Irish Pharmacist September 2023

for all that matters in pharmacy

FIRST PORT OF CALL

A pharmacist’s early intervention can save lives and money, writes

Fintan Moore

HEROIN ASSISTED THERAPY

Harm reduction must not morph into drug use normalisation, writes Terry Maguire

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If we avoid the sun or somehow prevent the UV rays from reaching our skin, it will reduce our ability to make vitamin D. It is difficult to get your full requirement of Vitamin D from diet alone. Therefore, to maintain a reasonable amount of vitamin D in your system it may be a good idea to consider taking a supplement like BioActive D-Pearls.

If we avoid the sun or somehow prevent the UV rays from reaching our skin, it will reduce our ability to make vitamin D. It is difficult to get your full requirement of Vitamin D from diet alone. Therefore, to maintain a reasonable amount of vitamin D in your system it may be a good idea to consider taking a supplement like BioActive D-Pearls.

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BioActive D-Pearls are small, soft gelatin capsules with 38, or 75 micrograms of vitamin D in each. This makes it easy for you to choose the right dose for the time of year and for your personal level of sun exposure.

• the vitamin D in BioActive D-Pearls is dissolved in cold-pressed olive oil for better absorption

• small capsules that are easy to swallow – or chew

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02 NEWS National and international news in the world of pharmacy and healthcare

13 SMART STEPS

A HSE study looks at the cost of treating melanoma skin cancer in Ireland

20 FINTAN MOORE

How pharmacists can be a big source of free, instant medical advice

22 TERRY

24 DR DES CORRIGAN

The illicit drug trade is helping to fuel terrorist campaigns

Editor David O'Riordan, david.oriordan@greenx.ie

Creative Director Laura Kenny, laura@greenx.ie

Administration Manager

Daiva Maciunaite, daiva@greenx.ie

Managing Director Graham Cooke, graham@greenx.ie

GreenCross Publishing was established in 2007. Publisher and Managing Director: Graham Cooke, graham@greenx.ie

© Copyright GreenCross Publishing Ltd 2023.

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

45 PRODUCT NEWS

A round-up of industry and product news

Disclaimer

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

44% OF PHARMACISTS ANXIOUS ABOUT ONCOLOGY MOVE TO HIGH TECH HUB

A recent Accord Healthcare Ireland with Pharmabuddy shows that 44% of Irish pharmacists are anxious about the forthcoming move to the High Tech Hub for all oncology medicines.

Accord Healthcare Ireland’s survey, which was conducted in June 2023, saw 154 pharmacists on the Pharmabuddy platform answer a range of questions on the High Tech Hub. This included the proposed move of the oncology high techs into the ordering hub.

Discussing the results of the survey, David Lane, Commercial Director for Accord Healthcare in Ireland, said: “We take our position of having the widest range of high tech medicines of any generic supplier on the Irish market very seriously. We acknowledged many years ago the duty of care we have to our customers in community pharmacy and the patients of Ireland.

“We know how busy pharmacists are and with this in mind, we ran a series of supports in the area of high techs including the creation of video assets for pharmacists on how to use the hub, issuing a handy reference folder explaining more about the high tech scheme and each of the high tech products offered by Accord; and, most recently, our involvement with the Lenalidomide Patient Safety hub which aims to ease the administrative burden on pharmacists when a patient of theirs is prescribed Lenalidomide.”

The High Tech Hub was rolled out by the HSE in March 2018 in an effort to streamline

administration of the scheme for pharmacists and to provide enhanced visibility of stock management and spending on this scheme.

Since then, medicines have moved into the hub on a phased basis with the first being IVF products. Now, in 2023 all high tech medicines, except for oncology, must be ordered through the hub.

Industry and pharmacists are anticipating the move of oncology products into the hub sometime this year.

“Globally, we in Accord Healthcare have

more than 40 oncology and oncologyrelated treatments making us one of the largest suppliers of chemotherapy products in Europe. We have therefore monitored the development of the High Tech Hub over the years and our research means we will continue to work in partnership with pharmacists to ensure their needs are met and the transition of the remaining oncology medicines will be smooth,” said Mr Lane Further information can be found at www.accord-healthcare.ie.

REGISTRATION OPEN FOR 28TH EAHP CONGRESS

Registration is now open for the 28th EAHP Annual Congress on  Sustainable healthcare – Opportunities and strategies, which will take place from March 20-22, 2024, in Bordeaux (France).

Over the course of the three days, there will be keynotes, seminars, workshops and interactive sessions, along with industry satellites, with the exhibition set to offer insight to reshaping processes and services towards a sustainable format with respect for quality, patient

safety and equality.

WHAT TO EXPECT:

 Live panel discussions by hospital pharmacy and healthcare experts;

 Social events and networking opportunities;

 Poster walk sessions;

 Exhibition area;

 Access to session presentations after the congress.

For more information visit www.eahp.eu

REVEALED: OVERWHELMING PUBLIC SUPPORT FOR EXPANDING THE ROLE OF PHARMACIES

There is overwhelming public support for plans to allow pharmacists to prescribe medicines for minor ailments, according to research by Behaviour & Attitudes (B & A). Minister for Health Stephen Donnelly has recently appointed an expert taskforce to make recommendations to support the expansion of pharmacist roles, including independent prescribing, measures which the research indicates would be welcomed by the vast majority of patients.

The Pharmacy Index 2023 was researched by B&A on behalf of the Irish Pharmacy Union. It found that almost half of the adult population (48% or nearly 1.9 million adults) now visit the pharmacy during a typical week. With 98% of people stating they value the advice pharmacists provide, it also found that nine in 10 adults agree that the role of pharmacists is becoming increasingly important.

Among the key findings was close to universal support for community pharmacies increasing the range of services they provide.

This includes:

 96% in favour of pharmacists being able to prescribe treatments for minor ailments such as back pain, migraine and indigestion;

 94% in favour of pharmacists being able to repeat certain prescriptions without recourse to a GP; and

 96% in favour of pharmacists offering a medicine service to improve adherence to new medicines.

With the IPU calling for contraception to be available directly from a pharmacist on foot of a structured consultation, 86% of adults in Ireland favour pharmacists being able to offer contraceptive care. Following the vital role pharmacists played in the Covid vaccination campaign, 78% of people would now welcome the availability of childhood vaccines in pharmacies.

Commenting on the findings, Kathy Maher, Chair of the IPU’s Pharmacy Contractors, said: “There is huge potential for pharmacies to expand the range of healthcare services

they provide. As the new expert taskforce commences its work it is heartening to see that patients across the country want to avail of these new services.

“Supporting the sector to provide enhanced healthcare services would deliver a revolution in community care.

“The pharmacy profession wants to do more for its patients, and it is clear patients would support this. However, achieving this potential will also require addressing the chronic underfunding of pharmacy services. When a pharmacy dispenses a medication on behalf of the state today, they are receiving a lower payment than they did in 2009 but facing much higher costs. This is creating huge pressure on our pharmacy network, which must be addressed before expansions can be realised.”

Concluding, Ms Maher said: “We look forward to engaging with the expert taskforce and hope that the recommendations lead to the most ambitious possible expansion of services.”

FIP VACCINATION RESOURCE HIGHLIGHTS THE VALUE OF TAKING A ‘LIFE - COURSE APPROACH’

A toolkit that encourages implementation of a ‘life-course approach’ to vaccination by the pharmacy profession has been published by the International Pharmaceutical Federation (FIP). A life-course approach recognises that health is shaped by a series of events that occur throughout life, including vaccinations known to benefit specific age groups and vulnerable groups.

Disease prevention and health promotion is just as important during older age as it is in childhood, the authors of the toolkit write. For example, older adults are more vulnerable to more severe forms of several vaccinepreventable diseases, including influenza, COVID-19 and pneumococcal pneumonia. Other diseases, such as herpes zoster, can often be highly debilitating and painful in this group, diminishing quality of life and increasing dependence on painkillers.

The World Health Organization Immunization Agenda 2030, recommends that all member states adopt a life-course approach to immunisation and the United Nations Decade of Healthy Ageing Action Plan 2021–2030 urges the scale-up of agefriendly primary healthcare to provide a full range of services for older people, including vaccination. Harnessing pharmacists' power to deliver the life-course approach to vaccination is key, the authors say.

The toolkit ‘Supporting life-course immunisation through pharmacy-based vaccination: enabling equity, access and sustainability’ outlines three key policy areas that need to be addressed:

 Regulations and prescribing;

 Service remuneration models; and

 Access to data and vaccination records. For each area, case studies from different

countries are presented along with enablers and barriers.

“Health equity is only achieved when there are no differences in the quality of and access to healthcare among all groups and at all ages in a society. This policy toolkit is aimed at FIP member organisations and seeks to accelerate pharmacy-based life-course immunisation. Taking lessons from our members, the toolkit provides a universal list of enablers and barriers that organisations can use to track and monitor their progress towards this goal,” said FIP CEO Dr Catherine Duggan.

“The presence of pharmacies in every community, with long opening hours, allows for the easy, convenient access of community members to a health facility. For that reason, pharmacies can help diversify and simplify vaccination pathways, especially for working adults and older adults.”

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References

BUDGET 2024: INVESTING IN COMMUNITY PHARMACIES A PRIORITY, SAYS IPU

Budget 2024 should be used as an opportunity to address the underfunding of Ireland’s community pharmacy sector, to prepare it for future growth. This was the central message of the Irish Pharmacy Union’s (IPU) pre-budget submission that was delivered to government recently. With Minister for Health Stephen Donnelly seeking recommendations on the future expansion of Ireland’s pharmacy services the IPU has said it is essential that the forthcoming budget ensures the sector’s long-term viability.

Outlining the key recommendations of the IPU’s pre-budget submission, Tom Murray IPU Honorary Treasurer, said: “Research from Fitzgerald Power has revealed the stark and concerning fact that right now one in 10 of Ireland’s pharmacies is loss-making. This is the result of years of underfunding and needs to be addressed to facilitate the sector’s expansion. For each medicine a pharmacy dispenses on behalf of the state, the state is paying pharmacies 24% less today than in 2009. This is clearly not feasible in the context of soaring costs.”

The central recommendation of the IPU in Budget 2024 is to restore funding to the sector via a new flat rate dispensing fee of €6.50. “This would represent an increase of a mere 50 cents on the rates that pertained

in 2009. This modest increase would be transformational for the sector and allow the levels of investment required to expand pharmacy services nationwide.”

Mr Murray said there is huge potential for the sector to alleviate problems across the health sector. “An expert group has been convened to make recommendations on how to expand pharmacy services. At a time when GPs are consistently raising concerns about their capacity, utilising the pharmacy sector to the maximum would provide a huge boost to community care.

“Investment should be provided for a

Minor Ailment Scheme that would allow pharmacies to dispense medications for a defined list of self-limiting conditions directly to medical card patients. Similarly, the new scheme that provides free contraception to women, which is due to be expanded next month, should be available direct from pharmacies. Both measures would reduce wait times for patients and free up precious GP time.”

“Pharmacists are the only healthcare profession yet to receive restoration to pay cuts administered during the pandemic,” said Mr Murray. “Next year will mark 15 years since the first cuts and while all other professions have had increased funding, pharmacies are left to continue to grapple with the current cost conditions with no increased state investment. The profession must be treated equally and to prevent future chasms the link to public sector pay should also be restored.”

Concluding, Mr Murray said that Budget 2024 represents a unique opportunity. “We have a profession that is ready and waiting to do more. We have a state with a very clearly defined need to expand communitybased care. The large budget surpluses predicted should mean there is no logical reason not to invest in pharmacy and expand pharmacy care.”

PUBLIC SURVEY ON MEDICINES ADMINISTRATION SERVICES IN PHARMACIES

PSI, the pharmacy regulator, is carrying out a survey with the public to learn more about some of the services that patients and the public are using in pharmacies. The survey should take no more than five minutes to answer and is anonymous. If you are a member of the public and live in Ireland, you can complete the survey here.

 WHAT IS THE PURPOSE OF THE SURVEY? The PSI is carrying out this short survey to gather more information on

some of the services that patients and the public are using in pharmacies – especially vaccine and medicines administration services. The PSI will use this information to support our work in continuing to assure the safety and effectiveness of pharmacy services. Information like this allows us to regulate more effectively.

 IS THE SURVEY ANONYMOUS?

Yes, this survey is anonymous. Your name or email address will not be recorded (unless you choose to write your name as

part of the survey).

 HOW LONG WILL IT TAKE TO COMPLETE THE SURVEY? It should take approximately five minutes to complete.

 WHAT IS THE PSI? The PSI is the pharmacy regulator. We are responsible for regulating pharmacists and pharmacies in Ireland and our role is to protect the health, safety and wellbeing of patients and the public who use pharmacy services.

NEW PROSTATE CANCER BIOMARKERS PROVIDE HOPE TO MILLIONS OF MEN

Trinity researchers – as part of an international team of scientists – have identified three new biomarkers for prostate cancer to help identify and differentiate potentially aggressive cases of the disease.

An international team of scientists led in Trinity College by Professor John O’Leary, Consultant Histopathology, School of Medicine, and Professor Doug Brooks at the University of South Australia (UniSA) has made a landmark breakthrough which will assist pathologists when visualising prostate cancer in patient tissue samples.

The research has been published in the international journals Pathology and Cancers

The team has identified three new biomarkers which will allow pathologists to determine which patients require immediate, radical treatment compared to those who need close monitoring.

With more than one million men diagnosed with prostate cancer worldwide each year, the research breakthrough is significant. Prostate cancer incidence in Ireland is currently the highest in Europe (GLOBOCAN, 2020). The number of deaths from prostate cancer was 554 per year, during the period 2016-2018. This represents 20.2 deaths per 100,000 of the population, attributing to 12% of male cancer deaths (NCRI, 2021).

The UniSA-based team has collaborated with the Australian company Envision Sciences on the technology to improve patient management and treatment outcomes.

Speaking on the discovery, Professor John O’Leary said: “This discovery made with colleagues from the University of South Australia, University of Adelaide, Royal Melbourne Institute of Technology, and the Prostate Cancer Research Consortium (PCRC), the biobank for which is maintained and curated by colleagues at UCD, marks an important breakthrough in prostate cancer diagnostics and prognostics and offers for the first time a precision medicine approach in prostate cancer diagnostics allowing pathologists to:

 Define the entire extent of the prostate cancer in a specimen;

 Establish whether it is indolent or aggressive disease and define the risk of

disease recurrence and metastasis; and

 Define the metabolic profile of the tumour to decide whether it is using sugar or lipid metabolism, which also defines outcome of the disease.”

Professor Doug Brooks (UniSA), also said: “It is anticipated this will lead to long-term improvements in the way prostate cancer is diagnosed and graded.

“The biomarkers are remarkably sensitive and specific in accurately visualising the progress of the cancer and confirming its grade. This discovery has led to the commercial development of a test designed to determine how advanced and aggressive the cancer is and whether immediate treatment is needed.”

Envision Sciences, which funded the development and translation of the

technology at UniSA, has signed a commercialisation agreement with the largest tissue diagnostic pathology company in the US, Quest Diagnostics, to take the technology into clinwical practice.

Pending a successful outcome in the US, it is expected that clinical trials using the innovative technology will be undertaken in Australia.

Prof O’Leary concluded: “This discovery and spin-out is transformative and disruptive in terms of prostate cancer diagnostics. Its adoption by Quest Diagnostics as a laboratory developed test (LDT) now ensures that the markers will be used in routine practice in the US. Our ambition is to see these markers used in Europe and Austral-Asia as well.”

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€2.4M GRANT LINED UP FOR RCSI RESEARCHER TO ADVANCE RESEARCH ON DEPRESCRIBING MEDICINES USING

BIG DATA

Dr Frank Moriarty, Senior Lecturer at RCSI School of Pharmacy and Biomolecular Sciences, has received a €2.4m Career Development Award from Wellcome to advance new methods to research deprescribing – the planned process of reducing or stopping medicines that may no longer be of benefit or may be causing harm.

