The Medical Independent 28th April 2022

Crunch time for NCHDs

NCHDs are considering potential industrial action, but addressing their key concerns may not be straightforward.

Catherine Reilly reports

PAGE 4-5

Medical professionalism

David Lynch reports from the RCSI Medical Professionalism Conference, which highlighted the significant pressure on doctors during the pandemic

PAGE 10

Rejected GP claims under maternity scheme skyrocketed

CATHERINE REILLY

The number of rejected GP claims for additional visits under the HSE Maternity and Infant Care Scheme rose steeply from just 29 in July 2019 to 195 in June 2020, and then to 664 in January 2021, and 1,615 in May 2021, according to figures obtained by the Medical Independent (MI) under Freedom of Information law. The data covers July 2019 to December 2021 inclusive.

Despite some fluctuation, there was a sharp overall rise in rejected claims before a consistent downward trend from August 2021: 1,076 in August, 658 in September, 616 in October, 201 in November, and 132 in December.

Overall, there were 11,796 GP claims for additional visits rejected by the HSE.

The scheme provides for a programme of antenatal and postnatal visits. In addition, patients with “major conditions” (eg, diabetes, hypertension) may also have up to five additional visits to their GP.

Care for illnesses not related to pregnancy does not form part of the scheme, according to the HSE. No audits had been carried out on the scheme during the request period and no new clinical guidance had been developed regarding eligibility, stated the HSE.

The main reasons (‘error codes’) provided for the rejected claims were: “Claim not approved based on detail/clinical information provided” (6,638); “Not approved as additional visit – considered part of a routine antenatal visit” (1,513); “Not appropriate to Maternity and Infant Care Scheme” (998); and

“Presenting complaint not exclusive to pregnancy” (962).

One error code, which the HSE said was no longer used, stated: “Only one additional claim valid post miscarriage.” There were four rejected claims in this category.

In a column in MI on 4 October 2021, (‘Maternity and Infant Care Scheme under threat’), Dr Lucia Gannon described how her practice’s claims for additional payments for hypertension, gestational diabetes, and urinary tract infections had been consistently rejected since April 2021. Subsequent enquiries by MI found many GPs were experiencing this issue.

A HSE spokesperson said the Primary Care Reimbursement Service has a legal responsibility to ensure appropriate use of resources. There had been “no new ‘cost saving’ pol-

Failure to appoint national genetics lead

DAVID LYNCH

The problem with risk

Life is short, so what should we do with the time we have, asks Dr Paddy Barrett

PAGE 19

icies introduced to this scheme”.

Prior to centralisation “there may have been different interpretations as to what constituted a valid claim”.

The number of claims approved or rejected per month varied depending on the number received;

clinical information provided; and availability of medical officers for review.

Claims are returned to GPs to enable them to provide additional clinical detail. Some 130,782 claims were reviewed last year.

The HSE has failed to appoint a national genetics and genomics lead after two “extensive international” search campaigns, the Medical Independent (MI) has been informed.

The search for a national genetics and genomics lead began in September 2020. At the time, the HSE told this newspaper that a company had been appointed to conduct a formal search campaign for the post.

In May 2021, MI reported that the development of a national genomics strategy would begin after the appointment of a new national lead for genomics, as outlined by the HSE.

The absence of a national strategy on genomics was a central theme at an online conference on bioethics hosted by the Royal Irish Academy in May 2021.

However, this month the HSE said the search for a new lead had not been successful to date.

“The HSE advertised for the post of national genetics and genomics lead on two occasions and following an extensive international search campaign no appointment was made,” a spokesperson told MI

“Pending the future appointment of a national lead, a priority for the HSE is to develop a single national strategy and implementation plan for genetics and genomics. This piece of work has been commissioned by the Chief Clinical Officer of the HSE, with the strategy expected to be completed in late 2022.

“In relation to cancer genetics specifically, the development of a model of care for cancer genetics has been prioritised.”

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Psychiatrist recruitment difficulties could impact ADHD programme

NIAMH QUINLAN

Concerns have been expressed about the impact of potential psychiatrist recruitment difficulties on funding and roll-out of the ADHD in Adults National Clinical Programme.

On 18 April, details on the continued roll-out of the programme were announced, with €1.8 million allocated this year for clinics in Community Healthcare Organisation (CHO) 4 (Kerry and Cork), CHO 7 (Kildare, west Wicklow, and Dublin west, south-west and south city) and part of CHO 8 (Laois, Offaly, Longford, and Westmeath).

This would provide 50 per cent of the population with access to adult ADHD clinics in their catchment area, the programme’s Clinical Lead Dr Margo Wrigley told the College of Psychiatrists of Ireland spring meeting.

Dr Wrigley told the Medical Independent (MI) that consultant posts take the longest to recruit compared to other positions and preparatory work commenced once funding was available. The positions for the new specialised clinics are being advertised by the HSE through the Public Appointments Service.

There were issues with funding in 2019 when some of the initial €1.3 million was not allocated, Dr Wrigley said. However, with the help of Dr Amir Niazi, National Clinical Advis-

Training bodies ‘vital part of NCHD eco-system’ – Chair

CATHERINE REILLY

There is “obviously” a role for postgraduate training bodies in improving the working lives of NCHDS, the IMO NCHD Chair has said.

On 11 April, the IMO launched its ‘Standing up for NCHDs’ campaign to seek reform on poor working conditions, unsafe and illegal working hours, and “routine breaches” of contract.

The IMO NCHD committee is initiating a ballot of NCHD members to seek approval for industrial action, up to and including strike action, “in the event that the HSE does not engage meaningfully to resolve the situation and implement much needed reform.”

To allow the situation to continue “would pose a substantial and unacceptable risk to patient safety”.

However, some of the issues raised by the IMO are connected to delivery of training, including the stress and financial burden associated with frequent rotations. The problem of working conditions is compounded by NCHDs being viewed as temporary workers, according to the union.

Asked about the role of training bodies on these matters, NCHD Chair Dr John Cannon said: “[Training bodies] are a vital part of the eco-system for NCHDs and there has to be connected thinking, there has to be joined-up thinking between the workforce strategy and the postgraduate training bodies, particularly if we are going to deliver things like family-friendly policies and flexible training schemes, and actually put in some common sense measures.”

Dr Cannon underlined that the current demographic of NCHDs is much more diverse in terms of gender and age than in the past.

“I’ve heard of many young doctor couples, the doctors have young children and they are being sent in separate directions on their rotation…. I don’t think this makes it into the eye of the general public.”

Mr Ken Mealy, Chair of the Forum of Irish Postgraduate Medical Training Bodies, said there was an understanding that greater regionalisation of training was necessary. He said NCHDs’ working conditions were raised with the HSE, but the training bodies were not the employer. See news feature, p4-5.

er for Mental Health, the funding was retrieved.

Dr Wrigley said, for example, this allowed for a consultant to be recruited to the CHO 3 [Clare, Limerick, and North Tipperary] service. The further €1.8 million allocated for 2022 is “really allowing us to do a good deal more this year”, she added. However, concerns have been raised that possible consultant recruitment problems could place the funding in jeopardy.

CEO of ADHD Ireland Mr Ken Kilbride told MI: “The funding is there to build those teams to give the 50 per cent coverage by the end of the year, subject to the recruitment of psychiatrists. If they don’t get the psychiatrists in by the end of the year, what happens to the funding at that point?”  However, Dr Wrigley said “it is possible to recruit staff, [but] it does need a good deal of effort”.

Crunch time for NCHDs

Chair of the IMO NCHD committee, Dr John Cannon, believes the union’s new campaign on illegal and unsafe working hours, and contract breaches, will resonate with the public.

He said the key message is that having “exhausted” doctors providing care in Irish hospitals is a major patient safety concern.

Public support and understanding will be crucial if the union embarks on industrial action. NCHDs comprise the bulk of the medical workforce. According to the HSE’s Medical Workforce Report 2020-2021, there were 7,442 NCHDs working in the system, including almost 2,600 in non-training posts. This compared with 3,425 consultants employed in the public health service.

On 11 April, the IMO announced it would ballot NCHD members to seek approval for industrial action, up to and including strike action, “in the event that the HSE does not engage meaningfully to resolve the situation and implement much-needed reform.”

The union’s campaign has raised an array of issues. In addition to unsafe working hours, briefing materials have highlighted burnout, mental ill-health, emigration, inability to take annual and educational leave, the structure of training, not being paid for hours worked, and delaying having children for fear of impact on training opportunities.

However, the central concern is illegal and unsafe working hours, Dr Cannon underlined.

“All junior doctors live in fear that they are going to be so exhausted and so tired that they are going to make a serious fatigue-related mistake. None of us want to be working 24 hours, none of us want to be working 80 hours a week. I think if you fix that core issue, then a lot of the other things will not be as acute – they won’t disappear completely, but it will relieve some of the pressure.”

According to an IMO survey, 40 per cent of NCHDs reported routinely working shifts of over 24 hours, 96 per cent routinely worked over 48 hours per week, and all NCHDs reported working beyond their contracted hours. Conversely, HSE data covering July-September 2021 stated 98 per cent compliance with the maximum 24-hour shift and 84 per cent compliance with the 48-hour week in acute hospitals. The union has repeatedly questioned the

integrity of the Executive’s data.

Under the hashtag ‘Standingup4NCHDs’, the campaign has gained traction on social media with scores of NCHDs sharing experiences of poor working conditions and unsafe working hours. The potential for strike action has also attracted national media attention.

Speaking to the Medical Independent (MI) on 13 April, Dr Cannon said: “We are hoping to get engagement from the highest levels of the HSE and hopefully from the Department of Health as well, as I think this is a systemic issue that requires engagement and real concrete proposals from the top echelons of the health service.”

Goals

Other than underlining that the current situation must be addressed, the union has not yet publicly set out specific demands.

At an online press conference on 11 April, MI suggested that the issues raised may take time to resolve and queried the union’s initial goals.

IMO CEO Ms Susan Clyne, an experienced operator in the field of industrial relations, responded: “A lot of the issues can actually be sorted quite quickly. It is not a radical request or radical suggestion that everyone is paid for every hour that is worked; it is not a radical suggestion that at the end of your roster you leave the hospital.”

The IMO would expect “really quite quick responses” on some issues, as well as “a proper engagement” and plan agreed with NCHDs.

As to what mechanisms could underpin any progress achieved, Dr Cannon told MI: “Firstly we need to investigate why the numbers are so disparate between what the HSE is reporting and junior doctors are reporting. Because I think those numbers have to be reliable and you have to stand over them for the current system to work.” There was also an “archaic system of doctors submitting their hours on paper slips, which I think is almost unthinkable in the digital age we are in”, he noted.

However, Dr Cannon underlined that the overarching problem was that medical manpower units “are trying to cover 100 per cent of the roster with 50 per cent of the staff”.

Consultants

A pivotal part of addressing the hospital waiting list crisis is cultivating the current crop of NCHDs and retaining them as con-

sultants, continued Dr Cannon.

“That is how we increase consultant numbers. And ultimately then, when we have done that, we can start changing the model. The model at the moment is a consultant supervised service, with a ratio of two junior doctors to every consultant. We need to flip that completely to a consultant-led service where we have two consultants for every junior doctor. And that won’t happen unless we bring through this crop of junior doctors and treat them well, and to do that, we need to significantly increase our junior doctor workforce because there is not a medical manpower unit in the country who could make an EWTD- [European Working Time Directive] compliant roster at the moment.”

Increasing NCHD numbers without significantly widening the NCHD-consultant ratio would seem a delicate process, MI suggested.

Dr Cannon said that for a time “NCHD numbers would need to expand, to allow us to increase consultant numbers in turn. However, a true ‘consultant-led’ service (if realised), would then unburden the NCHD group, and NCHD numbers could contract again. However, at the moment there is no hope for either NCHDs or the consultant crisis unless we increase the numbers of NCHDs and increase the proportion of those NCHDs who are in training.”

He said consultants have been supportive of the campaign. “I think there has been an unbelievable level of support from the consultant workforce for this campaign.”

As acknowledged by the NCHD Chair, there are fundamental problems that need to be addressed to improve working conditions for NCHDS, some of which are independent of the NCHD workforce itself.

MI asked what process the IMO had in mind, in terms of negotiating through those issues with the HSE and Government.

Dr Cannon said that, firstly, the union’s ballot needed to run its course and a mandate provided. The IMO would then consider its next steps.

“We will be guided by our members,” he told MI. “But doctors in Ireland, junior doctors and consultants, are incredibly selfless in my opinion, junior doctors shelved this discontent, which was really bubbling to the surface in 2019… we shelved it during the pandemic and put our shoulders to the wheel.…”

He said NCHDs would not strike except in the “most extreme circumstances, like we have now, with the flagrant breach of our contract and our illegal working hours”.

“I think we will be reasonable in terms of how we go about this,” added Dr Cannon, who noted that significantly bolstering the NCHD workforce cannot happen instantaneously. “But we do produce the most amount of medical graduates in the EU per 100,000 population; we are a net exporter of graduates and we train them to an incredibly high standard as well.”

2013 action

It is easy to overlook the progress made following the IMO’s ‘24 No More’ campaign and one-day national strike in 2013. At the time, shifts over 24 hours and working weeks over 100 hours were much more widespread. The HSE hired extra NCHDs (a significant proportion in non-training roles), a system of financial sanctions was instigated for hospitals breaching the maximum 24-hour shift, and a national verification and implementation group was established. However, progress stalled after a number of years.

Former IMO President Dr John Duddy, a Fellow in paediatric neurosurgery at Alder Hey Children’s Hospital in Liverpool, was involved in the 2013 campaign. He said the changes introduced “revolutionised” his life at the time. “I think for people who had been in the system up to that point, it really changed our lives,” he said.

“I was doing 36-hour shifts as a neurosurgery registrar in Beaumont, anything from one-to-four times in a week, and after that campaign, that changed to doing 12-hour night shifts once every six-to-eight

The potential for industrial action by NCHDs hovers on the near horizon, but addressing their key concerns may not be straightforward. Catherine Reilly reports

Ms Susan Clyne

Dr John Cannon

weeks. That revolutionised things for me and for thousands of NCHDs like me. That institutional memory of that time [among current NCHDs] has passed on, which is a great thing.” He noted, however, that the issue of illegal and unsafe working hours continues to be a reality for NCHDs.

From 2013 to 2016, there was a system-wide focus on improving conditions for NCHDs. However, “I think we have gone back to where we were, in terms of seeing NCHDs as a disposable part of the system.”

After the 2013 action, many positive changes were driven by Lead NCHDs who were introduced under the agreement between the IMO and health service management. “Maybe the impetus behind the NCHD Lead programme has been lost a little bit,” commented Dr Duddy, “I think [the role] has kind of been corporatised by the HSE.”

Dr Duddy said the measures agreed between the IMO and health service management, such as financial sanctions and the implementation and verification process, worked well for a time.

“Particularly the implementation process, when you had initially Ian Carter as head of the acute hospitals division and then subsequently Angela Fitzgerald and Liam Woods coming around, holding CEOs and HR managers to task for not implementing the changes they said they would do….

employed by the same place for four-toeight years, depending on the specialty. As a result, they would have to be treated with respect by their employer and all staff around the hospital.

“The issues around emergency tax, incorrect pay scales, different IT systems, etc, would be immediately resolved. If groups of NCHDs work together in one location for longer periods, they will be able to better organise themselves and challenge the other unacceptable employer practices, such as non-payment of overtime and access to leave. The NCHD cohort would be greatly strengthened as a result.”

There would likely be a need for national rotation for certain specialties like neurosurgery or cardiothoracic surgery, or short six-to-12-month rotations for specialist exposure in particular areas, but this should be the exception rather than the norm, he outlined.

Dr Duddy observed that resolving the current issues affecting NCHDs will require “major structural changes” involving not only the HSE and Department of Health, but also the training bodies.

He added: “In some ways, my own philosophy is the answer to NCHDs’ working hours is not to hire more NCHDs, it is to hire more consultants, and it is to hire more support staff, and I am a big believer in physician associates (PAs) in particular

understanding by the training bodies that these are issues they need to seriously do their best to address in the coming years.”

Mr Mealy, a Consultant General Surgeon, said “there has been a modest increase in trainee numbers over the last number of years. Whether that can be expanded to any greater extent or not, I do not know.” Barriers included the extent of further training opportunities in craft specialties as well as funding for training expansion.

Increasing the training numbers would also require more consultant trainers. “But there are just so many moving parts here.

If you cannot appoint permanent consultants into some hospitals, then it is very hard to have trainees in those hospitals.”

Is the issue of 24-plus hour shifts being discussed with the HSE?

“If you talk to the HSE they will tell you that hospitals are 98 per cent compliant, but of course if you talk to many doctors, they will say that is at odds with what they are experiencing. Is it reported accurately? I don’t know… I think one of the biggest issues is the level of staffing, so if somebody is sick or somebody is on holiday there is no cover for them… so that whoever is left has to fill those posts. So really what you would be saying is instead of having 20 SHOs and registrars in a hospital you should have 25 so that the work/ life balance is better, people get off earlier, they don’t have the same sort of rosters.

“But the problem there is, you are talking about expanding the NCHD numbers again. This brings us back to configuration of the health service where you have many 24/7 acute rosters that have to be staffed in units around the country when, if there was consolidation of the health service, you would not need as many acute rosters. But that is a political issue.”

MINDO NUMBERS

37

per cent of patients with a ST elevation myocardial infarction (STEMI) sought medical help within 60 minutes of onset of symptoms, according to the Irish Heart Attack Audit National Report 2017-2020

68 per cent of patients were admitted to a primary percutaneous coronary intervention (PCI) centre directly, with 28 per cent still presenting to a non-PCI hospital first, noted the report.

“I saw over the years how the rigidity in which the HSE implemented that, and how hard they came down on the hospitals, dissipated over time as well. Initially again the financial incentive was there for hospitals to do it… and I think they have probably factored those costs into their budgets now, so it is not as big a deal for them now to take a fine for not being EWTD compliant.”

Currently working in a large well-run teaching hospital in the NHS, Dr Duddy’s working hours are much better compared with a similar position in Ireland, due to the increased level of staffing. Most days, he can leave on time at five o’clock.

While there are some areas where NCHDs in Ireland have comparatively better entitlements – on paper at least – Dr Duddy cannot emphasise enough “how much better life is in the UK when you know you will generally finish work at the scheduled time. I would take that over enhanced pay or leave any day”.

Dr Duddy believes that the primary source of the problems for NCHDs is the system of rotation around the country.

“Because they are employed on temporary contracts for three-to-six months, most hospitals treat them as the temporary, disposable employees that they are. If a US-style residency programme was introduced, or at the very least regionalised training programmes, they would be

– I think the Irish system should be flooded with PAs to pick up a lot of the work that particularly interns and SHOs do. And ANPs [advanced nurse practitioners] have a very important role to play as well…. The ANP role in Ireland is very under-used compared to over here.”

He continued: “Given that these suggestions, along with the need to increase consultant numbers and support staff, such as ANPs and PAs, do not directly involve NCHDs, it remains to be seen if a NCHD-focused industrial relations campaign will address them. However, such a campaign may succeed in forcing the system to re-engage with NCHD issues as the 2013 campaign did, albeit for a two-tothree-year period. If this momentum can be regained and change follows, the campaign could be considered successful.”

Training bodies

Mr Ken Mealy, Chair of the Forum of Irish Postgraduate Medical Training Bodies, told MI greater regionalisation is being explored by the training bodies.

“We all understand moving house every year is a disaster, even independently of ease of getting accommodation. Just the costs of all of that and the inconvenience…. There are limitations [in progressing regionalisation], but for the generality of lots of medicine and surgery, I think there is an

According to Mr Mealy, the Forum has meetings with National Doctors Training and Planning (NDTP) and the Medical Council, where working conditions are raised. He believed there was also “great variation” in treatment of NCHDs across hospitals.

“We are not the employer, but these are the conversations we have with the HSE.…The big picture we all dance around, as I say, is the configuration of the health service. NDTP and [its Medical Director] Brian Kinirons have no control over how many acute rosters are in the country and likewise the Medical Council doesn’t either. Having said that, I have voiced these concerns [on configuration] at so many meetings….”

Official response

A Department spokesperson told MI on 14 April: “The Minister met with NCHDs last week with regard to a number of concerns they had raised. This group perform a very significant role in our public health system, not least through the last two years. The Department are following up on the issues raised by the NCHDs at present and will be engaging further in the coming weeks.”

However, it is understood the Minister’s meeting was with Lead NCHDs.

Asked to clarify whether there was an intention to meet IMO NCHDs, the spokesperson said: “We have nothing further to add to our response for the moment.”

The HSE had not commented by press time.

6,000 people with heart attacks are admitted to Irish hospitals every year. Approximately one-quarter of these patients suffer a STEMI.

100,089 children are now on some form of National Treatment Purchase Fund waiting list, the IHCA has highlighted.

34,000 of these children are waiting longer than a year for treatment or assessment by a hospital consultant, stated the IHCA, which noted almost one-in-five consultant paediatric posts are vacant/filled temporarily.

If this momentum can be regained and change follows, the campaign could be considered successful

Council report will highlight need for 'workforce strategy'

DAVID LYNCH

The Medical Council's upcoming Medical Workforce Intelligence Report 2021, "will definitely highlight the need for a workforce strategy for healthcare," the Council's CEO Mr Leo Kearns stated earlier this month.

Speaking on 8 April at the Medical Professionalism Conference 2022, hosted by the RCSI University of Medicine and Health Sciences, Mr Kearns ended his presentation with a slide and comments on the still unpublished report.

Mr Kearns said "this year what we are attempting to do is to identify what those key risks are relating to patient safety and the key strategic actions needed to address those risks... and it will definitely highlight the need for a workforce strategy for healthcare".

Earlier in his talk, Mr Kearns said a comprehensive medical workforce strategy was required. The strategy should address “immediate critical issues” such as European Working Time Directive compliance and medium- to long-term requirements in regard to consultant numbers and the ratio of trainee to non-trainee doctors.

A Medical Council spokesperson told the Medical Independent that the new Medical Workforce Intelligence Report is due to be published in "early May".

According to Mr Kearns’ slides, the upcoming report will set out the “critical risks to patient safety emerging from the

NDTP has commenced review of consultant recruitment in model 3 hospitals

HSE National Doctors Training and Planning (NDTP) has commenced a review of consultant recruitment difficulties in model 3 hospitals, led by its Medical Director Dr Brian Kinirons, according to the Executive.

NDTP has appointed a project manager and formed a representative steering group, a spokesperson added.

The HSE National Service Plan 2022 committed to compiling a report to “address consultant recruitment and retention challenges in model 3 hospitals through a structured review with recommended actions for implementation”.

The NDTP’s Medical Workforce Report 2020-2021 noted “significant challenges” for model 3 hospitals in regard to consultant recruitment. “Over onethird of all consultants working in these hospitals are 55 years old or over, model 3 hospitals are more likely to employ consultants not on the specialist register as well as consultants in non-permanent posts that have not been approved

VOX BOX

by the CAAC [consultant applications advisory committee],” wrote Ms Leah O’Toole, Assistant National Director, NDTP, in the report foreword.

Of the 4 per cent of consultants working in posts not approved by the CAAC, the greatest proportion of these were in model 3 hospitals, which was broadly similar to 2019, according to the report.

Consultants in model 3 hospitals were more likely than consultants in model 4 hospitals to hold general registration with the Medical Council.

Additionally, the report noted that non-training NCHD posts tended to be concentrated in certain specialties and geographical locations, particularly clinical specialties in which unscheduled care was delivered on a 24/7 basis and in peripherally located model 2 and model 3 hospitals.

“Safe and timely service delivery in the Irish healthcare system is dependent on these posts and the doctors who occupy them. However, unlike training posts, there is not the same rigorous oversight of their numbers and regulation.”

data analyses and key strategic actions necessary to support the development of a healthcare workforce strategy".

"It will highlight why a healthcare workforce strategy is required to address recruitment, retention, distribution, and supply challenges."

Also speaking at the RCSI conference, Medical Council President Dr Suzanne Crowe told online delegates that "it is clear that we have to address the shortages in our workforce, we do not have enough people to deliver care and that is a major concern to the Council".

"We are strongly petitioning for a workforce strategy to plan for the future of our health service, because at the Council we want to grow the next generation of doctors and ensure that they and their practice reach the highest standards for them and their patients into the future."

No plans to send medical corps to Ukraine’s neighbouring countries

CATHERINE REILLY

There is currently no plan to deploy members of the Defence Forces' medical corps to EU countries neighbouring Ukraine, a Department of Defence spokesperson told this newspaper in mid-April.

Over five million Ukrainians have fled their country since Russia’s invasion in February, according to the United Nations Refugee Agency.

A Defence Forces spokesperson stated that the role of the medical corps in relation to Ukrainians seeking protection in Ireland “is to assist the HSE as required” should the Executive request its medical support through official channels.

The medical corps will establish an emergency first aid station in Gormanston Camp, when it accommodates Ukrainians seeking protection in Ireland, added the spokesperson.

Currently, the medical corps has 16 medical officers; two dental officers; one psychologist; two members of the army nursing service; two pharmacists; 18 paramedics; 11 advanced paramedics; and 75 emergency medical technicians.

We believe that welltrained and talented gynaecological surgeons are crucial to accommodating Ireland’s increasing need for top-class services in women’s health, and this traineeship is the perfect opportunity to ensure we can meet the growing demand for services in this area.”

The Defence Forces also has a mixture of civilian and agency staff that assist across numerous roles (psychiatry, nursing, laboratory, dental, pharmacy, physiotherapy, general practice).

The primary focuses of the medical corps are occupational medicine; primary care; aid to the civil authority (eg, councils, HSE); review of pandemic-related policies and procedures; continuance of medical training within the Defence Forces and with external providers and partners.

In early April, the Department of Health issued an update on a range of medical supplies and equipment sent to Ukraine, with further donations planned. The State had also provided assistance in medical evacuations from Ukraine as part of the EU’s response.

An interim HSE health service support model was in operation at Dublin Airport and other ports of entry.

“For Ukrainian refugees placed in emergency accommodation, the HSE has put in place a framework which ensures provision of specific GP services and access to prescriptions.” In addition, Safety Net was providing GP clinics to facilities located in Dublin, added the statement.

Mr Brian O’Mahony, CEO of the Irish Haemophilia Society and haemophilia B patient, commenting ahead of World Haemophilia Week (which began on 17 April). The Society highlighted that, 20 years on from the Lindsay Tribunal Report, procurement of haemophilia medications in Ireland is now seen as the most effective model globally.

Master of the Rotunda Hospital, Prof Fergal Malone, commenting on its accreditation by the American Association of Gynaecologic Laparoscopists to run a Fellowship programme in minimally invasive gynaecologic surgery for gynaecology trainees.

Minister for Health Stephen Donnelly

announcing on 20 April that Ms Maura Quinn, outgoing CEO of the Institute of Directors, will conduct an external review into the process of the proposed secondment of the Chief Medical Officer and research proposal, “to examine learnings and recommendations that could inform future such initiatives.”

Mr Leo Kearns

Ms Quinn has offered to carry out this review pro bono and will report back to me in June. It is my intention to publish the report following its consideration."

CATHERINE REILLY

Unfortunately, we cannot change the past, but we are working hard together with the Minister for Health, the National Haemophilia Council, and Haemophilia Product Selection and Monitoring Advisory Board to ensure haemophilia patients in Ireland have access to world-class treatments."

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Significant protection against exacerbations*

TRIXEO Aerosphere is indicated as a maintenance treatment in adult patients with moderate to severe chronic obstructive pulmonary disease (COPD) who are not adequately treated by a combination of an inhaled corticosteroid and a long-acting beta2-agonist or combination of a long-acting beta2-agonist and a long-acting muscarinic antagonist.1

*Significant reductions in the rate of moderate or severe exacerbations vs LAMA/LABA (24%, n=2137 vs n=2120, annual rates 1.08 vs 1.42, 95% CI 0.69–0.83; p<0.001) and ICS/LABA (13%, n=2137 vs n=2131, annual rates 1.08 vs 1.24, 95% CI 0.79–0.95; p=0.003).1,2 COPD, chronic obstructive pulmonary disease; ICS, inhaled corticosteroid; LABA, long-acting beta2-agonist; LAMA, long-acting muscarinic antagonist. In the clinical trial programme for TRIXEO, LAMA/LABA refers to glycopyrronium/formoterol fumarate and ICS/LABA refers to budesonide/formoterol fumarate. ©AstraZeneca 2021. All rights reserved.

