Catherine Reilly speaks to sex workers, and those advocating for their welfare, about the health risks posed by Covid-19
Sixteen HSE area medical officers are seeking pay and conditions on par with senior medical officers.
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Beauty in lockdown?
Trainees at Our Lady of Lourdes Hospital, Drogheda, reported that some SHOs were rostered to work a continuous shift pattern of 19 days during periods of staff absence, according to a Medical Council inspection report.
The training standards inspection was conducted in 2019 and the report was approved by the Medical Council’s education and training committee in April this year.
The hospital provided European Working Time Directive (EWTD) compliance data to the Council team, which indicated 93 per cent compliance with the less-than 24hour shift and 86 per cent compliance with the 48-hour week. Most trainees who met with the Council team were not aware of the occupational health services available to them.
Elsewhere, trainees at Beaumont Hospital in Dublin described concerns in the emergency department due to the “limited physical space”
of the building and “limited lighting in the department at night”.
This inspection was also conducted in 2019 and the report approved by the Council’s education and training committee in April.
According to the inspection report, EWTD data indicated 77 per cent compliance with the 48-hour week. “Some trainees reported that they regularly work in excess of the EWTD criteria,” stated the document.
Cavan General Hospital was found non-compliant with Council specialist training standards in two categories, namely “clarity of educational governance arrangements” and “opportunities for trainers to train through protected training time”.
The lines of accountability for the learning environment “were not evident”. Additionally, trainers described how they “do not have protected time in their work schedules to fulfil their trainer duties”.
“Trainers described being strongly committed to the delivery of education and training at this site, but
noted that current consultant staffing levels at the site limit their time spent undertaking trainer duties.”
At Connolly Hospital, Blanchardstown, formal arrangements between the site and the postgraduate training bodies were “unclear” and the hospital was found non-compliant in the category of “clarity of educational governance arrangements”.
Trainees reported that “inflexible” duty rosters could result in 12 consecutive days of 13-hour shifts, and also weekend shifts followed by returning to work the following Monday. EWTD compliance data was provided, indicating 100 per cent compliance with the less-than 24-hour shift and 77 per cent compliance with the 48-hour week.
The inspection reports for sites in the RCSI Hospitals Group, which outlined a range of recommendations, also identified good practices in training delivery at the hospitals.
At the Rotunda Hospital in Dublin, for example, trainees described a range of formal and informal education and training opportunities, while teaching was
DAVID LYNCH
The “pay inequality” for new-entrant consultants is a “red line” issue for Irish doctors living abroad who may contemplate returning home.
That is according to leading members of the IHCA who spoke to the Medical Independent (MI) as part of the Association’s preBudget submission launch.
MI asked whether the current pandemic, with its resulting travel restrictions, had made the possibility of Irish doctors returning to Ireland less likely even if pay equality was restored to new-entrant consultants.
“I think a lot of it is down to individuals,” IHCA President Prof Alan Irvine told MI
“At the moment if you come back from the UK, for instance, you have to self-isolate for two weeks, so if you are doing a job in the UK for the moment it means you can’t see your family. So it’s pretty grim for
primarily consultant-led.
“Lecture time was noted to be protected and the team bleep structure in place at the site facilitates attendance at scheduled educational sessions. Additional informal opportunities arise day-to-day,
through the complex case-mix trainees have access to at the site.
“Trainers spoke of trainee feedback being useful in designing teaching schedules and gave examples of how tutorials have been revised based on such feedback.”
people who want to remain in touch.
“For some, coming home to a properly resourced, equally paid job, is actually quite attractive because they would be back in Ireland. This [pandemic] is going to run, there is no exit date for Covid; as far as we know, it is going to be a year or two. People are making some decisions around that, around some very personal, family-based decisions, that they would be quite happy to be in Ireland and to be close to people.
“Being away from your family is tough... and really tough at the moment, so I think a lot of people would come back.”
Dr Gabrielle Colleran, IHCA Vice President, told MI she is in a WhatsApp group with over 250 members, many of whom are Irish doctors who live and work abroad. She said the “consistent message is that the pay inequality is a red line issue for them” in terms of returning to Ireland.
INDIC
A T E D FOR
severe
arthritis (RA) in adult patients who have responded inadequately to, or who are intolerant to one or more disease-modifying antirheumatic drugs. XELJANZ® in combination with MTX is indicated for the treatment of active psoriatic arthritis (PsA) in adult patients who have had an inadequate response or who have been intolerant to a prior disease-modifying antirheumatic drug (DMARD) therapy.
It is projected that the next round of BreastCheck will take three years in order to catch up on missed screens and assessments in light of Covid-19.
Under normal circumstances, eligible women are invited for a mammogram every two years.
When the BreastCheck programme was paused, there were around 600 women with screen detected abnormalities that needed assessment.
“All women have now been assessed and the majority of women requiring surgery have had their operations and are on a specific care pathway,” said a HSE spokesperson.
The pause in screening and Covid-19 restrictions mean it will take the service many months to catch up on missed screens and assessments.
“It is therefore projected that it will take 36 months to complete the current round (screens and assessments completed within a
24-month period) of breast screening. Although we would not wish anyone to have a longer interval for screening in Ireland, there is no evidence that harm will accrue from a delayed screen,” emphasised the spokesperson.
The service will operate at a maximum of half the previous workload up to the end of February 2021, at the earliest, the HSE outlined.
The programme has been paused on public health advice since 16 March 2020.
“The pause was put in place to protect patients and staff by complying with so cial distancing guidelines,” said the spokesperson.
“In addition, the HSE temporarily redeployed staff and resources to the response to Covid-19. How ever, clinical staff have con tinued to work within the programme.”
The programme is currently working on a new approach to provid ing screening, including priority invites for those waiting longest.
NIAMH CAHILL
A GP out-of-hours (OOH) co-op has experienced a significant rise in its contact rate due to increasing calls from patients with Covid-19 symptoms.
Since the end of August, NEDOC, which covers Louth, Meath, Cavan, and Monaghan, has experienced a resurgence in the number of contacts to the service, with similar pressures facing other OOH services nationally.
44 per cent and 34 per cent respectively, compared to the same period in 2019.
“A significant number of those contacts are citing symptoms similar to Covid and patients seeking Cov id test referral as they are understandably concerned and want to rule it out.
“As patients are direct ed to contact their GP when they experience any Covid-like symptoms, all of which are common to other winter viruses and illnesses, demand on day time and GP OOH will only increase.”
Monaghan GP and Med ical Director of NEDOC, Dr Illona Duffy, said funding was urgently required to enhance the OOH service, which she stressed was not fully funded by the HSE.
“The HSE needs to look at funding the out-of-hours service in full or the co-ops will fail. There will be drastic cuts to the out-of-hours services if not.”
The recruitment competition for a new Medical Director in Sexual Health has taken place and a candidate had been selected, according to the HSE.
“It is anticipated that the post will be filled in Q4, 2020,” a spokesperson told the Medical Independent. The National Sexual Health Strategy 2015-2020 “will be updated once the current pandemic situation allows”.
In 2015, Dr Fiona Lyons, Consultant in Genitourinary and HIV medicine at St James’s Hospital, Dublin, was appointed as the first ever HSE National Clinical Lead for Sexual Health Services.
NGOs and clinicians working in sexual health are increasingly concerned about a potential upsurge in sexually transmitted infections (STIs) following the extensive curtailment of sexual health services during the pandemic.
“Many sexual health services reopened in July/August. The remaining services are preparing to re-open and will do so as (staff and physical) capacity allows,” stated the HSE spokesperson last month.
“All public sexual health services continue to face service restrictions in light of social distancing requirements. In general, public sexual health services operate on a triage basis, which includes prioritisation of those on treatment, such as for HIV, to ensure conti-
nuity of care, or those who have symptoms of an STI and require treatment.
“Services are working hard to get through any backlogs/waiting lists, or providing catch-up services, eg, vaccines, where clinic space is available.
Services have changed how they operate in order to maximise service provision within the current context, which includes a combination of online consultations, telephone support and faceto-face appointments.”
Data from the Health Protection Surveillance Centre has described a significant reduction in STI notifications compared to 2019. This trend is “likely to be multi-factorial”, said a HSE spokesperson.
See news feature, p4-6
Ms Arlene Fitzsimons, NEDOC Operations Manager, told the Medical Independent : “The first two weekends of September saw our contact rate rise
Dr Duffy highlighted that if she was unable to work a shift at NEDOC, she must pay more than €35 an hour for failing to work.
“This system that penalises GPs who are unable to work must change,” stressed Dr Duffy.
The pandemic has highlighted how vulnerable populations face additional health risks including exposure to Covid-19. Catherine Reilly speaks to sex workers, and those advocating for their welfare, about these challenges
In spring, when the Covid-19 crisis erupted, Zoe (not her real name) decided to stop meeting sex buyers and advertised video and phone sex only. She has continued with this practice due to health concerns and said that “clients accept this is my choice now”.
Nevertheless, since June, requests to meet have become more frequent. The “demand for online services is a lot less by now”, Zoe informed the Medical Independent (MI) by text message in mid-September.
During the national lockdown, sex workers oriented online “as much as they could”, said Ms Kate McGrew, a sex worker and Coordinator of Sex Workers Alliance Ireland (SWAI).
But this was not an option for everyone – due to personal circumstances or privacy concerns. Most people have since returned to in-person sex work, stated Ms McGrew. She criticised the lack of State income support for sex workers and the fact SWAI was not included on the vulnerable persons subgroup of the national public health emergency team (NPHET).
all related to direct provision accommodation.