Improvements in healthcare mean people are living longer, and as they get older, people are often prescribed increasing numbers of medicines to prevent and manage disease. This increase in the number of medicines can lead to a higher risk of medicine-related adverse effects. It is therefore important to develop robust approaches to identify medicines that might no longer be needed or could be contributing to medicine-related harm that can be safely stopped or deprescribed.

The research funded in this award will harness the large amounts of information already collected as part of routine healthcare, such as GP and hospital visits. New methods from pharmacoepidemiology will be used to analyse these datasets, to improve our understanding of deprescribing practices. As the focus of healthcare shifts to more personalised medicine and patientcentered approaches, research in this area will inform the decisions of patients and their healthcare professionals and support optimal treatment. Ultimately, this will help people age better with the right medicines for them.

In addition, as part of the project, which will be known as DIAMOND (Developing Innovative Analytical Methods for research ON Deprescribing), a tool will be developed to identify patients most at risk of side effects from antidepressant medicines. Given people can respond very differently to these medicines, this will help support the monitoring and review of antidepressants to promote the best outcomes for patients with mental health conditions.

Commenting on the announcement, Dr Moriarty said: “The support from this award will enable me to build a team to pave the way for high-quality deprescribing research and clinical practice. The evidence we hope to generate through innovative, data-driven

approaches will improve the quality of healthcare to benefit population health. We are embedding open science in this project, by sharing our methods and tools for other researchers to use in future studies and maximise our impact.”

The grant award will run over eight years, starting next year. As well as supporting research efforts and access to datasets, it will also facilitate the recruitment, training and development of new researchers.

“I would like to congratulate Dr Moriarty on this prestigious funding and acknowledge the support of Wellcome for awarding RCSI our first Career Development Award. This is an important milestone which recognises our dedication to advancing cutting-edge research and fostering talented scientists,” said Professor Fergal O’Brien, Deputy Vice Chancellor for Research and Innovation at RCSI.

“I look forward to seeing how this project will apply big data to a space where it has the exciting potential not only to improve medical practices but also to positively impact the lives of patients.”

Wellcome’s Career Development Awards are highly competitive grants supporting

mid-career researchers' career progression in biomedical science, health, and related fields. This award further enriches the RCSI research landscape, signifying the university’s continued commitment to excellence in scientific discovery and complementing previous successes in other Wellcome grant programmes.

On this project, RCSI will collaborate with researchers from University College Cork, University College London, Queen’s University Belfast, the University of British Columbia and Complutense University of Madrid.

Dr Sophie Hawkesworth, Senior Research Manager in Discovery Research at Wellcome, said: “I’m delighted that Wellcome are supporting this exciting award in such an important research area. Our Discovery Research schemes are designed to enable a really broad range of research questions that have the potential to transform our understanding of health and disease.

“This award is a great example of the research we are aiming to support that will bring new knowledge and new research tools to a really important and understudied area. I will be following the progress of the project with interest.”

DCU SCIENTISTS DEVELOP BLOOD TEST TO PREDICT RESPONSE TO BREAST CANCER TREATMENT

A blood test that can identify which patients will respond to breast cancer therapies has been developed by scientists at Dublin City University (DCU), and could inform better decisions on patient treatments.

“If doctors know in advance that a patient will not respond well to a first-choice therapy, they would have the option of putting that patient on a different treatment to improve their chances of responding,” said Dr Denis Collins, Principal Investigator for the Cancer Biotherapeutics Research Group at the National Institute for Cellular Biotechnology at DCU, whose team carried out the work.

The test, which is reported in the British Journal of Cancer, has been developed from a nationwide clinical trial (ICORG10-05) among patients in 11 Irish hospitals led by oncologist Professor John Crown involving women with early-stage HER2 positive breast cancer, which accounts for between 15% and 20% of all breast cancer and affects about 500 Irish women each year.

“Or if no other treatments are approved, the patient could be enrolled in a trial of a new

therapy,” Dr Collins added.  HER2-positive breast cancer needs HER2 to grow, and drugs have been developed that target HER2 to stop the cancer from growing. The trial tested the chemotherapy drugs carboplatin and Taxotere, and the HER2targeting therapies Herceptin and Tyverb. Blood samples were taken from patients before and after treatment and sent to DCU for processing.

Dr Nicola Gaynor, the Caroline Foundation Research Fellow and a member of Dr Collins’s Cancer Biotherapeutics Research Group, led the

work on the collected samples, collaborating with scientists in DCU, UCD, TCD, and RCSI.

The team was looking for changes in the activity and composition of anti-cancer immune cells in the blood due to treatment and also for any differences between patients who had no cancer remaining after treatment and those that did have cancer left.

The blood test uses the patient’s white blood cells and the anti-PD-1 drug Keytruda to identify patients who would not respond well to therapy.

“While further samples and studies are required to confirm the preliminary findings in this paper, these results could form the basis of a future blood test to help doctors make better decisions on treatment strategies for cancer patients. We are actively seeking collaborators to further develop this test for patient use,” said Dr Collins. “These kinds of national cancer trials in Ireland are essential to ensure access to cutting-edge drugs for Irish cancer patients and provide samples for scientists to find new tests and treatments to improve patient outcomes in the future.”

CLINICIANS PUBLISH FIRST GUIDELINES FOR TREATING PATIENTS WITH SEVERE COMMUNITY- ACQUIRED PNEUMONIA

A collaborative group led by Trinity researchers has published the first guidelines for treating patients with severe communityacquired pneumonia (sCAP) – a highmortality condition that describes people admitted to ICU.

These guidelines, published in two journals – Intensive Care Medicine, and the European Respiratory Journal – will benefit physicians dealing with the care of critically ill patients and help standardise the current treatment and management of sCAP.

Community-acquired pneumonia (CAP) is a very common respiratory infectious disease but approximately 40% of patients will require hospitalisation and 5% of those will be admitted to ICU, at which point they are clinically classified as having sCAP.

Patients with sCAP are primarily

admitted to ICU due to organ shock or the need for invasive or non-invasive mechanical ventilation and, because their mortality could be as high as 50% at this point, the guidelines fulfil a pressing need.

Ignacio Martin-Loeches, Professor in Clinical Medicine in Trinity’s School of Medicine and Consultant in Intensive Care Medicine in St James’s Hospital, is the lead author of the new guidelines. He said: “Implementing treatment is obviously challenging in any critical care setting, and depends on the healthcare systems and resources allocated, but these new guidelines provide clear, focused, and concise recommendations from which patients with the highest severity and mortality risk will benefit.

“We have also been careful to incorporate recommendations from specialists from different healthcare systems and medical

domains, in order to ease implementation and obtain a transversal approach.”

The guidelines have been created based on the European Respiratory Society (ERS) launching a task force, which brought together the Trinity team and other European societies, including the European Society of Intensive Care Medicine (ESICM), the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociación Latinoamericana del Tórax (Latin American Thoracic Association; ALAT).

This multidisciplinary group of clinicians has extensive expertise in managing patients with respiratory tract infections across Europe and North America, but the guidelines should also help the management of sCAP patients worldwide.

HSE STUDY ASKS: WHAT IS THE ECONOMIC COST OF MELANOMA SKIN CANCER IN IRELAND?

Research conducted by the HSE National Cancer Control Programme (NCCP) highlights the difference between the economic cost of diagnosing and treating a person with the earliest stage of melanoma skin cancer (stage IA) compared to those with late stage melanoma skin cancer (stage IV).

Early diagnosis of skin cancer is easier to treat and the patient is more likely to recover well, resulting in reduced economic cost for the health service and the patient.

The study found the cost of diagnosing and treating a person with late-stage melanoma was more than 25 times higher than for a person with early stage disease (stage IV €122,985 versus stage IA €4,269). The study did not take into account the additional wider economic and personal costs of melanoma skin cancer to patients, their families and society.

In Ireland, more than 1,000 people are diagnosed with melanoma skin cancer each year, a number which is predicted to double between 2015 and 2045. Melanoma skin cancer is the most dangerous form of skin cancer, as it can spread to other organs in the body and can be fatal.

Skin cancer is one of the most preventable cancers. We can reduce our risk of skin cancer by protecting our skin from the sun and other sources of ultraviolet radiation, such as sunbeds. Being SunSmart and never using a sunbed, can help reduce your risk of all types of skin cancer, including melanoma.

Minister for Public Health, Wellbeing and the National Drugs Strategy Hildegarde Naughton TD said: “This research reinforces the importance of prevention and early detection. We cannot treat our way out of rising skin cancer rates, so by working to reduce the number of cases every year we can also reduce the large cost burden that this disease places on our health services.

“We know that skin cancer is largely

preventable, so I would urge people to be vigilant in reducing their risk by being SunSmart and checking skin regularly for any changes.”

REMEMBER THE SUNSMART

5 S'S, EVEN WHEN IT’S CLOUDY:

1) Slip on clothing: Cover skin as much as possible, wear long sleeves, collared T-shirts, clothes made from close-woven material that does not allow sunlight through.

2) Slop on broad-spectrum (UVA/UVB protection) sunscreen: apply sunscreen with a sun protection factor (SPF) of at least 30+ for adults and 50+ for children, with high UVA protection and water-resistant. Reapply regularly. No sunscreen can provide 100% protection, it should be used alongside other protective measures such as clothing and shade.

3) Slap on a wide-brimmed hat: protect your face, ears and neck.

4) Seek shade: sit in the cover of trees to avoid direct sunlight. Use a sunshade on your buggy or pram. Keep babies and children out of direct sunlight.

5) Slide on sunglasses: guard your eyes against harm by wearing sunglasses with UV protection.

6) And remember, do not deliberately try to get a suntan. Avoid getting a sunburn. Never use a sunbed.

Overexposure to ultraviolet (UV) from the sun is the leading cause of skin cancer. The more UV you’re exposed to, the greater your risk. That’s why it's important for outdoor workers to protect their skin all year round. Even low UV levels can be harmful when

exposed for long periods. UV radiation from the sun is usually strongest between 11am and 3pm from April to September, even when it’s cloudy. So plan ahead, check the UV forecast for your area on Met Éireann’s website at https://www.met.ie/uv-index, and remember the SumSmart 5 S's.

Dr Triona McCarthy, Consultant in Public Health Medicine, HSE NCCP, said: “Investment in skin cancer prevention and early detection programmes show strong potential for health and economic benefits. The National Skin Cancer Prevention Plan 2023 – 2026 is focused on reducing risk across the population, by raising awareness of the actions we can all take to reduce our risk of skin cancer such as following the SunSmart 5 S's and avoiding use of sunbeds, and it sets out how we can support people to adopt these behaviours.”

When skin cancer does occur, picking it up early means that it is easier to treat and the patient is more likely have a good outcome, in addition to the reduced economic cost for the health services. Knowing what your skin normally looks like, and checking your skin and moles regularly for changes, will help you spot a possible melanoma at the earliest possible stage. Suspicious signs include:

 A change in the size, shape or colour of a mole that you already have;

 A mole that is often itchy or bleeding;

 A new mole that looks different to the other moles that you have;

 A change to a normal patch of your skin, like a new dark spot on your skin;

 A dark coloured line or patch under your nail, or any abnormal skin under your nail.

Contact your GP without delay in you notice any changes to your skin that are causing you concern.

For more information please see the SunSmart hub at www.hse.ie/sunsmart and check out #SunSmart on social media. ●

There is a significant difference in treatment costs, while early diagnosis and being SunSmart is important too

LUNG CANCER: MEETING PATIENTS’ NEEDS THROUGH INNOVATION

In recent years there has been an acceleration in new medicines to treat lung cancer, leading to an improvement in survival rates. However, only 20-25% of patients are alive five years after diagnosis. So, why are survival rates still poor  The answer, like lung cancer itself, is complicated. To begin with, cancer is not a single disease, but a constellation of diseases of immense complexity. Lung cancer has several causes, and includes various mutations and genomic alterations. In addition, it may be diagnosed at different stages and has a diverse patient population. Not all patients have the same mutations and respond in the same way to treatments, which means outcomes vary, even when a patient population is given the same therapy.   Taken together, this means no single approach is enough to address the unmet medical need (UMN) in lung cancer. This matters because, as we marked this year’s World Lung Cancer Day early last month, we found ourselves having an important conversation about the definition of UMN.

DEFINING PATIENT NEED

As part of the European Commission’s review of the EU pharmaceutical legislation, there is a risk that the definition of UMN may not be patient and science centered.   Addressing patients’ needs through research is what drives scientists in academia and industry, healthcare professionals, patient advocates and other key stakeholders. And even though developing new medicines is a long, complex and enormously risky process, medicine developers invest in it with the ambition of addressing an UMN.

Any attempt to define an unmet medical need must start from the patient and science perspective. Not doing so brings the risk of excluding the development of important therapies for people living with lung cancer. However, the Commission’s

current proposal is taking a very narrow approach, focusing on some outcomes, but not all patient relevant ones. It disadvantages diseases which are relevant for broader patient populations. This narrow approach directly clashes with the Europe’s Beating Cancer Plan and Cancer Mission’s commitment to save three million lives by 2030.

Furthermore, as a specific example, even though there is an UMN because deaths from lung cancers remain high, novel therapies to address lung cancers would be significantly challenged by the Commission’s proposed restrictive UMN definition.

SOLVING THE CHALLENGE TOGETHER

Understanding the science and nature of innovation, including how and where it happens, is critical to address unmet needs. It is unlikely that for any patient population with an unmet medical need, a single medicine will solve that need entirely. More likely, multiple medicines each solve a part of the unmet medical need, either by complementary effectiveness or by differentiation in the part of the patient population that benefits from them. That’s why we propose to include in the new EU pharmaceutical legislation a patientcentred, inclusive definition of unmet medical need that would encourage broad avenues of scientific discovery.

Narrowing the definition of UMN is the wrong answer to the real problem of incentivising continued investment in innovation. And it points to a broader issue: the absence of patient-centric measurements in determining the value of an intervention. Yes, five-year survival rates are a key metric; but how these five years are lived or endured reflected in patient satisfaction, treatment adherence, mode of administration, and quality of life are also crucial if we are to live up to the aspiration

of having a patient-centred system and reach the goal of the Europe’s Beating Cancer Plan and Cancer Mission.

People living with lung cancer deserve more treatment options addressing their needs; improving their quality of life; reducing the burden of treatment; extending their life to give them more time with family and friends; and allowing them to be active members of society. And they need these interventions as soon as possible. Lung cancer steals time.

To deliver what patients want – and need – the first step is simple: ask them. From there, we must incentivise more R&D in Europe which is patient-centred and strives to address patients’ needs is all their forms.

Lung cancer is a considerable scientific challenge. No one stakeholder, institution, or company can solve this alone. And there will not be a single perfect solution. However, with the right mix of incentives and collaboration, with patients at the centre, we can improve the outlook for lung cancer patients in Europe and beyond.

SIGNATORIES

 Johanna Bendell, Global Head Oncology, Pharma Research and Early Development, Roche

 David Bialek, Global Brand Lead, Tusamitamab & Head Commercial Strategy - Lung Cancer, Sanofi

 Rodney Gillespie, Global TA Head Solid Tumors, Novartis

 Alan McDougall, Senior Vice President, Medical Affairs, Astellas Pharma Europe Ltd.

 Cole Pinnow, Global Marketing Lung Cancer Lead, Pfizer

 Christine Roth, Member of the Executive Committee, Pharmaceuticals Division and Head of the Oncology SBU, Bayer

 Victoria Zazulina, MD and Head of Development Unit Oncology within Global Research & Development, Merck ●

An inclusive definition of unmet medical need is vital to driving better outcomes for patients

Dandruff?

What dandruff?