ABRIDGED PRESCRIBING INFORMATION

TRIXEO AEROSPHERE ® 5 micrograms/7.2 micrograms/160 micrograms pressurised inhalation, suspension (formoterol fumarate dihydrate/glycopyrronium/budesonide)

Consult Summary of Product Characteristics (SmPC) before prescribing

Indication: Trixeo Aerosphere is indicated as a maintenance treatment in adult patients with moderate to severe chronic obstructive pulmonary disease (COPD) who are not adequately treated by a combination of an inhaled corticosteroid and a long acting beta2 agonist or combination of a long-acting beta2 agonist and a long acting muscarinic antagonist.

Presentation: Pressurised inhalation, suspension. Each single actuation (delivered dose, ex-actuator) contains 5 micrograms of formoterol fumarate dihydrate, glycopyrronium bromide 9 micrograms, equivalent to 7.2 micrograms of glycopyrronium and budesonide 160 micrograms.

Dosage and Administration: The recommended and maximum dose is two inhalations twice daily (two inhalations morning and evening). If a dose is missed, take as soon as possible and take the next dose at the usual time. A double dose should not be taken to make up for a forgotten dose. Special populations: Elderly: No dose adjustments required in elderly patients.

Renal impairment: Use at recommended dose in patients with mild to moderate renal impairment. Can also be used at the recommended dose in patients with severe renal impairment or end-stage renal disease requiring dialysis, only if expected benefit outweighs the potential risk. Hepatic impairment: Use at recommended dose in patients with mild to moderate hepatic impairment. Can also be used at the recommended dose in patients with severe hepatic impairment, only if expected benefit outweighs the potential risk. Paediatric Population: No relevant use in children and adolescents (<18 years of age). Method of administration: For inhalation use.

To ensure proper administration of the medicinal product, the patient should be shown how to use the inhaler correctly by a physician or other healthcare professional, who should also regularly check the adequacy of the patient’s inhalation technique. Patients who find it difficult to coordinate actuation with inhalation may use Trixeo Aerosphere with a spacer to ensure proper administration of the medicinal product..

Contraindications: Hypersensitivity to the active substances or to any of the excipients.

Warnings and Precautions: Not for acute use: Not indicated for treatment of acute episodes of bronchospasm, i.e. as a rescue therapy. Paradoxical bronchospasm: Administration of formoterol/glycopyrronium/budesonide may produce paradoxical bronchospasm with an immediate wheezing and shortness of breath after dosing and may be life threatening. Treatment should be discontinued immediately if paradoxical bronchospasm occurs.

Assess patient and institute alternative therapy if necessary. Deterioration of disease: Recommended that treatment should not be stopped abruptly. If patients find the treatment ineffective, continue treatment but seek medical attention. Increasing use of reliever bronchodilators indicates worsening of the underlying condition and warrants reassessment of the therapy. Sudden and progressive deterioration in the symptoms of COPD is potentially life threatening, patient should undergo urgent medical assessment.

Cardiovascular effects: Cardiovascular effects, such as cardiac arrhythmias, e.g. atrial fibrillation and tachycardia, may be seen after the administration of muscarinic receptor antagonists and sympathomimetics, including glycopyrronium and formoterol. Use with caution in patients with clinically significant uncontrolled and severe cardiovascular disease such as unstable ischemic heart disease, acute myocardial infarction, cardiomyopathy, cardiac arrhythmias and severe heart failure. Caution should also be exercised when treating patients with known or suspected prolongation of the QTc interval (QTc > 450 milliseconds for males or > 470 milliseconds for females), either congenital or induced by medicinal products. Systemic corticosteroid effects: May occur with any inhaled corticosteroid, particularly at high doses prescribed for long periods. These effects are much less likely to occur with

inhalation treatment than with oral corticosteroids. Systemic effects include Cushing’s syndrome, Cushingoid features, adrenal suppression, decrease in bone mineral density, cataract and glaucoma. Potential effects on bone density should be considered particularly in patients on high doses for prolonged periods that have co existing risk factors for osteoporosis. Visual disturbances: May be reported with systemic and topical corticosteroid use. If patient presents symptoms such as blurred vision or other visual disturbances, consider ophthalmologist referral for evaluation of possible causes which may include cataract, glaucoma or rare diseases such as central serous chorioretinopathy (CSCR). Transfer from oral therapy: Care is needed in patients transferring from oral steroids, since they may remain at risk of impaired adrenal function for a considerable time. Patients who have required high dose corticosteroid therapy or prolonged treatment at the highest recommended dose of inhaled corticosteroids, may also be at risk. These patients may exhibit signs and symptoms of adrenal insufficiency when exposed to severe stress. Additional systemic corticosteroid cover should be considered during periods of stress or elective surgery. Pneumonia in patients with COPD: An increase in the incidence of pneumonia, including pneumonia requiring hospitalisation, has been observed in patients with COPD receiving inhaled corticosteroids. Remain vigilant for the possible development of pneumonia in patients with COPD as the clinical features of such infections overlap with the symptoms of COPD exacerbations. Risk factors for pneumonia include current smoking, older age, low body mass index (BMI) and severe COPD. Hypokalaemia: Potentially serious hypokalaemia may result from ß2-agonist therapy. This has potential to produce adverse cardiovascular effects. Caution is advised in severe COPD as this effect may be potentiated by hypoxia. Hypokalaemia may also be potentiated by concomitant treatment with other medicinal products which can induce hypokalaemia, such as xanthine derivatives, steroids and diuretics. Hyperglycaemia: Inhalation of high doses of ß2-adrenergic agonists may produce increases in plasma glucose. Blood glucose should be monitored during treatment following established guidelines in patients with diabetes.

Co-existing conditions: Use with caution in patients with thyrotoxicosis. Anticholinergic activity: Due to anticholinergic activity, use with caution in patients with symptomatic prostatic hyperplasia, urinary retention or with narrow-angle glaucoma. Patients should be informed about the signs and symptoms of acute narrow-angle glaucoma and should be informed to stop using this medicinal product and to contact their doctor immediately should any of these signs or symptoms develop. Co-administration of this medicinal product with other anticholinergic containing medicinal products is not recommended. Renal impairment: Patients with severe renal impairment (creatinine clearance of <30 mL/min), including those with end-stage renal disease requiring dialysis, should only be treated with this medicinal product if the expected benefit outweighs the potential risk. Hepatic impairment: In patients with severe hepatic impairment, use only if the expected benefit outweighs the potential risk. These patients should be monitored for potential adverse reactions..

Drug Interactions: Co-treatment with strong CYP3A inhibitors, e.g. itraconazole, ketoconazole, HIV protease inhibitors and cobicistat-containing products are expected to increase the risk of systemic side effects. Should be avoided unless the benefit outweighs the increased risk, in which case patients should be monitored for systemic corticosteroid adverse reactions.

This is of limited clinical importance for short-term (1-2 weeks) treatment.

Since glycopyrronium is eliminated mainly by the renal route, drug interaction could potentially occur with medicinal products affecting renal excretion mechanisms. Other antimuscarinics and sympathomimetics: Coadministration with other anticholinergic and/or long-acting ß2-adrenergic agonist containing medicinal products is not recommended as it may potentiate known inhaled muscarinic antagonist or ß2-adrenergic agonist adverse reactions. Concomitant use of other beta-adrenergic medicinal products can have potentially additive effects. Caution required when prescribed concomitantly with formoterol. Medicinal product-induced hypokalaemia: Possible initial hypokalaemia may be potentiated by xanthine

derivatives, steroids and non potassium sparing diuretics. Hypokalaemia may increase the disposition towards arrhythmias in patients who are treated with digitalis glycosides. β -adrenergic blockers: ß-adrenergic blockers (including eye drops) can weaken or inhibit the effect of formoterol. Concurrent use of ß-adrenergic blockers should be avoided unless the expected benefit outweighs the potential risk. If required, cardio-selective ß-adrenergic blockers are preferred. Other pharmacodynamic interactions: Concomitant treatment with quinidine, disopyramide, procainamide, antihistamines, monoamine oxidase inhibitors, tricyclic antidepressants and phenothiazines can prolong QT interval and increase the risk of ventricular arrhythmias.

L-dopa, L-thyroxine, oxytocin and alcohol can impair cardiac tolerance towards beta2-sympathomimetics. Concomitant treatment with monoamine oxidase inhibitors, including medicinal products with similar properties such as furazolidone and procarbazine, may precipitate hypertensive reactions. Elevated risk of arrhythmias in patients receiving concomitant anaesthesia with halogenated hydrocarbons.

Pregnancy and Lactation: Administration to pregnant women/women who are breast-feeding should only be considered if the expected benefit to the mother justifies the potential risk to the foetus/child.

Ability to Drive and Use Machines: Dizziness is an uncommon side effect which should be taken into account.

Undesirable Events: Consult SmPC for a full list of side effects. Common (≥ 1/100 to < 1/10): Oral candidiasis, pneumonia, hyperglycaemia, anxiety, insomnia, headache, palpitations, dysphonia, cough, nausea, muscle spasms, urinary tract infection. Uncommon (≥ 1/1,000 to < 1/100): Hypersensitivity, depression, agitation, restlessness, nervousness, dizziness, tremor, angina pectoris, tachycardia, cardiac arrhythmias (atrial fibrillation, supraventricular tachycardia and extrasystoles), throat irritation, bronchospasm, dry mouth, bruising, urinary retention, chest pain. Very Rare (< 1/10,000): Signs or symptoms of systemic glucocorticosteroid effects, e.g. hypofunction of the adrenal gland, abnormal behaviour. Not known: Angioedema, vision blurred, cataract, glaucoma.

Product subject to prescription which may be renewed (B)

Legal Category:

Marketing Authorisation Number: EU/1/20/1498/002 120 actuations

Marketing Authorisation Holder: AstraZeneca AB, SE-151 85, Södertälje, Sweden.

Further product information available on request from: AstraZeneca Pharmaceuticals (Ireland) DAC, Block B, Liffey Valley Office Campus, Dublin 22. Tel: +353 1 609 7100.

TRIXEO and AEROSPHERE are trademarks of the AstraZeneca group of companies.

Date of API preparation: 10/2021

Veeva ID: IE-3166

Adverse events should be reported directly to; HPRA Pharmacovigilance, Website: www.hpra.ie Adverse events should also be reported to AstraZeneca Patient Safety on Freephone 1800 800 899

1. TRIXEO AEROSPHERE 5 micrograms/7.2 micrograms/160 micrograms pressurised inhalation, suspension. Summary of Product Characteristics. Available at www.medicines.ie

2. Rabe KF et al. Triple inhaled therapy at two glucocorticoid doses in modeate-to-very-severe COPD. N Engl J Med. 2020;383:35–48. doi: 10.1056/

NEJMoa1916046 COPD. N Engl J Med. 2020;383:35–48. doi: 10.1056/NEJ-

Moa1916046

Benefits of LTFT working already found in Tallaght pilot

PAUL MULHOLLAND

Initial feedback to a project exploring less-than-full-time (LTFT) working for anaesthesiology trainees in Tallaght University Hospital (TUH) has been “extremely positive”, the Medical Independent (MI) has been told.

The project is a one-year pilot, which is supported by the College of Anaesthesiologists of Ireland (CAI) and funded by the HSE’s National Doctors Training and Planning (NDTP) unit.

For the pilot, three full-time training posts in anaesthesiology have been converted into four LTFT training posts (three at 80 per cent and one at 60 per cent of fulltime working).

Before this, anaesthesiology NCHDs could only apply for LTFT at 50 per cent of full-time working.

“There is a strong sentiment that this is both inadequate in terms of clinical experience and progression through training and financially impractical for the majority of doctors in training,” a spokesperson for TUH told MI

According to the spokesperson, Dr Karen Tan and Dr Victoria McMullan, who are both CAI tutors within Tallaght’s department of anaesthesiology, “recognised the incredible stress doctors in training have been under over the last two years in particular.”

“Furthermore, doctors in training frequently face their own personal and professional challenges for which they need additional time and support,” the spokesperson said.

“The opportunity to train at LTFT for a defined period of time offers some much-needed time and headspace to regain balance in their busy lives.”

Common reasons for working LTFT include family commitments, ill health, the pursuit of academic qualifications, and giving time to devote to personal pursuits.

“One of the key priorities for the project is to ensure the wellbeing of our doctors in training and to support them during difficult times,” the spokesperson said.

“Unfortunately, we have seen excellent doctors in training leave [anaesthesiology] due to the onerous nature of the working hours and accompanying exams. This is something we are keen to prevent.”

The project has been running for three months and will finish in January 2023.

“Verbal feedback to-date has been extremely positive,” according to the spokesperson.

“Although the doctors take a modest financial hit in

Specialty application for forensic pathology not yet submitted

CATHERINE REILLY

their pay, this is offset by this pay coming off a higher level of taxation. The extra time away from the hospital that working LTFT has afforded them has been a welcome relief from the intensity of work.”

After six months, formal feedback from the four doctors in training will be given to ascertain their experience of LTFT working.

“We also want to get feedback from our Lead NCHD rota organiser who has managed to offer our LTFT doctors fixed days off to facilitate predictable rostering.”

With the assistance of the human resources and finance departments in the hospital, the extra costs associated with converting three full-time posts into four LTFT posts were estimated. The salary-related costs were approximately €28,000 over the duration of the pilot, with funding provided by the NDTP under their developmental funding scheme.

“The €28,000 is the estimated cost of converting three full-time posts into four LTFT posts. This covers salary and predicted overtime payments over one year,” said the TUH spokesperson.

“The NDTP has overseen and funded this project. We will be feeding back to them at the end of the year. We, as a department, are enthusiastic to continue this in the longterm. The Committee of Anaesthesiology Trainees Ireland is also fully engaged and supportive that NCHDs should have the opportunity to work LTFT going forward.”

However, the spokesperson pointed out: “One obstacle we would need clarification on is how NCHDs who have worked LTFT for a period of time will make up the time at the end of their training and how this could be funded to make it sustainable.”

Department seeks policy advice for disability services

PAUL MULHOLLAND

The Department of Health has issued a tender for a consultancy service to provide advice and guidance “in relation to the development of evidence-based health sector policy and practices” for people with disabilities.

The successful candidate will be required to provide policy analysis expertise and advisory services to the Department on a range of disability-related issues, including economic and financial matters.

“This work will include the preparation of advice papers, research and analysis of disability data and trends, attendance at meetings with senior Departmental officials and the Minister, and presentations to senior health decision-makers, as and when required,” according to tender documents.

The budget for the service is €50,000 excluding VAT, while the timeframe is one year, with an option to extend the contract for 12 months, should the need arise.

The successful candidate should be able to demonstrate a good knowledge and understanding of the current disability regulatory framework, as well as a good knowledge of the disability services’ operational environment in Ireland and other relevant jurisdictions.

“Demonstrable experience in policy development, with a particular focus on financial and economic analysis, in the health sector is essential,” according to the tender.

The deadline for a response to the tender is 12 May.

It is noted that one of the key policy development priorities for the dedicated disability unit within the Department is progression of the Action Plan for Disability Services 2022-2025

The unit is also working on the reform of the disability sector under Sláintecare including implementation of the reconfiguration of residential services as recommended in Time to move on from congregated settings and rolling out the ‘New directions’ programme of day service improvements.

The Office of the State Pathologist (OSP) is “continuing to work” with the Department of Justice, Faculty of Pathology, and Medical Council, to prepare an application for specialty status for forensic pathology.

Making an application for specialty status was one of recommendations in a 2019 review of the OSP, undertaken by the RCPI.

According to the review, which was commissioned by the Department, the absence of a training pathway “appears to be a major barrier to recruitment and sustainability”.

While it was possible to train abroad, “the concern is that a trainee may not then return,” it noted.

The review outlined that while a forensic pathologist may train through the Royal College of Pathologists, UK, and then register with the UK General Medical Council as a forensic pathologist, in Ireland they would have to register as a histopathologist or on the general division of the Medical Council, “which is where they would have been eligible to register immediately after completion of internship. This would not be considered professionally attractive.”

The OSP currently has staffing of 9.4 whole-time equivalents (WTEs) with one vacancy for a Deputy State Pathologist. The total staffing consists of the Chief State Pathologist, two State Pathologists, one Deputy State Pathologist, one Senior Lab Analyst, 0.6 WTE Higher Executive Officer, one Executive Officer, and 2.8 Clerical Officers.

The OSP has taken on one Deputy State Pathologist (a qualified consultant histopathologist to train in forensic pathology) and will take on a second this year, according to the Department spokesperson.

“The Department has previously experienced challenges in attracting candidates for State pathology roles: This is not unique to Ireland, but rather reflects similar challenges encountered globally.

“The role of Deputy State Pathologist, previously called Acting Deputy State Pathologist, was introduced in order to ensure that a full cohort of pathologists is available to support the service provided by the OSP. In order to be considered for the Deputy role, candidates have to have a consultant level qualification, usually as a histopathologist, and to have been performing medico-legal autopsies throughout their training.

“The successful candidate would be expected to complete a fellowship-style programme in forensic pathology, fully supervised by the Chief State Pathologist and State Pathologists, and so complete their forensic training in a defined period. Upon successful completion of this training, that candidate would then be appointed as a State Pathologist.

“The Deputy State Pathologist is only permitted to undertake autopsies in criminal or homicide cases when they are deemed to have sufficient forensic experience by the Chief State Pathologist.”

powder and suspension for injection in vials (Please refer to SmPC before prescribing) Composition: After reconstitution, one dose (0.5 mL) contains: Varicella Zoster Virus glycoprotein E antigen1,2 50 micrograms. (1 adjuvanted with AS01B containing: plant extract Quillaja saponaria Molina, fraction 21 (QS-21) 50 micrograms, 3-O-desacyl-4’-monophosphoryl lipid A (MPL) from Salmonella minnesota 50 micrograms, 2 glycoprotein E (gE) produced in Chinese Hamster Ovary (CHO) cells by recombinant DNA technology). Therapeutic indications: Prevention of herpes zoster (HZ) and post-herpetic neuralgia (PHN) in adults 50 years of age or older and in adults 18 years of age or older at increased risk of HZ. The use of this vaccine should be in accordance with official recommendations. Posology and method of administration: For intramuscular injection only, preferably in the deltoid muscle. Primary Vaccination: Initial dose of 0.5 ml followed by a second 0.5 ml dose 2 months later. For flexibility the 2nd dose can be administered between 2 and 6 months after the first dose. For subjects who are or might become immunodeficient or immunosuppressed and whom would benefit from a shorter vaccination schedule, the 2nd dose can be given 1 to 2 months after the initial dose. Booster doses: need not established. Contraindications: Hypersensitivity to the active substances or any of the excipients. Special warnings and precautions for use: The name and the batch number of the administered product should be clearly recorded. Appropriate medical treatment and supervision should be readily available in case of an anaphylactic event. Administration of Shingrix should be postponed in subjects suffering from an acute severe febrile illness. However, the presence of a minor infection, such as cold, should not result in deferral. A protective immune response may not be elicited in all vaccinees. Never administer intravascularly or intradermally; subcutaneous administration not recommended as it may lead to an increase in transient local reactions. Caution in individuals with thrombocytopenia or any coagulation disorder since bleeding may occur following intramuscular administration. Syncope can occur following, or before any vaccination as a psychogenic response. This can be accompanied by several neurological signs such as transient visual disturbance, paraesthesia and tonic-clonic limb movements during recovery. It is important that procedures are in place to avoid injury from faints. There are no data to support replacing a dose of Shingrix with another HZ vaccine. There are limited data to support the use of Shingrix in individuals with a history of HZ and in frail individuals including those with multiple comorbidities. The benefits and risks of HZ vaccination should be weighed on an individual basis. Interactions: Shingrix can be given concomitantly with unadjuvanted inactivated seasonal influenza vaccine, 23-valent pneumococcal polysaccharide vaccine (PPV23) or reduced antigen diphtheriatetanusacellular pertussis vaccine (dTpa). The vaccines should be administered at different injection sites. Fertility, pregnancy and lactation: There were no effects on male or female fertility in animal studies. It is preferable to avoid the use of Shingrix during pregnancy. The effect on breast-fed infants of administration of Shingrix to their mothers has not been studied. It is unknown whether Shingrix is excreted in human milk. Effects on ability to drive and use machines: Shingrix may have a minor influence on the ability to drive and use machines in the 2-3 days following vaccination. Undesirable effects: Very common (≥1/10): Headache, GIT symptoms, myalgia, injection site reactions, fatigue, chills, fever. Common (≥1/100 to <1/10): injection site pruritus, malaise. Uncommon (≥1/1000 to <1/100): lymphadenopathy, arthralgia. Rare (≥1/1000 to <1/100): Hypersensitivity reactions. Legal Category: POM

A. Marketing Authorisation Number: EU/1/18/1272/001. Marketing Authorisation Holder: GlaxoSmithKline Biologicals S.A., Rue de l’institut 89, B-1330 Rixensart, Belgium. Further information is available from GlaxoSmithKline (Ireland) Ltd. 12 Riverwalk, Citywest Business Campus, Dublin 24. Telephone: 01-4955000. Code: PI-7757. Date of preparation: March 2021.

Adverse events should be reported directly to the Health Products Regulatory Authority (HPRA) on their website: www.hpra.ie. Adverse events should also be reported to GlaxoSmithKline on 1800 244 255.

RCSI Medical Professionalism Conference, virtual, 8 April 2022

Responsibility to make healthcare work environment ‘safer’

Employers, associations, and regulators “must recognise their responsibility to create a work environment which is safer” for healthcare staff, heard the Medical Professionalism Conference 2022 hosted by the RCSI on 8 April.

Prof Denis Harkin, Chair of Medical Professionalism at RCSI, said this recognition should start “with a decent employer agenda to make sure healthcare workers have job security, manageable workload, supports, education and career development and health and safety”.

Speaking to over 800 delegates from more than 20 countries, Prof Harkin said the Covid-19 pandemic placed “an enormous strain on an already overburdened, understaffed and under resourced healthcare system”.

He said the pandemic “has emerged to become the greatest health and societal disaster of our age”.

“The human cost is pretty staggering: 6.1 million deaths worldwide, over 10,000 on the island of Ireland, amongst them many health and social care workers.”

Prof Harkin praised the work of doctors and other healthcare workers, pointing out that the administration of billions of Covid-19 vaccines worldwide “must count amongst humanity's greatest achievements”.

“Recently we have taken a moment to breathe, but we must now rally again to the even greater task to rebuild safer services to address the enormous backlog of delayed care,” he said.

“The pandemic has exposed great inequalities in our health system and our society.”

Prof Harkin referenced challenges such as the ageing population, increasing demand for healthcare, growing waiting lists, and workforce pressures.

He warned that for healthcare workers “under repetitive strain, even resilience” has its limits.

Proportion of doctors without GP ‘worryingly high’

The high number of doctors without a GP is especially concerning given the threat posed to wellbeing during the Covid-19 pandemic, the Medical Council President told the Medical Professionalism Conference hosted by the RCSI.

Dr Suzanne Crowe said "the proportion of doctors who are not signed up to a GP remains worryingly high".

"We would encourage every doctor, if they have their own health concerns, to discuss it with their family doctor. If you don't have a GP, please sign up with one today,” said Dr Crowe.

Doctors experiencing mental health or substance misuse issues can also contact the Practitioner Health Matters Programme, "which is completely independent of the Medical Council.” The Council’s health committee also provides “confidential and independent support for doctors”.

Dr Crowe added that the Council had recently produced a guide on doctor wellbeing because the issue

VOICES FROM THE CONFERENCE

had "been of such concern" since the emergence of Covid-19 over two years ago.

She warned that "particularly when you are working in a healthcare system that's under siege, it's very easy to just run yourself into the ground."

"We encourage doctors to consider their own mental health and to take steps to refresh and refill the vessel. Because there is no doubt if you continue to just give to your patients and your family, there will not be anything left for yourself."

On the issue of patient safety, Dr Crowe said the Council fully acknowledged that "doctors are working in a health service, which is not resourced to what we would like it to be".

She said that "we would like doctors to maintain a culture of patient safety, but we acknowledge that this is often very challenging".

"So speak to those around you, within the hospital, within your clinic, and let them know about the kind of resources you need,” said Dr Crowe.

“I know this is exhausting to advocate and petition all the time, but it is how we will grow our health service."

Also speaking about Covid-19’s impact on the global health workforce, Mr James Campbell, Director, Health Workforce Department, World Health Organisation (WHO), said the strain on healthcare workers around the world was of real concern.

Mr Campbell said that the WHO believed that over 115,000 healthcare workers have lost their lives due to Covid-19.

“Data from over a hundred countries tells us that burnout, stress, anxiety, other mental health conditions, have accelerated exponentially... these stresses are creating more and more labour disputes and protests... the majority of these related to working conditions.”

He noted that as “the world tries to vaccinate its population, less than 60 per cent of healthcare workers [globally] were vaccinated” up to December last year.

Mr Campbell added that the collective impact of these issues are now translating into “worrying trends” of staff turnover, attrition and exits across the global health workforce.

The growth in the general division of the Medical Council's register has been "largely unplanned and reactive", the recent Medical Professionalism Conference hosted by the RCSI heard.

Mr Leo Kearns, CEO of the Medical Council, told the conference that about one-third of all clinically active doctors are registered on the general division.

He said the general division was “largely made up of international graduates, although there are a significant proportion who are Irish graduates as well".

Mr Kearns said Ireland has about three times the number of NCHDs not in training posts compared to other countries, such as Northern Ireland, Scotland, and Wales.

"This growth in the general division has been largely unplanned and reactive," said Mr Kearns. "By reactive I mean where there have been significant issues with the recruitment of doctors." He said the size of the general division "absolutely reflects a disproportionate reliance on international medical graduates".

Mr Kearns added that "there is no career pathway or progression for doctors on the general division broadly speaking.... so if you're on the training division there is clear progression towards specialist qualification.... For those on the

general division there really is no structure to career progression."

He said that "in addition to the safety issues that are there, it is exceptionally unfair on those doctors on the general division".

Mr Kearns also raised concerns over continued non-compliance with the European Working Time Directive (EWTD).

"We have about half of our interns and trainees working in excess of 48 hours. This is not a benign situation; it is significantly contributing to people's poor experience of working in the Irish health system."

On 11 April, at an emergency meeting of NCHDs, the IMO launched a ballot for industrial action up to and including strike action. The failure of hospitals to comply with the EWTD was among the main issues cited by the union.

At the RCSI meeting, Mr Kearns noted that Ireland's proportion of consultants was below the OECD average.

"So if we were even to begin to realign towards international ratios we would have to have a significant increase in the number of consultants and trainees and a significant decrease in the number of non-training doctors in Ireland."

Regarding the number of consultants, Mr Kearns said "Ireland is an outlier by a very significant margin".

Prof Denis Harkin

Rise in general division doctors was ‘unplanned’ – Council CEO

The resilience of all healthcare professionals has been and continues to be tested during the pandemic as never before. We are immensely proud of all who have worked so hard in the best interest of patients. The challenge as we hopefully emerge from the pandemic is to rebuild better and rebuild safer."

Prof Patrick Ronan O'Connell, President, RCSI.

Most of our systems are designed to focus on illness at the expense of health and wellbeing."

Professor the Lord Darzi of Denham, Institute of Global Health Innovation, Imperial College London, UK, who spoke on 'Shifting from sick care to pre-emptive medicine'.

The Medical Council takes a really poor view of bullying, because we know that toxic workplaces and toxic work practices... all contribute to an unsafe patient environment."

Dr

Suzanne Crowe, President of the Medical Council.