The organisation was connected to the NPHET subgroup through a HSE representative, who sits on the monitoring committee of the second national strategy on domestic, sexual and gender-based violence (of which Ruhama is a member).
Ideologies
SWAI and Ruhama are key non-governmental organisations supporting people involved in sex work, although their approaches are rooted in vastly different ideologies. SWAI supports a harm reduction policy and advocates that sex workers “should be granted the same rights as all other workers”.
Ruhama supports criminalisation of the purchase of sex. It does not use the term ‘sex work’ (MI has used this term descriptively and because ‘sex workers’ is the wording in the national sexual health strategy).
Sex workers are not a homogenous group –some are doing it by free will; others have been coerced and trafficked. Some may have relative financial stability (‘Zoe’ told MI she has private health insurance), others are existing day to day, potentially living in addiction. Some are migrants, documented and undocumented, and others are Irish. There are male, female, and transexual sex workers.
But all are at notable risk of contracting Covid-19 unless they work exclusively online. There have been no specific testing initiatives targeted towards sex workers.
A HSE spokesperson told MI data related to cases of Covid-19 associated with sex work was not collected by the Health Protection Surveillance Centre (HPSC). “To date, we are not aware of any clusters/outbreaks related to sex work,” they added.
A Department of Health spokesperson said SWAI was on its Covid-19 stakeholder mailing list (the vulnerable persons subgroup has now been stood down, as the work of NPHET subgroups is being “realigned” into various departments, organisations and bodies).
According to Ms McGrew, SWAI received “explicit written refusal for emergency funding from the Department of Justice who did give money to the abolitionist organisation here, Ruhama.
“They explicitly told us they won’t be funding us for as long as we talk about sex work as an economic activity as opposed to inherent exploitation of vulnerable people. It is pretty alarming for the Department of Justice to be making policy and funding decisions based on ideology as opposed to outcomes.”
She said while efforts were focused on ‘flattening the curve’, some people returned to working in “extremely risky” situations. To date, Ms McGrew said she was not aware of sex workers who had contracted Covid-19.
Ruhama, which “supports women in prostitution”, is aware of Covid-19 cases among its service-users. Service Manager Ms Sheila Crowley told MI these cases were
Meanwhile, sexual health services have been severely curtailed due to Covid-19, particularly walk-in clinics. This has led to broader concerns about a future upsurge in untreated sexually transmitted infections (STIs) – which often present asymptomatically.
During the pandemic, the behaviour of sex buyers has become “even bolder”, placing sex workers at additional risk, warned Ruhama’s Ms Crowley.
“We have some women who are living in homeless accommodation and they would have been going out during the pandemic [national lockdown], they would have been seeing clients who would be outside in a car and they would go out and get into the car…. There is something about the pandemic that has made punters feel even bolder.”
Some women were asked for unprotected sex but offered far less money than would be usual.
“The punters seem to be aware that the women who are selling sex during Covid are the women who really need the money. And they have been taking advantage of that. So our self-care group have been working with the women around putting more protection in place for themselves.”
This virtual support group has attendances
of up to 24 women at a time, according to Ms Crowley.
As well as delivering care packages to women during lockdown – including condoms and lubricant – Ruhama was funded by the Department of Justice and Equality to distribute smartphones and tablets to women who did not possess a device, as many of Ruhama’s supports went online.
It also set up a virtual parenting group – a space where women “could be very honest about the frustrations of being stuck with children all day, without feeling that there was a social worker involved”, outlined Ms Crowley.
SWAI has also run virtual support groups and crowdfunded to assist sex workers in financial distress.
“We were able to crowdfund a hardship fund of €26,000 and we were able to use that to give payments of €100-200 to 160 sex workers, which is good, but that really only boiled down to a few shopping trips,” said Ms McGrew.
SWAI has also worked with Gender Orientation Sexual Health HIV (GOSHH) and the Sexual Health Centre in Cork to develop and disseminate a harm reduction leaflet for outdoor sex workers.
If a sex worker is in a car, for example, they should turn off the air conditioning and leave the windows down. “Try to keep your faces away from each other, things like that,” explained Ms McGrew of the leaflet information.
Commenting on HSE support for sex workers during the pandemic, the Executive’s spokesperson referred to the Cork Sexual Health Centre’s #SafeRsexwork campaign, which provides a practical harm reduction guide for individuals undertaking sex work during the Covid-19 outbreak.
“This work was led by the Sexual Health Centre outreach worker and funding for this post is provided for by the HSE Sexual Health and Crisis Pregnancy Programme (SHCPP).
“In addition, the HSE community work department (HSE South) provided funding for the communications officer who designed, delivered and promoted this campaign.
“The HSE SHCPP included a link to this campaign on the ‘sex and coronavirus (Covid-19)’
information page which can be found here https://www.sexualwellbeing.ie/sexual-health/ sex-and-coronavirus/
“More information on the #SafeRsexwork can be found here: https://www.sexualhealthcentre.com/news/2020/4/9/the-sexual-healthcentre-launches-safety-guide-for-sex-workersduring-covid-19.”
The spokesperson said work on the aforementioned leaflet for street-based sex workers was led by the operations manager at GOSHH and funding for this post is provided by the SHCPP.
The HSE also operates the Women’s Health Service and the Anti-Human Trafficking Team and the Gay Men’s Health Service, where sex workers would be in the patient cohorts. It provides funding to Ruhama.
2017 law
The Criminal Justice (Sexual Offences) Act 2017 introduced a new offence of payment for sexual activity with a sex worker.
It also removed the offence of public solicita-
tion by sex workers. Brothel-keeping remains a criminal offence with increased penalties under the 2017 Act.
A recent HIV Ireland-commissioned report found the law has had a profoundly negative impact on the health and wellbeing of sex workers. It proposed repeal of the law to protect sex workers’ health, safety, and wellbeing.
The report’s recommendations for healthcare included: Increased staff training; greater inclusivity in terms of mental health supports; expansion of peer-led sexual health screening services; and greater awareness of the role of HIV pre-exposure prophylaxis (PrEP) as an option for sex workers in managing health risks.
Ms McGrew of SWAI said the law is associated with a myriad of concerns for sex workers. They fear disruption of income stream and being arrested “for working with a friend, because that is considered brothel keeping”.
“So what that means is that, at the very least, sex workers don’t want to raise any issue because they don’t want gardai knowing that they see clients, that they can have their clients taken off them. Then there is of course being arrested for ‘brothel-keeping’; there is a risk for some people of deportation, of being asked to quietly go home instead of being deported; there is risk of eviction; risk of having their children taken off of them.
“I mean, it was always legal to work alone so to say the law decriminalised us isn’t even true. SWAI pushed for an amendment to get decriminalisation of outdoor workers, and even for them, they are still getting gardai disrupting their work, pushing them into darker areas, and also falsely telling them it is illegal to work.”
When word gets around about garda raids “work quiets down, and we hear about girls taking clients that they are nervous about, we hear about girls dropping their prices. To outside people they think these are just inconveniences, but they are really dangerous for us – really legitimately dangerous
changes in how we work.”
At Ruhama the law is seen as hugely positive. It rebalances power in favour of the sex worker, according to Ms Crowley. She said women are now more inclined to report rape, assault, and robbery (this is “anecdotal” and the organisation will compile statistics, she said).
Ruhama hopes the law will lead to a decline in sex purchasing. Research it commissioned suggests there may have been a 2 per cent drop in the number of men reporting that they would buy sex in Ireland.
The legislation has made “a huge difference” to women on the streets, added Ms Crowley.
“They are often Irish women, they are often in addiction, and so they are much more aware that the guards are being nice, and maybe more protective of them rather than looking at them as a nuisance because they can no longer be charged.”
The contention that the law impedes healthcare access “doesn’t make sense”, she said.
“Why would a law, when you are not in any trouble at all, make you not go and get healthcare? You have to remember, with the majority of our clients, they came to us because they felt they had been exploited in the sex industry…. I am not representing necessarily a woman who feels very empowered by prostitution and is earning a lot of money….
“I do feel laws won’t suit everyone, but with any law, you are trying to help the people who are most exploited in that situation.”
Ms Crowley, who has worked with Ruhama for ten years, said the trauma experienced by many women may not be immediately evident.
“I always find it hard to find the ‘empowered sex worker’. I am not sure I have ever quite met one,” she added.
According to Ms McGrew, “people work in the sex industry on a spectrum of choice, circumstance and coercion”. She said the focus must be on “harm reduction models that make it as safe as possible”.
Most sex workers are mothers, some are put-
“We certainly cared for those who self-identify as sex workers during the Covid pandemic,” confirmed Dr Cathal Ó Broin, Consultant in Infectious Diseases and General Internal Medicine at St Vincent’s University Hospital in Dublin. Dr Ó Broin is the Clinical Lead for the Prevention Support Clinic, which is part of the hospital’s PrEP and sexual health service.
“This was very much a collaborative effort between St Vincent’s University Hospital and the community outreach team at HIV Ireland, led by Adam Shanley,” he told the Medical Independent. “The community team identified persons with increased sexual health needs, primarily sex workers and those involved in chemsex and recruited them to our clinic.
“Diego Caixeta is a member of this team and has created excellent links with this group. As a result of his efforts we were able better support cis and transgender persons, men who have sex with men, migrants and those with disabilities. Furthermore, Diego was able to identify key persons within the sex worker community who act as advocates and promote sexual health.