Capasal Therapeutic Shampoo

Triple Action Therapy

Salicylic acid removes scales, distilled coal tar relieves itching, with coconut oil to soften and moisturise the scalp

Recommend Capasal Therapeutic Shampoo

Prescribing information

Capasal™ Therapeutic Shampoo

Salicylic acid 0.5% w/w, coconut oil 1.0% w/w, distilled coal tar 1.0% w/w.

Uses: As a shampoo in the treatment of dry, scaly scalp conditions such as seborrhoeic eczema, seborrhoeic dermatitis, pityriasis capitis, psoriasis and cradle cap in children. It may also be used to remove previous scalp applications.

Directions: Adults, children and the elderly: Use as a shampoo, once or twice weekly until the condition improves. Therea er, occasional use may be necessary. Wet the hair thoroughly. Massage a small amount of the shampoo into the scalp, leaving on for a few minutes. Remove as much lather as possible with the hands, before rinsing out thoroughly under running water. Repeat if necessary.

Contra-indications, warnings, side e ects etc: Please refer to SPC for full details before prescribing. Do not use if sensitive to any of the ingredients. If there is no improvement a er 4 weeks, or the condition is aggravated, discontinue treatment. Keep away from the eyes. Keep out of the reach of children. Use in pregnancy: avoid use during rst trimester.

Package quantities, trade prices and MA number: 100ml bottle €3.48, 250ml bottle €6.96, PA23128/008/001.

Legal category: Supply through pharmacy only.

Further information is available from: Dermal Laboratories (Ireland) Ltd, Head O ce Tatmore Place, Gosmore, Hitchin, Herts, SG4 7QR, UK.

Date of preparation: February 2021. ‘Capasal’ is a trademark.

Adverse events should be reported. Reporting forms and information can be found at www.hpra.ie. Adverse events should also be reported to Dermal.

CAN A SPECIAL IMMUNE PROTEIN IN THE BODY BE HARNESSED TO STOP OVARIAN CANCER?

A significant study has discovered the anti-tumour activities of the immune protein interferon epsilon, which in pre-clinical models blocks the metastasis of ovarian cancer cells by instructing immune cells to kill the cancer cells

The search for preventions and cures for the most prevalent and deadly form of ovarian cancer has now turned inward with the discovery of the anti-tumour activities of an immune protein called ‘interferon epsilon’. This research was published in the journal Nature and was co-led by Trinity College Dublin researcher Dr Nollaig Bourke. Interferons (IFN) are a type of immune signalling protein, or cytokine, which can kill tumour cells and activate anti-tumour immune responses. Dr Nollaig Bourke, School of Medicine – who worked with colleagues in the Hudson Institute of Medical Researchin Melbourne, Australia, before returning to establish her own research immunology group at Trinity – explained: “Early in this study we found that women with high grade serous ovarian cancer no longer had the normal expression of an immune protein called interferon epsilon in their female reproductive tract.

“This was really interesting to us as we knew that interferon epsilon was part of a family of proteins known for their antitumour activities and we wondered what would happen if we could try and restore this lost expression – could giving interferon epsilon back help block the growth of ovarian cancer cells and therefore prevent the growth of primary and secondary tumours?”

A key motivation for the team is the poor survival rate for women with ovarian cancer, particularly high-grade serous ovarian carcinoma (HGSOC). Patients are often not diagnosed until later stages of the diseases when cancer cells have metastasised from the initial tumour to other sites in the body, making the disease really difficult to treat. About 400 women in Ireland are diagnosed with ovarian cancer each year.

A big advance in cancer treatment

in recent years has been cancer immunotherapies, where the immune system is harnessed to kill cancer cells. The researchers received pilot funding from the US Defence Department’s Ovarian Cancer Research Programme to assess interferon epsilon as a novel immunotherapy in ovarian cancer.

Dr Bourke continued: “What was really striking about our study was that when we gave interferon epsilon in our preclinical models, it was able to directly kill tumour cells but more importantly, it was really good at instructing immune cells in the body to target and kill cancer cells involved in metastasis, thus blocking the development of secondary tumours.”

This study was made possible by the team of expert immunology scientists and oncology clinicians who collaborated to make these discoveries, including former Trinity alumni Dr Nicole Campbell and Dr Niamh Mangan. Dr Campbell, who joined the research team after completing a PhD in Trinity, is the publication’s joint first author and has been working for several years on understanding how these treatments which target the body’s immune system can be optimised to

improve its ability to fight the tumour.

Dr Campbell said: “Cancer immunotherapies have been very successful in the treatment of other types of cancer, but they have had limited success in ovarian cancer – we’re looking to change that.

“We know that in High Grade Serous Ovarian Cancers [the commonest form of ovarian cancer] tumour cells recruit and activate ‘immunosuppressive’ cells which prevent anti-tumour immune cells from killing tumour cells, so we’re aiming to develop new therapeutics which can reverse that process and improve survival rates.”

Professor Paul Hertzog, Centre For Innate Immunity & Infectious Diseases, Hudson Institute of Medical Research, who co-led the study with Dr Bourke, said: “We now know that Interferon epsilon is naturally made in the [epithelial] cells lining organs such as the female reproductive tract where we knew it acts as a natural booster of immunity to infections. Our recent discovery is that it also acts as a tumour suppressant, and that it is lost during the process of ovarian tumour formation.

“We know from pre-clinical models that administering it will dramatically inhibit ovarian cancer growth, particularly in cases where the cancer has metastasised into the peritoneal cavity.”

The next step is to understand which immune cells are important to the antitumour activity of IFN epsilon, and to test whether it is effective on human cells.

Combining studies in mice and using the byproducts of human ovarian cancer treatment, the team now aim to better understand how IFN epsilon works to protect against ovarian cancer and move a big step closer to ‘first-in-human’ clinical trials. The goal is to develop IFN epsilon as a new immunotherapy for ovarian cancer. ●

REMINDER OF SERIOUS HEALTH RISKS WITH ‘MELANOTAN 2’ SELF - TAN PRODUCTS

Data shows large increase in online listings of dangerous and illegal substance targeting younger people

anaphylaxis,” said Ms Power.

UNAUTHORISED PRODUCT

Consumers should be aware that Melanotan 2 is not authorised by the HPRA or any medicines regulator to treat any condition. Despite how it may be presented, it is not a cosmetic product. The HPRA advises anybody using Melanotan 2 to stop using it immediately and to contact medical professionals regarding potential health concerns.

Ms Power continued: “As it is intended to be inhaled or injected, it cannot be classified as a cosmetic because it results in an action within your body. We urge consumers to carefully consider and question both what they are seeing online and the motivation of the individuals who profit from the sale and promotion of this substance. There are no legitimate suppliers of Melanotan 2 and those that do so illegally do not have your best interests or your health in mind. Taking this product simply puts your health at risk.”

SOCIAL MEDIA PROMOTION

The HPRA has noted a marked increase in activity on social media illegally advertising the sale and promotion of Melanotan 2 products.

The Health Products Regulatory Authority (HPRA) has reminded the public that the unregulated substance Melanotan 2 is not safe for use and may cause serious, long-term damage to your health. Often described as a self-tanning aid, the product is also referred to as Melanotan, Melanotan II or MT2. It is commonly sold as an injectable powder or in the form of drops and nasal sprays.

The HPRA is also concerned that products containing Melanotan 2 are increasingly being targeted towards young people by using bright colours, flavours, and branding. The HPRA will take action against individuals using social media and e-commerce to advertise and supply Melanotan 2 containing products, including the removal of content and accounts, and prosecution activity when there is significant risk to public health.

In this regard, the HPRA continues to engage with e-commerce and social media platforms with the goal of limiting the sale and

promotion of these untested products.

WHAT ARE THE RISKS OF MELANOTAN 2?

According to Grainne Power, Director of Compliance with the HPRA, this substance continues to be advertised for cosmetic purposes online despite known side effects. To protect the public, the HPRA works to remove these advertisements with a focus on stemming the supply of Melanotan 2. It is also important to raise awareness and inform people of the dangers of using this product.

“A substance like Melanotan 2 poses a threat to somebody’s health. There is no safety data to support its use, with no guarantees as to its quality, safety or effectiveness. If products advertised online seem too good to be true, it is likely that they are. Serious side effects of taking Melanotan 2 include the development of new moles, darkening of existing moles and freckles, potential loss of vision, muscle tremors, stroke and

Between July 2022 and June 2023, the HPRA has removed more than 500 social media or e-commerce listings relating to Melanotan 2. This is a noticeable escalation in activity when compared to a combined total of less than 500 listings removed across the previous two years.

WHAT YOU CAN DO

Members of the public can report suspicious activities around the supply of Melanotan 2 and other health products to the HPRA, in confidence, by emailing reportacase@hpra.ie or by calling 01 634 3871 or 01 634 3431.

Further information for consumers on the dangers of purchasing medicines online is available here.

Additional information relating to the dangers of using Melanotan 2 is available in the corresponding HPRA safety notice.

The HPRA’s advice to anyone using Melanotan 2 is to stop immediately. If you are concerned that you have experienced ill effects from using Melanotan 2, we recommend you speak to a medical professional.

You can also use our online form to report such effects to the HPRA. ●

WORKING IN VEIN

The vast majority of the attention that pharmacists receive focuses on our primary function, namely the dispensing of medicines. This is also the main source of our income, so we logically devote the bulk of our own efforts to that. What’s often overlooked, especially by various media commentators, is our value as a source of free and instantly available medical advice. This has always been an important role, but is even more so nowadays when GPs are stretched so thinly that appointments can be days away. We are effectively the first step in the triaging process for many patients. It’s probably impossible to accurately estimate the value of this to the health service, but our early interventions save lives as well as money.

A case in point occurred recently in my pharmacy when an elderly lady came in for advice. She had an American accent and asked me for an antihistamine because she had taken “an allergic reaction to an antibiotic”. She added that she’d been taking the antibiotic for a month and had now started to get itchy eyes and a swollen leg. A couple of things weren’t adding up properly in this scenario, so I explained that the antibiotic was unlikely to be the problem, that hayfever was probably causing the itchy eyes, and that I was more worried about the leg. She rolled up her trouser leg and one calf was definitely larger than the other. Fortunately, she also took off her shoe and that revealed some purple discolouration along the side of her foot that hadn’t been there earlier. Due to her accent I asked when she’d flown into Ireland, and she replied it had been just three days earlier and the swelling only started after arriving here. I gave her my opinion that she probably had a blood clot and to get to an A&E department immediately. Mercifully, she did, and she called back a couple of days later to say that I was right and to thank me. I’ll

chalk that one up as a win, but, unfortunately, it won’t appear in any other record to show the value of community pharmacy.

THE ROOF OF ALL EVIL

There’s a lot of talk within the profession about young graduates and even notso-young seasoned pharmacists being disgruntled with their lot. The job is often seen as stressful with the pressures of serving the public and the added burdens of dealing with Byzantine bureaucratic rules and neverending regulation. In general I’m sure our

out of his overalls into a tuxedo and have his limo take him to a Michelin-starred restaurant. Meanwhile, I Googled Felt Roof Repair, bought the internet-recommended €40 tin of ‘Thompsons 10-Year Roof Seal’ then spent a warm sunny afternoon painting it on. All told, it was easier being on top of the pharmacy fixing cracks in the felt rather than being in it covering up the cracks in the health service.

OWINGS IN THE WIND

parents were all very proud of us doing well in our Leaving Certs and going on to college to get a degree leading to “a good job”, but of late I’m coming round to the idea that if you really want to launch your kids on a path to financial success then just buy them a ladder and a clapped-out van with the word ‘Roofer’ on the side of it. My pharmacy has a flat concrete roof covered in felt that has seen better days. A recent deluge of rain found a crack that let some water seep through. It was nothing serious, but less than ideal, so I got a roofer out who patched it up in less than an hour for an amount of money that would have paid a locum pharmacist for at least a full afternoon. My roofer identified other areas in need of attention and gave me a quote for repairing them before heading off to change

After a couple of years in the making the longawaited Owings Protocol is finally becoming a reality in our computer systems. Apart from some very irritating bugs in the upgrade this is a development that I welcome. For too long there have been figures in the HSE and the Department of Health suggesting that there could be high levels of fraudulent activity in community pharmacy. The reality is that any pharmacist committing fraud would be playing a high-risk game because detecting it would be child’s play in the event of a HSE investigation. Anybody familiar with a dispensing package could find patterns of suspect activity in a matter of hours, so it’s telling that we’ve had so few publicised cases. However, if the implementation of the Owings Protocol gives an extra layer of comfort to officials and politicians then that’s a good thing because the huge untapped potential in pharmacy can better be utilised if they approach us cooperatively rather than negatively. ●

Pharmacists are trained to offer advice on the treatment of a variety of ailments – anything from headaches to skin rashes and throw in a bit of roofing and fraud detection for good measure, writes Fintan Moore

We are effectively the first step in the triaging process for many patients

Fintan Moore graduated as a pharmacist in 1990 from TCD and currently runs a pharmacy in Clondalkin. His email address is: greenparkpharmacy @gmail.com.

THE LOST 'WAR ON DRUGS'

Heroin assisted treatment is coming, but will it reduce drug harms? asks Terry Maguire

Increasingly it seems, politicians, columnists, and other opinion leaders support, sometimes actively promote, further liberalisation of recreational drug-use. The Utopia they seek is to rid society of the drug-pushers and the cartels while supporting the addict who they see as a victim. The damage recreational druguse creates in any society is unpleasant to say the least and when things are at their worst it is then, in moral panic, society moves; creatively, innovatively, frictionlessly, towards other ways of addressing the problem.

The ‘War on Drugs’ was lost years ago shortly after its inception in the early 1970s. Peter Hitchens in his 2012 book The War We Never Fought, makes the case that there never was much appetite by, what he calls, the British Establishment, to take on the social liberals hell-bent on liberalising druguse as a human right. How we view druguse in contemporary society is politicise with the Left supporting a more liberal, health and social care approach, while the Right support a Draconian, criminal justice approach. The problem is that today, as a result of liberal activists, recreational drugs are more available, and after experimental use, those predisposed end up dependent and in need of significant help and support in the long-term. Here again the Right and the Left differ; the Right see the addict as weak and selfish, the Left as a victim.

How this plays out in policy is very interesting. As the sides cannot agree and ideological views are entrenched things need reframed before they can move on. A key reframing was the promotion of the medical-model of addiction now dominant and which defines addiction as a disease and directs treatment policy. Another reframing has been harm-reduction; if the

addict does not wish to, or cannot stop, then drug use must be made as safe as possible. Harm reduction makes obvious sense. Coming late to this option it is only in the past 20 years that Northern Ireland introduced substitution prescribing (methadone and buprenorphine), needle exchange services, and naloxone services. Before that a dominant paramilitary grouping brutally kept the problem at bay (in republican areas at least), but that’s going off message.

productive lives and that in itself is an important outcome. But too many relapse.

A few years ago, I attended Addiction Northern Ireland’s 40th Anniversary event and I was impressed by the strength of the advocacy on behalf of addicts. Families, advocates, agitators, and service-users (they prefer not to be called addicts) had lots of criticisms of formal addition services. An emotional presentation from the CEO of the charity ‘Anyone’s Child’ told the personal and tragic story of her son

Harm reduction policies have saved lives and improved other outcomes; less criminality, less HIV and hepatitis, and more in recovery, but the number of addicts has grown and this must be seen as a problem. Few of those dependent on opiates get clean within a year of entering services and most working in addiction services appreciate that their patients using methadone or buprenorphine are unlikely to get cured of their dependency. Studies suggest only 2-to-5 per cent get clean within a year. Substitutes do not provide the rewards heroin brings, but reduces withdrawal (and blocks heroin when combined with naloxone) meaning those taking substitutes can live reasonably

who died of an “unnecessary overdose”. Her son did not want to use methadone and was trying “heroin assisted recovery”, but the system did not accommodate him and so he was left to use heroin of unknown strength supplied by dealers and he had to do so unsupervised. He died of a batch of heroin that was “too strong”.