Prescribing Information: Please read the Summary of Product Characteristics (SPC) before prescribing. Presentation: Prolonged-release tablet, containing mirabegron 25mg/50mg. Indication: Symptomatic treatment of urgency, increased micturition frequency and/or urgency incontinence as may occur in adult patients with overactive bladder (OAB) syndrome. Posology and method of administration: The recommended dose is 50 mg once daily. A lower dose of 25mg is recommended for specific patient populations (renal and hepatic impairment) as well as in specific patient populations in combination with strong CYP3A inhibitors such as itraconazole, ketoconazole, ritonavir and clarithromycin.

Renal impairment: End stage renal disease (GFR < 15 mL/min/1.73 m2 or patients requiring haemodialysis): Not recommended. Severe renal impairment (GFR 15 to 29 mL/min/1.73 m2): Reduce dose to 25 mg. Severe renal impairment and concomitant strong CYP3A inhibitors: Not recommended. Moderate renal impairment (GFR 30 to 59 mL/min/1.73 m2): 50 mg. Moderate renal impairment and concomitant strong CYP3A inhibitors: Reduce dose to 25 mg. Mild renal impairment (GFR 60 to 89 mL/min/1.73 m2): 50 mg. Mild renal impairment and concomitant strong CYP3A inhibitors: Reduce dose to 25 mg. Hepatic impairment: Severe hepatic impairment (Child-Pugh Class C): Not recommended. Moderate hepatic impairment (Child-Pugh B): Reduce dose to 25 mg. Moderate hepatic impairment and concomitant strong CYP3A inhibitors: Not recommended. Mild hepatic impairment (Child-Pugh A): 50 mg. Mild hepatic impairment and concomitant strong CYP3A inhibitors: Reduce dose to 25 mg. The tablet is to be taken once daily, with liquids, swallowed whole and is not to be chewed, divided, or crushed. It may be taken with or without food Contraindications: Hypersensitivity to the active substance or to any of the excipients (see the SPC for a list of excipients). Severe uncontrolled hypertension defined as systolic blood pressure ≥180 mm Hg and/or diastolic blood pressure ≥110 mm Hg. Special warnings and precautions for use: Renal impairment: Betmiga has not been studied in patients with end stage renal disease (GFR < 15 mL/min/1.73 m2 or patients requiring haemodialysis) and, therefore, it is not recommended for use in this patient population. Data are limited in patients with severe renal impairment (GFR 15 to 29 mL/min/1.73 m2); based on a pharmacokinetic study a dose reduction to 25 mg is recommended in this population. This medicinal product is not recommended for use in patients with severe renal impairment (GFR 15 to 29 mL/min/1.73 m2) concomitantly receiving strong CYP3A inhibitors. Hepatic impairment: Betmiga has not been studied in patients with severe hepatic impairment (Child-Pugh Class C) and, therefore, it is not recommended for use in this patient population. This medicinal product is not recommended for use in patients with moderate hepatic impairment (Child-Pugh B) concomitantly receiving

strong CYP3A inhibitors. Hypertension: Mirabegron can increase blood pressure. Blood pressure should be measured at baseline and periodically during treatment with mirabegron, especially in hypertensive patients. Data are limited in patients with stage 2 hypertension (systolic blood pressure ≥ 160 mm Hg or diastolic blood pressure ≥ 100 mm Hg). Patients with congenital or acquired QT prolongation: Betmiga, at therapeutic doses, has not demonstrated clinically relevant QT prolongation in clinical studies. However, since patients with a known history of QT prolongation or patients who are taking medicinal products known to prolong the QT interval were not included in these studies, the effects of mirabegron in these patients is unknown. Caution should be exercised when administering mirabegron in these patients. Patients with bladder outlet obstruction and patients taking antimuscarinic medicinal products for OAB: Urinary retention in patients with bladder outlet obstruction (BOO) and in patients taking antimuscarinic medicinal products for the treatment of OAB has been reported in postmarketing experience in patients taking mirabegron. A controlled clinical safety study in patients with BOO did not demonstrate increased urinary retention in patients treated with Betmiga; however, Betmiga should be administered with caution to patients with clinically significant BOO. Betmiga should also be administered with caution to patients taking antimuscarinic medicinal products for the treatment of OAB. Interactions: Pharmacokinetic interactions: Mirabegron is a substrate for CYP3A4, CYP2D6, butyrylcholinesterase, uridine diphosphoglucuronosyltransferases (UGT), the efflux transporter P-glycoprotein (P-gp) and the influx organic cation transporters (OCT) OCT1, OCT2, and OCT3. Pharmacokinetic interactions involving the potential for other medicinal products to affect mirabegron exposures: Increases in mirabegron exposure due to drug-drug interactions may be associated with increases in pulse rate. Strong CYP3A inhibitors See Posology and administration above for dose adjustments recommended during concomitant use of strong CYP3A inhibitors in patients with renal or hepatic impairment. Mirabegron exposure (AUC) was increased 1.8-fold in the presence of the strong inhibitor of CYP3A/P-gp ketoconazole. CYP2D6 inhibitors: No dose adjustment is needed for mirabegron when administered with CYP2D6 inhibitors (or in patients who are CYP2D6 poor metabolisers). Inducers: Inducers of CYP3A (such as rifampicin) or P-gp may decrease the plasma concentrations of mirabegron. No dose adjustment of mirabegron is required as this effect is not expected to be clinically relevant. Pharmacokinetic interactions involving the potential for mirabegron to affect exposures to other medicinal products: Inhibition of CYP2D6: Moderate and time dependent inhibition of CYP2D6 by mirabegron may result in clinically relevant drug interactions. CYP2D6 activity recovers within 15 days after discontinuation of mirabegron. Caution is advised if mirabegron is co-administered with medicinal

50mgs once daily

products metabolized by CYP2D6 with a narrow therapeutic index such as thioridazine, Type 1C antiarrhythmics (e.g.flecainide, propafenone) and tricyclic antidepressants (e.g., imipramine, desipramine). Caution is also advised if mirabegron is co-administered with CYP2D6 substrates that are individually dose titrated. Inhibition of P-gp: Mirabegron is a weak inhibitor of P-gp. For patients who are initiating a combination of Betmiga and digoxin, the lowest dose for digoxin should be prescribed initially. Serum digoxin concentrations should be monitored and used for titration of the digoxin dose to obtain the desired clinical effect. The potential for inhibition of P-gp by mirabegron should be considered when Betmiga is combined with sensitive P-gp substrates e.g. dabigatran. Fertility, pregnancy and lactation: The effect of mirabegron on human fertility has not been established. Betmiga is not recommended during pregnancy and in women of child-bearing potential not using contraception. Mirabegron should not be administered during breast feeding. Refer to SPC for full guidance. Driving and use of machines: Betmiga has no or negligible influence on the ability to drive and use machines. Undesirable effects: Summary of the Safety Profile: the safety of Betmiga was evaluated in 8433 patients with OAB, of which 5648 received at least one dose of mirabegron in the phase 2/3 clinical program, and 622 patients received Betmiga for at least 1 year (365 days). In the three 12-week phase 3 double blind, placebo controlled studies, 88% of the patients completed treatment with this medicinal product, and 4% of the patients discontinued due to adverse events. Most adverse reactions were mild to moderate in severity. The most common adverse reactions reported for patients treated with Betmiga 50 mg during the three 12-week phase 3 double blind, placebo controlled studies are tachycardia and urinary tract infections.

The frequency of tachycardia was 1.2% in patients receiving Betmiga 50 mg.

Tachycardia led to discontinuation in 0.1% patients receiving Betmiga 50 mg. The frequency of urinary tract infections was 2.9% in patients receiving Betmiga 50 mg.

Urinary tract infections led to discontinuation in none of the patients receiving Betmiga 50 mg. Serious adverse reactions included atrial fibrillation (0.2%). Adverse reactions observed during the 1-year (long term) active controlled (muscarinic antagonist) study were similar in type and severity to those observed in the three 12-week phase 3 double blind, placebo controlled studies. The following adverse reactions were observed with mirabegron in the three 12-week phase 3 double blind, placebo controlled studies. The frequency of adverse reactions is defined as follows: very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000); not known (cannot be established from the available data) Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness. The adverse events

are grouped by MedDRA system organ class. Infections and infestations: Common: urinary tract infection Uncommon: vaginal infection, cystitis Psychiatric disorders: Not known: Insomnia*, confusional state* Nervous system disorders: Common: headache* dizziness* Eye disorders: Rare: eyelid oedema Cardiac disorders:

Common: tachycardia Uncommon: palpitation, atrial fibrillation Vascular disorders:

Very rare: Hypertensive crisis* Gastrointestinal disorders: Common: nausea*, constipation*, diarrhoea* Uncommon: dyspepsia, gastritis Rare: lip oedema Skin and subcutaneous tissue disorders: Uncommon: urticaria, rash, rash macular, rash papular, pruritus Rare: leukocytoclastic vasculitis, purpura, angioedema* Musculoskeletal and connective tissue disorders: Uncommon: joint swelling Renal and urinary disorders: Rare: urinary retention* Reproductive system and breast disorders: Uncommon: vulvovaginal pruritus Investigations Uncommon: blood pressure increased, GGT increased, AST increased, ALT increased (*observed during post-marketing experience) Reporting of suspected adverse reactions: see below. Legal category: POM (S1B) Marketing Authorisation number: EU/1/12/809/003 25mg EU/1/12/809/010 50mg. Marketing

Authorisation holder: Astellas Pharma Europe B.V. Sylviusweg 62, 2333 BE Leiden, The Netherlands. Further information is available from: Astellas Pharma Co., Ltd, 5 Waterside, Citywest Business Campus, Dublin 24. Phone: +3531 467 1555. Summary of Product Characteristics with full prescribing information available upon request. Job number: BET_2019_0002_IE Date of preparation of API: 27 May 2019.

Reporting of suspected adverse reactions:

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via:

HPRA Pharmacovigilance Astellas Pharma Co. Ltd

Earlsfort Terrace, IRL - Dublin 2 Tel: + 353 1 467 1555

Tel: +353 1 6764971 E-mail: Irishdrugsafety@astellas.com

Fax: +353 1 6762517

Website: www.hpra.ie E-mail: medsafety@hpra.ie.

His 14th walk in the park since the day he started BETMIGA1

Research underscores importance of early intervention in psychosis

A newly published study by Irish clinicians suggests that the advantages of early detection and intervention for psychosis endure for at least 20 years. Senior Author and Consultant Psychiatrist Prof Mary Clarke spoke to Catherine Reilly about the findings

Anew study by Irish clinicians, published in April in the American Journal of Psychiatry, has provided “important and sound support” for the long-term impact of duration of untreated psychosis (DUP) on clinical, functional, and quality-of-life outcomes. That is according to an editorial in the journal by Prof Ashok Malla, Professor of Psychiatry at McGill University, Canada, and a leading global expert on psychosis.

The longitudinal study, led by researchers at the DETECT (Dublin and East Treatment and Early Care Team) Early Intervention in Psychosis Service, and the RCSI University of Medicine and Health Science, suggested that the advantages of early detection and intervention for psychosis endure for at least 20 years.

It established that people with longer delays in treatment had worse outcomes 20 years later in terms of symptoms (eg, hallucinations and social withdrawal), functioning (eg, employment status), and quality-of-life (eg, satisfying interpersonal relationships).

The authors found that while associations between delayed treatment and worse long-term outcome can vary depending on what outcome is measured, they are sustained across decades in a way that could not be explained by other factors.

“There were questions as to whether that relationship endured over the 20-year period, and we certainly found that it did,” Prof Mary Clarke, Senior Author, Clinical Professor of Psychiatry at University College Dublin and Consultant Psychiatrist at DETECT Early Intervention in Psychosis Service, told the Medical Independent (MI)

The study is believed to be the first to systematically examine DUP-outcome relationships among a first-episode psychosis (FEP) incidence cohort, at multiple, sequential time points, over a 20-year period. It was supported by the St John of God Research Foundation through funding from the Health Research Board and the Stanley Medical Research Institute, US.

Participants

The research involves 171 participants who first presented with psychosis to Cluain Mhuire Mental Health Service or St John of God Hospital in Dublin between 1995 and 1999. Of these 171 participants, outcome measures were provided by 170 at baseline, 116 at six-month, 136 at four-year, 113 at eight-year, 136 at 12-year, and 80 at 20year follow-ups.

Prof Clarke was also involved in the initial study in 1995. She said the research team has been fortunate to have supportive funders and participants who demonstrated great altruism. “Because these kinds of studies are very hard to do. And increasingly, with data protection legislation, they do become trickier,” she told MI “But I think it was a great reflection on the altruism of people who came back time after time, in the knowledge that they were not necessarily going to benefit from the study, but were hoping to help others.”

She said the results highlighted the importance of ensuring that people with a diagnosis of psychosis have timely access to evidence-based treatments. The findings also underscored the importance of investing in research that aims to improve the outcome of psychotic illnesses.

Earlier findings from this study provided the rationale and evidence-base to establish the DETECT Early Intervention in Psychosis Service at St John of God community services, which was the first early detection and intervention service for psychosis in Ireland.

In 2019 the HSE National Clinical Programme for

Early Intervention in Psychosis (EIP) published a model of care document, which noted extensive evidence showing that intervening early in psychotic disorders was associated with numerous benefits. These included lower levels of symptom severity, suicidality, and death; lower risks of progression to more enduring stages of psychosis; and better rates of remission, recovery, and relapse prevention.

Under the model of care, EIP services should be established throughout the HSE mental health system to ensure everyone aged 14 to 65, presenting with FEP to mental health services, has access to EIP services for up to three years. The development of EIP services nationally is ongoing.

Holistic

Evidence-based interventions for FEP include pharmacotherapy; physical health monitoring and lifestyle interventions; psychological therapies; family interventions; and social, occupational, and educational interventions.

According to Prof Clarke, the evidence now supports a “more holistic” approach to treatment of psychosis. Medication remains an important intervention, particularly at the initial stages.

“I think over the past 20 years [internationally] we have seen a huge interest and expansion in psychological services, particularly cognitive behavioural therapy

for the treatment of psychosis,” she noted.

There is increased recognition of the physical healthcare requirements of patients. In Ireland, the area of physical health monitoring requires ongoing improvement, confirmed Prof Clarke.

“A lot of the evidence is showing that people with psychosis have poor physical health and tend to die 10 to 15 years earlier than the general population, despite improvements in the general population healthcare, and the biggest cause of mortality in psychosis actually is cardiovascular disease.”

There is a “big emphasis” on ensuring people are educated and informed about the importance of looking after their cardiovascular health, the benefits of exercise, and potential side-effects of medication.

Medication for psychosis has the potential to raise glucose and cholesterol and cause weight gain. These changes “can happen quite quickly and can happen at an early stage, so that is the emphasis from the beginning, to be aware of it and educate people about it and also to educate the families about it”. Some of the medications are more prone to causing weight gain than others and it is important that this is monitored.

Physical activity has several benefits for people affected by psychosis. There is evidence that exercise can help with anxiety and mood symptoms, while research is ongoing into whether it can have a positive impact on some symptoms of psychosis. In addition, physical activity has a social aspect and helps with integration into the community.

“We have our own physical health programme here, which is tailored for people with serious mental illness, which we run within our mental health services in partnership with Dún Laoghaire-Rathdown Sports Partnership,” stated Prof Clarke.

Psychotic disorders, such as schizophrenia and mood disorders (with psychosis), affect about 3 per cent of the population in their lifetime. Each year in Ireland, approximately 1,300 adults and 230 adolescents develop a psychotic disorder for the first time.

The three years after FEP is regarded as a crucial period in terms of maximising improvement.

Some people develop psychosis very acutely and it is evident they are unwell. However, the signs may be subtle for many others. “Making a diagnosis of psychosis, particularly in the initial stages, can be quite complicated,” noted Prof Clarke.

On whether there were additional training requirements for GPs, Prof Clarke said: “I think the GPs do a fantastic job in picking up people with the signs and symptoms of psychosis and referring them on to the mental health services.” She said services, such as the DETECT Early Intervention in Psychosis Service and the national clinical programme, were conscious of the need to do more educational work with GP colleagues, “who do a great job.”

Another important message involves recovery. At 20year follow-up in the study, 26 of the 80 participants were not receiving any antipsychotic treatment and, according to Prof Clarke, this reflected the fact that many people recover from psychosis.

“The key message is at least a third of people will have one psychotic episode and make a full recovery, so it was not surprising that there were people taking no medication and who had fully recovered.”

Prof Clarke underlined that the earlier a person receives treatment for psychosis, the better the outcomes, as has been accepted for many physical illnesses. She said this is important to communicate to people.

Prof Mary Clarke

It was a great reflection on the altruism of people who came back time after time… hoping to help others

PRESCRIBING INFORMATION (PI)

RINVOQ® (upadacitinib) 15 mg and 30mg prolonged-release tablets. Refer to Summary of Product Characteristics (SmPC) for full prescribing information. PRESENTATION: Each 15 mg prolonged-release tablet contains upadacitinib hemihydrate, equivalent to 15mg of upadacitinib. Each 30mg prolonged-release tablet contains upadacitinib hemihydrate, equivalent to 30 mg of upadacitinib. INDICATION: Treatment of moderate to severe active rheumatoid arthritis (RA) and active psoriatic arthritis (PsA) in adult patients who have responded inadequately to, or who are intolerant to one or more disease-modifying anti-rheumatic drugs (DMARDs). RINVOQ may be used as monotherapy or in combination with methotrexate. Treatment of active ankylosing spondylitis (AS) in adult patients who have responded inadequately to conventional therapy. Treatment of moderate to severe atopic dermatitis (AD) in adults and adolescents 12 years and older who are candidates for systemic therapy. DOSAGE AND ADMINISTRATION: Intended for use under guidance and supervision of a physician experienced in diagnosis and treatment of conditions for which upadacitinib is indicated. Dosage: RA, PsA and AS: The recommended oral dose is 15mg once daily. Consideration should be given to discontinuing treatment in patients with AS who have shown no clinical response after 16 weeks of treatment. Some patients with initial partial response may subsequently improve with continued treatment beyond 16 weeks. AD (adults): The recommended oral dose is 15 mg or 30 mg once daily based on individual patient presentation. 30 mg once daily dose may be appropriate for patients with high disease burden and for patients with an inadequate response to 15 mg once daily. The lowest effective dose for maintenance should be considered. For patients ≥ 65 years of age, the recommended dose is 15mg once daily. AD (adolescents from 12 to 17 years): The recommended oral dose is 15mg once daily for adolescents weighing at least 30 kg. Adults and adolescents 12 years and older: Upadacitinib can be used with or without topical corticosteroids. Topical calcineurin inhibitors may be used for sensitive areas such as the face, neck, and intertriginous and genital areas. Consideration should be given to discontinuing upadacitinib treatment in any patient who shows no evidence of therapeutic benefit after 12 weeks of treatment. Special Populations: Elderly: For AD, doses higher than 15mg once daily not recommended in patients aged 65 years and older. Limited data for patients aged 75 and older. Renal: No dose adjustment required in mild-moderate renal impairment. Upadacitinib 15mg once daily should be used with caution in patients with severe renal impairment. Upadacitinib 30 mg once daily is not recommended for patients with severe renal impairment. Upadacitinib has not been studied in subjects with end stage renal disease. Hepatic impairment: No dose adjustment is required in patients with mild (Child Pugh A) or moderate (Child Pugh B) hepatic impairment. Should not be used in patients with severe (Child Pugh C) hepatic impairment. Paediatric Population: No data available in the following paediatric patient populations: children with AD below the age of 12 years; children and adolescents with RA, PsA and AS aged 0 to less than 18 years. CONTRAINDICATIONS: Hypersensitivity to active substance or excipients. Active tuberculosis (TB) or active serious infections. Severe hepatic impairment. Pregnancy. SPECIAL WARNINGS AND PRECAUTIONS: See SmPC for full details. Immunosuppression: Combination use, with immunosuppressants e.g. azathioprine, ciclosporin, tacrolimus, and biologic DMARDs or other JAK inhibitors has not been evaluated in clinical studies and is not recommended as the risk of additive immunosuppression cannot be excluded. Serious infections: Serious and fatal infections have been reported. Caution when treating patients ≥65 years. Frequently reported – pneumonia and cellulitis. Bacterial meningitis has been reported. Opportunistic infections reported –TB, multidermatomal herpes zoster, oral/oesophageal candidiasis, and cryptococcosis. Do not initiate treatment in patients with active, serious infection, including localised infections. Consider the risk/benefit of treatment in patients with: chronic or recurrent infection, history of serious or opportunistic infection, those exposed to TB, those who have resided or travelled in areas of endemic TB or endemic mycoses, those with underlying conditions that may pre-dispose patients to infection. Closely monitor patients and interrupt treatment if there are signs and symptoms of infection pre and post treatment. Tuberculosis: Pre-screen patients for active or latent TB. RINVOQ should not be given to patients with active TB. Consider anti-TB therapy in patients with previously untreated latent TB or in patients with risk factors for TB infection. Consult with a physician with experience in TB therapy to assess whether initiating anti-TB therapy is appropriate for an individual patient. Monitor patients for the development of signs and symptoms of TB, including patients who tested negative for latent TB infection prior to initiating therapy. Viral reactivation: Cases of herpes virus reactivation have been reported e.g. herpes zoster. If herpes zoster is reactivated, consider interruption of upadacitinib therapy until the episode resolves. Screen for viral hepatitis and monitor regularly for reactivation before starting and during therapy with upadacitinib. Patients, positive for hepatitis C antibody/hepatitis C virus RNA and hepatitis B surface antigen/hepatitis B virus DNA were excluded from clinical studies. If hepatitis B virus DNA is detected while receiving RINVOQ, a liver specialist should be consulted. Vaccination: Use of live, attenuated vaccines during or immediately prior to therapy is not recommended. It is recommended that patients be brought up to date with all immunisations, including

THE ITCH & RASH OF MODERATE TO SEVERE ATOPIC DERMATITIS

RINVOQ demonstrated in an integrated analysis of the MEASURE UP 1 & 2 monotherapy studies at Week 16:

• EASI 75 skin clearance rates of 76% and 65% for patients treated with RINVOQ 30 mg QD and 15 mg QD, respectively, vs 15% with placebo (p<0.001 for both comparisons)2

• Itch reduction (mean percent change from baseline in Worst Pruritus NRS) of –70% and –58% for RINVOQ 30 mg QD and 15 mg QD, respectively, vs –24% with placebo (p<0.001 for both comparisons)2

prophylactic zoster vaccinations prior to starting therapy, in agreement with current immunisation guidelines. Malignancy: Immunomodulatory therapies may increase the risk of malignancies including lymphoma and nonmelanoma skin cancer in RA patients. Malignancies were observed in clinical studies. Periodic skin examination recommended for patients who are at increased risk for skin cancer. See SmPC for full details. Haematological abnormalities: Do not start therapy if Absolute Neutrophil Count <1 x 109 cells/L, Absolute Lymphocyte Count <0.5 x 109 cells/L and Hb <8 g/dL. Monitor patients and temporarily stop therapy if abnormal haematological parameters as specified are detected during routine patient management. Diverticulitis: Events of diverticulitis have been reported in clinical trials and post-marketing. Upadacitinib should be used with caution in patients with diverticular disease and especially in patients chronically treated with concomitant medications associated with an increased risk of diverticulitis. Patients presenting with new onset abdominal signs and symptoms should be evaluated promptly for early identification of diverticulitis to prevent gastrointestinal perforation. Cardiovascular Risk: RA patients have an increased risk for cardiovascular disorders. Manage patient’s risk factors for e.g. hypertension, hyperlipidaemia as per usual standard of care. Lipids: Monitor total cholesterol, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) at 12 weeks and thereafter according to international guidelines. Elevated LDL in clinical trials decreased to pre-treatment levels in response to statin therapy, although evidence is limited. The effect of these lipid parameter elevations on cardiovascular morbidity and mortality has not been determined. Hepatic transaminase elevations: Monitor liver enzymes at baseline and thereafter according to routine patient management. Prompt investigation of the cause of liver enzyme elevation is recommended to identify potential cases of drug-induced liver injury. In such cases therapy should be interrupted until this diagnosis is excluded. Venous thromboembolism: Deep vein thrombosis (DVT) and pulmonary embolism (PE) have been reported in patients receiving JAKi, including upadacitinib. Use therapy with caution in patients at high risk for DVT/PE. Risk factors should be determined by patients age, obesity and medical history of DVT/PE, patients undergoing major surgery and prolonged immobilisation. If clinical features of DVT/PE occur discontinue therapy, evaluate and treat promptly. INTERACTIONS: Upadacitinib is metabolised mainly by CYP3A4 and plasma exposures may be affected by CYP3A4 inhibitors or inducers. Upadacitinib 15 mg once daily should be used with caution in patients receiving chronic treatment with strong CYP3A4 inhibitors. Upadacitinib 30 mg once daily dose is not recommended for patients receiving chronic treatment with strong CYP3A4 inhibitors. See SmPC for full details. FERTILITY, PREGNANCY AND LACTATION: Upadacitinib is contraindicated during pregnancy. Women of childbearing potential should be advised to use effective contraception during treatment and for 4 weeks following the final dose of upadacitinib. Female paediatric patients and/or their parents/caregivers should be informed about the need to contact the treating physician once the patient experiences menarche while taking upadacitinib. Upadacitinib should not be used during breast-feeding. The effect of upadacitinib on human fertility has not been evaluated. ADVERSE REACTIONS: Refer to SmPC for full details on adverse reactions. Very common adverse reactions (≥1/10): upper respiratory tract infections, acne. Common adverse reactions (≥1/100 to <1/10): bronchitis, herpes zoster, herpes simplex, folliculitis, influenza, anaemia, neutropaenia, hypercholesterolaemia, cough, abdominal pain, nausea, urticaria, fatigue, pyrexia, increased blood CPK/ALT/AST, increased weight and headache. This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse reactions via HPRA Pharmacovigilance; website: www.hpra.ie.

LEGAL CLASSIFICATION: POM (S1A). MARKETING AUTHORISATION NUMBER/ PRESENTATION: EU/1/19/1404/001 and EU/1/19/1404/006 – Calendar blister packs containing 28 prolonged-release tablets. MARKETING

AUTHORISATION HOLDER: AbbVie Deutschland GmbH & Co. KG, Knollstrasse, 67061 Ludwigshafen, Germany. Further information is available from AbbVie Limited, 14 Riverwalk, Citywest Business Campus, Dublin 24, Ireland.

DATE OF REVISION: December 2021. PI-1404-005

Abbreviations: EASI – eczema activity and severity index; NRS – numerical rating scale; QD – once daily; EU – European Union.

* The recommended dose of RINVOQ is 15mg once daily for adolescents weighing at least 30kg. The safety and efficacy of RINVOQ in children with atopic dermatitis below the age of 12 years have not been established. No data are available. No clinical exposure data are available in adolescents <40kg. The posology in adolescent patients 30kg to <40kg was determined using population pharmacokinetic modelling and simulation.2

Reference: 1. Langan S. et al. Atopic dermatitis. The Lancet. 2020;396(10247):345-360. DOI: https://doi.org/10.1016/ S0140-6736(20)31286-1.

2. RINVOQ Summary of Product Characteristics, available on www.medicines.ie

3. Baricitinib Summary of Product Characteristics, available on www.medicines.ie 4. Abrocitinib Summary of Product Characteristics, available on www.medicines.ie

RINVOQ, the first and only oral JAK inhibitor indicated for the treatment of both adults and adolescents ≥12 years* with moderate to severe Atopic Dermatitis in the EU

The life of a surgeon in South Sudan and Uganda

In the third part in her series ‘On the frontlines’, Bette Browne speaks with Dr Paul Okeny about the challenges involved in working as a surgeon in South Sudan and in his native Uganda

As civil war was raging across the new nation of South Sudan, Dr Paul Okeny was working inside a make-shift thea tre battling to save the life of a teenage girl and her baby.

“It was around the height of the civil war and there was danger everywhere. I was in a very remote area in South Sudan to set up a surgical unit. Just a few days after I arrived, a young girl of about 18 showed up who was pregnant. She went into labour and was trying to push but there was an obstruction and we needed to operate but we had no theatre yet,” Dr Okeny recalled in an interview with the Independent (MI).