“It was also noted by our service that drug use significantly increased during lockdown, much of this was due to self-reported anxiety and depression. We liaised with the Rialto Community Drug Centre who were able to provide phone counselling to those who needed it most. There is now an active, bilateral referral pathway.
“I think this project was successful as a result of the stronger interface between the community and the hospital. Diego will be working with us for one day per week from now on. His focus will be on improving accessibility, overcoming barriers to testing and increasing retention in services for minority populations. His role with us is supported by HIV Ireland and the Sexual Health and Crisis Pregnancy Programme.”
Asked about Covid-19 risk and symptom awareness among the sex worker population, Dr Ó Broin said: “Regarding Covid awareness, many of the sex workers insisted on appropriate hand hygiene and some reported mask use.”
Mr David Field, Clinical Nurse Specialist in Sexual Health and PrEP at the Mater Misericordiae University Hospital in Dublin, has observed that sex workers may face marginalisation on many levels.
“And because of the multiple impacts of marginalisation, they can find it even more difficult to access inclusive healthcare.”
He emphasised that the Mater provides “a sex worker inclusive sexual health service”.
“I would see that, a lot of the time, sex workers would find it difficult to navigate the system…. It is about having an awareness and doing in-depth sexual health assessments to make sure that you are picking up maybe more vulnerable people so we can provide them with services.”
Mr Field has sometimes perceived a reluctance among sex workers to disclose this information.
“Working in sexual health, disclosure and trust is something we would navigate quite a lot. But sometimes people are more hesitant, it might not be until their second, third or fourth visit before they will disclose that they are a sex worker….
“But without them disclosing that to us, it can be difficult to provide the most appropriate healthcare to them, so I would
always try and have as open and honest a discussion in as non-judgemental a way as possible, letting them know they can disclose anything they want to me and that it is imperative really for me to be able to provide the best service to them.”
Mr Field said PrEP clinical guidance facilitates access for sex workers outside the MSM categories, where they are identified.
“While the guidelines are geared towards gay, bisexual and other men who have sex with men, they allow for a certain amount of clinical judgement….
“If someone came into us and said ‘I am a female sex worker and I have sex with men’ that would absolutely be an indication that we start them on PrEP,” said Mr Field, emphasising the importance of a sex worker feeling comfortable disclosing this information.
The roll-out of the national PrEP programme has been impacted by the pandemic. “There is definitely decreased access to PrEP out there in the community at the moment, but I think different services have different approaches to correcting that.”
He confirmed the curtailment of sexual health services in many locations is a source of anxiety for healthcare professionals in this area.
“From a sexual health perspective, a lot of the infections we look for can be completely asymptomatic. Infections like chlamydia, because they are asymptomatic in nature, people will often have carried them and passed them on, and I think the fact there aren’t [usual] services there at the moment just allows infections to proliferate and for a larger pool of infections to develop in the community, which is obviously concerning to us in sexual health.”
In regard to improving access to sexual healthcare for sex workers, Mr Field suggests sex worker-specific training for sexual health services. He said dedicated clinic evenings or days, as part of an existing service, may warrant examination. Funding is one of the biggest challenges for sexual health services seeking to develop new approaches, he noted.
He confirmed that the law around sex work poses challenges for healthcare workers, in terms of sex workers’ reluctance to disclose information relevant to their care.
“I would always try to make it as clear as possible [to patients] that in healthcare our role is not to enforce a law or get into that kind of conversation. We are very much there to facilitate good sexual health and wellbeing.”
ting themselves through college, buying houses, and saving to start a business. Others are working on a “survival” basis, paying for that day’s hostel, food or drugs, she said.
The HSE’s spokesperson said it was aware the Department of Justice and Equality was conducting a review of the law. The HSE “will participate in the review as required”.
Sexual health services
The pandemic has curtailed access to public sexual health services, fuelling concerns about significant untreated infection and further spread of STIs, particularly in at-risk populations.
The HSE said many sexual health services re-opened in July/ August. The remaining services “are preparing to re-open and will do so as (staff and physical) capacity allows”.
They added that all public sexual health services “continue to face service restrictions in light of social distancing requirements. In general, public sexual health services operate on a triage basis, which includes prioritisation of those on treatment, such as for HIV, to ensure continuity of care, or those who have
symptoms of an STI and require treatment. “Services are working hard to get through any backlogs/ waiting lists, or providing catch-up services, eg, vaccines, where clinic space is available.”
There has been a notable reduction in STI notifications this year, according to the most recent HPSC summary report (week 37, 2020). For example, the report showed a 27 per cent decrease in chlamydia cases so far this year, compared with the same period of 2019; a 23 per cent decrease in gonorrhoea; and a 31 per cent decrease in syphilis (early infectious). HIV notifications reduced by 6 per cent. In contrast, HPSC data from late 2019 indicated that STI and HIV notifications were rising
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from the previous year.
Since May/June, there has been a “small but steady increase” in most of the STI notifications as restrictions eased, according to the HSE. “As the data is provisional at this time, we will continue to monitor the situation to determine whether it reflects a true indication of declines in STIs or delayed diagnosis/notification.”
Testing
Executive Director of HIV Ireland Mr Stephen O’Hare believed less testing was a key factor behind the data showing sizable STI reductions.
“It is very difficult to say that because [social venues] are closed, people are not getting together or hooking up or not engaging in sex work through the pandemic – we don’t have that data, but what we do know is there’s no testing or very limited amounts of testing.”
It is unclear why HIV notifications have remained relatively steady and a clearer picture may form in the coming months.
HIV runs the MPOWER Programme, which is a suite of peer-driven community-level interventions aimed at reducing acquisition of HIV and STIs and improving sexual health and wellbeing among gay, bisexual and men who have sex with men (gbMSM). The HSE also provides funding to this programme.
A member of the MPOWER team, who is originally from Brazil, works with migrants from South America who are gbMSM, including some sex workers.
Mr O’Hare said this illustrated the need for a broader understanding about who is engaged in sex work and who is buying sex in Ireland.
“There are multiple genders working in sex work -there are trans sex workers, male and female sex workers in Ireland, of different ages, of different nationalities and of different sexual orientations.”
Mr O’Hare said Covid-19 has impacted the roll-out of a national PrEP programme to groups at greater risk of HIV. He noted that the criteria for accessing PrEP tends to focus on MSM. However, other people can also qualify if they are deemed at greater risk of contracting HIV.
Sex workers engaged in heterosexual sex are unlikely to qualify for PrEP unless they disclose their status as a sex worker, and HIV Ireland research has indicated a reluctance among sex workers to reveal this information to healthcare professionals.
At SWAI, Ms McGrew is aware of a female sex worker whose client removed the condom during sex (known as ‘stealthing’) and who attended a hospital to access HIV post-exposure prophylaxis (PEP), which is available from emergency departments and clinics. However, she did not want to reveal herself as a sex worker and did not receive PEP.
“She is an undocumented migrant,” stated Ms McGrew. “She went to get PEP and they wouldn’t give it to her because she was female and she was afraid to tell them she was a sex worker.”
This type of occurrence underlined the need for more training in healthcare, according to Mr O’Hare.
Such services must be delivered in a manner that is “very non-judgemental” and “based on harm reduction”, he added.
Ms Crowley of Ruhama also expressed serious concern about the curtailment in drop-in sexual health services, particularly for women not already linked to service-providers such as Safetynet.
When women are linked to Ruhama, it can try and arrange financial support so they can access a private clinic.
“But the problem is, it is really about accessibility. What if somebody wants a termination and they can’t get the test in the first place?
It is very difficult to say that because [social venues] are closed, people are not getting together or hooking up or not engaging in sex work through the pandemic – we don’t have that data, but what we do know is there’s no testing or very limited mounts of testing
Mr Stephen O’Hare
SPEAKERS
SPEAKERS
SATURDAY 24 OCTOBER 2020
SATURDAY 24th OCTOBER 2020
ONLINE EVENT
ONLINE EVENT ONLY
SATURDAY 24th OCTOBER: AGENDA
SATURDAY 24th OCTOBER:
Update on cardiac complications of COVID-19
Prof. Robert Byrne, Director of Cardiology and Chair of Cardiovascular Research, RCSI
Update on cardiac complications of COVID-19
Prof. Robert Byrne, Director of Cardiology and Chair of Cardiovascular Research, RCSI
Screening & risk assessment for sudden cardiac death
Dr. Joseph Galvin, Consultant Cardiologist
Screening & risk assessment for sudden cardiac death
Dr. Joseph Galvin, Consultant Cardiologist
Bypass surgery or stents - improving quality of life in patients with advanced coronary artery disease
Bypass surgery or stents - improving quality of life in patients with advanced coronary artery disease
Dr. Colm Hanratty, Consultant Cardiologist
Dr. Colm Hanratty, Consultant Cardiologist
High resolution cardiac MRI in clinical practice
High resolution cardiac MRI in clinical practice
Dr. Roger Byrne, Consultant Cardiologist
Dr. Roger Byrne, Consultant Cardiologist
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DAVID LYNCH
St James’s Hospital, Dublin is planning “to engage to re-establish” a GP liaison committee, which has not met since late 2019.
The issue was recently raised on Twitter by Dublin GP Dr Conor O’Kelly (@DrConorOKelly), who wrote on 14 September that it was a year since the “GP liaison committee collapse” and he supposed “not much has happened since that’s worth discussing”.
GP and Medical Council President Dr Rita Doyle was one of the respondents to the tweet, stating that it was “urgent and pressing that [the
committee] is resuscitated”.