What she was referring to is now called Heroin Assisted Therapy (HAT) and is the next step in the harm-reduction reframing of our opiate epidemic. Scotland has introduced HAT in a limited way in Glasgow and the Scottish government has long opposed the insistence of the UK government to retain the legislation that technically makes HAT illegal across the

Harm reduction policies have saved lives and improved other outcomes; less criminality, less HIV and hepatitis, and more in recovery, but the number of addicts has grown and this must be seen as a problem

UK. We in Northern Ireland are moving this way too and I would predict a HAT service in Belfast in the coming months as our drug problem has, with recent deaths in the city centre, reached that level of moral panic necessary to support the next step.

I read Theodore Dalrymple’s book Romancing Opiates when it was first published back in 2008. A retired GP with prison work experience, Dr Dalrymple offered, back then, an interesting if simplistic view on drugs and their abuse in modern society. Drugs are not bad he claimed; its people’s behaviour that’s bad. Whereas there might be evidence that

people in methadone services commit less crime the evidence he presented indicates that they are still prone to commit crime. Crime does not necessarily stop it just lessens.

In short, his thesis is that people, particularly men, do not commit crime because of a drug habit; their propensity to criminality existed before their drug habit began; indeed, a propensity to criminality leads to drug experimentation and abuse in the first place. Those who are drug dependent, he suggests, are people who abuse the social system to their own gain; they find it easier to be

victims of social injustice than finding ways to help themselves. They complain of horrific withdrawal symptoms if they do not get a fix when in fact symptoms of heroin withdrawal are similar to the symptoms from a bout of flu. In a healthy individual this is unpleasant, but hardly lifethreatening, he asserts. You could safely say Dr Dalrymple is politically on the Right.

Addiction, according to Dr Dalrymple, is a social construct that drug-users create to ensure continued drug supply and social workers use to keep their jobs and social status. No, he declares, we need to keep the criminal focus on heroin abuse and not support prescribing in “shooting galleries”. His extreme view is that all harm reduction service should be closed down and investment made to support GPs dealing with the emerging clinical needs of dependent patients.

Dr Dalrymple’s views are too extreme for most tastes, but I do remain to be convinced of the merits of HAT and perhaps time will tell. How well HAT worked in Portugal and the other European countries now providing this service depends on who you ask. Portugal is having a rethink on its decriminalisation policy as the shine comes off that policy and reality sinks in; more drugs mean more addiction. We are not yet near a decriminalisation policy in the UK, but we have moved far into the harmreduction reframing of opiate use and I wonder if we will reach a point where harm reduction becomes public endorsement for, and normalisation of, the very problem it is trying to address. Advocates will always, of course, say that HAT is only for the medical treatment of those who are dependent and not free heroin on prescription. ●

CONTRIBUTOR INFORMATION

Terry Maguire owns two pharmacies in Belfast. He is an honorary senior lecturer at the School of Pharmacy, Queen’s University Belfast. His research interests include the contribution of community pharmacy to improving public health.

THE DRUG OF JIHAD

The so-called ‘Jihadi pills’ are counterfeit versions of fenethylline or Captagon as it was known when it was a licenced medicine. Its abuse is now common in the Middle East, notably among adherents to ISIS, hence the nickname. A recent press release from the Foreign and Commonwealth Office in the UK entitled “Tackling the illicit drug trade fuelling Assad’s war machine” drew attention to the fact that the 80 per cent of the world’s supply of Captagon produced in Syria, was estimated to be worth up to $US57 billion to the Assad regime. Both the UK and the US have imposed sanctions on 11 individuals including businessmen, militia leaders, Hezbollah associates, and relatives of Assad involved in the production and trade in Captagon.

Fenethylline is a synthetic molecule comprising amphetamine conjugated with theophylline and is a pro-drug of both. It was first used medically in 1961 for the treatment of ADHD, depression, and narcolepsy. Since amphetamine is a major metabolite it is not surprising that reported side-effects include dependence, acute heart failure, myocardial infarction, and psychosis. After it was scheduled under the UN Convention on Psychotropic Substances in 1986, legal production ceased, but counterfeit products have thrived since then. Those counterfeit versions often do not contain fenethylline, but other amphetamines mixed with other drugs including caffeine, ephedrine, theophylline, procaine, and even chloroquine.

Originally, clandestine synthesis was centred in the Balkans and the Captagon, and subsequently trafficked into the Arabian Peninsula. Nowadays, Syria is the main producer and it not only pays for arms for use in the civil war, but it also increases the endurance of fighters, on

both sides, apparently, by reducing the effects of lack of sleep and fatigue without diminishing alertness, allowing them to ignore pain from battlefield injuries and from torture. A paper in Basic and Clinical Pharmacology and Toxicology in 2016 noted that annual seizures of Captagon represent a staggering onethird of all amphetamine-type stimulants (ATS) worldwide and that three-quarters of patients treated for drug problems in Saudi Arabia are addicted to ATS in the form of Capatagon. The amounts involved

are enormous. Between 2013 and 2015 over 48 million tablets were seized, begging the question as to how many more were successfully trafficked into the Middle East and also North Africa. Seizures were made in Lebanon, Dubai, Turkey, and Saudi Arabia. According to an article in Addiction in 2016 by researchers from what is now the South East Technological University (formerly Waterford Institute of Technology), Captagon was used in Syria to stimulate aggression in fighters and to instil the ability to kill without moral compunction. Both sides seem to have

copied the actions of the Allies in World War II in their use of Dexedrine, and of Nazi Germany and Japan whose armed forces used methamphetamine. The idea of ISIS militants armed with AK 47s and/ or swords capable of beheading victims, being dosed up to their eyeballs with a psychotogenic amphetamine is terrifying. A 2021 report by the Radicalisation Awareness Network on behalf of the European Commission, entitled “Substance Use and Violent Extremism”, claimed that substance use might play a role in triggering pathways to both violent Islamic and violent right-wing extremism by lowering the behavioural and mental thresholds for committing violent acts. An article in Psychopharmacology in 2016 explored the potential role of Captagon and other psychoactive drugs in the Paris and Tunisian atrocities that took place in 2015. The terrorist who shot and murdered 38 tourists on a beach in Tunisia that summer had taken counterfeit Captagon before going on his murderous rampage. In November that year 130 people were killed in Paris in a series of suicide bombings and shootings, notably at the Bataclan theatre by extremists who claimed adherence to Islamic State in the Levant (ISIL) and who were believed to be under the influence of Captagon. That Psychopharmacology paper used the term ‘pharmaco-terrorism’ to describe what had happened and it is a more scientifically precise one than ‘narco-terrorism’, which is usually used. It is a more precise term because it is not just narcotics that are linked to terrorist organisations and acts, although one narcotic for which there is increasing evidence of terrorist involvement is tramadol. A 2018 article in the International Journal of Drug Policy

The ‘Jihadi pill’ is now a key part of the terrorist’s pharmacopoeia, writes Dr Des Corrigan

Syria is the main producer and it not only pays for arms for use in the civil war, but it also increases the endurance of fighters, on both sides, apparently

drew attention to the seizure of 37 million tramadol tablets by the Italian authorities in Genoa believed to be bound for North Africa and the Middle East. The authors suggested that there was growing evidence of tramadol abuse in those areas and that terrorists were using it to reduce pain (not surprisingly), but also to increase endurance and alter perception. There were suggestions that it was used in Gaza and by Boko Haram members in Nigeria.

Boko Haram is one of a number of Jihadi groups that infest the Sahel region of Africa. Others include Islamic State and al-Qaeda in the Islamic Mahgreb. They carry out attacks in many countries of the Sahel, an area that stretches from the Atlantic to the Red Sea and includes Senegal, Chad, Mali, and Niger among others. There are strong links between those terrorist groups and local and trans-national organised crime groups (OCG) due to the routing of cocaine destined for Europe from South America through West Africa and then the Sahel. Weak governments and porous

or non-existent borders facilitate the drug-trafficking with Guinea-Bissau in particular seen by many as a ‘narco-state’ due to the corrupt influence of OCGs. Not surprisingly, some of those drugs find their way onto local markets adding to the poverty, crime, and political instability plaguing many of those countries.

A particularly problematic consequence of the OCG/terrorist links is the use of drugged child soldiers in many of the recent civil wars in West African countries such as Liberia and Sierra Leone as well as in the Democratic Republic of

the Congo. What is particularly obscene is warlords using cannabis and other drugs to control these children and force them to commit appalling mutilations and killings. Now cannabis is not usually associated with violence in popular discourse because long-term users tend to be quite passive, but aggression is a recognised symptom of withdrawal from the drugs. More pertinent is the violence linked to the paranoia and psychosis induced by cannabis drugs in some users. A review of 14 such cases appeared in the International Journal of Environmental Research and Public Health in 2020. Among the case reports were several mass shootings in Florida, Texas, and Washington between 2016 and 2018 by known heavy users of cannabis. In terms of terrorist violence, the Boston Marathon bombers are an example, as is the perpetrator of the 2017 Manchester Arena suicide bombing who was known as a ‘party animal’ who used cannabis heavily and showed evidence of paranoia and aggression.

The links between organised crime, terrorist groups, and the illicit drugs market are pervasive and multifaceted. Some commentators in this country have highlighted the link between individual decisions to buy drugs and gang violence. Such ‘recreational’ users might also consider how their purchases are supporting international terrorism, whether it is called pharmacoor narco-terrorism. ●

CONTRIBUTOR INFORMATION

Dr Des Corrigan, Best Contribution in Pharmacy Award (winner), GSK Medical Media Awards 2014, is a former Director of the School of Pharmacy at TCD and won the Lifetime Achievement Award at the 2009 Pharmacist Awards. He was chair of the Government’s National Advisory Committee on Drugs from 2000 to 2011. He currently chairs the Advisory Subcommittee on Herbal Medicines and is a member of the Advisory Committee on Human Medicines at the IMB. He is a National Expert on Committee 13B (Phytochemistry) at the European Pharmacopoeia in Strasbourg and he is an editorial board member of the Journal of Herbal Medicine and of FACT — Focus on Alternative and Complementary Therapy

‘AND JUST LIKE THAT’ ON THE RECEIVING END OF HEALTHCARE

Having had more recent experience personally, and with family, on the receiving end of healthcare, it has offered some interesting thoughts and insights. Firstly, my mother-in-law, who we thought we were going to lose at Christmas, passed away early this morning. She was helped along with a palliative care cocktail of morphine and midazolam, but from when she "took a turn" to when she passed away, took over a week. A bedside vigil held by her family in the nursing home, where staff were very kind and understanding, went on 24/7 for that duration. Everyone wanting to make sure she was comfortable and not alone when she needed someone and when she eventually did pass on. Peacefully as it happens, although she held on longer than palliative care predicted, the third time around.

It caused significant upheaval for our young family, with one adult pretty much out-of-action for the last week, and no school happening or childcare booked. I'm lucky to have a great team that allows for flexibility at work and to be able to be here for our kids, well I was up to yesterday. In a more usual home situation where both adults are working full-time with little flexibility it would have been much more challenging. I think this offers a different perspective to consider when we have people coming to us at the counter a little tired, stressed or ratty in their demeanour. The value of having an established relationship in our community pharmacy with our patients, is often underestimated in such situations by patients, ourselves, and our paymasters, among others. We also have an opportunity as employers to show that we care enough about what's

going on in our employees lives from timeto-time, to offer them what we can, when it is important to them. Goodwill works both ways, and doing what we can to position our business model so that our team members are cared for like family, is the ideal situation. There are challenges to this of course, as I found out myself more recently, where a business isn't generating enough income to resource such good intentions and initiatives, which can leave one in a financial bind.

Our local GP practice has recently taken on a fifth practice in a neighbouring town, and in the middle of summer holidays, we had a longer than usual spin, albeit not excessive, to one of their practice bases to meet Neillí's usual GP. It was a last minute appointment, and I'd taken a voice message from said GP a few days earlier, that if we needed anything, given my mother-in-law's situation, to reach out to him directly. Very kind and thoughtful of them. I'm beside her asleep in her hospital bed now, where she's on IV antibiotics for suspected pneumonia. Neillí's grandmother (the one that's still alive as it happens) had brought her to said

GP appointment, and found the GP to be "quite abrupt" and "all business", which is of course understandable with two of his GP colleagues on their summer holidays and him spreading himself through several surgeries. He was never much of a chatter as long as I've known him, but he's certainly overstretched now, and in my own experience of him, the interpersonal relationship price is what's being paid. Maybe there'll be something lost through the lack of chat, given that what often comes out after chats at the counter is relevant, but we're here tonight thanks to his concern about high ketone levels, and dehydration. We can be part of the solution to overstretched GP services as pharmacists of course, given that 96 per cent of Irish adults would welcome community pharmacists being able to prescribe for minor ailments, and most people would also approve of them being able to repeat prescriptions without them having to go back to their GP. Huge potential for pharmacies to expand the healthcare services we provide, but at what cost we must consider. Given the shortage of pharmacists, we have to further consider what needs oversight and sign off from a pharmacist, and what needs hands-on supervision, or personal intervention. Why have we not got checking technicians yet? They're working that role in the UK since God was a boy. I've worked with technicians who were more intelligent, sharp, accurate, and wise than many of us pharmacists. I'm reminded of Atul Gawande's The Checklist Manifesto, for example, if we have a robust start to finish a checklist for a process or interview, with for example, a "consult pharmacist" if an answer is yes/no, and final sign-off by the pharmacist completed

Being on the receiving end of all kinds of healthcare professionals brings more questions than answers, writes Ultan Molloy

with the patient by a trusted and diligent staff member, why would that possibly not be enough. Overstretched pharmacists and burnout is already a serious issue, that we must anticipate, and be sensitive too, and an expectation of excessive interruptions and multitasking on a given day, will lead to greater levels or distraction, burnout, and ultimately affect patient safety.

I also had an experience as a patient of a different GP and pharmacy recently. Yes, the last 24 hours has been a s*@%t show. Having woken with a 41 degree fever in the morning, after being awake most of the night with aches, and alternating chills and sweating, my wife ignored my "I'll be fine after another hour in bed" please, me putting my morning fragility down to a heavy gym session the day before, and booked me a GP appointment at a nearby surgery. Needless to say, my "hour in bed" turned into five hours and I eventually arose at 2.30pm for a 3pm appointment nearby, kindly driven to by a friend, as Laura had gone to her mum in the nursing home. Like a narcoleptic rag doll I flopped into the car, and subsequently into the surgery, where I appeared to be the only patient. I do know that I was barely articulate, and nearly fell asleep in the waiting room again. Dr F showed little interest in having the bants about life in general, or indeed in listening to me at all as it transpired. He gave me no explanation, or diagnosis, and when I asked him what he was prescribing, he said Doxycycline, which I couldn't tolerate some years back, having had to take it for malaria prophylaxis. After a couple of days of puking it up a half hour after taking it, I decided to take my chances. "I don't get on with doxycycline, it cuts my stomach up a bit. Could I have Augmentin Duo if you're prescribing for my respiratory symptoms?" Ignored. And honestly, I was too flaked to assert myself. I also knew I had a box of Augmentin Duo at home mind you. So €55 later, and a 10 minute visit to the doctor I had a prescription for some doxycycline, steroids, Ventolin, and casacol, but no diagnosis or discussion about why I was in bits, and I wasn't able to drag any more blood from Dr Stone. I'll never go to him again.