“The nearest hospital was about two hours away and there was a lot of fighting going on. It was about nine o’clock at night and putting this young girl in an ambulance would have been too dangerous for her and those accompanying her, so I had to choose be tween risking that and putting together a make-shift theatre to operate.

“I knew we had a good team of midwives and a nurse anaesthetist, so we set about creating a make-shift the atre in the village. We were able to do the surgery and to our delight it worked and the girl delivered a very healthy baby. Then we saw the villagers had gathered outside and everyone started clapping. They had never seen such a major operation before in the village.”

The same night Dr Okeny and his team saved another woman from death.

“We had to prioritise and work on the younger girl who still had a live baby. The older lady, who was about 40, had a dead foetus at term. We couldn’t put her to sleep because she was very ill and waking her up following the operation would be a challenge as we didn’t have access to ICU. Using local anaesthetic, we opened into her uterus and removed the dead foetus.” The woman was very grateful to have received life-saving care and “a couple of weeks later she came back to us and brought us some live chickens. It was a wonderful experience. We saved three lives and everyone was so happy.”

In South Sudan, life is tough for most people and danger is ever present. The country is regarded as one of the most dangerous in the world for humanitarian workers. Since 2013, more than 100 aid workers have been killed in the country, according to Human Rights Watch.

long civil war.

Clashes between groups in the north and south began before Sudan even gained independence from Britain in 1956. Sparked initially by a mutiny in the south, the subsequent violence left up to two million people dead, many from starvation, during two civil

The creation of South Sudan grew out of a 2005 peace deal between the pro-Arab Muslim north and the predominantly Christian south of Sudan. But clashes resumed between splinter groups, government factions, and rebels. A shaky accord was agreed by the warring parties in 2018 and the country’s first general election is scheduled to take place in 2023.

The conflict has resulted in over two million people fleeing their homes, usually to neighbouring Ethiopia and Uganda, where Dr Okeny was born. Basic infrastructure such as health and education facilities have been destroyed. Fighting has also damaged the country’s economy, contributing to soaring inflation. Food prices continue to rise and 70 per cent of families in South Sudan go hungry.

As many as 6.3 million people, over half the country’s population, are severely food insecure. Famine was declared in 2017 and although humanitarian aid, including from Ireland, led to an improvement in the situation, current food security levels are still dire. “It is devastating to see the death, displacement, human rights abuses and human misery that has dominated

Dr Paul Okeny

I had a health background too because my mother was a midwife and I grew up within the premises of a local health unit in Karamoja

When a DPP-4 inhibitor is needed

Simplicity. Reinforced .

for a BROAD RANGE of adults with type 2 diabetes (T2D)

UNIQUE CONVENIENCE through always one dose, once daily 1 5mg once daily

Demonstrated

CV AND KIDNEY SAFETY PROFILE 2,3

PROVEN EFFICACY VS PLACEBO

for adults with T2D 1,4

References:

1. TRAJENTA® (linagliptin) Summary of Product Characteristics. SmPC available at: https://www.medicines.ie/

2. Rosenstock J, et al. JAMA. 2019;321:69–79

3. Rosenstock J, et al. Cardiovasc Diabetol. 2018;17:39

4. McGill JB, et al. Diabetes Care. 2013;36:237–44

Prescribing Information (Ireland) TRAJENTA® (Linagliptin)

Film-coated tablets containing 5 mg linagliptin. Indication: Trajenta is indicated in adults with type 2 diabetes mellitus as an adjunct to diet and exercise to improve glycaemic control as: monotherapy when metformin is inappropriate due to intolerance, or contraindicated due to renal impairment; combination therapy in combination with other medicinal products for the treatment of diabetes, including insulin, when these do not provide adequate glycaemic control. Dose and Administration: 5 mg once daily. If added to metformin, the dose of metformin should be maintained and linagliptin administered concomitantly. When used in combination with a sulphonylurea or with insulin, a lower dose of the sulphonylurea or insulin, may be considered to reduce the risk of hypoglycaemia. Renal impairment: no dose adjustment required. Hepatic impairment: pharmacokinetic studies suggest that no dose adjustment is required for patients with hepatic impairment but clinical experience in such patients is lacking.

Elderly: no dose adjustment is necessary based on age. Paediatric population: the safety and ef cacy of linagliptin in children and adolescents has not yet been established. No data are available. The tablets can be taken with or without a meal at any time of the day. If a dose is missed, it should be taken as soon as possible but a double dose should not be taken on the same day. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Warnings and Precautions: Linagliptin should not be used in patients with type 1 diabetes or for the treatment of diabetic ketoacidosis. Hypoglycaemia: Caution is advised when linagliptin is used in combination with a sulphonylurea and/or insulin; a dose reduction of the sulphonylurea or insulin may be considered. Acute pancreatitis: Acute pancreatitis has been observed in patients taking linagliptin. Patients should be informed of the characteristic symptoms of acute pancreatitis. If pancreatitis is suspected, Trajenta should be discontinued. If acute pancreatitis is con rmed, Trajenta should not be restarted. Caution

should be exercised in patients with a history of pancreatitis. Bullous pemphigoid: Bullous pemphigoid has been observed in patients taking Linagliptin. If bullous pemphigoid is suspected, Trajenta should be discontinued. Interactions: Linagliptin is a weak competitive and a weak to moderate mechanism-based inhibitor of CYP isozyme CYP3A4, but does not inhibit other CYP isozymes. It is not an inducer of CYP isozymes. Linagliptin is a P-glycoprotein substrate and inhibits P-glycoprotein mediated transport of digoxin with low potency. Based on these results and in vivo interaction studies, linagliptin is considered unlikely to cause interactions with other P-glycoprotein substrates. Effects of other medicinal products on linagliptin: The risk for clinically meaningful interactions by other medicinal products on linagliptin is low. Rifampicin: Multiple co-administration of 5 mg linagliptin with rifampicin, a potent inductor of P-glycoprotein and CYP3A4, decreased linagliptin steady state AUC and Cmax. Thus, full ef cacy of linagliptin in combination with strong P-glycoprotein inducers might not be achieved, particularly if administered long term. Coadministration with other potent inducers of P-glycoprotein and CYP3A4, such as carbamazepine, phenobarbital and phenytoin has not been studied. Effects of linagliptin on other medicinal products: In clinical studies linagliptin had no clinically relevant effect on the pharmacokinetics of metformin, glibenclamide, simvastatin, warfarin, digoxin or oral contraceptives (please refer to Summary of Product Characteristics for a full list of interactions and clinical data). Fertility, pregnancy and lactation: The use of linagliptin has not been studied in pregnant women. As a precautionary measure, avoid use during pregnancy. A risk to the breast-fed child cannot be excluded. A decision must be made whether to discontinue breast-feeding or to discontinue/abstain from linagliptin therapy taking into account the bene t of breastfeeding for the child and the bene t of therapy for the woman.

No studies on the effect on human fertility have been conducted

for linagliptin. Undesirable effects: Adverse reactions reported in patients who received linagliptin 5 mg daily as monotherapy or as add-on therapies in clinical trials and from post-marketing experience. Frequencies are de ned as very common (≥1/10), common (≥1/100 to <1/10), uncommon (≥1/1,000 to <1/100), rare (≥1/10,000 to <1/1,000) or very rare (<1/10,000). Adverse reactions with linagliptin 5 mg daily as monotherapy: Common: lipase increased. Uncommon: nasopharyngitis; hypersensitivity; cough; rash; amylase increased. Rare: pancreatitis; angioedema; urticaria; bullous pemphigoid. Adverse reaction with linagliptin in combination with metformin plus sulphonylurea: Very common: hypoglycaemia. Adverse reaction with linagliptin in combination with insulin: Uncommon: constipation. Prescribers should consult the Summary of Product Characteristics for further information on side effects. Pack sizes: 28 tablets. Legal category: POM. MA number: EU/1/11/707/003. Marketing Authorisation Holder: Boehringer Ingelheim International GmbH, D-55216 Ingelheim am Rhein, Germany. Prescribers should consult the Summary of Product Characteristics for full prescribing information. Additional information is available on request from Boehringer Ingelheim Ireland Ltd, The Crescent Building, Northwood, Santry, Dublin 9. Prepared in September 2021.

Adverse events should be reported. Reporting forms and information can be found at https:// www.hpra.ie/homepage/about-us/report-an-issue. Adverse events should also be reported to Boehringer-Ingelheim Drug Safety on 01 2913960, Fax: +44 1344 742661, or by e-mail: PV_local_UK_Ireland@boehringer-ingelheim.com

South Sudan’s first years as an independent state,” commented Irish Foreign Affairs Minister Simon Coveney at the time of the famine.

“We know that this is largely a man-made conflict. We can – and we will – keep giving humanitarian aid to save lives, but the only way we can move towards supporting long-term sustainable development in South Sudan is through a comprehensive political solution.”

But in the intervening years the country has continued to suffer greatly, with over eight million people estimated to be in need of humanitarian assistance in 2021, according to a report by the World Bank. Added to this already perilous situation is the Covid pandemic.

“Communities were hit hard by the triple shock of intensified conflict and sub-national violence, a second consecutive year of major flooding, and the impacts of Covid-19, exacerbating an already dire humanitarian situation,” the World Bank report said.

Health facilities are particularly badly impacted, Human Rights Watch says. “Conflict has caused health facilities to routinely face shortages of key medical supplies putting further civilian lives in danger. The fighting has also compounded food insecurity, with malnutrition becoming a greater threat.”

Against this background, it is easy to see why Dr Okeny’s work setting up a surgical service at a newly built hospital in a very remote area in South Sudan made such a difference for people. Indeed, the desire to make a difference in people’s lives was a major reason why he became a doctor in the first place in his native Uganda. His mother’s work as a midwife also inspired him to devote himself to medicine.

Karamoja

Dr Okeny was born in 1982 in the Karamoja Region, in north eastern Uganda. “I thought at an early age that the best way to serve the people was to be a doctor or [to work] in a similar profession,” he told MI

“I had a health background too because my mother was a midwife and I grew up within the premises of a local health unit in Karamoja.”

The Karamoja region is made up of dry grasslands and semi-nomadic cattle herders. The region’s dependence on agriculture makes people there vulnerable to changes in weather patterns and devastating droughts, which occur about every two to three years. Households that do not own livestock are particularly vulnerable to food insecurity.

But Karamoja is also a region with potential. It is ecologically diverse with opportunities for crop and livestock production and it has tourism potential. It is one of the most richly endowed regions in Uganda, with over 50 different minerals, including gold, silver, copper, iron, gemstones, limestone, and marble, although the scale and accessibility of all of these resources is not yet fully established. This represents a potential source of income for the region, but also increases the risks of exploitation, for example through land grabbing.

The Irish Government has been assisting Uganda as part of an aid programme that began back in 1994 and poverty rates have been declining in recent decades (from 50 per cent in 1992 to below 20 per cent in 2012).

Today Uganda is a growing economy and an important factor in the region, but there are high levels of inequality, according to an Irish Aid strategy paper. Over 90 per cent of people in Karamoja are classed as poor and vulnerable, as opposed to just under 11 per cent in the capital Kampala.

Uganda’s burden of disease is dominated by communicable diseases, which account for over 50 per cent of morbidity and mortality, according to the

World Health Organisation (WHO). Malaria, HIV/ AIDS, tuberculosis and respiratory, diarrhoeal, epidemic-prone, and vaccine-preventable diseases are the leading causes of illness and death. There is also a growing burden of non-communicable diseases, including mental health disorders. Maternal and perinatal conditions further contribute to the high mortality. Neglected tropical diseases remain a big problem in the country, affecting mainly rural poor communities. Dr Okeny said there are also wide disparities in health status across the country because of socio-economic, gender and geographical differences.

Surgical training

Driven by a desire to help alleviate such problems and equipped with a government scholarship to study medicine, in 2002 Dr Okeny headed to Mbarara, south western Uganda, for his undergraduate degree and went on to do his postgraduate degree in Makerere University in Kampala.

After five years of university, he went back to northern Uganda to do his internship from 2007 to 2008 at St Mary's Hospital in Gulu District. The hospital is administered and managed by the Catholic Archdiocese of Gulu and most of its funding comes from Italy.

Dr Okeny remained in Gulu for two more years doing further training before formally embarking on postgraduate surgical training.

Later, he was asked by CUAMM, the Doctors with Africa NGO, to set up a surgical service at one of their newly created hospitals in remote South Sudan.

“I was glad that I said yes because it was the best experience I have had as a doctor. There was a great need there for doctors. It was a very basic and very raw environment. The theatre was still under construction and almost no laboratory and not much human support around you, just one other doctor, no properly trained local nurses. It was very, very challenging.

“I treated lots of gunshot wounds. There were many tribal conflicts and cattle rustling. I remember treating a young man of about 24 who had gone to steal cattle and unfortunately sustained serious gunshot wounds. I found out later that his father was a chief in the local village. He was so happy and thanked me and promised me his daughter in marriage. I thanked him and said I would think about it.”

It was a rare moment of light relief for the young doctor.

When he returned to his native Uganda after 10 months, Dr Okeny faced a different set of challenges to those he had experienced in South Sudan. “I think the main problems in Uganda are not really medical, they are more about system and support issues, especially in rural areas.

“Uganda is producing a lot of doctors and has reasonable medical technology and service technicians. For example, five years ago endoscopy was a luxury, but now it’s available in most hospitals within the cities. Laparoscopy might be expensive, but it is available, though not in rural areas.

The major challenges affecting the health system are the lack of resources to recruit, deploy and retain health workers, particularly in remote localities; ensuring quality of the healthcare services delivered; ensuring reliability of health information in terms of the quality, timeliness, and completeness of data; and maintaining medicines and medical supplies.

The WHO says other key problems are the emergence of antimicrobial resistance due to the inappropriate use of medicines and poor prescription practices and the inadequate control of sub-standard, spurious, falsely labelled, falsified or counterfeit medicines.

The charity VSO Ireland launched a maternal and neonatal health programme in Karamoja in November 2018 with the help of funding from Irish Aid. This programme focuses on promoting and extending health services to pregnant adolescent girls, who are particularly at risk when giving birth, and to their babies. Irish volunteers work with Ugandan volunteers and local partners to increase local knowledge of disease prevention, diagnosis, and treatment to save the lives of more mothers and babies.

“As a surgeon you depend on other people doing their part, making sure there’s blood in the blood bank and that an oxygen supply is available. Sometimes you might have to sit down and wait for hours for all these things to be in place before you actually do the operation. So you could spend more than half of your day just waiting to do the operation.” These are the kinds of system issues he constantly faces, especially in remote areas.

The day after Dr Okeny spoke with this newspaper, he returned to his hospital in the Ugandan capital Kampala after a period as a research scholar at RCSI looking at patient-centred care, which he is now developing further in Uganda. “I have my qualifications, but at the end of the day everything centres around the patient. These are the people I want to help and I hope this improves my skills dealing with patients.”

Indeed, for Dr Okeny it all goes back to his reason for becoming a surgeon – helping people. He has spent much of his time caring for those in deprived rural areas by opening much-needed surgical departments in rural hospitals in his native Uganda and neighbouring South Sudan.

“In the cities it’s usually fine, there are plenty of doctors. But deep in the rural areas, in the villages, there are people who take months to see a doctor when they need one. Their need brings out the raw clinician in you. It brings you back to what you can do clinically. In the rural areas the doctor in you has to come out.”

Their need brings out the raw clinician in you. It brings you back to what you can do clinically

Dr Paul Okeny with local children

New cardiovascular policy should be on Department’s agenda

The Irish Heart Attack Audit (IHAA) National Report 2017-2020 was recently launched at the National Office of Clinical Audit Annual Conference 2022. The report analysed data on 5,629 patients with a ST elevation myocardial infarction (STEMI) over a four-year period. Since 2012, a standardised national STEMI care pathway has delivered primary percutaneous coronary intervention (PCI) at 10 locations in Ireland.

Dr Ronan Margey, Clinical Lead of the IHAA, said the report highlights the “considerable” progress that has occurred since 2012 in broadening access to primary PCI as the preferred treatment for STEMI.

“It shows the current quality of care delivered by our ambulance service personnel, emergency doctors and nurses, cardiologists, and cardiac nurses throughout our hospital system, but particularly in the PCI centres,” he said.

However, while standardisation of care has occurred and access to reperfusion has gotten better, there is still room for improvement. Only 37 per cent of patients with a STEMI sought medical help within 60 minutes of onset of their symptoms. The report showed 68 per cent of patients were admitted to a PCI centre directly, with 28 per cent still presenting to a non-PCI hospital first. This can lead to delays in reperfusion, which directly affects heart attack survival. Some 84 per cent of patients brought directly by ambulance to a PCI centre arrived within the target of 90 minutes or less; however, only 22 per cent of patients who were transferred from another hospital to a PCI centre arrived within this target.

“Particular focus needs to be given to improving symptom recognition, in-

creasing pre-hospital diagnosis of STEMI and then transporting patients directly to PCI centres so that the right patient receives the right care in the right location at the right time,” according to Dr Margey.

“We can see from our data that this results in faster restoration of blood flow to the heart, translating into improved heart attack survival.”

While high blood pressure and high cholesterol were the most common risk factors for heart attack identified, active smoking remains disproportionately high in people admitted with a STEMI. According to the report, 34 per cent of patients with a STEMI were active smokers at the time of their heart attack. This compares to an average national smoking rate of 17 per cent in the general population.

The Irish Heart Foundation (IHF) has responded to the findings with a call for the Department of Health to develop a new cardiovascular strategy. The IHF highlighted that while Changing Cardiovascular Health: Cardiovascular Health Policy 2010-2019 established a framework for the prevention, detection, and treatment of cardiovascular diseases, the timeframe for the policy has lapsed.

“The plan is now out of date and no formal review of the policy and the implementation of its recommendations has taken place,” according to Medical Director of the IHF Dr Angie Brown.

“The scope and parameters of the current national cardiac services review does not include a full and holistic approach to cardiovascular health, so preparations must begin for the development of a new cardiovascular health policy, with a lead unit in the Department of Health.”

The results of the audit provide a basis and impetus for this work to commence.

READER COMMENTS

REACTION TO

OUR NEWS STORY, 'HSE TO RECOGNISE CLIMATE ACTION "FAILURE" AS RISK', 7 APRIL

“HSE to recognise climate action ‘failure’ as risk. This is great because from my experience to-date, HSE ironically has been a risk to climate action failure – as they can make it challenging/impossible to implement some sustainable healthcare projects!" Dr Tom Downs, @DrTomDowns, 13 April

“This is a big step in the right direction and needs to be followed by action. The @LancetCountdown has said that climate breakdown ‘threatens to undo the health gains of the last century’. This will become increasingly apparent in the coming years #ClimateActionNow." Irish Doctors for the Environment, @IrishDocsEnv, 13 April

“There is a systematic unwillingness to seriously tackle this issue, but this is not unique to the HSE. The agriculture sector is seeking a bailout for pig farms at a time of dependent emission reductions, water quality crisis, and air pollution issues."

Plant Based Doctors Ireland, @plantbaseddocIE, 7 April

REACTION TO DR PAT HARROLD'S COLUMN, 'THE PASSING OF THE STORM', 7 APRIL

“Wise words as always @drpatharrold." Dr Geraldine McGinty, @DrGMcGinty, 12 April

REACTION TO OUR NEWS STORY, 'HRT ADVICE SHARED AMONG GPS IN ONLINE GROUP', 7 APRIL

“@drbriankennedy is such an enthusiastic teacher and gives his time so generously. This has been an excellent resource, both for education as well as developing valuable networks amongst colleagues." Dr Liz Barry, @LizBarryMid, 6 April

REACTION TO OUR MEDICO-LEGAL ARTICLE, 'RISKY BUSINESS –WHAT TO DO WHEN PATIENTS PREFER NOT TO KNOW', 7 APRIL

“Interesting case study in the @med_indonews from my colleague @RachelB03187922 of @MPSdoctorsIRE discussing a case study where a patient did not want to know the risks of surgery." Michelle-Herbert, @MichelleMPS, 13 April

REACTION TO OUR BREAKING NEWS STORY, ‘INTOLERABLE PRESSURE’ ON EDS POSING MAJOR RISK FOR PATIENTS AND STAFF – IAEM', 28 MARCH

“Agree. Emergency departments under severe pressure and along with the rest of the acute hospitals we’re the only part of the acute unscheduled health service open 24/7. We’re shouldering a well-described capacity deficit that has been neglected for a decade – long prior to Covid." Dr Ger O'Connor, @drgeroconnor, 28 March

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Coroners’ investigations –your questions answered

Medical Defence Union Medico-Legal Adviser Dr Ed Farnan explains what to do if you are asked to write a report for the coroner or give evidence at an inquest

When a loved one dies unexpectedly, their families want and deserve to know what happened and doctors have an important role in that process. In the context of the Covid-19 pandemic, it is no surprise that the coroner service’s caseload has increased in the last two years. According to the coroner’s annual returns for 2021, there were more than 25,400 cases last year compared with just over 17,800 in 2019.

Unsurprisingly, the Medical Defence Union (MDU) has received more calls from members seeking advice about coroners’ inquiries during the last two years. Most want to clarify their ethical and legal duties and may be nervous about writing a report for a coroner or being asked to attend an inquest.

The first thing to say is that the vast majority of coroners’ cases do not result in an inquest. In fact, the number of inquests (virtual and in-person) recorded in the annual returns for 2021 was less than before the pandemic (2,101 compared with 2,225). The core function of the coroner is not to apportion blame, but rather to investigate sudden or unexplained deaths so a death certificate can be issued.

As a doctor, you should co-operate with coroners’ inquiries and respond professionally. This MDU advice should help.

If you are asked to write a report

In line with the Medical Council’s Guide to Professional Conduct and Ethics for Registered Medical Practitioners (para 40.2), the reports you write “must be relevant, factual, accurate and not misleading”. Here are some do’s and don’ts:

 Do include your details and qualifications

State your full name and qualifications (eg, Bachelor of Medicine rather than MB) and status (eg, ‘GP trainee’ or ‘consultant surgeon for 10 years’).

 Do be specific about your contact with the patient

For example, did you see them on a publicly-funded basis or privately? Did you see them alone or with someone else during each consultation? If so, give the name and status of the other person.

 Do not use jargon or medical abbreviations

Write medical terms in full and when mentioning drugs, give an idea of what type of drug it is, the full generic name, dosage, and route of administration.

 Do not criticise other clinicians

Identify any other clinician involved in caring for the patient by their full name and professional status, eg, if you made

a hospital referral. Describe your understanding of what they did and the conclusions they reached on the basis of your own knowledge or the clinical notes, but do not comment on their performance.

 Do give a factual chronology of events with reference to the clinical notes Your report should stand on its own and not assume the reader has any knowledge of the case.

Write in the first person, describing each relevant consultation or telephone contact and include your observations, working diagnosis or your differential diagnoses. Say what you found, but also what you looked for and did not find. If your report clearly demonstrates your history and examination were thorough, you are less likely to be called to explain your evidence at an inquest.

 Do specify what your account is based on This could be your memory, the contemporaneous notes you or others wrote, or your usual or normal practice. A coro -

ner will not expect you to make notes of every last detail, or to remember every aspect of a consultation that at the time appeared to be routine. It is perfectly acceptable to quote from memory, as long as you are making it clear that this is what you are doing.

If you cannot recall the details, state what your usual or normal practice would have been in the circumstances.

 Do not forget to copy the records

The coroner will often need the whole medical record to be disclosed so take a full copy including a physical copy of all information held digitally. Even when not asked, it is often helpful to disclose a copy of the contemporaneous clinical notes. It is also useful to give the exact dates spanned by the notes, as this is not always obvious from the entries.

 Do seek advice

Your medical defence organisation (MDO) can review a draft of your statement before you submit it.

If you are asked to attend an inquest

The law on inquests is set out in the Coroners Act 1962 and its later amendments. Here are the answers to some of the most common queries from members:

Why is it necessary to hold an inquest?

The purpose of an inquest is to determine who has died and when, where and how the person died, and – to the extent the coroner considers necessary – establish the circumstances in which the death occurred.

Possible verdicts include accidental death, misadventure, medical misadventure, suicide, natural causes, open verdict or a narrative verdict. A verdict of unlawful killing can also be returned, but this would not be expected in an inquest relating to the medical care of a patient. Coroners or juries can also make recommendations of a general nature to help prevent future deaths or in the interests of public health or safety.

How should I prepare?

If you have never attended an inquest before, you may find it helpful to do so as member of the public. It is useful to see first-hand the layout of the court and how witnesses are questioned by the coroner and other representatives.

This guidance from the Department of Justice may also help. (www.gov.ie/en/publication/inquest-an-inquiry-held-in-public-/)

Do I need legal representation?

In most cases it would not be necessary to have legal representation and it can even send the wrong signal to the family of the deceased. Considerations include whether the deceased’s family are legally represented, whether you may be criticised and whether there is a jury. It may be helpful to have a discussion with your MDO and/or the coroner if you are called to give evidence.

Your hospital legal services manager may liaise with the coroner and arrange legal representation. Keep in mind that there might occasionally be a conflict of interest between you and the hospital. The hospital’s legal advisers will normally let you know if such a conflict arises and you can contact your MDO.

What can I expect when I give evidence?

As a witness you will be asked factual questions about your involvement in the deceased’s care. Your responses to questions should be polite, factual, and not omit relevant information. If you do not know an answer to a question, explain your difficulty rather than speculate. Avoid giving an opinion, disparaging colleagues or trying to answer questions that are beyond your expertise or experience.

Can I be criticised?

The purpose of an inquest is not to apportion blame, but it is possible for a doctor to be criticised about their involvement in the patient’s care. Seek advice from your MDO if this happens.

MDU membership is open to consultants and hospital doctors not currently in training posts working in public hospitals. To find out more information, visit www.themdu.com/ ireland or follow us on Twitter @the_mdu

The first thing to say is that the vast majority of coroners’ cases do not result in an inquest

The problem with risk

Given the shortness of life, the question is what we should do with the time we have

DR PADDY BARRETT

Read more by Dr Paddy Barrett at www.mindo.ie @Paddy_Barrett

Doctors typically express risk in terms of the 10-year probability of heart attack or death. If you are a clinical trialist, expressing risk this way provides a helpful framework for conducting a clinical trial. But for most people it is a statistic that is as close to useless as makes no difference.

It’s not that this information isn’t useful, it’s simply that as humans we do a poor job at understanding or conveying the implications of probabilistic risk.

Most people really do not know what to do with the statement that “you have a 4.3 per cent chance of having a heart attack or dying in the next 10 years”.

Let’s look at this another way. There is a 100 per cent chance you will die. Of something. In the very near future. That should terrify you.

But most of us tend to breeze on by that statement with the thought: “I know. But not here. Not now.”

About one-third of us will die from cardiovascular disease and another one-third from cancer. These are the biggest threats. But there is a 100 per cent chance you will die from something.

We know that optimising nine factors including exercise, cholesterol, and blood pressure can add over a decade to your life, and in percentage terms that is a very long time, relatively speaking.

But let’s be honest, the universe is about 13.8 billion years old.

Adding another 10 years even to the life of a centenarian, in relative terms, is but a tiny fraction of the total existence of the universe.

So, no matter which way you look at it, whether or not you do all the right things and avoid all the factors that can shorten your life, your life is exceptionally short.

The real question then becomes, with this tiny sliver of time afforded to us, what should we do with that time?

How you live your life is a very personal question that I will make no attempt to answer.

We do know some things with relatively high confidence, however: Namely, that spending time with those you care about is important.

The question is how much time do you really have left with those who are most important to you? Take for example the number of remaining visits you have with your parents, assuming you live in a different city.

In this scenario you visit your parents maybe once every two months if you are lucky, but in reality probably every

three to four months. Far less if you are in a different country.

That works out to about four to five visits a year throwing in the odd extra trip.

If your parents are fortunate enough to live another 10 years that means you might only have another 40 to 50 visits left with your parents. Most of the time you will ever spend with your parents is already behind you.

Did you spend your last visit with your parents as if you had just ticked one of those visits off the list?

For some that visit will have been their last and they will likely have had no idea. How would you think of each notable event in your life as if it was the last time?