A spokesperson for St James’s Hospital told the Medical Independent “the hospital values its partnerships with all community services and will continue to engage to re-establish this committee”.
Asked when the committee had last met, the hospital spokesperson said it was “late last year”, prior to the start of the current pandemic.
The spokesperson said the hospital has engaged with the chief officer of the area’s community healthcare organisation to work on the re-establishment of the liaison committee.
Regarding the importance of liai -
son work with local GPs during the pandemic, the spokesperson said: “We can confirm that GP representatives were invited to participate in and attended an oversight group to support the resumption of ambulatory services at St James’s Hospital after the initial Covid-19 outbreak”. Separately, a campaign highlighting the “advantages of a career in general practice” has been launched by the ICGP. The #BEaGP social media initiative will run over the coming weeks.
A new category of emergency medicine is now included under an expanded scheme for recognition of prior learning.
DAVID LYNCHA surveillance robot project recently deployed by the HSE for Covid-19 data processing may be used for other respiratory infections during the influenza season, this newspaper has been told.
“We are endeavouring to have the robot developed and deployed to process influenza lab notifications and create influenza events on CIDR (computerised infectious disease reporting system) this influenza season,” a HSE spokesperson told the Medical Independent
The spokesperson added that “other respiratory infections similar in clinical presentation to Covid-19 will be prioritised, such as respiratory syncytial virus (RSV), as an increase in positive laboratory results is expected due to increased testing of influenza-like illnesses, like Covid-19, influenza, RSV, etc”.
According to a report in the September issue of Epi-Insight, a project team led by the Executive and the Health Protection Surveillance Centre (HPSC) explored the possibility of a robotic solution to relieve some of the burden of Covid-19 data processing.
“Through site visits to HSE Departments of Public Health, stakeholder workshops, business process analysis, a set of processing rules were agreed nationally and reference files for hospitals and community care areas (CCAs) were delivered,” outlined the Epi-Insight report.
“The robot was programmed by Deloitte to apply these rules and navigate the CIDR system by replicating human behaviour.”
The live trial results of the robot project included “a successful degree of automation (ie, the robot could perform the processing just like a human), successful time-saving in processing time and the ability to operate outside of core hours to maximise its benefit”.
In terms of the project’s cost, the HSE’s spokesperson said: “This project has been delivered by the HSE-HPSC, working with the HSE-HBS process automation centre of excellence team and supported by Deloitte.
“Deloitte provided its services to this project on a pro bono basis. The solution is now in production and can be built upon to support other infectious diseases.”
The Mental Health Commission (MHC) expressed concerns about the lack of detail contained in the Government’s new mental health policy at its board meeting in June, the Medical Independent (MI) can report.
Sharing the Vision – a Mental Health Policy for Everyone was published in June as a successor document to the previous strategy, A Vision for Change
At a meeting on 18 June, the minutes of which were seen by MI, board members noted a number of concerns with the new policy. According to the minutes, these concerns were that “the document was very general and lacked specific detail, the absence of any detail of funding, the absence of any information on the staffing required and certain parts were out of date.”
However, members acknowledged “certain positives” in the new policy, including the section on attention deficit hyperactivity disorder.
A meeting has since taken place between MHC representatives and new Minister for Mental Health and Older
People Mary Butler.
At the June board meeting, there was also a discussion about telemedicine and its use during the Covid-19 pandemic.
While benefits were acknowledged, “it should not be seen as the answer to staffing or resource shortages, but as an addition to the existing services”.
The minutes noted instances “where service-users become distressed during a call or where the call is disrupted”.
Meanwhile, the MHC recently published a Covid-19 review paper on how mental health services responded to the pandemic from March to July. It stated that the national testing system was “inconsistent and untimely” and there was confusion in some services as to which health guidance they should be following.
NIAMH CAHILL niamh@mindo.ie
Some 16 HSE area medical officers (AMOs) are seeking pay and conditions on a par with that of their senior medical officer (SMO) colleagues. Niamh Cahill reports
The IMO was very disappointed with the outcome of the Workplace Relations Commission (WRC) in relation to this issue but remain committed to addressing this longstanding unfair treatment of our members.”
That is according to Mr Thomas Smyth, Manager, IMO Member Advisory Services.
Mr Smyth was referring to the decision by a WRC adjudication officer earlier this year against the IMO in a case where the union argued that a member, an area medical officer (AMO), was denied a promotion to senior medical officer (SMO) as a result of indirect age discrimination.
The IMO has referred the matter to the WRC for conciliation and the HSE has agreed to attend. This meeting will take place on 13 October.
“We hope to come to agreement on this matter, but failing this we would then look to refer the matter to the Labour Court for a recommendation,” explained Mr Smyth.
There are currently 16 AMOs, or community health doctors, in Ireland, some of whom work on a part-time basis.
AMOs are doctors who work in various HSE community health services nationally.
Since 2003, the number of AMOs has been dwindling and some community medical departments are already without any AMOs. History
When the health boards were established, departments of community medicine were established in each community health area. Outside of Dublin, this meant that most departments were created by county.
There would have been one senior manager AMO post and a number of AMO posts in each area.
But consequent to industrial action in 2003 there was a restructuring and some posts were transferred to separate departments of public health.
The changes resulted in the establishment of a principal medical officer in charge of a community medical department, with an increased number of senior posts than previously.
The basic grade AMO posts “were left behind” following the reorganisation, according to Dr Ann Hogan, Principal Medical Officer, HSE West.
Dr Hogan is a former IMO President and Chair of the IMO Public Health and Community Health Doctors Committee.
“The critical thing was the 2003 agreement contained the phrase, ‘there will be no further recruitment at AMO level’. That meant the senior medical officer post became the entry grade. Any new staff coming into the department after that had to be of senior medical officer grade,” explained Dr Hogan.
“In the Mid-West, for example, we went from three senior AMO posts to a principal medical officer and five senior medical officer posts. The remaining posts were then all at area medical officer grade, so it increased the height of the triangle if you like.”
This resulted in an inequality among AMO and SMO positions - a problem exacerbated by the 2008 economic crash.
Dr Hogan remarked: “At the time of the agreement in 2003 a number of AMOs got promoted to senior posts straightaway and then there was a feeling that as the holders of the senior posts retired or resigned or left, that each replacement post would have to be at senior grade, so there was a hope and expectation that over time all the AMOs would attain the senior grade.”
However, when the crash occurred in 2008 the HSE introduced a recruitment moratorium for several years. Therefore, when individuals vacated posts many were not replaced at all.
“We’ve only been recruiting again since 2014 and any competition that has been advertised since that time, there has been quite a lot of interest and of course, we have to have interviews, and they have to be fair,” said Dr Hogan.
“Some of the longstanding AMOs, because they entered the service as AMOs with the entry criteria that was there for AMOs at the time, didn’t have some of the qualifications that are now required for the senior post. Some of them were eligible to apply for senior posts but have been unsuccessful in being appointed so far, and others couldn’t apply because they didn’t have the qualifications.”
Dr Hogan explained that the problem is that AMOs are largely carrying out the same work as senior medical officers.
“Now AMOs are in the minority in every department and some departments have no AMOs left at all. The idea that all senior med-
ical officers have some management responsibility and two or three AMOs do not have management responsibility; it’s difficult to understand how that might be. But in practice, in my department I’m responsible for, all the doctors do the same work.”
Role
AMOs and senior medical officers provide immunisation and child health services in what is a wide and varied role, which includes clinical work.
According to the HSE, they may provide “a specialist child health clinic for development problems in children with physical, sensory and intellectual disability”.
Medical officers can also carry out the medical assessment of grants and allowances administered by the HSE, county councils and revenue commissioners and an allowances appeals process “for those deemed non-eligible”.
“They provide medical assessment for long-term illness cards, over-scale medical cards and hardship drugs. In some areas medical officers provide targeted community medical services for socially excluded groups such as refugee/asylum seekers, Travellers and the homeless.”
Speaking about the role of AMOs, Dr Hogan said: “Our doctors would have been instrumental in rolling out the HPV vaccine when it came in first and certainly we’re on the frontline of dealing with all the various issues and concerns that arose in relation
to the vaccine. They were strongly committed to the HPV vaccine and we seem to have turned a corner in relation to uptake of the vaccine. That’s a real success story.”
As illustrated, AMOs conducted clinical, face-to-face work. Public health nurses undertake the core schedule of visits for children up to the age of four, but they can refer children they have concerns about to community health doctors for assessment, added Dr Hogan.
Both AMOs and SMOs are on a salary scale with six points, followed by two long service increments at the end of their term.
According to Dr Hogan, most AMOs are on the maximum salary scale currently, as they have all been in the system since before 2003.
The salary scale for AMOs, based on October 2020 figures, begins at €70,000 to a maximum of €82,728.
For SMOs, the salary scale begins at €83,796, increasing to a maximum annual salary of €97,370.
AMOs are seeking the same salary scale that SMOs currently enjoy, along with improved terms and conditions, said Dr Hogan.
She remarked: “You would expect there should be equal pay for equal work.”
“It is very disheartening for staff who have been in the job for a long time and who are doing excellent work to see much younger people come in and to know that they are immediately going on a salary scale that’s higher than theirs to do what is, essentially the same or a very similar job,” she pointed out.
“As new staff are appointed you expect existing staff to train them in. You have a situation where you have a doctor who is on a lower pay scale with officially lower status training in the new person who comes in.”
The issue has been raised through internal HSE channels in the past.