We went to a pharmacy in the town that's handy for parking, and given the other two neighbour one another on a street with little parking, it's not surprising that it's the one

that's fastest growing in the town. What is surprising is that it took the best part of an hour to get my prescription. My friend and driver went in to collect the prescription, over the course of his wait, I had two naps in the car, only to be woken by him each time apologising to me, and saying: "I don't know what they're doing... there are like six of them going around in the back behind the counter... but no sign of your prescription yet. I'm sorry." I was sorry too. Sorry, that I brought him to that particular pharmacy for the sake of a parking place. So many pharmacy colleagues are obviously not workflow planning and predicting patient returns every 28 days to have prescriptions ready in advance. If you're not doing this in your pharmacy, know now, that you are robbing your patients of their time, you are robbing your staff of their time, and you are robbing yourself of the resources required to pay them for the lack of your systems, and patient "pull" led bottlenecks. Figure out how to do it, and you'll have plenty of time to deal with acute prescriptions coming in, as your chronic/ repeat prescriptions will be prepared already. Yes, yes, yes, I know about potential rework in returning items to shelves, and PMR file changes, and they mightn’t want everything every time... just exclude those handful of people, note on their files, suck up the proportional handful of return to shelves, and get on with it, for Christ's sake.

My driver yesterday, and friend, were sitting together on holiday recently, having a late drink, and he mused about something being "just like" something else. Rather curtly, just as when my aged mother starts to lecture me on medicine matters, "It's not, just like," I said, "It is." He continued on with his "well you know, it's like.... ", and I more bluntly interrupted, "It's not like... it is!" getting progressively more irritated in my tone, at which point he jested "easy tiger" and burst out laughing. I've seen the funny side of it since, and he kindly, and at every opportunity brings "It's not just like... it is" up in conversation.

If you're still thinking using a "push" system (preparing your patients prescriptions in advance, and letting them know they're ready when they're due) sounds like a good idea. It's not just "like" a good idea, for everyone’s sake. I'd be very surprised if anyone has waited more than 20 minutes in our pharmacy for an

extensive acute or last minute prescription in the last three years. That is with the proviso that we hadn't queries for the prescriber, or had a stock issue/shortage, which would be discussed with the patient to keep them in the loop. Nor should they have to. I should note that we have an excellent counter person and lead tech who are constantly scanning and touching base with people about what they're in for, or if there's any queries to discuss (for example, if they step out to the shop next door and return). How we might operate additional services on top of our supposed core competencies (clinical review, dispensing, accuracy checking, etc) remains to be seen in this environment. If we can't even get a four-item prescription out within the hour, then many of us could have a way to go to manage and incorporate this successfully into the service mix in our communities, with any reasonable level of service.

I am cautiously optimistic as always. Extended services through community pharmacies are not just "like" an excellent idea. I just hope that they're looked at, and funded, taking in the bigger picture of our business model. Pharmacies come under the drugs budget, rather than the primary care budget, bizarrely. Any increasing service level, clinical scope and professional scope for pharmacists needs to be uncoupled from "the more labels you stick on boxes in a day, the more the pharmacy gets paid in order to pay you". We presently have none of the perks of paid leave, practice supports, and so much more that's in the GP contract. So, if you want more pharmacy services, you will ultimately need more pharmacists, who don't come cheap, but can bring astounding value to our primary care setting and for the communities we serve. ●

COMMON NUTRITIONAL PROBLEMS IN IRELAND

How food choices can prevent them

Ireland like other developed countries, faces several common nutritional challenges. Nutrition plays a vital role in overall health, and addressing these problems is crucial to ensure the wellbeing of the population. This article will try to shed light on some of the most prevalent nutritional problems encountered and how some simple food choices and habit changes relating to food can help prevent them.

THE TOP NUTRITION - RELATED HEALTH PROBLEMS

1. OBESITY

Obesity has become a major public health concern in Ireland over the past few decades. A sedentary lifestyle, unhealthy dietary habits, and easy access to highcalorie, processed foods contribute to the rising prevalence of obesity. This condition increases the risk of chronic diseases such as heart disease, diabetes, and certain cancers.

2. VITAMIN D DEFICIENCY

Ireland's location and climate contribute to significant vitamin D deficiency in the population. With limited sunlight during the winter months and low dietary intake of vitamin D-rich foods such as oily fish and fortified dairy products, many individuals fail to meet their vitamin D requirements. High-risk groups include infants, pregnant women, the elderly, and those with limited sun exposure.

3. IRON DEFICIENCY ANAEMIA

Iron deficiency anaemia is a common nutritional problem, particularly among

children, women of childbearing age, and vegetarians. Insufficient intake of iron-rich foods, poor iron absorption, and blood loss due to menstruation or other causes contribute to this problem. Men on average need 8.7mg of iron a day, while women on average need 14.8mg a day. Many get enough iron from their diet; small amounts of iron are lost from

our body in urine, faeces, and dead skin cells. Much more is lost if blood is lost, which is why women who have heavy periods are more at risk of anaemia.

HOW TO ENSURE YOU GET ENOUGH IRON IN YOUR DIET?

Meats, especially liver, followed by beef are the best sources of iron. Most seafood, especially oysters, are also good sources of iron. Vegetables and fruit with the highest levels of iron are sundried tomatoes (9mg per 100g), dried apricots (6mg per 100g), fresh parsley (6mg per 100g), cooked spinach (3.5mg per 100g), coconut (3.3mg per 100g), olives (3.3mg per 100g), and raisons (3mg per 100g).

Vitamin C helps the body to absorb iron. Thus, eating fruits or vegetables high in vitamin C in addition to those high in iron helps make the iron foods more effective. Good sources of vitamin C include peppers, sweet potatoes, oranges, and kiwi fruit. Some drinks reduce the absorption of iron from the digestive tract. Phosphates found in carbonated soft drinks can decrease iron absorption. Tea and coffee contain polyphenols which bind to iron and make it harder to absorb. People prone to iron deficiency should cut down on fizzy drinks, tea, and coffee to increase their iron levels. It is very unlikely to overdose on iron from diet alone. Normally, the only cases of iron overdose are due to the use of iron supplements.

4. LOW FRUIT AND VEGETABLE INTAKE

Despite the numerous health benefits associated with fruit and vegetable consumption, it remains a challenge for many people in Ireland to meet the recommended intake. Factors such as cost, availability, and personal food preferences can contribute to this problem. Solutions include a varied and balanced diet, use of local and seasonal produce, and practical tips

for incorporating fruits and vegetables into daily meals.

5. EXCESSIVE SALT INTAKE

High salt consumption is prevalent in Ireland and is associated with an increased risk of hypertension and cardiovascular diseases. Many Irish individuals unknowingly consume excess salt through processed foods, takeaways, and restaurant meals. Solutions include reading food labels, choosing low-sodium alternatives, cooking meals from scratch,

and raising awareness about the health risks associated with excessive salt intake.

6. INADEQUATE FIBRE INTAKE

Low fibre intake is a common problem in Ireland, resulting from a high consumption of refined carbohydrates and processed foods. Insufficient fibre intake can lead to constipation, diverticular disease, and an increased risk of chronic diseases like colorectal cancer. Healthcare providers should encourage the consumption of whole grains, fruits, vegetables, legumes, and nuts to increase fibre intake. Additionally, they can provide practical tips to help individuals incorporate more fibre-rich foods into their diet.

7. MALNUTRITION

Malnutrition can occur due to inadequate intake of essential nutrients or imbalanced diets. It affects people of all ages, with particular concern for older adults and vulnerable groups such as children and those on low incomes.

8. CARDIOVASCULAR DISEASE

Poor nutrition, including diets high in saturated fats, salt, and sugar, can contribute to the development of cardiovascular diseases such as high blood pressure, heart disease, and stroke.

9. TYPE 2 DIABETES

The incidence of type 2 diabetes is on the rise in Ireland, partly due to unhealthy eating habits and sedentary lifestyles. Poor nutrition and excessive consumption of sugary foods and drinks play a significant role in the development of this condition.

Insufficient fibre intake can lead to constipation, diverticular disease, and an increased risk of chronic diseases like colorectal cancer

10. FOOD ALLERGIES AND INTOLERANCES

Many people in Ireland suffer from food allergies or intolerances, including coeliac disease, lactose intolerance, and nut allergies. These conditions require careful dietary management to avoid triggering symptoms or allergic reactions.

11. DENTAL

PROBLEMS

Frequent consumption of sugary foods and beverages can lead to tooth decay, cavities, and gum diseases. Poor oral health can have a significant impact on overall wellbeing.

12. GASTROINTESTINAL

ISSUES

Unhealthy food choices such as highfat and processed foods, can contribute to gastrointestinal problems like constipation, bloating, and irritable bowel syndrome (IBS).

13. PERNICIOUS ANAEMIA

I discussed Iron deficiency anaemia earlier, but there are some other nutritional reasons for a deficiency in red blood cells. For example, folic acid and vitamin B12 are also needed to produce red blood cells, so insufficient B12 and folic acid in the diet can lead to a drop in red blood cells. Anaemia caused by vitamin B12 deficiency is called pernicious anaemia. Not eating enough foods that contain vitamin B12 is a common cause. A vegetarian or vegan diet can cause B12 deficiency as vitamin B12 is only found in foods of animal origin such as meat, fish, eggs, and milk. Another cause of vitamin B12 deficiency is a lack of a protein called intrinsic factor, a protein produced by the stomach lining that helps with vitamin B12 absorption in the small intestine. The exact cause of loss of intrinsic factor is not fully understood, but there is thought to be a genetic reason (meaning it runs in families). Older people and young women are particularly at risk of vitamin B12 deficiency. Many of the symptoms of pernicious anaemia are like other types of anaemia including tiredness,

paleness, palpitations, breathlessness, dizziness, and fainting. Other signs may include a sore tongue, loss of appetite, weight loss, and tingling or numbness in the hands and feet. A blood test from the GP can confirm diagnosis. If diagnosed with low vitamin B12 levels, the GP may prescribe vitamin B12 injections, and the advice will be to eat more foods containing vitamin B12, for example, eggs and meat.

THE WORST FOODS TO AVOID

1. HIGHLY PROCESSED FOODS

Processed foods often contain excessive amounts of added sugars, unhealthy fats, sodium, and artificial additives. Regular consumption has been linked to obesity, heart disease, and diabetes. Examples include sugary cereals, microwave meals, and packaged snacks.

2. SUGARY DRINKS

Drinks like fizzy drinks, fruit juices, energy drinks, and sweetened teas are loaded with added sugars, but are low in nutritional value. Regular consumption can contribute to excess weight gain, diabetes, tooth decay, and an increased risk of chronic diseases.

3. TRANS FATS

Found in many fried and processed foods, trans fats are artificially created during food processing. They raise LDL cholesterol levels, lower HDL cholesterol levels, increase inflammation, and can significantly raise the risk of heart disease. These fats are often present in fast foods, packaged baked goods, and margarine.

4. REFINED GRAINS

Refined grains such as white bread, white rice, and refined pasta, have been stripped of their fibre and nutrients. Eating excessive amounts of refined grains has been linked to obesity, type 2 diabetes, and an increased risk of heart disease. Opting for whole grains is generally a healthier choice.

5. PROCESSED MEATS

Processed meats contain high amounts of preservatives, sodium, and unhealthy fats. Regular consumption of processed meats has been linked to an increased risk of colorectal cancer, heart disease, and type 2 diabetes. Examples include deli meat, sausages, hot dogs, and bacon. Moderation is key, and a balanced diet with a variety of whole, unprocessed foods is generally recommended for maintaining good health.

GOOD FOOD CHOICES THAT HAVE A POSITIVE EFFECT ON HEALTH

When considering the best food choices from a positive health perspective, it is essential to focus on nutrient-dense foods that provide a wide range of vitamins, minerals, and other beneficial compounds. Here are five examples:

1. LEAFY GREENS AND CRUCIFEROUS VEGETABLES

Vegetables like spinach, kale, broccoli, and cauliflower are packed with essential nutrients, fibre, and antioxidants. They are low in calories and can help promote weight management, protect against chronic diseases, and support digestive health.

DRACMA: Diagnosis and Rationale for Action against Cow’s Milk Allergy; GOS: Galacto-Oligosaccharides; FOS: Fructo-Oligosaccharides

1. Jensen SA et al. World Allergy Organization Journal. Diagnosis and Rationale for Action against Cow’s Milk Allergy. 2022;15:100668. 2. Burks AW et al. Pediatr Allergy Immunol. 2015;26(4):316–22. 3. Candy DCA et al. Pediatric Res. 2018;83(3):677–86. 4. Fox AT et al. Clin Transl Allergy. 2019;9(1):5. 5. Chatchatee P et al. JACI. 2021;0091-6749(21)01053-8 6. Van der Aa LB et al. Clin Exp Allergy. 2010;(40):795–804. 7. Martin R et al. Benef Microbes. 2010;1(4):367–82. 8. Wopereis H et al. Pediatr Allergy Immunol. 2014;25:428–38. 9. West CE et al. J Allergy Clin Immunol. 135(1):3–13. 10. Walker WA et al. Pediatr Res. 2015;77(1):220-8.

IMPORTANT NOTICE: Breastfeeding is best. Foods for special medical purposes should only be used under medical supervision. May be suitable for use as the sole source of nutrition for infants from different ages, and/or as part of a balanced diet from 6 months onwards. Refer to label for details.

Nutricia Ireland Deansgrange Business Park, Deansgrange Co. Dublin. Date of publication: March 2023

2. FATTY FISH

Fish such as salmon, mackerel, and sardines are excellent sources of omega-3 fatty acids, which are beneficial for heart health. These fish also provide highquality protein, essential vitamins, and minerals. Aim for at least two servings of fatty fish per week.

3. WHOLE GRAINS

Including whole grains like quinoa, brown rice, oats, and wholewheat in the diet is beneficial due to their high fibre content and essential nutrients. They provide sustained energy, aid digestion, and may lower the risk of heart diseases, type 2 diabetes, and certain cancers.

4. BERRIES

Berries like blueberries, strawberries, and raspberries are rich in antioxidants, fibre, and vitamins. They have been linked to a reduced risk of chronic conditions, including heart disease, certain cancers, and age-related cognitive decline. Incorporate them into smoothies, yogurt, or enjoy them as a snack.

5. LEGUMES

Beans, lentils, and chickpeas are excellent plant-based sources of protein, fibre, vitamins, and minerals. They are low in fat and can contribute to heart health, blood sugar control, and weight management. Adding legumes to salads, soups, or making plant-based meals with them is a great idea. This list is not exhaustive, and it's essential to have a diverse diet that includes a variety of fruits, vegetables, lean proteins, and healthy fats to meet nutritional needs.

TIPS TO HELP PREPARE HEALTHY FOOD CONVENIENTLY

1. Plan meals: Invest some time in creating a weekly meal plan. This will help organise groceries and ensure nutritious meals are ready throughout the week. Always have a list for the supermarket and do not do the supermarket shop while hungry, as shopping while hungry increases the temptation to pick up unhealthy food choices.

2. Batch cooking: Cook a larger quantity of food and store meal-sized portions in the fridge or freezer. This way, they can simply be reheated on busy days, saving time and effort.

allow addition of nutritious ingredients like vegetables.

6. Stock up on healthy snacks: Keep the kitchen and fridge filled with healthier snack options like cut fruits, nuts, yogurt, or pre-made smoothies rather than the likes of crisps, sweets, chocolates, and fizzy drinks. This will make it easy to grab something nutritious when in a hurry.

7. Invest in time-saving kitchen tools: Time-saving gadgets like a food processor or a good blender can make meal preparation quicker and easier. Air fryers can cook foods quickly without the need to wait for ovens to heat up.

3. Use a slow cooker: This appliance allow preparation of healthy meals with minimal effort. The idea is to add the ingredients, set it, and let it cook while focusing on other tasks.

4. Prepare pre-cut vegetables: Spend some time washing, cutting, and storing pre-cut vegetables in the refrigerator. This will make it easier to add them to meals, whether in salads, stir-fries, or as a side dish.