A magical Christmas morning with your kids, swimming in the ocean, feeling the rain on your face, seeing your child’s smile. All of these you will do for a last time.

Some of them you may already have done for the last time. When we express the risk of a heart attack in 10year terms there is an understandable sense that the heart attack won’t happen, not just in the next 10 years, but at any time. And that might be true.

The same logic doesn’t hold true for death, however.

Whether you have a 4.3 per cent or an 80 per cent chance of dying in the next 10 years one thing is for certain: That number will reach 100 per cent for all of us at some point. The problem is that we often behave as if that is not the case. The bigger question then becomes what are you going to do between then and now. Not just to delay the timing of death, but how you are going to spend your remaining time with those who are most important to you.

When it comes to death the risk is always 100 per cent. I find it always helps to start there and work backwards.

As the wisdom of Buddhism states: “The problem is, you think you have time.”

The rise of the sartorial shrinks

Paul Rudd’s role as a psychiatrist in ‘The Shrink Next Door’ is but the latest example of how the portrayal of the profession has changed

PROF BRENDAN KELLY

Read more by Prof Brendan Kelly at www.mindo.ie

In 2021, People magazine named the actor Paul Rudd as the sexiest man alive. Rudd, for those who do not know him, is an American actor who has appeared in numerous films including Clueless, Romeo and Juliet, This Is 40 and Ghostbusters: Afterlife . Rudd also featured in the sitcom Friends . Perhaps most famously, Rudd played Ant-Man in Ant-Man and Ant-Man and the Wasp – neither of which I have seen or have any wish to see.

For the most part, Rudd plays amiable characters, earnest rather than edgy, likeable rather than menacing. He cooks, listens and does the right thing. Despite this – or possibly because of it – Rudd’s “sexiest man” award seemed rather unlikely to many, although not entirely unjustified.

But it should also be pointed out that around the time Rudd won the coveted award, he was appearing in The Shrink Next Door, a TV series in which Rudd plays – wait for it – a psychiatrist. Coincidence? I don’t think so.

You might argue that I, a psychiatrist, would obviously take this position, but we have been here before. This is not the first time that psychiatrists have been held up as exemplars. We have form.

Close readers of The Economist Intelligent Life magazine (now called 1843) will recall an article about white shirts in the May/June 2012 edition. (As I write these words, it occurs to me that perhaps nobody will have the faintest

notion what I am talking about, but that would not be new, so I will simply carry on.)

In the article about white shirts, beneath a photograph of designer Tom Ford, Michael Bywater wrote: “The white-shirted Tom Ford has the neutrality and discretion of a good psychiatrist and the same aura of knowingness.” Indeed he does: Ford looks superb in his crisp white shirt, every bit the psychiatrist.

First Tom Ford, now Paul Rudd, and, of course, my eternally stylish colleagues? I think there is a pattern here – and not just a poorly patterned sweater, either, but a rather stylish one. Psychiatrists have finally emerged as sartorial heroes, taking fashion to the next level, leading the field, and paving the way for other specialties to follow (if they dare).

Rudd, of course, is not alone. Jeff Bridges plays a psychiatrist in K-Pax , a 2001 movie based on the novel of the same name by Gene Brewer. The story of K-Pax is an intriguing one, as Kevin Spacey plays a perplexing patient who claims to be an alien. As the treating psychiatrist,

Bridges rises to the occasion with cool curiosity and a wardrobe that speaks of both professionalism and lateral thought. Bridges’s suits and ties might suggest conformity, but his tousled hair gives the game away: He is open to being convinced by his patient. Maybe Spacey came from space? Maybe Bridges is a bridge?

In the past, psychiatrists were known for corduroy suits and questionable ties, but all is changed now. The first inkling of this revolution in Ireland came in the 2001 film, On the Edge, co-written and directed by John Carney. The movie – which is well worth watching – stars Cillian Murphy, Tricia Vessey, Jonathan Jackson, and – gloriously – Stephen Rea as the psychiatrist, Dr Figure. Happily, Dr Figure acquits himself well in substantive and sartorial terms throughout most of the film.

If we focus on fashion, we see Dr Figure in thoughtful mode for much of the time, pensive in the face of challenges, and always dressed appropriately, with understated ties and – at one stage – a really splendid jumper. A thesis could be written on Rea’s wardrobe, let alone his broader performance. He would fit in nicely with Frasier Crane and his brother Niles, an even sharper dresser.

But that is a conversation for another day. Suffice it for now that a clear line can be drawn between Rea’s pioneering work in the portrayal of psychiatrists in Ireland in 2001 and Paul Rudd’s accolade some two decades later. The Serious Freud Squad is, it seems, forever Jung at heart.

Brendan Kelly is Professor of Psychiatry at Trinity College Dublin and author of The Science of Happiness: The Six Principles of a Happy Life and the Seven Strategies For Achieving It (Gill Books).

Adding another 10 years even to the life of a centenarian, in relative terms is but a tiny fraction of the total existence of the universe

This is not the first time that psychiatrists have been held up as exemplars. We have form

Mater Private Network 2022 Cardiology Masterclass for GPs

Mater Private Network hosted its third annual Cardiology Masterclass webinar for GPs on 26 March, which featured presentations from a number of its leading cardiologists on the latest management approaches across a range of cardiology topics.

The meeting was divided into three main sessions, each of which was chaired by a GP – Dr Róisín Lyons, Dublin; Dr Mike Thompson, Cork; and Dr Ken Fitzpatrick, Dublin.

The Masterclass was opened by Prof Robert Byrne, Director of Cardiology at Mater Private Hospital, Dublin, and Chair of Cardiovascular Research at the RCSI, who welcomed everyone and said the main aim of the meeting was sharing knowledge and continuing to strengthen the relationship with colleagues in primary care.

He briefly outlined details of the Cardiovascular Research Institute Dublin, a collaboration between Mater Private Network and the RCSI, which is currently carrying out a number of outcomes-based research projects, including an open clinical trial on treatment of resistant hypertension, which GPs can refer suitable patients to, with full details available at www.cvridublin.ie

“We hope to be one of the first, if not the first, hospital in Ireland to publish the outcomes of all patients undergoing cardiac procedures on our website in a publicly accessible manner, so patients and referring doctors can inform themselves exactly what the outcomes of patients undergoing procedures are. There are also a number of clinical trials we are happy to collaborate with GPs on,” Prof Byrne said.

Session one: Heart failure and structural heart disease

The first speaker of Session One was Prof Jim O’Neill, Consultant Cardiologist, Mater Private Network, Dublin, and Clinical Professor, RCSI, who spoke about heart failure, which he described as “truly a multisystem disease” with an array of treatment options to enable patients to live well, even if not ‘cured’.

He said that contemporary management of heart failure is the synthesis of all that is good in modern medicine, and in particular, cardiology. Unfortunately, it has an image problem, which possibly originates from the title ‘heart failure’ that is by its very nature the epitome of negativity, “This is troubling for a variety of reasons – it is a frightening term for our patients and flies in the face of the fact that we can do an enormous amount for our patients – who should really be referred to as ‘patients with cardiomyopathy’. We don’t call diabetes ‘pancreas failure’, we use the correct term, which is understood by all.”

Multidisciplinary care and a nuanced, individualised approach with good communication is the cornerstone of treating cardiomyopathy patients, according to Prof O’Neill, and he especially praised the role of the heart failure nurse.

The key treatment approaches can be summarised as the ‘3 Ds’ – “Diet (everything we do by way of advice to the patient), Drugs (of which we have many new ones), and Devices (an ever-complex world of increasingly minimally invasive approaches with amazing outcomes).”

Prof O’Neill also spoke about the need for clinicians to have a “heart failure conscience” so that every time they meet their cardiomyopathy patients, even if they are feeling well, they take the opportunity to assess and uptitrate their medicines.

“Know the four pillars” – beta blockers (BBL), angiotensin-converting-enzyme inhibitors (ACEi)/angiotensin receptor-neprilysin inhibitors (ANRI), mineralocorticoid receptor antagonists (MRA), and SGLT-2 inhibitors.

A red flag to look out for in cardiomyopathy patients is unexplained weight loss, while cachexia is another potential red flag that should not be ignored. Prof O’Neill said that digoxin can be useful in certain acute situations, and sacubitril-val-

sartan can be (very carefully) used with low BP.

Once cardiomyopathy patients have improved, even with normalisation of cardiac function, disease-modifying agents should not be stopped, Prof O’Neill stressed, as cardiomyopathy is never ‘cured’ as such.

Concluding, Prof O’Neill said that community cardiology services being rolled out by the HSE nationally will provide a vital link to strengthen shared care. The Mater already operates a Virtual Community Cardiology Clinic, which he said is continuing to work very well in optimising care for patients and reducing hospitalisation.

The next speaker in this session was Dr James Dollard, Consultant Cardiologist, Mater Private Network, Cork, who spoke about resistant hypertension. He began by reminding the audience of the huge prevalence of hypertension, which increases with age; “so about 50 per cent of people by the age of 50 have it, and 70 per cent at 70, and so on.” However, hypertension remains significantly underdiagnosed in Ireland, “at about 50 per cent,” and therefore untreated. Even among those who are diagnosed, treatment is suboptimal said Dr Dollard, quoting TILDA data (2015) showing that of those who were aware of their hypertension diagnosis, only 50-to-65 per cent were on treatment and 50 per cent were controlled.

Dr Dollard thus stressed the importance of screening, which should be done opportunistically, and in the presence of symptoms, being conscious of the potential for masked or white coat hypertension. There has been a move towards more widespread use of 24-hour BP monitoring in recent years to get a more complete, accurate picture, he noted.

In terms of initiating treatment, Dr Dollard said to have a low threshold (as per the European Society of Cardiology (ESC) guidelines algorithm). Lifestyle advice (diet, smoking cessation, physical activity) is the first step, with pharmacotherapy also needed in most cases, to be initiated on a stepwise approach.

If the patient is not controlled despite using a number of agents they could have resistant hypertension (representing 10-to-21 per cent of total hypertension), which can significantly increase their risk of cardiovascular-related complications/events and deaths.

Resistant hypertension is defined (American Heart Association definition) as BP in a hypertensive patient that remains elevated above goal despite concurrent use of three antihypertensive agents of different classes (RAASi, calcium channel blockers (CCB) and a diuretic), at maximum tolerated doses, with the exclusion of therapy non-adherence and white coat hypertension.

These patients are more likely to be male, obese, and have chronic kidney disease and obstructive sleep apnoea. It is important to investigate potential medication (contraceptive pill, etc) or lifestyle causes (dietary sodium, obesity, liquorice, alcohol, and activity), as well as secondary causes (sleep disorders, endocrine conditions, renal disease, vascular disease, and intracranial causes).

In relation to managing resistant hypertension, as well as trying to deal with the underlying causes and salt sensitivity, Dr Dollard said the guidance advises maximum therapy with three agents and the addition of a fourth agent if needed (such as spironolactone).

The final speaker of this session was Prof Mark Spence, Head of Structural Heart and Consultant Cardiologist, Mater Private Network, Dublin, and Professor of Structural and Interventional Cardiology, RCSI, who discussed ‘structural heart disease’, a term which has become common-place over the last 20 years and encompasses those non-coronary related cardiology conditions for which transcatheter therapies now exist.

Prof Spence said this field is growing quickly due to increasing patient numbers (ageing population), continued innovations, and the development of new treatments, and many research studies that have given the international cardiology guideline committees the confidence to recom-

mend these treatments.

During his talk he outlined several case vignettes of patients with structural heart problems treated according to the most recent guideline recommendations, with procedures including transcatheter aortic valve implantation (TAVI), and he stressed the importance of patient-centred care and a multidisciplinary team approach

Session 2: Cardiac arrhythmia

The first speaker of the second session was Dr Usama Boles, Cardiologist and Electrophysiologist, Mater Private Network, Dublin, who discussed atrial fibrillation (AF) and supraventricular tachycardia (SVT) guidelines. He pointed out that AF represents a growing burden in medical practice – it is the most common cardiac arrhythmia, and up to one-in-four people has AF at the age of 80 years.

Stroke prevention is recommended (ESC guidelines) in mild- to moderate-risk AF patients (CHA2DS2-VASc). Direct oral anticoagulants (DOACs) are now accepted as first-line agents, but there is no role for antiplatelets (eg, aspirin) in CV thromboembolic events prevention with AF, he said.

Ablation is now emerging as the most accepted approach in the majority of arrhythmias, according to Dr Boles; “ablation for AF is feasible, curative and has a quite low risk for complications.” He said that AF ablation/rhythm strategies would be a good option for younger patients, those with relatively recent diagnosis of AF, controlled risk factors, non-tolerant to medications, development of reduced systolic function, and/or valvular cardiac disease.

Atrioventricular nodal re-entrant tachycardia (AVNRT) is the most common type of SVT encountered in practice, after AF, Dr Boles said, and treatment with ablation is well-established with a very high success rate >95 per cent.

As per the 2019 ESC recommendations, electrophysiology studies (EPS) and ablation should be considered in a wide range of patients with accessory pathways (AP) (antidromic atrioventricular re-entry tachycardia (AVRT) or Wolff-Parkinson-White (WPW) syndrome). Examples include patients who are very active, athletes, rapidly conducting AP in EPS, worsening LV systolic function with chronic pre-excited ECG and AF with pre-excitation.

Atrial flutter (typical or atypical) should also be referred for consideration for ablation, he advised. Atrial flutter anticoagulation should follow the same role as AF, with careful consideration to bleeding risk, Dr Boles concluded.

The next speaker was Dr Jim O’Brien, Consultant Cardiologist, Mater Private Network, Dublin, whose presentation focused on recognising different types of atrial arrhythmias. He noted that atrial arrhythmias are common and can be due to re-entry: AVNRT, AVRT, flutter; and automaticity: AT, AF.

Medication therapy (beta blockers, NDCC, amiodarone, adenosine) comes up a lot for all atrial arrhythmias, he said, adding that if there any concerns when an ECG has a delta wave, or if there is a broad complex tachycardia, adenosine should be avoided.

Catheter ablation now has class I/IIa recommendations for almost all atrial arrhythmias – all SVTs, most flutters, and paroxysmal AF/persistent AF when symptomatic or in heart failure, Dr O’Brien noted, so referral to an appropriate service should be considered.

The final speaker of this session was Dr Mahesh Pauriah, Consultant Cardiologist and Cardiac Electrophysiologist, Mater Private Network, Cork, who discussed when rhythm control is superior to rate control in AF, citing his preference in patients who are supposedly asymptomatic and patients with heart failure. He noted how the use of catheter ablation in AF, particularly cryoablation and radio

Prof Jim O’Neill

Dr Jim O’Brien

frequency ablation, has continued to increase, with higher success rates and less risk or side-effects now as technology and techniques have evolved.

Session 3: Coronary disease and device management

The first speaker of this session was Dr Ronan Margey, Clinical Director, Mater Private Network, Cork, and National Clinical Lead, Irish Heart Attack Audit, National Office of Clinical Audit, who discussed the impact of the Covid-19 pandemic on heart attack hospital admissions and out-of-hospital cardiac arrest. The impact included a reduction in recorded STEMIs and non-STEMIs presenting to hospital, less admissions from nursing homes, less inter-hospital transfers, and an increased time from first medical contact to reperfusion.

Dr Margey highlighted the difficulty of accessing data from separate systems (HiPE, etc) in Ireland and the need for better data collection resourcing and sharing. He stressed the importance of public health messaging regarding recognition of MI symptoms and early access to primary percutaneous coronary intervention (PPCI) regardless of the pandemic. Pre-hospital delays remain too long and deteriorated during the pandemic, he acknowledged, adding that particular focus should be given to reducing door-in door-out times from non-PCI hospitals to PPCI sites. Some changes introduced during the pandemic should remain, however – Dr Margey said ED bypass protocols should be widely adopted post-pandemic, and cardiac rehab programmes should continue virtually.

The next speaker was Ms Grainne Pelly, Chief II Cardiac Physiologist, Mater Private Network, Dublin, who gave an overview of practical issues in the management of implantable cardiac devices (ICDs) in the community. Cardiac rhythm management devices include pacemakers, implantable cardioverter defibrillators and loop recorders. The function of these devices is to perform bradycardia pacing, monitoring for arrhythmias, cardiac resynchronisation for heart failure, defibrillation, and anti-tachycardia pacing for tachyarrhythmias. Potential (rare) issues can include malfunction, infection, erosion, shocks, and the need to be aware of the risk from MRI machines.

As patients age, their heart failure burden progresses, or they develop other life-limiting conditions (cancer, dementia) focus can turn to the benefit of the ICD being turned on, and healthcare/palliative care services can discuss with the patient about having it switched off, Ms Pelly explained.

If a patient dies with their ICD in place it is vital that it is deactivated before post-mortem to prevent mortuary workers getting an electric shock from an activated device, and to ensure the information from the ICD is extracted, she said. If death is unexpected, device interrogation can confirm if the patient died due to an arrhythmia, device malfunction, or other cause.

ICDs must also be explanted prior to cremation due to the risk of lithium battery explosion. If a patient with a cardiac device dies suddenly, Ms Pelly said that emergency deactivation can be achieved by placing a magnet over the device and putting adhesive tape over it. This is a temporary measure until the cardiology team can come.

The final speaker of this session was Dr Róisín Colleran, Consultant Interventionalist Cardiologist, Mater Private Network, Dublin, who discussed the management of left main coronary artery disease; when to use bypass surgery or stenting. During her talk, she outlined the main recommendations of the 2018 Joint ESC/EACTS Guidelines on Myocardial Revascularisation, which are based in part on overall anatomic complexity.

“In stable patients with significant left main stem disease, with coronary anatomy suitable for both PCI and coronary artery bypass graft (CABG), with a low predicted surgical mortality, and with low to intermediate anatomic disease complexity, both treatment options are reasonable,” she summarised.

The totality of the evidence shows similar results for overall mortality at five years, without evidence of a difference in

trials with follow-up extended to 10 years, Dr Colleran said.

There is a higher rate of spontaneous MI with PCI (absolute risk difference of 3.5 per cent; number need to treat with CABG to prevent one MI of 29).

Similar rates of stroke are seen with both treatments, although there is an excess risk of stroke of 1.0 per cent in the first year with CABG, she noted.

Repeat revascularisation is more common after PCI (absolute risk difference of 7.6 per cent over five years; with a number needed to treat with CABG to prevent one repeat revascularisation of 14), Dr Colleran concluded.

Mater Private Network | Cherrywood

Rapid Access Cardiology Clinic

Patients seen within 24 hours of GP referral or next working day

Each session was followed by a Q&A session where questions were put to the expert panel, including when to initiate particular therapies, what therapies were suitable for pregnant and breastfeeding patients, what diagnostic tests should be ordered for particular patients (eg, when to use calcium scoring), and what procedure would be advised for certain ages, etc. Attendees were also provided with the speaker presentations after the event. It is hoped the 2023 Masterclass will be held in person.

For more information contact events@materprivate.ie

Rapid Access Cardiology Clinic now available Monday to Friday at Mater Private Day Hospital Cherrywood

Access for routine appointments within 24 hours (or next working day) of GP referral to:

• Cardiologist Consultation & Treatment Plan Initiation

• Advanced Diagnostic Imaging & Cardiac Testing

Participating Cardiology Consultants

VHI Insurance Cover*:

• Cardiac MRI with GP and Consultant Referral

• Echo with Consultant referral only

*excl. Smart Plan 150 / 250 / 500 / Family

Suitable Patients: Routine, non-urgent care with one of eight participating consultants

Unsuitable Patients: Urgent symptoms requiring emergency care. Refer to Urgent Cardiac Care service. Tel: 1800 247 999

For more information visit www.materprivate.ie

Lucan

Clonee

Rathcoole

Blessington

Bray

Dun Laoghaire Dundrum Cherrywood Luas Stop

Rathgar Greystones

Dr. Róisín Colleran Prof. Gábor Széplaki

Dr.

O’Brien

Sugrue

Mahon

Dr

Shared features with Toujeo ® SoloStar

• Pen size

• 5-second hold time5,6

• 42-day shelf life after first use1

• Same technical platform

*Toujeo ® DoubleStar™ is recommended for patients requiring at least 20 units of basal insulin per day1

Prescribing Information:

Toujeo (insulin glargine 300 units/ml)

Please refer to Summary of Product Characteristics (SmPC) before prescribing.

Presentation: Toujeo SoloStar and DoubleStar pre-filled pens. Each ml contains 300 units of insulin glargine. SoloStar pen contains 1.5ml (450 units) of solution for injection. DoubleStar pen contains 3ml (900 units) of solution for injection.

Indication: Treatment of diabetes mellitus in adults, adolescents and children from the age of 6 years. Dosage and Administration: Toujeo is administered subcutaneously, by injection into the abdominal wall, the deltoid or the thigh, once daily, at any time of the day, preferably at the same time every day. Injection sites must be rotated within a given injection area from one injection to the next in order to reduce the risk of lipodystrophy and cutaneous amyloidosis. The dose regimen (dose and timing) should be adjusted according to individual response. Do not administer intravenously. In type 1 diabetes mellitus, Toujeo must be combined with short-/rapid-acting insulin to cover mealtime insulin requirements. In patients with type 2 diabetes mellitus, recommended daily starting dose is 0.2 units/kg followed by individual dose adjustments. Toujeo can also be given together with other anti-hyperglycaemic medicinal products. Switch between insulin glargine 100 units/ml and Toujeo: Insulin glargine 100 units/ml and Toujeo are not bioequivalent and are not directly interchangeable. When switching from insulin glargine 100 units/ml to Toujeo, this can be done on a unit to unit basis, but a higher Toujeo dose (approximately 10-18%) may be needed to achieve target ranges for plasma glucose levels. When switching from Toujeo to insulin glargine 100 units/ml, the dose should be reduced (approximately by 20%). Switching from other basal insulins to Toujeo: A change of dose and/or timing of the basal insulin and concomitant anti hyperglycaemic treatment may be required. Dose adjustments may also be required if the patient’s weight or lifestyle changes, the timing of insulin dose is changed or other circumstances arise that increase susceptibility to hypo- or hyperglycaemia. Toujeo must not be mixed or diluted with any other insulin or other medicinal products. Close metabolic monitoring is recommended during a switch and in the initial weeks thereafter. SoloStar 1-80 units per single injection in steps of 1 unit and DoubleStar 2-160 units in steps of 2 units. When changing from Toujeo SoloStar to Toujeo DoubleStar, if the patient’s previous dose was an odd number then the dose must be increased or decreased by 1 unit. Toujeo DoubleStar prefilled pen is recommended for patients requiring at least 20 units per day. Special Populations: Insulin requirements may be diminished in the elderly or patients with renal or hepatic impairment. Paediatric: When switching basal insulin to Toujeo, dose reduction of basal and bolus insulin needs to be considered on an individual basis, in order to minimise the risk of hypoglycaemia. The safety and efficacy of Toujeo in children and adolescents below 6 years of age have not been established. Contraindications: Hypersensitivity to insulin glargine or any excipients. Precautions and Warnings: Traceability: In order to improve the traceability of biological medicinal products, the name and the batch number of the administered product should be clearly recorded. Toujeo is not the insulin of choice for treatment of diabetic ketoacidosis. Patients must be instructed to perform continuous rotation of the injection site to reduce the risk of developing lipodystrophy and cutaneous amyloidosis. There is a potential risk of delayed insulin absorption and worsened glycaemic control following insulin injections at sites with these reactions. A sudden change in the injection

® Adverse events should be reported. Reporting forms and information can be found at www.hpra.ie; email: medsafety@hpra.ie Adverse events should also be reported to Sanofi Ireland Ltd. Tel: 01 403 5600. Alternatively, send via email to IEPharmacovigilance@sanofi.com

site to an unaffected area has been reported to result in hypoglycaemia. Blood glucose monitoring is recommended after the change in the injection site, and dose adjustment of antidiabetic medications may be considered. Hypoglycaemia: In case of insufficient glucose control or a tendency to hyper/hypoglycaemic episodes, the patient’s adherence to the prescribed treatment regimen, injection sites and proper injection technique and all other relevant factors must be reviewed before dose adjustment is considered. Particular caution should be exercised, and intensified blood glucose monitoring is advisable for patients in whom hypoglycaemic episodes might be of clinical relevance and in those where dose adjustments may be required. Warning signs of hypoglycaemia may be changed, less pronounced or absent in certain risk groups, potentially resulting in severe hypoglycaemia and loss of consciousness. Risk groups include patients in whom glycaemic control is markedly improved, hypoglycaemia develops gradually, an autonomic neuropathy is present, or who are elderly. The prolonged effect of subcutaneous insulin glargine may delay recovery from hypoglycaemia. Intercurrent illness: Requires intensified metabolic monitoring and often it is necessary to adjust the insulin dose. Insulin antibodies: administration may cause insulin antibodies to form. Use with pioglitazone: Cases of cardiac failure have been reported when pioglitazone was used in combination with insulin, especially in patients with risk factors for development of cardiac heart failure. If the combination is used, patients should be observed for signs and symptoms of heart failure, weight gain and oedema. Pioglitazone should be discontinued if any deterioration in cardiac symptoms occurs. Medication errors: Insulin labels must always be checked before each injection to avoid errors between Toujeo and other insulins. Patients must be instructed to never use a syringe to remove Toujeo from the SoloStar or DoubleStar pre-filled pen, A new sterile needle must be attached before each injection. Needles must not be re-used. Pregnancy and lactation: There is no data from exposed pregnancies in controlled clinical trials. However, there is a large amount of data on use of insulin glargine 100 units/ml in pregnant women indicating no specific adverse effects on pregnancy and no specific malformative nor feto/neonatal toxicity. The use of Toujeo may be considered during pregnancy, if clinically needed. Careful monitoring of glucose control is essential. It is unknown if insulin glargine is excreted in breast milk. Interactions: Substances that affect glucose metabolism may require adjustment of insulin glargine. Adverse Reactions: Very common: Hypoglycaemia. Prolonged or severe hypoglycaemia may be life-threatening. Common: Lipohypertrophy, injection site reactions, including redness, pain, itching, hives, swelling, or inflammation. Legal Category: POM. Marketing Authorisation Number: SoloStar 3 Pen pack: EU/1/00/133/034, DoubleStar EU/1/00/133/038. Marketing Authorisation Holder: Sanofi Aventis Deutschland GmbH, D-65926 Frankfurt am Main, Germany. Further information is available from: Medical Information, Sanofi 18 Riverwalk, Citywest Business Campus, Dublin 24 or contact IEmedinfo@sanofi.com. Date of preparation: July 2020.

References: 1. Toujeo® Summary of Product Characteristics.