This route has thus far failed to result in any positive outcome for AMOs and the IMO is now actively progressing the matter through the WRC, and failing that, the Labour Court.
The planned meeting on 13 October is considered a crucial one in the eyes of AMOs, who will continue to seek improved terms despite the outcome.
Furthermore, the emergence of Covid-19 has added impetus to their pursuit for equality.
As Mr Smyth pointed out, the role of AMOs is a significant one from a public health perspective.
“The IMO is seeking the upgrading of the entire group. This is a very significant issue for AMOs and they are working side by side with SMO colleagues, undertaking the same role and being paid on a lower scale. This has been particularly emphasised during Covid-19, when many AMOs and SMOs were redeployed and worked side-by-side assisting their public health colleagues,” said Mr Smyth.
“They played a key role in assisting with this and may do so again in future. In addition they have been heavily involved in relation to undertaking catch-up clinics during the summer and will be engaged in the continued rollout of the HPV vaccine when that resumes.”
As new staff are appointed you expect existing staff to train them in. You have a situation where you have a doctor who is on a lower pay scale with officially lower status training in the new person who comes in
Hospitals and their patients rely on hospital laboratory staff to provide clinical results round the clock. Lives depend on it.
The existence of a significant recruitment and retention issue within the profession, therefore, puts the entire operation of hospitals at risk.
Roles for medical scientists are advertised, but no applicants apply in some cases.
“There’s a statistic that’s often bandied about, that 70 per cent of clinical decisions in a hospital setting rely on laboratory results,” Mr Kevin O’Boyle, Senior Medical Scientist at Our Lady of Lourdes Hospital, Drogheda, told the Medical Independent (MI)
Hospital labs play a crucial role in diagnosis, patient management and monitoring therapy.
Mr O’Boyle qualified in 2000 and since this time the profession and attitudes among graduates towards the profession have altered dramatically. Laboratory science has become increasingly complex and many new areas of expertise have developed over time.
There are between 90 and 100 medical scientist graduates annually, but they are not coming into the profession, according to Mr O’Boyle. They are well trained, with a good mixture of scientific and clinical skills – a skillset that makes them attractive to the pharmaceutical industry, among others.
Of the nearly 100 graduates per year, nearly half do not enter the profession. They will return to further study, postgraduate medicine, research and academia, or they will find work in the pharmaceutical sector. Some will emigrate.
“In my day you wanted a job when you came out of college, now they [graduates] very much want a career and are very much looking at the career trajectory ahead of them. Medical science is not really offering that,” he told MI
In hospitals, the medical scientist grade moves upward from basic grade to senior, chief and then laboratory manager.
“This shunts them into a management, human resources role that is not what we’re trained for and came into this profession for.
“When you see 10 per cent of the graduates going back to do postgraduate medicine you realise that the reason why they’re not coming into the profession is they are not seeing a career progression.”
Medical scientists in hospitals work an emergency on-call service outside of the hours of 8-8pm Monday to Friday.
Mr O’Boyle and his colleagues at Our Lady of Lourdes Hospital work an on-call shift at least once a week, which he said, “has run us into the ground”.
“We need more people on the roster, but we just can’t get them. We’ve advertised for staff numerous times and had no applicants. It’s really bad.
“We have a terrible recruitment challenge at the moment for medical scientists.
“I am looking at members of staff in their 60s still working all night. They are on
mandatory rosters, so they’ve no choice, it’s part of their job. They have to come in here at all hours and run big batches of Covid tests while they’re supposed to be providing only emergency duty for what’s needed for the night.”
The pay for on-call work is not very attractive, as it was negotiated when hospitals were less busy, according to Mr O’Boyle, and does not reflect the current 24/7 environment.
“You are working all the time and the pay rates don’t reflect that on-call service.”
Structure and education
There are around 2,600 medical scientists employed in hospital laboratories in Ireland in public, public voluntary and private hospitals.
The title “medical scientist” was introduced in 2001 to replace “medical laboratory technician” in recognition of the increased role of the laboratory in healthcare delivery.
The change of title was recommended in the Report of the Expert Group on Medical Laboratory Technician/Technologist Grades
The report remains the basis for the laboratory workforce structure to this day, but many of its recommendations remain unimplemented, such as the introduction of
a unified career structure, said Mr O’Boyle.
In November 2016, then Minister for Health Simon Harris confirmed the establishment of the Medical Scientists Registration Board at CORU to regulate the profession.
Compulsory registration will be mandatory for all Medical Scientists by March 2021. CORU regulations include a requirement to participate in continuous professional development (CPD), which will be audited by the registration board. Education is a lifelong process for medical scientists.
Inequality
A small number, between 60 and 80, of clinical biochemists are employed in the biochemistry department of hospital laboratories.
They have equivalent qualifications to medical scientists, and they work side by side with them, completing the same tasks on the same rosters, said Mr O’Boyle.
Yet biochemists have the opportunity to progress to the post of consultant biochemist, once the FRCPath has been completed.
Biochemists are encouraged to pursue this career trajectory, which is unavailable to their medical scientist colleagues.
The two-tier system causes ill-will within the departments where biochemists are employed, but also in haematology, microbiology, transfusion science and histology laboratories where the service is crying out for advanced practitioners, but there is no career pathway in place, Mr O’Boyle explained.
There is a shortage of laboratory consultants and he believes medical scientists are ideally placed to fill this role.
The Academy of Clinical Science and Laboratory Medicine (ACSLM) is currently in talks with the RCPI Faculty of Pathology to establish a formalised training scheme for medical scientists leading to a clinical leadership role as a consultant medical scientist.
The ACSLM and the Medical Laboratory Scientists Association (MLSA) have had discussions with the Department of Health on the issue.
Talks
The Medical Laboratory Scientists Association (MLSA) is the sole trade union representing medical scientists in Ireland who provide laboratory services to the HSE, public voluntary hospitals, private hospitals and laboratories, the Irish Blood Transfusion Service (IBTS) and universities in Ireland.
The Association is an affiliate of SIPTU and a member of the Irish Congress of Trade Unions (ICTU).
As chairperson, Mr O’Boyle is engaged in talks with the Department of Health, HSE and the Department of Public Expenditure and Reform (DPER) on how to tackle the recruitment and retention challenges facing the profession by amending the career structure and addressing uncompetitive pay scales.
According to Mr O’Boyle, health officials are very open to engagement on the issue
and want to see positive developments.
“They [Department of Health] are very much on our side,” said Mr O’Boyle.
At a meeting of laboratory managers in January 2019, it was reported that there were 131 vacancies in hospital laboratories nationally.
This represents about 5 per cent of the total workforce. The figure does not include posts that are awaiting approval or those that are part of business cases based on new services.
“Laboratories are crying out for staff. Some have had to outsource work to a private laboratory,” said Mr O’Boyle.
Despite the support for change, the reality is the healthcare budget, particularly at present, is under intense strain due to the pandemic, he admitted.
Another meeting was scheduled to take place with health officials at the end of September, but whether this will yield improvements for the profession, remains to be seen.
The pandemic has placed huge pressure on hospital laboratory departments, according to Mr O’Boyle.
Resources were stretched to the limit before the arrival of Covid-19, but the crisis has been further strained by the demand for testing that has occurred.
Hospital laboratories perform all hospital Covid-19 tests, including tests for staff and patients, pre-operative admissions, emergency admissions and symptomatic cases.
“Because of this, what we’re finding now is that the medical scientist on call in the microbiology department is putting through large batches of Covid tests at 3 o’clock in the morning when they’re on emergency duty, so it’s really put pressure on the service, particularly at night,” he revealed.
Staff in microbiology laboratories, where Covid-19 testing is performed, have had to take on extra shifts, in addition to their emergency on-call rosters, to keep the service going.
“As we move into winter and months of overcrowding in our hospitals, there are no medical scientists to recruit and laboratories are in crisis,” warned Mr O’Boyle.
The threat of a Covid-19 outbreak in a hospital laboratory looms large and is an ever-present risk for staff.
“I’d be very worried about keeping the hospital labs going through the winter. When people start going off to self-isolate because of staff outbreaks it could take a lab down in a hospital very easily,” said Mr O’Boyle.
“We wear masks all the time in work and social distance as much as we can, but space is always at a premium in any hospital and labs tend to be shoved into whatever space is available so social distancing is not really possible in any hospital lab in the country.
“We do the best we can. Nationally we’ve been lucky, we haven’t had an outbreak in a lab, but that is a very big danger for us.”
As we move into winter and months of overcrowding in our hospitals, there are no medical scientists to recruit and laboratories are in crisisMr Kevin O’Boyle
Prof. Derek O’Keeffe
Consultant Endocrinologist, Galway University Hospital
New Advances in Digital Medicine
Dr. Aidan Flynn
Consultant Cardiologist, Portiuncula Hospital
The Many Faces of Angina
Dr. Aidan O’Brien
Respiratory Consultant, University Hospital Limerick
An Update on COPD and the COVID-19 Pandemic
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Date of Item: September 2020. IR-MEN-79-2020
We need an imaginative, focused and detailed plan over the next two to three years to expand and staff the hospital capacity that Government reports have shown is required to provide high quality and timely healthcare. Additional capacity is needed to run our hospitals at 80 to 85 per cent capacity, without trolleys and to provide elective care in timely fashion. We also must decide if we are going to be bold, to build and expand our way out of the current economic and healthcare problem or if we should take the austerity approaches of the 1980s and 2010s, which were disastrous in removing capacity, the consequences of which continue to be felt today. It is imperative that the discrimination against new-entrant consultants is ended. We must treat our new consultants with equity; it is the only way we will fill the 500 vacant permanent posts in the service.
