity, angioedema, urticaria, pruritus, rash, arthralgia, back pain, joint swelling, urinary retention, urinary tract infection, dysuria. Not known (cannot be estimated from the available data): Nasopharyngitis, dehydration, glaucoma, intraocular pressure increased, sinusitis, intestinal obstruction ileus paralytic, dysphagia, gastrooesophageal reflux disease, glossitis, dental caries, anaphylactic reaction, skin infection and skin ulcer, dry skin. Serious undesirable effects consistent with anticholinergic effects: glaucoma, constipation, intestinal obstruction including ileus paralytic and urinary retention. An increase in anticholinergic effects may occur with increasing age. The occurrence of undesirable effects related to beta-adrenergic agonist class should be taken into consideration such as, arrhythmia, myocardial ischaemia, angina pectoris, hypotension, tremor, nervousness, muscle spasms, fatigue, malaise, hypokalaemia, hyperglycaemia and metabolic acidosis. Prescribers should consult the Summary of Product Characteristics for further information on side effects. Pack sizes: Single pack: 1 Respimat re-usable inhaler and 1 cartridge providing 60 puffs (30 medicinal doses); Single refill pack: 1 cartridge providing 60 puffs (30 medicinal doses) Legal category: POM. MA numbers: PA 775/9/1. Marketing Authorisation Holder: Boehringer Ingelheim International GmbH, D-55216 Ingelheim am Rhein, Germany. Prescribers should consult the Summary of Product Characteristics for full prescribing information. Additional information is available on request from Boehringer Ingelheim Ireland Ltd, The Crescent Building, Northwood, Santry, Dublin 9. Prepared in October 2019

SPIOLTO® RESPIMAT® (tiotropium and olodaterol)

Inhalation solution containing 2.5 microgram tiotropium (as bromide monohydrate) and 2.5 microgram olodaterol (as hydrochloride) per puff. Action: Inhalation solution containing a long acting muscarinic receptor antagonist, tiotropium, and a long acting beta2-adrenergic agonist, olodaterol. Indication: Maintenance bronchodilator treatment to relieve symptoms in adult patients with chronic obstructive pulmonary disease (COPD). Dose and Administration: Adults only aged 18 years or over: 5 microgram tiotropium and 5 microgram of olodaterol given as two puffs from the Respimat inhaler once daily, at the same time of the day. Contraindications: Hypersensitivity to tiotropium or olodaterol or any of the excipients; benzalkonium chloride, disodium edetate, purified water, 1M hydrochloric acid (for pH adjustment); atropine or its derivatives e.g. ipratropium or oxitropium. Warnings and Precautions: Not for use in asthma or for the treatment of acute episodes of bronchospasm, i.e. as rescue therapy. Inhaled medicines may cause inhalation-induced paradoxical bronchospasm. Caution in patients with narrow-angle glaucoma, prostatic hyperplasia or bladder-neck obstruction. Patients should be cautioned to avoid getting the spray into their eyes. They should be advised that this may result in precipitation or worsening of narrow-angle glaucoma, eye pain or discomfort, temporary blurring of vision, visual halos or coloured images in association with red eyes from conjunctival congestion and corneal oedema. Should any combination of these eye symptoms develop, patients should stop using Spiolto Respimat and consult a specialist immediately. In patients with moderate to severe renal impairment (creatinine clearance ≤ 50ml/min) use only if the expected benefit outweighs the potential risk. Caution in patients with a history of myocardial infarction during the previous year, unstable or lifethreatening cardiac arrhythmia, hospitalised for heart failure during the previous year or with a diagnosis of paroxysmal tachycardia (> 100 beats per minute) as these patients were excluded from the clinical trials. In some patients, like other beta-adrenergic agonists, olodaterol may produce a clinically significant cardiovascular effect as measured by increases in pulse rate, blood pressure and/or symptoms. Caution in patients with: cardiovascular disorders, especially ischaemic heart disease, severe cardiac decompensation, cardiac arrhythmias, hypertrophic obstructive cardiomyopathy,

Adverse events should be reported to the Health Products Regulatory Authority at www.hpra.ie or by email to medsafety@hpra.ie. Adverse events should also be reported to Boehringer Ingelheim Drug Safety on 01 291 3960 or by email to PV_local_uk_ireland@boehringer-ingelheim.com References: 1. Hochrainer D et al. J Aerosol Med Pulm Drug Deliv 2005;18(3):273–82. 2. Dalby R et al. Int J Pharm 2004;283(1–2):1–9. 3. Pitcairn G et al. J Aerosol Med 2005;18(3):264–72. 4. Hansel M et al. Adv Ther 2019;36(9):2487–92. 5. SPIOLTO® Respimat® Summary of Product Characteristics.

Date of preparation: February 2020

PC-IE-100738

12

THE MEDICAL INDEPENDENT | 12 MARCH 2020

News Feature

Health protection and health security in Ireland in the time of Covid-19 Consultant in Public Health Medicine and member of the IMO public and community health committee Dr Ina Kelly outlines the importance of public health medicine in combating the spread of the new coronavirus

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he recent international reporting of a novel coronavirus (Covid-19) in Wuhan, Hubei province, China, has heightened awareness of the global risks of new serious infectious diseases, for which no human immunity exists. It has also highlighted the work of an under-appreciated specialty within our public health service, namely that of public health medicine.

Public health medicine reaches beyond the usual boundaries of the healthcare system. Doctors in this specialty work in national government agencies, local community and voluntary organisations, as well as within the health service. Public health medicine works to improve and protect the health of the population, rather than treating individual patients. Public health physicians have specialist knowledge of health protection, health service development, and health improvement.

One of the largest domains of public health medicine is health protection. The International Health Regulations 2005 aim is to “prevent, protect against, control, and provide a public health response to the international spread of disease”, and each country’s obligation is mainly carried out by their public health medical service. In short, public health medicine carries statutory responsibility for the health security of the State.

While the global response requires co-ordinated efforts from all, including governments and frontline healthcare services, as in other UN member states, the public health medicine services in Ireland lead on biological emergencies, anticipate emerging pathogens (and all other hazards), and prepare to protect health when new risks occur. Most of this preparedness involves considerable unseen expertise and workload so that in an emergency the response is as effective as possible. To maximise protection we in public health medicine use our legislation to facilitate timely and effective investigation, surveillance, and control actions for our population. The ultimate goal is to prevent any avoidable case of such infection within Ireland and to contribute to global efforts to control the new infection.

HPSC The health protection services in Ireland are mainly led by the Health Protection Surveillance Centre (HPSC) and the eight Departments of Public Health, each of which has public health responsibility for a defined geographic region.

The HPSC is the national focal point for information from the World Health Organisation (WHO) and European Centre for Disease Prevention and Control to Ireland, and vice versa. It disseminates epidemiological information, expert advice and monitors global developments, including international preparedness efforts to inform Irish policy and practice. A recent report by the Global Preparedness Monitoring Board was clear in its analysis that “the world is not prepared for the next global pandemic”.

Preparedness needs significant investment, in capacity and capabilities. The cost from being unprepared may vastly outweigh the

cost of prevention. The size of the SARS outbreak in Canada in 2003 with 44 deaths was associated with reduced public health capacity. Tourism costs alone were cited as 1.5 billion Canadian dollars. This is not just a health issue, but a financial issue. The World Bank Working Group on Financial Preparedness makes detailed recommendations in its report From Panic and Neglect to Investing in Health Security, including to prioritise health security in budgets. In Ireland, while we take preparedness seriously, significantly more investment is needed to ensure that systems are robust and tested during the interpandemic phases of the emergency response cycle. We are in a world where preparedness investment is a necessity, not a luxury. In fact, after the devastation of the 2014 Ebola outbreak in West Africa, the WHO set up the WHO Emergency Programme to: • Address the gap in preparedness investment; • To ensure readiness to diminish public health risks in countries with high vulnerability; and • To provide life-saving health services to affected populations in countries with ongoing emergencies.

Part of preparedness is the ongoing risk assessment. When suspected cases of disease appear in Ireland, the investigation and control actions are carried out by specialists in public health medicine/medical officers of health in Departments of Public Health that cover the eight regions. The public health medicine service works with the existing emergency management structures, providing the necessary risk assessments,

contact tracing, and medical advice to all who need it.

Since the first notifications of 2019 novel coronavirus in early January 2020, public health medicine working groups have been developing algorithms to assist streamlined, evidence-based and efficient care and risk assessment. These algorithms are modified in response to new risk information, which occurs generally every few days. As of 30 January, when the WHO declared a Public Health Emergency of International Concern (PHEIC), the service has been gearing up to provide surge capacity as needed.

Crowe Horwath The Crowe Horwath final report on the Role, Training, and Career Structures of Public Health Physicians in Ireland recognised the challenges and unsustainability facing the current public health medicine service and recommended it be strengthened in many ways including the need for consultant contracts. Industrial action was deferred in late 2018 because the IMO is now in negotiations with the Department of Health to strengthen the public health medicine service through provision of consultant contracts and significant reform of the service.

Many of our newly trained consultant level doctors are depending on a satisfactory resolution of negotiations to continue their careers here in Ireland. The status quo has been acknowledged at all levels as unsustainable.

Despite the challenges of lack of investment in health security, the public health medicine service is stepping up to provide extended frontline hours, additional weekend services and doubling of on-call cover,

despite already stretched rosters.

Our goal as always is to protect people, so that while we may not be able to prevent a case entering Ireland, we will do all in our power to prevent secondary cases from occurring. We will also deal with calls from anxious members of the public and provide advice to health professionals, hospitals and other healthcare facilities, communications and media proactively and reactively. There is a need to balance sufficient communication and information with the need to manage uncertainty among both healthcare professionals and the general public. We hope to be able to maintain capacity throughout this PHEIC [Public Health Emergency of International Concern], although the specialty has been much reduced and underfunded in recent years.

We have great faith that Ireland will see the value in investing in health security into the future, towards a strengthened public health medicine service to protect us all. The coronavirus is an unfortunate reminder of the need to have a strong and robust public health medicine service with appropriate structures and governance to ensure adequate health protection measures and capability are in place for such events.

Health protection is just one aspect of public health medicine with health service improvement, health service development and population health initiatives also being essential elements of the public health medicine specialty. Now more than ever we need to invest in the specialty to ensure that future generations can enjoy better health systems, public health initiatives, and public health security.

14

THE MEDICAL INDEPENDENT | 12 MARCH 2020

News Interview

Addressing hearing and vision impairment may help dementia Prof Iracema Leroi speaks about her research and work with the European research programme, SENSE-Cog

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he notion of sensory cognitive health is a relatively new idea,” according to Prof Iracema Leroi, a dementia expert at the Global Brain Health Institute, Associate Professor in Geriatric Psychiatry at Trinity College Dublin, and a Consultant Psychiatrist in St James’s Hospital, Dublin. She is discussing her ongoing work on the innovative European research pro-

gramme SENSE-Cog: Promoting health for eyes, ears, and mind, which examines the impact of sensory impairments on those with dementia.

SENSE-Cog, which is funded by the EU’s Horizon 2020 programme, has been in existence since 2016 and runs until the end of 2021. It is at the forefront of the new field of sensory-cognitive health for people with dementia and the project

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has produced a number of illuminating pieces of research since its inception. Prof Leroi is the project’s Chief Investigator and will be presenting insights from this innovative five-year programme at the RCPI’s upcoming conference, Dementia – A Clinical Update, on 25 March.

Origins Talking about the research to-date, Prof Leroi says that the idea for the project initially arose from a conversation with a colleague at the University of Manchester about the impact of hearing impairment on people with dementia – statistics show that seven-in-10 Europeans over the age of 65 live with sight or hearing problems and over two-thirds live with depression or dementia.

Prof Iracema Leroi

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“We thought looking at hearing and vision impairment in older adults with cognitive impairment would be very important because there is a huge gap in our understanding and practice and no one really had looked at this before.”

The overarching idea behind the project was to “think about sensory cognitive health as a cohesive whole”, something which might often be overlooked in a person with a diagnosis of dementia. There are many reasons why this can happen, says Prof Leroi.

“It’s partly a lack of awareness, it’s partly because people have difficulty reporting these problems and partly because people’s general health gets marginalised as they develop dementia. The focus becomes less on the physical health.”

She says that the way care is delivered can also be a factor in this respect as treatment and assessment can be “very segmented”. “Psychiatrists don’t necessarily talk to the optometrists or audiologists [and vice versa]...”

She says that “upwards of 80 per cent of people with dementia in some settings have hearing impairments and most often it’s not identified”.

Prof Leroi continues: “As people get older the risk of developing cognitive impairment leading to dementia increases, likewise hearing impairment and vision impairment increase. Hearing impairment and vision impairment are disciplines that people look at very separately. Instead we are aiming for interdisciplinarity and bringing them all together to better understand how we can support people’s cognitive-sensory health.”

The idea behind the project is to eventually “develop new tools and at-home support that could improve quality-of-life and help optimise health and social care budgets and resource allocation across Europe”.

Early intervention When it comes to the effect of sensory impairment on someone with dementia, Prof Leroi says that the results of their first phase of research, released in February 2019, revealed

15

THE MEDICAL INDEPENDENT | 12 MARCH 2020

Interview News some key information.

“Our data showed that people with poor hearing have lower cognitive function as they age, so the normal age-related cognitive decline is more rapid [and] the trajectory of that decline is steeper.”

An important takeaway from this concerned early intervention when it comes to providing treatment such as hearing aids or cataract removal. Prof Leroi says that research is suggesting that, “if you get an intervention, like a hearing aid, the trajectory of your decline may slow.”

One area which sensory impairment also feeds into, when it comes to dementia and cognitive decline, is in the area of loneliness.

“What we looked at is loneliness in relation to cognitive impairment,” she says.

“What we clearly showed was that there was a direct relationship between hearing impairment and cognition and loneliness.”

SENSE-Cog’s ongoing research looks set to be equally thought-provoking. Their latest project aims to develop a test to diagnose dementia that can be taken by those who may have a sensory impairment. It is based on the Montreal Cognitive Assessment (MoCA) model – the MoCA team is supporting the project – but with adaptations that take into account the limitations of the test for those with hearing and/or vision impairment.

Prof Leroi explains “If someone’s hearing or vision is impaired it’s very difficult to do assessments because they generally involve a traditional neuropsychological battery.

These batteries are very dependent on having intact hearing and vision.”

The adapted MoCA for hearing and vision impairment is now being validated in over 600 participants across Europe.

It is Prof Leroi’s hope that this could be a breakthrough tool in the diagnostic process for cognitive impairment in those with sensory impairments.

With recent estimates from Dementia in Europe Yearbook 2019 (Alzheimer Europe) saying that in Ireland by 2050 some 141,200 people will be living with dementia – more than double the number currently living with the condition – such an increase puts into sharp relief the need for a diagnostic test of this kind.

While the primary goal would be to first roll out the test as best practice across Europe, Prof Leroi hopes that interventions of this kind and the research of SENSE-Cog might assist globally to help those with dementia.

If someone’s hearing or vision is impaired it’s very difficult to do assessments because they generally involve a traditional neuropsychological battery.

These batteries are very dependent on having intact hearing and vision

“We are now looking for pragmatic cost-effective interventions that can be scaled up into different settings. Thus, we are conducting a clinical trial to evaluate whether improving hearing and vision in people already living with dementia will improve their quality-of-life.” The trial is being conducted in five EU countries. In Dublin, Prof Brian Lawlor is leading this part of the work at St James’s Hospital. Prof Leroi mentions lower- and middle-income countries, where she says this non-drug intervention could be a relatively simple and cost-effective way of helping, not only in terms of people with dementia, but in breaking down “stigma and lack of understanding about dementia in those countries”.

This is something that feeds into her work at the Global Brain Health at Trinity College Dublin where the SENSECog research takes place.

Dementia burden Prof Leroi says that it is important to keep in mind the global

brain health agenda and “addressing the burden of dementia in these countries. These are precisely the places that don’t have the recognition, the awareness, services, and the support for people with dementia. So, whereas we are testing these interventions and developing here, we’re working closely with partners in South Asia and Latin America, and other companies, to see whether our approach can work globally.”

Looking to the future, Prof Leroi says that SENSE-Cog’s next area of research will focus on what she calls “wraparound cognitive care”, a trial which can use the acquired learnings so far to improve the quality-of-life of people already living with dementia.

Prof Leroi is the co-author of a paper on the ‘Development of international practice recommendations for the recognition and management of hearing, vision and cognitive impairment’. This initiative, currently under review, was created with the international hearing, vision, and cognition practice recommendations taskforce consisting of 16 hearing, vision, and dementia professionals from Europe, North America, and Australia. The objective of this is: “To devel-

op internationally relevant, multi-disciplinary practice recommendations for professionals involved in the diagnosis, care, and management of older people with these concurrent conditions.”

The impact, says Prof Leroi, “will expand the way that we view care for people with dementia and the role of their care partners, as well as identifying simple supports that might be available to really enhance an individual’s quality-of-life.”

Translating this research so that it can be implemented in a care home setting is something that Prof Leroi would like to see. She says this could help reshape the approach to support people with sensory impairment who have dementia.

“It’s the same concept, but a lot of work has to be done to adapt to the unique environment of care homes, but that’s definitely the future.”

This article was produced by the RCPI. Prof Leroi will be speaking on 25 March at the RCPI’s conference, Dementia – A Clinical Update, which takes place at 6 Kildare Street.

To book your place visit www.rcpi.ie. To find out more about the work of SENSE-Cog visit www.sense-cog.eu.

ADVERTORIAL

Little Medical School Franchise: Inspiring the next generation of Medical Professionals

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he US children’s education franchise Little Medical School is planning to roll out 25 franchises across Ireland over the next 4 years.

Little Medical School is an educational play franchise that uses the medium of play to inspire the next generation of medical professionals, promote health awareness and wellness amongst our youngest generation, while also introducing children, aged 3-14, to the fundamentals of Science, Technology, Engineering and Maths (STEM).

Through innovative programming, fun activities and structured role-play, students use realistic medical supplies and interactive tools while dressed in white lab coats, Little Medical School creates a unique, entertaining and engaging learning experience.

Irish education entrepreneur and Master Franchisee for Little Medical School in Ireland, Karl Fitzpatrick, who has previously achieved phenomenal success with the Bricks 4 Kidz franchise in Ireland, stated that “With a franchise currently operating in Wexford, we are already in advanced talks with franchisees for Dublin, Cork, Kildare, Limerick and Waterford.”

The teaching of STEM through educational play is an emerging trend within the global education sector and Little Medical School is at the forefront of this.

The business model is underpinned by the comprehensive curriculum which has been developed by the Little Medical School team of educators and board-certified physicians.

Speaking about the expansion of Little Medical School into Ireland, the creator of the concept Dr. Mary Mason stated “Little Medical School (LMS) is thrilled to welcome Karl Fitzpatrick as the owner of our newest Master Franchise. The combination of Ireland’s high education standards and Karl’s excellent track record in franchising and educational play, gives us great confidence that Karl and his team will continue our mission to inspire children’s interest in medical careers and health awareness”.

The concept is surprisingly scalable, with over 20 revenue streams including seasonal camps, after school classes, in-school workshops, parties and preschool classes.

Little Medical School offers a low cost, proven business model, with year-round income and recurring revenue streams.

Fitzpatrick said that “Franchisees will receive comprehensive training and continuous support across all areas of their business, along with a regular flow of new and innovative content from our curriculum development team.”

In this regard, the Little Medical School curriculum development team has created an interactive workshop which will teach children the importance of hand washing and will enable them to implement effective hand washing techniques.

Particularly relevant to the increased prevalence of Coronavirus cases in Ireland, these workshops will also seek to allay some of the fears that children may have developed about contracting the virus.

Prospective franchisees may be able to access funding for a Little Medical School business through the Start-Up Refunds for Entrepreneurs (SURE) initiative. This initiative may enable entrepreneurs to access a refund on the PAYE income tax which they have paid over the last six years.

Play your part in inspiring our next generation of medical professionals by contacting Peter Clark on peter@eduplay.ie or call 01 485 1166 or visit eduplay.ie

16

THE MEDICAL INDEPENDENT | 12 MARCH 2020

News Feature

How to address rural America’s healthcare deficit?

A shortage of doctors is creating ‘medical deserts’ across rural America, leaving millions of people without adequate healthcare, writes Bette Browne

F

unding cuts, poor working conditions and tough immigration measures have combined to turn huge swathes of rural America into “medical deserts” where doctors are few and far between and where some have to cover an area one-third the size of Ireland.

This is a problem that affects millions of Americans and it is getting worse. About 20 per cent of the US population – more than 60 million people – live in rural areas, but only 9 per cent of the nation’s doctors practise in rural communities. Indeed, the federal government has designated nearly 80 per cent of rural America as “medically underserved”. The town of Van Horn in south western Texas, for example, has one doctor covering an area of 11,000 square miles.

Data from the Association of American Medical Colleges (AAMC) shows that by 2032, the United States will see a shortage of up to 122,000 doctors, and rural areas will be worst hit by the crisis.

“People who are underserved are really going to suffer the most,” according to AAMC Executive Vice President Dr Atul Grover.

Among the reasons he cited for the shortages are population growth and a cap on US congressional funding that covers residency training for doctors. This cap, established by Congress in 1997, has remained unchanged despite significant overall growth in the US population, a large wave of seniors with more complicated health needs, an expansion of health insurance coverage and a

shortage of doctors as more retire.

A poll by the Harvard T H Chan School of Public Health, the Robert Wood Johnson Foundation and National Public Radio found that more than four-in-10 rural adults without health insurance (42 per cent) do not get care when they need it, while about one-infour rural Americans with health insurance (24 per cent) do not get care when they need it.

Chronic diseases are the leading causes of death and disability in America and they affect some populations more than others.

People who live in rural areas, for example, are more likely than urban residents to die prematurely from all of the five leading causes of death: Heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke, according to the Centres for Disease Control and Prevention (CDC). Residents of rural areas who have cancer, for example, are diagnosed at later stages of the disease, have less access to clinical trials, worse outcomes, and spend 66 per cent more time travelling to see cancer care providers, the CDC says.

Doctor shortages As of December 2018, there were more than 7,000 areas in the US with shortages of health professionals, nearly 60 per cent of which were in rural areas. The New England Journal of Medicine, looking at the ‘greying’ of the rural doctor population – more than half are now 50 or older – forecasts that retirement will account for 23 per cent fewer rural doctors by 2030.