Date of preparation: November 2021 | MAT-IE-2101574 (v1.0)

Toujeo ® DoubleStar™ holds more units per pen than any other basal insulin pen on the market1-4

Toujeo ® is available in two pre-filled insulin devices allowing you to choose the most suitable device for your patients

THERESA LOWRY-LEHNEN, RGN, GPN, RNP, BSc, MSc, M Ed, PhD, Clinical Nurse Specialist and Associate Lecturer, Institute of Technology, Carlow

A comprehensive overview of the presentation and management of type 2 diabetes

iabetes is the most common chronic metabolic disease and a major source of morbidity and mortality. Type

Type 2 diabetes mellitus D

2 diabetes mellitus (T2DM) is the most prevalent form, accounting for around 90 per cent of cases worldwide. Figures released by the International Diabetes Federation (IDF) in December 2021 show that more than half a billion adults globally are living with diabetes. This is a rise of 16 per cent (74 million) since the previous IDF estimates in 2019. Worldwide, 537 million adults aged 20-79 years are living with diabetes, and 541 million adults have pre-diabetes, which places them at highrisk of developing T2DM. The prevalence of diabetes worldwide is growing at an alarming rate, and is predicted to rise to 643 million by 2030, and 784 million by 2045. The diabetes epidemic is unfolding because of increasing obesity rates, sedentary lifestyles and an ageing population.1

There is still no National Diabetes Registry in Ireland, therefore national estimates are not fully accurate. The figures provided by Diabetes Ireland (Table 1, January 2022) use data modelled from the Scottish Diabetes Register. In Scotland, the prevalence of diabetes was 5.6 per cent of the total census population in 2020. Table 1 estimates the total diabetes prevalence in Ireland at approximately 266,664 people. The prevalence of T2DM is estimated at 234,398 people (87.9 per cent of the total diabetes population) and type

1 diabetes at 28,800 (10.8 per cent of the total diabetes population), based on the Scottish prevalence. The true prevalence of T2DM in Ireland, however, is likely to be higher, as hyperglycaemia develops gradually, and at the early stage many cases go undiagnosed.1

According to the 2015 Irish Longitudinal Study on Ageing (TILDA), 10 per cent of adults aged 50 and over in Ireland have T2DM, rising to 16 per cent in those aged 80 and over. The TILDA study revealed that 1:10 people with diabetes in this population are undiagnosed, and that a further 5.5 per cent of the older population have pre-diabetes, which puts them at an increased risk of developing T2DM in the future. 2 The study also found that T2DM is more common in men (12 per cent) than women (7 per cent), and those with a self-reported history of hypertension, high cholesterol, and being centrally obese, while having low levels of physical activity also has a strong correlation with both diabetes and pre-diabetes. 2

The IDF Atlas 2021 ranked Ireland seventh in the world for diabetes-related health expenditure per person.3 The economic burden of diabetes on the Irish healthcare system is a major challenge for Government and the HSE. National estimates comparing health-service use between people over 50 years of age with and without diabetes (2009-2011) show that diabetes was associated with an 87 per cent increase in outpatient visits, a 52 per cent

increase in hospital admissions, and a 33 per cent increase in emergency department attendances.1

The CODEIRE study (2006) stated that costs associated with diabetes in Ireland consume between 4-to-6 per cent of annual healthcare expenditure. If the same percentage (4-to-6 per cent) was to be applied to the Irish healthcare expenses in 2019, the costs associated with diabetes would have been as high as €1.2 billion to €1.4 billion, with approximately 50 per cent of the costs associated with hospitalisations and treatment of complications. With the growing prevalence of diabetes in Ireland, comprehensive economic data is required to ensure that appropriate resources are allocated to the management of the disease.4

Pathophysiology

T2DM is an insulin-resistance condition with associated beta-cell dysfunction. It occurs when blood glucose levels are too high (hyperglycaemia) due to insufficient insulin production, or when the insulin that is produced by the pancreas is not working effectively. T2DM results from an interaction between genetic and environmental factors, and ranks high on the international health agenda as a global pandemic, and as a threat to human health and global economies. 5

In T2DM, the response to insulin is diminished, and this is defined as insulin resistance. During this state, insulin is ineffective and is initially countered by an increase in insulin production to maintain glucose homeostasis. However, as the disease progresses, beta cells change and insulin secretion is unable to maintain glucose homeostasis, producing hyperglycaemia, resulting in T2DM.6

lar risk. The mechanisms linking obesity and T2DM are complex and still being understood. It is thought to involve a combination of adipose tissue release of excess circulating fatty acids, glycerol, hormones and pro-inflammatory cytokines, impairing cellular insulin signalling and increasing insulin resistance; and chronically raised lipid levels leading to impaired islet beta-cell function and lower levels of insulin production.7

 Smoking, high alcohol consumption, and reduced physical activity: These are key factors that contribute to obesity and insulin resistance.

 Age: Although T2DM can occur at any age, older age from >40 years is associated with the progressive reduction in glucose tolerance, partly owing to the gradual decrease in responsiveness of beta-cells to carbohydrates.7

 Genetics: Other risk factors include first-degree relatives of someone with diabetes, and women with GDM or PCOS, which increases the risk of impaired glucose regulation. The risk of first-degree relatives of people with T2DM developing the condition is 40 per cent compared with just 6 per cent for the rest of the general population.7

DIABETES TESTING IN ASYMPTOMATIC ADULTS

1. Testing for diabetes should be considered in all adults who are overweight (BMI ≥25kg/m2) and who have one or more additional risk factors:

 Physical inactivity

 First-degree relative with diabetes

 Are hypertensive (≥140/90mmhg) or on therapy for hypertension

 Dyslipidaemia – HDL<0.9 and/or triglycerides >2.82

 Have established arterial disease (IHD, CVA, PVD)

 High-risk ethnicity (eg, African, Asian, Hispanic, etc)

 Members of the Travelling Community

 Have delivered a baby weighing >4.1kgs or have a history of gestational diabetes mellitus (GDM)

 On previous testing had impaired glucose tolerance (IGT ) or impaired fasting glucose (IFG)

 Have other clinical conditions associated with insulin resistance (eg, polycystic ovary syndrome (PCOS), acanthosis nigricans, long-term steroid use, or severe obesity

2. In the absence of the above additional risk factors, testing for diabetes should begin at age 45 years

3. If the results are normal, testing should be repeated at least at three-yearly intervals. Patients with IFG or IGT should be tested annually

T2DM is most commonly seen in people over the age of 40. However, it is also now increasingly seen in children, adolescents, and younger adults due to rising levels of obesity, physical inactivity, and energy-dense diets.6 Most patients with T2DM are obese or have a higher body fat percentage, distributed predominantly in the abdominal region. This adipose tissue promotes insulin resistance through various inflammatory mechanisms, including increased FFA release and adipokine dysregulation. Lack of physical activity in people with hypertension or dyslipidaemia also increases the risk of developing T2DM.6

Chronic hyperglycaemia can cause damage to various organ systems, leading to the development of disabling and life-threatening health complications, most prominent of which are microvascular (retinopathy, nephropathy, and neuropathy) and macrovascular complications, leading to a two-to-four-fold increased risk of cardiovascular disease.6

Risk factors

 Obesity: Obesity and T2DM are closely linked and are increasing in prevalence worldwide. Both chronic conditions have a multisystem impact and are associated with increased mortality and cardiovascu-

 Ethnicity: T2DM is two-to-four times more likely in people of south-Asian, Afro-Caribbean or black-African descent than people of white-European origin. Migration of various ethnic subgroups has led to a change in dietary habits, with a higher consumption of calories and fat than in their countries of origin; hence the prevalence of diabetes is often higher in immigrant communities than in their country of origin.7

 Inflammation: Systemic inflammation also contributes to insulin resistance as an improvement in inflammatory markers, such as C-reactive protein and interleukin-6, are linked to an improvement in beta-cell function.7

Signs and symptoms

Symptoms of T2DM originate from persistent hyperglycaemia and the impaired ability to use glucose as fuel, and include polyuria, nocturia, polydipsia, fatigue, and weight loss. A person with diabetes may also experience other symptoms, such as blurred vision, reduced sensations or pain in the hands and feet, along with recurrent genitourinary infections.7

Owing to insulin deficiency and altered energy metabolism, diabetes increases the risk of developing hyperosmolar hyperglycaemic states and ketoacidosis, both of which are life-threatening emergencies that require prompt hospital treatment. Diabetic ketoacidosis is less

TABLE 1: Diabetes prevalence in Ireland. Source: Diabetes Ireland. Available at: www.diabetes.ie/about-us/diabetes-in-ireland/

Criteria for testing for diabetes in asymptomatic adults. Source: ICGP (2016)10

common in people with T2DM, because most people are insulin resistant rather than insulin deficient.7

Criteria for testing for diabetes in asymptomatic adult individuals

T2DM has a long pre-clinical phase and may be asymptomatic until well after longterm microvascular and macrovascular complications have occurred. T2DM can be detected before the onset of symptoms and clinical signs by identifying people who are at risk and performing diagnostic testing (see Table 2). The onset of T2DM is subtle and early detection in general practice requires clinical suspicion combined with systematic and opportunistic findings. Early identification of patients and initiation of treatment can reduce the development of complications, and therefore testing for diabetes in asymptomatic patients with risk factors associated with the development of diabetes is recommended.10

Diagnosis

A thorough medical history, physical examination and investigative tests are required to form a diagnosis for T2DM. The patient’s history will include an assessment for risk factors such as a family history of diabetes, ethnicity, and increased age >40 years old. The patient’s vital signs and height, weight, and BMI should be recorded. The skin should be examined for wounds and signs of infection. Pulses should be palpated to examine for peripheral arterial disease, and microfilament testing to determine the presence of peripheral neuropathy. The eyes should be examined with an ophthalmoscope and assessed for retinopathy. A series of blood tests will be carried out including a fasting blood glucose. Urinary glucose should not be used as a diagnostic test owing to its low sensitivity. Additional diagnostic tests are often required, such as ‘GAD’ autoantibody tests or C-peptide tests, to distinguish between T1DM and T2DM. Other types of DM must also be excluded, such as maturity-onset diabetes of the young, which is characterised by impaired insulin secretion with minimal or no defects in insulin action resulting from genetic defects in beta-cell function.7

Diagnosis can be made when fasting plasma glucose is ≥7.0mmol/L or random plasma glucose is ≥11.1mmol/L in the presence of symptoms, such as frequent urination, thirst, and unexplained weight loss.7, 8

The oral glucose tolerance test (OGTT) can also be used as a diagnostic tool, where a diagnosis is made if a plasma glucose level of ≥11.1mmol/L is measured two hours after the ingestion of a 75g glucose solution. The OGTT has largely been replaced by the HbA1c test, and is now mainly used in the diagnosis of GDM. An HbA1c result of 48mmol/mol (6.5 per cent) is recommended as the threshold for diagnosing diabetes.7, 8

In an asymptomatic person, diagnosis should be confirmed with a repeat HbA1c or plasma glucose test, preferably using the same test. However, if both HbA1c or plasma glucose measurements are in diabetic range, a diagnosis can be

FIGURE 1: The International Diabetes Federation and World Health Organisation criteria for T2DM 8,9

ANNUAL REVIEW10

Along with the areas monitored at the regular review, surveillance of the following should also be carried out annually, according to the ICGP guidelines:

SYMPTOMS Ischaemic heart disease, peripheral vascular diseaseneuropathy, erectile dysfunction. All patients with symptoms that might reflect vascular disease, particularly ischaemic heart disease, should be investigated

FEET Footwear, deformity/joint rigidity, poor skin condition, ischaemia, ulceration, absent pulses, sensory impairment

EYES Visual acuity and retinal review by ophthalmologist/ retinal screening programme

KIDNEY Renal damage, albumin excretion, serum creatinine and calculate EGFR

ARTERIAL RISK Blood glucose, blood pressure, blood lipids, and smoking status, ECG

ATTENDANCES Podiatry/dietitian/other as indicated

TABLE 3: Structured education programme tailored to the patient’s individual needs10

made. If only one measurement is in range, a second abnormal result using the same test is required to confirm the diagnosis.7,8 There are patient groups in whom HbA1c is inappropriate for diagnosis, including:

 Children;

 Pregnant women;

 People who are taking medicines such as steroids or antipsychotics that can cause an acute glucose;

 People with acute pancreatic damage;

 People with haematological conditions that may influence HbA1c and its measurement, eg, haemoglobinopathies, decreased erythropoiesis/administration of erythropoietin, erythrocyte destruction, alcoholism, chronic kidney disease, and chronic opioid use.7

Treatment and management

The introduction of the HSE's Cycle of Care for diabetes in October 2015 was the first step in the provision of reimbursement for structured diabetes care in general practice. To support the implementation of the Cycle of Care, A Practical Guide to Integrated Type 2 Diabetes Care was updated by GP Dr Velma Harkins on behalf of the ICGP with the support of the HSE’s National Clinical Programme for Diabetes (2016).

The Programme then published its Model of Integrated Care for Patients with Type 2 Diabetes18 document in 2018, which outlines the framework for the delivery of evidence-based practice guidelines to people with T2DM in Ireland.

Under the HSE’s National Integrated

Model of Care, 18 patients with uncomplicated T2DM are seen three times a year in primary care in a structured fashion. Visits are every four months with an annual review. Patients who develop complications are referred from primary to secondary or tertiary care for an expert specialist opinion and their care will become shared between primary and secondary or tertiary care. These patients will be seen at least once a year in secondary care for their annual review or more frequently according to the severity of the diabetes-related complication and up to twice a year in primary care at four-monthly intervals.10

Diabetes care should encompass patient education, dietary and lifestyle advice, management of cardiovascular risk, skin and foot care, as well as detection and management of long-term complications. Patients with T2DM should be encouraged to eat high-fibre, low glycaemic index sources of carbohydrates such as fruit, vegetables, wholegrains and pulses, as well as low-fat dairy products and oily fish. They should be advised to maintain a healthy weight to maintain a BMI of between 20 and 25kg/m 2 10,11 Patients should be taught how to measure and understand their blood glucose levels. Quality control of the glucose monitor should be checked four times a year and monitors should be changed or upgraded every two years. Patients should be advised to record home glucose readings in their patient record book and to bring the book to each of their diabetic reviews.10

The UK’s NICE guidelines recommends that all patients with T2DM should be referred to a diabetes structured education programme at or around the time of diagnosis. Structured diabetes education is a group programme that provides patients with the knowledge, skill and ability to manage their diabetes.

All patients with diabetes should receive the following checks at least once per year to reduce the risk of long-term complications: HbA1c level; blood pressure; cholesterol; retinal screening (depending on risk); foot examination; kidney function; urinary albumin; BMI; and smoking status. Reducing glucose levels lowers the risk of all longterm complications of diabetes, while reducing cholesterol levels lowers the risk of heart attacks and strokes.12

Blood glucose targets

Tight control of blood glucose with diet and/or medication reduces long-term diabetes-related complications and is central to the overall management of diabetes. Blood glucose targets should be individualised and discussed with the patient. A HbA1c ≤53mmol/l is appropriate for most people with T2DM and has been shown to reduce diabetes-related complications.18

A HbA1c ≤ 58mmol/l or less stringent A1c goals may be appropriate for:

 People with a history of:

 Severe hypoglycaemia;

 Limited life expectancy;

 Advanced microvascular or macrovascular complications;

 Extensive co-morbid conditions; or

 Where social circumstance may prevent tight glucose control.

A HbA1c ≤48mmol/l may be appropriate for newly-diagnosed people with T2DM and no significant co-morbidities. Targets should be set in consultation with the individual and should be seen as a guide because a person’s individual circumstances need to be considered when setting and agreeing targets, according to the HSE’s Model of Care.18 The HbA1c should be checked more than twice a year in patients to maintain treatment targets.

Medications

Healthy eating and exercise are the cornerstones of T2DM management, but frequently people need the addition of medications to help improve blood glucose control. When lifestyle modification fails to

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achieve the targeted blood glucose levels, the first-line medication prescribed is metformin,18 both for those who are overweight (BMI >25.0kg/m2) and not overweight. Metformin is contraindicated in those with renal impairment and with end-stage cardiac and hepatic failure. Metformin should be stopped in patients with eGFR <30mls/ min and at possibly higher values in patients prone to dehydration.10

The HSE's Model of Care contains an algorithm with a step-wise treatment approach, with second-line and other agents including DPP-4 inhibitors, sulphonylureas, GLP-1 receptor agonists, pioglitazone, acarbose, meglitinides, sodium glucose co-transporter 2 (SGLT2) inhibitors, and insulin.18

Since 2015, NICE has been advocating a patient-centred approach to glycaemic control and provides best practice advice on setting glycaemic targets and selecting hypoglycaemic agents for treatment intensification after metformin first-line treatment for T2DM in those with inadequate diabetes control.12

Most guidelines recommend the use of insulin alone or in combination with other GLDs when persons with T2DM are unstable, with sign and symptoms of acute decompensation including dehydration, acute weight loss, acute illness, very high glucose levels, and presence of ketones. Basal insulin should be preferred and it can be temporary. Most insulin algorithms start with 10 units or 0.2 units/kg and titrate once or twice weekly at one-to-two units each time to achieve a target fasting blood glucose between 3.9-and-7.2mmol/L (70-and-130mg/dL).8

Diabetic Foot Model of Care 2021: T2DM

In 2021 the HSE published its Diabetic Foot Model of Care13 document. The aim of diabetic foot screening and risk classification is to establish the person’s risk of diabetic foot ulceration. All persons with diabetes are assigned a risk category and where appropriate referred for ongoing foot screening, a foot assessment, and a clinical care plan. The care plan ensures that all people with diabetes receive annual or more frequent foot screening, foot care education and review according to their clinical needs and in the most appropriate setting.13

Exception: Those with very complicated T2DM should have annual foot screening and care provided by the endocrinologist and their team.

Based on the findings of this screening the person is categorised as being low-, moderate- or high-risk of future diabetic foot ulceration, or if known to have prior foot ulceration will be categorised as being in remission or categorised as active foot disease, if foot ulceration is present or active Charcot is suspected.13

Complications of T2DM

Long-term complications of T2DM include diabetic retinopathy, diabetic nephropathy, diabetic neuropathy, and macrovascular problems.

Diabetic retinopathy is one of the most common causes of blindness in the working age population in Ireland. Up to 10 per cent of people with diabetes are at risk of sight-threatening retinopathy. Diabetic retinopathy may have no obvious symp-

DIABETIC FOOT SCREENING PROCESS: SCREENING INCLUDES:13

the programme’s seven treatment centres before any significant visual symptoms occur. Adding patients to the register to be screened is easy, and can be done by a patient’s GP, or allied health professionals using the free phone number: 1800 454 555 or email info@diabeticretinascreen.ie. Full screening information is available at www. diabeticretinascreen.ie

Diabetic nephropathy is a significant cause of chronic kidney disease and endstage renal failure globally. If untreated, diabetic nephropathy can lead to impaired kidney function, dialysis, and/ or kidney transplant. Diabetic nephropathy is identified when eGFR is <60mL/ min/1.73m² and albuminuria >30mg/g creatinine.8,14 Annual assessment (at least) with urine ACR, serum creatinine and eGFR) is recommended.18

Diabetic neuropathy is the most common complication associated with diabetes mellitus. Diabetes causes a broad spectrum of neuropathic complications, including peripheral, autonomic, proximal, and focal. Diabetic peripheral neuropathy (DPN) is the most common form of nerve damage, and it most often affects the nerves to the hands and feet. DPN leads to distressing and expensive clinical sequelae, such as foot ulceration, leg amputation, and neuropathic pain. DPN is often diagnosed late when irreversible nerve injury has occurred, and its first presentation may be with a diabetic foot ulcer.1 DPN may be present at time of diagnosis in more than 10 per cent of patients and may affect up to 50 per cent of patients with long-standing diabetes. In 50 per cent of cases, DPN may be asymptomatic, but for 16-to-26 per cent of patients with diabetes the neuropathy is painful. Patients should be examined for DPN from time of diagnosis.18

Macrovascular: T2DM can also affect the large blood vessels, causing plaque to build up, leading to a heart attack, stroke and peripheral vascular disease. Cardiovascular disease (CVD) is the leading cause ( 70 per cent) of death in people with T2DM. People with diabetes have a four-fold greater risk for having a CVD event than people without diabetes after controlling for traditional risk factors for CVD, such as age, obesity, tobacco use, dyslipidaemia, and hypertension.16

Prevention and patient education

Patient education and effective lifestyle modifications including weight loss and adoption of a healthy diet together with increased physical activity are the cornerstones for the prevention of type 2 diabetes mellitus. Emphasis must be placed on promoting a healthier lifestyle and finding solutions for increased adherence and compliance, especially for high-risk individuals.

toms in its early stages, but when caught early, treatment is effective at reducing or preventing damage to sight.10 The national diabetic retinopathy screening programme, Diabetic RetinaScreen, has been providing free retinal screening to all dia-

betes patients in Ireland over the age of 12 years since 2013.18 Since the programme’s launch, prevalent, undiagnosed, and untreated diabetic retinopathy and maculopathy have been successfully identified and referred for evidence-based treatments at

Diabetes SMART is a new free interactive online education course developed by Diabetes Ireland, for people diagnosed with T2DM. The Diabetes SMART programme contains six interactive modules, covering topics that explain what diabetes is, understanding the key medical information, such as blood glucose levels, managing illness, and providing tips on healthy eating, and getting active. The programme was developed by diabetes healthcare professionals,

TABLE 4: Diabetic topics and issues

TABLE 5: Diabetic foot screening categories

TABLE 6: Diabetic foot screening process

and the resource will give people with T2DM the knowledge and accessible tools to learn how to manage their condition and protect their future health.1

The HSE also provides a number of free educational resources and support courses to diabetes patients, both online and in person. See www.hse.ie/services/diabetes-support-courses/diabetes-support-courses.html for more information.

Outlook

While there is still no cure for T2DM, several drugs are in the developmental stages. Perhaps, the most anticipated is the glucagon-like peptide-1 (GLP-1) receptor agonists, which induce insulin production while also suppressing the secretion of glucagon.7

Imeglimin, a drug being developed by the French company Poxel, has shown great promise in a phase 3 clinical trial in Japan. Damage to the mitochondria, the structures that generate energy within cells, plays a key role in the progression of metabolic diseases, and Imeglimin

Cholesterol and hypercholesterolaemia

Authors: Dr Daniel Delaney, Registrar in Cardiology; and Prof David Burke, Consultant Cardiologist and Director of Cardiology, Cardiology Department, Beacon

protects mitochondria from damage. With this unique method of action, imeglimin has the potential to treat T2DM by acting in three organs at once: The pancreas, the liver, and the muscles to reduce blood glucose levels.16

Adjustments to dietary nutrient composition, insulin-secreting cell implants, bariatric surgery, and agents primarily designed to suppress appetite and reduce adiposity, will also greatly contribute to the future management of T2DM.

References

1. Diabetes Ireland (2022). Diabetes Prevalence in Ireland. Diabetes Ireland. Available at: www.diabetes.ie/about-us/ diabetes-in-ireland/

2. Leahy S, O'Halloran AM, O'Leary N, Healy M, McCormack M, Kenny RA, O'Connell J. Prevalence and correlates of diagnosed and undiagnosed type 2 diabetes mellitus and pre-diabetes in older adults: Findings from the Irish Longitudinal Study on Ageing (TILDA). Diabetes Res Clin Pract. 2015 Dec;110(3):241-9. doi: 10.1016/j. diabres.2015.10.015

3. International Diabetes Federation Diabetes Atlas (2021), Available at: https://diabetesatlas.org/

4. Nolan J, O’Halloran D, McKenna T, Firth R, Redmond S. (2006). CODEIRE. The cost of treating type 2 diabetes. Available at: http://archive.imj.ie/ViewArticleDetails. aspx?ArticleID=1508

5. Bellou V, Belbasis L, Tzoulaki I, Evangelo E. (2018). Risk factors for type 2 diabetes mellitus: An exposure-wide umbrella review of meta-analyses. PLoS One. 2018 Mar 20; 13(3):eo194127. doi: 10.1371/journal.pone.0194127

6. Goyal R, Jialal I. Diabetes Mellitus Type 2. In StatPearls Publishing; 2022 Jan. Available from: www.ncbi.nlm.nih. gov/books/NBK513253/

7. Lam M. (2019). Diagnosis and management of type 2 diabetes mellitus. The Pharmaceutical Journal. Vol 303; No 7929; 303. doi: 10.1211/PJ.2019.20206770

8. International Diabetes Federation. (2017). IDF clinical practice recommendations for managing type 2 diabetes in primary care. Available at: www.idf.org/e-library/guidelines/128-idf-clinical-practice-recommendations-for-managing-type-2-diabetes-in-primary-care.html

9. World Health Organisation. (2011). Use of glycated haemoglobin (HbA1c) in the diagnosis of diabetes mellitus: Abbreviated report of a WHO consultation. Available at: www.who.int/diabetes/publications/report-hba1c_2011.pdf?ua=1

10. ICGP (2016). A practical guide to integrated type 2 diabetes care. Irish College of General Practitioners, Ireland.

11. Goyal R, Jialal I, Castano M. (2022). Diabetes Mellitus Type 2 (Nursing) In StatPearls Publishing; 2022 Jan. Available from: www.ncbi.nlm.nih.gov/books/NBK568737/

12. National Institute for Health and Care Excellence. Type 2 diabetes in adults: Management. NICE guideline [NG28]. 2019. Available at: www.nice.org.uk/ guidance/NG28

13. HSE. (2021). Diabetic foot model of care. Health Service Executive. Available at: www.hse.ie/eng/about/ who/cspd/ncps/diabetes/moc/diabetic-foot-model-of-care-2021.pdf

14. Lim A. (2014). Diabetic nephropathy – complications and treatment. Int J Nephrol Renovasc Dis. 2014 Oct 15;7:361-81. doi: 10.2147/IJNRD.S40172

15. Yang H, Sloan G, Ye Y, et al (2020). New perspective in diabetic neuropathy: From the periphery to the brain, a call for early detection and precision medicine. Front Endocrinol, 17 January 2020. doi: 10.3389/fendo.2019.00929

16. Cade WT. (2018). Diabetes-related microvascular and macrovascular diseases in the physical therapy setting. Physical therapy, 88(11), 1322–1335. doi: 10.2522/ptj.20180008

17. Smith J. (2019). French first-in-class diabetes drug Nails phase III trial. Labiotech.eu. Available at: www.labiotech.eu/trends-news/poxel-type-2-diabetes-japan/

18. HSE. (2018). Model of Integrated Care for Patients with Type 2 Diabetes. A guide for healthcare professionals (Clinical Management Guidelines). Available at: www.hse.ie/ eng/about/who/cspd/ncps/diabetes/moc/model-of-integrated-care-type-2-diabetes-2018.pdf

Continued from p26 ▸

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Irish Neurological Association, 58th Annual Meeting, Ormonde Hotel, Kilkenny, 12-13 May 2022

Annual conference to hear latest developments in neurology

Paul Mulholland speaks to President of the Irish Neurology Association Dr Paul Crowley about what delegates can expect at its Annual Meeting, which marks the return of face-to-face conferences for the Association

The 58th Annual Meeting of the Irish Neurological Association (INA) will take place on 12 and 13 May in the Kilkenny Ormonde Hotel.

Unlike previous years, the meeting programme will take place over two whole days, rather than the traditional day-and-a-half.

According to the new INA President, Dr Paul Crowley, the return of face-to-face meetings after the virtual sessions held during the Covid-19 pandemic is a development to be welcomed. Dr Crowley, who is a Consultant Neurologist in University Hospital Waterford and St Luke’s General Hospital, Kilkenny, praised the work of his two direct predecessors, Prof Tim Lynch and Dr Donal Costigan, for their work in the role at a difficult period.

The chairs of the different sessions will each give a talk about research and developments in their sub-specialty that may have been missed or neglected due to the pandemic.

Covid-19 has put pressure on neurological services in terms of increases in waiting lists, as it has affected other aspects of the health service. However, Dr Crowley said that the neurological impact of the virus on people infected has been less than initially feared.

“The impact of Covid directly on neurology illness has been really quite small,” Dr Crowley told the Medical Independent (MI).

“A lot of people in the neurology community were worried there might be a burst of Guillain-Barré syndrome (GBS) or even encephalitis, or direct brain involvement. There has been a small percentage increase in GBS on account of it, but not much. Bell’s palsy has been slightly higher. It took some time to prove that wasn’t just background noise. There has been a few Miller Fishers, which has been interesting. But again, small numbers. And [the loss] sense of smell and taste, which was a neurological symptom, didn’t really lead to anything in terms of big workloads.”

Dr Crowley pointed out this is not to say there may not be neurological consequences of Covid infection in the future. Encephalitis lethargica was an epidemic associated with the 1918 Spanish influenza pandemic. Numerous symptoms characterised this disease, including headache, diplopia, fever, fatal coma, delirium, oculogyric crisis, lethargy, catatonia, and psychiatric symptoms.

“The concern is if the virus is lodged in the brain there could be future trouble,” Dr Crowley said.

“But there is no evidence of that at this point in time.”

Like other specialties, virtual consultations became more regular in neurology as a result of the pandemic. However, Dr Crowley said virtual consultations are more suitable for some conditions than others. He pointed out that consultations for Parkinson’s disease, which require a physical exam, are much better done face-to-face.

Waiting lists

Even before Covid-19, waiting lists for neurology were long, with many patients waiting years for a consultation. While the number of neurologists in Ireland is lower than the OECD average, Dr Crowley said the specialty is increasing, with appointments continuing to be made over the past two years despite the pandemic. He added that the number of consultants is not the only reason for long waiting lists.

