Cheap medicines mean Ireland is always at a disadvantage when medicine supplies are allocated, writes Fintan Moore
CLINICAL CONTENT ON:
Psychiatry, IVF, Vitamins & Minerals, and Migraine
Does in-pharmacy music affect purchasing habits, and does it matter what kind of music you play?
02 NEWS National and international news in the world of pharmacy and healthcare
12 HITTING THE RIGHT NOTE
A look at research into the psychological effects of playing music in the pharmacy and whether it influences buying habits
15 FINTAN MOORE
Low drug prices in Ireland mean that we will always come off second-best when it comes to medicine supplies
18 TERRY MAGUIRE
The media's handling of a number of tragic child deaths due to Strep A left a lot to be desired and created a public panic
21 DES CORRIGAN
A review of the evidence on whether Brahmi could be an Ayurvedic answer to improving Alzheimer's disease symptoms
44 MOTORING
Dr Alan Moran reviews the Mercedes EQE — a safe, comfortable, solid and relaxed drive
46 FOOD AND DRINK
Editor Pat Kelly, pat@greenx.ie
Creative Director Laura Kenny, laura@greenx.ie
Administration Manager
Daiva Maciunaite, daiva@greenx.ie
Managing Director Graham Cooke, graham@greenx.ie
24 PSYCHIATRY POST- COVID Prof Brendan Kelly and Prof Gautam Gulati discuss the longerterm consequences of the pandemic on mental health
27 A HELPING HAND IN FERTILITY
A look at the challenges and opportunities for couples struggling to conceive and the role of IVF
31 THE RIGHT STUFF
An overview of vitamins and minerals and how they can help to maintain health at any age
39 MIGRAINE MATTERS
A synopsis of migraine in all its forms, including self-help techniques and pharmacological treatment options
47 PRODUCT NEWS
A round-up of industry and product news
Tom Doorley describes his 'rules of engagement' with food and drink, a 30year process of discovery 18
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The International Pharmaceutical Federation (FIP) has teamed up with colleagues from the International Sports Pharmacists Network to publish a global overview of sports pharmacy practice and education, released recently. The report highlights how pharmacists have been using their pharmacy knowledge and skills to act as key athlete support personnel through pharmaceutical care, doping control and providing services at sporting events. It defines sports pharmacy as a specialty area and outlines the knowledge and skills required to practise it.
“Since the publication of FIP guidelines on ‘The role of the pharmacist in the fight against doping in sport’ in 2014, the work of many individual pharmacists has nurtured sports pharmacy into an expanding specialty. This growth occurred parallel to and often intertwined with growth of the anti-doping movement. Internationally, major stakeholders acknowledge sports pharmacists as key contributors to anti-
doping and clean sport initiatives. Facets of pharmaceutical care for athletes led by experienced sports pharmacists have become embedded in sports medicine around the world. The specialty of sports pharmacy is no longer a niche area, but is one gaining traction as a recognised speciality on a global scale,” explained Mr Mark Stuart, coauthor and a sports pharmacist who has worked at many Olympic Games. The report’s authors are now calling for formalised and quality education on sports pharmacy alongside international undergraduate curricula and for a system of credentialling sports pharmacists. Although stakeholders in sport recognise the usefulness of qualified sports pharmacists, few countries specify registration to prove qualifications or to recognise sports pharmacists, with Japan providing the most substantial example, and Turkey rapidly developing exemplary educational models, the report details.
“Sports pharmacists are characterised by a commitment to uphold the health of athletes and fairness in sport, their dedication to remain current on evidencebased recommendation for health in sport and the anti-doping movement, which will optimise safe and effective use of medicines. Pharmacists with an interest in sports pharmacy can use this document to assess their learning needs and identify the areas where they may require additional education and learning. Educators can utilise the knowledge and skills described as a guide for course development,” said Ms Ashley Anderson, co-author and lead editor of the report, and sports pharmacist, International Sports Pharmacists Network, USA.
In addition to discussing sports pharmacy education and qualifications, the report includes sections on pharmacists’ roles in the anti-doping movement, therapeutic use of prohibited medicines, and risk assessment of dietary supplements.
On World AIDS Day in December 2022, the International Pharmaceutical Federation (FIP) published a new handbook for pharmacists on the prevention, screening and management of HIV.
“While immense progress has been made in terms of prevention, testing, treatment and quality of life for people living with HIV, the virus remains both a major global health threat and burden for individuals, health systems and societies. Concerted efforts by all stakeholders and healthcare providers are essential to control this epidemic, but pharmacists certainly have an important role to play,” said Mr Gonçalo Sousa Pinto, FIP lead for practice development and transformation, and coeditor of the handbook.
In particular, he added that, as with many prevention strategies, pharmacists are ideally placed to support patients with ways to reduce the risk of transmission, including advising on safer sex practices. In some countries, pharmacists are contributing to improved access to, and supporting the use of pharmacological approaches to prevention, such as pre- or post-exposure prophylaxis, and also to harm reduction strategies for intravenous drug users. They are also contributing to screening and testing, helping to identify cases that need to receive treatment and care.
A section of HIV Prevention, Screening and Management: A Handbook for Pharmacists is dedicated to the public health roles for pharmacists in this disease
area. These include campaigning to raise community awareness, tackling stigma, preventing sexual violence (which is often associated with HIV and other sexuallytransmitted infections) and supporting its victims, and advocacy work.
“This handbook aims to provide pharmacists and their teams with concise information on the variety of actions they can take to reduce the burden of HIV, offering examples and additional resources. FIP hopes that colleagues around the world will find it a valuable and easily accessible resource,” Mr Sousa Pinto said. The handbook was developed in collaboration with an international advisory group of experts from Brazil, Canada, Malaysia, South Africa, the USA and the International AIDS Society.
Scientists have discovered there is a ‘Goldilocks’ effect in identifying the size of a vaccine adjuvant that can trigger strong immune responses and, as an example, have recently shown that a safe, biodegradable adjuvant can boost the action of cancer-killing cells if the particles are the correct size.
The discovery has wide-ranging implications for the design of new, improved vaccines that are badly needed to enhance cell-mediated immune responses against cancers and a host of infectious diseases, say the authors.
Prof Ed Lavelle, Professor in Trinity College Dublin’s School of Biochemistry and Immunology, who is based in the Trinity Biomedical Sciences Institute (TBSI), is the senior author of the research article published in the leading journal Cell Reports Medicine. He said: “To allow the rational design of vaccines, we need to know what the rules are governing how adjuvants activate different types of immune response. If we have that crucial info, we can then tailor vaccine development for specific applications,
as the responses required depend on the disease — one size does not fit all.
“Adjuvants are essentially special ingredients that enhance the effectiveness of a vaccine, for example by boosting killer T cells or antibody production, which results in longerlasting immunity, or in reducing the dose of the active agent — the ‘antigen’ — needed in the vaccine.”
In particular, scientists have been hunting for better adjuvants that enhance cell-mediated immune responses. One key application of such adjuvants would be eliciting cytotoxic T-cells that can kill tumours and virally infected cells.
Prof Natalia Munoz-Wolf, Research Assistant Professor in Trinity’s School of Medicine, and Ross Ward, PhD student in the School of Biochemistry and Immunology, are the first co-authors of the research article. They said:
“In this work, we have established that the size of adjuvant particles is critical for determining the induction of cellmediated immune responses — including the action of cytotoxic T cells — and that
People in Ireland eat more daily portions of fruit and vegetables than in any other EU country, according to a report released by the Organisation for Economic Cooperation and Development (OECD).
Across all EU member states, just 12 per cent of adults consume the recommended five or more portions of fruit and vegetables per day. However, 33 per cent of adults in Ireland reach this target, with a further 48 per cent consuming between one and four portions daily.
The figures are included in the latest OECD Health at a Glance 2022 Report, which also highlights Ireland’s
progress in reducing smoking rates over the last decade.
In 2020, almost one-in-five adults (19 per cent) across EU countries smoked daily, in comparison to 16 per cent of adults in Ireland.
Smoking rates in Ireland dropped by 8 percentage points, from 24 per cent in 2010. This is the second-largest drop across EU countries, behind Estonia, which saw its smoking rates fall from 27 per cent in 2010 to 18 per cent in 2020.
In addition, the report reveals how Ireland’s public coverage of pharmaceutical costs is among the most
a biodegradable polymer can be used to develop a highly effective adjuvant that promotes cytotoxic T-cells if the particles are the correct size.
“We have shown for the first time that nanoparticles of around 50nm in size can activate a signalling pathway called the non-canonical inflammasome that allows the induction of effective cell-mediated immune responses. We propose that small nanoparticles like this promote reactive oxygen species in cells, which in turn lead to the activation of key components of this pathway, including caspase 11 and gasdermin proteins, which are essential for generation of cellmediated immunity.”
In combination, the work represents a significant step forward in the development of next-generation adjuvants for improved anti-cancer and antiviral vaccines, said the researchers.
This work was supported by Science Foundation Ireland, the Irish Research Council and the Health Research Board. The research article can be read at: https://bit.ly/3Wpmafj.
generous in the EU.
On average, government and compulsory insurance schemes cover 70 per cent of all retail pharmaceutical spending, but in Ireland, 81 per cent of pharmaceutical spending is covered. This compares with 85 per cent in Cyprus and just 41 per cent in Iceland.
The report also praises Ireland’s swift implementation of the Covid-19 vaccination programme. By the end of 2021, the average EU vaccination rate was 77 per cent of the population, but more than 90 per cent of the adult population in Ireland completed an initial vaccination course.
Collaborative research between University of Galway and Brunel University London has found that patients with severe and complicated obesity respond differently to a dietary weight loss programme based on their genes.
The GERONIMO project studied patients attending the obesity clinic at Galway University Hospital who were undergoing an intensive short-term programme of medically supervised dietary restriction in order to attempt to reverse some of the medical problems with severe obesity.
During the research, scientists were able to analyse small variations in hundreds of genes that are known to be associated with obesity. By combining information from these measured gene variations together, a genetic risk score was calculated for six different obesity-related traits.
Prof Francis Finucane, senior lecturer in the School of Medicine at University of Galway and Consultant Endocrinologist at Galway University Hospitals, who led the clinical study,
said: “Mechanistic studies like these, which help us to understand why some people respond better than others to the same intervention, are really important in providing more personalised and effective treatments for people with obesity.
“We know that in general, heritability and genetics play a huge role in influencing body weight and the risk of obesity-related complications like diabetes, but finding the genes that account for this risk has been a challenge.”
Prof Alex Blakemore, Professor in Human Genomics at Brunel University, said: “No-one chooses their genes, so, as a society, we need to recognise that when it comes to maintaining a healthy weight, the challenge is greater for some people than for others. This study reveals just a small part of the picture of how our genes can help or hinder us in reaching our health goals.”
The GERONIMO project involved 93 patients who volunteered for the study. They were monitored while taking part in a
meal replacement programme.
Their average body mass index at the start of the study was 52kgm-2, which means that they weighed more than twice their maximum ‘healthy weight’.
The participants lost an average of 16 per cent of their body weight, or 21kg, after 24 weeks.
The research found that the ‘waisthip ratio’ genetic risk score, which measures an individual’s genetic tendency to hold on to central or abdominal fat, was associated with less weight loss after the intervention.
Speaking about next stages in the research, Prof Finucane said: “This work is exciting and important because it is the first Irish study to demonstrate a genetic effect on the response to a treatment for obesity.
“The genetic effects we found here were subtle, but we think it would be good to explore this further, in larger studies and with different obesity treatments, such as drug therapy or metabolic surgery.”
Scientists at University of Galway have detailed a new discovery with the potential to improve treatment options for superbug MRSA infections with penicillin-type antibiotics that have become ineffective on their own.
The research has been published in the flagship journal of the American Society for Microbiology, mBio.
Prof James P O’Gara and Dr Merve S Zeden in the School of Biological and Chemical Sciences, University of Galway, led the study.
Prof O’Gara said: “This discovery is important because it has revealed a potentially new way to treat MRSA infections with penicillin-type drugs, which remain the safest and most effective antibiotics.”
The antimicrobial resistance (AMR)
crisis is one of the greatest threats to human health, with superbugs like MRSA placing a significant burden on global healthcare resources.
The microbiology research team at University of Galway showed that MRSA could be much more efficiently killed by penicillin-type antibiotics when combined with purines, which are the building blocks for DNA.
Dr Zeden said: “Purine nucleosides, Adenosine, Xanthosine, Guanosine, are sugar versions of the building blocks of DNA, and our work showed that they interfere with signalling systems in the bacterial cell, which are required for antibiotic resistance.”
This study was recently highlighted in the American Society for Microbiology’s
This Week in Microbiology podcast. The discussion noted the drugs derived from purines are already used to treat some viral infections and cancers.
Aaron Nolan is a PhD student at University of Galway and was co-first author on the paper. He said: “Finding new ways to re-sensitise superbugs to currently-licenced antibiotics is a crucial part of efforts to tackle the AMR crisis. Our research implicated the potential of purine nucleosides in re-sensitising MRSA to penicillin-type antibiotics.”
This research, which was funded by the Health Research Board, Science Foundation Ireland and the Irish Research Council, was conducted in collaboration with scientists at Imperial College London and the University of Sheffield.
RCSI researcher Prof Killian Hurley has been awarded a European Research Council (ERC) Starting Grant to conduct innovative research into treatments for the lethal lung condition, pulmonary fibrosis.
The project, called STAR-TEL, is one of 408 projects chosen out of almost 3,000 applications to receive ERC funding. A total value of €636 million has been awarded across all ERC Starting Grant projects.
Pulmonary fibrosis occurs when lung tissue becomes damaged and scarred. While existing medications can slow the progression of the disease, currently there is no known cure, with many patients dying within three years of diagnosis as a result.
STAR-TEL will seek new personalised treatments for patients with pulmonary fibrosis by first investigating how the disease develops, and then generating new mRNA medications specifically designed for individual patients. The treatments will be tested in innovative stem cell models, known
as ‘lung-in-a-dish’ models, to ensure their effectiveness and understand potential sideeffects prior to administering them to patients.
The drugs will be targeted at the lungs specifically, so that patients only get the treatment where they need it. It is hoped this will result in life-changing personalised treatments for patients with this devastating lung disease.
Prof Hurley, who is a Principal Investigator in RCSI’s Department of Medicine and Tissue Engineering Research Group and Consultant Respiratory Physician at Beaumont Hospital, commented on the award: “I am delighted to receive an ERC Starting Grant to help STAR-TEL find new personalised treatments for patients with pulmonary fibrosis. By developing the ‘lung-in-a-dish’ models in the lab using adult stem cells, we can learn if medications work for individual patients and about the side-effects or toxicity of drugs before ever giving them to real-life patients. Our overall aim is to better understand how
Amidst record levels of overcrowding in Irish hospitals, the community pharmacy sector could provide solutions to free-up capacity elsewhere in the health system, according to the Irish Pharmacy Union (IPU).
Speaking as health authorities continue to warn that the crisis in our health system is set to continue, President of the IPU Mr Dermot Twomey MPSI said: “The pharmacy sector is, as it always is, ready to step up to do more to support patients and provide care in our communities. Ireland’s 1,900 pharmacies are located in practically every community. They are easily accessible and should be among the first line of defence for our health system. But we need to be empowered to do so by the relevant authorities.
“[Recently] the public were advised to avoid A&Es by the HSE, who recommended they visit pharmacies and GPs instead. Pharmacies are of course well placed to provide care and health advice to those who need it. However,
we cannot understand why the HSE is directing patients into pharmacies while consistently doing nothing to increase the range of clinical services we can provide.
“There is huge potential in community pharmacy and much more the sector can do to deliver on the Sláintecare vision of one universal health service for all, providing the right care, in the right place at the right time, in turn relieving pressure on the healthcare system.”
Mr Twomey cited several examples of services he claims pharmacies could start offering almost immediately, which would free-up capacity elsewhere in the health system. “If properly resourced and if allowed to do so, there is a range of new clinical services which we could deliver. A key priority among these is the development and roll-out of a national community pharmacy-based triage programme, including a minor ailments scheme, use of emergency medicines, and the treatment of minor injuries. A lot of these services are
pulmonary fibrosis happens and to provide improved medications to patients, allowing them to live normal and healthy lives.”