The crisis is compounded by the fact that these underserved rural areas are often the very parts of the country that need doctors most. Rural residents have higher rates of conditions, such as obesity and high blood pressure, and they also have higher rates of smoking, which increases the risk of many chronic diseases.

Rural counties also have fewer healthcare workers, specialists, critical care units, emergency facilities, and public transportation.

Residents are also more likely to be uninsured and to live farther away from health services.

It is hardly surprising then that numerous studies have demonstrated a significant gap in health outcomes between individuals living in urban areas and those living in rural ones. Yet the very factors that tend to make rural pa-

Prof Amitabh Chandra

tients sicker are also the same factors that make it difficult to recruit and retain healthcare providers for those areas, according to Prof Amitabh Chandra, Director of Health Policy Research at Har-

vard University’s John F Kennedy School of Government.

“There are likely a lack of jobs in many of these places, as well as lower quality schools and housing. Doctors know better than anyone the importance of good healthcare to a thriving community,” Prof Chandra points out.

“Will they be comfortable moving to an area and raising a family in a place where you can’t get great hospital care – or perhaps any hospital care at all within a hundred miles?”

Hospital closures The situation is made worse by the fact that rural hospitals are also in decline and the number closing their doors has been growing in recent years. Over 100 rural hospitals have closed in the last decade and hundreds more are facing closure.

The North Carolina Rural Health Research Programme says that 19 rural hospitals closed in 2019, up from 15 closures in 2018, continuing a steady double-digit trend in closures since 2013.

Indeed, despite a booming US economy, 2019 was the worst year for hospital closings since at least 2005. Since that year, the North Carolina researchers tracked 162 hospital closings, with 60 per cent of the closures occurring in southern states. In many of these states, poverty rates are higher, people are generally less healthy and less likely to be able to afford private health insurance and pay their hospital bills, leaving rural hospitals and hospitals in low-income areas with mounting costs.

Most hospitals have closed be-

cause of financial problems. About 38 per cent of rural hospitals are unprofitable. In 2016, for example, 1,375 acute care hospitals out of 4,471 urban and rural acute care hospitals (31 per cent) were unprofitable, including 847 rural hospitals (versus 528 unprofitable urban hospitals).

University of Minnesota research shows that between 2004 and 2014, a total of 179 rural counties lost all hospital-based obstetrics services. Another disturbing statistic that underscores the problem is that over the last 15 years, the difference in mortality between rural and urban areas has tripled – from a 6 per cent to an 18 per cent difference in 2015.

The National Rural Health Association, an advocacy body for rural healthcare issues says “continued cuts to rural providers are creating a hospital closure crisis in rural America, jeopardising millions of rural patients’ access to medical care and devastating the already fragile rural economy”.

Currently one-in-three rural hospitals is in financial risk. At the current rate of closure, the association says, 25 per cent of all rural hospitals will close within less than a decade.

“Once a hospital closes, many of the health professionals employed by the hospital, including physicians, nurses, and pharmacists move from the community,” according to the Association.

“Medical deserts are appearing across rural America, leaving many of our nation’s most vulnerable populations without timely access to care.”

17

THE MEDICAL INDEPENDENT | 12 MARCH 2020

Feature News Incentives Different methods of tackling the crisis are being explored. While the most straightforward approach may seem to be to offer more financially lucrative deals to doctors to encourage them to practise in rural areas, Prof Chandra of Harvard University says simply throwing money at the problem is not the answer.

“The amount of money that you’d need to try and make up for what these doctors could make in the city would be cost-prohibitive,” he says. “We aren’t talking about the state or other agencies adding 5 per cent in extra wages, but more like 40 per cent, 50 per cent, maybe even 60 per cent to make up the difference. Instead of focusing on salary, we need to think more creatively about how we can make rural America more attractive to doctors and their families.”

Most physicians tend to practise where they are trained and the majority of medical schools and residencies are affiliated with hospitals in urban areas. Rural salaries are also lower, and young doctors often factor large loan repayments into decisions about how and where to practise. Such loans can be substantial. The Association of American Medical Colleges found that among the three-quarters of students in the class of 2018 who needed loans to pay for medical school, the median debt was $195,000 (€177,000).

With that in mind, one suggestion to address the issue is that new doctors could have their medical school loans paid for if they agreed to go into primary care in an underserved rural area for a given number of years.

South Dakota has a recruitment assistance programme that offers an incentive payment of $231,384 (€200,000) for qualifying physicians or dentists who make a three-year commitment to one of the state’s community clinics and more than $66,000 (€60,000) for qualifying physician assistants, nurse practitioners, or nurse midwives. Alabama, which ranks in the bottom five US states for healthcare, offers scholarships and a rural physician tax credit.

Democratic Presidential hopeful Joe Biden, seeking to take on President Donald Trump in the November election, has made improving rural healthcare a key piece of his strategy for boosting rural America. He says his top goals are to keep rural hospitals open and to reduce out-of-pocket expenses paid by rural Americans.

He is not the first to call for investment into rural healthcare.

‘Scope of practice’ legislation Several state and federal programmes and legislation are also aimed at improving the situation. In recent years, more and more states have enacted ‘scope of practice’ legislation, which has broadened the ability of non-physician practitioners to provide care for Americans. Such moves are also helping to address the

shortage of doctors in rural areas.

More than 40 states introduced scope of practice legislation during the 2019 legislative sessions.

The National Conference of State Legislatures’ Scope of Practice Policy website has tracked a total of 177 bills. Fifty-four bills from 30 states were enacted into law related to behavioural health providers, physician assistants, nurse practitioners and oral health providers.

Behavioural health providers saw 17 bills address certification and licensure standards, supervisory and prescribing authority, and reimbursement requirements. Arkansas passed at least three bills relating to peer support specialist certification and practice and prescribing authority for nurse practitioners. Individuals with prior drug-related offences can now work with people receiving substance abuse treatment as peer support specialists.

Twelve states enacted legislation addressing licensure and reciprocity for addiction counselors.

The states of Minnesota, North Dakota and Washington each established a reciprocity programme for addiction counselors applying for certification in their states.

Sixteen bills nationwide addressed the relationship between a physician assistant and a physician, and authorised additional procedures that could be performed by the physician assistant.

California, for example, now allows physician assistants to work in collaboration with a physician instead of under delegation and allows for development of the practice agreement in collaboration with a physician. Missouri allows for collaboration between a physician assistant and a physician, and the physician also no longer needs to practise at the same facility as the physician assistant. Nurse practitioners saw six bills address prescribing ability.

The bipartisan Training the Next Generation of Primary Care Doctors would authorise nearly $650 million (€588 million) over five years to train medical residents in low-income, underserved rural and urban neighbourhoods.

The American Academy of Family Physicians found that physicians, who practise family medicine, have a rural background and take part in rotations in rural areas while in medical school are more likely to choose to practise in rural areas. That was confirmed in a study published in the Journal of Rural Health showing that an eight-week rural rotation was enough to give urban students positive opinions about living and working in rural communities.

The Quillen College of Medicine at East Tennessee State University is among a small group of medical schools in the US with programmes aimed at bolstering the number of primary care doctors in rural communities.

The schools send students to live in small towns and train with ru-

ral doctors. Like Quillen College, some also organise outings and cultural experiences to try to encourage students to continue living there after they graduate.

Schools have taken students to a ranch to brand cattle, brought in local story tellers and offered local delicacies to show students what rural life can offer.

The federal government has also allocated $20 million (€18 million) in grants to help create 27 rural residency programmes where new doctors go for practical training before they can be fully licensed. A bipartisan bill that aims to encourage more medical professionals to work in small towns has also been introduced in the US congress by Illinois Senator Dick Durbin. This legislation would allow eligible doctors to participate in a sliding scale loan repayment programme that would incentivise them to work in the places with the most severe shortages of doctors.

The Rural America Health Corps Act would create a new programme that improves the existing National Health Service

Senator Dick Durbin

Corps (NHSC) by providing new dedicated student loan forgiveness funding for healthcare providers who agree to work in rural communities. Twenty per cent of Americans live in rural communities, yet only 11 per cent of physicians practise in such communities. Across the state of Illinois, with a population of some 12 million, about 3.3 million people live in communities with shortages of doctors, five million people live in communities with shortages of mental health professionals, and 2.3 million people live in communities with shortages of dentists.

“Patients across rural Illinois face challenges accessing the healthcare they need because of serious workforce shortages, with too few medical providers and long distances between them,” Senator Durbin said when introducing the Rural America Health Corps Act. “Our bipartisan bill provides new funding and support for rural communities by expanding loan forgiveness programmes so we can attract and retain more doctors, dentists, behavioural health specialists, and nurses.”

The current National Health Service Corps programme provides up to $50,000 (€45,000) annually to repay student loans for primary care doctors, dentists, behavioural health clinicians, nurse practitioners, and physician as-

sistants for two years of service in a “health professional shortage area”. Eligible locations include urban and rural hospitals and community health clinics with a shortage of providers. It provides approximately 3,100 new loan forgiveness awards each year – but only 30 per cent of participants in the National Health Service Corps programme serve in rural communities.

The Rural America Health Corps Act would create a new $25 million (€23 million) programme that would bolster the existing rural placements and would provide funding for up to five years – an increase from the current two-year forgiveness period – for doctors, dentists, behavioural health specialists, and nurse practitioners, which would help recruitment and retention efforts.

Telemedicine is also helping, as are physician assistants, while a new bill to improve broadband connectivity in areas with limited access to care has been introduced in the Senate. The Data Mapping to Save Moms’ Lives Act will allow for the mapping of areas that lack maternal care and access to the internet, with the goal of improving tele-health technology infrastructure in areas with critical maternal healthcare needs.

Global problem Many of these problems in the US will sound familiar to rural doctors in some parts of Ireland.

Hundreds of GPs are due to retire around the country in the coming years and it is feared that few young doctors will be prepared to work in more remote rural areas because of the greater workload and reduced resources. Instead, young graduates tend to be more attracted by working conditions and training opportunities abroad, or they prefer to live and work in large urban areas.

Indeed, the World Health Organisation (WHO) sees the issue as an important global challenge that affects rural and low-population areas in many developed and developing countries worldwide.

Many developed nations, it says, have an aging population, which in countries like Japan and Germany, is putting pressure on their healthcare systems and services for both rural and urban populations. “Ease of access to healthcare in rural communities is an important global challenge that must be tackled and is one of the priorities of the WHO.” A study from a consortium of five Japanese universities has shown that different university programmes to promote the equal geographic distribution of doctors increases the number of graduates practising in rural areas in Japan. Graduates from these programmes were on average 24 per cent more likely to work in non-metropolitan areas than those not involved in these programmes.

Japan has admissions programmes integrated in each university with a medical school, which either obliges or encour-

ages medical school graduates to practise in rural areas. There are three types of programmes: The regional quota programme where a certain number of the incoming high-school students in a medical course must be from a local region, the scholarship programme where the medical students benefit from a scholarship for six years in exchange for practising in designated areas after graduation, and a combined quota and scholarship programme.

Immigrant doctors Immigrant doctors could also play a critical role in filling physician shortages in rural communities across the United States. Yet they often face tough immigration and licensing barriers that prevent them from serving in these communities, according to the Centre for American Progress, a non-partisan policy institute.

“It’s also clear that current state and federal regulatory frameworks pose barriers for immigrant doctors who want to work in rural areas,” says Silva Mathema, the institute’s senior policy analyst of immigration policy. “The United States needs reforms at all levels of government to harness the talents of immigrant doctors to help minimise physician shortages and ensure that patients in rural communities get the care they need.”

Immigrants make up a sizeable proportion of the US healthcare workforce. According to data from the Migration Policy Institute, 30 per cent of all active physicians and surgeons are immigrants, but many are being hit by tough immigration measurers introduced by the Trump administration.

Iran and Syria, for example, two of the countries whose citizens are now generally banned or face tight restrictions entering the US, are the sixth and 10th largest contributors of immigrant doctors.

Data from the Association of American Medical Colleges shows that foreign-trained doctors do a disproportionate amount of the work in certain areas. They make up more than 50 per cent of geriatric medicine doctors, almost half of nephrologists, nearly 40 per cent of internal medicine doctors, and nearly a quarter of family medicine physicians.

Compared with US-trained physicians, immigrant doctors are also more likely to practise in rural areas. Many enter the US on visas that allow them to stay if they work in an underserved area for three years after residency. And the patients they treat in these rural areas are getting high quality care.

A 2017 study in the BMJ concluded that patients treated by international graduates had lower mortality than patients cared for

by US graduates. The study suggested that this may be because such graduates probably represent “some of the best physicians in their country of origin” and had to overcome intense competition and years of training to finally practise in the United States.

18

THE MEDICAL INDEPENDENT | 12 MARCH 2020

Editorial

Letters to: The Editor, The Medical Independent, Greencross Publishing Ltd, Top Floor, 111 Rathmines Road Lr, Dublin 6 or email paul@mindo.ie

PAUL MULHOLLAND

An outbreak in the information age

P

erhaps the only thing to match the spread of the new coronavirus, or Covid-19, are news articles and social media posts about the spread of the virus.

This editorial can be added to the latter’s growing number. The scale of the outbreak has the potential not only to put significant strain on the healthcare services of individual nations, but on the entire worldwide economy. Given this impact, it is unsurprising that coronavirus has come to dominate the news agenda.

There is no vaccine for the virus, nor is one likely to appear for at least a year. In the absence of a vaccine, or treatment, prevention is the focus in curbing the spread of Covid-19. And for adequate prevention measures to take place, information is key, be it at an official level or through the media. The Department of Health has

already found out what a fraught affair the release of information can be. The decision, firstly not to specify exactly where on the east coast the two people who had the virus were diagnosed, and then not to name the school forced to close for 14 days as a result of the first case, was not universally accepted as the best course of action. Many people, particularly on social media, criticised the decision, saying they had the right to know whether they or their family were in danger of contracting the virus. Many doctors argued that the Department’s decision was correct in the interests of patient confidentiality. Their argument is that patient confidentiality must be assiduously protected if other people are to come forward should they suspect they have been infected with the virus. Others counter that the name of a county could at least be offered, which would not compromise the names of the

individuals concerned. With social media, protecting confidentiality is more difficult than in the past, while the spread of fake information is made easier.

The health service did not do itself any favours by initially stating that a HSE letter, requesting that a musical band in contact with the first diagnosed case self-isolate, was a hoax. It later transpired the letter was genuine. To garner trust, it is vital that the voice of experts, namely public health doctors, is heard. It is good to see that messages on hand-hygiene have been reiterated again and again across multiple platforms. A study published in Health Security in June 2018, ‘Coverage of Epidemics in American Newspapers Through the Lens of the Crisis and Emergency Risk Communication Framework’, looked at over 5,000 news articles from American newspapers such as The New York Times and the Wall Street Journal to examine

how they covered outbreaks from the last 10 years: Swine flu, Ebola and Zika. Almost half of the articles looked at the social consequences of the disease, such as their effect on the economy or politics, while only one-in-five articles included practical information about the steps individuals could take to avoid infection.

Finding a happy medium between informing the public and not inducing mass panic is a tough balancing act. What one person sees as reasonable steps by the media to cover an imminent threat to public health, another person might see as sensationalist scaremongering. The WHO has produced guidance for the media to cover suicides. Might it produce something similar for the coverage of future epidemics? This will be a steep learning curve, not just for the healthcare sector, but for society as a whole. As the WHO stated, the world is entering “uncharted territory”.

MINDO CARTOON

READER COMMENTS REACTION TO OUR NEWS STORY, ‘IMO SEEKS UPDATE ON VACANCIES AMID COVID-19 CONCERNS’, 2 MARCH “Doesn’t really matter what the HSE say. They won’t ever fill their specialist roles until they treat their public health specialists like their other consultants. The only future I can see is more specialists joining me in Oz with a proper consultant contract and a full team.”

Dr Niall Conroy, @NICU_doc_salone, 2 March REACTION TO OUR NEWS FEATURE, ‘THE HEALTH IMPACT OF HOMELESSNESS’, 2 MARCH “@austinoc_austin is an amazing doc, humanity personified.”

22Q11 Ireland, @22Q11_Ireland, 2 March

REACTION TO OUR NEWS STORY, ‘“CONFUSION” EXPECTED WITH INTRODUCTION OF HPV SCREENING — PRACTICE NURSES’, 2 MARCH “I don’t like negativity but interview I gave @NiamhyCahill of @med_indonews reflects the experience of @PracticeNurses.”

Orla Loftus, @LoftusOrla, 2 March “Thank you very much Orla for being an advocate and highlighting the accurate feelings of GPNs nationwide, many of whom will be delivering the new screening service.”

Theresa Lowry-Lehnen, @lehnent, 1 March REACTION TO DR NEASA CONNEALLY’S COLUMN, ‘DOES YOUR HOSPITAL HAVE A CASE OF TTWTADH?’, 20 FEBRUARY “Hit the nail on the head, @neasaconneally.”

Dr Kimberly Humphreys, @kimhumphreys123, 23 February

“I really enjoyed this ‘tongue in cheek’ article by @neasaconneally. Really hits the nail on the head.

TTWTADH is a blood-boiling trigger for me.”

Dr John Cannon, @DrJohnCannon, 23 February “Fantastic article, Neasa.”

Editor: Paul Mulholland, paul@mindo.ie News Editor: Catherine Reilly, catherine@mindo.ie

Dr Naomi Smith, @naomibsf, 23 February

OUR PAPER IS NOW COMPOSTABLE, AS WELL AS RECYCLABLE 12 MARCH 2020 ● ISSUE 6 VOLUME 11 ● NEXT ISSUE 23 MARCH 2020 €5.95

Modernising the intern year The intern year, which demarcates the transition from student to doctor, is currently the focus of a major reform programme.

Catherine Reilly reports

PAGE

4-5

Ireland in the time of Covid-19

Rural America’s healthcare problem

Three cheers for Sláintecare?

Consultant in Public Health Medicine Dr Ina Kelly outlines the importance of public health medicine in combating the spread of the new coronavirus

A shortage of doctors is creating ‘medical deserts’ across rural America, leaving millions of people without adequate healthcare, writes Bette Browne

Sláintecare is unlikely to provide the solution to the problems of the health service, according to Dr Christine O’Malley

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NEWS 1-17 ● OPINION 19 ● CLINICAL 23-30 ● LIFE DIARY 32 ● FOOD & DRINK 34 ● QUIZZES 33 ● GALLERY 35-36 ● PRODUCTS 37 ● RECRUITMENT 38-39

“Really enjoyed it and identified with it, Neasa. One or two particular issues stand out in memory but TTWTADH shouldn’t be accepted. Well done.”

Dr Fiachra Lambe, @FiachraLambe, 23 February REACTION TO OUR NEWS FEATURE, ‘SLÁINTECARE AND NEUROLOGICAL SERVICES’, 20 FEBRUARY Neurological

REACTION TO OUR NEWS STORY, ‘SALARY PAYMENTS MADE IN ERROR RISE IN 2019’, 20 FEBRUARY

“Reading article, seems overpayments recovered and due to mundane things (payments to deceased staff, etc). But HSE pay budget is €6.5 BILLION p/a, so €3.446 million is about 0.05 per cent of that, or 1/20th of 1 per cent. Surely this is a very small error rate?”

Dr David Robert Grimes, @drg1985, 20 February “Plenty money in this country — for all the wrong things.”

Stephen O’Connell, @oconne10, 20 February

REACTION TO TOM DOORLEY’S COLUMN, ‘LETTING GO OF CARBS’, 6 FEBRUARY “Interesting read, Tom. Nice reference to Paolo!”

Sandra Ní Dhubhda, @dhubhda, 18 February

“Helpful article, thx Tom. Where do sweet potatoes fit in to low-carb eating?”

Sub-Editor: Pat Kelly, pat@greenx.ie

Recruitment: Louis O’Hegarty, louis@mindo.ie Creative Director: Antoinette Sinclair, antoinette@greenx.ie

“The @HSELive are refusing medical cards to the terminally ill and yet this happens. Disgusting. #medicalcardscandal.”

John Wall, @walls2, 20 February

LushT, @tlush, 18 February

“After a while eating low carb, you generally stop looking for carb replacements! I give my members recipes for nut and seed breads and crackers etc, but after a while they realise they really don’t need them. Or certainly not often.”

Rosaleen Mackeown, @RunwithRos 18 February “Nice piece. I am more ‘incidentally’ low-carb-only protein-dense foods difficult to combine w/ high carb intake but I get fair share of lactose. (I suppose I could drink kefir instead to bring me down to keto standard levels but difficult to get good unsweetened Irish kefir.)”

Shane, @scary_biscuits, 18 February

PAUL MULHOLLAND

Journalists: David Lynch, david@mindo.ie Niamh Cahill Advertisements: Graham Cooke, graham@greenx.ie

“Great piece by @PriscillaLynch on our recent event on Sláintecare and neurological care.”

Alliance of Ireland, @naiireland, 28 February

Audit reports identify need for consultant work practice plans

Designer: Emer Keogh, emer@greenx.ie Publishers: Maura Henderson, maura@greenx.ie Graham Cooke, graham@greenx.ie

Photo: Jason Clarke

“Only surpassed by that phenomenon of the visiting consultant with ‘notions’, a malady otherwise known as TTWIDIMBH... ‘That’s The Way It’s Done in My Bigger Hospital’. Most times, things are done this way in a rural hospital for a reason.”

Dr Martin Schranz, @martinpschranz, 23 February

Clinical Editor: Priscilla Lynch, priscilla@mindo.ie

Women working on the new children’s hospital project gathered at the 12 acre construction site of the hospital in Dublin to mark International Women’s Day (8 March). Pictured are staff from the National Paediatric Hospital Development Board, Children’s Health Ireland (CHI), the design team and contractors working on the construction of the hospital, which is the single most significant investment in healthcare in the history of the State. Professionals pictured range from scaffolders, architects, health and safety officers, quantity surveyors, and engineers to consultants, nurses, HR and financial professionals, and administrators. Pictured at the front is Chief Executive of CHI, Ms Eilish Hardiman.

Figures reveal spiralling cost of HSE high tech drugs NIAMH CAHILL HSE spending on high-tech drugs jumped by 28 per cent between 2017 and 2019, new figures obtained by the Medical Independent (MI ) reveal.