“I was talking to one of the retired people today about the conference,” Dr Crowley told MI

“He was saying when there was only eight of us, or 10 of us in the country, there were waiting lists of eight months. There are now [approximately] 50 and there are waiting lists of four years. What has changed is the workload in terms of complexity. When he was doing his practice, there was virtually no treatment for multiple sclerosis (MS). There are now almost 20 drugs. I could possibly spend my entire week just managing the drugs of my MS patients.”

He added that conditions previously thought incurable, such as amyloidosis, now have treatments.

“So, it is changing.”

Patients are now surviving longer and have greater expectations than in the past as a result of improvement in medical intervention.

Dr Crowley argued that patients who have been on a waiting list for a long time should be re-evaluated to assess whether a consultation is still necessary.

He also highlighted that the current difficulty in seeing patients is particularly dangerous for people with sub-acute conditions.

“By sub-acute, I mean things that are evolving over two-to-eight weeks, like spinal cord syndromes, for example. Because that can go badly wrong quickly and patients can have very bad outcomes. That’s really where the problem lies.”

One of the highlights of the meeting will be the Noel Callaghan guest lecture. Dr Callaghan was the first neurologist appointed in Cork and had a very busy and productive clinical and academic career. While his work covered many areas of neurology, his outstanding contribution was to the understanding of epilepsy polyphar-

macy and his studies demonstrated the value of drug level monitoring and monotherapy in epilepsy.

Guest lecture

Prof Atte Meretoja will deliver the guest lecture at the meeting. Prof Meretoja is Medical Director at the Helsinki University Hospital (HUH). He was trained by stroke unit and thrombolysis pioneer Prof Markku Kaste, and has medical specialist degrees in neurology and public health medicine. He graduated, together with Dr Crowley, from the first class of the European Masters in Stroke Medicine at the Donau University Krems, Austria, supervised by past European Stroke Organisation and World Stroke Organisation (WSO) President Prof Michael Brainin. He joined past WSO presidents Prof Stephen Davis and Prof Geoffrey Donnan in Melbourne, Australia, between 2011 and 2015 and has worked in Helsinki, Finland since. He is a board member of the WSO and on the editorial boards of Stroke, International Journal of Stroke, and European Stroke Journal. With over 150 original publications, at an average impact factor of 21, and over 60,000 citations, his research interests are in the streamlining of acute ischaemic stroke reperfusion therapies, epidemiology and economics of stroke, and developing acute therapies for intracerebral haemorrhage.

He was involved in the ‘Global, regional, and national burden of stroke and its risk factors, 1990–2019: A systematic analysis for the Global Burden of Disease (GBD) Study 2019’. GBD produces the most comprehensive estimates of the global, regional, and country-specific burden of stroke. Population-level estimates for stroke incidence or mortality have been published by World Health Organisation and independent research groups, but those of GBD include more extensive estimates by age, sex, location, and year.

“Globally, over the past three decades, the total number of stroke-related DALYs [disability-adjusted life years] due to risk factors increased substantially (by 33.5 million, from 91.5 million in 1990 to 125 million in 2019), with diverging trends in World Bank high-income countries and low-income to upper-middle-income countries: A relatively small decrease in the high-income group

SOCIAL PROGRAMME

The INA President’s reception will take place on Wednesday 11 May at 19.30 in Butler Gallery, John’s Quay, Kilkenny. Dr Paul Crowley will welcome INA meeting delegates and guests to this vibrant contemporary art gallery in the historic Evans’ Home. Colleagues will enjoy meeting again following the extended period of virtual conferences,

as they view the O’Malley and Butler Gallery collection. The Butler Gallery is located just a short walk from the INA meeting venue at the Ormonde Hotel.

The INA dinner will take place on Thursday 12 May at the Medieval Mile Museum, 2 St Mary’s Lane, High Street, Kilkenny. This venue is also just a short walk from the Kilkenny Ormonde Hotel.

and large increases in the low- to upper-middle income groups,” according to the study, which was published in Lancet Neurology

“The large increase in the global burden of stroke was probably not only due to population growth and ageing, but also because of the substantial increase in exposure to several important risk factors, such as high BMI, ambient particulate matter pollution, high fasting plasma glucose, high systolic blood pressure, alcohol consumption, low physical activity, kidney dysfunction, and high temperature.”

This study is also the first systematic analysis to determine the effect of non-optimal temperature on stroke burden.

“The greater age-standardised burden of stroke in World Bank low-income to upper-middle-income countries than in the high-income countries might also relate to poorer acute healthcare for stroke, poorer stroke awareness, and greater prevalence or effect of some risk factors (eg, tobacco use, poor diet, diabetes, hypertension, cardiovascular disease, rheumatic heart disease, dyslipidaemia, and obesity) in low-income countries than in upper-middle-income countries, which highlights the inadequacy of primary prevention efforts in these settings.”

The title of Prof Meretoja’s lecture is ‘Treatment options in intracerebral haemorrhage – beliefs, evidence, and practice’.

Dr Crowley described intracerebral haemorrhage as the ‘Cinderella subject’ in stroke.

“There’s no medical treatment to date in it,” he explained.

“You either let the bleed recover or remove it by surgery. It’s been seen as a neuro-surgery problem. But there hasn’t been really much progress in it over the years.”

Prof Meretoja is also expected to speak about the Finnish model of healthcare. According to Dr Crowley, the Finnish health service is a world-leader with regards to interventions, such as thrombolysis. Its reputation for innovation has been facilitated by its use of unique patient identifiers, he said.

“I thought the vaccine programme was the perfect time to introduce a patient identifier here. What a missed opportunity,” he stated.

Dr Crowley said he wanted the meeting to have a focus on stroke, and to highlight how it is not only an issue for geriatric medicine. In addition to Prof Meretoja, three other speakers will deliver talks on the subject of cerebrovascular neurology: Dr Ferghal McVerry, Altnagelvin Hospital, Derry; Dr Áine Merwick, Cork University Hospital; and Prof Peter Kelly, Mater Misericordiae University Hospital, Dublin.

Dr Crowley has also organised a neuroscience event for transition year students in the Parade Tower in Kilkenny Castle on the day before the meeting.

He said that Kilkenny’s reputation for festivals has made it an ideal location for the Annual Meeting and the return of face-toface conferences.

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Duodopa 20 mg/ml + 5 mg/ml intestinal gel (levodopa/carbidopa)

Refer to Summary of Product Characteristics (SmPC) for full prescribing information. Presentation: Intestinal gel containing 20mg/ml levodopa and 5mg/ml carbidopa monohydrate. Indication: Advanced levodopa-responsive Parkinson’s disease with severe motor fluctuations and hyperkinesia or dyskinesia when available combinations of Parkinson medicinal products have not given satisfactory results. Dosage and Administration:

Adults/Elderly: Administration by portable pump directly into the duodenum or upper jejeunum via a percutaneous endoscopic gastrostomy (PEG) or radiological gastrojejunostomy tube. Initially a nasoduodenal/nasojejunal tube should be considered to determine patient’s response before a PEG-J tube is placed. Where the physician considers this assessment is not necessary, the nasojejunal test phase may be waived and treatment initiated directly with placement of PEG-J. Duodopa is given initially as monotherapy and dose adjusted to optimal response for the individual patient. Total dose/day is composed of three individually adjusted doses: morning bolus, continuous maintenance and extra bolus doses administered over approximately 16 hours. Total morning dose usually 5-10ml (100-200mg levodopa) but not exceeding 15ml (300mg levodopa). Continuous maintenance dose should be between 1-10ml/hr (20200mg levodopa/hr) but usually 2-6ml/hr (40-120mg levodopa/hr). Maximum recommended daily dose is 200ml. Extra bolus doses (if patient becomes hypokinetic during the day) are normally 0.5-2.0ml. Increase maintenance dose if more than 5 extra bolus doses/day are needed. Fine adjustments to the morning bolus, maintenance and extra bolus doses should be made over a few weeks after the initial dose setting. Sudden deterioration in response with recurring motor fluctuations indicates tube may have moved from duodenum/ jejunum into stomach and needs repositioning. Medicine cassettes are for single use only and should not be used for longer than 24 hours, even if some medicinal product remains. Treatment is usually administered during the patient’s awake period. If medically justified, Duodopa may be administered for up to 24 hours. Opened cassettes should not be reused. Children: No relevant use in the paediatric population. Renal/hepatic impairment: No studies on the pharmacokinetics of carbidopa and levodopa in patients with hepatic or renal impairment. Dose titration should be conducted with caution in patients with severe renal and hepatic impairment. Contraindications, Warnings, Precautions etc: Contraindications: Hypersensitivity to ingredients, narrow-angle glaucoma, severe heart failure or cardiac arrhythmia, acute stroke. Conditions where adrenergics are contraindicated (e.g. pheochromocytoma, hyperthyroidism, Cushing’s syndrome). Nonselective MAO-inhibitors and selective MAO type A inhibitors are contraindicated and should be withdrawn at least two weeks before starting Duodopa. Duodopa should not be used in patients with suspicious undiagnosed skin lesions or a history of melanoma. Warnings/Precautions: Not recommended for drug-induced extrapyramidal reactions. Caution in severe pulmonary or cardiovascular disease, bronchial asthma, renal, hepatic or endocrine disease, or history of peptic ulcer disease or of convulsions, past or current psychosis, chronic wide-angle glaucoma, co-administration with antipsychotics with dopamine receptor blocking properties or with medicines which may cause orthostatic hypotension. In patients with a history of myocardial infarction who have residual nodal or ventricular arrhythmias, cardiac function should be monitored with care during initial dose adjustments. Monitor all patients for development of mental changes, depression with suicidal tendencies and other serious mental changes. Neuroleptic Malignant like Syndrome with secondary rhabdomyolysis has not been reported with Duodopa but may occur on abrupt dose reduction/withdrawal. Periodically evaluate hepatic, haematopoietic, cardiovascular and renal function during extended therapy. Increases in impulse control disorders have been reported and patients should be monitored and reviewed.

Patients and providers are advised to monitor for melanomas on a regular basis when using Duodopa. Ideally, periodic skin examinations should be performed by dermatologists. Dose may need to be adjusted downwards to avoid levodopa induced dyskinesia. Sudden or gradual worsening of bradykinesia may indicate an obstruction in the device and should be investigated. Duodopa contains hydrazine, a degradation product of carbidopa that can be genotoxic and possibly carcinogenic, clinical significance of exposure unknown. Reported complications in clinical studies include abscess, bezoar, ileus, implant site erosion/ulcer, intestinal haemorrhage, intestinal ischaemia, intestinal obstruction, intestinal perforation, intussusception, pancreatitis, peritonitis, pneumonia (including aspiration pneumonia), pneumoperitoneum, post-operative wound infection and sepsis. Before initiation of treatment, patients and caregivers should be warned of the potential risk of developing Dopamine Dysregulation Syndrome (DDS). Polyneuropathy has been reported in patients treated with levodopa/carbidopa intestinal gel. Before starting therapy evaluate patients for history or signs of polyneuropathy and known risk factors, and periodically thereafter. Drug Interactions: Antihypertensives, tricyclic antidepressants, anticholinergics, dopamine receptor antagonists, benzodiazepines, isoniazide, phenytoin, papaverine, sympathicomimetics, iron, protein-rich diet, COMT inhibitors (e.g. tolcapone, entacapone) amantadine. Duodopa dose adjustment may be needed when used with these drugs. Duodopa can be taken with MAO type B inhibitors (e.g. selegiline) although serious orthostatic hypotension may occur and the dose of levodopa may need to be reduced. Fertility, Pregnancy and Lactation: Limited data relating to the use of levodopa/carbidopa in pregnant women. Duodopa is not recommended during pregnancy. Breast-feeding should be discontinued during treatment with Duodopa. No adverse reactions on fertility have been observed in preclinical studies with carbidopa or levodopa alone. Ability to Drive and Operate Machinery: Caution; Duodopa can have a major influence on the ability to drive and use machines. Refrain from driving/operating machinery if somnolence and/or sudden sleep episodes occur. Side Effects: Very common: Weight decreased, Anxiety, Depression, Insomnia, Dyskinesia, Parkinson’s disease, Orthostatic hypotension, Nausea, Constipation, Fall, Common: Anaemia, Increased weight, Amino acid level increased (Metylmalonic acid increased), Blood homocysteine increased, Decreased appetite, Vitamin B6 & B12 deficiency, Abnormal dreams, Agitation, Confusional state, Hallucination, Impulsive behaviour, Psychotic disorder, Sleep attacks, Sleep disorder, Dizziness, Dystonia, Headache, Hypoaesthesia, On and off phenomenon, Paraesthesia, Polyneuropathy, Somnolence, Syncope, Tremor, Heart rate irregular, Hypertension, Hypotension, Dyspnoea, Oropharyngeal pain, Abdominal distension, Diarrhoea, Dry mouth, Dysgeusia, Dyspepsia, Dysphagia, Flatulence, Vomiting, Dermatitis contact, Hyperhidrosis, Oedema peripheral, Pruritus, Rash, Muscle spasms, Neck pain, Urinary incontinence, Urinary retention, Fatigue, Pain, Asthenia. Device and Procedure Related Adverse Reactions: Very common: Postoperative wound infection, Abdominal pain, Excessive granulation tissue, Complications of device insertion, Incision site erythema, Post procedural discharge, Procedural pain, Procedural site reaction. Common: Incision site cellulitis, Post procedural infection, Abdominal discomfort, Abdominal pain upper, Peritonitis, Pneumoperitoneum, Pneumonia/Aspiration pneumonia, Device dislocation, Device occlusion, Gastrointestinal stoma complication, Incision site pain, Postoperative Ileus, Post procedural complication, Post procedural discomfort, Post procedural haemorrhage. Laboratory values: May change. Prescribers should consult the SmPC for the complete list of reported side effects. HCPs are asked to report any suspected adverse reactions via HPRA Pharmacovigilance; website: www.hpra.ie. Marketing Authorisation Number: PA 1824/2/1. Legal Category: POM (S1B). Further information is available from: AbbVie Limited, 14 Riverwalk, Citywest Business Campus, Dublin 24. Date of Revision: January 2021. PI/2/005

References: 1. Duodopa® Summary of Product Characteristics, available on www.medicines.ie 2. Nyholm D. The rationale for continuous dopaminergic stimulation in advanced Parkinson’s disease. Parkinsonism Relat Disord. 2007;13(suppl):S13-S17. doi:10.1016/j.parkreldis.2007.06.005.

IE-DUOD-210040. Date of Preparation: September 2021.

Duodopa® is indicated for the treatment of advanced levodoparesponsive Parkinson’s disease with severe motor fluctuations and hyperkinesia or dyskinesia when available combinations of Parkinson medicinal products have not given satisfactory results1

People in this piece are models, not actual patients.

Clinical utility of Ongentys® (opicapone) 50 mg confirmed by real-world data in Parkinson’s disease patients with motor fluctuations

Clinical insights from principle investigator and lead author Prof. Dr. med. Heinz Reichmann, Department of Neurology, Technische Universitaet Dresden, Fetscherstrasse 74, 01307 Dresden, Germany

Heinz Reichmann is a member of the German Neurological Society, The European Neurological Society and is a fellow of the American Academy of Neurology. His major research interests cover etiopathogenesis and treatment in Parkinson’s disease, premotor symptoms in Parkinson’s disease, and neuroprotection.

OPTIPARK, a Phase IV, open-label study conducted in the UK and Germany under clinical practice conditions, supports the efficacy of Ongentys® 50 mg observed in the pivotal Phase III studies.1

Ongentys® 50 mg, as an adjunct to levodopa in patients with motor fluctuations, significantly improved perception of patients’ global Parkinson’s disease (PD) condition (≥70% as judged by clinicians and the patients themselves) 3 months after they started treatment with Ongentys® 50 mg.1 Ongentys® is a once-daily catechol-O-methyltransferase (COMT) inhibitor. COMT inhibitor treatment is appropriate for PD patients taking levodopa/dopa decarboxylase inhibitor (DDCI) therapy where there is evidence of motor fluctuations.1

OPTIPARK: real-world clinical data in adult PD patients with motor fluctuations

Rationale for OPTIPARK

Findings from two pivotal Phase III studies, BIPARK I and II,2,3 highlighted that global assessments using Clinician’s Global Impression of Change (CGI-C) and Patient’s Global Impression of Change (PGI-C) showed clinical improvements for Ongentys®

50 mg versus placebo2,3 and entacapone2 (CGI-C: p=0.0005 versus placebo, and p=0.007 versus entacapone; PCI-C: p=0.0091 versus entacapone).2 The OPTIPARK open-label, prospective study set out to confirm these results in a real-life setting,1 with CGI-C selected as the primary endpoint, and PGI-C as one of the secondary endpoints.

Study protocol and methodology for OPTIPARK (n=506 patients)1

• Key inclusion criteria: Men or women (≥30 years) with idiopathic PD reporting ≥1 symptom on the 9-symptom Wearing-off Questionnaire (WOQ-9), Hoehn and Yahr Stages I–IV (during ON), and treated with 3–7 daily doses of levodopa/DOPA decarboxylase inhibitor (DDCI)

• Treatment protocol: Ongentys® 50 mg once daily for 3 months (German sites) or 6 months (UK sites) in addition to current treatment with levodopa/DDCI. Total daily levodopa/DDCI dose could be adjusted according to the individual’s condition throughout the study (except on Day 1)

• Primary endpoint: CGI-C after 3 months

• Secondary endpoints: PGI-C, the Unified PD Rating Scale (UPDRS), PD Questionnaire 8 items (PDQ-8), Non-Motor Symptoms Assessment Scale (NMSS)

Primary endpoint: OPTIPARK confirms the clinical utility of Ongentys® 50 mg

After 3 months treatment with Ongentys® 50 mg in a clinical setting of fluctuating PD patients, there were improvements in global PD condition: 71.3% of patients showed clinical improvement as rated by the CGI-C, with 43% reported as much or very much improved.1

Clinical Global Impression of Change (CGI-C) n=477

Source: Adapted from Reichmann H et al. Transl Neurodegner 20201

Secondary endpoints: Ongentys® significantly improved motor scores, quality of life and non-motor symptoms

After 3 months treatment with Ongentys® 50 mg in UK and German PD patients, 76.9% self-reported a clinical improvement (PGI-C), with 48.1% of patients reporting they were much or very much improved.1,4

Patient’s Global Impression of Change (PGI-C) (n=393)

Adapted from Reichmann H et al. Transl Neurodegner 20201,4 Prescribing

“In routine clinical practice, once-daily Ongentys® 50 mg as an adjunct to levodopa-treated PD patients with motor fluctuations significantly improved patients’ perceptions about their global PD condition”, Heinz

Reichmann

Both clinical and statistical improvements were evident for activities of daily living (ADL) and motor scores after 3 months. UPDRS scores showed a statistically significant improvement from baseline for ADL (UPDRS Part II) during OFF periods: mean±SD, –3.0±4.6 (p<0.0001), and motor scores (UPDRS Part III)during ON periods (–4.6±8.1, p<0.0001), as well as total scores (UPDRS Parts II + III), –6.4±10.4, p<0.0001.1,4

Motor scores in OPTIPARK1,2

Motor scores in OPTIPARK1,4

Significant improvements in activities of daily living and motor scores (UPDRS II and III)

Significant improvements in activites of daily living and motor scores (UPDRS II and III)

Safety profile: The majority of drug-related treatment-emergent adverse events (TEAEs) were reported during the first week5

The safety profile in this large-open label study was comparable to adverse event data from the two pivotal studies.2,3 In the 74.9% of patients who experienced TEAEs, the majority were mild or moderate in severity. Dyskinesia was the most common treatment-related TEAE (11.5%), leading to discontinuation in 1% of patients. The most common TEAE leading to withdrawal was nausea (2%).1

Clinical practice points:1

• This large real-life study in 495 patients treated with Ongentys® 50 mg mirrored a clinical setting through the inclusion of a broad population of fluctuating PD patients (Hoehn and Yahr I-III) compared to the two Phase III studies

SD, standard deviation; UPDRS, Unified Parkinson’s Disease Rating Scale.

There was also a statistically significant improvement in quality of life (PDQ-8) and non-motor symptoms (NMSS) versus baseline: PDQ-8 (mean±SD) –3.4±12.8 (p<0.0001); NMSS, –6.8±19.7(p<0.0001).1

Quality of life and non-motor symptoms1

Quality of life and non-motor symptoms1

Significant improvements in quality of life (PDQ-39) and non-motor symptoms (NMSS)

Significant improvememts in quality of life (PDQ-39) and non-motor symptoms (NMSS)

• Despite optimised PD therapy (according to clinician’s judgement), and most patients in OPTIPARK (78.8%) receiving levodopa/DDCI plus another PD medication, clinically significant improvements were reported for UPDRS motor and ADL scores

• More patients were judged by the clinician to have shown an improvement in OPTIPARK than reported in the pivotal Phase III studies (71.3% vs 59.6%) 6

OPTIPARK confirms the clinical utility of Ongentys® 50 mg as an effective and generally well-tolerated adjunct option in patients with Parkinson’s disease with motor fluctuations1

References

1. Reichmann H, et al. Effectiveness and safety of opicapone in Parkinson’s disease patients with motor fluctuations: the OPTIPARK open-label study. Transl Neurodegener 2020;9:1–9.

2. Ferreira JJ, et al. Opicapone as an adjunct to levodopa in patients with Parkinson’s disease and end-of-dose motor fluctuations: a randomised, double-blind, controlled trial. Lancet Neurol 2016;15:154–65.

3. Lees AJ, et al. Opicapone as adjunct to levodopa therapy in patients with Parkinson disease and motor fluctuations: a randomised clinical trial. JAMA Neurol 2017;74:197–206.

4. Reichmann H, et al. Correction to: Effectiveness and safety of opicapone in Parkinson’s disease patients with motor fluctuations: the OPTIPARK open-label study. Transl Neurodegener 2020;9:14.

5. Lees A. Onset of drug-related adverse events in Parkinson’s disease patients with motor fluctuations treated with opicapone in clinical practice: OPTIPARK post-hoc Analysis. Mov Disord. 2020;35(suppl 1),S462,abst 1029

NMSS, Non-Motor Symptom Scale; PDQ-8, Parkinson's Disease Questionnaire, 8 items; SD, standard deviation

Prescribing information Ongentys® (opicapone)

Please refer to the SPC before prescribing. Presentation: Capsules containing 50 mg of opicapone. Indication: Adjunctive therapy to preparations of levodopa/DOPA decarboxylase inhibitors (DDCI) in adult patients with Parkinson’s disease and end- ofdose motor fluctuations who cannot be stabilised on those combinations. Dosage and administration: The recommended dose is 50 mg of opicapone. It should be taken once daily at bedtime at least one hour before or after levodopa combinations. Ongentys is to be administered as an adjunct to levodopa treatment and enhances the effects of levodopa. Hence, it is often necessary to adjust levodopa dosage by extending the dosing intervals and/or reducing the amount of levodopa per dose within the first days to first weeks after initiating the treatment with opicapone according to the clinical condition of the patient. If one dose is missed, the next dose should be taken as scheduled. The patient should not take an extra dose to make up for the missed dose. Elderly patients: No dose adjustment is needed for elderly patients. Caution must be exercised in patients ≥ 85 years of age as there is limited experience in this age group. Patients with renal impairment: No dose adjustment is necessary in patients with renal impairment, as opicapone is not excreted by the kidney. Patients with hepatic impairment: No dose adjustment is necessary in patients with mild hepatic impairment (Child- Pugh Class A). There is limited clinical experience in patients with moderate hepatic impairment (Child- Pugh Class B). Caution must be exercised in these patients and dose adjustment may be necessary. There is no clinical experience in patients with severe hepatic impairment (Child-Pugh Class C), therefore, Ongentys is not recommended in these patients. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Phaeochromocytoma, paraganglioma, or other catecholamine secreting neoplasms. History of neuroleptic malignant syndrome and/or non-traumatic rhabdomyolysis. Concomitant use with monoamine oxidase (MAO-A and MAO-B) inhibitors (e.g. phenelzine, tranylcypromine and moclobemide) other than those for the treatment of Parkinson’s disease. Pregnancy: Ongentys is not recommended during pregnancy and in women of childbearing potential not using contraception. Lactation: Breast-feeding should be discontinued during treatment with Ongentys. Warnings and precautions: Opicapone enhances the effects of levodopa. To reduce levodopa-related dopaminergic adverse reactions (e.g. dyskinesia, hallucinations, nausea, vomiting and orthostatic hypotension), it is often necessary to adjust the daily dose of levodopa by extending the dosing intervals and/or reducing the amount of levodopa per dose within the first days to first weeks after initiating treatment with Ongentys, according to the clinical condition of the patient. Patients and care-givers should be made aware that impulse control disorders including pathological gambling, increased libido, hypersexuality, compulsive spending or buying, binge eating and compulsive eating can occur in patients treated with dopamine agonists and/or other dopaminergic treatments. Patients should be monitored regularly for the development of impulse control disorders and review of treatment is recommended if such symptoms develop. Increases in liver enzymes were reported in studies nitrocatechol inhibitors of catechol-O-methyltransferase (COMT). For patients who experience progressive anorexia, asthenia and weight decrease within a relatively short period of time, a general medical evaluation including liver function should be considered.

6. Ferreira JJ, et al. Long-term efficacy of opicapone in fluctuating Parkinson’s disease patients: a pooled analysis of data from two phase 3 clinical trials and their open-label extensions. Eur J Neurol 2019;26:953–60.

Excipients: Ongentys contains lactose. Patients with rare hereditary problems of galactose intolerance, the total lactase deficiency or glucose-galactose malabsorption should not take this medicinal product. Drug interactions: Concomitant use of opicapone with MAO inhibitors (e.g. phenelzine, tranylcypromine and moclobemide) other than those for the treatment of Parkinson’s disease is contraindicated. Concomitant use of opicapone and MAO inhibitors for the treatment of Parkinson’s disease, e.g. rasagiline (up to 1 mg/day) and selegiline (up to 10 mg/day in oral formulation or 1.25 mg/day in buccal absorption formulation), is permissible. There is no experience with opicapone when used concomitantly with the MAO-B inhibitor safinamide. Therefore, their concomitant use should be considered with appropriate caution. Opicapone may interfere with the metabolism of medicinal products containing a catechol group that are metabolised by COMT, e.g. rimiterole, isoprenaline, adrenaline, noradrenaline, dopamine, dopexamine or dobutamine, leading to potentiated effects of these medicinal products. Careful monitoring of patients being treated with these medicinal products is advised when opicapone is used. Concomitant use with tricyclic antidepressants and noradrenaline re-uptake inhibitors (e.g. venlafaxine, maprotiline and desipramine) should be considered with appropriate caution. Particular consideration should be given to medicinal products metabolised by CYP2C8 and their co-administration must be avoided. Particular consideration should be given to medicinal products transported by OATP1B1 and their concomitant use should be considered with appropriate caution. Adverse events: Refer to the SPC for all side effects. Very common side effects (≥ 1/10): Dyskinesia. Common side effects (≥ 1/100 to < 1/10): Abnormal dreams, Hallucination, Hallucination visual, Insomnia, Dizziness, Headache, Somnolence, Orthostatic hypotension, Constipation, Dry mouth, Vomiting, Muscle spasms, Blood creatine phosphokinase increased. Uncommon side effects (≥ 1/1,000 to < 1/100): Decreased appetite, Hypertriglyceridaemia, Anxiety, Depression, Hallucination auditory, Nightmares, Sleep disorder, Dysgeusia, Hyperkinesia, Syncope, Dry eye, Ear congestion, Palpitations, Hypertension, Hypotension, Dyspnoea, Abdominal distention, Abdominal pain, Abdominal pain upper, Dyspepsia, Muscle twitching, Musculoskeletal stiffness, Myalgia, Pain in extremity, Chromaturia, Nocturia, Weight decreased. Legal Category: POM. Basic UK NHS cost: Ongentys pack of 30: £93.90. Marketing authorisation numbers: PLGB 21566/0004 EU/1/15/1066/003. Marketing authorisation holder: Bial-Portela & Ca., S.A., A Avenida da Siderurgia nacional 4745-457 Coronado (S. Romao e S. Mamede) – Portugal. Further Information from: Bial Pharma UK Ltd., Admiral House, St. Leonard’s Road, Windsor, SL4 3BL, UK.