Covid-19 has changed everything in medicine for now and for the foreseeable future. There is no clear exit strategy from Covid. The key immediate challenges relate to the additional stress Covid-19 has placed on the already under-resourced system. We have the longest waiting lists in Europe and the lowest number of consultants per head of the population in the EU. Government reports have shown we need an additional 2,600 acute beds and a doubling of our ICU beds (the Prospectus ICU report has been on the shelf for 11 years). We must fill the 500 permanent consultant posts that are vacant and in addition create additional posts in virtually all specialities.
Covid-19
The Covid-19 pandemic has underlined how
dependent our society and economy are on frontline healthcare professionals. The HSE’s Winter Plan is a welcome recognition that the system is playing catch-up, but the plan will not succeed unless and until we invest in the people patients depend upon. The plan is a promise to invest in services but not in the professionals required to deliver them. The big promises in the plan can only be realised if we have additional consultants and healthcare professionals. The plan includes few specifics. Building capacity requires both investing in space and in more hospital consultants. Two-thirds of the €600 million will not be deployed until 2021. These factors immediately cause concern about the ability of this plan to adequately address the challenge of a ‘winter like no other’.
The patient waiting list currently stands at over 840,000 people. On the surface, the headline promise of 1,500 additional beds is striking and would go a long way to addressing current concerns, but looking deeper, it appears that over 800 of these beds are already in the system. Now more than ever, we need to level with people. We must be honest as to how achievable it is to keep the promises made in the plan given that 500 consultant posts remain unfilled.
Winter Plan
The Winter Plan 2020/21 has merits; the fact that it is published in September, rather than in the grip of winter is very welcome. The core interaction in healthcare, what makes it work and what makes it rewarding for patients and professionals is people with skills looking after people who need these skills in well supported and adequately resourced en-
FIRST SESSION: STATUTORY REPORTS & MOTIONS
9:00 am Chair: Prof Alan Irvine, President
9.05 am Statutory Reports
• Mr Martin Varley, Secretary General
• Dr Conor O’Riordan, Membership Secretary
• Prof Clare Fallon, Treasurer
9:30 am Motions
9.50 am Break
SECOND SESSION
vironments. This plan as currently set out fails to show a clear path to enabling these necessary changes.
We needed a level of honesty and transparency about what we can and cannot provide in our health service and following from that explain clearly how the system rations what is being provided.
In more sophisticated countries, care is rationed by consciously not providing treatment for certain low-grade interventions, in an open and transparent way. In Ireland, we ration by waiting lists and by restricting access to new treatments. It is a more dishonest way of rationing. A waiting list for four years is not providing any service at all. We need more reflection and honesty. We have some of the leading pharmaceutical manufacturers in Europe in Ireland, yet our people are routinely at the back of the European queue in getting access to many new drugs, because the drug budget is relatively easy to curtail. This is not good care, consistent with an advanced health system. New medicines that meet safety, efficacy and health economic target assessments should be made available to patients in a timely fashion.
We need more local ownership of the means to solve local problems. For too long there has been a drift towards centralisation of management. That is no reflection on the current HSE management, it’s a common pattern seen in many large bureaucratic or-
ganisations. We need more non-centralised, devolved, local functions. Centralised protocols for many competencies such as setting standards, key performance indicators, and centralised purchasing among others make sense, but local administrative units need to be more autonomous and be in a position to innovate local solutions to local problems. For example, local HSE managers should be in a position to explore where appropriate local private provision, and how that might work for the specific needs of their public patients. There needs to be more local autonomy on recruitment; local clinicians and managers know what is required for local service needs. This is bottom up, devolved problem-solving. Sláintecare was announced in May 2017, but realistically it has not been funded to any significant degree and hasn’t expanded any capacity so far. The worry is that will become a slogan, under which all new health innovation is branded, rather than a truly cohesive, transformative multi-year, costed initiative that delivers meaningful change for patients.
I would like to thank my predecessor, Dr Donal O’Hanlon, who led the Association in developing and rolling out our ongoing #CareCantWait campaign aimed at raising awareness of solutions to resolve the consultant recruitment and retention crisis in Ireland and other hospital deficits. The IHCA will continue this campaign, holding Government to account for the fact that there are now almost one million people waiting for some form of hospital care in Ireland.
I look forward to engaging and working with all health stakeholders including Minister for Health Stephen Donnelly and the Chief Executive of the HSE, Mr Paul Reid.
10:00am Resourcing and Provision of Acute Hospital and Mental Healthcare in a Challenging Environment
• Prof Alan Irvine, President, Consultant Dermatologist, Children’s Health Ireland, Crumlin
• Mr Stephen Donnelly, Minister for Health
• Mr David Cullinane, Health Spokesperson, Sinn Féin
• Mr Alan Kelly, Health Spokesperson and Labour Leader (TBC)
• Panel Discussion and Q&A Session: Moderator – TBC
11:15am Break
THIRD
•
When a DPP-4 inhibitor is needed
References:
1. TRAJENTA® (linagliptin) Summary of Product Characteristics. Available at: https://www.medicines.ie/medicines/trajenta-5-mg- lm-coated-tablets-34014/
2. McGill JB, et al. Diabetes Care. 2013;36:237–44
3. Rosenstock J, et al. JAMA. 2019;321:69–79
4. Rosenstock J, et al. Cardiovasc Diabetol. 2018;17:39
5. ICGP Guidelines: A Practical Guide to Type 2 Diabetes December 2019. Available at: https://www.icgp.ie/go/library/catalogue/item
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 efficacy of linagliptin in children and adolescents has not yet been established. No data are available. Take the tablets 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. 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 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 confirmed, Trajenta should not be restarted. Caution should be exercised in patients with a history of pancreatitis. 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. The risk for clinically meaningful interactions by other medicinal products on linagliptin is low and 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 information on clinical data). Fertility, pregnancy and lactation: 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 benefit of breast-feeding for the child and the benefit 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 defined 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 December 2019.
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
32nd IHCA AGM, Saturday 10 October 2020, Virtual Annual General Meeting and Conference
Secretary General of the IHCA Mr Martin Varley writes that the potential is there to agree practical plans and workable solutions to address the capacity deficits and reduce the impact of further waves of Covid-19
Even before Covid-19 hit our health services in March, our public hospital system and the patients who rely on them for a service were in an extremely exposed position because successive governments didn’t address gaping capacity deficits over the past decade. The glaring deficits in hospital beds and consultants have left the country in an extremely perilous situation facing into potential future Covid-19 waves, on top of the enormous increases in hospital waiting lists and the escalating demand for hospital care. The Government needs to provide increased beds and other facilities in public hospitals and end, as a matter of urgency, the salary discrimination against consultants appointed since 2012, so that hospitals can fill hundreds of vacant permanent consultant posts.
There is an insufficient number of hospital consultants, which is leading to record and unacceptable waiting lists. The number and the length of lists have disimproved, while around 500 permanent consultant posts have failed to be filled over the past number of years, because of a flawed Government decision.
The number of people on public hospital outpatient waiting lists exceeded 610,000 in August, which is a two-thirds increase on the 364,000 waiting six years ago. The number waiting over 12 months now exceeds 243,000, compared to 41,000 six years ago.
There were over 77,000 patients on inpatient and day case waiting lists in August, which is nearly double that of 2012, while over 17,000 are waiting for longer than a year, compared with 386 in 2012.
Ireland has the lowest number of hospital consultants per 100,000 of population in the EU. We still don’t have the 3,600 consultants recommended in the Hanly Report by 2013. When adjusted for population increases in the interim, the revised equivalent would be closer to 4,500. The National Doctors Training and Planning unit’s recently published report, confirms that there will be a requirement for 50 per cent or more increase in consultant numbers in most hospital specialties by 2028.
The decision to impose discriminatory salaries on consultant appointees since 2012 has proven to be a false economy. Patients are deteriorating clinically on unacceptable waiting lists, resulting in longer and more expensive hospital lengths of stay and poorer outcomes. In addition, medical agency staff costs have more than doubled since 2012, increasing by €50 million per annum and the cost of clinical indemnity has more than quadrupled, increasing to approximately €180 million per annum. The increased costs are multiples of the expected saving arising from the imposed consultant salary cut. In view of the damaging impact of the persistent consultant recruitment and retention crisis, it is past time for the Government to restore pay parity for consultants appointed since 2012, so that they are paid the salary applicable to their colleagues.
The 2008 consultants’ contract contains
the very significant core principle that:
“Both the consultant and employer recognise that the relationship must be founded upon mutual trust and respect for each other.’’ Also, the contract, which was negotiated between IHCA representatives and the HSE, Department of Health, and the Department of Finance, provides that its terms and conditions will be reviewed by the same parties. It is unacceptable that the Minister for Health in 2012 unilaterally breached the contract principles and provisions that had been agreed to by his predecessor in 2008. The breach, which imposed a 30 per cent salary cut on consultants taking up the contract since October 2012, has been extremely damaging for many reasons including the high levels of international competitiveness and mobility of hospital consultants. It is expected that the current Government will rectify these errors based on the commitments and statements by the Taoiseach on the Dáil record, the Minister for Public Expenditure and Reform and the Minister for Health while
pital bed capacity needed to be increased by 2,600 within 10 years.
In addition, it recommended the need for an additional 4,500 community and step-down beds. The review also outlined if community services were not expanded the required increase in public hospital beds could be of the order of 7,500.
same time as the winter surge.