An analysis of high-tech drug wholesaler and manufacturer payments shows the Executive paid out €887 million in 2019. This is compared to €692 million in 2017 and €816 million in 2018. In January 2020 alone, the HSE spent €81 million.

The above figures do not include payments to pharmacists for dispensing high-tech drugs, it is understood. In 2019 pharmacists were paid more than €20 million in high-tech dispensing and non-dispensing fees.

High-tech medicines are usually prescribed in hospitals and are often expensive, recently-developed medicines, which offer huge patient benefit.

The HSE is attempting to increase the use of “biosimilars”, drugs that are similar to another, approved biological medicine, but are cheaper, as part of efforts to alleviate the increase in spending.

In January the HSE’s primary care reimbursement service (PCRS) wrote to prescribing consultants and pharmacists advising them of new reimbursement arrangements for “best value medicines” (BVMs) for adalimumab and etanercept.

According to the correspondence, seen by MI, from the start of February 2020, for patients who have “never been treated with adalimumab or etanercept previously under hightech arrangements, reimbursement will only be supported for the BVBs medicines (ie, Imraldi or Amgevita for adalimumab and Benepali for etanercept) in adult patients commencing such therapy”.

The move follows a recommendation by the HSE Medicines Management Programme last year that patients on a biological medicine containing a tumour necrosis factor-alpha (TNF-α) inhibitor be prescribed a BVM biological medicine for adalimumab and etanercept.

The latest advice issued relates to reimbursement and is part of HSE efforts to reduce spending on “high-

tech drugs”.

The correspondence notes that since May last year, when changes were first recommended, prescribing of the BVB medicines for adalimumab and etanercept has increased.

“As of 20 January 2020, over 3,800 patients have been prescribed one of the BVB medicines for adalimumab and etanercept.

“The HSE may identify additional BVB medicines for adalimumab and etanercept in 2020.”

The HSE National Service Plan 2020 outlines the aim to expand the range of medicines administered through the high-tech ordering and monitoring hub to encompass, on a phased basis, all therapeutic areas.

The plan notes the importance of promoting the switch to biosimilar drugs to enable continued access to high-tech and other medications by offsetting cost growth and the Department of Health-led sustainability programme on community pharmaceutical costs to enable continued access to high-tech and other medications.

The lack of complete work practice plans for consultants was criticised in reports by the HSE’s internal audit division last year, the Medical Independent can report.

In an audit of consultants’ public and private practice in University of Limerick Hospitals Group, completed in February 2019, a sample review identified work practice plans and various versions of work schedules on file for only eight of 15 consultants (53 per cent).

“Some were noted to be sketchy on detail for activities, time allocation to activity, total hours work, etc,” according to the report.

Only three of the eight documents presented a complete plan denoting allocated times for public and private practice and total weekly hours.

In another HSE internal audit report for consultant practice in Connolly Hospital, Dublin, from January 2019, it was noted that work practice plans “were not available” for eight out of the 15 consultants assessed.

The issue was also identified in another consultant public/ private report relating to Cork University Maternity Hospital conducted by the division and completed in May 2019.

According to the report, the work practice plans were “hand-written in multiple formats” and did not include the total scheduled number of weekly hours.

All three reports referenced the fact that many work practice plans were not signed off by a senior consultant or clinical director. It was recommended that complete plans are in place for all consultants to facilitate the monitoring of contractual terms and conditions.

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19

THE MEDICAL INDEPENDENT | 12 MARCH 2020

Opinion

When cheers for Sláintecare ring hollow Sláintecare is unlikely to provide the solution to the problems of the health service DR CHRISTINE O’MALLEY Read more by Dr Christine O’Malley at www.mindo.ie

T

hree cheers for Sláintecare!

During the general election 2020, we were spared the usual rubbish from politicians about healthcare. Each party in turn hid behind the fig leaf of Sláintecare.

I was glad. Consider the last few elections. In 2007, the general election was all about co-locating commercial private hospitals on public hospital land. That would be unthinkable now. The 2011 election promised universal health insurance, which makes everyone a private patient.

Since election 2016, we have Sláintecare, which insists we’re all public patients.

Confused? You should be!

After the election, RTÉ asked me to comment on the case of Mrs Murphy, from West Cork, who spent days on a trolley. In case the politicians were on to something, I read Sláintecare a second time. No, it’s just an aspirational essay, without any real answers.

Whenever a report emerges, I look for a solution to the trolley problem. Sláin-

tecare’s big idea is that hospital capacity will be increased by having more primary and community care, better integration of care, and by abolishing private practice in public hospitals. Sorry, lads, that ain’t gonna do it. By the way, the terms of reference state that the best outcomes and value for money are in primary and community care, so I reckon the solutions were chosen before they started.

My mind wanders back to the disastrous 2007 bed capacity report written by management consultants. I’m probably the only person who plodded through all four volumes and I spoke to people who did the extensive hospital surveys. Based solely on the medical file, they had to guess (my choice of words) what was needed to discharge patients. If I did that in real life, I could be sued for negligence. This ridiculous “research” concluded that Ireland needs only 9,000 hospital beds, provided we move to a model of community care.

Bad reports can have serious consequences. Our great tragedy is that the HSE followed the 2007 report as a blueprint.

For a decade, instead of adding beds, hospital wards were closed at every opportunity, aiming for the magical 9,000 beds. That madness has finally stopped: New wards have opened, but according to a senior HSE manager, there are 90 beds fewer now than in 2009. Meanwhile, the population heads towards five million.

So that is why the trolley crisis became worse each year, not better. That is why generations of medical students think it’s normal for patients to be in an emergency department (ED) for days – until they see a functioning hospital system in Australia.

I get angry at physicians and surgeons for saying nothing, leaving it to the ED people. I’m sorry, it’s not enough to just treat the trolley patients.

I get so very angry because I’ve experienced it with my own family and friends, and also through patients. In 2003, my mother was on a trolley overnight in St Vincent’s Hospital with a badly broken arm. She didn’t mind. But more wards closed; now seriously ill patients can’t get to a ward and are stuck on trolleys. People close to me have been overnight in ED with heart rhythm problems, bowel obstruction, and stroke with seizures. Patients have said “I’d rather die” or “put me down” when faced with ED again.

Mrs Murphy’s story is really very boring. It happens every day, in every Irish hospital. The GP was concerned about a possible stroke. Despite health insurance,

a private hospital sent her on to public ED, where she spent days on a trolley. In fact, she had infection and fluid overload; following “phenomenal” treatment, she is recovering. Her 90-year-old husband simply couldn’t bear to see his wife’s misery and distress at the chaotic surroundings.

Here’s a question. Did the Sláintecare people know how many trolley patients are like Mrs Murphy? How many are referred by a GP? How many with health insurance? They couldn’t: The HSE doesn’t collect that data. I’m guessing (my choice of words) they don’t know that when 600 patients are on trolleys, all we know is that they were accepted for admission, but couldn’t get a bed. I’m guessing they don’t know you must be in the whole of your health to go to a private hospital. Go right ahead: Take private care out of public hospitals. Mrs Murphy will still be on that trolley.

The scary bit is that Sláintecare could make it all much worse. Giving away free GP care could overload general practice, and make it as dysfunctional as the hospitals. Meanwhile, abolishing private practice in the hospitals will cut €650 million from the €4.4 billion budget. Instead of necessary hospital treatment, Mrs Murphy could be told to stay in West Cork with home help. That’s community care.

Would Mrs Murphy and her family give three cheers for Sláintecare? Two cheers?

One cheer? I wonder.

The great AI myth AI will not replace doctors and should be considered as just another clinical tool to help achieve more accurate diagnoses most of their diagnostic time testing them by collecting more data. This approach is underpinned by cognitive processes that can be either intuitive or analytical. Intuition – sometimes referred to as “pattern

DR MUIRIS HOUSTON Read more by Dr Muiris Houston at www.mindo.ie @muirishouston

H

ave you noticed the increased frequency with which AI appears in your social media feeds and even journal content pages?

The concept of AI was developed in the 1950s and has been defined as “the use of a computer to model intelligent behaviour with minimal human intervention”. It is an alternative to human intelligence, and has been touted as a replacement for the diagnostic skill of physicians. For several years, the scientific literature and lay media have suggested that nonhuman intelligence could equal or even exceed human intelligence in diagnostic tasks.

AI, as is often the case with new ideas, is now presented as THE future of medical practice. To which my response is a clear, ‘ah here now, steady on’ (with a hat tip to the late broadcaster, Marian Finucane).

What is the difference between human and artificial intelligence? Human intelligence is what doctors use when they undertake clinical reasoning, which has been defined as “the internal mental processes that a physician uses when approaching clinical situations”.

This central component of physicians’ competence is how we make diagnoses.

Artificial intelligence, on the other hand, refers to several different methods. Most AI diagnostics are based on machine learning algorithms that are “intelligent” enough to handle difficult and complex problems; however, algorithms rely on human intelligence for their creation. A lot of recent progress in the field has been made through the resurgence of neural networks – a family of methods of machine learning.

A recent paper in the Canadian Medical Association Journal (CMAJ) analysed differences in the ways humans and AI approach diagnostic reasoning, with the authors concluding (thankfully) that human reasoning will not become obsolete in medical diagnosis.

“A physician solves most clinical problems in an intuitive and deductive way, whereas AI problem-solving depends on access to and analytical and inductive processing of large quantities of data that relate to the case,” according to the paper.

The principles underlying learning are similar for human and artificial intelligences, but the respective approaches to diagnosis are markedly different, they conclude.

After generating diagnostic hypotheses early, doctors and med students spend

AI, as is often the case with new ideas, is now presented as THE future of medical practice. To which my response is a clear, ‘ah here now, steady on’ (with a hat tip to the late broadcaster, Marian Finucane)

recognition” – is a process that works automatically and subconsciously. It allows humans to generate diagnostic hypotheses early by taking a few pieces of information, associating them and comparing the result with patterns stored in long-term memory.

Machine learning, on the other hand, depends on the development of an algorithm that “learns” important features from a data set known as a “training set” to then make predictions about other unknown data. AI is limited to the specific information provided for a specific task. Furthermore, for every new task, AI systems must usually start from scratch.

The rate of diagnostic errors in medical practice is estimated at about 5-15 per cent, depending on the specialty. For AI to gain traction this will be a key metric. Some of the initial research, in targeted situations, is encouraging. For example, an AI algorithm trained on a data set of more than 100,000 images was better than specialist radiologists at detecting pneumonia using chest x-rays.

Some of the responses to the paper were lively: “AI is an emerging technology that is generating more fear and enthusiasm than is required. Just like historical revolutions, like the wheel, steam engine, printing press, computers, internet, it is just another tool in the great human journey... AI is a tool that will do what we will tell it to do.

Teaching ethics to AI will be our biggest challenge,” was typical.

So, much to my relief, the paper’s conclusion is that the wholesale replacement of human intelligence by AI in diagnostic tasks is unlikely, apart from some highly targeted tasks; instead, AI should be considered as just another tool to help clinicians in their reasoning.

That AI is able to learn on its own and will replace physicians is a myth that we in the medical profession must challenge.

Fictional patient, for illustrative purposes only

**Moderate exacerbati exacerbati

TRELEGY Ellipta (FF/UMEC/VI) 92/55/22 mcg OD is indicated for maintenance treatment in adult patients with mo severe COPD who are not adequately treated by a combination of an ICS and a LABA or a combination of a LAMA ▼This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse reactions.

***Co-primary endpoints were change from baseline in trough FEV1 and SGRQ at week 24 (n=1810). A subset of patients (n=430) remained on blinded study treatment for 52 weeks. Trelegy showed an improvement in trough FE improvement in health-related quality of life (SGRQ) of 2.2 units (p <0.001, 95% CI 3.5, 1.0) at week 24. At week 52 in a subset of patients Trelegy showed a 44% reduction in annualised rate of moderate/severe exacerbations TRELEGY Ellipta is generally well tolerated. Common adverse reactions include: pneumonia, upper respiratory tract infection, bronchitis, pharyngitis, rhinitis, sinusitis, influenza, nasopharyngitis, candidiasis of mouth and throat, urinary FF, fluticasone furoate; ICS, inhaled corticosteroid; LABA, long-acting ß2-agonist; LAMA, long-acting muscarinic antagonist; OD, once-daily; UMEC, umeclidinium, VI, vilanterol References: 1. TRELEGY Ellipta SmPC 2019. 2. Lipson DA et al. Am J Respir Crit Care Med 2017; 196:438–446. 3. Lipson DA et al.N Engl J Med 2018; 378:1671–1680.

Trelegy▼ Ellipta (fluticasone furoate/umeclidinium/vilanterol [as trifenatate]) Prescribing information.

Please consult the full Summary of Product Characteristics (SmPC) before prescribing. Trelegy Ellipta (fluticasone furoate/umeclidinium/vilanterol [as trifenatate]) inhalation powder. Each single inhalation of fluticasone furoate (FF) 25 mcg provides a delivered dose of 92 mcg FF, 55 mcg UMEC and 22 mcg VI. Indications: Maintenance treatment in adult patients with moderate to severe COPD who are not adequately treated by a combination of an inhaled cortico antagonist. Dosage and administration: One inhalation once daily at the same time each day. Contraindications: Hypersensitivity to the active substances or to any of the excipients (lactose monohydrate & magnesium stearate). Pr abnormalities, convulsive disorders or thyrotoxicosis, pulmonary tuberculosis or patients with chronic or untreated infections, narrow-angle glaucoma, urinary retention, hypokalaemia, patients predisposed to low levels of serum potass for systemic corticosteroid-related adverse reactions. Eye symptoms such as blurred vision may be due to underlying serious conditions such as cataract, glaucoma or central serous chorioretinopathy (CSCR); consider referral to oph corticosteroids. Risk factors for pneumonia include: current smokers, old age, patients with a history of prior pneumonia, patients with a low body mass index and severe COPD. Patients with rare hereditary problems of galactose i symptoms: Not for acute symptoms, use short-acting inhaled bronchodilator. Warn patients to seek medical advice if short-acting inhaled bronchodilator use increases. Therapy should not be abruptly stopped without physician superv at high doses for long periods, but much less likely than with oral corticosteroids. Interactions with other medicinal products: Caution should be exercised with concurrent use of ß-blockers. Caution is advised when co-administering treatments or non-potassium-sparing diuretics. Co-administration with other long-acting muscarinic antagonists or long acting ß2-adrenergic agonists is not recommended. Pregnancy and breast-feeding: Experience limited. Balan infection, bronchitis, pharyngitis, rhinitis, sinusitis, influenza, nasopharyngitis, candidiasis of mouth and throat, urinary tract infection, headache, cough, oropharyngeal pain, arthralgia, back pain. Uncommon (≥1/1,000 to <1/100): dry mouth, fractures; Not known (cannot be estimated from the available data): vision blurred. Marketing Authorisation (MA) Holder: GlaxoSmithKline Trading Services Limited, Curabinny, Co. Cork, Ireland. MA No. [EU/1/17/1236/00 on request from GlaxoSmithKline, 12 Riverwalk, Citywest Business Campus, Dublin 24. Tel: 01-4955000.

For COPD patients on treatment with ICS/LABA and at risk of exacerbation*1 *A worsening of symptoms or a history of exacerbation treated with antibiotics or oral corticosteroids in the past 12 months

It’s the things you do today that make 1-3 a big difference to their tomorrows TRELEGY Ellipta provides your patients with statistically superior improvements in lung function and health-related quality of life, and reduction in annualised rate of moderate/severe exacerbations** vs. budesonide/formoterol***1–3 Start your patients on TRELEGY Ellipta today, expect more from tomorrow1,2

oderate exacerbation is a worsening of symptoms or a history of acerbation treated with antibiotics or oral corticosteroids. A severe acerbation is a worsening in symptoms that required hospitalisation.

h moderate to AMA and a LABA1

Today. Tomorrow. TRELEGY. 2-3

trough FEV1 of 171mL versus budesonide/formoterol (p < 0.001, 95% CI 148,194) at week 24. Trelegy showed an cerbations versus budesonide/formoterol (95% CI 15,63, p=0.006, Absolute difference 0.16).

t, urinary tract infection, headache, cough, oropharyngeal pain, constipation, arthralgia, back pain

1

roate (FF) 100 micrograms (mcg), umeclidinium bromide (UMEC) 62.5 micrograms and vilanterol as trifenatate (VI) ed corticosteroid (ICS) and a long-acting ß2-agonist (LABA) or a combination of a LABA and a long acting muscarinic earate). Precautions: Paradoxical bronchospasm, unstable or life-threatening cardiovascular disease or heart rhythm m potassium, diabetes mellitus. In patients with moderate to severe hepatic impairment patients should be monitored ral to ophthalmologist. Increased incidence of pneumonia has been observed in patients with COPD receiving inhaled alactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take Trelegy. Acute an supervision due to risk of symptom recurrence. Systemic effects: Systemic effects of ICSs may occur, particularly ministering with strong CYP3A4 inhibitors (e.g. ketoconazole, ritonavir, cobicistat-containing products), hypokalaemic ted. Balance risks against benefits. Side effects: Common (≥1/100 to <1/10): pneumonia, upper respiratory tract <1/100): viral respiratory tract infection, supraventricular tachyarrhythmia, tachycardia, atrial fibrillation, dysphonia, 7/1236/002]. Legal category: POM B. Last date of revision: June 2019. Code: PI-2093. Further information available

Find out more here:

www.trelegy.ie or request a visit from a GSK representative A full list of adverse reactions for TRELEGY Ellipta can be found in the Summary of Product Characteristics.

Adverse events should be reported to the Health Products Regulatory Authority (HPRA) using an Adverse Reaction Report Form obtained either from the HPRA or electronically via the website at www.hpra.ie.

Adverse reactions can also be reported to the HPRA by calling: (01) 6764971. Adverse events should also be reported to GlaxoSmithKline on 1800 244 255.

TRELEGY Ellipta was developed in collaboration with ©2020 GSK Group of Companies or its licensor Trademarks are owned by or licensed to the GSK Group of Companies PM-IE-FVU-ADVT-200001 | January 2020

Genuair -has it ‘clicked’ yet? ®

The ONLY prefilled inhaler with visual and audible feedback for confirmed dose delivery 1-4

Genuair - a simple to use inhaler for patients with COPD 4

LAMA + LABA

LAMA Abbreviated Prescribing Information Eklira® Genuair® 322 micrograms inhalation powder. Please consult the Summary of Product Characteristics (SPC) for the full prescribing information. Presentation: Inhalation powder in a white inhaler with an integral dose indicator and a green dosage button. Each delivered dose contains 375 µg aclidinium bromide equivalent to 322 µg of aclidinium. Also, contains lactose. Use: Maintenance bronchodilator treatment to relieve symptoms in adult patients with chronic obstructive pulmonary disease (COPD). Dosage: For inhalation use. Recommended dose is one inhalation of 322 micrograms aclidinium twice daily. Patients should be instructed on how to administer the product correctly as the Genuair inhaler may work differently from inhalers used previously. It is important to instruct the patients to read the Instructions for Use in the pack. No dose adjustments are required for elderly patients, or those with renal or hepatic impairment. No relevant use in children and adolescents. Contraindications: Hypersensitivity to aclidinium bromide or to any of the excipients. Warnings and Precautions: Stop use if paradoxical bronchospasm occurs and consider other treatments. Do not use for the relief of acute episodes of bronchospasm. Use with caution in patients with myocardial infarction in the previous 6 months, unstable angina, newly diagnosed arrhythmia within the previous 3 months, or hospitalisation within the previous 12 months for heart failure functional classes III and IV. Dry mouth, observed with anticholinergic treatment, may be associated with dental caries in the long term. Use with caution in patients with symptomatic prostatic hyperplasia or bladder-neck obstruction or with narrow-angle glaucoma. Do not use in patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption. Interactions: Do not administer with other anticholinergiccontaining medicinal products. No other interactions expected. Please consult the SPC for more details. Fertility, pregnancy and lactation: No data on use in pregnancy. Risk to newborns/infants cannot be excluded. Consider risk-benefit before using during lactation. Unlikely to affect fertility at the recommended dose. Side-effects: Common (1-10%): Sinusitis, nasopharyngitis, headache, cough, diarrhoea, nausea. Uncommon (0.1- 1%): Dizziness, blurred vision, tachycardia, palpitations, dysphonia, dry mouth, stomatitis, rash, pruritus, urinary retention. Rare (0.01-0.1%): hypersensitivity.

Not known: angioedema, anaphylactic reaction. Pack sizes: Carton containing 1 inhaler with 60 unit doses. Legal category: POM Marketing Authorisation Number: EU/1/12/778/002 Marketing Authorisation holder: AstraZeneca AB, SE-151 85 Södertälje, Sweden. Marketed by: A. Menarini Pharmaceuticals Ireland Ltd., Castlecourt, Monkstown Farm, Monkstown, Glenageary, Co. Dublin A96 T924. Further information is available on request to A. Menarini Pharmaceuticals Ireland Ltd. or may be found in the SPC. Last updated: May 2018

This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse reactions to: HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2, Tel: +353 1 6764971, Fax: +353 1 6762517, Website: www.hpra.ie, e-mail: medsafety@ hpra.ie. Adverse events should also be reported to A. Menarini Pharmaceuticals Ireland Ltd. Phone no: 01 284 6744.

Date of item: October 2019. IR-BRI-16-2019

References:

1. MIMS Ireland October 2019 2. Eklira Genuair Summary of Product Characteristics, last updated February 2018 3. Brimica Summary of Product Characteristics, last updated August 2019 4. Magnussen, H et al. COPD. 2019 Apr;16(2):196-205

Abbreviated Prescribing Information Brimica® Genuair® 340 micrograms/12 micrograms inhalation powder. Please consult the Summary of Product Characteristics (SPC) for the full prescribing information. Presentation: Inhalation powder in a white inhaler with an integral dose indicator and an orange dosage button.

Each delivered dose contains 396 µg aclidinium bromide (equivalent to 340 µg of aclidinium) and 11.8 micrograms of formoterol fumarate dihydrate. Also, contains lactose. Use: Maintenance bronchodilator treatment to relieve symptoms in adult patients with chronic obstructive pulmonary disease (COPD). Dosage: For inhalation use. Recommended dose is one inhalation of 340 µg/12 µg twice daily. Patients should be instructed on how to administer the product correctly as the Genuair inhaler may work differently from inhalers used previously. It is important to instruct the patients to read the Instructions for Use in the pack. No dose adjustments are required for elderly patients, or those with renal or hepatic impairment. No relevant use in children and adolescents.