RCSI’s Deputy Vice Chancellor for Research and Innovation, Prof Fergal O’Brien, welcomed the announcement, saying: “I congratulate Prof Hurley on this prestigious award from the European Research Council, which is testament to the high-quality health sciences research taking place at RCSI. We are very proud to be hosting another ERC award in RCSI and it’s a real testament to the quality of Prof Hurley’s own research and his developing international reputation. The STAR-TEL project will do important work to deepen our understanding of pulmonary fibrosis and how it can be treated, and ultimately help to improve the lives of those who suffer from it.”
The ERC, set up by the European Union in 2007, is the premier European funding organisation for excellent frontier research. It funds creative researchers of any nationality and age, to run projects based across Europe.
available in other jurisdictions and would potentially eliminate thousands of needless GP and A&E visits each month.
“With an increase in the number of GP-only medical cards on the way this year increasing pressure on an already overworked sector, the HSE needs to actively put in place plans to manage their capacity. Providing greater opportunities for pharmacies to provide patient care would benefit patients and the health system alike.”
In conclusion, Mr Twomey criticised health authorities for "sleepwalking" into the current crisis and ignoring obvious solutions. “The surge in viral infections across the country in recent weeks was predictable and predicted. It is no longer acceptable to explain away the scenes in our hospitals as the result of some extraordinary event. We must do everything practical to enhance the availability and accessibility of patient care. This must include the involvement of the pharmacy sector.”
RCSI University of Medicine and Health Sciences and FutureNeuro are co-leading, with University College Dublin, the Irish element of a new EU project to support the integration of genomics into healthcare and advance new treatments for patients.
Jointly funded by the European Commission, under the Digital Europe Programme, and the Health Research Board (HRB), Genomic Data Infrastructure (GDI) Ireland is part of a consortium of 20 EU Member States with the goal of enabling access to genomics and corresponding clinical data across Europe by creating secure data infrastructure. The project will facilitate a cross-border federated network of national genome collections for biomedical research and personalised medicine solutions.
GDI Ireland National Co-Lead, Prof Gianpiero Cavalleri, School of Pharmacy, RCSI, Professor of Human Genetics at RCSI and Deputy Director of the SFI FutureNeuro Research Centre, said: “By realising this federated analysis system, we will enable Irish genomes to be safely and securely analysed alongside similar datasets from other
European countries. Such infrastructure can accelerate the discovery of genetic causes of disease and inform the development of muchneeded treatments for conditions such as cancer that can have a devastating impact on our lives.”
The Irish GDI hub will establish best practice to manage the Irish genetic data, protecting the security of the personal data contributed by individuals. Work will be informed by the experience and technology developed by European partners.
The GDI project positions Ireland to participate in the ambitious Europe-wide ‘1+ Million Genomes’ initiative, which is driving the development, deployment, and operation of sustainable data-access infrastructures within each participating country.
Commenting on the announcement, Dr Mairead O’Driscoll, Chief Executive of the Health Research Board, said: "The GDI project brings together national agencies, research organisations, technology providers and patient organisations in 20 countries.
"The overarching goal is to design, develop
and operationalise a cross-border federated network of national genome collections and other relevant data to advance data-driven personalised medicine for the benefit of European citizens.
“Ireland’s participation in this project will see our researchers, clinicians, patient representatives, experts in data governance, data analysts and others collaborating on a roadmap for data infrastructure in Ireland and conducting proof-of-concept work using synthetic data.”
Prof Cavalleri and Prof Denis Shields, University College Dublin, are Co-Directors of the GDI Ireland project with Prof Aedin Culhane (University of Limerick) and Prof Markus Helfert (Maynooth University) as coapplicants. The team will be supported by the SFI Centre for Research Training in Genomics Data Science, the Irish Platform for Patient Organisations and Industry (IPPOSI) and Health Research Charities Ireland (HRCI). For further information on the project, visit: https://gdi.onemilliongenomes.eu/.
A decision-making framework and its application to help pharmacists deal with different ethical dilemmas in pharmacy practice are presented in a new format of continuing professional development — ‘FIP CPD Bites’ — from the International Pharmaceutical Federation (FIP), launched recently.
“FIP already offers numerous resources to support the profession with CPD, including webinars, digital events, congress sessions and publications such as handbooks and knowledge and skills guides. However, we understand that people have different learning styles and preferences, and the growing demands on pharmacists’ time means that there is a need for concise, engaging, evidencedriven and easily accessible learning materials. ‘FIP CPD Bites’ aims to meet this need through short videos with roleplays, analysis and advice,” said Dr Dalia Bajis, FIP lead for
provision and partnerships.
‘FIP CPD Bites’ provides learning support on different topics relevant to practice, science and education in pharmacy. FIP’s first series in this new format comprises seven videos developed by FIP experts on ethics. “As practising pharmacists, we are clinically, ethically and socially accountable for decisions we make regarding the allimportant pharmaceutical care of our patients. We often experience ethical dilemmas, where two or more issues could be pulling in opposite directions, making it difficult to decide what direction to take that would be justifiable and in the best interests of the patient. To enable better understanding of our obligations, these CPD bites offer real-life examples in role-play, accompanied by clear, simply articulated analyses and recommended actions to help colleagues
make professionally justifiable ethical decisions,” said Dr Betty Chaar, chair, FIP Working Group on Ethics.
The first video in this Ethics in Pharmacy Practice series introduces a framework for decision-making on ethical dilemmas. Three other CPD bites address specific topics of professional autonomy, privacy and confidentiality, and provision of advice on medication. Three further videos will be released during 2023.
“Every day, pharmacists are faced with ethical issues to manage during the provision of pharmaceutical care, alongside their relationships with other members of the healthcare team. ‘FIP CPD Bites’ aims to support pharmacists in upholding ethical principles and providing quality patient and professional services in challenging situations in a speedy and accessible way,” Dr Bajis said.
ATTR-CM=transthyretin amyloid cardiomyopathy; CV=cardiovascular.
References: 1. Maurer MS, Schwartz JH, Gundapaneni B, et al. Tafamidis treatment for patients with transthyretin amyloid cardiomyopathy. N Engl J Med. 2018;379(11):1007-1016. 2. VYNDAQEL Summary of Product Characteristics. Vyndaqelq 61 mg soft capsules (tafamidis) Prescribing Information: Before prescribing Vyndaqel please refer to the full Summary of Product Characteristics. Presentation: Vyndaqel 61 mg soft capsules. Each soft capsule contains 61 mg tafamidis. Uses: Vyndaqel is indicated for the treatment of wild-type or hereditary transthyretin amyloidosis in adult patients with cardiomyopathy (ATTR-CM). Dosage: Treatment should be initiated under the supervision of a physician knowledgeable in the management of patients with amyloidosis or cardiomyopathy. When there is a suspicion in patients presenting with specific medical history or signs of heart failure or cardiomyopathy, etiologic diagnosis must be done by a physician knowledgeable in the management of amyloidosis or cardiomyopathy to confirm ATTR-CM and exclude AL amyloidosis before starting Vyndaqel, using appropriate assessment tools such as: bone scintigraphy and blood/urine assessment, and/or histological assessment by biopsy, and transthyretin (TTR) genotyping to characterise as wild-type or hereditary. The recommended dose is one capsule of Vyndaqel 61 mg (tafamidis) orally once daily. Vyndaqel 61 mg (tafamidis) corresponds to 80 mg tafamidis meglumine, tafamidis and tafamidis meglumine are not interchangeable on a per mg basis. Vyndaqel should be started as early as possible in the disease course when the clinical benefit on disease progression could be more evident. Conversely, when amyoid-related cardiac damage is more advanced, such as in NYHA Class III, the decision to start or maintain treatment should be taken at the discretion of a physician knowledgeable in the management of patients with amyloidosis or cardiomyopathy. There are limited clinical data in patients with NYHA Class IV. If vomiting occurs after dosing, and the intact Vyndaqel capsule is identified, then an additional dose of Vyndaqel should be administered if possible. If no capsule is identified, then no additional dose is necessary, with resumption of dosing the next day as usual. There are no recommended dosage adjustments for elderly patients or patients with renal or mild and moderate hepatic impairment. Limited data are available in patients with severe renal impairment (creatinine clearance less than or equal to 30 mL/min). Tafamidis has not been studied in patients with severe hepatic impairment and caution is recommended. There is no relevant use of tafamidis in the paediatric population. Method of Administration: The soft capsules should be swallowed whole and not crushed or cut. Vyndaqel may be taken with or without food.
Contra-indications: Hypersensitivity to the active substance or to any of the excipients as listed in section 6.1 of SPC. Warnings and Precautions: Contraceptive measures should be used by women of childbearing potential during treatment with tafamidis and for one month after stopping treatment. Tafamidis should be added to the standard of care for the treatment of patients with transthyretin amyloidosis. Physicians should monitor patients and continue to assess the need for other therapy, including the need for organ transplantation, as part of this standard of care. As there are no data available regarding the use of tafamidis in organ transplantation, tafamidis should be discontinued in patients who undergo organ transplantation. Increase in liver function tests and decrease in thyroxine may occur.
This medicinal product contains no more than 44 mg sorbitol in each capsule. Sorbitol is a source of fructose. The additive effect of concomitantly administered products containing sorbitol (or fructose) and dietary intake of
sorbitol (or fructose) should be taken into account. The content of sorbitol in medicinal products for oral use may affect the bioavailability of other medicinal products for oral use administered concomitantly. Pregnancy and Lactation: Tafamidis is not recommended during pregnancy and in women of childbearing potential not using contraception.Available data in animals have shown excretion of tafamidis in milk.A risk to the newborns/infants cannot be excluded. Vyndaqel should not be used during breastfeeding. Interactions: In a clinical study in healthy volunteers, 20 mg tafamidis meglumine did not induce or inhibit the cytochrome P450 enzyme CYP3A4. In vitro tafamidis inhibits the efflux transporter BCRP (breast cancer resistant protein) at the 61 mg/day tafamidis dose with IC50=1.16 μM and may cause drug-drug interactions at clinically relevant concentrations with substrates of this transporter (e.g. methotrexate, rosuvastatin, imatinib). In a clinical study in healthy participants, the exposure of the BCRP substrate rosuvastatin increased approximately 2-fold following multiple doses of Page 2 of 2 2020-0065522 61 mg tafamidis daily dosing. Likewise, tafamidis inhibits the uptake transporters OAT1 and OAT3 (organic anion transporters) with IC50=2.9 μM and IC50=2.36 μM,respectively,and may cause drug-drug interactions at clinically relevant concentrations with substrates of these transporters (e.g. non-steroidal anti-inflammatory drugs, bumetanide, furosemide, lamivudine, methotrexate, oseltamivir, tenofovir, ganciclovir, adefovir, cidofovir, zidovudine, zalcitabine).
Based on in vitro data, the maximal predicted changes in AUC of OAT1 and OAT3 substrates were determined to be less than 1.25 for the tafamidis 61 mg dose, therefore, inhibition of OAT1 or OAT3 transporters by tafamidis is not expected to result in clinically significant interactions. No interaction studies have been performed evaluating the effect of other medicinal products on tafamidis. Undesirable Effects: The following adverse events were reported more often in 176 ATTR-CM patients treated with tafamidis meglumine 80 mg compared to placebo: flatulence [8 patients (4.5%) versus 3 patients (1.7%)] and liver function test increased [6 patients (3.4%) versus 2 patients (1.1%)]. A causal relationship has not been established. Safety data for tafamidis 61 mg are not available as this formulation was not evaluated in the double-blind, placebo-controlled, randomised phase 3 study. Legal category: S1A. Marketing Authorisation Numbers: EU/1/11/717/003– 61mg (30 capsules).
Marketing Authorisation Holder: Pfizer Europe MA EEIG, Boulevard de la Plaine 17, 1050 Bruxelles, Belgium. For further information on this medicine please contact: Pfizer Medical Information on 1800 633 363 or at EUMEDINFO@pfizer.com. For queries regarding product availability please contact: Pfizer Healthcare Ireland, Pfizer Building 9, Riverwalk, National Digital Park, Citywest Business Campus, Dublin 24 + 353 1 4676500. Last revised: 04/2021 q This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse reactions. See section 4.8 of the SmPC for how to report adverse reactions.
Ref: VY 61MG 2_0
The first and only treatment indicated to reduce: • all-cause mortality frequency of CV-related in patients with wild-type or hereditary ATTR-CM.
Indicated for the treatment of wild-type or hereditary transthyretin amyloidosis in adult patients with cardiomyopathy (ATTR-CM). 2
Does playing music in your pharmacy have any effect on consumer behaviour, and does it matter what kind of music you play?
The process of dispensing healthcare advice and consultations is now acknowledged as being among the core values of the Irish pharmacist, albeit with a lack of full recognition from health authorities in terms of remuneration. However, when the business of healthcare has been taken care of, patients become customers and the job of the pharmacist or their staff is to encourage people to pick up their sundry healthcare items at their local pharmacy, rather that at the supermarket or other local store. So, does music in the pharmacy help to encourage or otherwise affect purchasing habits?
A number of companies and institutions have looked at the effects of music on consumer behaviour. Something may cause a customer or patient may feel ill at ease when they enter retail premises, and this may lead them to spend less time than they otherwise might. A number of studies have indicated that well-chosen music can help to make the wait for a prescription seem a little shorter, and can help to create a warmer atmosphere. The same waiting-time principle is utilised when a person is on hold for a telephone service, although this has evolved from years gone past, when Greensleeves played on a continuous loop, much to the annoyance of the caller, therefore having the opposite effect for which ‘hold music’ was intended.
A 2005 study in the Journal of Service Research looked at the effects of atmospherics on consumer behaviour. The authors note that individual consumers exhibit different
shopping ‘styles’, with one key characteristic that differentiates them being a tendency to engage in impulsive or unplanned buying behaviour. They pointed to 1978 and 1995 studies, which indicated that between 27 per cent and 62 per cent of department store purchases are unplanned.
However, they also make a distinction between ‘unplanned’ and ‘impulse’ purchases. Based on previous research, ‘impulse’ buys are defined as “when consumers suddenly decide to purchase something they had not planned on buying… and [purchases] are made because of a sudden, often powerful and persistent urge to buy something immediately”. While almost all shoppers will make an unplanned purchase at some time, impulsive shoppers are more prone to making these purchases than what are described as “contemplative shoppers” who did not report making unplanned purchases.
The authors wrote: “Impulse buying is characterised as an effectively-charged hedonic experience associated with high levels of emotional activation and low levels of cognitive control… In contrast, contemplative buying is characterised by more deliberative, cognitive and controlled processing, generally devoid of high levels of emotional activation.” Background music is likely to have less impact on contemplative buyers, they added.
They also looked at the effects of a scent on buying behaviours. They postulated that if a retailer feels that their customers tend to make their purchases in a contemplative way, using product comparison and information-gathering, then ambient scents may help to encourage
purchasing. However, if the typical customer tends to be more impulsive, background music may enhance sales. “In terms of product category considerations, the use of ambient scent might be more appropriate when selling ‘big-ticket’ items such as automobiles or personal computers, as these are frequently bought on impulse,” they wrote. “Music might be more appropriate for items more commonly purchased on impulse, such as some types of clothing, food, and health and beauty aids. The results also suggest that managers should be cautious about randomly combining atmospheric factors to avoid creating a service climate that presents a stimulus overload or cue incongruency situations.”
Lead researcher on the study Prof Maureen Morrin, Professor of Marketing and Director of Business Analytics at Rutgers University, US, commented on a separate study involving 774 participants in a shopping mall in Canada over a period of one month. Speaking at the American Psychological Association’s annual conference in 2005, Prof Morrin reported that any type of shopper purchases less than usual when both scent and music are present. This equates to a ‘less is more’ approach, as “this could be a caveat for managers — don’t throw everything you have at your customers,” she said.
Over the course of the month, on different days, slow-tempo music was played and the mall was filled with a citrus scent. Alternately on other days, music was played without the scent, and on some days the mall’s ambiance
was unaltered. Shoppers were then surveyed to establish how much they had spent and whether they had made any unplanned purchases. They were also asked subjective questions, such as how easy it was to find items or if they had enjoyed their shopping experience.