The ongoing capacity deficits are causing horrendous delays and problems for our public hospital patients and if the deficits are not urgently resolved they will create even more shocking delays for patients over the winter and spring.
Solutions
There is huge potential to agree practical plans and workable solutions that will address the capacity deficits and in turn resolve the waiting lists and reduce the impact of further Covid waves. The first and obvious step for Government is to end the salary inequity imposed on consultants taking up contracts since 2012, so that hospitals can fill the 500 vacant permanent posts. This would have a massive impact in reducing waiting lists for outpatient, inpatient and day case appointments. The consequences of not addressing the consultant recruitment and retention crisis is for the Government to perpetuate and exacerbate the deterioration in public hospital capacity to provide care to patients.
The country’s population has grown to almost five million based on CSO data, an increase of 492,300 compared with 2008. The number of people over the age of 70 has increased more significantly. There is now an urgent need to accelerate the expansion of our acute hospital capacity. The winter ahead will be more challenging than any other because of the risk of further Covid waves, backlogs, and record waiting lists.
in opposition during 2018 and 2019. It is also encouraging to note the strong position taken by the Taoiseach, Micheál Martin, when he publicly outlined his annoyance and anger at the fact that the UK was contemplating breaching an agreement it had entered into with the EU and its Members States. The Taoiseach’s respect for agreements and the need to maintain trust is well based as it is the foundation on which agreements are entered into and on which progress is advanced in any walk of life. These principles need to guide the current Government in immediately ending the inequity by honouring their own commitments and the terms of the 2008 consultants’ contract in full for all consultants including those who have taken up the contract since 2012.
It is also critically important that the Department of Health and Government Ministers frontloaded the expansion of public hospital capacity, in terms of acute hospital beds, ICU beds and other facilities. This requirement preceded Covid-19, as has been confirmed in the 2018 Health Capacity Review, which recommended, at a minimum, that public hos -
However, the pace of expansion has fallen behind and not enough has been achieved in the interim in expanding capacities in public hospitals and at community level.
The HSE commissioned 2009 Prospectus ICU Report recommended that the 289 ICU bed capacity needed to be expanded to 418 beds within a year and doubled to 579 ICU beds by 2020. This contrasts starkly with the current capacity of about 280 ICU beds. Failure to implement the Prospectus recommendations and advance the Capacity Review recommendations more rapidly left our public hospitals extremely exposed to the Covid-19 pandemic.
Despite the odds, consultants and their teams in hospitals managed to limit the extent of the damage of Covid-19 to less than had been feared at the outset. However, public hospitals are now entering the autumn, winter and spring still with overwhelming capacity deficits which create major risks in providing day-to-day urgent public hospital care in addition to the high probability of further waves of Covid-19 infected patients who will require hospital and ICU care at the
While the early publication of the HSE’s Winter Plan 2020/21 is welcome, it is disappointing that the increase in beds provided for is less than will be needed and it has failed to make provisions to resolve the consultant recruitment and retention crisis. These are the essential fundamentals to provide quality hospital care on time and end the provision of care to admitted patients on trolleys and growth in unacceptable waiting lists.
The Government must also address the situation in relation to clinical indemnity and the law of tort concerning such cases. The failure to put in place a system for pre-action protocols to reduce delays and costs in settling cases is disappointing, especially as State Claims Agency clinical indemnity costs have increased steeply, at significant cost to the health budget. Indemnity for practising consultants has more than doubled, quadrupling for some specialties, since to 2012. These cost increases make Ireland much more costly to practise medicine and provide care to patients than most other countries.
The new Government and Minister for Health take over responsibility for the economy and the health services in very challenging times. Through engagement there are opportunities to rectify the mistakes of the past decade. The Association will be engaging regularly with them to assist with the process to address the capacity deficits in our hospitals.
‘The Government needs to end, as a matter of urgency, the salary discrimination against consultants appointed since 2012’
There were over 77,000 patients on inpatient and day case waiting lists in August, which is nearly double that of 2012, while over 17,000 are waiting for longer than a year, compared with 386 in 2012Mr Martin Varley
CPD points applied for and pending
Date & Time Topic Speaker
Thursday 30th July 2020 13.00-14.00
Improving Communication in Virtual Consultations
Thursday 13th August 2020 13.00-14.00
Thursday 15th October 2020 13.00-14.00
Mr Eoghan McDermott, Director, The Communications Clinic
Suicide Risk Assessment Prof Jim Lucey, Consultant Psychiatrist, St Patrick’s University Hospital, Dublin
Management of Depression in Pregnancy Dr Mas Mahady Mohamad, Consultant Perinatal Psychiatrist, University Maternity Hospital, Limerick
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“The only reason doctors return to Ireland to work is for family reasons. It’s not because of working conditions or job satisfaction - both are better in first-world systems in US, Canada, Australia, New Zealand and UK. New entrant pay discrimination is also a factor. Sort it out @DonnellyStephen.” Deirdre, @morande7, 24 September
“Niall says ‘I trained in public health medicine in Australia, where being a consultant at the end of training was the norm, so it was very hard to go back to a system that told me I’m worth less than other doctors’ @roinnslainte @ DonnellyStephen.” Dr Ina Kelly, @DrInaKelly1, 23 September
“This is why Ireland risks losing its skilled public health leaders. It’s in your hands to be able to retain Public Health consultants whose training was found to be among the best in the world.” Regina Kiernan, @KiernanRegina, 23 September
“This post makes me so sad. We need Niall here but Government policy has driven him away. In a pandemic.” Dr Gabrielle Colleran, @ProfSuperJunior, 23 September
“Answered a few questions for @med_indonews on being an Irish Doc abroad in these pandemic times. Funny how being just across the Irish Sea suddenly isn’t too different to being all the way over in Australia like my esteemed colleagues @fiachrama & @NICU_doc_salone.” Dr Mary Ni Lochlainn, @maryniloc, 23 September
“Covid was not mentioned in the visa application last year. @med_indonews asked a few questions that made me think about what I’m doing and where I am.”
Dr Fiachra Maguire, @fiachrama, 23 September
“Had a good chat with @humphries_niamh about my choice to emigrate and ongoing difficulties getting to Oz this year. Three flights cancelled so far, hoping to get over in November (Crossed fingers). Really good research, glad to be a part of it.”
Denise, @deni_mono, 23 September
REACTION TO OUR NEWS STORY, ‘IRISH-BASED PUBLIC HEALTH SPECIALISTS BEING “HEAD-HUNTED” AS PATH TO CONSULTANT STATUS BLOCKED,’ 24 SEPTEMBER.
“@DonnellyStephen, @MichealMartinTD. What state will we be in if this happens?”
Louise, @Louise11121850, 23 September
“’The only thing keeping them here is because this is about their family and country, but at a certain point you have to stop the martyrdom’. Too right @DrInaKelly1. Time to stop eating worms and doing the martyr on things. Time to stand up for ourselves and our population @IMO_IRL.” Sinead Donohue, @sinead_donohue, 23 September
“This should be a red-flag emergency for urgent govt action.”
Karlin in a galaxy far far away Lillington, @klillington, 22 September
“The saddest thing I’ve read in ages about how badly @mmcgrathtd @IRLDeptPER, @DonnellyStephen treat Ireland’s public health doctors. Even in the context of government’s awful Covid response, this has showcased them at their worst.” Dr Niall Conroy, @NICU_doc_salone, 22 September
“And when they are gone they are gone.” Dr Richard Joyce, @Dickdoc123, 22 September
When the HSE’s Winter Plan 2019/20 was published, our editorial at the time asked if the name was appropriate anymore. Was it, in management speak, ‘fit for purpose’? Although these plans acknowledge the additional pressure on health services during the winter months, most of the initiatives they contain could apply any time throughout the year due to the chronic problems of emergency department overcrowding and long inpatient and outpatient waiting lists.
This year’s Winter Plan is essentially a Covid-19 plan, at least in terms of how the pandemic impacts upon health services.
The HSE has strong influence over pandemic policy, being represented on the national public health emergency team (NPHET) and holding important responsibilities in terms of Covid-19 testing and contact tracing. However, it is outside the Executive’s remit to decide whether to impose ‘lockdowns’ or social restrictions to limit the spread of Covid-19. It must have faith in (the increasingly uncertain) Government strategy that the numbers contracting the novel coronavirus can be reduced as much as possible, so as not to overburden our very fragile health service.
The Winter Plan is dependent on the Government in that Exchequer funding is required to finance the measures it contains. The HSE has received an allocation of an additional €600 million to support the plan. For context, last year’s plan received an additional €26 million. This huge increase is an acknowledgement of the scale of Covid-19, which, as we hear so often, is a once-in-a-lifetime event. Last year’s plan was announced in November, in the depths of winter; the 2020/21 iteration has been published earlier, again as a response to the current crisis.
631 rehabilitation beds are promised. The document states that 409 of the acute beds and 395 of the sub-acute beds are already in place, leading bodies such as the IHCA to question the real capacity gain over the coming months.
The IMO points out that the ‘new’ beds announced are temporary beds in the system. In a statement responding to the publication of the plan, the Organisation stated there is no funding for additional sustained long-term beds in acute and other sectors. While additional beds are welcome, the IMO said they are simply insufficient given the long-term capacity deficit; the emerging needs of the population; and the expected Covid-19 surge.
“The proposed increase in intensive care beds is woefully inadequate given the circumstances we face,” according to the IMO.