Contraindications: Hypersensitivity to the active substances or to any of the excipients. Warnings and Precautions: Do not use in asthma. Stop use if paradoxical bronchospasm occurs and consider other treatments. Do not use for the relief of acute episodes of bronchospasm. Use with caution in patients with myocardial infarction in the previous 6 months, unstable angina, newly diagnosed arrhythmia within the previous 3 months, or hospitalisation within the previous 12 months for heart failure functional classes III and IV. Discontinue if increases in pulse rate, blood pressure or changes in ECG occur. Use with caution in patients with a history of or known prolongation of the QTc interval or treated with products affecting the QTc interval. Use with caution in patients with severe cardiovascular disorders, convulsive disorders, thyrotoxicosis and phaeochromocytoma.

Hypokalaemia may occur, is usually transient and supplementation not needed. In patients with severe COPD, hypokalaemia may be potentiated by hypoxia and concomitant treatment. Use with caution in patients with symptomatic prostatic hyperplasia, urinary retention or with narrow-angle glaucoma. Dry mouth, observed with anticholinergic treatment, may be associated with dental caries in the long term. Do not use in patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption. Interactions: Do not administer with other anticholinergic and/or long-acting β2-adrenergic agonist containing medicinal products.

Caution in use with methylxanthine derivatives, steroids, non-potassium-sparing diuretics, β-adrenergic blockers or medicinal products known to prolong the QTc interval. Please consult the SPC for more details. Fertility, pregnancy and lactation: No data on use in pregnancy. Consider risk-benefit before using during lactation. Unlikely to affect fertility at the recommended dose. Sideeffects: Common (1-10%): Nasopharyngitis, urinary tract infection, sinusitis tooth abscess, insomnia, anxiety, headache, dizziness, tremor, cough, diarrhoea, nausea, dry mouth, myalgia, muscle spasms, peripheral oedema, increased blood creatine phosphokinase. Uncommon (0.1- 1%): Hypokalaemia, hyperglycaemia, agitation, dysgeusia, blurred vision, tachycardia, electrocardiogram QTc prolonged, palpitations, angina pectoris, dysphonia, throat irritation, stomatitis, rash, pruritus, urinary retention, increased blood pressure. Rare (0.01-0.1%): Hypersensitivity, bronchospasm, including paradoxical.

Not known: anaphylactic reaction, angioedema. Pack sizes: Carton containing 1 inhaler with 60 unit doses. Legal category: POM Marketing Authorisation Number: EU/1/14/963/001 Marketing Authorisation holder: AstraZeneca AB, SE-151 85 Södertälje, Sweden. Marketed by: A. Menarini Pharmaceuticals Ireland Ltd., Castlecourt, Monkstown Farm, Monkstown, Glenageary, Co. Dublin A96 T924. Further information is available on request to A. Menarini Pharmaceuticals Ireland Ltd. or may be found in the SPC. Last updated: October 2019 This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse reactions via HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517. Website: www.hpra.ie; E-mail: medsafety@ hpra.ie. Adverse events should also be reported to A. Menarini Pharmaceuticals Ireland Ltd. Phone no: 01 284 6744.

23

THE MEDICAL INDEPENDENT | 12 MARCH 2020

Respiratory Clinical THERESA LOWRY LEHNEN PHD Clinical Nurse Specialist Practitioner and Associate Lecturer at Institute of Technology Carlow, and Assistant PRO, Irish Student Health Association

Cystic fibrosis in 2020 A look at the Irish CF population, as well as diagnosis and treatment advances Cystic fibrosis (CF) is an inherited chronic disease, primarily affecting the lungs and digestive system. This lifelong condition usually becomes more severe with age and affects both males and females in equal proportions. The symptoms and severity of CF vary from person to person, but the majority of people with the disease have both respiratory and digestive problems. There is no cure for CF, however, life expectancy has increased steadily over the past 20 years due to better disease understanding, treatment advances, and earlier diagnosis.

Pathophysiology CF is caused by a gene mutation leading to dysfunction of the cystic fibrosis transmembrane conductance regulator (CFTR) protein, a chloride channel of exocrine glands.

The defect leads to diminished chloride secretion, which in turn leads to increased sodium absorption through epithelial sodium channels and removal of water from secretions, which become abnormally viscous.

Essentially this causes the body to produce unusually thick sticky mucus that clogs the lungs and obstructs the pancreas, stopping natural enzymes from enabling the body to break down and absorb food. The effects cause obstruction, inflammation, infection in the lungs and upper airways, tissue reorganisation, and loss of function.

CF affects multiple organ systems including the lungs, pancreas, upper airways, liver, intestine, and reproductive organs to varying degrees. The severity of the disease in the individual depends on variable organ sensitivity and on the genetically determined residual function of the CFTR protein. Almost all (97-98 per cent) affected male patients are infertile because of obstructive azoospermia and 87 per cent of patients have exocrine pancreatic insufficiency. Disease severity, particularly the degree of pulmonary involvement, also depends on other disease-modifying genes and a number of factors including socioeconomic background.

Symptoms People with CF present with a variety of symptoms, including very salty-tasting skin, persistent coughing with phlegm, frequent lung infections, wheezing or shortness of breath, poor growth/weight gain despite a good appetite and frequent greasy, bulky stools or difficulty in bowel movements.

Symptoms usually appear in the first year of life, although occasionally they can develop later. The thick, viscous mucus in the body affects a number of organs, particularly the lungs and digestive system. Typical respiratory symptoms include cough and wheeze. Recurring chest and lung infections are caused by the continual build-up of mucus in the lungs, which provides an ideal breeding ground for bacteria.

Ivacaftor (Kalydeco) Ivacaftor (Kalydeco) potentiates the CFTR protein, a chloride channel present at the surface of epithelial cells in multiple organs. This facilitates increased chloride transport by potentiating the channel-open probability of certain CFTR gene mutations.

It is indicated for CF in adults and children aged six months or older who have one mutation in the CFTR gene. It is not effective when used without a CFTR corrector (eg, lumacaftor) if the patient is homozygous for the F508del mutation in the CFTR gene.

Lumacaftor/ivacaftor (Orkambi) This combination product contains lumacaftor, a CFTR corrector. Lumacaftor corrects the processing and trafficking defect of the F508del-CFTR protein to enable it to reach the cell surface where the CFTR potentiator, ivacaftor, can further enhance the ion channel function of the CFTR protein. Ivacaftor facilitates increased chloride transport by potentiating the channel-open probability of the CFTR proteins. The combination is indicated for CF in patients aged six years or older who are homozygous for the F508del mutation in the CFTR gene. This combination is well-tolerated in young children.

Tezacaftor/ivacaftor (Symdeko/Symkevi) CFTR corrector and potentiator combination regimen. It is indicated for CF in patients aged ≥6 years who are homozygous for the F508del mutation or who have at least one mutation in the CFTR gene that is responsive to tezacaftor/ivacaftor based on in vitro data and/or clinical evidence.

Table 1: CFTR potentiators and correctors

Diagnosis Early diagnosis provides opportunities for earlier medical intervention and improves the quality- and length-of-life of CF patients. Providing infants with the best possible care results in better nutritional and lung function outcomes later in life.

Chronic disease of the lungs and paranasal sinuses varies among patients with CF and can be difficult to distinguish from frequent recurrent bouts of bronchitis and/ or pneumonia, especially in young children. Children with cough, sputum production, or wheezing of more than three months’ duration, persistently abnormal radiological findings, persistently positive bacterial cultures of respiratory secretions, or clubbing of the fingers should undergo diagnostic testing for CF even if their neonatal screening test was negative. The same applies for children with bilateral chronic rhinosinusitis with frequent exacerbations, with or without nasal polyps.

Most cases of CF are diagnosed through screening tests, which are carried out early in life. However, some babies, children, and even young adults are diagnosed later following unexplained illness. The main ways of diagnosing CF are newborn screening (heel prick test), antenatal testing (chorionic villus sampling (CVS)), carrier testing (genetic screening), and sweat testing. If both parents are carriers of the faulty gene, but don’t have CF, a child has a one-in-four chance of being born with CF; a two-in-four chance of being a carrier, but not having the condition; and a one-in-four chance of being completely free of the condition.

About 2,000 CFTR gene mutations have been identified to-date and genetic testing provides important information to assist the diagnosis and treatment of CF. F508del is the most commonly detected CFTR mutation in Irish people living with CF. In 2016, 91.6 per cent of the CF population had at least one copy of F508del, 15.2 per cent had at least one copy of G551D, and 5.8 per cent had at least one copy of R117H. All

other CFTR mutations affect less than 5 per cent of the CF population. Just over 55 per cent of patients living with CF in Ireland in 2016 had two copies of the F508del mutation (F508del homozygous). Approximately one-in-19 of the indigenous population are thought to carry one copy of the altered gene that causes CF. Testing is available at the National Centre for Medical Genetics in Crumlin, Dublin.

Associated health issues Organisms detected in the airways of individuals with CF in Ireland in 2016 included Staphylococcus aureus (54.7 per cent) and Haemophilus influenza (29.0 per cent), found most frequently in children. Pseudomonas aeruginosa was detected in at least one respiratory sample of 60.3 per cent of adults.

Two strains of bacteria that commonly infect people with CF are Pseudomonas aeruginosa and Burkholderia cepacia complex. They multiply in the thick mucus inside the lungs and may cause serious health problems and repeated chest infections.

As more and more people with CF become infected with these bacteria, antibiotic resistance is a growing issue, which is why cross-infection is such a problem. Lung infections caused by Pseudomonas aeruginosa and Staphylococcus aureus can become chronic and cause an irreversible reduction in lung function.

CF causes mucus to block the ducts in the pancreas leading to malnutrition, steatorrhoea, and diabetes. People with CF who develop diabetes may find it difficult to gain weight or may lose weight and see a decline in their lung function. CF-related diabetes is usually controlled by regular injections of insulin. Diabetes rarely occurs in children with CF. Pancreatic insufficiency (PI) is manifested by voluminous, fatty, shiny, malodorous, pulp-like stools, abdominal symptoms, Continues on p24 ▸

24

THE MEDICAL INDEPENDENT | 12 MARCH 2020

Clinical Respiratory THERESA LOWRY LEHNEN PHD Clinical Nurse Specialist Practitioner and Associate Lecturer at Institute of Technology Carlow, and Assistant PRO, Irish Student Health Association ▸ Continued from p23

dystrophy, and deficiencies of fat-soluble vitamins (eg, haemolytic anaemia due to vitamin E deficiency) and trace elements (eg, zinc dermatosis). The diagnosis can be established by a low faecal elastase measurement. Patients with primary pancreatic insufficiency are at increased risk of chronic and/or recurrent pancreatitis.

People with CF are also prone to sinusitis and hay fever.

Older children with CF can develop a form of arthritis in joints such as the knee, which improve with time and treatment. Older children and adults with CF are also prone to osteoporosis due to repeated infection, poor growth or weight, lack of physical activity and lack of vitamins and minerals due to digestive problems, with steroid use also a risk-factor.

One-in-ten babies with CF is born with meconium ileus and an operation to remove the blockage will probably be required.

In nearly all men with CF, the spermatic tubes do not develop correctly, making them infertile.

Women with CF may find their menstrual cycle becomes absent or irregular if they are underweight. There is also an increased thickness of cervical mucus, which may reduce fertility. However, most women with CF can conceive without any difficulty. If the bile ducts in the liver become blocked by mucus as the disease progresses, this can be serious and in some cases a liver transplant may be necessary.

Treatment There remains no cure for CF. Improved diagnosis and symptomatic treatments have increased the survival rates of people with the condition, however, from a life span of only a few months in the 1950s to a global median age of 40 years today. The predicted median age of survival for a person in Ireland with CF is early to mid-30s. Aside from symptomatic treatment, the first mutation-specific treatments have recently become available.

The aim of symptomatic treatment is to clear and control infections in the lungs and digestive system and reduce long-term damage caused by infection and organ complications.

Inhaled bronchodilator drugs are used to relax the muscles surrounding the airways and help the person breathe more easily. Antibiotics are prescribed to treat infections in the lungs. All young children diagnosed with CF are started on a course of oral antibiotics to protect them from certain bacteria, which will be continued until they are three years of age. Steroids are used to help reduce the swelling of the airways, which can help with breathing and DNase, an enzyme, which is usually inhaled, is used to help thin and break down the viscous mucus in the lungs, so it is easier to expectorate.

Pancreatic enzyme replacement therapy (PERT) is required by almost all individuals with CF, due to pancreatic insufficiency. When the exocrine pancreas no longer functions adequately, the production of pancreatic enzymes is reduced, leading to fat malabsorption. The consequences of this include steatorrhoea, malnutrition, and fat-soluble vitamin deficiencies. The vast majority (91 per cent) of patients with CF in Ireland received PERT in 2016. Supplementary feeding can be required due to continued weight loss. Nearly 38 per cent of individuals with CF in Ireland required supplemental feeding in 2016. Approaches to supplemental feedings included oral supplementation, gastrostomy tube/button feeding, nasogastric tube feeding, and total parenteral nutrition.

Pancreatic enzymes are taken before and during every meal and fat-containing snack or drink, helping the digestive system break down food so that it can be digested and absorbed. The number of enzyme capsules taken needs to be adjusted depending on the amount of fat in the meal, snack, or drink. The enzymes should be taken with the meal and the timing may vary depending on the age of the person with CF. It is essential that people with CF receive advice about enzymes from a specialist CF dietitian.

Fat-soluble vitamin supplements (A,D,E, and K) are taken to help replace lost vitamins and to prevent deficiencies.

Because people with CF lose fat in their stools, they also lose the fat-soluble vitamins. Nutritional supplements can help compensate for poor digestion and provide additional energy and nutrients.

Bisphosphonates are taken to treat osteoporosis, which can occur as a result of CF, to help maintain bone density and reduce the risk of fractures.

It is important that people with CF are up-to-date with all the required vaccinations and should have the flu vaccine

annually, as they are more susceptible to complications as a result of infection.

Daily physiotherapy is usually required and if the person with CF has a chest infection the amount of airway clearance will need to be increased. Physiotherapy is tailored to the individual’s needs. While physiotherapy for CF mainly focuses on airway clearance, its role has expanded to include daily exercise, inhalation therapy, posture awareness, and in some cases for the management of incontinence.

In severe cases of CF, when the lungs fail, a double lung transplant may be required. Lung transplantation for CF has a good success rate: 70 per cent of patients survive one or two years after transplantation and the longest surviving patients had their transplant operation over 15 years ago.

CFTR potentiators and correctors used in the treatment of CF: CFTR potentiators are the first available treatments that target the defective CFTR protein, the underlying cause of cystic fibrosis. CFTR correctors (elexacaftor, lumacaftor, tezacaftor) correct the processing and trafficking defect of the F508del-CFTR protein to enable

flutiform® k-haler® (fluticasone propionate/formoterol fumarate) 50 μg/5 μg and 125 μg /5 μg pressurised inhalation suspension. Prescribing Information Republic of Ireland. Please read the Summary of Product Characteristics (SPC) before prescribing. Presentation Pressurised inhalation suspension, in a breath-actuated pressurised aerosol inhaler. Indications Regular treatment of asthma where the use of a combination product (inhaled corticosteroid [ICS] and long-acting β2-agonist [LABA]) is appropriate: (i) for patients not adequately controlled with ICS and ‘as required’ inhaled short-acting β2-agonist (SABA) (ii) for patients already adequately controlled on both an ICS and a LABA. For adults and adolescents aged 12 years and above. Dosage and administration for inhalation use. Patients should be shown how to use the inhaler correctly by a healthcare professional. Patients should be given the strength of flutiform k-haler containing the appropriate fluticasone propionate dose for their disease severity (50 μg/5 μg per actuation is not appropriate in patients with severe asthma). The appropriate strength should be taken as two inhalations, twice daily (normally morning and evening) and used every day, even when asymptomatic. flutiform k-haler is not recommended in children under 12 years. Prescribers should be aware that in asthmatics, fluticasone propionate is as effective as some other inhaled steroids when administered at approximately half the total daily microgram dose. Patients should be assessed regularly and once asthma is controlled, treatment should be reviewed and stepped down to the lowest effective dose, or an ICS alone. ICSs alone are first line treatment for most patients. flutiform k-haler is not intended for initial treatment of mild asthma. For patients with severe asthma the ICS therapy should be established before prescribing a fixed-dose combination product. Patients on flutiform k-haler must not use an additional LABA. An inhaled SABA should be taken for immediate relief of asthma symptoms

IRE/FLK-19015 Date of Item September 2019

it to reach the cell surface where the CFTR potentiator, ivacaftor, can further enhance the ion channel function of the CFTR protein (See Table 1).

Trikafta: New treatment for CF to become available in Ireland in 2020: Trikafta, the first drug to treat the underlying cause of CF, was recently approved for cover by the HSE – before it received European Medicines Agency (EMA) approval. The HSE announced in December 2019 that it had reached agreement with the manufacturer, Vertex Pharmaceuticals, to expand its existing reimbursement agreement to include Vertex’s first triple combination therapy Elexacaftor (VX-455), Tezacaftor, and Ivacaftor (Kalydeco) – known as Trikafta for Irish CF patients. The agreement with Vertex arises from the 2017 pipeline agreement with the company, which provided funding for existing products as well as new ones then in development. Trikafta is the first approved treatment that is effective for CF patients aged 12 years and over with at least one F508del mutation, which affects 90 per cent of the population with CF worldwide and 80 per cent of the CF population in Ireland. All CF

arising between doses. Patients should be advised to contact their prescriber when flutiform k-haler dose counter is getting near zero. Contra-indications Hypersensitivity to the active substances or to any of the excipients. Precautions and warnings flutiform k-haler should not be used as the first asthma treatment, to treat acute asthma symptoms or for prophylaxis of exercise-induced asthma. It should not be initiated during an exacerbation, during significantly worsening or acutely deteriorating asthma, and should not be stopped abruptly. If a patient experiences serious asthma-related adverse events or exacerbations, they should continue treatment and seek medical advice. Patients should be reviewed as soon as possible if there is any indication of deteriorating asthma control. In case of sudden and progressive deterioration, seek urgent medical assessment. Caution in patients with: pulmonary tuberculosis; quiescent tuberculosis; fungal, viral or other infections of the airway; thyrotoxicosis; phaeochromocytoma; diabetes mellitus (consider additional blood sugar controls); uncorrected hypokalaemia; predisposition to low levels of serum potassium; impaired adrenal function (monitor HPA axis function regularly); hypertrophic obstructive cardiomyopathy; idiopathic subvalvular aortic stenosis; severe hypertension; aneurysm or other severe cardiovascular disorders; unstable or acute severe asthma and other conditions when the likelihood for hypokalaemia adverse effects is increased. There is risk of potentially serious hypokalaemia with high doses of β2-agonists or concomitant treatment with β2-agonists and drugs that can induce or potentiate a hypokalaemic effect. Monitoring of serum potassium levels is recommended during these circumstances.

Formoterol may induce prolongation of the QTc interval. Caution must be observed when treating patients with existing prolongation of QTc interval. flutiform k-haler should be discontinued immediately if there is evidence of paradoxical bronchospasm. Visual disturbance may be reported with corticosteroid use.

25

THE MEDICAL INDEPENDENT | 12 MARCH 2020

Respiratory Clinical THERESA LOWRY LEHNEN PHD Clinical Nurse Specialist Practitioner and Associate Lecturer at Institute of Technology Carlow, and Assistant PRO, Irish Student Health Association patients in Ireland who are aged 12 years and over and who have at least one copy of the F508del gene mutation will get access to Trikafta as soon as it is approved by the EMA. While a decision by the EMA was originally expected to be made in the first quarter of 2020, with the drug becoming available by June, Cystic Fibrosis Ireland said it predicts that the decision is now more likely in the autumn/winter of 2020, with the likely reason for non-fast tracking of Trikafta because it would be important that the EMA license for Trikafta is as broad as possible, ie, covering as many altered gene combinations as possible.

Once approved by the EMA, it is anticipated that most patients on existing CF drugs such as Orkambi will transfer over to Trikafta depending on the advice of their clinician. One clinical trial has shown Trikafta to increase lung function by a mean of 14 per cent, while other research has shown its use to cause a decrease in exacerbations by up to 60 per cent. Commenting on the development, Mr Philip Watt, CEO of Cystic Fibrosis Ireland, said: “The decision effectively means Ireland will be the first country in Europe to receive this drug for its patients. We have great hope now

that the life expectancy of people with cystic fibrosis in Ireland will increase steadily over the next few years and, indeed, Ireland may overtake other countries.”

While news of this new drug is very welcome, about 10 per cent of CF patients remain without an available corrective therapy, since they do not make any CFTR protein.

Cystic Fibrosis Ireland Annual Conference Dr Preston Campbell, former president and chief executive officer of the Cystic Fibrosis Foundation in the US, and a leading medical expert in CF, has been announced as the keynote speaker at the forthcoming Cystic Fibrosis Ireland annual conference taking place in Galway from Friday 3 April – Sunday 5 April. Full information at www.cfireland.ie. The conference comes ahead of Cystic Fibrosis Ireland’s annual flagship fundraising appeal, 65 Roses Day, on Friday, 10 April, where people can lend their support by buying a purple rose for €2 or by donating online at www.65RosesDay.ie.

References on request

Intelligently designed.

Simple to use.

1,2

The first and only ICS/LABA delivered in a breath-actuated aerosol inhaler

Systemic effects with an ICS may occur, particularly at high doses for prolonged periods or when combined with potent CYP3A4 inhibitors, but are less likely than with oral corticosteroids. Possible systemic effects include Cushing’s syndrome, Cushingoid features, adrenal suppression, growth retardation in children and adolescents, decrease in bone mineral density and cataract glaucoma. Children may also experience anxiety, sleep disorders and behavioural changes. Increased exposure can be expected in patients with severe hepatic impairment. Prolonged treatment with high doses of corticosteroids may result in adrenal suppression and acute adrenal crisis, particularly in children and adolescents or potentially as a result of trauma, surgery, infection or rapid dose reduction. flutiform k-haler contains a negligible amount of ethanol that does not pose risk to patients. Interactions Co-treatment with CYP3A inhibitors (e.g. ritonavir, atazanavir, clarithromycin, indinavir, itraconazole, nelfinavir, saquinavir, ketoconazole, telithromycin, cobicistat) should be avoided unless the benefit outweighs the increased risk of systemic side-effects.