The music and scent did not affect shoppers’ mood, but the responses showed that it did influence their spending habits. On average, those surveyed spent $32.89 more on unplanned purchases than the control group if music was played. However, in the presence of a scent alone, they actually spent $8.66 less. But this applied to impulsive buyers and unplanned purchases; contemplative buyers spent around $1 less when music was played, but with the citrus scent, they spent $5.71 more than normal.
In 2015, Pharmacy Times reported that music from the 1950s and 1960s seems to have the best results in terms of encouraging shopping purchases. “Annoying or repetitive music tends to frustrate the staff and create a negative atmosphere. On the other hand, fun, snappy and multigenerational music tends to produce a workplace that helps everyone focus and remain calm,” said Jason Poquette of Pharmacy Healthcare Solutions, who has experimented with using different music genres in the workplace. “The pharmacy can be hard on patients and employees alike, [but] music can soften the blow. As Bob Marley once said, ‘One good thing about music: when it hits you, you feel no pain’.”
Enhancing the in-store shopping experience has become even more important since Covid-19 and the shopper exodus to online trading. By masking the noise from other voices through background music, this provides the shopper with a degree of personal ‘privacy’ as they browse or hold their own conversations with friends or family. Some research has suggested that playing slower music encourages leisurely browsing and helps customers to feel that they have a little more time. Loud music, on the other hand, appears to hasten the customer’s departure. The same principle is thought to apply when people are waiting in line, for example for a prescription to be filled. The wait will feel shorter and less irritating.
Customers may not even consciously be aware that music is playing, but it has real underlying psychological effects. One 2005 study
even suggested that playing classical music in a retail environment encourages customers to buy more expensive products, as it evokes feelings of elegance and high quality.
Another study published in Nature in 1997 went one step further. In this research, different types of music were played in an off-licence — it was shown that when French music was played in-store, people were more inclined to drink French wines. Similarly, when German music was played, more German wines were sold. In the study, the shoppers themselves were unaware on a conscious level of the type of music that was being played.
customers, there are simple steps that can be taken, such as combining the window display with an appropriate choice of music. The authors suggest that audio speakers should be placed at the door so that visitors can hear the music that plays inside. This, combined with an inviting storefront, enhances the shopping experience, they wrote.
Not only does music seem to enhance the shopping experience and help to encourage purchasing, it has been suggested that it also has an effect on overall staff productivity, morale and focus. A study by DJS Research Agency published in 2013 showed that 77 per cent of business owners said their staff were more productive when music was played in their workplace. But, as above, the choice of music is important — a separate study of 1,000 shoppers in the UK revealed that 50 per cent of them had at some time left a store because the music was too loud or irritated them in some way.
In another study published in the Journal ofMarketing in 1990 indicated that different aspects of the music played in-store are important and elicit different responses. For example, low-pitch music is associated with serious thoughts and even sadness, whereas high-pitch tunes provoke happiness. Personal preference in music is also a factor — if a tune is playing that the shopper knows, this familiarity helps to put the shopper at ease.
A 2022 study by researchers in India postulated that while managers may not be able to totally control the purchasing habits of
In recent years more than ever, the online shopping component of retail sales cannot be ignored. A 2022 study looked into this and the authors wrote that their results suggest that while it is not common, playing background music on a website can also affect consumption. “The background music of a shopping site can play a significant role in influencing the experience and behaviour of online shoppers,” they stated. “In this study, we derived a new research model based on the SOR [Stimulus Organism Response] model and explored the effect of the background music on online shoppers through an experimental approach in which a mock shopping website was built. The data analysis showed that consumers' experiences were more positive when there was the background music, regardless of the theme of it. The background music helps create visitors' higher arousal and resulted in more positive shopping experiences.”
Communications consultant and Director of d2 Communications Don Delaney told Irish Pharmacist that the value of this ‘feelgood factor’ should not be underestimated. “Research has shown the benefits of music for the shopping experience. It helps the time to fly by while waiting for a prescription. It might even encourage a shopper to try out some nice new scents for an upcoming concert. It can also help maintain a degree of privacy in helping to mask customers’ conversations with a pharmacist or pharmacy assistant.
“But, more than all of that, it’s the feelgood factor. For a start, it puts colleagues in good humour, and a happy staff means a happy business. If a customer is feeling down, perhaps with a cold or flu, music helps lift their mood too. It can also help spark fun conversations among customers and staff, and people get to know each other – and their musical tastes –better. It even has the potential to lead to love across the pharmacy floor! Now if only we could offer a prescription for that.” l
In recent years more than ever, the online shopping component of retail sales cannot be ignored
Salicylic acid removes scales, distilled coal tar relieves itching, with coconut oil to soften and moisturise the scalp
Prescribing information
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.
e simple fact is that a lot of medicines on the Irish market are now too cheap and money may be the root of all medicine shortages, writes Fintan Moore
Medicine shortages have been the bane of our lives for months now, and it feels like every second prescription has some kind of issue associated with it. I’ve lost track of the number of times I’ve had to change the generic pantoprazole that I’m dispensing. Having said that, at least I
haven’t actually run out of pantoprazole, or at least not yet. The same can’t be said for lots of other medications, even critical items such as paracetamol and prednisolone. Reasons given for a lot of the shortages include manufacturing and supply chain issues caused by Brexit, the Ukraine war, staff unavailability and energy costs, but for a significant
number of them, it simply comes back to money. Whenever you’re looking for the cause of a problem, the root of all evil can always be relied upon.
The simple fact is that a lot of medicines on the Irish market are now too cheap, especially when you consider the extra costs of delivering them from Europe or further afield. If you have a
warehouse full of product in France, why would you bother trying to deliver it to our sodden rock on the edge of the Atlantic when you can just send it a couple of hours down the road to Germany or Italy and sell it at a higher price? To take the products I mentioned above — the factory gate price for 100 paracetamol is €1.73 in Ireland, but the EU average is €7.35. For 98 prednisolone 5mg, the Irish price is €3.06 versus the EU price of €7.49. Simple economics dictates that we’re going to be on the hind teat whenever supplies get allocated. This problem has been brewing for years as our medicine prices came down, and there is no quick fix because it will require a rethink in the decision process for deciding how much the State pays for medication. However, there are obvious measures that could be taken to alleviate the situation in the short-term. For some of the products that are unavailable, there are often unlicensed equivalents that pharmacists are able to source, usually at similar prices to the licensed version. The ULMs are generally from other EU countries, so the standard of manufacture is not a problem. It would be simple for the HSE to arrange a temporary GMS code to allow us to dispense these on State schemes, but the people with power in the HSE don’t seem to like simple answers — and I doubt that we’re paying them less than the EU average.
PROGRAMME NEEDS REBOOTING
Another Government body that could use more pharmacist input is the Medicines Management Programme. To quote the HSE: “The Medicines Management Programme aims to promote safe, effective and costeffective prescribing.” Community pharmacists will know them best for the restrictions brought in on the dispensing of blood-glucose testing strips, and the categorisation of many Oral Nutritional Supplements into List A or List B, depending on their payment
approval. Both of these initiatives have been a pain in the backside to operate, and the inflexibility of the PCRS has been disgusting when it comes to paying for items dispensed in good faith, but not in compliance with the red tape. However, to give credit where credit is due, prior to these changes there was major over-prescribing of test strips and of ONS, so the cost-savings for the State are significant.
The major failure of the people in the MMP is that they seem oblivious to the cost to the State of the bureaucracy surrounding the supply of medication.
from Crumlin Children’s Hospital for a specific strength of Propranolol liquid, and the prescriber was adamant that we dispense that particular strength because it’s the hospital’s preferred option, and changing to a different one would create a risk of dosing error. Fair enough. However, their preferred option doesn’t have a GMS code, even though other strengths of the product do. So for any child with a medical card, the only route to getting the correct medication would be via the Hardship Scheme, despite the associated bureaucratic waste. This is easily fixed, but somebody in authority would have to care.
ME BANANAS
Community pharmacists hate the Hardship Scheme because of the extra administrative workload of getting product approval, the delays in getting paid, and the uncertainty of getting paid correctly. Patients and their families suffer from the stress and delays caused by the approval process. But in addition to the extra workload on the pharmacist, all of these issues similarly require extra work by staff in hospitals getting consultants to request approvals, and by HSE staff processing the approval requests and dealing with claims for payment. The ludicrous part of all this extra work is that it saves the HSE no money whatsoever.
The MMP should be focused on wiping the Hardship Scheme out of existence, or at the very least identifying the top 50 most frequently dispensed items on the Hardship Scheme and issuing them with GMS codes. There are obvious examples — I recently had a prescription
I’m stating the obvious when I mention that prices have been going up a lot on just about everything. We’re all liable to notice it in relation to different things, whether it be the price of a pint, a latte or a litre of diesel. In my case I’m a creature of habit, and I get the same mid-morning snack every working day, and have done for a couple of decades — namely a banana and a raisin scone. Up to a couple of years ago, this combination cost exactly €1. Then about a year ago, the scone went up in price, so the total price became €1.20. Recently, the scone went up again and the banana also went up in price, so my tea-break now costs €1.50. This is a 50 per cent hike over a couple of years. So I’ve got to confess that I’m feeling a bit hard done by when my dispensing fees on State schemes haven’t gone up for about a decade. When the inflation rate was low it didn’t hurt so much, but now it’s a different kind of Banana Republic. l
Fintan Moore graduated as a pharmacist in 1990 from TCD and currently runs a pharmacy in Clondalkin. His email address is: greenparkpharmacy@ gmail.com.
Simple economics dictates that we’re going to be on the hind teat whenever supplies get allocated
*Provides significant improvement in quit rate vs patch alone. To verify contact: verify@perrigo.com Lindson N et al. 2019 Different doses, durations and modes of delivery of nicotine replacement therapy for smoking cessation. Cochrane Library. IRE NIQ 2022 55 NiQuitin CLEAR 24 hrs transdermal patches contain nicotine and are indicated for the relief of nicotine withdrawal symptoms including cravings as an aid to smoking cessation. Indicated in adults and adolescents aged 12 years and over. NiQuitin patches should be applied once a day, at the same time each day and preferably soon after waking and worn continuously for 24 hours. Apply a patch to non-hairy clean dry skin surface, a new skin site should be used every day. Therapy should usually begin with NiQuitin 21 mg/24 hrs and reduced according to the following dosing schedule: Step 1: NiQuitin Clear 21 mg/24 hrs transdermal patches first 6 weeks. Step 2: NiQuitin Clear 14 mg/24 hrs transdermal patches next 2 weeks. Step 3: NiQuitin Clear 7 mg/24 hrs transdermal patches last 2 weeks Light smokers (less than 10 cigarettes per day) are recommended to start at Step 2 (14 mg) for 6 weeks and decrease the dose to NiQuitin 7 mg/24 hrs for the final 2 weeks. In some instances (e.g. heavy smokers, those who have relapsed after NRT, or when one NRT product is not enough to control cravings), NiQuitin patches may be used in combination with a nicotine oral format (refer to the package leaflet for dosing guidance). Contraindications: Non-smokers, hypersensitivity, children under 12 years and occasional smokers. Precaution: Supervise use if hospitalised for MI, severe dysrhythmia or CVA, if haemodynamically unstable. Use with caution in patients with active oesophagitis, oral and pharyngeal inflammation, gastritis, peptic ulcers, GI disturbances, susceptible to angioedema, urticaria, renal/hepatic impairment, hyperthyroidism, diabetes, phaeochromocytoma, seizures & epilepsy. Discontinue if severe persistent skin rash. Pregnancy and lactation: Oral formats preferable to patches unless nauseous. Remove patches at bedtime. Side effects: Sleep disorders, abnormal dreams, insomnia, headache, dizziness, nausea, vomiting, application site reactions, nervousness, palpitations, dyspnoea, pharyngitis, cough, dyspepsia, upper abdominal pain, diarrhoea, constipation, dry mouth, sweating, localised pain, urticaria, hypersensitivity, tremor, nervousness, palpitations, tachycardia, contact & allergic dermatitis, photosensitivity, arthralgia, myalgia, asthenia, malaise, influenza-type illness, fatigue, chest or limb pain, pain, seizures and anaphylaxis. Legal classification: GSL: PA 1186/018/004, PA 1186/018/005 & PA 1186/018/006. MAH: Chefaro Ireland DAC, The Sharp Building, Hogan Place, Dublin 2, Ireland. Date of preparation: 04/2022. RRP (ex. VAT) 7 pack €19.83, 14 pack €35.73. SPC: https://www.medicines.ie/medicines/niquitin-clear-7-mg-24-hours-transdermal-patch-33085/ spc https://www.medicines.ie/medicines/niquitin-clear-14-mg-24-hours-transdermal-patch-33083/spc https://www.medicines.ie/medicines/niquitin-clear-21-mg-24-hours-transdermal-patch-33084/spc NiQuitin Mini 2mg/4mg Mint Lozenges contain nicotine and are used for the treatment of tobacco dependence by relief of nicotine withdrawal symptoms and cravings. Indicated in adults and adolescents aged 12 years and over NiQuitin Mini 2 mg are suitable for those who smoke 20 cigarettes or less a day. NiQuitin Mini 4 mg are suitable for smokers who smoke more than 20 cigarettes a day. Place a lozenge in the mouth whenever there is an urge to smoke, allow to dissolve completely. Do not chew or swallow whole. In heavy smokers, those who have relapsed after NRT, or when one NRT is not enough to control cravings, NiQuitin Minis may be used in combination with NiQuitin patches (refer to the package leaflet for dosing guidance). Abrupt cessation: Use a lozenge whenever there is an urge to smoke, maximum of 15 lozenges a day. Continue for up to 6 weeks, then gradually reduce lozenge use. Gradual cessation Use lozenges whenever there is an urge to smoke in order to reduce the number of cigarettes smoked for up to 6 weeks, followed by abrupt cessation. Adolescents (12-17 years): Only with advice from a healthcare professional. Should not quit with a combination NRT regimen. Contraindications: Hypersensitivity to nicotine or any of the excipients, children under the age of 12 years and non-smokers. Precaution: Supervised use in dependent smokers with a recent myocardial infarction, unstable or worsening angina pectoris including Prinzmetal’s angina, severe cardiac arrhythmias, uncontrolled hypertensions or recent cerebrovascular accident. Use with caution in those with; stable cardiovascular diseases, diabetes mellitus, susceptibility to angioedema & urticaria, renal/hepatic impairment, phaeochromocytoma & uncontrolled hyperthyroidism, GI disease & seizures. Side effects: Nausea, mouth/throat and tongue irritation, irritability, anxiety, insomnia, sleep disorders, dizziness, headaches, cough, sore throat, vomiting, diarrhoea, upper abdominal pain, GI and oral discomfort, flatulence, hiccups, heartburn, dyspepsia, dry mouth, constipation, ulcerative stomatitis, pharyngitis, pharyngolaryngeal pain, nervousness, depression, palpitations, heart rate increased, dyspnoea, rash, angioedema, pruritus, erythema, hyperhidrosis, urticaria, fatigue, malaise, asthenia, chest pain, anaphylactic reactions, hypersensitivity, tremor, dysgeusia, paresthesia mouth, seizures & epilepsy, dysphagia, eructation, salivary hypersecretion, influenza like illness.
“Since I quit smoking, I enjoy a healthier me”
Samantha
The death of a child from an infectious disease is shocking and heartbreaking in equal measure. It’s thankfully so rare nowadays that when it occurs, and the event is local, it understandably causes concern.
In early December, BBC reported the tragic death of a five-year old girl following a spike in Strep A infection locally linked with other child deaths across the UK (there have been an estimated 24 deaths to date). These were stark headlines and the public went straight to panic mode. The media reporting was sustained and sensational in the extreme, calling for another lockdown or at least school closures. The pressure on out-of-hours GP services over that weekend of 3 December was unmanageably intense and by Tuesday, GPs surgeries were still inundated with calls from concerned parents seeking help, and most pharmacies were out of relevant antibiotics. The Belfast Hospital for Sick Children was forced to stop all planned surgeries and appointments as parents of over 200 children arrived seeking attention. It was a huge problem for a health service already under immense pressure.