5. Opt for one-pot meals: Simplify the cooking process by preparing one-pot meals like soups, stews, or stirfries. They require fewer dishes to clean and are convenient to reheat and they

8. Embrace meal kits or meal delivery services: Consider using meal kits or a reliable meal delivery service that offers healthy options. This way, you can save time on meal planning, grocery shopping, and still enjoy nutritious meals. Convenience and health don't have to be mutually exclusive. By implementing these tips, it is possible to prepare tasty and nourishing meals without sacrificing convenience. ●

References upon request

Written by Eamonn Brady, MPSI (Pharmacist). Whelehans Pharmacies, 38 Pearse St and Clonmore, Mullingar. Tel 04493 34591 (Pearse St) or 04493 10266 (Clonmore). www.whelehans.ie Eamonn specialises in the supply of medicines and training needs of nursing homes throughout Ireland. Email: info@whelehans.ie.

When considering the best food choices from a positive health perspective, it is essential to focus on nutrient-dense foods that provide a wide range of vitamins...

INFANT PAIN MANAGEMENT

Donna Cosgrove, PhD, takes a look at the management, treatment and diagnosis of infant pain and how the pharmacist can improve the quality of life for these patients

The modern thinking that pain is negative, and the aim to alleviate it with medical management, was not common in earlier times. In the 19th Century, pain was seen as useful in diagnosis and in treatment because it was associated with the body’s reaction to healing. Up until as recent as the 1980s, there was even a scepticism about the existence of infant pain.1 During this time, parent activism and paediatric pain research resulted in this view being challenged. Research indicates that infants experience pain similar to adults, possibly more intensely. This can lead to negative long-term consequences if the pain is not adequately managed.2 Noxious stimulation does not elicit the same pattern of activity in newborns as it does in adults. The immaturity of the synaptic circuits means that the infant pain experience is more diffuse and less spatially focused than in adults, and also under reduced endogenous control. This means it is potentially more powerful.3 Even now, paediatric pain is less understood, and less adequately managed, compared to that of older children and adults.4 Analgesic protocols designed for adults and older children cannot be scaled down for infants. This is due, not just to differing metabolism, but also because many pharmacological targets of analgesic medication are still developing and changing during infancy.3

PAIN ASSESSMENT IN INFANTS

In all patients, appropriate, frequent, and documented assessment of pain is vital to satisfactory pain control. Selfreporting of the patients’ pain levels is preferred due to the subjective nature of the experience, however, this is not possible

in infants or non-communicative children. Additional assessment approaches, eg, pain assessment tools can help. The pain score from any assessment should not be viewed in isolation: Information such as family feedback, patient satisfaction, and physiological parameters also need to be

considered.4 Infants have no language, so measuring pain expression in a reliable manner is a long recognised challenge. Assessment tools use combinations of behavioural measures, eg, leg movements and crying; physiological measures such as heart rate and oxygen saturation; and

characteristic facial expressions of pain. An example of one of these, the FLACC pain assessment tool is shown in Table 1. It is a behavioural pain assessment scale used for nonverbal or preverbal patients who are unable to self-report their level of pain. No pain-to-mild pain is indicated by a score of zero-to-three, moderate-to-severe is indicated by a score of four-to-10.5

Untreated pain in infancy can lead to lasting consequences that persist into adulthood. This is because tissue injury in infancy may alter the normal course of development, leading to alterations in somatosensory processing and sensitivity to pain.3 Inadequate analgesia in infants leads to adverse perioperative outcomes, but this must be balanced with the risk of adverse effects with analgesic administration. Because controlled trials in infants and neonates are limited due to ethical and methodological constraints, published evidence of infant pain management is limited. Postop, procedural, and intensive care pain management in infants is mostly based on clinical experience.

PHARMACOLOGICAL MANAGEMENT OF INFANT PAIN

Immunisations (at two, four, six, 12, and 13 months in Ireland) are likely the most common painful events in infancy.2 Data suggests that as many as 95 per cent of babies will have been given paracetamol by the time they are nine months old.6 While paracetamol is universally recommended for use from neonatal life onwards, the maximum daily dose beyond this varies from 60mg/kg/day in New Zealand and the United Kingdom (UK) to 90mg/kg/day in the United States (US). Ibuprofen use in the US is only recommended from the age of six months, compared with three months in the UK and Ireland, and with a higher maximum daily dose compared to the UK and Ireland. Sugar free versions of paracetamol and ibuprofen preparations are preferable for infants because the ones that contain sugar are more damaging to teeth. Over-the-counter (OTC) paracetamol preparations are safe for children aged two months and older, and OTC ibuprofen is safe for children aged three months and older who weigh more than 5kg.7

Paracetamol has traditionally been recommended as a first-line treatment for fever and pain in children. Despite the widespread use of these medications in a young paediatric population, some scientific literature cautions against the use of ibuprofen in, for example, young infants in terms of acute kidney injury risk, especially where the baby is dehydrated; and in primary

investigating the risks of using paracetamol and ibuprofen in children, information about specific adverse effects on children under two, and particularly infants under six months, is sparse.

In terms of making the choice between ibuprofen and paracetamol in infants, studies comparing the safety and efficacy of ibuprofen and paracetamol show that ibuprofen is at least as effective in analgesia as paracetamol, and more efficacious as an antipyretic. No differences in safety between the two drugs were reported. However, the populations included in these studies were quite broad: Children aged from one month to 18 years, meaning that these conclusions were based on a more general paediatric population and may not be specifically applicable to infants and younger children.

Varicella infection (chicken pox) where ibuprofen has been associated with a twoto-five-fold risk in the odds of developing a soft tissue infection. Growing evidence also suggests a link between paracetamol use in children and the development of asthma and atopic disease. Although there are studies

INDICATOR SCORE 0

Face No particular smile or expression

Legs Normal position or relaxed

Activity Lying quietly, normal position, moves quietly

Cry No cry (awake or asleep)

Consolability Content, relaxed

Authors of a 2020 meta-analysis6 identified 19 studies with data specifically available to compare the treatment of fever or pain with paracetamol or ibuprofen in children and infants under two years old. Compared with paracetamol, ibuprofen has a superior antipyretic effect at less than four hours and at four-to-24 hours (but the superiority over paracetamol did not continue beyond 24 hours). Disappointingly, data for analgesia outcomes was not

SCORE 1

Occasional grimace or flow, withdrawn, disinterested

SCORE 2

Frequent to constant quivering chin, clenched jaw

Uneasy, restless, tense Kicking, or legs drawn up

Squirming, shifting back and forth, tense

Moans or whimpers, occasional complaint

Reassured by occasional touching, hugging, or being talked to, distractible

Arched, rigid or jerking

Crying steadily, screams or sobs, frequent complaints

Difficult to console and comfort

Table 1: FLACC pain assessment tool, suggested for two months to seven years. Each indicator category is scored from zero-to-two, giving a total score of zero-to-105

Paracetamol has traditionally been recommended as a firstline treatment for fever and pain in children

Infant Pain

available for pain outcomes within four hours of treatment. Evidence suggests that ibuprofen shows a benefit over paracetamol in pain outcomes from four-to-24 hours.

In terms of safety, both drugs were found to have a similar safety profile in terms of serious adverse events, which were overall uncommon or rare. Most studies reported no adverse events. In this 2020 metaanalysis, authors conclude there was not enough information to compare the safety of paracetamol and ibuprofen in the under six months old cohort. In the only large scale RCT including infants younger than six months (The Boston Fever Study), which assessed the safety of ibuprofen for treating fever, none of the 319 infants aged one-tosix months were hospitalised for acute GI bleeding, acute kidney failure, asthma, or bronchiolitis, and risk of hospitalisation did not matter by antipyretic choice. No studies comparing ibuprofen and paracetamol and neonates are available so caution should be used when extrapolating results to this age group.

The authors of the review found no evidence to support the perceived risk of ibuprofen, or indeed paracetamol, causing toxic kidney effects in infants even with concomitant dehydration. There was insufficient evidence to support or refute the hypothesis that ibuprofen is responsible for an increased risk of serious bacterial infection in children (specifically invasive group A streptococcal skin infection in the context of primary Varicella infection). Results may be confounded because ibuprofen is usually used in more severe illness.6

Opioids are commonly used in the hospital setting in neonates and infants, with multimodal analgesia increasingly being used.3 World Health Organisation’s (WHO) guiding principles for the management of post-operative acute pain4 advises:

 Use of oral medication where possible;

 Administration of analgesics at regular intervals;

 Administration based on pain severity assessed by a pain intensity scale;

 Dosing tailored to the individual patient;

 Attention to detail throughout prescribing and administration.

NON-PHARMACOLOGICAL MANAGEMENT OF INFANT PAIN

Non-pharmacological pain management options in older children and adults include massage, heat compresses, ice packs, repositioning, or physical activity as appropriate.4 Clearly nonpharmacological pain management measures are often not suitable for infants because they require a level of cognitive functioning not yet developed, for example, breathing training, relaxation, and imagery. In neonates and babies, sucrose, non-nutritive sucking and breastfeeding all reduce distress and the negative behavioural response to procedural interventions, for example, heel sticks, insertion of intravenous lines, and nasogastric tubes. 3 Parental presence, reassurance, and distraction are also useful to reduce distress. In a study examining the effects of distraction in infants aged two months to two years, distraction was observed to reduce distress associated with immunisation (injection). Infants were scored using the Measure of Adult and Infant Soothing

and Distress (MAISD), a behavioural observation rating scale developed to evaluate the behaviours of infants, their parents, and nurses during painful paediatric medical procedures. Parents were instructed in distraction techniques for the child. During the immunisation, a movie (either Sesame Street or Teletubbies) was played. Parents were encouraged to redirect the infant’s attention to the movie (for example, ‘‘Big bird is singing you a song!’’ or ‘‘Look at that!’’). Infants showed low levels of “anticipatory” distress prior to injection, but clearly distress increased sharply during the injection. Infants at this stage of the immunisation procedure may not be receptive to distraction techniques. However, distraction was found to be very effective in decreasing distress after the injection during the recovery period, as opposed to a “typical care” condition where the infant's distress actually increases in the minutes following the injection. Distraction techniques are a cost-effective, time-efficient, and easyto-use intervention that can help comfort infants during these distressing visits.2 ●

REFERENCES

1. Rodkey EN, Riddell RP, 2013. The infancy of infant pain research: The experimental origins of infant pain denial. The Journal of Pain, 14(4), 338-350.

2. Cohen LL, MacLaren JE, Fortson BL, Friedman A, DeMore M, Lim CS, et al, 2006. Randomised clinical trial of distraction for infant immunisation pain. Pain, 125(1-2), 165-171.

3. Fitzgerald M, Walker SM, 2009. Infant pain management: A developmental neurobiological approach. Nature Clinical Practice Neurology, 5(1), 35-50.

4. Gai N, Naser B, Hanley J, Peliowski A, Hayes J, Aoyama K, 2020. A practical guide to acute pain management in children. Journal of Anaesthesia, 34, 421-433.

5. National Health Service, 2021. Paediatric Clinical Practice

Guideline: Management of acute pain in children. Available at: www.bsuh.nhs.uk/library/wpcontent/uploads/sites/8/2021/07/ Paediatric-prescribing-guidelineAcute-Pain-Management-2021.pdf

6. Tan E, Braithwaite I, McKinlay C J, Dalziel SR, 2020. Comparison of acetaminophen (paracetamol) with ibuprofen for treatment of fever or pain in children younger than two years: A systematic review and meta-analysis. JAMA network open, 3(10), e2022398-e2022398.

7. National Health Service, 2021. Medicines for babies and children. Available at: www.nhs.uk/conditions/ baby/health/medicines-for-babiesand-children/#:~:text=You%20 can%20give%20paracetamol%20 to,pharmacist%20before%20 giving%20them%20ibuprofen

This information is intended for healthcare professionals only

WHY MEDICATE? TRY NUTRITION FIRST

EAACI 2022 recognises that medications are often inappropriately used in the treatment of GER and GERD in infants1

APTAMIL ANTI-REFLUX is a unique formulation for the dietary management of reflux and regurgitation in formula-fed infants

Thickened with carob bean gum

Significantly reduces reflux episodes and regurgitation severity scores2

Helps to normalise oesophageal pH3

Greater viscosity in the stomach compared to starch-based feeds4

IMPORTANT NOTICE: Breastfeeding is best. Aptamil Anti-Reflux is a food for special medical purposes for the dietary management of frequent reflux and regurgitation. It should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. Suitable for use as the sole source of nutrition for infants from birth and as part of a weaning diet from 6-12 months. This product should not be used in combination with antacids or other thickeners and is not suitable for premature infants. Refer to label for details.

PUTTING YOUR BEST FOOT FORWARD

With regular foot care, patients can manage everyday foot issues like calluses, blisters, and fungus infections with help from their pharmacist, but older adults need to be mindful about certain problems that can impede their foot health, like diabetic foot, writes

INTRODUCTION

Humans have used footwear for about 30,000 years, originally with the aim of protecting the foot.1 On average, we walk about 100,000 miles in our lifetime, so it is not surprising that many of us require treatment for foot conditions due to wear and tear, among other things. Foot pain affects

about 30 per cent of the population. It can impact quality-of-life, as well as some foot problems associated with disability and fall-related morbidity. 2

In particular, ageing is associated with changes in foot characteristics, which impact foot pain and functional ability. Women are more likely to have poor foot health compared to men.

Donna Cosgrove, PhD

In order to help keep their feet healthy, people should be advised to: 3

 Wear properly fitting shoes.

 Wear flip-flops in, eg, changing rooms and showers to avoid verrucas and athlete’s foot.

 Keep the feet clean, dry them properly after a bath, shower or swimming, and let air get to the toes when possible.

 Wear cotton socks and change them everyday.

 Alternate between different pairs of shoes so that they have a chance to dry out before being worn again.

 Don’t share towels when they have an infectious foot problem such as a verruca, athlete’s foot, or a fungal nail infection.

Many common ailments can be adequately managed with over-thecounter products (OTC) products.

FOOTWEAR

Incorrectly fitted footwear leads to a host of problems including structural foot disorders, corns, and calluses. As foot morphology can be highly variable from person to person, finding the correct fit from an “off the shelf” shoe can be tricky. Authors of a review estimating the prevalence of incorrectly fitted footwear and its effects, which included 18 studies, found that between 63 and 72 per cent of people wore an incorrect shoe fit, based on length or width.1 A strong association was observed between footwear that was too tight and foot pain, with between 84 and 91 per cent of people with tight shoes reporting pain. Incorrectly fitted footwear is also associated with lesser toe (ie, the second to the fifth toes) deformity and the presence of corns in older people. There was also a

strong link between incorrectly fitted shoes in older people with diabetes and current foot ulceration – people with foot ulceration were five-times more likely to be wearing incorrectly fitted shoes than those without ulceration.

For people (like pharmacy staff) who stand for most of the workday, shoes that provide comfort and support are

pain and rubbing on the metatarsal joints, or neuroma (nerve damage). Appropriately structured and supportive shoes are necessary in this kind of work also, because if the foot position is compromised, this can result also in improper positioning further up in the knees, hips, and back. A stable shoe base (and heel counter) can help prevent this.

OLDER PEOPLE

very important. The right shoe size is required for comfort. The shoe should be about a thumb width longer than your longer toe to allow for swelling of the feet, which is likely if standing all day, and the shoe should accommodate the widest part of the forefoot comfortably.4 Too tight or small shoes can cause ingrown toenails, calluses, corns, and

 Properly fitted shoes do not need to be broken in and instead should be comfortable to wear right out of the box

 Shoes should be fitted on both feet during weight bearing, preferably at the end of the day when the feet are most swollen

 Allow a space of half an inch between the end of the shoe and the longest toe. For athletic shoes, allow up to one inch

 Check the width. Adequate room

should be allowed across the ball of the foot. The first metatarsophalangeal joint should be in the widest part of the shoe

 The heel should fit snugly

 Check the fit over the instep. A shoe that laces allows for adjustment of this area

 Orthotics and inserts will change the fit of shoes. Shoes should be fitted while wearing the orthotic

In a Finnish study looking into foot care in older people, 6 participants described the practice of foot selfcare as the following practices: 1) nail cutting; 2) washing the feet; 3) drying the feet; 4) using exfoliators and foot files; 5) soaking the feet in water; 6) moisturising the legs and feet; 7) massaging the feet; 8) exercising the feet; 9) wearing hosiery; and 10) wearing shoes. However, taking care of the rest of the body was prioritised over the feet. Nail-cutting was one of the most difficult self-care activities for participants. Stiffness of the back, old age, and gaining weight impeded the nail-cutting position. Nail-cutting was also the main reason for seeking help for foot care.