Caution is advised with concomitant use of non-potassium sparing diuretics (e.g. loop or thiazide), xanthine derivatives, glucocorticosteroids, L-Dopa, L-thyroxine, oxytocin, alcohol or other adrenergic drugs, including anaesthesia with halogenated hydrocarbons and digitalis glycosides, β-adrenergic drugs, known to prolong the QTc interval, such as tricyclic antidepressants or MAOIs (and for two weeks following their discontinuation), antipsychotics (including phenothiazines), quinidine, disopyramide, procainamide, antihistamines, furazolidone and procarbazine. flutiform k-haler should not normally be used with β-blockers including those that are used as eye drops to treat glaucoma. Under certain circumstances, e.g. as prophylaxis after myocardial infarction, cardioselective β-blockers could be considered with caution.

Pregnancy and lactation flutiform k-haler is not recommended during pregnancy unless the benefits

to the mother outweigh risks to the foetus. A risk to the breastfeeding infant cannot be excluded. Sideeffects Uncommon (<1/100) but potentially serious: hyperglycaemia, agitation, depression, aggression, behavioural changes (predominantly in children), vision blurred, vertigo, palpitations, ventricular extrasystoles, angina pectoris, tachycardia, hypertension, dyspnoea, peripheral oedema. Please consult the SPC a full list of side-effects and those reported for the individual molecules. Legal category POM Package quantities One inhaler (120 actuations) Marketing Authorisation numbers PA 1688/013/004-005 Marketing Authorisation holder Mundipharma Pharmaceuticals Limited, Millbank House, Arkle Road, Sandyford, Dublin 18, Ireland. Tel: +353 (0)1 2063800. For medical information enquiries, please contact medicalinformation@mundipharma.ie. ® FLUTIFORM is a registered trademark of Jagotec AG, and is used under licence. ® K-HALER is a registered trade mark of Mundipharma AG. © 2018 Napp Pharmaceuticals Limited. UK/FLUT-K-18036a(1). Date of Preparation July 2019.

Adverse events should be reported to: HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517. Website: www.hpra.ie; E-mail: medsafety@hpra.ie.

Adverse events should also be reported to Mundipharma Pharmaceuticals Limited on drugsafetyireland@ mundipharma.ie or by phone on 01 2063800 (1800 991830 outside office hours) References: 1. https://www.medicines.ie/medicines/flutiform-k-haler-50-microgram 5-microgram-125microgram-5-microgram-peractuation-pressurised-inhalation suspension--34603/ last accessed September 2019.

2. Bell D et al. J Aerosol Med Pulm Drug Deliv 2017; 30:425–34.

CF in Ireland Ireland has the highest incidence per head of population of CF in the world, with three times the rate of the US and the rest of the European Union. Between 2008 and 2016 an average of 38 individuals in Ireland were diagnosed with CF each year, with 22 diagnosed in 2016.

At the beginning of each year, the CF Registry of Ireland conducts a survey of hospitals known to provide care to people with CF in the Republic of Ireland. The registry has gathered information on people with CF since 2002. The annual hospital census carried out by the registry in 2016 showed that 1,339 people were living with CF in Ireland. Most patients attended one hospital for CF care (n=1,107, 82.7 per cent), whereas 17.3 per cent (232) shared care at two or more hospitals. The year 2016 was also the first time that the median age for people with CF reached 20 years (half of the population were aged over 20 years and half under) in Ireland, while 8.9 per cent of the CF population in Ireland was recorded as over 40 years old. There were 1,266 individuals (565 children and 701 adults) with CF on the registry on the last day of 2016, representing 94.5 per cent of people living with CF in Ireland in that year.

Over half of individuals with CF in 2016 were located in Leinster, approximately a third in Munster, and the remainder (14.6 per cent) in Ulster and Connaught.

The counties with the largest numbers of individuals included Dublin (n=354), Cork (n=165), Limerick (n=76), Galway (n=59) and Tipperary (n=59), and more males (58.0 per cent) than females (42.0 per cent) were recorded living with CF. The number of people (children and adults) diagnosed in 2016 (n=22) and 2015 (n=28) is likely to be an underestimate, resulting from a delay in joining the registry. Since the introduction of the National Newborn Bloodspot Screening Programme (NNBSP) in July 2011, 156 individuals have been diagnosed as a result of the screening programme. Sixteen of the 22 new CF diagnoses made in 2016 (72.7 per cent) were made following newborn screening.

Hospitalisations recorded by the registry reflect admission for a variety of reasons, both CF and non-CF related. In 2016, 954 hospitalisations were recorded in 497 individuals. Over 70 per cent of hospitalisations (71.3 per cent) were for the purpose of treating a pulmonary exacerbation. A total 363 individuals, 32.1 per cent of individuals attending CF centres/clinics in that year, were hospitalised for treatment of a pulmonary exacerbation; 20.8 per cent of children (n=106) and 41.1 per cent of adults (n=257). Of those hospitalised for treatment of a pulmonary exacerbation in 2016, 44.4 per cent (n=161) were admitted to hospital two or more times in the year. The cumulative total number of days spent in hospital by individuals with CF for treatment of a pulmonary exacerbation in 2016 was 9,278 days; 1,689 days for paediatric patients, 7,589 for adult patients.

The number of days spent on IV antibiotics for pulmonary exacerbation for all people with CF in Ireland in 2016 came to a total of 14,084. The mean duration of pulmonary exacerbation treatment was 16.4 days and median duration was 14 days.

The registry recorded 6,792 outpatient visits to CF specialist centres and CF clinics across the country by 1,133 individuals with CF in 2016, however, CF day-unit and drop-in visit statistics are thought to be underestimated.

The number of deaths from CF in Ireland varies from year to year. Since 2000, an average of 18 individuals died annually (range: Seven to 31). The deaths of 13 people with CF occurred in 2016 (nine female, four male). These individuals died between the ages of 11 and 59 years, with the median age of death 32.5 years.

Deaths were due to respiratory/cardio-pulmonary causes (n=9), transplant-related issues (n=2) and the cause of death in two individuals was not known to the registry at the time of reporting.

26

THE MEDICAL INDEPENDENT | 12 MARCH 2020

Clinical Respiratory DR SEAMUS J LINNANE Consultant Respiratory and General Physician at Beacon Hospital, Dublin, and UCD Assistant Clinical Professor

Managing adolescent and adult asthma Sublingual immunotherapy and other updates on adolescent and adult asthma The prevalence of asthma has been increasing internationally for several decades. Ireland has one of the highest prevalence figures for asthma in the world with estimates approaching half a million people affected.

This is disappointing during a time when Ireland has made significant, slow but steady progress, combating tobacco dependence. The reasons behind this shift and the consequent significant burden of illness is not fully understood, but is felt to represent changing environmental factors such as increasing exposure to allergens and reducing bacterial infections in a genetically susceptible population.

Burden of disease Asthma consistently figures in the most common reasons for hospital admission.

Over 90 per cent of these admissions are emergency or unscheduled. Four times as many admissions are treated and presumably discharged home from emergency departments. National intelligence data is for public hospitals only and does not factor in patients attending insurance-funded acute care units or the increasing activity in emergency rooms attached to private hospitals.

At least 20 per cent of patients report poor control of their asthma with impacts on quality-of-life and mortality risk. The Asthma Society of Ireland reports that children lose five school days while adults lose seven work days annually as a result of their asthma. The Irish Thoracic Society reports that mortality rates from asthma increased in the last decade with a five-

year standardised mortality rate of 1.92 and notes that these figures are a source of concern.

Definition of asthma Asthma is defined as an inflammatory disease of the airway. Triggers such as viruses, allergens or exercise, narrow the airway through luminal obstruction, muscle contraction, and structural changes.

Patients experience airflow limitation with symptoms of cough, breathlessness, and wheeze.

General principles of treatment Beta-adrenergic bronchodilators, both short- and long-acting, relax airway smooth muscle tone, increasing luminal diameter and reducing airway obstruction.

Glucocorticoids, ideally inhaled, reduce the airway inflammatory response to the asthma trigger, preventing the downstream cascade series of events responsible for daily symptoms and acute exacerbations.

Long-acting anti-muscarinic (LAMA) bronchodilators are also licensed for the treatment of asthma as adjunctive therapy in more severe cases. Immunisation helps mitigate airway infections while identification of individual triggers such as exercise or inhalation of cold air can help manage specific triggers for a given patient. The importance of allergen management has been recognised for many years, but is often limited to avoidance strategies that are hampered by the ubiquity of sensitising allergens such as house dust mite or airborne pollens.

The role of immunotherapy Desensitisation to specific allergens has been feasible and practised back to the early part of the last century. This approach works by reducing the inflammatory response to a sensitised antigen and represents an intervention early in the pathway from triggering agent exposure through to symptomatic disease. The appeal of this approach was tempered by the need to administer desensitising doses of antigen parenterally with anaphylaxis, collapse, and death rare, but much feared adverse events in published reports. As a result immunotherapy was restricted to specialised centres or clinics with logistic and medical infrastructure designed to manage such risks safely. An alternative administration route, specifically sublingually delivering desensitising doses of antigen topically under the tongue was developed. Sublingual immunotherapy (SLIT) delivers comparable reductions in allergen reactivity with a more acceptable side-effect profile. Widespread implementation of this approach has been hampered by the need to prepare allergen solutions by specialist manufacturers, which are dispensed in bottles with a prescribed number of drops of allergen solution administered each day. Allergen tablets with consistent and biologically standardised doses of allergen have been developed, which extend the scope of immunotherapy from specialist clinics to general respiratory and ENT services and into primary care for GPs with an interest in allergic airway disease.

In Ireland this therapeutic approach was limited to SLIT for grass pollen allergy, however, house dust mite and tree pollen products are scheduled to be available imminently.

Figure 1: GINA 2019 Stepwise Management of Asthma

Personalised asthma management: Assess, Adjust, Review response Confirmation of diagnosis if necessary Symptom control and modifiable risk factors (including lung function) Comorbidities Inhaler technique and adherence Patient goals

Symptoms Exacerbations Side-effects Lung function Patient satisfaction

Treatment of modifiable risk factors and comorbidities Non-pharmacological strategies Education and skills training Asthma medications

PREFERRED CONTROLLER To prevent exacerbations and control symptoms Other controller options

STEP 2 Daily low-dose inhaled corticosteroid (ICS), or as-needed low-dose ICS-formoterol *

STEP 1 As-needed low-dose ICSformoterol * Low-dose ICS taken whenever SABA is taken †

Leukotriene receptor antagonist (LTRA), or low-dose ICS taken whenever SABA taken †

As-needed low dose ICS-formoterol *

PREFERRED RELIEVER Other reliever options

STEP 3 Low-dose ICSLABA

Medium-dose ICS, or low-dose ICS+LTRA #

STEP 4 Medium-dose ICSLABA

High-dose ICS, addon tiotropium, or add-on LTRA #

STEP 5 High-dose ICSLABA Refer for phenotypic assessment ± add-on therapy, e.g. tiotropium, anti-IgE, anti-IL-5/5R, anti-IL-4R Add low-dose OCS, but consider sideeffects

As-needed low dose ICS-formoterol ‡

As-needed short-acting β2 -agonist (SABA) * Off-label; data only with budesonide-formoterol (bud-form) † Off-label; separate or combination ICS and SABA inhalers

© Global Initiative for Asthma, www.ginasthma.org

‡ Low-dose ICS-form is the reliever for patients prescribed bud-form or BDP-form maintenance and relieved therapy # Consider adding HDM SLIT for sensitised patients with allergic rhinitis and FEV1 >70 per cent predicted

The Global Initiative for Asthma The Global Initiative for Asthma (GINA) is an international self-funded collaboration of major pulmonary and health organisations dedicated to improving knowledge and treatment of asthma worldwide. GINA produces a regularly updated set of evidence-based management principles with the most recent iteration produced in 2019.

Traditionally asthma management has been seen as an escalating stepwise series of interventions beginning with short-acting bronchodilators with subsequent increments of inhaled steroids and long-acting bronchodilators. Adjunctive and systemic therapy is reserved for those with more severe disease and most likely attending secondary or tertiary care clinics.

A major change at Step One The most radical development of the new GINA document is the abandonment of short-acting bronchodilators alone as acceptable therapy for the management of asthma. A review of published studies identified that treatment with short-acting bronchodilators alone was associated with a risk of sudden exacerbation and death that was mitigated by the use of any inhaled steroid.

As a result Step One of the GINA report now states that patients with symptoms twice per month or less should use a combined inhaled corticosteroid and long-acting beta adrenergic bronchodilator (ICS/LABA) as required. Budesonide/formoterol is the recommended combination as most of the relevant studies have focused on this pairing, however, the authors note that beclomethasone/formoterol may also be appropriate.

Step Two For patients with more frequent or persistent symptoms regular low-dose ICS are recommended. This can pose some challenges as it de-emphasises the role of the combined inhaler, which may be reintroduced if the patient has to proceed to higher treatment steps for adequate symptom control. The use of ICS/LABA is considered off-licence at this step although studies have shown non-inferiority when compared with ICS alone. In practice the patient may oscillate between Step One and Step Two themselves in the absence of medical supervision. Irrespective, the use of more regular ICS at Step Two seems key to success as other agents such as leukotriene receptor antagonists, while useful, appear less efficacious than regular ICS alone for reducing exacerbation frequency.

Finally, economic considerations might favour ICS over dual agents at this step as exacerbation rates are similar though the time taken to establish control is shorter when the dual agent is used.

Step Three Step Three is unchanged in the 2019 document with a definite role for regular ICS/ LABA. For patients with more than one exacerbation in the previous year, maintenance and reliever treatment with inhaled budesonide/formoterol or beclomethasone/formoterol produces superior results to short-acting bronchodilator and regular ICS with or without a long-acting bronchodilator. Mixing inhaled ICS/LABA formulations (ie, one ICS/LABA for maintenance and a different ICS/LABA for relieving) is Continues on p28 ▸

GD: AB 447551

Native File: Indesign CC Windows Generated in: Acrobat Distiller 11.0

fluticasone furoate

Allergic rhinitis relief

Relieving the symptoms of allergic rhinitis in patients over 6 years1

The incidence of epistaxis during long term treatment was higher than 10% but was generally mild to moderate in intensity1 www.avamys.ie Prescribing Information (Please refer to the full Summary of Product Characteristics before prescribing) Avamys Nasal Spray Suspension (fluticasone furoate 27.5 micrograms/metered spray) Uses: Treatment of symptoms of allergic rhinitis in adults and children aged 6 years and over. Dosage and Administration: For intranasal use only. Adults and adolescents (12 years and older): Two sprays per nostril once daily (total daily dose, 110 micrograms). Once symptoms controlled, use maintenance dose of one spray per nostril once daily (total daily dose, 55 micrograms). Reduce to lowest dose at which effective control of symptoms is maintained.

Children aged 6 to 11 years: One spray per nostril once daily (total daily dose, 55 micrograms). If patient is not adequately responding, increase daily dose to 110 micrograms (two sprays per nostril, once daily) and reduce back down to 55 micrograms daily dose once control is achieved. Contraindication: Hypersensitivity to active substance or excipients. Special warnings and precautions: Systemic effects of nasal corticosteroids may occur, particularly when prescribed at high doses for prolonged periods. These effects are much less likely to occur than with oral corticosteroids and may vary in individual patients and between different corticosteroid preparations. Potential systemic effects may include Cushing’s syndrome, Cushingoid features, adrenal suppression, growth retardation in children and adolescents, cataract, glaucoma and more rarely, a range of psychological or behavioural effects including psychomotor hyperactivity, sleep disorders, anxiety, depression or aggression (particularly in children). Treatment with higher than recommended doses of nasal corticosteroids may result in clinically significant adrenal suppression. Consider additional systemic corticosteroid cover during periods of stress or elective surgery. Caution

when prescribing concurrently with other corticosteroids. A reduction in growth velocity has been observed in children treated with fluticasone furoate 110 micrograms daily for one year. Therefore, children should be maintained on the lowest possible efficacious dose which delivers adequate symptom control. It is recommended that growth of children receiving prolonged treatment with nasal corticosteroids is regularly monitored. Consider referring to a paediatric specialist. May cause irritation of the nasal mucosa. If a patient presents with visual disturbance they should be considered for referral to an ophthalmologist for evaluation of possible causes which may include cataract, glaucoma, central serous chorioretinopathy. Drug interactions: Caution is recommended when co-administering fluticasone furoate with potent CYP3A inhibitors including cobicistat-containing products as an increase in the risk of systemic side effects is expected. Co-administration should be avoided unless the benefit outweighs the increased risk.

Co-administration with ritonavir is not recommended because of the risk of increased systemic exposure of fluticasone furoate. Pregnancy and Lactation: No adequate data available. Recommended nasal doses result in minimal systemic exposure. It is unknown if fluticasone furoate nasal spray is excreted in breast milk. Only use if the expected benefits to the mother outweigh the possible risks to the foetus or child.

Side effects: Very common (≥1/10): epistaxis. Epistaxis was generally mild to moderate, with incidences in adults and adolescents higher in longer-term use (more than 6 weeks). Common (≥1/100 and <1/10): headache, nasal ulceration. Uncommon (≥1/1000 and <1/100): rhinalgia, nasal discomfort (including nasal burning, nasal irritation, and nasal soreness), nasal dryness. Rare (≥1/10,000 and <1/1000): hypersensitivity reactions including anaphylaxis, angioedema, rash,

and urticaria. Very rare (<1/10,000): Nasal septum perforation. Not known: transient ocular changes, vision blurred, growth retardation.

Marketing Authorisation (MA) Holder: GlaxoSmithKline (Ireland) Limited, 12 Riverwalk, Citywest Business Campus, Dublin 24, Ireland.

MA Number: EU/1/07/434/003. Legal category: POM B. Last date of revision: December 2018. Job Ref: IE/FF/0002/16(5). Further information available on request from GlaxoSmithKline, 12 Riverwalk, Citywest Business Camp, Dublin 24. Tel: 01-4955000.

Trademarks are owned by or licensed to the GSK group of companies.

Adverse events should be reported to the Health Products Regulatory Authority (HPRA) using an Adverse Reaction Report Form obtained either from the HPRA or electronically via the website at www.hpra.ie. Adverse reactions can also be reported to the HPRA by calling (01) 6764971. Adverse events should also be reported to GlaxoSmithKline on 1800 244 255.

24 HOUR EFFECT1

Reference: 1. Avamys Summary of Product Characteristics, available on www.medicines.ie, accessed April 2019.

PM-IE-FLF-ADVT-190004 Date of preparation: April 2019

Not actual size

28

THE MEDICAL INDEPENDENT | 12 MARCH 2020

Clinical Respiratory DR SEAMUS J LINNANE Consultant Respiratory and General Physician at Beacon Hospital, Dublin, and UCD Assistant Clinical Professor â&#x2013;¸ Continued from p26

not recommended and patients using a maintenance LABA other than formoterol should be prescribed a short-acting bronchodilator for intermittent use. At this step SLIT may be considered for patients on appropriate symptomatic therapy with rhinitis who are allergic to house dust mite, provided FEV1 is >70 per cent.

Step Four Further escalations at Step Four include the addition of tiotropium via mist inhaler, leukotriene antagonists, and increasing the dose of ICS. SLIT is also considered at this step if it has not been utilised at an earlier stage.

Step Five Patients at Step Five generally require management in a specialist clinic with access to biologic therapy including anti-IgE (omalizumab), anti-IL5 (mepolizumab), anti-IL5R (benralizumab), anti-IL4R (dupilumab), and oral corticosteroids.

Other management considerations The fundamentals of good asthma management apply across the spectrum of disease from mild to severe, but particularly beyond Step Two. These include avoidance of triggers including smoking, inhaler technique, compliance with treatment, and management of comorbidities such as gastro-oesophageal reflux disease (GORD). Failure to respond to an appropriate intervention should prompt a review of diagnostic assumptions and consideration of other entities such as asthma/COPD overlap syndrome.

The one airway hypothesis Pathology of the upper airway should also be considered as part of the management of asthma. Upper airway disease can be considered a comorbid condition complicating asthma, however, the overlap of triggers and treatment responses suggests a more intimate association. The one airway hypothesis was proposed widely in the 1990s and suggested the respiratory epithelium was a single and continuous structure from the nose right through to the respiratory bronchioles. Pathophysiological processes are equally pertinent and prevalent in the

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The clinical history and antigen exposure A clear and focused history will often suggest if allergy or atopy is contributing to asthma symptoms and may also increase the confidence of the asthma diagnosis. Sensitisation generally requires repeated exposure and a careful enquiry into occupational and domestic exposures can identify suspected antigens. Geography also plays a role. For example, olive tree pollen poses a significant challenge for Mediterranean populations, but is seen only under exceptional circumstances in an Irish context. Seasonality and timing of exposure is also important. Symptoms worsening in summer months are easily identified as manifestations of grass pollen allergy (typically Timothy and Rye varieties). Tree pollen allergy is less often considered and can cause an otherwise inexplicable deterioration in control as early as February. Hazel, Alder, and Birch are particular considerations though any flowering tree may be responsible and a modicum of arboreal familiarity can prove invaluable. House dust mite is a perennial allergen, which can cause year-round symptoms in heavily exposed susceptible individuals. A surge in symptoms is, however, seen around autumn when indoor temperatures and humidity increases, favouring the proliferation of mites and subsequent antigenic load.

B

Appropriate allergy testing When an allergic trigger is suspected, confirmatory testing is required as allergen avoidance can be both costly and time-consuming. Testing should be guided by history and clinical suspicion as blanket or otherwise uninformed testing may produce spurious results leading to ineffective management strategies. As a rule food-based or ingested allergens are only rarely significant in adults with the vast majority of triggers being inhaled or aero-allergens. Serologic testing can be performed by measuring IgE specific antibodies. Total IgE levels may be normal and should not preclude more detailed analysis if the clinical suspicion remains high. Skin prick testing is available in many laboratories and correlates closely, but not exactly with serologic testing. Candidate allergens for testing must be chosen on the basis of history and clinical suspicion. The choice of serology or skin prick test will largely be determined by availability and local resources. Skin prick testing offers the advantage of immediate results at a lower cost and can easily be performed by suitably trained individuals as part of a clinical review. Blood IgG measurement has no place in the management of atopic asthma although precipitating antibodies have a role in the diagnosis of allergic bronchopulmonary aspergillosis in specialist clinics.