I do not underestimated the risk to life caused by a spike in Strep A infection, but I do wonder how an infection we know very well and can treat effectively should suddenly become a major public health crisis. Once the public panicked, our ability to manage the surge in a calm, disciplined and dispassionate way disappeared and it became crisis management, with all its attendant risks and inefficiencies.
Central to this crisis was not Strep A but the media, and I think we need to
learn some lessons from what occurred and ensure it doesn’t happen this way again. I am concerned that, on too many occasions and especially when it comes to health, sensationalism can get the better of editors and news-desk producers so that they chase the story with exaggerated statements, and they ignore the damage they are inflicting on the health service.
more children will get more viral and bacterial infections this winter and a very small number will get Strep A infections; strep throat, scarlet fever and the very rare but potentially fatal invasive Gram A Strep (iGAS). In iGAS, the streptococcus enters the systemic circulation and if not treated, can be fatal. So it’s important to identify those with the bacterium, for example those with a red sandpaper-like rash on the body, sore throat, and raised temperature — the classic symptoms of scarlet fever.
In response to the panic, the Public Health Agency gave out clear and essential information in a timely fashion on how to spot these signs and symptoms, and what action to take. There was no need to close down schools, but that seemed insufficient to many interviewers and reporters. Once the panic set in, every child with a runny nose, raised temperature or feeling out of sorts became a potential death about to happen and yes, I get that, I know how scary that is, but I know it didn’t have to be that way.
Strep A infection occurs regularly and we had a spike in infections in 20172018, which across the UK saw over 300 deaths, mostly in older people. We always need to be vigilant, and suspected cases should be treated as soon as possible with appropriate antibiotics, mainly Penicillin V, but others antibiotics are effective, including clarithromycin and amoxicillin. Public health experts are concerned that with the strict lockdowns during the pandemic, there is now an 'immunity debt' in the population, which means
The Pharmacy Network dispensed one month’s supply of liquid antibiotics in a few days and given the number of true infections, this was hard to justify. As the panic progressed, GPs were told to have a high degree of suspicion with any cases presented and if in doubt, prescribe. It was not a good policy. Years of antibiotic stewardship had been squandered and this prescribing has a real potential to create Strep A bacterial resistance that could lead to more than expected deaths in the future. But what else could we do?
In 2019, I assessed the possible use of a
Lessons need to be learned from the media hysteria created by some tragic child deaths in the UK and the Pharmacy Network also could have done better, writes Terry Maguire
The Belfast Hospital for Sick Children was forced to stop all planned surgeries and appointments as parents of over 200 children arrived seeking attention
pharmacy Test and Treat Service for Strep A. It was published in the Pharmaceutical Journal in 2020 and our results were supported by a similar, larger service development study in Wales, which is now commissioned under the Pharmacy First Service for the Welsh population. In our service, 92 patients presented in the pharmacy with symptoms, were assessed using a Centor scale (FeverPAIN) commonly used in A&Es to establish if the sore throat is most likely a virus or a bacterium. Where the score is high, a bacterial infection is more likely and then the bacterium’s presence is confirmed by a simple and inexpensive throat swab test. Of the 92 who presented, 30 were swabbed and 14 had a positive result, and all of the 14 were prescribed penicillin V in the pharmacy under a Patient Group Direction without the need to visit the GP. The others were given reassurance and simple analgesics. In the Welsh service, some 2,000 presented and only 149 warranted swabs, with 36
found to be Strep A positive and all were treated in the pharmacy with Penicillin V. This service is designed to support the Antibiotic Stewardship policy and clearly reduces the inappropriate prescribing of antibiotics by 90 per cent and does not add additional costs, as the GPs were not involved. Sadly, in spite of these results, our health service in N Ireland did not commission the service. If we had, then we could have calmed the panic.
Sadly, community pharmacy’s role in the panic was merely to complain that we did not have stocks of antibiotics and, where we did, it was at a price the health service would not pay, potentially threatening our businesses. And the most disappointing thing for me was that few of us who were featured on the BBC realised how tragic and pathetic this public message was. After 20 years of government saying community pharmacy should be the first port of call for common aliments, we sounded like local grocers.
Perhaps when the panic dies down there can be calm discussions on whether or not it would be appropriate to commission this service as part of our transformed health service.
In the meantime, I would respectfully ask the local media to think about how their reporting in the first week of December 2022 might have exacerbated and disrupted the routine and well established management of an infection and turned it into a crisis where the system nearly lost control. l
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.
This month’s article was inspired by a recent visit to a branch of an Australian chain of DIY/gardening shops with an advertising jingle that is equally familiar to Irish people used to frequenting a very similar chain of shops here. I was there to buy chilli peppers on behalf of my son, who I am convinced is addicted to capsaicin, as my instructions were to ignore common or garden varieties and seek out exotics such as the Carolina Reaper, notorious for its zillions of those Scoville Units used to measure the fiery heat of chillies. While there, my eye was caught by a plant label that stated 'Brahmi — the memory herb'. The plant in question turned out to be Bacopa monnieri, which further intrigued me, as I have up to this time associated the name Bacopa with a white flowering plant that I use as a window box plant at home. But what we call 'Bacopa' is in fact another totally unrelated South African plant named Sutera cordata. Genuine Bacopa has a long history of use in the Indian system of traditional medicine known as Ayurvedic Medicine, particularly in neurodegenerative diseases and memory loss. Because of this, Bacopa has attracted Western attention as a possible source of active molecules of value in such conditions.
In Ayurveda, three energies (Doshas), namely Vata, Pitta and Kapha, are believed to influence the body. A predominance of Vata results in neurodegenerative diseases, including
memory loss. Ayurvedic formulations that balance Vata are of scientific interest as a basis for research into possible medicines targeting such diseases.
The sub-tropical creeper Brahmi, found growing in marshy conditions, is one of the main herbs in such formulations. The sheer number of papers on Brahmi that showed up on my usual PubMed search came as another surprise.
been shown, in a number of animal studies, to enhance aspects of mental function, learning ability and memory. A 2017 paper in the Annals of Neurosciences noted that an extract of Brahmi (EBM) promoted free radical scavenger mechanisms and protected cells in the prefrontal cortex, hippocampus and striatum against cytotoxicity and DNA damage implicated in Alzheimer’s. EBM also reduced anticholinesterase activity comparable to donepezil, rivastigmine and galantamine; reduced β -amyloid deposition in the hippocampus; improved cerebral vasodilation and also total memory score with the maximum effect on logical memory and paired associate learning in humans. There were no reported serious clinical, neurological or haematological complications, with only mild nausea and GIT upsets seen in humans.
The main constituents believed to be responsible for the neuroprotective effect of Bacopa plants are the dammarane-type triterpene saponins Bacoside A and B. A review of the experimental evidence on neuroprotection with Bacopa monnieri appeared in Molecular Biology Reports in 2021. Among the effects relevant to neuroprotective activity noted were antioxidant activity, acetyl-cholinesterase inhibition, β -amyloid reduction, and increased cerebral blood flow. Extracts of the plant standardised on Bacoside content and the isolated bacosides have
A meta-analysis of RCTs on cognitive effects of EBM appeared in the Journal of Ethnopharmacology in 2014. A total of nine studies involving 437 subjects showed improved cognition as measured by the shortened Trail B test and decreased choice reaction time. The authors called for a large, well-designed “head to head” trial against an existing medication to provide definitive data on efficacy in healthy or dementia patients. A more recent meta-analysis was published in Nature Research Scientific Reports in January 20221. Eleven studies involving 645 participants were included in the meta-analysis. Those studies that involved healthy volunteers found
Dr Des Corrigan looks at studies of varying quality into the potential benefits of the so-called 'memory herb'
The sheer number of papers on Brahmi that showed up on my usual PubMed search came as another surprise
one or two measures of memory to have statistically significant differences between the Brahmi treatment and placebo, but any such changes were small. Two trials reported significant improvements in memory in older people with memory loss but who did not suffer from Alzheimer’s. Here again, the effect was modest. The one study in Alzheimer's patients used a polyherbal formulation, making it impossible to attribute any effect to the Bacopa component. That formulation did, however, appear to be equal to donepezil in those patients. This did not prevent the authors from concluding that there is no clinical evidence that Brahmi improves memory in healthy adults or in those with age-related memory complaints.
A 2022 systematic review of randomised controlled trials of Brahmi in the treatment of dementia due to Alzheimer's has appeared online in the Interactive Journal of Medical Research. It found five RCTs eligible for inclusion.
The authors concluded that very lowcertainty evidence suggests that there is no difference between Bacopa and placebo or donepezil in the treatment of Alzheimer’s or mild cognitive impairment in such patients, which is hardly a ringing endorsement. The difficulties inherent in such trials is perhaps illustrated by a 2020 paper in the Annals of the Indian Academy of Neurology, titled 'Efficacy of Bacopa monnieri (Brahmi) and donepezil
in Alzheimer's disease and mild cognitive impairment: A randomised double-blind parallel Phase 2B study'. The paper states that this study of Brahmi versus donepezil showed no significant difference between them after one year of treatment. On the surface this seems positive, until one reads further that the study was terminated after three years and nine months after recruiting just 34 patients because of slow recruitment and a high drop-out rate. On that basis, I wonder why they bothered publishing what is essentially a non-study.
There is also some evidence of an effect in epilepsy and in depression, according to a 2020 clinical study in patients with depression-linked anhedonia published in Phytotherapy Research. There was a statistically significant improvement in the Snaith-Hamilton Pleasure Scale (SHAPS) and in the HAM-D in patients given an extract of Brahmi containing 20 per cent Bacosides along with citalopram compared to a group given citalopram alone.
Given the extent of the pre-clinical data, which is highly impressive, there is clearly potential for using Brahmi extracts and its constituents in these most distressing and intractable of neurodegenerative conditions. However, the quality of the clinical data does not yet match that of its pre-clinical counterpart. It may do so in the future but that, perhaps not surprisingly, has not stopped the supplement industry from marketing a wide range of Brahmi products over the Internet. If you were asked by patients or concerned family members about this herb, the best reply might be 'perhaps, perhaps, perhaps'. l
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
The Covid-19 pandemic has brought extensive changes to the lives of everyone around the world. Even people who do not contract the virus themselves find their worlds transformed: Family members ill or deceased, public health restrictions limiting activities, lives and livelihoods under threat, and free-floating anxiety everywhere. It is an extraordinary time, not least because of the prominence that personal and public health have taken in our day-to-day lives. Issues relating to personal and social responsibility dominate the airwaves, and everyone has learned a new language, from ‘flattening the curve’ to the ‘R number’.
This article focuses on certain aspects of the impact of the pandemic on mental health and, especially, the longer-term psychiatric consequences of infection with Covid-19. In particular, it explores the concept of ‘postCovid-19 syndrome’, which is increasingly recognised as one of the potential sequelae of acute Covid-19.
Unsurprisingly, the Covid-19 pandemic has had a substantial impact on mental health. Evidence to date indicates that the combined effects of the pandemic itself and the public health restrictions it necessitates have resulted in approximately one person in every five in the general population experiencing significantly increased psychological distress.1 This distress commonly manifests as anxiety, stress and symptoms of depression.
The rate of this distress is remarkably consistent across countries, cultures and various different settings. In some ways, we are more similar than we think, especially when
Prof Brendan Kelly and Prof Gautam Gulati discuss the longer-term consequences of the pandemic, including ‘PostCovid-19 syndrome’
confronted with a common challenge, such as the pandemic. Even so, particular risk factors for poor mental health during Covid-19 have been identified, including being female and living alone. This is an especially difficult time for people who had limited social connections prior the pandemic. The advent of Covid-19 has had a particular impact on them as a result of quarantine orders, social distancing and general limits on services and interactions. They require additional support.
Among healthcare workers, rates of psychological distress during the pandemic are approximately double those in the general population. Much of this distress is understandable in the context of the medical emergency triggered by the virus. This has led to longer working hours for many healthcare workers, changing shift patterns, increased pressures in the workplace, and ongoing concerns about infection. These are in addition to further pandemicrelated complexities in the personal lives of healthcare and other workers as a result of restrictions, school closures, family members falling ill, and all of the other consequences of the public health emergency.
Regrettably, many of the steps required to alleviate these problems among healthcare workers are more difficult in a pandemic: Careful rostering, ability to take leave, organisational support from employers, and ‘psychological first aid’ for those in distress. Despite the challenges, all of these measures can help to ameliorate the pressures faced by healthcare workers and other frontline staff, once they are supported by specialist mental healthcare for people who are in particular need. Collegial support is especially important during these difficult times.
In addition to the general stresses of the pandemic, and those specific to healthcare workers, Covid-19 infection itself impacts on mental health in both the short-term (ie, anxiety, depression) and the longer term, especially among those who are hospitalised. These longer-term consequences can include persistent anxiety, post-traumatic stress, post-viral syndromes and various other manifestations of poor mental health.
People with pre-existing mental illness are at particular risk of infection with Covid-19
and require additional support both during the pandemic and in its aftermath. Often, people with chronic mental illness experience difficulty accessing regular health services and preventive care, both of which are especially important at this time.
From the outset, it was clear that the Covid-19 pandemic was likely to affect mental health significantly.2 What is increasingly apparent, however, is that ‘post-Covid-19 syndrome’ is more common and more potentially disabling than many might have expected. In addition, it is also now clear that this syndrome has significant psychological and psychiatric
for Health and Care Excellence (NICE) published an up-to-date Covid-19 Rapid Guideline: Managing the Long-Term Effects of Covid-19 in November 2021, in collaboration with the Scottish Intercollegiate Guidelines Network (SIGN) and the Royal College of General Practitioners (RCGP).4 This guidance provides as much clarity as is possible at the moment, given the evolving state of evidence in this field. Experience with the longer-term effects of Covid-19 is necessarily limited, but knowledge is growing every month.
One of the most useful parts of the guidance from NICE, SIGN and RCGP is its clarification of the terminology used to describe the persistent effects of Covid-19. The document states that post-Covid-19 syndrome is present when signs and symptoms that develop during or after an infection consistent with Covid-19 last for more than 12 weeks and are not better explained by an alternative diagnosis. Often, there are clusters of symptoms, which commonly overlap, can fluctuate, can change over time, and can impact on any body system.
The term ‘long Covid’ describes signs and symptoms that continue or develop after acute Covid-19 infection, and this term therefore includes both ongoing symptomatic Covid-19 (from four-to-12 weeks) and post-Covid-19 syndrome (12 weeks or more).
dimensions that merit close attention and careful management. While information is still relatively scarce, it is useful to reflect on what we know at this point. More information will surely follow.
Within the first year of the pandemic, many clinicians observed that some Covid-19 patients had persistent symptoms of the infection, even after the acute illness had improved and the patient had apparently recovered.3 Common persisting symptoms included fatigue, shortness of breath, joint pain, chest pain and diminished quality of life. It is now clear that, for many patients, these lingering effects of the virus are substantial, disabling and persistent.
In light of a growing body of evidence along these lines, the UK’s National Institute
At this point, more than 250 million people around the world have been infected by Covid-19 (with numbers currently rising, particularly in China). Over five million have died. These statistics are likely to be underestimates, owing to difficulties with diagnosis in many places, suboptimal health services in certain parts of the world, and uneven reporting systems. Future studies are likely to determine that the incidence was higher.
Even based on the figures we have today, however, it is clear that some hundreds of millions of people will be at risk postCovid-19 syndrome after this pandemic ends. The implications for public health are enormous. The prominence of psychological and psychiatric symptoms in this syndrome suggests that the implications for public
Among healthcare workers, rates of psychological distress during the pandemic are approximately double those in the general population
mental health will form an especially challenging part of the work that lies ahead. With this in mind, it is important to establish precisely how common post-Covid-19 syndrome is, in order to estimate future healthcare needs. One cohort study followed up 277 Covid-19 patients and identified post-acute Covid-19 syndrome in 50.9 per cent of them between 10 and 14 weeks after disease onset.5 Radiological and spirometric changes tended to be mild and were found in less than 25 per cent of patients. By way of contrast, over one-third of these patients experienced fatigue and two-thirds of those with post-acute Covid-19 syndrome reported diminished quality of life. Clearly, this is a syndrome with substantial psychological and neuropsychiatric components that are significantly disabling for many sufferers. Symptoms of poor mental health are present even in the early stages after acute infection. Studies conducted two weeks after physical recovery from Covid-19 detect high levels of anxiety (22 per cent), depression (21 per cent), and post-traumatic stress disorder (20 per cent) among patients.6 Over one-third (36 per cent) report psychological distress, and a similar proportion (35 per cent) have sleep disorders. These problems appear to be more common among survivors of Covid-19 than certain other infections. Rates of anxiety and depression following Ebola, for example, are 14 per cent and 15 per cent, respectively, compared to 22 per cent and 21 per cent with Covid-19. It is not entirely clear why Covid-19 is especially corrosive of mental health, but it is.