DIABETES

Foot complications are a cause of morbidity and mortality in diabetes, as well as leading to an increase in healthcare costs. Incidence of peripheral neuropathy and peripheral arterial disease in diabetes is linked with a higher risk of developing foot ulcers and infection that may lead to amputation.7

Structural deformity, limited joint mobility, microvascular complications, increased levels of glycated haemoglobin

Table 1: Guidelines for proper shoe fit to avoid foot problems5

Foot complications are a cause of morbidity and mortality in diabetes, as well as leading to an increase in healthcare costs

(HbA1C), and onychomycosis are also linked with increased risk for developing a foot ulcer. Adults with diabetes have a 20-times greater likelihood of being hospitalised for non-traumatic lower limb amputation than adults without diabetes. Prevention through education and early and aggressive treatment of foot problems is important for diabetic foot care.

BUNIONS (HALLUX VALGUS)

These are characteristic deformities at the first metatarsophalangeal joint which can lead to osteoarthritis of the joint. 2 There is a higher prevalence of bunions in the female population (female:male ratio of 9:1), which is likely due to both biomechanics (joint laxity/ instability) and shoe wear demands. 8 Conservative treatment typically involves modification of shoe wear with splints, pads, and orthotics; with varying degrees of success. Indications for surgical correction include painful progressive deformity and inhibition of activity or lifestyle.

CORNS AND CALLUSES

These are hyperkeratotic conditions caused by the stimulation of the epidermis through increased pressure or friction, for example, shoes, repetitive movements, and bunions. Treating these conditions involves redistributing forces to allow the skin to heal. Thick, cushioned socks with wide, comfortable shoes with a low heel, and a soft sole that does not rub can help, as well as use of soft insoles/heel pads. Measures like soaking corns and

calluses in warm water to soften them, regularly using a pumice stone/foot file to remove hard skin, and moisturising to help keep skin soft are also useful.9

ONYCHOMYCOSIS

Onychomycosis is a fungal infection of the nail, causing discoloration and thickening of the affected nail plate, and is the most common nail infection worldwide, caused by dermatophytes and non-dermatophytes.10 Microscopy and fungal culture are the gold standard techniques for onychomycosis diagnosis. It has an estimated prevalence of 6-to14 per cent in the general population

of the plantar fascia. 2 It seems likely that plantar fasciitis is not due to inflammation, but rather repetitive microtears in the contracted fascia. The idea that there is no inflammatory mechanism behind the condition could explain why NSAIDs often do not work very well in this condition, and why OTC remedies like heel cups are at least as effective as steroid injections. Studies have shown that OTC shoe inserts are as effective as custom orthotics for improving plantar fasciitis pain.

TINEA PEDIS

and is more common in people with tinea pedis. Oral antifungals have higher cure rates and shorter treatment periods than topical treatments, but have adverse side-effects such as hepatotoxicity and drug interactions.

PLANTAR FASCIITIS

Plantar fasciitis is pain on the bottom of the foot, around the heel and arch. It is due to straining the plantar fascia, which connects the heel to the toes.11 In 80 per cent of cases of plantar fasciitis, symptoms resolve with OTC and home therapies within six months of starting treatment. Successful therapies address biomechanical and environmental factors like a reduced angle of ankle dorsiflexion (raising toes towards shin), prolonged standing, and obesity. Stretching can provide relief because it counteracts shortening

Tinea Pedis, or athlete’s foot, is a fungal infection of the skin caused by dermatophytes, usually Trichophyton rubrum , Trichophyton mentagrophyte, and Epidermophyton floccosum . 12 Over 70 per cent of the population experience athlete’s foot at some stage. Tinea pedis onychomycosis (nail involvement) is more common in older people. Strategies to prevent it include ensuring that the interdigital spaces dry, wearing wellventilated shoes and socks made of natural fibres, and covering the feet when in communal areas. Tinea pedis is successfully treated with both topical allylamines (eg, terbinafine 1 per cent) and azoles (eg, miconazole 2 per cent), with allylamines possibly superior in efficacy to azoles. Topical terbinafine has been found to work more quickly (within one week within many cases), whereas longer use of topical azoles is required.13 Antifungal powder can help keep the interdigital area dry.

WARTS AND VERRUCAS

These are most common in childhood, affecting 20 per cent of children aged four-to-12 years of age. Most (two-thirds) resolve spontaneously within two years. 2 It can take weeks or even months for a wart or verruca to appear after infection. If the wart or verruca breaks up and bleeds, the virus spreads more easily. To help stop the infection spreading:14

 Wash hands after touching a wart or verruca.

 Change socks daily.

Plantar fasciitis is pain on the bottom of the foot, around the heel and arch

 Cover with a plaster when swimming.

 Take care not to cut a wart when shaving.

The aim of treatment is to remove the wart without it returning and without scarring. The main treatments include salicylic acid and cryotherapy. There is not much evidence to indicate which of these types of OTC treatment is superior to the other.15 Overall, the evidence for the use of salicylic acid products is the most consistent.

XEROSIS

Xerosis is dryness in the epidermal layers of the skin which results in scaling, flaking and itching.16 Topical moisturisers are beneficial in managing

REFERENCES

1. Buldt AK, Menz HB, 2018. Incorrectly fitted footwear, foot pain, and foot disorders: A systematic search and narrative review of the literature. Journal of foot and ankle research, 11(1), 1-11.

2. Available at: www.aafp.org/pubs/ afp/issues/2018/0901/p298.html

3. National Pharmacy Association, 2019. Footcare. Available at: www.npacpdhub.co.uk/444273footcare-2019

4. Available at: https://respod. co.nz/2020/04/17/supportingour-pharmacists-and-pharmacytechnicians-some-tips-for-those-longdays-on-your-feet/

5. Bedinghaus JM, Niedfeldt MW, 2001. Over-the-counter foot remedies. American Family Physician, 64(5), 791-797.

6. Miikkola M, Lantta T, Suhonen R, Stolt M, 2019. Challenges of foot self-care in older people: A qualitative focus-group study. Journal of Foot and Ankle Research, 12(1), 1-10. Available at: www.ncbi.nlm.nih.gov/

pmc/articles/PMC6339366/.

7. Embil JM, Albalawi Z, Bowering K, Trepman E, 2018. Foot care. Canadian Journal of Diabetes, 42, S222-S227. Available at: www.canadianjournalofdiabetes. com/article/S1499-2671(17)308304/fulltext

8. Hart ES, Deasla RJ, Grottkau BE, 2008. Current concepts in the treatment of Hallux valgus. Orthopaedic Nursing, 27(5), 274-280.

9. National Health Service, 2022. Corns and calluses. Available at: www.nhs.uk/conditions/cornsand-calluses/

10. Gupta AK, Stec N, Summerbell RC, Shear NH, Piguet V, Tosti A, Piraccini BM, 2020. Onychomycosis: A review. Journal of the European Academy of Dermatology and Venereology, 34(9), 1972-1990.

11. National Health Service, 2022. Plantar fasciitis. Available at: www. nhs.uk/conditions/plantar-fasciitis/

12. Ward H, Parkes N, Smith C, Kluzek S, Pearson R, 2022. Consensus for the treatment of tinea pedis: A systematic

this skin dryness with the most beneficial being those that contain higher urea concentrations (40 per cent).

FOOTCARE IN PHARMACY

People frequently visit community pharmacies for foot care advice and treatments of related foot conditions. Many of these can be sufficiently treated, or even prevented, with advice and products from the pharmacy. Older people and people with diabetes are particularly susceptible to foot problems and may appreciate some time to learn more about foot care. ●

review of randomised controlled trials. Journal of Fungi, 8(4), 351. Available at: www.mdpi.com/2309608X/8/4/351/html

13. Thomas B, Falk J, Allan GM, 2021. Topical management of tinea pedis. Canadian Family Physician, 67(1), 30-30.

14. National Health Service, 2020. Warts and verrucas. Available at: www.nhs.uk/conditions/warts-andverrucas/

15. Kwok CS, Gibbs S, Bennett C, Holland R, Abbott R, 2012. Topical treatments for cutaneous warts. Cochrane database of systematic reviews, (9). Available at: www.cochranelibrary.com/cdsr/ doi/10.1002/14651858.CD001781. pub3/full

16. Parker J, Scharfbillig R, J ones S, 2017. Moisturisers for the treatment of foot xerosis: A systematic review. Journal of Foot and Ankle Research, 10(1), 1-10. Available at: https://jfootankleres. biomedcentral.com/articles/ 10.1186/s13047-017-0190-9

AN INTRODUCTION TO THE WORLD OF THE FUTURE

Many years ago, the Mercedes A-class was the best-selling model in the Mercedes range in the UK. Now their bestselling model worldwide is the GLC. It is a sign of the times that their best-seller is no longer a small hatchback, but an SUV. It is also a sign of the times that we are having difficulty fitting our cars into the car park spaces in hotel car parks and apartment blocks that were sketched out nearly 30 years ago. In Ireland, we remain thinking small, as the Mercedes best-seller (beepbeep.ie) is the GLA,

which is their smallest SUV.

The GLC is a car Mercedes have to get right. In line with expectations, it is only available as a hybrid, whether plug-in or mild hybrid, with its 48-volt starter/ generator. This translates into real-life starting with no discernible noise or sensation of engine firing.

I picked up the car from Dublin fully charged. I got home to Drogheda at motorway speeds and was driving around all the following day before I managed to deplete the battery (I got about 95kms of range, Mercedes say 129kms) and then the

engine gently woke up. Only for the revcounter moving I would not have known. From then on, driving was a mix of electric and petrol propulsion. My wife, sitting beside me, never knew at any time when the petrol engine was working, unless I floored it. Even then it remained refined.

My impression of the GLC was that it was big. It is 6cms longer than the outgoing model, not that you’d notice. It has a larger rear overhang giving it increased (+70 litres) boot capacity despite the elevated floor to accommodate the electrical stuff. Many

Dr Alan Moran reviews the Mercedes GLC, a car the manufacturer has to get right

years ago, we talked about drag coefficients (Cd) for cars. The GLC has an excellent value for an SUV of 0.29Cd.

I’m told that the GLC is at home on any terrain, but I’m not taking a €91,000 Mercedes across any sandbanks or muddy fields any time soon. For those who need to know, towing capacity is 2.5 tonnes. Let me say that I know a family who used to swear by Land Rovers and are now loving their new GLC, as well as a builder who travels to Dublin daily entirely on electric power. And yes, he tops it up on site in Dublin.

At home, I plugged the GLC into a threepin socket in the garage. It told me it would take 17 hours to fill from empty. If I had the Mercedes wall adapter it would have been substantially less. Negotiate for one of these with your purchase.

The information I got said that the specification has been significantly upgraded with over €16,000 of extras compared to the outgoing model. Don’t expect a list from me, but I am also told that the MBUX infotainment system is even more intelligent. It seemed to understand me better than Alexa at home. By that I mean spoken commands, not my moods….

There have been lots of improvements

in vehicle technology over the years, with some lifesavers such as the antilock brakes, airbags, and stability control systems. Later examples include radar distance control and active brake assist, which can activate if I drive too close to the car in front.

Engine choice is four-cylinder petrol or diesel, with a further choice of mild or plug-in hybrid. Power ranges from 190kW (250bhp approximately) and 400Nm of torque (that’s lots) in the petrol GLC to 195kW and 450Nm in the diesel, and both add 17kW and 200Nm of torque with the starter/generator electric motor. Provided it is fully charged, of course.

All cars have nine-speed automatic gearboxes and all-wheel drive.

The almost two-tonne GLC has a 0-100kmh time of 6.7 seconds and a top speed of 218km/h. More good news, road tax is €140. In my opinion, when it comes to hybrid, the only way is plug-in.

After all that, the GLC is a wonderful introduction to the world of the future. It is large, pleasant, and when used intelligently, it is economical and quiet when under electric or petrol power.

And for those who need to get to Cork or Kerry from Dublin without stopping, there’s a backup engine you can use. ●

The almost twotonne GLC has a 0-100kmh time of 6.7 seconds and a top speed of 218km/h

WHAT EXACTLY DOES A LOW LEVEL OF ALCOHOL CONSUMPTION MEAN?

Tom Doorley reports on the revelation that 'one or two' drinks a day may bring long-term benefits

Having adopted a policy of drinking less wine, but better quality, quite a while ago, more recently I’ve been avoiding alcohol during the week and finding it surprisingly easy. There are some foods that I tend to avoid – steak and pasta, for example – but not many. I sleep better and can read for a lot longer at bedtime. Overall, there’s a pleasant sense of wellbeing and even virtue!

Now I read that researchers at Massachusetts General Hospital have found evidence that low levels of daily alcohol consumption may protect against cardiovascular events. It has long been established that small amounts of alcohol help to suppress the amygdala’s reaction to threats, but this paper suggests that “one or two” alcoholic drinks every day may have long-term benefits.

“When the amygdala is too alert and vigilant, the sympathetic nervous system is heightened, which drives up blood pressure and increases heart rate,” according to Cardiologist Dr Ahmed Tawakol, the lead researcher. “If the stress is chronic, the result is hypertension, increased inflammation, and a substantial risk of obesity, diabetes, and cardiovascular disease.”

The problem with research into what

people swallow is that we have to take their word for it, there being some 50,000 participants in this instance. It’s well-known that we’re inclined to tell researchers what they want to hear, and we all know that the words “one or two glasses of wine” doesn’t contain any indication of what size of drinking vessel is involved. Often, “one or two” could easily mean, in reality, three or four. Of course, there’s a thin line between this supposedly beneficial effect and less desirable ones in terms of how much alcohol is appropriate, and there is no agreement on the amount.

Our nationally dysfunctional relationship with alcohol is complex, no doubt, but our tradition of keeping it quite separate from food must be a big factor. The Spanish, like the French, consume plenty of wine (but less than they used to), but most bars offer tapas or pintxos, often free of charge, to drinkers. Irish people who enjoy “a rake” of pints, would be lucky to be offered a few crisps or dry roasted peanuts.

Under my new wine regime, the question of what to drink with the evening meal had to be addressed. We have excellent tap water, thanks to having our own very deep well, and there’s always a bottle of sparkling mineral water in the fridge. A large glass of this, sharpened up with the juice of half a lime, is my usual beverage. I have been known to have an occasional sugar-free water kefir (I’m a fan of the Dublin-made King of Kefir) and very rarely a can of alcohol-free beer, such as Run Wild and Punk AF IPAs and Aldi’s Roadworks Early Start. But, to be honest, I’m happy to stick with my lime-scented fizzy water.

Lunching at Derry and Sallyanne Clarke’s The Club at Goffs, the sommelier brought me a glass of Natureo Muscat by Torres and it was actually excellent with a dish of scallops. The problem with such alcohol-free wines, apart from the fact that most don’t taste even remotely like wine, is the sweetness that’s added in order to fill the gap left by the alcohol. However, in this instance

it was ideal with the scallops, a little like an off-dry Alsace wine.

One of the better non-alcoholic wine ranges is called Null, but I find the whites are better than the reds. The Riesling is quite varietal and fairly dry; it makes a reasonable glass of ‘wine’ with some simply cooked seafood but, ironically, whenever I’ve tried it, I have not been tempted to have a second glass. I don’t have the same issue, as a rule, with the real stuff.

2,4,6-tribromoanisole, substances that are detectable in very few parts per million. They can occur when chlorine compounds come into contact with mould and steam and this can happen when corks are being processed. The problem was widespread 20 years ago when one bottle in 12 was corked. These days the figure is about 2 per cent.