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upper and lower airways and indeed causally interdependent.

While this seems an oversimplification of the asthmatic airway it does provide a useful paradigm for the management of more complex asthma patients and is certainly reflected in the observation of allergic rhinosinusitis preceding an unstable period of asthmatic airway tone. Upper airway disease is reported by up to three-quarters of patients with asthma, particularly those with atopic or allergic disease. Simple nasal washes have been shown to reduce asthma symptom scores as well as improving upper airway symptoms in suitably selected patients. Topical steroids, antihistamines, and leukotriene receptor antagonists can all improve asthma control in part by reducing the upper airway inflammatory response. SLIT has a role in both upper and lower airway disease once suitable allergens are identified.

pharmacist

pharmacistCPD.ie

SLIT in clinical practice SLIT for house dust mite in mild-to-moderate asthma was associated in one large study with a small, but significant reduction in inhaled steroid dose at one year without a deterioration in asthma control as evidenced by lung function, quality-of-life scores, and exacerbation rate.

A second study examined patients with poorly controlled asthma despite ICS use and found a reduction in the risk of moderate to severe exacerbation. There were no reports of severe allergic reaction to treatment although mild-to-moderate oral pruritus was frequently encountered. In practice the first dose of immunotherapy is administered in a healthcare setting although subsequent uninterrupted daily treatments appear to be safely administered at home.

Conclusion Asthma remains a highly prevalent and burdensome condition both for patients and healthcare systems. The pattern of disease is highly variable ranging from sporadic or purely seasonal symptoms through to highly complex presentations.

Care is required as patients can transition from mild unobtrusive symptoms to life-threatening exacerbations relatively rapidly. Treatment and advice continues to evolve with new treatment options becoming available across all levels of care from general practice through to subspecialty clinics.

SYMBICORT

®

(budesonide/formoterol)

as-needed reliever

with maintenance

SYMBICORT TURBOHALER IS NOW A PREFERRED RELIEVER* in moderate-to-severe asthma patients on top of Symbicort® maintenance1

SYMBICORT® Turbohaler® is indicated for children (6 years), adolescents (12-17 years) and adults (18 years) in the regular treatment of asthma where use of a combination (inhaled corticosteroid and long-acting ß2-adrenoceptor agonist) is appropriate: patients not adequately controlled with inhaled corticosteroids and “as needed” inhaled short-acting ß2-adrenoceptor agonists; or patients already adequately controlled on both inhaled corticosteroids and long-acting ß2adrenoceptor agonists. SYMBICORT® Turbohaler® 100/6 Maintenance and Reliever is indicated for use in adults and adolescents (12 years and older). SYMBICORT® Turbohaler® 200/6 Maintenance and Reliever is indicated for use in adults and adolescents (12 years and older). SYMBICORT® Turbohaler® 400/12 is indicated in adults and adolescents aged 12 -17 years as a maintenance treatment only. In this document, the Maintenance and Reliever dosage regimen is also described as ‘SYMBICORT® Turbohaler® as-needed reliever with maintenance’. * GINA 2019 guidelines have positioned low dose ICS-formoterol as the preferred reliever to use in moderate to severe asthma patients (GINA steps 3 to 5) over a SABA in addition to their ICS/LABA maintenance therapy.

ABRIDGED PRESCRIBING INFORMATION SYMBICORT® TURBOHALER® 100 micrograms/6 micrograms/inhalation, inhalation powder. SYMBICORT® TURBOHALER® 200 micrograms/6 micrograms/inhalation, inhalation powder. SYMBICORT® TURBOHALER® 400 micrograms /12micrograms /inhalation, inhalation powder (budesonide/formoterol fumarate dihydrate) Consult Summary of Product Characteristics (SmPC) before prescribing.

Indication: Indicated in adults, adolescents aged 12 years and older and children aged 6 years and older (100/6 only), for the regular treatment of asthma where use of a combination (inhaled corticosteroid and long-acting β2 adrenoceptor agonist) is appropriate: 1) patients not adequately controlled with inhaled corticosteroids and ‘as needed’ inhaled short-acting β2 adrenoceptor agonists or 2) patients already adequately controlled on both inhaled corticosteroids and long-acting β2 adrenoceptor agonists. Symbicort 100/6 is not appropriate for patients with severe asthma. Symbicort 200/6 and 400/12 only: Indicated in adults aged 18 years and older for the symptomatic treatment of patients with COPD with FEV1 <70% predicted normal (post-bronchodilator) and an exacerbation history despite regular bronchodilator therapy. Presentation: Inhalation powder. Symbicort 100/6: Each metered dose contains budesonide 100mcg/inhalation and formoterol fumarate dihydrate 6mcg/inhalation. Symbicort 200/6: Each metered dose contains budesonide 200mcg/inhalation and formoterol fumarate dihydrate 6mcg/inhalation. Symbicort 400/12: Each metered dose contains budesonide 400mcg/inhalation and formoterol fumarate dihydrate 12mcg/inhalation. Dosage and Administration: Asthma: The dose should be titrated to the lowest dose at which effective control of symptoms is maintained. Symbicort maintenance therapy: Patients should be advised to have their separate rapid-acting bronchodilator available for rescue use at all times. Adults (18 years and older): 100/6 and 200/6: The recommended dose is 1-2 inhalations twice daily. Some patients may require a maximum of 4 inhalations twice daily. 400/12: 1 inhalation twice daily. Adolescents (12-17 years): 100/6 and 200/6: The recommended dose is 1-2 inhalations twice daily.

400/12: 1 inhalation twice daily. Children 6-11 years (100/6 only): The recommended dose is 2 inhalations twice daily. Children under 6 years: Not recommended. Symbicort 400/12 is not recommended for children under 12 years. Symbicort maintenance and reliever therapy: 100/6 and 200/6 only (not indicated with 400/12 strength) Adults and adolescents (12 years and older): The recommended maintenance dose is 2 inhalations per day, given either as one inhalation in the morning and evening or as 2 inhalations in either the morning or evening. Patients should take 1 additional inhalation as needed in response to symptoms.

If symptoms persist after a few minutes, an additional inhalation should be taken. No more than 6 inhalations should be taken on any single occasion. A total daily dose of more than 8 inhalations is not normally needed, a total daily dose of up to 12 inhalations could be used for a limited period. Patients using more than 8 inhalations daily should be strongly recommended to seek medical advice. Children under 12 years: Not recommended. COPD (200/6): The recommended dose in adults is 2 inhalations twice daily. COPD (400/12): The recommended dose in adults is 1 inhalation twice daily. Elderly: No special dosing requirements required. Patients with hepatic or renal impairment: Increased exposure is expected in patients with severe liver cirrhosis. Symbicort 200/6: Patients taking Symbicort as reliever, preventative use of Symbicort for allergen- or exerciseinduced bronchoconstriction should be discussed between physician and patient. The recommended use should take into consideration the frequency of need. In case of frequent need of bronchodilation without corresponding need for an increased dose of inhaled corticosteroids, an alternative reliever should be used. Contraindications: Hypersensitivity to active substance(s) or excipients. Warnings and Precautions: Recommended that the dose is tapered when the treatment is discontinued and should not be stopped abruptly. If treatment is ineffective, or exceeds the highest recommended dose, medical attention must be sought. Sudden and progressive deterioration in control of asthma or COPD is potentially life threatening and patient should undergo urgent medical assessment. Consideration should be given for increased therapy with corticosteroids, e.g. orally, or antibiotic treatment if infection present. Patients should have their rescue inhaler available at all times. Patients should be reminded to take their maintenance dose as prescribed, even when asymptomatic. Once asthma symptoms are controlled, consideration may be given to gradually reducing the dose. Patients should not be initiated on Symbicort during an exacerbation or if they have significantly worsening or acutely deteriorating asthma. Paradoxical bronchospasm may occur with an immediate increase in wheezing and shortness of breath after dosing. Symbicort should be discontinued immediately and an alternative therapy instituted if necessary. Systemic effects may occur, particularly at high doses prescribed for long periods e.g. Cushing’s syndrome, Cushingoid features, adrenal suppression, growth retardation in children and adolescents, decrease in bone mineral density, cataract and glaucoma, and more rarely, a range of psychological or behavioural effects including psychomotor hyperactivity, sleep disorders, anxiety, depression or aggression (particularly in children). Recommended that height of children receiving prolonged treatment is regularly monitored and if growth is slowed, therapy should be re-evaluated and consideration given to referring the patient to a paediatric respiratory specialist. If adrenal function is impaired from previous systemic steroid therapy, care should be taken when transferring patients to Symbicort therapy. Patients transferring from oral steroids may remain at risk of impaired adrenal reserve for a considerable time. HPA axis function should be monitored regularly. Prolonged treatment with high doses of inhaled corticosteroids may result in clinically significant adrenal suppression. Additional systemic corticosteroid cover should be considered during periods of stress such as severe infections or elective surgery. Rapid reduction in dose of steroids can induce acute adrenal crisis, symptoms may include anorexia, abdominal pain, weight loss, tiredness, headache, nausea, vomiting, decreased level of consciousness, seizures, hypotension and hypoglycaemia. Treatment with systemic steroids should not be stopped abruptly.

Transfer from oral steroid therapy to Symbicort may result in the appearance of allergic or arthritic symptoms such as rhinitis, eczema, muscle and joint pain. Specific treatment should be initiated for these conditions. In rare cases, tiredness, headache, nausea and vomiting can occur due to insufficient glucocorticosteroid effect and temporary increase in the dose of oral glucocorticosteroids may be necessary. To minimise risk of oropharyngeal candida infection, patients should rinse mouth with Date of Preparation: December 2019 Veeva Approval ID: IE-1571

water after inhaling doses. Concomitant treatment with itraconazole, ritonavir or other potent CYP3A4 inhibitors should be avoided. Observe caution in patients with thyrotoxicosis, phaeochromocytoma, diabetes mellitus, untreated hypokalaemia, hypertrophic obstructive cardiomyopathy, idiopathic subvalvular aortic stenosis, severe hypertension, aneurysm or other severe cardiovascular disorders such as ischaemic heart disease, tachyarrhythmias or severe heart failure. Observe caution when treating patients with prolongation of the QTc-interval. Re-evaluate need for Symbicort in patients with active or quiescent pulmonary tuberculosis, fungal and viral infections in the airways. Hypokalaemia may occur at high doses of β2 adrenoceptor agonists. Particular caution recommended in unstable or acute severe asthma. Monitor serum potassium levels.

As for all β2 adrenoceptor agonists, consider additional blood glucose monitoring in diabetic patients. Visual disturbances may be reported with systemic and topical corticosteroid use. If a patient presents with these symptoms, consideration to ophthalmologist referral should be given to evaluate possible causes which may include cataract, glaucoma or rare diseases such as central serous chorioretinopathy. The excipient lactose contains small amounts of milk proteins, which may cause allergic reactions. 100/6: The reliever inhalations should be taken in response to asthma symptoms but are not intended for regular prophylactic use e.g. before exercise, separate rapid-acting bronchodilator should be considered. 200/6: Complete withdrawal of inhaled corticosteroids should not be considered unless it is temporarily required to confirm diagnosis of asthma.

200/6 & 400/12: An increase in the incidence of pneumonia, including pneumonia requiring hospitalisation, has been observed in patients with COPD receiving inhaled corticosteroids. Physicians should remain vigilant as clinical features of such infections overlap with symptoms of COPD exacerbations. Risk factors include current smoking, older age, low BMI and severe COPD. Potential effects on bone density should be considered especially in patients on high doses for prolonged periods that have co-existing risk factors for osteoporosis. Drug Interactions: Potent CYP3A4 inhibitors (e.g. ketoconazole, itraconazole, voriconazole, posaconazole, clarithromycin, telithromycin, nefazodone and HIV protease inhibitors) are likely to increase plasma levels of budesonide and concomitant use should be avoided. If this is not possible the time interval between administration should be as long as possible. Symbicort maintenance and reliever therapy is not recommended in patients using potent CYP3A4 inhibitors. Not to be given together with beta-adrenergic blockers (including eye drops) as can weaken or inhibit the effect of formoterol, unless compelling reasons. Concomitant treatment with quinidine, disopyramide, procainamide, phenothiazines, antihistamines (terfenadine) and TCAs can prolong the QTc-interval and increase the risk of ventricular arrhythmias. L-Dopa, L-thyroxine, oxytocin and alcohol can impair cardiac tolerance towards β2-sympathomimetics.

Concomitant treatment with MAOIs, including agents with similar properties such as furazolidone and procarbazine, may precipitate hypertension reactions. Elevated risk of arrhythmias in patients receiving anaesthesia with halogenated hydrocarbons. Concomitant use of other beta-adrenergic drugs or anticholinergic drugs can have a potentially additive bronchodilating effect. Hypokalaemia may increase the disposition towards arrhythmias in patients taking digitalis glycosides.

Hypokalaemia resulting from beta2-agonist therapy may be potentiated by concomitant treatment with xanthine derivatives, corticosteroids and diuretics. Pregnancy and Lactation: Use only when benefits outweigh potential risks during pregnancy and breastfeeding. Budesonide is excreted in breast milk; at therapeutic doses, no effects on child are anticipated. Not known whether formoterol passes into human breast milk. Undesirable Events: Consult SmPC for full list of side effects. Common: Headache, palpitations, tremor, candida infections in the oropharynx, coughing, mild irritation in the throat, hoarseness and pneumonia (in COPD patients using Symbicort 200/6) Uncommon: Tachycardia, muscle cramps, aggression, psychomotor hyperactivity, anxiety, sleep disorders, nausea, dizziness, blurred vision and bruises. Rare: Hypokalaemia, cardiac arrhythmias including atrial fibrillation, supraventricular tachycardia and extrasystoles, bronchospasm and immediate and delayed hypersensitivity reactions including exanthema, urticaria, pruritus, dermatitis, angioedema and anaphylactic reaction. Very rare: Depression and behavioural changes (predominantly in children), angina pectoris, prolongation of QTc-interval, hyperglycaemia, taste disturbances, Cushing’s Syndrome, Cushingoid features, adrenal suppression, growth retardation in children and adolescents, decrease in bone mineral density, cataract, glaucoma and variations in blood pressure. Paradoxical bronchospasm may occur in very rare cases. Package Quantities: Each Symbicort Turbohaler 100/6 or 200/6 contains 120 inhalations. Each Symbicort Turbohaler 400/12 contains 60 inhalations. Legal Category: Product subject to prescription which may be renewed (B) Marketing Authorisation Numbers: PA 1019/020/001-003 Marketing Authorisation Holder: AstraZeneca AB SE-151 85 Södertälje, Sweden Further Information Available on Request From: AstraZeneca Pharmaceuticals (Ireland) DAC, Block B, Liffey Valley Office Campus, Dublin 22. Tel: +353 1 609 71 00. SYMBICORT and TURBOHALER are trademarks of the AstraZeneca group of companies. Date of API preparation: 09/2019 API REF: IE-1557 Adverse events should be reported directly to: HPRA Pharmacovigilance. Website: www.hpra.ie.

Adverse events should also be reported to AstraZeneca Patient Safety on Tel: +353 1 6097100.

References: 1: GINA Guidelines 2019.

30

THE MEDICAL INDEPENDENT | 12 MARCH 2020

Professional Development Dermatology

Article and series in association with

UCD CHARLES INSTITUTE SEMINAR SERIES

Understanding eczema Attendees at UCD’s Charles Institute Seminar Series heard a presentation from epidemiologist Prof Sinéad Langan on advances in atopic eczema that provide a deeper understanding of the condition The Charles Institute, Ireland’s national dermatology research and education centre, played host to a range of guest speakers who covered a variety of topics ranging from skin cancer to psoriasis, among others. The series, which was sponsored by RELIFE (part of the A.Menarini group), was designed to provide expert advice from a range of distinguished national and international experts in their respective fields and was chaired by Prof Desmond Tobin, Full Professor of Dermatological Science at UCD School of Medicine and Director of the Charles Institute of Dermatology. The seminars were broadcast to attendees with a special interest in dermatology in other locations, who accessed the talks remotely via an audio-visual link.

Attendees at the series heard a presentation from Prof Sinéad Langan, Wellcome Senior Clinical Fellow and Professor of Clinical Epidemiology at the London School of Hygiene and Tropical Medicine and Honorary Consultant Dermatologist at St John’s Institute of Dermatology, London.

Prof Langan presented the seminar with an overview of research on atopic eczema (also known as atopic dermatitis or eczema), its prevalence and effect on a patient’s quality of life.

She summarized recent research findings from a group using data from the Avon Longitudinal Study of Parents and Children (ALSPAC) showing different trajectories of eczema throughout life. This birth cohort study which involved 14,000 individuals recruited in utero with many followed-up into adolescence showed that different patterns of eczema emerged, she said. “Some people had transient, early-life eczema that went away,” explained Prof Langan. “But there were also different patterns — people with later-onset eczema and other people with persisting eczema. These patterns, in addition to recent genetic findings and different responses to treatments suggest that there might be important subgroups of eczema. Researchers are interested in these subgroups because they want to find out if there are different endotypes or different biological mechanisms that might underlie those different subgroups.”

Prof Langan and her colleagues, among others, are now working on efforts to more fully understand and refine these subgroups.

Comorbidities As well as the psychological comorbidities that are associated with eczema, Prof Langan highlighted recent research suggesting associations between the condition and physical health outcomes. “In other inflammatory conditions, , e.g. in rheumatoid arthritis, increased risks of cardiovascular outcomes are reported.“ “We conducted a study using data from UK general practice linked to hospitalization data, to see if eczema was associated with an increased risk of cardiovascular outcomes. We found that there was an association between severe and persistently active eczema and cardiovascular outcomes at a population level. “However, translating these risks into absolute numbers, we see that the absolute numbers are quite small —one extra event in 40,000 people compar-

ing people with eczema to people without eczema. But should we be doing anything different from the standard cardiovascular screening? There is currently a lack of evidence to support doing additional screening for people with eczema.”

Fractures Prof Langan also presented data from a cohort study on fracture risk in patients with eczema. “Cross-sectional studies can be problematic, in that the timing of events can be tricky to determine,” she told the attendees. A cohort study allows us to assess the timing of exposures and outcomes more accurately. Prof Langan presented findings from a matched cohort in the UK primary care population where people were followed-up over time to see if there was an incidence of major fractures, such as pelvic, wrist, spine and hip fractures, major fractures that could be associated with osteoporosis.

“We found, overall, approximately a 10 per cent increase in fracture risk in people with eczema, compared to those who did not have it,” she said. “This risk was particularly relevant for hip, spine and pelvic fractures, compared to people that did not have eczema. When we looked at increasing eczema severity, we found that people with severe eczema had a much more significant increase in risk of fractures. This translated into double the risk of spinal fracture, 66 per cent in pelvic fractures, and a 50 per cent increased risk of hip fractures. But, Prof Langan emphasised, ‘‘The overall risk is still very low.’ To put it into context, if you compared a group of 100,000 people with eczema with another group of 100,000 people without eczema, there would be 164 more fractures or breaks in the eczema group.

Overall, then, the risk is still very small but higher than for the general population.

“These results may not be surprising to dermatologists,” she continued. “If you have severe eczema, it may limit your ability to exercise because sweating irritates the skin.

People with very severe eczema may also have an associated food allergy, leading to dietary restrictions. They may also have associated asthma and may have taken oral steroids — we did adjust for people ever having taken 20mg of steroids or greater per day, but we did not adjust for them having taken numerous smaller courses, which could build up and have an influence on fracture risk.”

Prof Langan also pointed out that spinal fractures are perhaps more likely to be diagnosed in eczema patients because they see a physician regularly for prescriptions, “but that is unlikely to be the explanation for the findings for pelvic, wrist and hip fractures”.

Prof Langan and colleagues are looking into scrutinising more closely the association between different doses and durations of oral corticosteroid use and fracture risk, she told the attendees.

“There is much research work to be done in order to try to understand those associations,” said Prof Langan.

“Sleep can still be important in people who have mild eczema and also in people who have inactive eczema and we need to explore what that means for long-term out-

Prof Sinéad Langan

comes,” she continued.

She also discussed paradigms around eczema and told the seminar: “Do people really ‘grow out’ of eczema? I think perhaps less so than we previously believed. Is it all one disease type? There is increasing evidence suggesting that there is a lot of heterogeneity and by looking at eczema as one disease — the ‘yes/no’ approach — we may limit our understanding of the condition,” she said. “Do we need to be thinking beyond the skin itself? I think we do; we need to focus on how eczema affects people’s mental health and to do more research to understand associations with other health outcomes.

There are many important questions to be answered, including: (1) “Can we identify and modify risks of physical and mental health outcomes? It would be great if we could identify people who may develop problems with their health associated with eczema. (2) Who should we be treating and can we target treatments better so that people do better in the long term, and does treating eczema improve these outcomes?

Prevalence During a lively Q&A session following the presentation, Prof Tobin asked whether the prevalence of atopic eczema varied between different geographic UV latitudes, diets, environments, ancestry and other factors that may predispose people to the condition. “What’s your feeling in the huge variations in incidence and severity across the planet?” Prof Tobin asked.

“It may be a combination of latitude, geographical region and urban versus rural location, as well as some of the factors you highlighted,” replied Prof Langan. “What has been shown with the ISAAC [International Study of Asthma and Allergies in

Children] study is that as countries become more westernised, the prevalence of eczema tends to increase, but then the prevalence of eczema seems to plateau.”

Prof Tobin added that a patient’s socioeconomic status, including lifestyle and diet, also seem to have an effect on incidence rates. Prof Langan commented: “The socioeconomic aspect is very interesting, because we know that atopic eczema has been associated with higher socioeconomic status, but some more recent data suggests that there may be a relationship between lower socioeconomic status and more severe eczema, so there are interesting aspects that we don’t yet fully understand.”