To compound matters, these psychiatric sequelae of Covid-19 tend to persist. In the first six months after infection, one-third of patients have a neurological or psychiatric diagnosis, increasing to almost half (46.4 per cent) of those admitted to intensive therapy units.7 Anxiety disorders, in particular, are present in 17.4 per cent of all Covid-19 patients during this period, and 19.1 per cent of those admitted to intensive therapy units. Again, these problems appear more common following Covid-19 than other infections. For example, the risk of psychosis following Covid-19 is twice as high as it is following influenza. Again, Covid-19 presents a particular risk to mental health, even in its aftermath.
Most healthcare professionals are familiar with different post-viral syndromes that affect our patients to varying degrees. The mental health consequences of Covid-19, however, appear especially common and severe, and therefore the challenges to mental health services and public mental health will be even greater. Even the bare numbers of people affected by Covid-19 are sufficient to confirm that postCovid-19 syndrome will be a health issue of the greatest magnitude in the years ahead.
In the first instance, adhering to public health guidance, promoting vaccination, and supporting good general health are all important preventive measures for Covid-19
in the first place. Prompt diagnosis and treatment of Covid-19 infection is also vital. The basics still matter and will hopefully prevent yet more people being at risk of post-Covid-19 syndrome in the future.
Second, we need to identify post-Covid psychiatric symptoms as early as feasible and provide appropriate multidisciplinary care. There is very little evidence about the usefulness of specific psychiatric treatments during the post-Covid period in particular, but the usual principles of bio-psychosocial psychiatry will clearly still apply.
Third, we need more data. Longitudinal studies are essential to better understand post-Covid-19 syndrome, calculate its incidence, estimate the public health impact, and — hopefully — identify specific interventions that work. The need for information has never been greater. Now that this syndrome is recognised, this information can hopefully be gathered and used to relieve the considerable suffering associated with the condition. l
AUTHOR: Prof Brendan Kelly, Professor of Psychiatry, Trinity College Dublin, and Prof Gautam Gulati, Consultant Forensic Psychiatrist and Adjunct Professor at the University of Limerick. Prof Kelly is author of The Science of Happiness: The Six Principles of a Happy Life and the Seven Strategies for Achieving It (Gill Books, 2021). Prof Gulati is co-author of Psychiatry Algorithms in Primary Care (WileyBlackwell, 2021).
1. Kelly BD. Impact of Covid-19 on mental health in Ireland: evidence to date. Ir Med J 2020; 113: 214-7.
2. Cullen W, Gulati G, Kelly BD. Mental health in the Covid-19 pandemic. QJM 2020; 113: 311-2.
3. Mahase E. Covid-19: What do we know about ‘long Covid’? BMJ 2020; 370: m2815.
4. National Institute for Health and Care Excellence (NICE), Scottish Intercollegiate Guidelines Network
(SIGN), Royal College of General Practitioners (RCGP). Covid-19 Rapid Guideline: Managing the LongTerm Effects of Covid-19. London, National Institute for Health and Care Excellence, 2021.
5. Moreno-Pérez O, Merino E, LeonRamirez J-M, Andres M, Ramos JM, Arenas-Jiménez J, et al. Post-acute Covid-19 syndrome. Incidence and risk factors: a Mediterranean cohort study. J Infect 2021; 82: 373-8.
6. Khraisat B, Toubasi A, AlZoubi
L, Al-Sayegh T, Mansour A. Meta-analysis of prevalence: The psychological sequelae among Covid-19 survivors. Int J Psychiatry Clin Pract 2021: 1-10. [Epub ahead of print].
7. Taquet M, Geddes JR, Husain M, Luciano S, Harrison PJ. 6-month neurological and psychiatric outcomes in 236 379 survivors of Covid-19: A retrospective cohort study using electronic health records. Lancet Psychiatry 2021; 8: 416-27.
Couples with fertility difficulties sometimes face a long and difficult road to conception, but advances in fertility treatment provide hope
It is estimated that approximately one-in-six couples in Ireland struggle with fertility problems. However, according to the HSE, some 85 per cent of couples conceive a child naturally after one year of trying (the Executive defines ‘trying’ as unprotected sex every two-to-three
days for one year). Ninety-five per cent of couples usually conceive successfully after two years.
Despite these high rates, the process of conception is complex and requires each step of the reproduction process to happen successfully. The physiological steps are as follows:
1. One of the woman’s ovaries releases a mature egg.
2. This egg is picked up by the fallopian tube.
3. Sperm ‘swim’ up the cervix, pass through the uterus, and move into the fallopian tube in order to reach the egg for fertilisation.
4. The fertilised egg then travels down the fallopian tube to the uterus.
5. The fertilised egg implants on the inside of the uterus and subsequently grows. There are two basic types of infertility: Primary infertility, where the woman who has never been pregnant has problems conceiving, either through a flaw in the reproductive system of her or her partner; or secondary infertility, where the couple have had previous successful pregnancies, but are having difficulty conceiving again. A GP will refer a couple to specialist clinic if necessary. However, despite advanced modern testing being thorough, in 20 per cent of cases of infertility in Ireland, no specific cause is ever found. There are a number of risk factors associated with infertility, some of which are within the patient’s control. These include:
Body weight: A BMI over 30 is known to reduce fertility in both men and women. In addition, if a woman is underweight and has a BMI of less than 18, this can affect successful ovulation.
Smoking: Quitting the habit will improve the quality of sperm in men, and also for women, quitting smoking increases the chances of successful conception. Second-hand smoke can also affect the chances of becoming pregnant.
Age: This is a factor for women more than men, and fertility may decline from the mid-30s.
Alcohol consumption: Similar to smoking, excessive alcohol can reduce the quality of a man’s sperm.
Sexually-transmitted infections: These can have a negative effect on fertility.
Stress: When under severe stress, fertility can be affected.
Environmental exposure: For men, exposure to some metals, solvents and certain pesticides can affect sperm health.
While some of the above factors can be addressed, many couples find themselves unable to conceive due to physiological reasons. For these couples, in-vitro fertilisation (IVF) represents an option to greatly improve their chances of conceiving. IVF can help couples to overcome whatever may be preventing fertilisation.
The issues that can interfere with fertilisation are varied, but may include damage to the fallopian tubes. This could be caused by a number of factors, including previous surgeries (also surgeries to the lower abdomen), pelvic inflammatory disease, tubal ligation, fibroids or polyps
As mentioned above, another potential cause of infertility is an excess of prolactin. Prolactin is the hormone responsible for milk production/lactation and certain breast tissue development — high levels in the bloodstream can manifest as irregular periods, infertility, or erectile dysfunction in men.
In terms of male fertility, around four-in-10 couples cannot conceive because of reproductive issues, which are most commonly problems with the man’s sperm. The sperm count may be low, the sperm may not be as mobile as they once were, or they may be abnormal under microscopic examination. This can result in them having difficulty in penetrating the egg.
Low sperm count is considered to be a contributory factor if the man has less than 15 million sperm in a millilitre of semen. However, the quality of the sperm is also an important consideration.
in the uterus, ectopic pregnancy, or endometriosis. In addition, a submucosal fibroid can grow from the muscle wall and into the fallopian tube, which can also affect fertility by blocking the tube. Sometimes, ovulation disorders can affect fertility and mean that an egg is not produced each month. Ovulation disorders can be a result of:
Excessive exercise.
Polycystic ovarian syndrome.
Unhealthy BMI or stress (as stated above).
Hormonal problems (such as thyroid gland).
Over-production of the hormone prolactin.
Early menopause also prevents conception. Although menopause in women under the age of 40 happens to only one-in-100 women, it obstructs successful pregnancy and is also termed ‘premature ovarian failure’.
A wide range of varied factors can influence sperm quality — aside from the obvious risk factors, sperm can be damaged by cocaine or cannabis, genetic disorders, certain medications, hormone problems, and surgery or tumours on the testes, among other factors. Chemotherapy or radiation therapy have the potential to eliminate sperm completely. Certain issues, such as hormonal problems, can be treated with the right medications.
A range of tests in a fertility clinic or hospital department will investigate the potential causes of infertility and specialists will recommend a course of treatment individualised to the couple’s circumstances. These may include fertility assessments, and the earlier a problem is detected, the better the chances of achieving a positive outcome. The clinic may recommend further diagnostic testing to follow-on from basic testing.
Female fertility assessment may involve BMI assessment, as being
In 20 per cent of cases of infertility in Ireland, no specific cause is ever found
Folic Acid - helps prevent Spina Bifida and other NTDs1.
Clonfolic is the market-leading brand2. Take one tablet daily.
Folic Acid - helps prevent Spina Bifida and other NTDs1.
Clonfolic is the market-leading brand2. Take one tablet daily.
• Studies have shown over 70% of first time NTDs1, such as Spina Bifida can be prevented by taking 0.4mg of folic acid daily.
• Almost 50% of pregnancies are unplanned.
• Studies have shown over 70% of first time NTDs1, such as Spina Bifida can be prevented by taking 0.4mg of folic acid daily.
• It’s important to take 0.4 mg of folic acid every day for at least 14 weeks before you become pregnant and continue taking it for at least the first 12 weeks of pregnancy.
• Almost 50% of pregnancies are unplanned.
• It’s important to take 0.4 mg of folic acid every day for at least 14 weeks before you become pregnant and continue taking it for at least the first 12 weeks of pregnancy.
Clonfolic.ie
Clonfolic is contraindicated in cases of Vitamin B12 deficiency. Caution is advised for patients under therapy for folate-dependent tumours when taking folic acid. Women with pre-existing diabetes, obesity, family history of neural tube defects, or previous pregnancy affected by neural tube defect have an increased risk of having a pregnancy affected by a neural tube defect and higher doses should be considered. For women taking anti-seizure medication the requirement for folic acid may be different and they should be under the supervision of a physician while taking folic acid supplements. The tablet also includes lactose monohydrate. A copy of the summary of product characteristics is available on request. Clonfolic 0.4mg tablets. PA 126/95/1. PA Holder: Clonmel Healthcare Ltd, Waterford Road, Clonmel, Co Tipperary, Ireland. www.clonmel-health.ie Medicinal product not subject to medical prescription. Supply through general sales.
References: 1. NTDs (neural tube defects). 2. Leading sales brand in pharmacy – IQVIA, IRLP audit, units, MAT Jan 20. Date prepared July 2020. 2020/ADV/CLO/048H
Clonfolic is contraindicated in cases of Vitamin B12 deficiency. Caution is advised for patients under therapy for folate-dependent tumours when taking folic acid. Women with pre-existing diabetes, obesity, family history of neural tube defects, or previous pregnancy affected by neural tube defect have an increased risk of having a pregnancy affected by a neural tube defect and higher doses should be considered. For women taking anti-seizure medication the requirement for folic acid may be different and they should be under the supervision of a physician while taking folic acid supplements. The tablet also includes lactose monohydrate. A copy of the summary of product characteristics is available on request. Clonfolic 0.4mg tablets. PA 126/95/1. PA Holder: Clonmel Healthcare Ltd, Waterford Road, Clonmel, Co Tipperary, Ireland. www.clonmel-health.ie Medicinal product not subject to medical prescription. Supply through general sales.
References: 1. NTDs (neural tube defects). 2. Leading sales brand in pharmacy – IQVIA, IRLP audit, units, MAT Jan 20. Date prepared July 2020. 2020/ADV/CLO/048H
either over- or underweight can affect prospects of female fertility. Ovarian assessments may also be carried out to establish the number of eggs that remain — some couples decide to have a child later in life, and the amount of fertile time a woman has left in life can be established. A vaginal ultrasound scan may also be appropriate to look for any abnormalities. Other ultrasound tests may be necessary, such as on the fallopian tubes, and an x-ray may also be necessary to check for blockages in these tubes. There are other specialist tests that may be required, such as screening for undetected infections.
Male fertility assessment can involve a semen test to assess motility and sperm count, as well as other diagnostic factors. A couple may also be tested simultaneously.
As well as offering lifestyle advice, a fertility specialist may recommend medical or surgical treatment if a problem is detected. Medications can sometimes help if a fallopian tube is blocked, or to help stimulate ovulation. For women with polycystic ovarian syndrome, a medication commonly used for diabetes treatment (metformin) is sometimes used to improve fertility.
Some clinics use genetic testing if it is suspected that the infertility is caused by an inherited condition. In this procedure, pre-implantation genetic testing assesses an embryo for inherited disease prior to both implantation and the pregnancy itself. One important aspect of this is to minimise the risk of passing the condition on to future generations.
Some of the diseases that have the potential to be passed on to the next generation include cystic fibrosis, Beta Thalassaemia (an inherited blood disorder in which the body makes suboptimal levels of beta globin), and Fanconi anaemia (a rare disease passed down through families that mainly affects bone marrow).
Specialist clinics will also offer a number of other procedures to assist fertility. These are broadly described as:
IVF: This is where a woman’s eggs are fertilised with a man’s sperm in a laboratory in a bid to create embryos. The embryos are assessed for quality and the best one is then transferred to the womb, usually followed by medication to help the ovaries to produce eggs. When these eggs have been retrieved, they are mixed with sperm to form embryos, which are then inserted in the womb. Remaining embryos that are of good quality can then be frozen for later use if necessary. The HSE estimates that approximately one-in-four IVF procedures results in a successful pregnancy.
This is a basic guide only and different clinics may vary in their approach. There are some potential complications associated with fertility treatment that the couple should be aware of. These include the potential for twins and other multiple pregnancies, which are more common after undergoing fertility treatment. The potential for an ectopic pregnancy is also increased following fertility treatment.
Another potential complication of fertility treatment is ovarian hyperstimulation. When ovaries are over-stimulated, this can result in some cysts on the ovaries, so these women will be monitored by the clinic using ultrasound scans. The symptoms of ovarian cysts include bloated stomach, nausea and vomiting.
STIGMA
Intrauterine insemination (IUI) is where a sample of a man’s sperm is injected into a woman’s womb using a small plastic tube. This may be accompanied by medications to stimulate ovulation.
Intracytoplasmic sperm injection (ICSI): This is where the sperm is injected directly into the egg. Only one sperm is required for ICSI, so this method may be preferred if the male has a low sperm count, or if the sperm have reduced motility and poor ability to penetrate the egg.
Sometimes, surgery may be required to improve the chances of conceiving. Typical instances where surgery is necessary include when unblocking or repairing fallopian tubes, or in treating endometriosis. Surgery may also be necessary to remove scar tissue from the pelvis, or laparoscopic drilling for polycystic ovarian syndrome may be required.
Research into Irish couples with fertility issues, published in the journal Human Fertility, examined the journey of 12 Irish couples along their IVF treatment and their final outcomes. The research, which was funded by the Health Research Board, showed that these couples were initially shocked by their inability to conceive, as they felt they were ready to have a child in terms of finances and other life circumstances. While they stayed patient, the couples increasingly experienced feelings of stigma, social exclusion and regret. Finally, the couples sought medical advice and began their IVF journey and they stated that going through the procedures stiffened their resolve.