Job code: UK/ON/2021/016(1). Date of preparation: October 2021.

Adverse events should be reported. Reporting forms and information can be found at www.yellowcard.mhra.gov.uk or in Ireland: www.hpra.ie. Adverse events should also be reported to BIAL on +44 (0)1628 531171 or bial@pharmalex.com

Irish Neurological Association, 58th Annual Meeting, Ormonde Hotel, Kilkenny, 12-13 May 2022

THURSDAY 12 MAY FRIDAY 13 MAY

08.00 –

SESSION VI – Platform presentations

Chair: Prof Sinead Murphy

Developments in neuromuscular disease: What we may have missed during the Covid-19 period Prof Sinead Murphy, Tallaght University Hospital

I – Platform presentations

SESSION II – Platform presentations (epilepsy)

Chair: Dr Ged O’Connor

Developments in epilepsy: What we may have missed during the Covid-19 period

Dr Ged O’Connor, University Hospital Waterford

–

SESSION VII – Plenary session –(cerebrovascular neurology)

Chair: Dr Ferghal McVerry

Dr Ferghal McVerry, Altnagelvin Hospital, Derry Developments in cerebrovascular disease: What we may have missed during the Covid-19 period

Dr Áine Merwick , Cork University Hospital

Small vessel disease

Prof Peter Kelly, Mater Misericordiae University Hospital Inflammation – the new risk factor and treatment target for stroke prevention

SESSION VIII – Noel Callaghan, guest lecture

Chair: Dr Paul Crowley

–

Associate Prof Atte Meretoja, Helsinki University Hospital

Treatment options in intracerebral hemorrhage – beliefs, evidence, and practise

–

SESSION IV – Platform presentations (multiple sclerosis)

Chair: Dr Maria Gaughan

SESSION III – Poster viewing session expert-led poster tours 14.15 –15.45

Developments in multiple sclerosis: What we may have missed during the Covid-19 period

Dr Maria Gaughan , St Vincent’s University Hospital

–

–

SESSION IX –Poster viewing session expert-led tours

SESSION X - Platform presentations (movement disorders)

Chair: Prof Timothy Counihan

–

SESSION V – INA Business Meeting (members only)

Chair: Dr Paul Crowley

–

Neurology Trainee Session

–

Developments in movement disorders: What we may have missed during the Covid-19 period

Prof Timothy Counihan, Galway University Hospital

Announcement and presentation of awards

1. Harold Millar Prize for best overall presentation

2. John Kirker Prize for best epilepsy-related presentation

3. Mark Gibson Medal for best movement disorder presentation

4. Hugh Staunton Medal for best undergraduate or intern presentation

5. Best neurosurgical presentation –not currently named in anyone’s honour

6. Dr John Lynch Prize for best poster presentation

SPORTS QUIZ WIN €50 28 April 2022

Q1 Who was sacked as manager of Premier League strugglers Burnley?

Q2 Who was recently named as the new head coach of Munster Rugby from next season onwards?

Q3 Name the winning horse of the Irish Grand National?

Q4 The 2022 All Ireland Football championships are under way. Who are the defending senior champions?

Q5 Who holds the WBC heavyweight championship belt after last weekend’s bout in Wembley?

Q6 The fixtures for the 2023 Six Nations were announced last week. Which two nations face off in the opening fixture of the tournament?

CROSSWORD COMPETITION

28 April 2022

The winner of the 7 April 2022 Sporting Quiz Competition is Dr Clare Smith, Co Dublin

The winner of the 7 April 2022 Crossword is Dr Carol O’Dowd, Dublin 15

Q1 Who scored the winning goal for Ireland in their recent match against Lithuania? A: Troy Parrott

Q2 Who are the 2022 National Hurling League champions? A: Waterford

Q3 The World Snooker Championship cues off later this month. Who is the defending champion? A: Mark Selby

Q4 Rachael Blackmore completed the coveted hat-trick of National Hunt glory by adding the Gold Cup to her Champion Hurdle and Grand National successes. What horse did she ride to victory? A: A Plus Tard

Q5 Who won the opening Formula One Grand Prix of the season in Bahrain? A: Charles LeClerc

Q6 Mo Salah and Egypt will not appear at this year’s World Cup after penalty shoot-out heartbreak in their play-off. Which nation defeated them? A: Senegal

Post your answers to: Mindo Quizzes, The Medical Independent , Greencross Publishing Ltd, 1 Mortons Lane, Wicklow Town, A67RX38 Closing date for entries is 10 May 2022

The returning pleasure of seasonal cooking

Ihave a framed menu from Jammet’s, Dublin’s grandest restaurant, which closed in 1967. Extravagantly French and unashamedly luxurious, it featured dishes, such as escalope de veau Viennoise for 7 shillings and Lobster Newburg for 12 shillings and 6 pence; that would be roughly 40 cent and 60 cent in euros respectively, I reckon.

As it dates from December 1953, I was surprised for a moment to see that amongst the legumes, asparagus was listed (for about 35 cent). Back then, eating was seasonal and asparagus is a spring vegetable in this part of the world. And then I understood. This would be tinned or bottled asparagus, probably the blanched white variety and, while it’s not a patch on the real thing, it’s pleasant enough in the depths of winter. I keep some bottled asparagus in the cupboard and it’s particularly good with some mayonnaise and a few shrimp.

The whole notion of seasonal eating is coming back into focus as rocketing fuel prices must be considered alongside our insistence that all manner of fresh produce should be available right through the year. I absolutely refuse to buy strawberries or asparagus in the winter. But I do like being able to buy a glossy aubergine when I don’t have my own ones from the polytunnel, and it’s a short season, usually from July to October. Making an aubergine – sorry melanzane Parmigiana – in March, using tinned tomatoes from Italy, is a happy and a wholesome procedure. And I’m willing, on occasion, to buy green beans all the way from Morocco or Kenya. Moroccan and Kenyan farmers deserve a bit of our food spend, surely?

But food miles do matter. Although it takes a lot of hard work, I’m delighted that most of the vegetables and fruit that we eat at home during the summer and autumn have welly miles, travelling all of 150 metres from veg plot to kitchen. Thanks to this, I can confidently say that unless you grow your own sweetcorn and get it into boiling water within a couple of minutes of picking, you have never really tasted the stuff. Freshly picked peas are one of life’s great luxuries and I would much sooner have them than caviar. Again, they have to be cooked within minutes, otherwise they will go starchy and rather horrible.

Anyway, seasonality is about to come back into fashion, for reasons of price. And it’s not just the cost of fuel to heat greenhouses and run engines, it’s the cost of fertiliser too. If you’re a conventional farmer you have to replace nutrition taken from the soil with synthetic fertilisers derived, once again, from fossil fuels. Organic farming is not dependent in this way, but it still needs tractors and trucks.

I’m old enough to remember when avocados were a rare delicacy, always called “avocado pears”, and very much a winter thing. And I recall when you only got to eat asparagus if you had it in your garden as we did, and then only in April and May. Now avocado on toast is mainstream – a combination that has no appeal for me, I have to say – and asparagus is on sale every week of the year.

Most of it comes from Peru thanks to a United States initiative to encourage farmers there to grow something more wholesome than coca leaves for cocaine. But they didn’t think it through. Asparagus doesn’t like the high-altitude climate favoured by the coca plant; it’s far happier in sandy coastal soils. So the US created a brand new Peruvian asparagus industry, the coca farmers carried on as they always had, and the centuries-old asparagus-growing community in Washington State was put

out of business by its own government.

Very little asparagus is grown in Ireland and traditionally the seasonal stuff has been imported from Britain where the best is grown in the beautiful Wye Valley on the Welsh border. How Brexit will affect this remains to be seen. The mild winter means an early crop, but I have yet to see any English asparagus in Marks & Spencer or Tesco, both of whom had it last year. However, we should see some from France and Spain soon. Dutch asparagus, mostly the white kind, tends to be snapped up by the home market.

Growing your own needs space and patience. You can pick one spear from each plant a year after planting, two the next year, then three. In year four you can pick as much as you like, but only for six weeks, as then the spears must be allowed grow to re-energise the plant.

However, your own asparagus is certainly the best you will ever taste. Incidentally, I have a small asparagus bed in the polytunnel and a larger one outside and, even then, we rarely get enough at one time to gorge ourselves.

My wife Johann and I wrote Grow and Cook – it does what it says in the title – published in 2007. It sold moderately well, but it would have flown off the shelves if it had appeared in 2009 when, reeling from the global financial crisis, more and more people started to grow their own veg. Maybe it’s time for a new edition as we’re forced to rediscover the pleasures of seasonality?

Many people of my mother’s generation knew all about the art of preserving. Fresh produce was pickled, bottled or turned into jam for the colder months of the year. I can still remember the taste of bottled plums, better, I thought, than fresh ones. And the tangy smell of marmalade being boiled in January when the Seville oranges are in season.

Of course, we have freezers now, but I think I might become a bottler and a pickler when this year’s crops are ready. There are uncertain times ahead.

WINE OF THE MONTH

The best way to preserve the grape harvest is making wine, of course, and I’d like to suggest a red that helps to take the chill off a spring evening. Château de Paraza Minervois 2018 (€16.95, O’Brien’s) is dark and intense, full of Languedoc sunshine. Ripe plums, pepper, liquorice, mulberries. It’s all here in your glass. Have it with a steaming casserole.

The whole notion of seasonal eating is coming back into focus as rocketing fuel prices must be considered alongside our insistence that all manner of fresh produce should be available right through the year

CHILDHOOD TRAUMA KEY INDICATOR OF SUICIDE IDEATION IN COLLEGE STUDENTS

New research from the School of Psychology at Trinity College Dublin has shown that cumulative exposure to childhood trauma was a key indicator of suicide ideation among university students. Screening for adverse childhood experiences could help to improve college services and supports, according to the authors of the study.

The research, conducted by Mr Madhav Bhargav, PhD candidate, and Dr Lorraine Swords, Assistant Professor in Child and Adolescent Psychology, has recently been published in BJPsych Open The study was based on a cross-sectional survey of 321 college students primarily recruited from universities in Ireland.

Adverse childhood experiences refer to negative life events that individuals encounter during their first 18 years of life. They include neglect or maltreatment and significant dysfunction in the home, such as domestic violence, drug or alcohol addiction, and abuse.

A growing body of research has established a relationship between adverse childhood experiences and suicidal thoughts and behaviours and has indicated that the prevalence of suicidal phenomena is higher among individuals with a history of adverse childhood experiences. However, there is a lack of understanding of the process by which adverse childhood events lead to suicidal ideation in particular.

The researchers found that adverse childhood experiences were common in college students with 35.2 per cent reporting oneto-three such events and a further 39.6 per cent reporting four-to-12 adverse childhood experiences.

The study also found serious levels of suicide ideation among the research group meaning many students expressed feelings of burdensomeness, a belief that there are no solutions to problems, and planning, or communicating intent, to die by suicide.

Moreover, the research highlighted the relationship between higher ad -

verse childhood experiences scores and poorer mental health in the form of psychological distress and suicide ideation.

The findings also provided strong evidence that factors, such as feelings of not belonging and feelings of being a burden on others, can mediate the relationship between higher cumulative adverse childhood experiences scores and suicide ideation.

Mr Bhargav said: “Adverse childhood experiences scores may be useful as an identifying marker for university services to ensure that students get the most out of their time in college. Creating a trauma-informed culture within the college community would foster an awareness of how past adverse experiences can affect students’ present functioning so that appropriate supports can be advertised and provided. However, any attempt to screen for students exposed to potentially traumatic early experiences as part of a trauma-informed approach to college services must be done sensitively.”

Dr Swords added: “Our research shows that many young people enter college with prior potentially traumatic experiences that may have an impact on their academic and social life. It is important to acknowledge that young people who have experiences of early adversity are not a homogenous group, and not all are negatively affected in the long-term by these early encounters. Future studies that explore the role of risk factors known to exacerbate the effects of early adverse experience, such as low socio-economic status, would be valuable in this research area.”

The paper, entitled ‘Role of thwarted belongingness, perceived burdensomeness, and psychological distress in the association between adverse childhood experiences and suicidal ideation in college students’, was published online in BJPsych Open

It is available to read at the following link: www. cambridge.org

The HSE National Clinical Programme for Respiratory is continuing to rollout 34 community-based dedicated pulmonary rehabilitation teams around the country.

According to the HSE, this provision will help “empower” people living with chronic obstructive pulmonary disease (COPD) to improve their symptom management and decrease hospitalisations.

The HSE and National Clinical Programme for Respiratory ‘end-to-end model of care for COPD’ is supporting people in community and hospital settings, with the establishment of specialist teams in the community including respiratory integrated care teams.

Services that will be made available in the community include evidence-based interventions, such as pulmonary rehabilitation, stated the HSE.

COPD is the most prevalent respiratory disease in Irish adults and is a major cause of morbidity and mortality. It is estimated that 380,000 people are living with COPD, yet only 110,000 are diagnosed. At least 1,500 patients die each year of this disease and over 15,000 patients are admitted to hospital. COPD has considerable impact on the quality-of-life of the patient, families, and carers. The course of the disease involves ongoing medical care and, in certain patients, results in frequent hospital admissions.

Ms Angela Ryan, Programme Manager, HSE National Clinical Programme for Respiratory, said: “As part of both the integrated care for chronic disease management being rolled out in GP

current national and international guidelines. It involves supervised classes, twice weekly for eight weeks and can be delivered in-person and online.

clinics and the national respiratory model of care, patients with COPD and asthma are being actively monitored by their GP and practice nurse to improve management of their conditions. This programme facilitates care in the community, closer to home, and can facilitate referral to the local pulmonary rehabilitation team, based in the community.

“The pulmonary rehabilitation teams include dedicated teams of specialist physiotherapists and nurses. Pulmonary rehabilitation improves dyspnoea (breathlessness), health status, and exercise tolerance in patients with stable COPD and reduces hospitalisation in patients who have had a recent exacerbation. It leads to a reduction in symptoms of anxiety and depression.

“Education and self-management are core components of pulmonary rehabilitation. Self-management education with a healthcare professional, improves health status and decreases hospitalisations and emergency department visits.

“Pulmonary rehabilitation is a comprehensive intervention based on thorough patient assessment followed by patient-tailored therapies that include, but are not limited to, exercise training, education, self-management intervention aiming at behaviour change, designed to improve the physical and psychological condition of people with chronic respiratory disease, and to promote the long-term adherence to health-enhancing behaviours,” explained Ms Ryan.

Pulmonary rehabilitation is strongly recommended in the management of patients with COPD by

Ms Brenda Deering, Clinical Specialist Physiotherapist Pulmonary Rehab Co-ordinator, HSE, said: “Being one of the first respiratory physiotherapists to bring pulmonary rehabilitation from the hospital into the community has been a challenge, but has also been immensely rewarding on both a personal and professional level. Exercise is the cornerstone to the success of pulmonary rehabilitation; prescribing individualised exercise programmes for patients with an underlying lung condition takes skill and expertise and is based on a thorough assessment.

Once the assessment is

The Rotunda Hospital in Dublin has become the first centre in Europe to receive accreditation by the American Association of Gynaecologic Laparoscopists (AAGL) for a Fellowship in minimally invasive gynaecologic surgery (FMIGS) for gynaecology trainees.

According to the hospital, the addition of this internationally recognised programme will assist future gynaecologic surgeons in developing their skills and expertise. The FMIGS programme will be led by Consultant Gynaecologist Dr Hassan Rajab, alongside Dr Kushal Chummun and Dr Conor Harrity, in collaboration with RCSI partners Beaumont Hospital and Connolly Hospital. The new faculty across the three hospital sites will also include fertility specialists and urogynaecology, urology and colorectal surgeons.

The extensive application process for the programme included a detailed assessment of the Rotunda Hospital’s policies and protocols, its demonstration of a sufficient volume of surgical workload with appropriate complexity, availability of didactic teaching and simulation training, as well as appropriate research opportunities. The accreditation was completed with

complete, my challenge is to ask patients who may never have exercised before, to exercise in a breathing zone they are not initially comfortable with whilst making it both fun and educational. Seeing people build new friendships and improve their health and quality-of-life is what makes my work so enjoyable.”

Dr Mark O’Kelly, GP, Rialto Medical, said: “The experience in our practice has been that patients who have engaged in the community pulmonary rehab programmes have benefited greatly. They have a better understanding of their disease and are better equipped from a self-management perspective also. This means that they are having less flare ups of their disease and have improved symptom control also.”

a recent visit to the hospital, where its facilities, programme directors, local faculty and allied surgical specialities were assessed.

This announcement follows the opening of its new gynaecology unit in March 2021. These developments are part of the Rotunda’s ongoing efforts to “upscale, reduce patient waiting lists, alleviate pressure in theatre capacity and improve overall patient care”.

Prof Fergal Malone, Master of the Rotunda Hospital, said: “We are delighted to receive this accreditation and to be the first European centre to offer the AAGL-accredited FMIGS programme to gynaecology trainees. This development highlights the existing expertise and dedication to high-quality gynaecology services and patient-centred care here at the Rotunda Hospital, and we are looking forward to being able to build upon this even further.

“We believe that welltrained and talented gynaecological surgeons are crucial to accommodating Ireland’s increasing need for top-class services in women’s health and this traineeship is the perfect opportunity to ensure we can meet the growing demand for services in this area.”

HSE CONTINUES ROLL-OUT OF 34 NEW PULMONARY REHABILITATION TEAMS NATIONALLY

ROTUNDA ANNOUNCED AS FIRST EUROPEAN CENTRE TO OFFER PRESTIGIOUS GYNAECOLOGY TRAINING PROGRAMME

PRACTICE NURSE REQUIRED

Full-time practice nurse required to join the friendly team at Banagher Family Practice, Co Offaly. We are a fully computerised, four GP practice with one practice nurse and phlebotomist currently, good admin support and we are based in a new Primary Care Centre.

Previous experience of phlebotomy, cervical screening, and childhood immunisations is essential and nurse needs to be organised, enthusiastic, and a good communicator. Excellent remuneration for right candidate. See our website www.bfphealth.com

Apply with CV and cover letter to practice manager diane@bfphealth.com

GP EDUCATIONAL WEBINAR ON PVFS AND ME/CFS

Dr Ros Vallings, a New Zealand GP who is an expert on myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), will present a free talk entitled Key messages for primary care on the diagnosis and management of post viral fatigue syndrome and ME/chronic fatigue syndrome followed by a Q&A session on Monday, May 30 at 7:30pm.

Approved for 1 CPD point by the ICGP For more info, contact CPD@irishmecfs.org

MATCH MEDICS GP RECRUITMENT TEAM ARE HEADING TO SPAIN AND PORTUGAL IN JUNE!

We are meeting GPs and Family Medicine Doctors who are interested in making the move to Ireland to live and work. Would you like us to tell them about your practice? What it is like to live and work in your part of Ireland?

Would you like me to find a full-time doctor to fill your staffing needs?

REGISTER YOUR INTEREST TODAY: shirley.osullivan@matchmedics.com or call me for a chat: 086 803 0891

SHANE O’TOOLE

Specialist Medical Accountant, RCSI Lecturer and author of Fit moneythe key to financial freedom

Now offering:

• Monthly Profit Growth Model

• Annual Accounts and Tax Returns

• Outsourced Bookkeeping and Payroll

• Support in Selling and Buying a Practice

Contact 01 8013 116 for help and support

GP LOCUM REQUIRED

Fancy a summer GP locum job in West Cork?

Would you like to work and enjoy the summer in West Cork near the sea?

GP locum sessional or full-time work available in a GP group practice. On-call commitment optional. Very supportive nursing and admin staff.

Please email any queries and cv to: westcorkmedical@gmail.com

GP REQUIRED

Permanent/temporary/locum –Kilkenny/Tipperary/Waterford Border

 GP required for a growing two-centre practice

 6–8 sessions available with attractive package

 Immediate start available with long-term potential

 Partnership opportunity for the right person

 Established, well-located, busy practice with huge potential to grow

 Fully computerised using Socrates

 Excellent nurse and admin support – fully resourced for chronic disease management

 Member of CareDoc

 MICGP/MRCGP or equivalent essential

Email: piltownhc1@eircom.net

EXCELLENT GP LOCUM OPPORTUNITIES

Outstanding earnings potential  18 hrs @ weekend = 75K p/a.

 20 hrs overnight = 93K p/a.

 8 hrs evening (Earning top up) = 30K p/a.

 Day time GP opportunities for qualified GPs. Contact us on 046 924 1533 Email: info@medsource.ie Visit

MEDICAL SUITES AVAILABLE IN DUBLIN 2

Medical Suites available at 26 Clare Street, Dublin 2. Adjacent to the National Gallery.

Suitable for a range of medical uses including GP practice - Private or GMSOut-of-hours service or walk-in clinic – physio clinic – beauty clinic, etc. Full medical planning permission.

Please contact Mr Aidan Ringrose on +353 87 951 9786 or mornwill26@gmail.com for further information or to arrange viewing

WATERFORD CITY GP PRACTICE TAKEOVER

Opportunity for 1-2 full-time general practitioners to take over established Waterford City practice (~900 GMS patients and ~2,000 private patients), supported by 1 WTE nurse and administration.

Principal GP wishes to retire within a year.

Based in residential area, near UHW and Ardkeen, the practice occupies a large two-story building, with three treatment rooms and additional space. No buy-in. Work within the year only. Start date is negotiable.

To express interest, please text 087 6772 475 to set up a call

FULL-TIME GP REQUIRED

For a busy established practice in Wexford Town. The practice is fully computerised using Socrates. Excellent nursing and administration support

Mixed GMS and private practice.

Attractive remuneration package.

Applications to: GPvacancywexfordtown@gmail.com

GP REQUIRED

GP wanted for vibrant training practice in Youghal (full- or part-time). We are flexible and interested in meeting with all interested parties.

Youghal is a beautiful seaside town with a growing population and economy. Home to Ireland’s only Iron Man. Easy commute from Cork, South Tipperary, and West Waterford.

For enquiries contact Lisa: lisa@emmetplace.ie

GP ASSISTANT WITH A VIEW

Vocationally trained GP required immediately for 6+ sessions for a busy dynamic practice with a great team of people in Waterford City. GP training practice, 8 other doctor colleagues with varying speciality interests. 2 nurses – one an advanced nurse prescriber, another nurse/midwife, and also a medical technician.

Fully computerised practice with administrative support. We operate a 15-minute appointment system and use Socrates practice management system. No out-of-hours commitment.

Close to the City Centre, 8 minutes from Tramore beach and beside an Ecopark. Waterford voted “Best place to live” in Ireland.

Great Package for the right person.

Please forward CV by email to our Practice Manager Jean Hubbard practicemanager@waterfordmedicalcentre.com

GP REQUIRED

Well-established group practice in East Galway requires a full-time GP with view to partnership.

Fully computerised with Socrates and great practice support.

Contact Dr John Kilraine or Dr Cathal Nugent at 091 842144 or send your contact details to admin@mainstreetclinic.net and we will get back to you GP

Locum required in Tallaght, Dublin 24

Dates:

April: 19th, 20th, 21st, 22nd/28-29th

May: 20th

June: 10th, 13th, 14th, 15th, 16th, 17th

Full Month of July and August

15 min appointments  No house calls  Excellent practice nurses and helpful administration staff and well organised  Nice mix of GMS/private  Flexibility with session times  Potential for ongoing work throughout the year if desired Please

SUITE 23 BEACON CONSULTANTS CLINIC, SANDYFORD, DUBLIN 18

World class medical facility, strategically located adjacent to the Beacon Hospital

 Contemporary office space c.31sq.m

 Fully serviced space suitable for range of medical and dental specialities

 Secure designated parking

 Sought after complex ideal for expanding current practice

 Quality investment suitable for self-administered pension

Price on application Ivan Tuite, Assoc. SCSI/MIPAV + 353 (0)1 4968 111

O’Connor Shannon

PSRA No: 003320

If you have anything you would like to share, please email: info@mindo.ie

A round-up of news and oddities from left field by Dr Doug Witherspoon

A sour note: If music be the food of love, what if you had no appetite?

Many of the conditions you treat are terribly cruel by their nature. Some kill, some destroy quality-of-life, and some do both. Then there are others which take something essential from us.

Such a condition, although thankfully a rare one, is musi-

cal anhedonia. In short, it is the inability to enjoy music on any level, to remember lyrics, and to be denied the biological and psychological responses similarly associated with other ‘rewards’, such as food or sex.

With musical anhedonia, the sufferer is also denied the social rewards associated with music, such as sharing interests

with friends, going to concerts or festivals, or playing an instrument. It takes effort to imagine such an affliction. Music has been part of us vsince pre-history and no doubt there are certain songs or musical arrangements that you associate with a certain time in life. Just as the sense of smell has powerful effects in terms of memory recall, to be denied an appreciation of music is to be deprived of a fundamental part of life.

A 2016 study in PNAS reported that musical anhedonia cannot be explained by perceptual problems, such as hearing difficulties or a specific impairment in perceptual capabilities. Nor can it be explained by general anhedonia, ie, the inability to take pleasure from all types of rewarding stimuli.

The E volution of Precision Science

The Evolution of Precision Science

When measuring skin conductance response and heart rate measurements, it was found that compared with those who have ordinary or high sensitivity to music, people with musical anhedonia showed a lower emotional arousal, as indexed by autonomic nervous system activity.

The authors noted that previous studies show how music stimulates the mesolimbic reward circuitry, particularly the nucleus accumbens (NAcc), as well as the auditory and frontal cortices. Other research also shows “the reward value of a novel piece of music was predicted by the functional connectivity between the NAcc and auditory cortices, as well as regions involved in valuation, such as the amygdala and orbitofrontal and ventromedial prefrontal regions”. In short, the NAcc in people with the condition shows less activity and sufferers have suboptimal connectivity between the auditory processing and the brain’s reward centres. In a quirky twist, those with musical anhedonia have no difficulty in enjoying and appreciating the other sensory pleasures in life.

At the other end of the scale, there is ‘musical synesthesia’. This is a ‘condition’, if it can be described as such, where the listener hears music in multiple dimensions, seeing colours that they associate with certain notes, for example. For these people, music also evokes shapes, a certain sense of smell or taste when listening to music, and even sensory experiences involving their fingers.

Duke Ellington, for example, was documented as having chromesthesia, a particular type of musical synesthesia that meant he ‘saw’ shapes associated with certain pieces of music. Another famous musician and songwriter with chromesthesia is Billy Joel, whilst others include Pharrell Williams, Franz Liszt, and someone called Charli XCX (no, neither had I).

Contains a unique combination of two clinically researched synergetic strains

Whilst it was too early for MRI scans at the time, it is also strongly suspected that Arthur Rimbaud had a form of grapheme-colour synesthesia, which led him to associate vowels with colour values. I’ll leave you with Rimbaud’s poem Vowels, which may represent a diagnostic red flag. Enjoy your music, with a thought spared for those who can’t get into the groove.

Calcium: Contributes to the normal function of digestive enzymes.

Contains a unique combination of two clinically researched synergetic strains.

Pantothenic Acid, Vitamin B6: Contribute to the reduction of tiredness and fatigue.

✝Calcium: Contributes to the normal function of digestive enzymes.

Pantothenic Acid, Vitamin B6: Contribute to the reduction of tiredness and fatigue.

Group

A Black, E white, I red, U green, O blue: Vowels, I shall tell, one day, of your mysterious origins:

A, black velvety jacket of brilliant flies which buzz around cruel smells, Gulfs of shadow; E, whiteness of vapours and of tents, lances of proud glaciers, white kings, shivers of cow-parsley; I, purples, spat blood, smile of beautiful lips in anger or in the raptures of penitence; U, waves, divine shudderings of viridian seas, the peace of pastures dotted with animals, the peace of the furrows which alchemy prints on broad studious foreheads; O, sublime Trumpet full of strange piercing sounds, silences crossed by [Worlds and by Angels]: O the Omega! the violet ray of [His] Eyes!