Speaking to the Medical Independent (MI) following her presentation, Prof Langan commented on other conditions that can sometimes be confused with atopic dermatitis. “These could include contact dermatitis, where people are allergic to things they are exposed to,” she said. “Also, seborrheic dermatitis can mimic atopic dermatitis, although the distribution of the disease tends to be different.

Dr Langan was also asked how treatments have advanced during her career and the current treatment gaps that still exist.

“There have been major advances,” she told MI. “The first new targeted biologic drug for severe eczema was introduced last October by the NHS. There are a lot of other biologic and small-molecule drugs in trials at present for the treatment of people with severe eczema, and there are major research efforts focused on improving treatments for people with eczema. There are also efforts to understand whether we can prevent people developing eczema.”

RELIFE has had no input into the content of this article or series of seminar

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Distributed by: A.Menarini Pharmaceuticals Ireland Ltd, Castlecourt, Monkstown Farm, Monkstown, Glenageary, Co. Dublin. www.relife.ie IE19019 IR-REL-22-2019 Date of item April 2019

32

THE MEDICAL INDEPENDENT | 12 MARCH 2020

Diary Life

MI

MARCH

33 34 35 36 MINDO QUIZ

Test your knowledge and win €50

FOOD & DRINK

Tom Doorley on the art of the artichoke

GALLERY

RCPI Certificate of Satisfactory Completion of Specialist Training ceremony

GALLERY

Bon Secours Hospital, Dublin – GP Study Evening

FRIDAY 20 The Irish Nephrology Society’s Annual Scientific Meeting will take place on Friday 20 March at the RCPI, Kildare Street, Dublin 2.

This year’s meeting will bring together a distinguished faculty of experts to gain insights into the latest breakthroughs in scientific research into kidney disease, as well as updates on current clinical nephrology practice by both leading Irish and international scientists.

Topics include: Renal ageing and disease — the role of the exposome; IgA receptor CD89/gut-kidney axis in IgA nephropathy; CKD-MBD; NRO update; and kidney disease in the Irish health system. Plenary sessions will be presented by both national and international speakers, including Prof Paul G Shiels, University of Glasgow, UK; Prof Renato Monteiro, Centre de Recherche sur L’Inflammation, Paris, France; Prof John Cunningham, UCL Medical School, Royal Free, London, UK; Prof George Mellotte, NRO; and Prof Austin Stack, National Kidney Disease Surveillance System, Ireland. Call for abstracts: All related specialties are invited to submit abstracts for a poster and oral presentation by 5pm, Friday 6 March.

Email submissions to: catherinem. brown@hse.ie. Prizes for Best Clinical Science Presentation; Best Basic Science Presentation; Best Medical Student/Intern Abstract; and Best Moderated Poster. The Sinead Kinsella INS Mundipharma Research Bursary 2020 will be awarded at the meeting. Registration is available online at an early bird rate of €75.

Registration is €85 on the day. Medical students will be admitted free of charge (contact Ms Ruth Walshe at ruth@medevents.ie to request complementary admission). Conference enquiries: contact Ms Ruth Walshe, ruth@medevents.ie.

THURSDAY 26-FRIDAY 27 The College of Psychiatrists of Ireland spring conference takes place on 26-27 March 2020 in the Lyrath Estate Hotel, Kilkenny. Visit www.irishpsychiatry.ie for further information.

SATURDAY 21 The Women in Medicine in Ireland Network will host its third annual conference in Belfast on Saturday March 21 2020. We are delighted to be bringing our conference across the border, to the stunning surroundings of Riddel Hall at Queen’s University Belfast. This will be an excellent opportunity for female medics from North and South to meet and discuss issues relevant to their working and professional lives. Our theme for this year is Diversity and we will be exploring the experiences of women and men from differing backgrounds, aiming to widen our understanding of the challenges they may face due to disability, race, religion or sexual orientation.

SPEAKERS: Alexandra Adams is a deaf blind medical student from Cardiff who campaigns for improved access to medical education for those with disabilities; Dr Malihah Mohamad is a Core trainee in general medicine, based at the Ul-

ster Hospital in Dundonald; Salome Mbugua is the Head of Operations and Strategy with AkiDwA which is a national network established in 2001 whose mission is to promote equality and justice for migrant women living in Ireland; Dr Christopher Morrison is a member of the BMA’s Equality, Diversion and Inclusion advisory group, and is cochair of the GLADD (The Association of LGBT Doctors and Dentists); Dr Mary Doherty is a consultant anaesthetist recently returned to clinical practice after a 6 year career break; Dr Aoife Kirk is currently a Clinical Fellow in Integrated Medicine in St Thomas Hospital, London with an interest in ageing health, preventative medicine and public health; and Ms Irene Bellini is a Transplant Surgeon in Belfast City Hospital. This is just a selection of the wonderful speakers and contributors that we will hear from on the day, and we are very much looking forward to sharing the WiMIN experience with our Northern colleagues.

And because it is a WiMIN conference, there will of course be free childcare on site, and breastfeeding/ pumping facilities, as well as plenty of opportunity for catching up with old and new friends throughout the day! For more information, visit our website at www.wimin.ie and follow us on Twitter, Facebook and Instagram @WomenMedIreland.

WEDNESDAY 26-THURSDAY 27 The 39th Annual International Nursing and Midwifery Research and Education Conference SPEAKERS: Lord Nigel Crisp, CoChair of the UK’s All-Party Parliamentary Group on Global Health, Co-Chair of the Nursing Now campaign, and former NHS Chief Executive and Permanent Secretary of the UK Department of Health 2000-2006. Ms Gabrielle Jacob, Programme Manager/Unit Head, Human Resources for Health Programme, WHO Regional Office for Europe, Copenhagen, Denmark Ms Elizabeth Iro, Chief Nursing Officer, WHO, Geneva, Switzerland Prof Richard Ricciardi, President-Elect, Sigma Theta Tau International and Professor, George Washington University, School of Nursing, Washington, DC, US. SATURDAY 28-SUNDAY 29 Rock Steady Boxing Affiliate.

Learn how to use the Rock Steady method to ‘Fight back against Parkinson’s’. Portlaoise Boxing Club, Kylekiproe, Portlsoide, Co Laois. Tel: 089 962 1701. Email: info@rocksteadyboxing.org.

APRIL FRIDAY 3 Now in its fourth year, the very popular narrative medicine symposium, MindReading, returns to Dublin in April 2020. Led by Dr Elizabeth Barrett, University College Dublin (UCD) Associate Professor of Child and Adolescent Psychiatry, this international academic collaboration involves patients, poets, clinicians, literature and medical humanities experts, writers, and experts by experience.

The academic collaboration in-

volves UCD Child and Adolescent Psychiatry, UCD Humanities, the Diseases of Modern Life Group at St Anne’s College, University of Oxford, and the Department of English Literature, University of Birmingham. Programme timings to be confirmed.

FRIDAY 3-SUNDAY 5 Cystic Fibrosis Ireland annual conference. Dr Preston Campbell, former President and Chief Executive officer of the Cystic Fibrosis Foundation in the US, and a leading medical expert in cystic fibrosis (CF), has been announced as the keynote speaker at the forthcoming Cystic Fibrosis Ireland annual conference taking place in Galway from April 3-5. Aimed at people with CF, their families and friends, registration for the conference in the Ardilaun Hotel, Taylors Hill, is now open at www.cfireland.ie. Ireland has the highest incidence of CF in the world, with almost 1,400 people diagnosed with the disease. The conference comes ahead of Cystic Fibrosis Ireland’s annual flagship fundraising appeal, 65 Roses Day, on Friday 10 April, where people can lend their support by buying a purple rose for €2 or by donating online at www.65RosesDay.ie. In addition to Dr Campbell’s keynote, there will be a number of other presentations on a range of topics including: Positive mental health

by Dr Alistair Duff, Head of Psychological Services, St James’s University Hospital, Leeds; Superbugs

by Prof John Moore and Prof Cheri Millar, clinical microbiologists at Belfast City Hospital; Gene editing by Dr Patrick Harrison, Senior Lecturer, University College Cork; Diet research by Dr Audrey Tierney, Director for the MSc in Human Nutrition and Dietetics, University of Limerick; Relaxation by Ms Charlotte Farragher and Mr Rory Murphy, instructors at Tuam Yoga and Pilates Studio; and The impact of new drug therapies in children and gastrointestinal CF developments

by Prof Paul McNally, Consultant, Children’s Health Ireland, Crumlin Hospital. For more details on registration, telephone 01 4962433 or email info@crireland.ie.

TUESDAY 7 The Access to Medicines Ireland conference, themed ‘Towards an alternative future for medicines’, takes place on Tuesday 7 April at the RCSI, York Street, Dublin 2. This meeting is co-ordinated by Access to Medicines Ireland, which is a group committed to exploring mechanisms that ensure that medicines are developed with the objective of public health rather than shareholder profit. The conference intends to engage and inform all stakeholders: Government officials, policy-makers, patient advocates, healthcare professionals, industry, NGOs, civil society groups and members of the public alike. It will also offer an opportunity to explore how Ireland can implement proposed reforms and use its influence internationally to support the reform movement. Speakers include: Dr Gaelle Krikorian, Head of Policy, MSF Access Campaign; Dr Andrew Hill, Research Fellow, University of Liverpool, UK; Mr Simon

Brasch, Patient Leader, Just Treatment, UK; Mr Jaume Vidal, Senior Policy Advisor, European Projects, Health Action International; Prof Susi Geiger, Principal Investigator, Misfires (UCD)/AMI; Dr Manuel Martin, Medical Innovation and Access Policy Advisor, MSF; and Ms Natalie Rhodes, European Co-ordinator, Universities Allied for Essential Medicines. Representative of the pharmaceutical industry to be confirmed.

THURSDAY 23-SATURDAY 25 The European Society of Gastrointestinal Endoscopy (ESGE) invites healthcare professionals to ESGE Days 2020, taking place in the Convention Centre, Dublin, on 23-25 April 2020. According to the Society, ESGE Days aims to bring together the whole endoscopy team.

In Dublin, renowned experts will gather for a state-of-the-art meeting that will include live demonstration, lectures, hands-on training, specialised symposia and discussions. After welcoming more than 1,400 participants in Budapest in 2018 and 2,400 participants from 97 countries in Prague in 2019, the ESGE anticipates a highly successful congress in Dublin. For more information, email secretariat@esgedays.org or visit www.esgedays.org.

MAY FRIDAY 8-SATURDAY 9 The ICGP annual conference and AGM will take at the Convention Centre, Dublin, on 8-9 May 2020. Visit www.icgp.ie for further information.

SATURDAY 16-SUNDAY 17 Sexually Transmitted Infections Foundation (STIF) Course. Updated and Revised Courses from the British Association for Sexual Health and HIV (BASHH) — STIF CORE: 16 May. STIF PLUS: 17 May, Catherine Mc Auley Centre, 21 Nelson Street, Dublin 7. Course directors: Dr Lambert and Dr Low. Course organiser: Gordana Avramovic, Tel +00353 1 716 4562. For further information, please visit http://www.bashh.org.

AUGUST TUESDAY 25-FRIDAY 28 University College Dublin has been chosen to host the Universitas 21 Health Sciences Group Annual Meeting from 25-28 August 2020. Universitas 21 is a network of research-intensive universities that empowers its members to share excellence, collaborate across borders and nurture global knowledge exchange. The Health Sciences Group is a collaborative network of numerous interdisciplinary projects and activities for both staff and students of relevance to the Health Sciences with a focus on global health issues.

The Health Sciences Group 2020 Dublin meeting will have a central theme of ‘One Health’. Any academic or clinical staff interested in participating in this event should contact the Associate Dean for Global Engagement by email margaret.tiuchta@ucd.ie. For further information on the Universitas 21 Health Sciences Group, visit vu21health.org/.

33

THE MEDICAL INDEPENDENT | 12 MARCH 2020

Mindo Quizzes Life

Post your answers to: Mindo Quizzes, The Medical Independent, Greencross Publishing Ltd, Top Floor, 111 Rathmines Road Lr, Dublin 6. Closing date for entries is 24 March 2020

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SPORTS QUIZ COMPETITION

WIN €50

12 March 2020

Q1

Q3

Q5

Liverpool FC suffered their first defeat of this season’s Premier League. Who beat them?

Name the two Kildare schools who will face-off in the Leinster Schools cup final on St Patrick’s day?

Name the five-time tennis grand slam champion who announced her retirement from professional tennis recently?

Q2 Who are the 2020 All-Ireland senior hurling club champions?

Q4

Q6

Which horse won the Champion Hurdle earlier this week at the Cheltenham Festival?

Ireland’s cycling sprint king rides for which team?

CROSSWORD COMPETITION

SUDOKO

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SCRIBBLE BOX

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Solution to Sudoku

Answers to Sports Quiz Competition Solution to Crossword Competition

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The League of Ireland season has just kicked-off. Who are the defending Premier Division champions? A: Dundalk Name the American who won her maiden grand slam title at last month’s Australian Open? A: Sofia Kenin Name the Scotland rugby player who was sensationally dropped from the squad on the eve of their opening match of this year’s Six Nations against Ireland?

A: Finn Russell The Olympic games will be staged this year. Which city will host the games?

A: Tokyo Who was recently appointed manager of Arsenal? A: Mikel Arteta Who won Super Bowl LIV? A: Kansas City Chiefs

Q3

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The winner of the 20 February 2020 Sports Quiz is Gordon Reid, Sligo.

The winner of the 20 February 2020 Crossword is Marion Glasheen, Waterford.

Q2

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20 FEBRUARY 2020 ANSWERS, SOLUTIONS, AND WINNERS

Q1

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WIN €50

12 March 2020

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ACROSS 77 - Undergo (6) Undergoaahardship hardship (6) 8 Eg, spring or winter (6) 89 - EgBrave spring winter (6) andoradmired person (4) 10 Custom (8) 911 - Brave admired person Love;and genre of fiction (7) (4) 13 Happen (5) 10 - Custom (8) 15 Threshold (5) 16 Division of a book (7) 11 - Love; genre of fiction (7) 18 Have a different opinion (8) 19 ___ in: eat 13 - Happen (5)heartily (4) 21 Strong-smelling bulb (6) 22 Change gradually (6) 15 - Threshold (5)

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Down

DOWN 1 - A single time (4) 1 A single time (4) 2 In a reflex manner (13) 2 - In a reflex manner (13) 3 Admire deeply (7) 4 English homework assignment (5) 3 - Admire deeply (7) 5 Involvement (13) 6 Come to an end (8) 4 - English homework assignment (5) 12 Inventive; creative (8) 14 Anybody (7) 5 - Involvement (13) 17 Large motor vehicle (5) 20 Underground chamber6(4) - Come to an end (8)

12 - Inventive; creative (8)

16 - Division of a book (7)

14 - Anybody (7)

NAME: 18 - Have a different opinion (8)

17 - Large motor vehicle (5)

19 - ___ in: eat heartily (4) EMAIL:

20 - Underground chamber (4)

21 - Strong-smelling bulb (6)

ADDRESS:

22 - Change gradually (6)

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THE MEDICAL INDEPENDENT | 12 MARCH 2020

Life Food & Drink

Artichokes have an august reputation, despite their digestive after-effects

Read more at www.mindo.ie @tomdoorley

TOM DOORLEY

I

braved the elements last weekend to give the artichokes a good mulch of well-rotted manure in time for the spring that is so far proving elusive. I’m hoping this tender care will result in a bumper crop as it’s one of our favourite vegetables. Not only do they taste delicious, they are rich in inulin, a fructo-oligosaccharide no less, that feeds the good guys in the gut flora (and promotes a degree of flatulence, of course).

When we lived in one of Dublin’s leafier suburbs we had globe artichokes growing just inside our cast-iron Victorian railings. The plants were remarkably prolific and produced dozens of big, fleshy flower-heads, which we picked before they opened. Steamed, or boiled, we fell upon them gladly armed with ramekins of melted butter.

Our first crop was reduced somewhat by having four of the heads nicked by some nocturnal pedestrian with gastronomic tendencies. And when we told a rather snobbish friend about this we were told “oh, that’s the sign of a very good residential area…”.

Well, oddly enough, and despite the fact that growing artichokes is one of the easiest things anyone can do (essentially: Plant, wait, eat), they do have rather a posh reputation. According to one early 19th century book, the Scottish upper classes thought it impertinent if the lower orders culti-

vated the artichoke. And, of course, it has always been part of what you might loosely call “country house cuisine” (and we’re not talking dormer bungalows here, more of a Georgian with wings).

Perhaps this is because the eating of globe artichokes involves a certain knack of the kind that is handed down in families like silver and Roman noses. Essentially, you pull off the scales and eat the fleshy morsel at the base of each. When all these are gone, you scoop out the choke, or bristly bit, to reveal the heart or, as the French say, fond.

This is the best bit. Melted butter or vinaigrette is used for dipping.

I once overheard a woman in a rather smart restaurant complaining that her artichoke (parboiled, I think, then split and finished on the char-grill), was “tough”. The waiter’s response was diplomatic beyond the call of duty. My own view is that you shouldn’t complain about stuff which you have not eaten before; how do you know it’s not meant to be like that?

Global artichoke Globe artichokes (Cynara scolymus, to be precise) are very easily grown if you can persuade someone to let you have a side shoot with a bit of root.

You just plant it, ideally in fairly fertile soil, and it looks after itself. They seem to thrive in any kind of soil; some of mine are still producing prolifically having not had a feed of anything for years.

You see them occasionally in garden centres (more, I think, as a stylish and striking plant rather than a vegetable) but growing from seed offers the most fun if you have the room to run a trial.

This is because a packet of globe artichoke seed will produce several dozen plants, each unique.

You can grow a selection and then choose the ones you most like; in most cases, these will be the ones that produce the fleshiest heads. Alternatively, you may think that life is too short.

Some strains of artichoke produce flower heads which, when very young and immature, can be sliced very thinly and eaten raw with a drizzle of olive oil and a squeeze of lemon. In the past, this

way with artichokes was thought to have aphrodisiac qualities. One of the Elizabethan herbals claimed that raw artichokes “engender noughtie humours”, which must have attracted considerable interest. These heads can also be steamed and eaten whole, which is one of an artichoke lover’s concepts of nirvana. But generally speaking, globe artichokes are stringy, fibrous, and bristly things only a few parts of which are edible.

Conde de Valdemar Rioja Gran Reserva 2010 €19.95, O’Brien’s Reduced from €33.95 for the month of March, this is too good to miss. It has oodles of strawberry fruit with a generous seasoning of vanilla-scented oak and lovely structure and length.

Modern in style, with deep colour and a certain plumpness to the fruit. For me, this is a rare beef red and it could even laugh in the face of horseradish if you were so inclined.

Jerusalem artichoke There is an easier artichoke which, despite the name and a virtually identical flavour, is not related. This is the Jerusalem artichoke, Helianthus tuberosus, a kind of sunflower. It has nothing to do with Jerusalem, the name being a corruption of ‘girasole’, the Italian for sunflower.

Like the globe version, once of you plant one of these knobbly tubers, you will have them forever.

They grow like weeds but, unlike globe artichokes, they provide inulin through the depths of winter.

They are potent in this respect and it’s not for nothing that they are called ‘fartichokes’.

The best variety, to my mind, is one called Fuseau that is relatively – and I really do stress relatively – smooth. Jerusalem artichokes’ tendency to knobbliness, and therefore waste, is legendary.

The best way to cook them is to peel and slice thickly, then put them in a covered pan with olive oil, garlic, some rosemary and a small splash of water. Put them on the heat and shake the pan every minute or so until they are tender. This, I am told, is called “stoving”. They also roast quite well, under a joint, and can become delightfully caramelised.

Both kinds of artichoke destroy wine (with the arguable exception of Bandol Rosé, but that’s another day’s work); however, if you add lemon, juice or zest, they seem to take less exception to the stuff. Indeed lemony artichokes with a dry fino sherry, like Tio Pepe, is a very pleasing combination: Two flavours that are unfamiliar to most normal human beings, indeed.

35

THE MEDICAL INDEPENDENT |12 MARCH 2020

Gallery Life

Further photos on www.mindo.ie Photos: David Coleman - Bobby Studio

RCPI Certificate of Satisfactory Completion of Specialist Training (CSCST) Ceremony

Pictured L-R: Dr Saad Ahmed; Dr Barry McDonagh; Dr Niamh Keane, Haematology; and Dr Jeremy Sargent, National Specialty Director, Haematology

Dr Grace O’Carroll, Cardiology and GIM; Dr Susan Murray, Nephrology and General Internal Medicine (GIM); Dr Cathal O’Broin, Infectious Diseases and GIM; Prof Mary Horgan, President, RCPI; Mr Eoin Hunt, Respiratory Medicine and GIM; Elliot Hunt; Dr Ruth O’Riordan, Infectious Diseases and GIM; and Mr Eoin Fahey, Cardiology and GIM

Dr Jacinta Mulroe who received her CSCST in Public Health Medicine and Mr Mark O’Duffy

Dr Sarah O’Brien; Dr Greg Martin; Dr Douglas Hamilton; Dr Fiona Cianci; Dr Mairin Boland, NSD Public Health Medicine; Dr Naomi Petty Saphon; and Dr Jacinta Mulroe

Mr Kevin O’Riordan, Dr Lynda McSorley, who received her CSCST in Medical Oncology; and Ms Grainne McSorley

Mr John Larkin and Dr Grainne Holleran, CSCST in Gastroenterology and GIM

Mr Tom Beirne; Dr Avril Beirne, Geriatric Medicine and GIM; Ms Mary Beirne; Mr Sean Keogh; and Prof Richard Costello, Vice President, RCPI

Geriatric Medicine and GIM conferrees: Dr Sarah Mello; Dr Elaine Shanahan; Prof Mary Horgan; Dr Diarmuid O’Shea, Registrar, RCPI; Dr Colm Byrne; and Dr Avril Beirne

Ms Christine O’Carroll; Mr Michael Pierce; Dr Grace O’Carroll, Cardiology and GIM; and Mr James O’Carroll

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THE MEDICAL INDEPENDENT | 12 MARCH 2020

Life Gallery

Further photos on www.mindo.ie Photos: Brendan Lyon/Imagebureau

Bon Secours Hospital, Dublin - GP Study Evening

(

Mr Niall Davis, Consultant Urologist, Bon Secours; and Dr Agnes Baranski, GP, Coke Lane

Pictured L-R: Dr Niamh King, GP, Navan Road; and Dr Robert Dybkowski, GP, Coke Lane

Dr Dermot Halpin, GP, Santry; and Prof James Paul Oâ&#x20AC;&#x2122;Neill, Consultant ENT Surgeon, Bon Secours

Dr Gerry Kelly, GP, North Frederick Street; and Dr Grainne Hampson, GP, Collins Avenue

Dr Tom Kelly, GP, Irish Family Planning Association; and Dr Sinead Hussey, GP, Raheny

Dr Matilde Zamuner, Consultant Endocrinologist, Bon Secours; and Dr Ronan Cahill, Dental Surgeon, Navan Road

Dr WIlliam Purcell, GP, Naas; and Dr Joe Purcell, GP

Dr Catherine Finucane, GP, Navan Road; and Dr Barry Teeling, GP, Donnycarney

Dr Patricia Behan, GP, Dublin; and Dr Hassoon Al-Sarraf, GP, Clontarf

Dr Fionnuala Brophy, GP, Navan Road; and Dr Mags Edgeworth, GP, Drumcondra

Dr Hugh Durkin, GP, Tallaght; and Mr Seamus McHugh, Consultant Vascular Surgeon, Bon Secours

37

THE MEDICAL INDEPENDENT | 12 MARCH 2020

Product Focus RXDX CHILDVISION RECEIVES €25K DONATION FROM SCOPE FUNDRAISING INITIATIVE

Pictured are Scope CEO Mr Tom Freyne; ChildVision student Ms Freya Peeper; and ChildVision CEO Mr Brian Allen.