The authors wrote: “The findings suggest that health policy should raise awareness of infertility and advise women to become aware of it — just as in the past, when health policy addressed contraception. Increased public knowledge would reduce the stigma attached to the inability to have a baby. In the Irish case, infertility diagnosis should be reviewed with a view to giving eligible couples earlier access to IVF.” l
References on request
Ovarian assessments may also be carried out to establish the number of eggs that remain
Vitamins and minerals are chemical compounds necessary for homeostasis and metabolism, and are essential micronutrients required in the human body in varying amounts. There are 13 vitamins, organic substances that fall into two groups: Water-soluble, and fat-soluble vitamins. The fat-soluble vitamins are A, D, E and K and the water-soluble vitamins include the B complex vitamins and vitamin C. There are eight B vitamins, including B1, B2, B3, B5, B6, B7, B9 and B12.1
Minerals are inorganic micronutrients and are divided into two main categories: Major minerals, and trace minerals. Major minerals are required in the body in greater amounts than trace minerals. Major minerals include calcium, phosphorus, potassium, sodium, chlorine, magnesium, and sulphur. Trace minerals include iron, iodine, fluoride, zinc, manganese, chromium, cobalt, molybdenum, copper, and selenium.3
Vitamins and minerals are called micronutrients because unlike macronutrients (proteins, fats and carbohydrates), they are required in only very small amounts in the body. However, the absence of vitamins and minerals in the body can contribute to various illnesses. Although vitamins and minerals are both micronutrients, they differ in basic ways. Vitamins are organic substances that can be broken down by heat, air, or acid, while minerals are inorganic and maintain their chemical structure.2
Vitamins and minerals are required in small amounts for normal growth, development and ongoing wellbeing. They are found naturally in the diet; however,
Theresa Lowry Lehnen provides a clinical overview of the importance of a number of vitamins and minerals for overall health and wellbeing
food supplements may be used to augment dietary intakes of vitamins and minerals and are specifically recommended at life stages, ie, folic acid for women of childbearing age, and vitamin D in infancy.5
Most vitamins can be provided solely in the diet. Requirements for some vitamins can be partly met through direct or indirect synthesis in the body, ie, vitamin D can be formed in the skin on exposure to UVB radiation, niacin can be synthesised from the amino acid tryptophan, and vitamin K can be produced by bacterial fermentation in the gut. However, as biological synthesis of these nutrients is limited for various reasons, dietary intake remains essential to meet physiological requirements.5
Excess of some vitamins and minerals can have detrimental effects on health, therefore, EU legislation provides for the setting of maximum safe levels of vitamins and minerals in food supplements by the European Commission. However, these are yet to be established. Currently, maximum levels of vitamins and minerals in food supplements are at the discretion of the manufacturer, provided the supplement is not unsafe. In the absence of official EU maximum levels, the Food Safety Authority of Ireland (FSAI) evaluates the safety of vitamins and minerals in food supplements in Ireland to protect consumer health and to provide guidance to the food industry. When consumed according to manufacturer’s instructions, the daily amount of a micronutrient in a food supplement as labelled, added to the usual daily intake from food sources (from foods including fortified foods, excluding supplements) of the highest consumers (95th percentile), should not exceed the tolerable upper intake level (UL) for the population groups for whom the food supplement is intended.5
COMPLEX AND VITAMIN C
There are nine water-soluble vitamins, the B complex vitamins (thiamine, riboflavin, niacin, pantothenic acid, pyridoxine, biotin, folate, and cobalamin), and vitamin C.
Water-soluble vitamins dissolve in water upon entering the body. They are not stored in the body, and excess amounts are excreted in the urine. Regular intake is required to avoid deficiency due to the transient nature of water-soluble vitamins.6
VITAMIN B1 (THIAMINE): Thiamine, or vitamin B1, acts as a coenzyme in carbohydrate and branched-chain amino acid metabolism. It helps the body to break down and release energy from foods, and keeps the nervous system healthy. Thiamine is found in food sources such as wholegrain breads, legumes, nuts, fortified breakfast cereal, and liver. The RDA of thiamine for adults aged 19-to-64 is 0.8mg/day for women and 1mg/day for men. 3, 4
for adults aged 19-to-64 is 13.2mg/day for women, and 16.5mg/day for men.3, 4
VITAMIN B5 (PANTOTHENIC ACID): Pantothenic acid, or vitamin B5, has several functions, such as helping the body release energy from foods. It acts as a key component of coenzyme A and phosphopantetheine, which are crucial for fatty acid metabolism. Pantothenic acid is widespread in foods, including all vegetables, wholegrain foods and meats. There is no listed RDA in Ireland for pantothenic acid.3, 4
VITAMIN B6 (PYRIDOXINE): Vitamin B6, or pyridoxine, acts as a coenzyme for amino acid, glycogen, and sphingoid base metabolism. Vitamin B6 is found widespread in food groups. The RDA for adults aged 19-to-64 is 1.4mg/day for men, and 1.2mg/day for women.3, 4
Vitamin B7 (biotin): Biotin, or vitamin B7, acts as a coenzyme in carboxylation reactions dependent on bicarbonate. It is needed in very small amounts to help the body make fatty acids. Biotin is found widespread in foods, especially egg yolks, soy beans, and whole grains. There is no RDA for biotin, however, taking too much may be harmful. 0.9mg or less daily in supplement form is unlikely to cause any harm. 3, 4
VITAMIN B2 (RIBOFLAVIN): Riboflavin, or vitamin B2, acts as a coenzyme in redox reactions. Riboflavin is present in food sources such as enriched and whole grains, milk and dairy products, leafy vegetables, and beef. The RDA of riboflavin for adults aged 19-to-64 is 1.1mg/day for women, and 1.3mg/day for men.3, 4
VITAMIN B3 (NIACIN): Niacin, or vitamin B3, acts as a coenzyme to dehydrogenase enzymes in the transfer of the hydride ion, and is an essential component of the electron carriers NAD and NADP. Niacin provides the release of energy from foods, and helps keep the nervous system and skin healthy. It is present in enriched and whole grains and high-protein foods such as meat, milk, and eggs. The RDA of niacin
VITAMIN B9 (FOLATE): Folate, or vitamin B9, acts as a coenzyme in singlecarbon transfers in nucleic acid and amino acid metabolism. It is found in enriched and fortified grains, green leafy vegetables, and legumes. Folate helps the body to form healthy red blood cells. The RDA of folate for adults is 200mcg/day. The man-made form of folate is folic acid. The recommendation for pregnant women or women trying to conceive is 400mcg/day of folic acid from supplements until 12 weeks' pregnant, to decrease the risk of neural tube defects in the unborn baby. Women at risk of a pregnancy affected by a neural tube defect are advised to take 5mg of folic acid daily until 12 weeks' pregnant.3,4
VITAMIN B12 (COBALAMIN): Vitamin B12, or cobalamin, acts as coenzymes for the crucial methyl transfer reaction in
Thiamine, or vitamin B1, acts as a coenzyme in carbohydrate and branched-chain amino acid metabolism
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converting homocysteine to methionine and the isomerisation reaction that occurs in the conversion of L-methylmalonyl-CoA to succinyl-CoA. Vitamin B12 is only present in animal products because it is a product of bacteria synthesis. Many foods are also fortified with synthetic vitamin B12. The RDA of vitamin B12 for adults aged 19-to-64 is 1.5mcg/day. A lack of vitamin B12 can lead to vitamin B12 deficiency anaemia.3, 4
VITAMIN C (ASCORBIC ACID): Vitamin C, or ascorbic acid, is an essential water-soluble vitamin that acts as a reducing agent in enzymatic reactions and non-enzymatically as a soluble antioxidant. It helps protect cells, keeping them healthy, and is important for healthy skin, blood vessels, bones and cartilage, and promotes wound healing. Vitamin C is found primarily in fruits and vegetables, and also in some foods of animal origin, such as liver and kidneys. The RDA of vitamin C for adults aged 19-to-64 is 40mgs. When deficiency occurs, it can result in scurvy, which can present with swollen and bleeding gums, loss of teeth, poor woundhealing, and poor tissue growth.3, 4, 6
FAT-SOLUBLE VITAMINS
(A, D, E AND K)
The body absorbs fat-soluble vitamins into newly-forming micelles in the small intestine. Micelles are lipid clusters that contain hydrophobic groups internally, and hydrophilic groups externally. This process relies on the secretion of bile and pancreatic enzymes. After absorption into enterocytes, fat-soluble vitamins become packaged into chylomicrons, which then get secreted into the lymphatic system before entering the bloodstream. Chylomicrons are metabolised by lipoprotein lipase, which causes the release of fat-soluble vitamins into tissues for use and storage.7
Unlike water-soluble vitamins, fat soluble vitamins are stored in the body. Whilst the body needs fat soluble vitamins every day to work properly, foods containing them do not need to be consumed daily. If the body does not require fat soluble vitamins for immediate use, it stores them in the liver and fatty tissues for future use. However, too much fat-soluble
vitamins accumulated in the body can be harmful, and fat-soluble vitamins consumed in excess pose a greater risk of causing toxicity than water-soluble vitamins.5
VITAMIN A (RETINOL): Vitamin A is a generic descriptor for compounds that exhibit the biological activity of retinol and provitamin A carotenoids. Retinol is an unsaturated 20-carbon cyclic alcohol. Provitamin A carotenoids exhibit a 40-carbon basal structure with cyclic end groups and a conjugated system of double bonds.3 Vitamin A, its analogues and its metabolites, function in vision, cell differentiation, embryogenesis, the immune response, reproduction and growth. Carotenoids also have a variety of different actions, including possible antioxidant activity, immune-enhancement, inhibition of mutagenesis and transformation, reduced risk of age-related macular degeneration and cataracts, decreased risks of some cancers, and decreased risk of cardiovascular events. Good sources of vitamin A include cheese, eggs, oily fish, fortified low-fat spreads, milk, yogurt, liver and liver products. The body can convert beta-carotene into vitamin A. The main food sources of beta-carotene are yellow, red and green leafy vegetables, such as spinach, carrots, sweet potatoes, red peppers, and any yellow fruit such as apricots, mango and papaya.4 RDA of vitamin A for adults aged 19-to-64 are 600ug for women, and 700ug for men. Vitamin A deficiency is common in the developing world, but is rare in developed countries. Severe deficiency causes night blindness and xerophthalmia, Bitot’s Spots, xerosis conjunctiva, and keratomalacia. 5
VITAMIN D (CHOLECALCIFEROL):
Vitamin D helps regulate the amount of calcium and phosphate in the body, which helps keep bones, teeth and muscles healthy. Vitamin D is found primarily in two forms, D2 and D3. The body produces vitamin D3 (cholecalciferol) naturally from direct sunlight on the skin, hence the name the ‘sunshine vitamin’. However, there are very few rich natural food sources of vitamin D2 (ergocalciferol), and the main dietary sources are oily fish, cod liver oil, egg yolk and fortified foods. Studies have shown that adults in Ireland have low vitamin D
levels. A lack of vitamin D can lead to bone deformities such as rickets in children, and osteomalacia in adults.4 Vitamin D is measurable in the serum in two forms, 25-hydroxyvitamin D and 1,25-dihydroxy vitamin D. 25-hydroxyvitamin D is the principal circulating form (levels in ng/ ml). It has a half-life of two weeks, and is the best measure of vitamin D status. Testing is indicated in populations at high risk for fractures, including those with osteoporosis, osteopaenia, and the elderly.7
Infants from birth to one year of age who are being breastfed should be given a daily supplement containing 5 micrograms (µg) of vitamin D. This should be provided by a supplement containing vitamin D exclusively. Infants from birth to one year of age who are fed infant formula should not be given a daily vitamin D supplement if they are having more than 300ml of infant formula a day. This is because infant formula is fortified with vitamin D and other nutrients.5,7 Children aged one-tofour years require 4-5µg of vitamin D as a supplement between October and March. It is difficult for people to get enough vitamin D from sunlight and food alone, and a supplement of 10µg is recommended for adults and children over four years of age during the autumn and winter months (October-March).8 Taking more than 100µg of vitamin D a day can be harmful for adults, the elderly and children aged 11-to17. Children aged one-to-10 years should not have more than 50µg of vitamin D daily and infants under 12 months should not have more than 25µg daily.8
Vitamin D toxicity, although rare, can occur in individuals taking large doses of vitamin D supplements with a heavy intake of fortified foods. Most symptoms of hypervitaminosis D stem from hypercalcaemia caused by excessive calcium absorption in the duodenum and distal convoluted tubule. Clinical manifestations include gastrointestinal issues such as decreased appetite, diarrhoea, nausea, vomiting, and constipation. Hypercalcaemia can result in polyuria, polydipsia, pruritus, and the development of kidney stones. Bone, muscle, and joint pain are also common manifestations.7
VITAMIN E (TOCOPHEROL): Vitamin E encompasses eight lipophilic compounds that include four tocopherols and four tocotrienols, each of which has a designation as α-, β-, γ-, and δ-. Each of these compounds contains a chromanol ring and a lipophilic tail. Tocotrienols differ from tocopherols with their unsaturated side chains. α-tocopherol is the only form of vitamin E that is known to reverse deficiency symptoms.3 Vitamin E helps strengthen the immune system and maintain healthy skin and eyes. Good sources of vitamin E include plant oils, nuts and seeds and wheatgerm. The RDA is 4mg/day for men and 3mgs/day for women.9
VITAMIN K (PHYLLOQUINONE; MENAQUINONE): Vitamin K occurs naturally in two main forms: K1 (phylloquinone), and K2 (menaquinone), which has many different forms. Vitamin K also occurs in the synthetic form of vitamin K3 (menadione), which contains only the 2-methyl-1, a 4-naphthoquinone nucleus common to all forms of vitamin K. The natural forms differ by the number of isoprenoid units in their isoprenoid side chains.3 Vitamin K is needed in the body for blood clotting and wound-healing. It is present in green leafy vegetables, cabbage, and cauliflower, and lesser quantities are found in fish, meat, and some fruits. Adults need approximately 1µg of vitamin K for each kg of their body weight.10 Vitamin K is stored predominantly in the liver in the form of menaquinone and is excreted in the urine and faeces.3
MINERALS: MAJOR AND TRACE MINERALS
MAJOR MINERALS: Major minerals required in the body include calcium, phosphorus, potassium, sodium, chlorine, magnesium, and sulphur.
CALCIUM: Calcium is important for strong bones and teeth, muscle contraction and blood clotting. Sources of calcium in the diet include milk, cheese and dairy products, green leafy vegetables, sardines, and foods fortified with calcium, such as bread.11 The intestine, kidney, bone, and parathyroid gland work together to tightly regulate calcium balance in the body. Most of the calcium is absorbed in the small intestine
via paracellular diffusion. The remainder of calcium is absorbed transcellularly through the calcium channel TRPV6 when luminal calcium levels are low. Some 99 per cent of the calcium in the body is found in the bones and teeth, while the remainder is found in soft tissues and plasma, both intracellularly and extracellularly. Most calcium is reabsorbed in the kidney, but the remainder is excreted in urine and faeces.3 Adults aged 19-to-64 need 700mg of calcium/day.11
PHOSPHORUS: Phosphorous is a mineral that helps build strong bones and teeth and release energy from food. Good dietary sources include red meat, dairy products, fish, poultry, bread, brown rice and oats. Adults require 550mg of phosphorous per
19-to-64 need 3,500mg of potassium daily.13 Most of the dietary potassium is absorbed in the small intestine via passive transport. The kidney maintains potassium homeostasis. About 90 per cent of the potassium consumed is excreted in the urine, with the remaining small amount excreted in stool and sweat. Most of the potassium content in the body is found in the intracellular space of the skeletal muscle.3
day.12 Throughout the body, phosphorus is distributed 85 per cent in the skeleton, 0.4 per cent in the teeth, 14 per cent in the soft tissue, 0.3 per cent in the blood, and 0.3 per cent in the extravascular fluid. The kidney plays a role in phosphorus homeostasis through the reabsorption of inorganic phosphate from the glomerular filtrate in the proximal convoluted tubule. Approximately 75-to-85 per cent of phosphorus is reabsorbed per day, and the remainder is excreted in the urine.3
POTASSIUM: Potassium helps regulate fluid balance, muscle contractions and nerve signals, and supports normal blood pressure. Good dietary sources of potassium include bananas, vegetables such as broccoli and brussels sprouts, beans and pulses, nuts and seeds, fish, beef and chicken. Adults aged
SODIUM CHLORIDE: Sodium and chloride minerals are needed in small amounts to maintain the fluid balance in the body. Chloride also helps the body digest foods. Adults should consume no more than 6g of sodium daily.14 Sodium and water balance are closely linked and maintained by the kidneys. Half of the sodium in the body is found in extracellular fluid, while around 10 per cent is found in intracellular fluid. The remaining 40 per cent of sodium is found in the skeleton. Small losses of sodium can occur through urine, faeces, and sweat.3 The kidneys regulate chloride concentration. Around 99 per cent of chloride is reabsorbed in the proximal tubule of the kidneys both paracellularly and transcellularly via the Cl−/HCO3− exchanger. The remainder of chloride can be excreted in urine, faeces, or sweat.3
MAGNESIUM: Magnesium is necessary in the body to convert food into energy, and is important for proper functioning of the parathyroid glands. Good sources of dietary magnesium include spinach, nuts and wholemeal bread. The RDA for adults aged 19-to-64 is 300mgs/day for men, and 270mgs/day for women.15 About 70 per cent of serum magnesium is available for glomerular filtration, and 96 per cent of the filtered magnesium is reabsorbed in the kidneys through several mechanisms in the proximal tubule, ascending limb, and distal tubule. The remaining magnesium
Magnesium is necessary in the body to convert food into energy, and is important for proper functioning of the parathyroid glands
is excreted in the urine. Some 99 per cent of magnesium in the body is stored intracellularly in bone, muscle, and soft tissues, while 1 per cent of magnesium in the body is found in extracellular fluid.3
SULPHUR: Sulphur is necessary for insulin production, and enables the cells of the body to use glucose as energy. Keratin, a sulphurcontaining protein, is a key structural component of the outer layer of human skin. Sulphur is involved in certain amino acid production in the body, and in the synthesis of collagen. There is no RDA for sulphur in the diet. Sources include dairy, eggs, beef, poultry, seafood, onions, garlic, turnips, kale, and broccoli.3
TRACE MINERALS: Trace minerals include iron, iodine, fluoride, zinc, manganese, chromium, cobalt, molybdenum, copper, and selenium.