The same conditions can apply in water works and, in fact, the reason why so much Chinese garlic tastes musty is, once again, because the snow-white outer skins are bleached. I avoid the stuff and buy French or Spanish when I’m between garlic crops at home.

I also bring water from home when I’m in our Dublin home. Otherwise I would be denied proper tea! ●

I’m always amazed when people say that they think bottled water is a waste of money and that they are perfectly happy drinking what comes out of the domestic tap. I suppose it depends on your tolerance of chlorine and maybe some people actually like the tang of swimming pool. Perhaps they find bottled water too bland.

In south County Dublin, where we have our bolthole in the capital, I find the tap water revolting. It even manages to have, in addition to the chlorine, a touch of mustiness, the kind of taint you get in a ‘corked’ bottle of wine. ‘Corked’ doesn’t mean that there’s a rogue piece of cork floating in your glass; the solution to this is to stick your finger in and pull out the offending fragment.

A corked wine is contaminated with TCA or TBA. The full names are 2,4,6-trichloroanisole and

DRINK OF THE MONTH

When the weather is warm and dry this summer, it will be time for pink wine, something that seems to poke fun at us on a cold, damp November evening. My summer rosé of choice at the moment is the Côteaux Varois en Provence from Aldi for €9.99. As far as I’m concerned, you’re welcome to your overpriced Whispering Angel and the like. This crisp, fresh, gloriously dry pink wine is just made for sunny evenings.

Of course, there’s a thin line between this supposedly beneficial effect and less desirable ones in terms of how much alcohol is appropriate, and there is no agreement on the amount

EUROPEAN COMMISSION APPROVES TALQUETAMAB – THERAPY FOR TREATING PATIENTS WITH RELAPSED AND REFRACTORY MULTIPLE MYELOMA

The Janssen Pharmaceutical Companies of Johnson & Johnson announced that the European Commission (EC) has granted conditional marketing authorisation (CMA) of TALVEY® ▼ (talquetamab) as monotherapy for the treatment of adult patients with relapsed and refractory multiple myeloma (RRMM) who have received at least three prior therapies, including an immunomodulatory agent, a proteasome inhibitor, and an anti-CD38 antibody and have demonstrated disease progression on the last therapy.1,2

Talquetamab is a bispecific T-cell engaging antibody that binds to CD3, on the surface of T-cells, and G proteincoupled receptor class C group 5 member D (GPRC5D), a novel target expressed on the surface of multiple myeloma cells and hard keratinised tissues, with minimal to no expression detected on B-cells and B-cell precursors.1 Talquetamab is approved as a weekly (QW) or biweekly (Q2W) subcutaneous (SC) injection, after an initial step-up phase.1

“As multiple myeloma progresses and patients cycle through treatments, the disease becomes more difficult to treat and remission periods shorten,” said Maria-Victoria Mateos, MD, PhD, Consultant Physician in Haematology, University Hospital of Salamanca.†

“Targeting GPRC5D has been shown to deliver deep responses, and unlike many other targets for multiple myeloma, its expression is limited on immune cells providing an important new approach to targeting this heterogenous disease.”

The CMA was supported by positive results from the Phase 1/2 MonumenTAL-1 study (Phase 1: NCT03399799; Phase 2: NCT04634552), evaluating the safety and efficacy of talquetamab in patients with RRMM. 3,4 The latest data from the study were recently presented at the 2023 American Society of Clinical Oncology (ASCO) Annual Meeting (June 2-6, Chicago) and the 2023 European Hematology Association (EHA) Congress (June 8-11, Frankfurt).

Patients in the study (0.8 mg/kg Q2W: n=145; 0.4 mg/kg QW: n=143) had received a median of five (range, 2-17) prior lines of therapy and showed meaningful overall response rates (ORR) across both doses. With a median follow-up of 12.7 months, 71.7% (95% Confidence Interval [CI], 63.7-78.9) of response-evaluable patients treated at the 0.8 mg/kg Q2W dose achieved a response, 60.8% achieved a very good partial response (VGPR) or better and 38.7% achieved a complete response (CR) or better.1

With a median follow-up of 18.8 months, 74.1% (95% CI, 66.1-81.1) of response-evaluable patients treated with the 0.4 mg/kg QW dose achieved a response, 59.5% achieved a VGPR or better and 33.6% achieved a CR or better.1 Responses were durable with a median duration of response not reached (95% CI, 13-Not Estimable [NE]) in the 0.8 mg/kg Q2W dose group and 9.5 months (95% CI, 6.7-13.3) in the 0.4 mg/kg QW dose group.1 An estimated 76.3% and 51.5% of patients maintained a response for at least nine months at the 0.8 mg/kg Q2W and 0.4 mg/kg QW doses, respectively.1

The MonumenTAL-1 study also included 51 patients with prior T-cell redirection therapy. 2 Patients had received a median of five (3-15) prior lines of therapy, including prior exposure to a bispecific antibody (35.3%), CAR-T cell therapy (70.6%) or both (6%).2 With a median duration of follow-up of 14.8 months, 64.7% of patients achieved a response, 54.9% achieved a VGPR or better and 35.3% achieved a CR or better.2 Median duration of response was 11.9 months (95% CI, 4.8-NE) and the 12-month overall survival rate was 62.9%. 2

“Today’s EC decision brings a new off-the-shelf option with a novel cellular target and the immediate option of biweekly dosing, to an area of high unmet clinical need,” said Edmond Chan, MBChB MD (Res), Senior Director EMEA Therapeutic Area Lead Haematology, Janssen-Cilag Limited. “The high overall

response rates in patients with heavily pretreated multiple myeloma, including those with prior T-cell redirection therapy, are encouraging and we believe talquetamab has the potential to offer physicians flexibility and versatility when determining the optimal treatment regimen for their patients.”

The most common adverse events (AEs) observed in the study were cytokine release syndrome (CRS; 77%, 1.5% Grade 3 or 4), dysgeusia (72%, all Grade 1 or 2), hypogammaglobulinaemia (67%, all Grade 1 or 2) and nail disorders (56%, all Grade 1 or 2).1 In addition, 40% of patients experienced weight loss, including 3.2% with Grade 3 or 4 weight loss.1

The most common infections were upper respiratory tract infection (29%, 2.1% Grade 3 or 4) and COVID-19 (19%, 2.9% Grade 3 or 4).1 Neurologic toxicities were reported in 29% of patients, including immune effector cell-associated neurotoxicity syndrome (ICANS; 10 percent, 2.3% Grade 3 or 4).1 Adverse reactions leading to treatment discontinuation were mainly due to ICANS (1.1%) and weight loss (0.9%).1

The EC approval follows the US Food and Drug Administration (FDA) approval of talquetamab for the treatment of adult patients with relapsed or refractory multiple myeloma who received at least four prior lines of therapy, including a proteasome inhibitor, an immunomodulatory agent, and an antiCD38 antibody, in August 2023.

“As our fifth innovative therapy and second bispecific antibody for multiple myeloma, talquetamab is testament to our continued ambition to discover and develop a portfolio of innovative and complementary therapies,” said Peter Lebowitz, MD, PhD, Global Therapeutic Area Head, Oncology, Janssen Research & Development, LLC. “We now look forward to bringing this new option to patients and physicians.”

References on request

EXPANSION OF LAURA BRENNAN HPV VACCINE CATCH - UP PROGRAMME ANNOUNCED

Minister for Health Stephen Donnelly has announced the expansion of the Laura Brennan HPV (Human Papillomavirus) Vaccine Catch-Up Programme to include all males up to their 22nd birthday.

From August 29, 2023, those who are now eligible can register to get the vaccine at www.hpv.ie, under this programme which is open until December 31.

Since its launch last year, the programme has offered free HPV vaccines to all boys and girls in second-level education who were previously eligible to receive the vaccine in school and who had not yet received it.

It is also open to young women up to the age of 25 who have left secondary school and did not previously receive the vaccine.

The vaccine protects against the types of HPV that cause about 90% of cervical cancers, 90-95% of HPV-related anal cancer, and 90% of genital warts.

HPV infection can lead to cancer in men, including penile, anal, oral, and throat cancers, as well as anogenital warts.

To-date, the Laura Brennan HPV Vaccine Catch-Up Programme has provided free vaccines to more than 3,500 young people who were previously eligible to receive it in schools and had not yet received it.

It is named in memory of Laura Brennan who campaigned for higher uptake of the HPV vaccine before her death from cervical cancer at the age of 26, in 2019.

Minister Donnelly said: “I am delighted to announce the addition of males up to the age of 22 to the list of those who are eligible to receive the HPV vaccine as part of the Laura Brennan HPV Vaccine CatchUp Programme which is open until the end of December.

“Huge credit for this programme is due to the Brennan family who continue to campaign tirelessly in the memory of their brave daughter Laura. Laura herself was also an incredible patient advocate and her campaigning led to increased uptake of the life-saving HPV vaccine.

“It is by increasing HPV vaccination and

screening among our population that we will finally reach our goal of eliminating cervical cancer in Ireland.

“I’m also encouraging young men to take this opportunity to protect themselves against a number of cancers caused by HPV.”

Chief Medical Officer Prof Breda Smyth said: “The HPV vaccine is proven to be safe and effective and it saves lives. I am urging all young people who did not previously avail of the vaccine in school to consider getting it. It’s a simple step that will increase protection against cervical and other types of cancer.”

Laura Brennan’s parents Bernie and Larry Brennan said: “As a family we know only too well the devastation that cervical cancer can cause. While we miss our wonderful daughter constantly, we are very heartened that the work she dedicated so much of her life to is being continued through the Laura Brennan HPV Vaccine Catch-Up Programme which is offering another opportunity for eligible females and now males up to age 22 to receive the HPV vaccine for free through the HSE vaccination clinics if they have not received it before.

“Laura was determined to increase uptake of the HPV vaccine to help protect people from various cancers and eliminate cervical cancer. The HPV vaccine is effective in preventing cancer and we encourage everyone who is eligible to take this opportunity to protect their health.”

Dr Éamonn O’Moore, Director of National Health Protection HSE, said: “The HSE welcome the Minister’s announcement about the expansion of the Laura Brennan HPV Vaccine Catch-Up programme to include older males. This week I would encourage people to visit www.hpv.ie to read more about why it is important for young people to get vaccinated.

“On August 29, the HSE will make the booking system available for people to book their appointment in a local HSE vaccination clinic.”

PHARMA IN SPOTLIGHT AS IRELAND’S EXPORTS DECLINE BY €3BN AT HALF -YEAR STAGE

A fall of €3bn in the value of Irish exports at the half-year stage has again put a focus on medical device and pharmaceutical products in particular, the Irish Examiner has reported.

The Central Statistics Office (CSO) figures show the total value of goods exports fell to €102bn between the start of January to the end of June, from a little more than €105bn in the same period last year.

A marked decline in medical and pharma exports from last year was also reflected in the steep decline of exports destined for the US, down by 18% at the halfway stage.

Exports of medical and pharmaceutical products, which account for the largest share by far of all Irish goods exports, fell to €37.7bn in the first six months from €42.7bn in 2022. However, there were signs of recovery as the value of medical and pharma exports in June 2023 rose from June 2022.

The US is a major market for medical device and pharma products made by foreignowned multinationals which have located big facilities in Ireland, and the fall in pharmaceutical exports has raised concerns about the significant industry based here.

Some economists have said the performance of pharma exports will need to be closely watched should the policies of the Biden administration to lure high-value manufacturing back to the US have an impact on Ireland.

UNIVERSITY OF GALWAY SCIENTIST AWARDED ERC FUNDING FOR PROJECT TO REDUCE CHEMOTHERAPY SIDE EFFECTS

University of Galway researcher Professor Martin O’Halloran has been awarded a European Research Council (ERC) Proof of Concept grant worth €150,000.

This latest accolade for Prof O’Halloran brings his total ERC awards to seven with a combined value of €4.25m in funding since 2015, making him the joint-highest ERC awardee in Ireland.

The ERC Proof of Concept is being awarded for his research work on NeuroProtect – a novel therapy to prevent peripheral neuropathy in patients undergoing chemotherapy. The side-effect results in nerves located outside of the brain and spinal cord (peripheral nerves) being damaged and can lead to weakness, numbness and pain, usually in the hands and feet which can cause significant disability and pain for cancer patients.

Professor O’Halloran is Techrete Professor of Medical Electronics, Executive Director of the University of Galway-Enterprise Ireland

funded BioInnovate Ireland and Director of the Translational Medical Device Lab at the College of Medicine, Nursing and Health Sciences at University of Galway. His research projects to have been awarded ERC grants include:

 BioElecPro – Examining the electrical properties of human tissue as a platform for new medical devices;

 Realta – Microwave ablation for the treatment of adrenal tumours;

 Draiocht – Medical device for the treatment of varicose veins;

 Hydrolieve – A long-lasting drug-free effective treatment for chronic Trigeminal Neuralgia pain;

 EndoSolve – A novel medical device for the treatment of Endometriosis;

 Arth-Alleve – Development of novel therapies for osteoarthritis pain.

Prof O’Halloran said: “This represents our seventh European Research Council grant

since 2015, and addresses a medical problem significant to cancer patients – to minimise the long-term side effects of chemotherapy. It builds on ever growing collaborations between engineering and medicine at the university, and we hope to have an impact in the clinic in the very near future.”

Professor Jim Livesey, Vice-President Research and Innovation at University of Galway, said: “The record ERC awards for Professor O’Halloran are a striking recognition of the quality and level of research he and his teams are leading at University of Galway, as well as the potential for impact on people’s quality of life. The ERC awards also demonstrate the role which our university plays regionally, nationally and internationally and its value in the medtech sector on a global stage.”

Proof of Concept grants are awarded to ERC grant holders as top-up funding to explore the commercial or innovation potential of the results of their ERC-funded research.

TOOLKIT PROVIDES MORE EFFICIENT ANALYSIS OF HEALTH DATA TO DRIVE IMPROVEMENTS IN PATIENT CARE

Researchers from Queen’s University have developed a new toolkit that harnesses the power of Big Data for digital health with the aim of driving improvements in patient care and outcomes through datadriven innovation.

The toolkit named eHDPrep has been made freely available to allow both the researchers themselves and other researchers to more effectively and reliably analyse large health datasets.

The understanding that arises from these analyses is hoped to produce better and more effective clinical tools that provide information to assist health professionals in making clinical decisions, such as determining which treatment may be more effective to treat a certain type of cancer.

The research has been published in the journal Gigascience and is a collaboration between various groups at Queen’s, and the LifeArc Data Sciences Group.

The eHDPrep tool enhances data quality which is a current major issue with effective use of health data. For example, providing methods for elimination of inconsistencies, removal of redundancy, increasing completeness and appropriately coding the data so that it is machine-interpretable, which is crucial for computational analyses.

The tool also enables a better understanding of health data by joining information together into higher level concepts that can reveal non-obvious links between different patients – in a process called ‘semantic enrichment’.

This semantic enrichment process provides greater statistical power to make discoveries, for example highlighting key factors that drive disease progression in cancer and cardiovascular disease.

The research team have applied the eHDPrep tool to two datasets from colorectal cancer, one from Northern Ireland and

another from The Cancer Genome Atlas (USA). The data cleaning and enrichment processes from eHDPrep is an important enabling step for them to develop new ways of grouping patients in order to advance colorectal cancer precision medicine.

The researchers hope this new understanding will ultimately lead to new treatments and diagnostics that will benefit colorectal cancer patients.

Tom Toner, PhD student from the Overton Research Group in Patrick G Johnston Centre for Cancer Research at Queen’s University and first author on the research, said: “We are excited about the potential impact of eHDPrep on advancing precision medicine, particularly in the field of colorectal cancer. By making this toolkit freely available, we’re ensuring that other researchers can also benefit from its capabilities and contribute to the collective efforts in improving patient outcomes.”