Scope, an Irish-owned healthcare supplier company, has donated €25,000 to ChildVision.

Scope employees raised €12,500, which the company matched, bringing the total donation to €25,000 Ms Amie Hynes-Fitzpatrick, Corporate Social Responsibility (CSR) Lead at Scope, said: “On behalf of Scope, we are delighted to be in a position to raise €25,000 for ChildVision. This is a charity that is close to our heart, especially considering the work we do in eye care.

“It’s great to see that the funds we have raised will provide clinical psychologist care for both the children and their families at ChildVision.

We hope that we can continue to fundraise and donate towards this charity so that the children who need help can continue receiving it.”

Scope is a family-owned Irish company that has been working within the healthcare sector for over 80 years. It offers management products for ocular surface disease and age-related macular degeneration, as well as a food supplement range.

As part of SCR, the company has committed to working with ChildVision, Ireland’s only dedicated centre providing education and therapy

to blind and multi-disabled children from all over Ireland, ranging in age from birth to 23 years of age.

The partnership will see Scope fundraise and donate proceeds to ChildVision on an ongoing basis. Scope employees raised €12,500 in 2019 by organising and running a charity golf tournament. Scope matched this donation, allowing the company to donate a total of €25,000 to ChildVision.

The cheque for €25,000 was presented to Child Vision Chief Executive Mr Brian Allen, with students and their families also present.

This donation will be used

by ChildVision to provide clinical psychologist support for children and young adults whose families can also avail of the service.

Mr Allen commented: “We are very proud to be associated with Scope; they have visited the campus, seen the need and responded so generously. We look forward to a long partnership with the team, who are also working every day to improve eye care.

“The donation presented will be used to fund an urgent and compelling need by ChildVision to provide clinical psychologist input across campus to the children and their families.”

DUBLIN CLINICAL NEGLIGENCE EXPERT TO LEAD EXPANSION OF MPS IN IRELAND

Mr Tom Hayes

Medical Protection Society (MPS) has announced that its members in Ireland will soon benefit from a more local service. This development will see cases and clinical negligence claims handled within the country, and clinical negligence expert Mr Tom Hayes appointed to

lead the expansion.

MPS is the world’s leading protection organisation for doctors, dentists and healthcare professionals, supporting more than 300,000 members around the world — with over 21,000 of those in Ireland. In 2019, it supported members in Ireland with more than 1,800 medical and dental cases, ranging from complaints through to more complex issues, such as claims of clinical negligence, regulatory matters, inquests and criminal investigations.

With additional services soon to be available in-country, MPS said its support for members will be geographically more accessible than

ever before. “The move will enable MPS to better understand and address the concerns of members in Ireland, and will also provide it with greater clarity on the risks and trends faced by practitioners,” it outlined.

Announced as Head of Service Delivery in Ireland, Mr Hayes joins MPS this month.

He has a remit to manage the delivery of the new services and a plan to have the office — which is likely to be situated just outside central Dublin — fully operational in the next 12-to-18 months.

Mr Hayes has an extensive background in medical law and malpractice. Since 2007, he has been based in Dublin, working for Matheson, where he established its healthcare services. During his tenure with Matheson, he headed up the 140-strong litigation department and was the senior partner for MPS’s work. Prior to this, Mr Hayes practised clinical malpractice law in London, where he was a partner at Capsticks.

Mr Hayes commented: “Having worked alongside MPS legal teams in Ireland for many years, the opportunity to move across and join them at a time of exciting progress and evolution was too good to turn down. The quality of service from the UK office has never been in doubt, but by providing cases and claims-handling support in-country, we will be able to improve the experience for members even further.”

Ms Melanie Rowles, Director of Delivery Services at MPS, added: “Getting closer to members wherever they are in the world is a key part of the MPS strategy, which is designed to ensure we are best placed to meet the increasingly diverse range of issues faced by doctors, dentists and other healthcare professionals. I was thrilled to appoint someone of the calibre of Tom, and members in Ireland are going to benefit enormously from the many years of experience he has gained in the healthcare legal field.”

TCD RESEARCH HAS IMPORTANT IMPLICATIONS FOR TREATING AMD Scientists from Trinity College Dublin have made an important discovery, with implications for those living with age-related macular degeneration (AMD).

They have discovered that the molecule TLR2, which recognises chemical patterns associated with infection in the body, also seems to play an important role in the development of retinal degeneration.

AMD is the most common form of central visual blindness in adults, with approximately 70,000 Irish people living with the condition.

People with AMD may have difficulty recognising faces, reading, watching television and driving as their central retina degenerates.

Ageing is the greatest risk factor for development of AMD, with one-in-four people over the age of 75 living with the condition. To date, no pharmaceutical interventions are available to prevent the progression of disease. Patients living with dry AMD are generally advised to make lifestyle changes, such as stopping smoking and improving diet and exercise regimens.

Dr Sarah Doyle, Assistant Professor of Immunology at Trinity, who led the study published in Cell Reports, said: “The lack of approved therapies for AMD is mainly because the factors involved in triggering the disease are not very well understood.

Understanding and identifying early molecular events that may trigger dry AMD will allow us to develop a more targeted approach to ther-

apy. In this case, we believe that regulating the activity of TLR2 may, over time, help to prevent the progression of dry AMD.” Two biological processes involved in AMD are the uncontrolled ‘oxidative stress’ that results in the formation of bleach-like chemicals in the retina, and the laying down of a protein called complement, that ‘tags’ whatever it touches for elimination.

In this study, the scientists implicated TLR2 as a critical bridge between oxidative damage and complement-mediated retinal degeneration. TLR2, which is found on the surface of cells, is part of the immune system because it is known to sense infection through recognising chemical danger signals that are found on micro-organisms like bacteria and yeast.

Once TLR2 is activated by a danger signal, it triggers a signal cascade, which is somewhat like a cellular assembly line, with information about the cells’ immediate environment passed to our genes, which then respond with an inflammatory response.

“In the case of the eye, TLR2 appears to act as a sensor of oxidative stress, recognising a chemical pattern that is generated during oxidation, rather than infection, and triggering a signal cascade that ends in promoting the laying-down of complement,” said first author on the paper Dr Kelly Mulfaul from Trinity College.

Dr Doyle added: “A function for TLR2 has not previously been reported in retinal

neurodegenerative disease pathology, but it is likely to play an important role, because when we remove TLR2 from our experimental model systems, we reduce the level of complement and this has the effect of protecting cells that are essential for vision from dying.

“With the continual increase in life expectancy outpacing the rate at which drugs for age-related conditions are

developed, new avenues of therapy are badly needed, so the fact that blocking this single protein can have such a protective effect in the eye is a particularly exciting discovery.”

This research was supported with funding from BrightFocus Foundation USA, Science Foundation Ireland, Health Research Board Ireland and the Irish Research Council.

TEVA LAUNCHES THE FIRST NATIONAL RESPIRATORY INHALER RECYCLING PILOT Last month, Dr Cara Augustenborg, environmental scientist and broadcaster, launched the first national respiratory inhaler recycling initiative on behalf of Teva Pharmaceuticals Ireland (Teva).

The launch took place at O’Connor’s Pharmacy, Dublin 4, and is part of a nationwide pilot scheme which aims to encourage people living with respiratory-related illnesses to recycle their used or out-of-date inhalers.

There are an estimated 560,000 people in Ireland currently living with a respiratory-related illness. Until last month, however, no free public recycling facility had been made available to dispose of used inhalers in Ireland.

Currently, in Ireland, people living with respiratory-related illnesses are encouraged to return their used inhalers to their local pharmacy, where they are then disposed of with other medical waste through incineration.

However, it is unclear how many Irish consumers dispose of their inhalers correctly. When inhalers are not disposed of correctly, they are sent to landfill, which is harmful to the environment both in plastic material waste and in greenhouse gas emissions, as the residual gas from canisters may be released to the atmosphere.

In a first for the Irish pharmaceutical industry, Teva has launched a pilot initiative which will empower people living with respiratory-related illnesses to recycle their used inhalers.

Teva has partnered with global recycling group TerraCycle to bring its Zero Waste Box scheme to 100 Irish pharmacies across Ireland in a 12-month recycling pilot scheme. TerraCycle’s Zero Waste Box is a cardboard box that collects and stores used inhalers until they are collected by TerraCycle and then recycled to help make new products, including playground materials and garden equipment.

People living with respiratory-related illnesses can

Dr Cara Augustenborg, environmental scientist and broadcaster

find out where their nearest participating pharmacy is located by visiting www.inhalerrecycling.ie.

Teva’s Specialty Medicines Director Ms Clodagh Kevans commented: “Teva is an environmentally-conscious company and we are continuously taking steps towards improving our impact on the environment. One of those steps is this new pilot programme, which will provide pharmacists and people with respiratory-related illnesses the opportunity to recycle their inhalers for the first time in Ireland.

“We at Teva Ireland realise that our work and contributions to creating healthy communities are essential for leading a responsible business. We also know that in all areas of life, consumers are increasingly supportive of environmentally-sustainable initiatives.

“We’re excited to launch this pilot with the Asthma Society of Ireland and we hope that with their support, with buy-in from our pharmacy partners and people living with respiratory-related illnesses, this pilot programme can make a difference.”

Ms Sarah O’Connor, CEO of the Asthma Society of Ireland, said it is encouraging members and patients to utilise the pilot scheme as much as possible over the coming months.

Dr Augustenborg added that this initiative “will be welcomed by people living with asthma, COPD and other respiratory conditions who are looking to the industry leaders to adopt more sustainable practices”.

38

THE MEDICAL INDEPENDENT | 12 MARCH 2020

Classifieds & Recruitment Advertise today, call Louis on 01 4410024 or email louis@mindo.ie

MEDICAL SUITE TO RENT

GP/CONSULTANT REQUIRED GP WANTED (LONG-TERM) FETHARD, CO TIPPERARY GP wanted as soon as possible for sessional work on short- or long-term basis.

This practice is well-organised with full-time practice nurse and secretarial staff.

Fully computerised with Health One and member of Caredoc.

Two-doctor practice planning to move up to three-doctor practice. From July 2020 one doctor on leave until middle of next year and 2nd doctor happy to step back to allow incoming doctor to get fully immersed if so wishes.

This practice has huge potential for any doctor who would like a nice work/life balance in small town near Clonmel.

I am flexible re number of sessions worked.

Medical indemnity costs reimbursed by the practice.

GMS list available to suitable candidate if interested.

I would be very happy to discuss long-term plans with any interested doctor.

Contact me by email: drcnorthgate@hotmail.com or

Phone: 087 2479083 GP WANTED WEST WICKLOW Looking for a Country Practice but not quite sure?

Opportunity to work one day per week/ work for a 3-6 month period to decide. A well organised GP practice in West

MEDICAL SUITES AVAILABLE DUBLIN 2 (CLOSE TO DAWSON STREET LUAS)

GP REQUIRED WATERFORD GP required for part-time work with view to partnership.

Initially 4+ sessions weekly, this and starting date negotiable.

We are a two-doctor practice in KILMACTHOMAS ON THE WATERFORD GREENWAY, operating from a purpose built health centre with full ancillary practice staff.

20 minutes from Dungarvan and from Waterford, 10 minutes from Comeragh Mountains and Copper Coast beaches.

We would be delighted to talk to you if you think you might be interested.

Please phone (051) 294300 or email kilmachc1@gmail.com GP WANTED LETTERKENNY Assistant GP required at Ark Medical Centre, Letterkenny, Co Donegal.

We are a 6 doctor, fully computerised expanding practice in Letterkenny.

Our team operates in a new Primary Care Centre with Practice Nurses and full administrative support.

We are also members of CareDoc out of hours co-operative.

Salary and working sessions are negotiable.

E-mail enquiries and Curriculum Vitae to: arkmedicalcentre@eircom.net

PRACTICE MANAGER REQUIRED

Wicklow is looking for one doctor initially, but will need 1-2 fellow GPs to complete the team. Existing GPs are willing to work until the new structure is in place.

Contact us at drpcarolan@eircom.net GP WANTED (LONG-TERM) LONGFORD TOWN ●● Modern, busy progressive practice. Socrates software. ●● Full nursing and administrative staff. ●● Potential for long-term arrangement. ●● Central location 20 mins to Athlone, 60 mins Galway, 90 mins Dublin.

Please call 086 1742955

Medical Suites available at 26 Clare Street, Dublin 2.

Adjacent to the National Gallery.

Suitable for a range of medical uses including GP Practice - Private or GMS - Out-of-Hours Service or Walk In Clinic - Physio Clinic - Beauty Clinic, etc. Full medical planning permission.

These suites would suit many uses due to the high footfall passing the door every day. The suites are 5 minutes walk from Grafton Street with several amenities close by. There is direct access from all areas of Dublin to the suites via the Dart and Bus and The Luas runs to Dawson Street, 5 minutes walk away.

There is a big concentration of new businesses in the area.

Trinity College, Merrion Square and Pearse Street are on the doorstep.

Very favourable and flexible terms. 2 Suites available ‒ self-contained ‒ bathroom/waiting room/consulting rooms ‒ 440sq feet and 690sq feet ‒ both newly renovated. High speed broadband, etc.

Please contact Mary Anne on 087 6394946 for further information or viewing.

GP WANTED SOUTH DUBLIN Vocationally trained GP required for GP Teaching Practice in South Dublin. We are three full time GPs with Registrar, Practice Manager, Nursing, Secretarial, and Receptionist staff. The premises are modern purposebuilt, fully computerised Helix Practice Manager, 15 min consultations, your own consulting room. The hours are based on your wishes and can be tailored to your requirements. One principal GP due to retire next year - so great long-term potential and pension. No nights or weekends or on call work.

Contact drramiah@yahoo.ie or 086 2533588

PART TIME PRACTICE MANAGER SOUTH DUBLIN We are looking for an experienced practice manager to join our friendly team in South County Dublin.

2 partner practice, using HealthOne, with very helpful experienced admin staff in situ.

Flexible working hours, c. 20 per week. Flexibility for school/summer holidays if required.

Appropriate qualifications and experience required please.

If interested, please email phillymcp@gmail.com

PRACTICE NURSE REQUIRED PRACTICE NURSE REQUIRED CORK CURRAHEEN CLINIC, BISHOPSTOWN, CORK is hiring a full-time practice nurse. We are looking for a practice nurse with prior experience and training in cervical smear taking, vaccinations, wound care, and venepuncture. The role also involves administration, occupational medicine and other areas of interest are encouraged.

Surgery hours are 8:30 - 17:00 Monday to Friday.

Replies to corkcitygpsurgery@gmail.com

Is your practice ready for Asthma & COPD as part of the Integrated Structured Chronic Disease Prevention and Management?

I am an experienced Advanced Nurse Practitioner & Registered Nurse Prescriber with extensive experience in Asthma & COPD in the primary care setting. I am currently available to: • provide Asthma & COPD clinics in your practice or • provide support, education with a resource pack to your practice to set up Asthma & COPD structured care

To advertise, call Louis on 01 4410024 or email louis@mindo.ie

GP LOCUMS REQUIRED NORTH EAST REGION Earn €44K p/a working 12 midweek hours per week Earn €75k p/a working 18 weekend hours per week Day practice cover also needed - €600 Gross per day Medsource Medical Services has job opportunities to suit every lifestyle Out of Hours and Day Surgery Positions available weekly

For further information, contact: ruthmorrow89@gmail.com Ruth Morrow MSc., BNS., RANP., RNP., RGN., Nurse Educator & Consultant

Contact Jenny or Ellie today to register as a Locum with Medsource 046 9241533 / info@medsource.ie / www.Medsource.ie

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THE MEDICAL INDEPENDENT | 12 MARCH 2020

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THE MEDICAL INDEPENDENT | 12 MARCH 2020

The Dorsal View

If you have anything you would like to share, please email: info@mindo.ie

A round-up of medical news and oddities from left field by Dr Doug Witherspoon

The gender agenda: Rights or wrongs?

In 2018, pressure from certain groups led the government in Sweden to propose a new law to reduce the minimum legal age for gender reassignment medical care from 18 to 15, eliminate the need for parental consent and permit children as young as 12 years old to legally change gender.

The world-famous Karolinska University Hospital has faced criticism for performing double-mastectomies on children as young as 14 and in the more ‘liberal’ areas of the US, there are few restrictions, depending on the respective jurisdictions.

But the backlash has begun. Last year, psychiatrist at Gothenburg’s Sahlgrenska Academy Dr Christopher Gillberg wrote in Dagbladet that surgery and hormone treatment for children is “a big experiment”. Other doctors around the world are raising red flags on the psychological difficulties, including risk of suicide, among people who have surgical,

Let me begin this brief piece by saying genuine, clinically-diagnosed gender dysphoria (GD) is an extremely upsetting and troubling condition for both a child and their parents and should be addressed with care by qualified, responsible medical professionals. And it is important to add that GD is distinct from gender ‘non-conformity’. The DSM-5 has now classified gender dysphoria in its own chapter, distinct from the one on ‘Sexual Dysfunctions and Paraphilic Disorders’.

However, according to the DSM-5, the proportion of the population with genuine GD is between 0.005–0.014 per cent for birth-assigned males, and 0.002–0.003 per cent for birth-assigned females. So it was with alarm that I read about a report from Sweden’s Board of Health, which showed that there has been a 1,500 per cent rise in diagnoses of GD between 2008 and 2018 among 13-to-17 year-olds born as girls.

That’s incongruous.

irreversible gender reassignment and subsequently feel that they have made a mistake and are unable to re-transition to their original gender.

Ireland often lags behind other jurisdictions in matters of healthcare and in this instance, I’m glad that we do.

The ‘trend’ of gender reassignment is a runaway train that at the very least needs to be handled responsibly by parents and some people in the medical profession.

Name and shame Apropos of nothing, Ireland has the highest birth rate and lowest death rate in Europe, according to a Eurostat report from last year. If you have a child named Jack, James, Emily or Emma, you’re going with the flow, as these are the most popular baby names in Ireland, according to stats from the Central Statistics office. However, some prefer more exotic monikers for their children and others take it to the extreme, so much so that legislation has been introduced to prevent the sublime transitioning to the ridiculous — and no, it’s not just in the US. Here are a few examples below, so if you have ever cursed your parents for giving you an unusual name, read on and consider yourself lucky. I am always glad to receive any comments, opinions, contributions or jokes to info@mindo.ie.

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The home of Irish CPD Free, independent CPD for doctors, nurses and pharmacists… all under one roof

The issue of what baby names should be prohibited raises its head from time-to-time, and so it was the case when an Australian mother-of-four was told recently that naming her son ‘Citizen’ was not allowed (and no, his surname is not ‘Kane’). The mother announced on Instagram (it was either going to be there or Twitter): “We tried to change it. ‘Disco’ even came back into play! But nothing else felt right for you as a Libra, with a (very sensible and grounded) Capricorn moon. So Citizen you are, and always will be — a Citizen of the world.” Her three other children are called Atlas, Everest and Zephyr, so we probably should have seen that one coming from “sensible and grounded” parents.

French authorities banned a couple from naming their baby girl ‘Liam’ — surprising, considering the present-day culture that is heavily laden with political correctness.

Another couple with more time and money than I have spent four years in a legal battle to be allowed to name their baby ‘Yoda’, but other names that have been banned outright include ‘Metallica’ (in Sweden) and ‘Miatt’ in Germany, because it doesn’t indicate whether the baby is either a boy or girl.

Also in Sweden, you won’t be able to name your newborn ‘Ikea’, which is probably just as well.

If you’re a communications consultant on such matters in Portugal, you probably did very nicely out of an 80-page government document regulating the naming of babies. For example, you can’t call your baby ‘Ovnis’ in Portugal, as that translates to ‘UFO’.

Another courtroom battle ensued in 2015, when it was decided that a couple in Valenciennes in northern France could not name their baby ‘Nutella’, while in Mexico, the state of Sonora was compelled to outlaw the names ‘Facebook’, ‘Traffic’, ‘Lady Di’, ‘Circumcision’, ‘James Bond’ and ‘Robocop’.

Closer to home in Wales, in 2017 a mother — who already had a child called ‘Preacher’ — was sensibly prevented by a court from naming her baby ‘Cyanide’.

But my personal favourite comes from New Zealand. During a custody battle, a judge took the unusual step or renaming a child, who was already nine years old, and had until then lived her young life with the name ‘Talula Does The Hula From Hawaii’.

Dishonourable mentions from around the world go to ‘Devil’, ‘Chow Tow AKA Smelly Head’, ‘Jihad’, ‘Peppermint’, ‘Snake’, ‘Anus’, ‘Lucifer’, and the memorable ‘Brfxxccxxmnpcccclllmmnprxvclmnckssqlbb11116’.

My father had an expression that springs to mind: “You need a licence to catch a fish, but any eejit can have a baby.”