IRON: Iron is important for production of red blood cells, which carry oxygen around the body. A lack of iron can lead to iron deficiency anaemia. Good sources of iron include liver (avoid during pregnancy), red meat, beans, nuts, dried fruit and fortified breakfast cereals. The RDA of iron is 8.7mg for men over 18, 14.8mg/day for women aged 19-to-50, and 8.7mg/day for women over 50. Very high doses of iron can be fatal, particularly in children. Iron supplements should always be kept out of reach of children.16
IODINE: Iodine is an essential component of the thyroid hormones thyroxine (T4) and triiodothyronine (T3). Thyroid hormones regulate many important biochemical reactions, including protein synthesis and enzymatic activity, and are critical determinants of metabolic activity. They are also required for proper skeletal and central nervous system development in the foetus and infants.18 Good dietary sources of iodine include sea fish and shell fish. It can also be found in plant-based foods such as cereals and grains, but levels depend on the amount of iodine in the soil where the plants are grown. Adults require 140ug of iodine daily. If following
a strict vegetarian or vegan diet, supplements may be required.17
FLUORIDE: Sodium fluoride protects teeth from acid demineralisation, and strengthens tooth enamel while preventing tooth decay by bacteria. Excess fluoride exposure during tooth mineralisation, especially in children one-to-three years old, may cause fluorosis. In humans, the only clear effect of inadequate fluoride intake is an increased risk of dental caries for individuals of all ages.3 While fluoride is not essential for human growth and development, excess intake can cause fluorosis, affecting teeth and bone density. Since 2007, the level of fluoride in public water supplies in the Republic of Ireland has been set at between 0.6 and 0.8 mg/L.5
long time may cause muscle pain and nerve damage, and may also cause symptoms of fatigue and depression.20
CHROMIUM: Chromium helps form a compound in the body that enhances the effects of insulin and lowers glucose levels. Good sources of chromium include meat, nuts, and cereal grains. Approximately 25ug of chromium per day is required for adults.21
COBALT: Cobalt helps absorb and process vitamin B12. In addition, cobalt helps treat illnesses such as anaemia and certain infectious diseases. Cobalt also aids in repair of myelin, which surrounds and protects nerve cells, and helps in the formation of haemoglobin. Good food sources include fish, nuts, green leafy vegetables such as broccoli and spinach, and cereals, such as oats. Getting enough vitamin B12 in the diet provides enough cobalt in the body. Adults need approximately 0.0015mg (1.5ug) of vitamin B12 a day.22
ZINC: Zinc helps blood to clot, is essential for taste and smell, and bolsters the immune response. It is involved in the production of new cells and enzymes, processes carbohydrates, fat and protein in food, and promotes wound-healing. Good sources of zinc include meat, shellfish, dairy products such as cheese, bread, and wheatgerm. The RDA of zinc for adults aged 19-to-64 is 9.5mg/day for men, and 7mg for women.19
MANGANESE: Manganese helps activate certain enzymes in the body and to carry out chemical reactions. Good dietary sources of manganese are bread, nuts, wholegrain cereals and green vegetables, such as peas. For most people, taking 4mg of manganese supplements is unlikely to cause any harm. Older people may be more sensitive to manganese, however, taking 0.5mg or less of manganese supplements is unlikely to cause harm. Taking high doses of manganese for a
MOLYBDENUM: Molybdenum helps make and activate enzymes that produce genetic material. Molybdenum is found in a wide variety of foods, and good sources include potatoes and carrots. There is no recommended daily intake for molybdenum. The average intake via diet is usually around 76mcg per day for women and 109mcg for men. If taken in supplement form, a maximum of around 45mcg per day is suggested. The upper limit, where it may cause harm, is estimated to be 2,000mcg per day.23, 24
COPPER: Copper produces red and white blood cells and helps form several enzymes, one of which assists with iron metabolism and the creation of haemoglobin, which carries oxygen in the blood. It is also important for infant growth, brain development, the immune system and strong bones. Good dietary sources include nuts, shellfish and offal. Adults aged 19-to-64 require 1.2g of copper per day. Taken in high doses over long periods of time, copper can cause liver and kidney damage.25
SELENIUM: Selenium is an essential component of various enzymes and proteins called selenoproteins that help to make
Zinc helps blood to clot, is essential for taste and smell, and bolsters the immune response
DNA and protect against cell damage and infections. These proteins are also involved in reproduction and the metabolism of thyroid hormones. Most selenium in the body is stored in muscle tissue, although the thyroid gland holds the highest concentration of selenium due to various selenoproteins that assist with thyroid function.26 Good sources of dietary selenium include Brazil nuts, fish, meat and eggs. The RDA for adults aged 19-to-64 is 75ug/day for men, and 60ug/ day for women. If taking supplements, it is important not to take too much, as it can
1. T Baj, E Sieniawska (2017). Chapter 13 – Vitamins. Pharmacognosy: Fundamentals, Applications and Strategies. Academic Press, pp; 281-292, ISBN 9780128021040. https://doi. org/ 10.1016/B978-0-12-802104-0.00013-5.
2. Harvard Helpguide (2022). Vitamins and minerals. Available online at https:// www.helpguide.org/harvard/vitamins-andminerals.htm.
3. Morris A, Mohiuddin S (2021). Biochemistry Nutrients. In StatPearls Publishing. Available at: https://www.ncbi. nlm.nih.gov/books/NBK554545/.
4. HSE (2022). B vitamins and folic acid. Health Service Executive. Available at: https://www2. hse.ie/conditions/vitamins-and-minerals/bvitamins-and-folic-acid/.
5. FSAI (2020). Report of the Scientific Committee of the Food Safety Authority of Ireland. The Safety of Vitamins and Minerals in Food Supplements. Establishing Tolerable Upper Intake Levels and a Risk Assessment Approach for Products Marketed in Ireland (Revision 2). FSAI. Dublin.
6. Lykstad J, Sharma S (2022). Biochemistry, Water Soluble Vitamins. StatPearls Publishing; January 2022. Available from: https://www.ncbi. nlm.nih.gov/books/NBK538510/.
7. Reddy P, Jialal I (2022). Biochemistry, Fat Soluble Vitamins. StatPearls Publishing; January 2022. Available from: https://www.ncbi.nlm.nih. gov/books/NBK534869/.
8. HSE (2021). Vitamins and Minerals; Vitamin D. Health Service Executive. Available at: https://www2.hse.ie/conditions/vitamins-and-
be harmful to the body. Too much selenium in the body can lead to a metallic taste, GI symptoms, and cause selenosis, the mildest form of which causes hair loss and brittle and discoloured nails.27
Micronutrients are needed by the body in very small amounts. However, their impact on the body’s health is very important, and deficiency in any of them can cause severe and even life-threatening conditions. Micronutrient deficiencies can cause visible and dangerous health conditions, but can also lead to less clinically notable
minerals/vitamin-d/.
9. HSE (2021). Vitamins and Minerals; Vitamin E. Health Service Executive. Available at: https://www2.hse.ie/conditions/ vitamins-and-minerals/vitamin-e/.
10. HSE (2021). Vitamins and Minerals; Vitamin K. Health Service Executive. Available at: https://www2.hse.ie/conditions/vitaminsand-minerals/vitamin-k/.
11. HSE (2021). Vitamins and Minerals; Calcium. Health Service Executive. Available at: https://www2.hse.ie/conditions/vitaminsand-minerals/calcium/.
12. HSE (2021). Vitamins and Minerals; Phosphorous. Health Service Executive. Available at: https://www2.hse.ie/conditions/ vitamins-and-minerals/others/#phosphorus.
13. HSE (2021). Vitamins and Minerals; Potassium. Health Service Executive. Available at: https://www2.hse.ie/conditions/vitaminsand-minerals/others/#potassium.
14. HSE (2021). Vitamins and Minerals; Sodium Chloride. Health Service Executive. Available at: https://www2.hse.ie/conditions/vitamins-andminerals/others/#sodium-chloride-salt.
15. HSE (2021). Vitamins and Minerals; Magnesium. Health Service Executive. Available at: https://www2.hse.ie/conditions/vitamins-andminerals/others/#magnesium.
16. HSE (2021). Vitamins and Minerals; Iron. Health Service Executive. Available at: https://www2.hse.ie/conditions/ vitamins-and-minerals/iron/.
17. HSE (2021). Vitamins and Minerals; Iodine. Health Service Executive. Available at: https://www2.hse.ie/conditions/ vitamins-and-minerals/iodine/.
18. NIH (2022). Iodine: Fact sheet for Health
reductions in energy levels, mental clarity and overall capacity. Many of these deficiencies are preventable through nutrition education and consumption of a healthy, balanced diet containing diverse foods, as well as food fortification and supplementation, where needed. l
AUTHOR: Theresa Lowry Lehnen, RGN, GPN, RNP, BSc, MSc, M. Ed, PhD, Clinical Nurse Specialist and Associate Lecturer, Institute of Technology, Carlow
Professionals. National Institute of Health. Available at: https://ods.od.nih.gov/factsheets/ Iodine-HealthProfessional/.
19. HSE (2021). Vitamins and Minerals; Zinc. Health Service Executive. Available at: https://www2.hse.ie/conditions/vitaminsand-minerals/others/#zinc.
20. HSE (2021). Vitamins and Minerals; Manganese. Health Service Executive. Available at: https://www2.hse.ie/conditions/vitaminsand-minerals/others/#manganese.
21. HSE (2021). Vitamins and Minerals; Manganese. Health Service Executive. Available at: https://www2.hse.ie/conditions/vitaminsand-minerals/others/#chromium.
22. NIDirect (2022). Cobalt. Available at: https://www.nidirect.gov.uk/articles/cobalt-0.
23. HSE (2021). Vitamins and Minerals; Molybdenum. Health Service Executive. Available at: https://www2.hse.ie/conditions/ vitamins-and-minerals/others/#molybdenum.
24. SAGA (2021). Molybdenum: foods, benefits & RDA. SAGA Magazine. UK. Available at: https://www.saga.co.uk/ magazine/health-wellbeing/treatments/ vitamins-minerals/molybdenum.
25. HSE (2021). Vitamins and Minerals; Copper. Health Service Executive. Available at: https:// www2.hse.ie/conditions/vitamins-and-minerals/ others/#copper.
26. Harvard Edu. (2022). Selenium. Harvard Edu. The Nutrition Source. USA. Available at: https://www.hsph.harvard.e du/nutritionsource/selenium/.
27. HSE (2021). Vitamins and Minerals; Selenium. Health Service Executive. Available at: https://www2.hse.ie/conditions/vitamins-andminerals/others/#selenium.
An overview of migraine, including its effects on quality of life, self-help measures and pharmacological treatment options
Migraine is among the most individualised conditions, as the symptoms can vary somewhat from person-to-person, making it challenging to diagnose and treat with the right medications and lifestyle changes. Despite this, it is overall the seventhmost disabling disease worldwide in the general population, and the fourthmost disabling for women. In worldwide terms, migraineis the most common neurological condition and affects between 12-to-15 per cent of people. It is usually inherited and is three times more common in men than in women.
According to Migraine Ireland, it is possible for the observant healthcare professional to distinguish it from ‘regular’ headaches, and different types of migraine can be categorised according to their characteristics.
DIFFERENT
Generally, a migraine will feature an episodic, one-sided headache with throbbing. An attack can last anywhere from a few hours to days or weeks and the pain is normally worsened by physical activity or even simple movement. Although head pain is the most widelyknown symptom of migraine, other symptoms can include nausea, vomiting, as well as high sensitivity to light and sound.
Some people experience a visual aura as a type of ‘warning sign’ before, or in conjunction with, the migraine. These phenomena can include blind-spots or flashes of light and can also result in difficulty speaking, or tingling on one side of the face, or in an arm or leg. However, for some people, there may be other warning signs in the days leading up to an attack. These can include:
Fluid retention.
Excessive yawning.
Food cravings.
Neck stiffness.
Constipation.
Mood changes.
Increased urination.
It can also be challenging to distinguish migraine from conditions such as a cluster headache, which is in fact more rare than migraine and is treated as a separate disorder with its own treatment recommendations. Figure 1 illustrates some of the prominent differences between these two conditions for ease of reference, as some of the symptoms of the two can overlap. The basic types of migraine are broken down as follows:
Migraine without aura: This accounts for the majority of migraine sufferers. This type of migraine usually presents as throbbing, intense pain on one side of the head, lasting for up to 72 hours and worsened by movement.
Hemiplegic: Another rare form of migraine that features the pain that usually accompanies other types of migraine, but with numbness, weakness and in some cases temporary paralysis on one side of the body. This is one of the more challenging migraines to diagnose, as the symptoms can often mimic the effects of a stroke.
Ophthalmoplegic: Another very rare form of migraine, this mainly occurs in younger people and is often accompanied by muscle weakness in the eye, as well as other eye manifestations.
Migraine aura without headache: This occurs in only around 1 per cent of migraineurs, where the sufferer experiences aura, but without the accompanying headache.
Whilst hemiplegic migraine is rare, since the beginning of 2022, Migraine Ireland says it has seen an increase in patient contact and diagnosis for hemiplegic migraine. Recently, the Migraine Association of Ireland hosted an online presentation by hemiplegic migraine expert Prof Anne Ducros of Montpellier University Hospital, France, who has been studying this condition for over 25 years, and who outlined what hemiplegic migraine is, the genetic origins, and how to treat it.
Migraine with aura: Some 20 per cent of sufferers experience migraine with aura and as well as the aura described above, the sufferer may experience ‘zig-zag’ patterns. Sensitivity to light, sounds and smells may also be present, as well as a stiff neck. These aura usually last for 20-to-60 minutes before the migraine begins.
Basilar migraine: This is a more rare form of migraine that can feature doublevision, blurred vision, loss of balance, possible fainting and speaking difficulties. Also known as ‘migraine with brainstem aura’, it is characterised by symptoms such as dysarthria, vertigo, or ataxia, without evidence of motor weakness.
She said that hemiplegic migraine is essentially a subtype of migraine with aura, and can be either familial hemiplegic migraine (FHM) where there is strong family history, or sporadic hemiplegic migraine (SHM), where someone is the first person in their family with hemiplegic migraine.
Abnormal variations in three genes, the CACNA1A gene, the ATP1A2 gene, and the SCN1A gene, have all been shown to cause the familial forms, with some people affected by as-yet-unidentified genes.
Despite its monogenic inheritance, FHM is characterised by a broad clinical spectrum with marked phenotypic variability and genetic heterogeneity, Prof Ducros noted.
In worldwide terms, migraine is the most common neurological condition and affects between 12-to-15 per cent of people
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Author: Eamonn Brady, MPSI (Pharmacist)CLINICAL FEATURES
History of previous attacks of typical HM (two attacks or one at least in case of FHM).
Other neurological features consistent with FHM/SHM.
Familial history in first- and seconddegree relatives.
“Clinical examination (not during an aura) is usually perfectly normal, except sometimes for cerebellar syndrome. Investigations are normal in attack-free periods, except for cerebellar atrophy in some cases of FHM/SHM with cerebellar signs; there are no white matter abnormalities or signs of stroke on MRI,” Prof Ducros said.
TREATMENT OF HEMIPLEGIC MIGRAINE ATTACKS
Management of FHM/SHM is mostly based on what is known about the treatment of other forms of migraine with aura as hemiplegic migraine is so rare, and there is no difference in the treatment of FHM and SHM. The low mean frequency of attacks (three-four
per year) means taking no preventive treatment may be a choice.
REDUCTION OF AURA SEVERITY AND DURATION (STUDIES)
Intranasal ketamine in 5/11 patients.
IV naloxone 0.4mg in two patients with SHM.
IV verapamil in one patient (another with seizure).
IV dihydroergotamine in one patient.
There are a number of migraine triggers that patients should be careful to avoid. These include:
Drinks. These include alcohol, especially wine, and too much caffeine, such as coffee.
Stress.
Sleep changes. Including missing sleep or getting too much sleep.
Hormonal changes in women. Fluctuations in oestrogen, such as before or during menstrual periods, pregnancy and menopause.
Hormonal medications, such as
oral contraceptives, also can worsen migraines. Some women, however, find that their migraines occur less often when taking these medications.
Sensory stimuli such as bright or flashing lights or loud sounds can induce migraines. Strong odours can also trigger migraines in some people.
Physical factors. Intense physical exertion, including sexual activity, might provoke migraines.
Weather changes. For example, a change in barometric pressure.
Foods. Aged cheeses and salty and processed foods might trigger migraines. However, skipping meals can also be an influencing factor.
Food additives. Such as aspartame and monosodium glutamate.
Certain medications. These include oral contraceptives and vasodilators.
Migraine sufferers can also take other measures to improve their self-help and to better understand their condition and potential responses to treatment. A migraine diary is recommended and is typically taken over a one-month period
and is used to record attacks, as well as any medications and when they are taken (with the exception of preventative medications).
Patients can rate the severity of their migraine on a scale of one-to-10 and can record their responses to lifestyle, environmental and dietary factors in the 48 hours before an attack. A template of a migraine diary, as well as detailed instructions on how to use it, are provided by the Migraine Association of Ireland and a printable template is available at www.migraine.ie. For young migraine sufferers, a digital/desktop app is also available to help them maintain a migraine diary in a more accessible and supportive way for younger people.
As stated above, the key to successful treatment of migraine includes an accurate diagnosis and outruling other causes, such as medication overuse headache. Some of the proven treatment approaches to migraine are outlined below.
Patients should be advised to see their doctor or visit the emergency department without delay if they exhibit symptoms that could indicate a more serious medical problem. These include:
Headache after a head injury.
Headache with fever, stiff neck, confusion, seizures, double vision, numbness or weakness in any part of the body (possible stroke).
An abrupt, severe headache.
A chronic headache that is worse after coughing, exertion, straining, or sudden movement.
New headache pain after the age of 50 years.
Patients should be advised that the two main types of treatment for acute migraine, analgesics and triptans, should be taken as early as possible to prevent an exacerbation and to maximise the drug’s efficacy.
A traditional first line of defence, aspirin has anti-inflammatory properties that
can help alleviate many of the physical symptoms of migraine.
Used to target area-specific pain and are especially effective if taken as early as possible once an attack begins.
Evidence shows ibuprofen to be highly effective and it is generally used for more severe migraine attacks. Soluble forms may act quicker than the tablet form for those where stomach issues are part of their migraine episode.
As effective as aspirin, but without the anti-inflammatory effects.
These include drugs that contain aspirin or paracetamol, along with another agent such as codeine or caffeine. Codeine and other opiates are best avoided due to addiction, side-effect risk and risk of triggering overuse headaches.
For some, the fear of a migraine may itself lead to stress, which can in turn increase the chances of an attack. For these patients, they may opt to use preventative therapy in an effort to reduce the frequency of their migraines.
For these people, preventatives may be suitable if the patient:
Wants to break the cycle of attacks.
Has attacks that follow a regular pattern, for example, around the time of menstruation.
Suffers from more than two or three attacks per month.
If the attacks are particularly severe or disabling and do not respond well to normal acute treatments.
Triptans are highly effective, reducing the symptoms or aborting the attack within 30-to-90 minutes in 70-to-80 per cent of patients. Triptans target the neural serotonin receptors specifically involved in migraine attacks and can be used in the treatment of migraine with or without aura. All of them are available in tablet form, with some brands also available as fast-melt tabs, nasal spray, or SC injection.
There are currently seven triptans in Ireland and they are considered to be an effective first-line treatment of choice. They are:
Almotriptan.
Frovatriptan.
Sumatriptan.
Eletriptan.
Rizatriptan.
Naratriptan.
Zolmitriptan.
If the patient suffers from rare forms of migraine, such as hemiplegic or basilar. It has been reported that preventatives have a success rate of between 50-to-60 per cent. However, they are ineffective once an attack has started. Preventatives are normally taken for a period of between six-to-12 months and some patients may respond to a particular treatment better than others, so some tweaking of the therapy and dosage may be required.
The most common types of migraine preventatives include beta-blockers; antiepilepsy (anticonvulsant) agents; calcium channel blockers; 5-HT agonists; and tricyclic antidepressants. It is important to bear in mind that in the case of anticonvulsants, sodium valproate should not be used in female children, female adolescents, in women of childbearing potential, or in pregnant women. These are important contraindications, given the significant teratogenic potential of these medications. l
References on request
Triptans target the neural serotonin receptors specifically involved in migraine attacks
As a family, we have owned a Mercedes for 20 years, a sum total of two cars. We have no intention of selling the second, yet. Our current E200 has proven to be comfortable, solid, and dependable, if a little slow. We’ll come to that later.
I had the privilege of testing the EQE recently. Despite being a petrol-head (there’s a strong family history), I love electric cars. The smoothness complements the EQE’s character exceptionally well. With passengers new to electric driving, I love surprising them with the quiet and smooth start.
Many electric cars give an electric purr as they progress. Not the EQE. If anything, there’s a little bit of tyre noise, entirely dependent on the road surface. Safety is famously associated with the
Mercedes brand, and the EQE raises passive safety to a new level. We know about active brake assist that stops the car in an emergency if the driver doesn’t. Now it’s upgraded to tension the seat belts repeatedly and flash red on the ambient cabin lighting before anchoring the car to the ground. I’m not sure how grateful I am to let everyone in the car know I’m not paying full attention. Recently, I was stopped at a T-junction
waiting to turn right. A driver in front (coming from the left) had stopped and the driver on the right was slowing with his left indicator on, so I made a dash across the road. It’s not a situation you can repeat too often on an open road. I didn’t know exactly what was chirping and flashing at me, but it was obvious the EQE didn’t like what I was doing.
It is a Mercedes, so the standard air suspension copes well with whatever the Irish roads can throw at it. Rear seat-room is good, with plenty of leg-room despite the battery using the underfloor area.
I’ve learned that Mercedes navigation uses ‘what3words’, a system to identify any location with a resolution of about three metres. Of course, you have to use the website or the app to find your unique three words. You might suggest the eircode, but
I felt no matter what happened, the EQE would look after me
‘what3words’ works anywhere, whether it’s along a motorway or up an unmapped country lane.
One of the first questions I get asked about any electric car is the range. The dash showed 483kms for 99 per cent charge when I got it, so take it that’s 500km or 300 miles. At an average speed of 100kph or 60mph, that’s five hours' driving non-stop. With a fast charger, I got from 50-to-80 per cent in 40 minutes. That’s 150km. The secret is to charge it at home and leave the house every day with a full tank.
The base price of the EQE starts at €85,703, and you can get to pay up to twice that with options and performance. The 350+ model is rated at 0-100kmh of 7.4 seconds, also called fast enough, but much quicker models are available. The base model is much quicker than the family E200. Personally, I’d add the four-wheel steer and the optional extra motor for four-wheel drive. There’s only so much adhesion two tyres can provide on wet tarmac as the EQE weighs over two tonnes and I’m cornering a bit fast. Don’t worry, the silicon chip inside the engine will look after you.
Towards the end of the test, I was driving the EQE home along the motorway. Adaptive cruise control was engaged, as was lane assist. As I was driving, it adapted to the speed of the car in front, and the steering wheel gave the occasional nudges as it felt I was a bit close to the edge. The lane assist had
turned from an intrusive, grumpy, reluctant assistant, to a gentle, new best friend. Something relaxing was playing on Lyric FM, and I felt no matter what happened, the EQE would look after me…. It felt safe, comfortable, solid, and relaxed. Looks like it’s bordering on S-Class territory. l
It has taken me an awfully long time to develop my rules of engagement with food and drink. If I’d had even a rough draft, say, 30 years ago, I would have saved myself a certain amount of angst and almost certainly money. I say 30 years ago because that was when I was on the nursery slopes of parenthood, had acquired a mortgage and — briefly — a proper job, so I still see it as the time when I put behind me childish things and became a grown-up.
Well, up to a point. I have no intention of ever going the whole hog on the growing up thing.
So, what have I learned? Well, over the past six or seven years, I’ve been consuming vastly less sugar. I wish I had not swallowed the nonsensical reassurance that 'sugar is just another food'. It’s not; it’s addictive and useless as anything other than an occasional treat. And the less you have, the less attractive it becomes. I used to love lemon curd roulade; it’s just too much for me now.
I’ve also discovered that strawberries and raspberries are deliciously sweet on their own; I used to think that they needed sugar to 'draw out the flavour', another nonsense peddled by sugar apologists.
Some 30 years ago, serious bread was a rarity, but these days I’ve learned to confine myself mostly to really good sourdough. Not only does it have terrific cohesion, it’s also easy to digest, and a little goes a long way. Toasted sourdough is an occasional treat, certainly not a daily thing. And I will confess that a toasted slice of Barron’s pan (from Cappoquin) beneath a layer of butter, supporting a softly poached egg, and some streaky bacon, makes a Sunday morning special
— especially if there’s just enough left to accommodate a spoonful of homemade marmalade (sugar again!).
I’m surprised that it took me so long to realise that buying conventional pork is worse than a waste of time. Why eat meat with all the charm and flavour of compressed sawdust when you can have the real thing in the form of free range meat from pigs bred for flavour and fat? My latest adventure with it was a chunk
with the exception, in my case, of olive oil, as the people in question would have been from Monaghan and Offaly, where olive groves are thin on the ground.
It took me a long time to realise that the best part of a crab, by far, is what lies inside the main shell (excepting the mouth parts and the 'dead man’s fingers'). I wasted decades when I ignored the joys of brown crab meat and failed to recognise all the good stuff that can be picked from the crab’s bony under-carriage if you’re prepared to put in the time.
And then there are those foods that I tried to persuade myself to like: Liver (kidneys were never a runner), sardines, herring, kale, swede, foie gras
There was even a time when I was so infected by wine snobbery that I refused to countenance even the idea of a cocktail and thus denied myself one of the greatest alcoholic pleasures that the world has to offer: The dry martini (ideally stirred, not shaken, being my preference). And, of course, the Manhattan, which I prefer to be made with an Irish pot still whiskey instead of those over-assertive Bourbons.
of free range belly (bones in) cooked on my Weber barbecue over indirect heat (ie, charcoal on the far side) with minimal air for two hours. Meltingly tender, with crisp, but not tooth-shattering, crackling on top, and that lovely touch of savoury smoke.
I wasted many years cooking with sunflower oil when I could have been using light olive oil or butter, straight from the fridge or clarified. Or other demonised, but delicious fats: Goose, duck, beef dripping, lard. In other words, the fats our great-grandmothers used,
At the same time, I tried to persuade myself that I like gin and tonic. I certainly did when I first encountered the combination at the age of 17, but over the years, I’ve come to find it too sweet. Instead, I enjoy gin with lots of ice, a good squeeze of fresh lime juice, topped up with chilled soda water.
On the other hand, when I first had a negroni, many years ago, I thought it was cloyingly sweet. These days, when I make it with gin, Campari and Punt e Mes with a very generous dollop of orange bitters, I cope very well with the sugar content.
Some 30 years ago, serious bread was a rarity, but these days I’ve learned to confine myself mostly to really good sourdough
But, as always with sweet stuff, it’s an occasional treat.
What else have I learned over the years? That the more expensive the kitchen, the less likely it is to see any serious cooking action. That I tend to freeze stuff knowing it will never be used. That guanciale really is better in a carbonara than pancetta. That pizza can be one of the world’s great dishes. That wild salmon is from a different solar system compared to the farmed stuff. That a slow-cooker is a brilliant investment… And that classic wines are often overlooked in favour of newer, quirky ones. Which is a shame. l
Acuro Rioja Reserva 2017 (€13.95, O’Brien’s) is possibly the best value red wine on the market at the moment, being reduced from over €20. It’s also made from organically grown fruit in the modern Rioja style with swathes of ripe fruit, but all nicely balanced and sensitively seasoned with new oak. It’s the kind of wine that cries out for a rare steak or some barbecued lamb that remains pink and moist, with a touch of smoke. I’ve certainly learned to stock up on such wines when I can.
Nordic Pharma Ireland are pleased to announce the launch of Dnord, a prescription-only treatment for Vitamin D deficiency. Dnord is available in 255 microgram soft gel capsules of calcifediol as calcifediol monohydrate, which comes in a pack of 10 capsules.
Nordic Pharma are the Marketing Authorisation (MA) Holder for Dnord, which is indicated for the following:
Treatment of vitamin D deficiency (ie, 25(OH)D levels < 25nmol/L) in adults.
Dnord is a one capsule, once a month dosing for patients with vitamin D deficiency and prevention of vitamin D deficiency in patients with identified risks or adjuvant for the specific treatment of osteoporosis.
Higher doses may be necessary in some patients after analytical verification of the extent of the deficiency. In those cases, the maximum dose administered should not exceed one capsule per week.
Dnord should not be administered with a daily frequency.
Accord Healthcare Ireland launches a new mobile app called ‘Me & My Methofill’ for patients with rheumatoid arthritis
Methotrexate is one of the most incorrectly dosed medicines. The Health Products Regulatory Authority (HPRA) adopted the recommendations issued by the European Medicines Authority (EMA) for methotrexate prescribed once weekly in autoimmune conditions. The recommendations were to prevent serious potential errors with dosing, which included more prominent warnings on product packaging and providing educational materials for patients and HCPs.
The ‘Me & My Methofill’ mobile app supports rheumatoid arthritis patients to take care of their own health and wellbeing. It provides patients with weekly
medication reminders to support correct dosing, how to inject animations and patient materials, and adverse event reports information.
“We are delighted to be rolling out our second patientcentred app to Irish patients, which continues to demonstrate our support to patients across therapy areas with app technology. This new app will allow patients prescribed Methofill to help manage their self-dose treatment, from the comfort of their own home. We are committed to supporting the patients and HCPs of Ireland and we believe our ‘Me & My Methofill’ app will do just that,” says Tracy Kivlehan, Accord Healthcare Ireland's Head of Hospitals & Speciality Brands.
The app is available to download free of charge from iTunes and Google Play.
Prevention of vitamin D deficiency in adults with identified risks, such as in patients with malabsorption syndrome, chronic kidney disease, mineral and bone disorder (CKD-MBD), or other identified risks.
As adjuvant for the specific treatment of osteoporosis in patients with vitamin D deficiency or at risk of vitamin D deficiency.
Dnord is reimbursed under the General Medical Services and Community Drugs Scheme and has been available from 1 January 2023.
Please refer to the Summary of Product Characteristics (SmPC) for further information. The SmPC is available at www.hpra.ie or from Nordic Pharma Ireland on 01 468 8998.