The Winter Plan promises a “recruitment campaign, both domestic and international, of a scale that has not been done before”. However, both the IMO and the IHCA criticise the lack of detail regarding the appointment of new consultants and frontline healthcare workers.
The ongoing provision of Covid-19 community assessment hubs and the extension of these to incorporate the treatment of acute respiratory illness through acute respiratory assessment and treatment hubs is also referred to in the Winter Plan.
There are currently seven community assessment hubs in operation. The plan is to have 20 hubs in total available from January to March of next year.
“Recruitment and retention of Public Health Doctors in Ireland is in crisis – only 60 specialists nationally to protect 5 million people + not given adequate resources to do so during a pandemic - this puts lives at risk.”
Will the increase in funding, as significant as it is, be enough? Under the plan, 892 acute beds; 484 sub-acute beds; and
It is too soon to tell whether the plan is sufficient to cope with the current crisis. At the time of writing, Covid-19 cases are on the rise. The capacity deficits in the Irish acute system make it very vulnerable to a second surge. The HSE must do all in its power to cope with what has been termed ‘a winter like no other’, but will also have to hope that Government policies to curb the spread of Covid-19 are a success.
Dr Cliodhna Ni Bhuachalla, @DrCliodhna, 22 September
“It’s critical that the government does not fool itself into believing that public health doctors’ goodwill is limitless. Their skills are at a global premium.”
Tony O’Brien, @tweetsnolimits, 23 September
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Dr Steve Thomas (PhD) argues why it is important to make health systems resilient in the face of shocks, such as Covid-19
Catastrophic events occurring over the last decade or so have highlighted the need to understand how to govern health systems in the face of shocks. In high-income countries this was triggered by the economic crisis from 2008 and in low and middle income countries by the sudden outbreaks of infectious diseases, such as Ebola, as well as civil conflicts, with catastrophic consequences. Most recently, the emergence and rapid spread of Covid-19 has severely tested almost all health systems around the world.
While the first wave is over for Ireland, the duration of impact of Covid-19 is likely to be long-term. We may be teetering on a second wave and the economy will not recover for some years. In addition, there is the threat of Brexit to provide a more localised shock with implications for our health system and economy. Along with increasing, extreme, climate events, it seems that we may have to get used to shocks to the health system. The concept of health system resilience is important to understand to help us steer our way through the current and future shocks. There is much to learn from international experience of building health system resilience. In this article we will look at what is health system resilience to shocks, what strategies can build resilience and where do we go from here with Ireland.
Fundamental to the idea of health system resilience is the notion of bouncing back from a shock or perhaps even ideally moving through it to strengthen health system performance. Yet resilience is more than just reacting to an event. Health system resilience can be best understood as the ability to prepare for, manage and learn from shocks. Resilient health systems are those that are able to manage well each stage of the shock cycle (see Figure 1). They must be: Well prepared for different shocks; able to quickly identify when a shock starts and how it is affecting the system; able to absorb the shock and, where necessary,
adapt and transform the system to ensure that health system goals are still achieved; and, finally, once the shock has passed they are able to identify the legacy of the shock in relation to health system performance and remedy any negative consequences.
While preparedness is helpful and can mean that systems are quick to respond it does not guarantee a good outcome. Some of the allegedly best-prepared health systems for the Covid-19 pandemic, such as the USA and UK (https://www.ghsindex. org/), were found wanting. At the same time countries that were less well prepared, such as New Zealand and Cost Rica, were able to respond to the problem well with speedy and effective governance, limiting the impact of the shock.
As noted, in today’s global context extreme shocks are becoming more common (extreme weather events, epidemics, mass migration, economic crises). The nature of the required strategic response will be determined by the type and severity of the shock. Intuitively, the more severe the crisis the more resilience is required to deal with it.
Shocks can also be differentiated into those that primarily affect the demand side of the health system (eg, increased need for healthcare following health epidemics) and those that primarily or initially affect the supply side (eg, economic crisis and reduced resources). It is useful to understand the different pathways of each shock. For example, in the case of an epidemic, there will be an increase in demand for care. Nevertheless, the epidemic will also impair the supply side response. There will be a reduction in the ability to cope with all needs as health professionals are themselves impacted by the epidemic; and the need for focussing on the response to the epidemic may crowd out existing healthcare problems, which may create or exacerbate unmet need. In Ireland’s case this translates into even longer waiting lists. Similarly, economic crises also have both demand and supply side impacts. On the demand side, households may experience re-
duced income and less ability to pay for healthcare, where they do not have free care, thus reducing their access to needed services. Moreover, adverse economic conditions such as a reduction in income, indebtedness or unemployment in themselves result in poorer population health. At the same time governments may find themselves with fewer resources and less able to supply healthcare when required, even offloading some costs on to households to manage their own budgets or reducing the state-funded basket of care. Ireland had some notable cost-shifting to the old and sick in the austerity era following 2008. Furthermore, austerity may produce demotivation of staff and even emigration further reducing the supply side capacity to meet needs).
Perhaps the biggest challenges is where one shock bleeds into another. With Covid-19 we have the reality of a series of shocks both epidemic and economic. Even as shocks go Covid-19 is extreme, a once in a lifetime occurrence.
Learning and lessons
So what can be done to build health system resilience in such difficult times? A team of researchers from Trinity College Dublin and the World Health Organisation explored this question, publishing its results in June 2020 (https:// www.euro.who.int/en/about-us/ partners/observatory/publications/policy-briefs-and-summaries/ strengthening-health-systems-resilience-key-concepts-and-strategies-2020)
We conducted a rapid review of the literature examining the strategies and metrics used to build or evaluate resilience across all countries and all shocks in the last 10 years. The review utilised 16 peer review articles and nine reports in the grey literature. Thirteen strategies were identified to be deployed at different stages of the shock cycle. These strategies can be categorised according to governance, financing, resource deployment and service delivery, and are highlighted below.
• Governance: (1) Effective and participatory leadership with strong vision and communication; (2) Coordination of activities across government and key stakeholders; (3) Organisational learning culture that is responsive to crises; (4) Effective information systems and flows; and (5) Surveillance enabling timely detection of shocks and their impact.
• Financing: (6) Ensuring sufficient monetary resources in the system and flexibility to reallocate and inject extra funds; (7) Ensuring stability of health system funding through countercyclical health financing mechanisms and reserves;
(8) Purchasing flexibility and
reallocation of funding to meet changing needs; and (9) Comprehensive health coverage.
• Resources: (10) Appropriate level and distribution of human and physical resources; (11) Ability to increase capacity to cope with a sudden surge in demand; and (12) Motivated and well-supported workforce.
• Service delivery: (13) Alternative and flexible approaches to deliver care.
Next steps for Ireland
Space precludes me from examining and applying all of these strategies in detail, but I will highlight and expand on a few key approaches that I think will be essential to Ireland over the coming period in managing Covid-19, recession and Brexit-related impacts on the health system.
In many ways health system resilience depends on the actions of staff under duress. Well-motivated and supported staff, in terms of effective human resource management and conditions, are more likely to temporarily take on extra burdens to see the system through a transition. Nevertheless, an extended shock tends to undermine motivation without very careful management and support. While health sector staff have responded valiantly to the current challenges, the potential onset of a second wave means that should not be taken for granted. Health workers cannot be expected to put themselves continually on the line without support. Boosting motivation and engagement is complex and multi-faceted, with a whole range of factors that can help, including but certainly not limited to salary increases. Key factors are the safety and security of staff, alongside better equipment, guaranteed supplies, receptive management, feasible workloads, better training opportunities, appreciation and, of course, remuneration. No one strategy is sufficient, but a combination is helpful. Well-motivated staff who are supported are the key to a resilient response.
The additional health burden of Covid-19 and the fear of contracting it have added to the already-present barriers to getting timely care when needed in the Irish health system. There are two key elements to solving this.
Firstly, where possible I would recommend dropping financial barriers and access costs. Many household incomes will suffer over the next year or two, but their health needs will not go away and many with chronic conditions may not be accessing appropriate care. In Lithuania, during their severe economic crisis, fees for accessing care
were lowered for the duration of austerity to ensure people get care when needed. Similar strategies may be required for those with chronic conditions or those with a potential cancer diagnosis. One of our own key successes over the austerity era was that the medical card scheme proved durable. Still, many elements of care have a financial barrier for many people and this may not prove helpful where demand for that care has been additionally suppressed by fear of Covid-19 contraction.
Secondly, we need to encourage flexible and innovative provision. One of the most amazing responses to the pandemic was the speedy and effective way that the GP community moved to remote consultations with the Government paying for access for Covid-19 patients. Such rapid innovation continues to be required. The huge waiting lists prior to Covid-19 have been exacerbated. All resources need to be galvanised – telemedecine, phone consultations, contracting with private sector capacity on an industrial scale, home-based care. Using private hospitals to clear the huge waiting list does not solve the causes of long waits for public care but there is little alternative with the problem at hand. While some existing commitment to private patients would need to be honoured, all patients should be on an equal footing for care based on needs.
Finally, effective leadership is obviously important where it is visionary, a step ahead and solidarity building. While this is not new I would recommend that the solidarity building component extends not just to effective communication but also to financing. The measures to cope with this pandemic will cost. I cannot think of a more needy time than this. Historic cases of resilient responses often show health systems drawing on rainy-day funds or utilising counter-cyclical financing of the health system. This is not the time for austerity. Given low interest rates and exceptional need, government borrowing would be very wise to fund the extra capacity required. Furthermore suggestions of leaving older people to die have little sense or cost-effectiveness when your economic and public health response depends on social cohesion and trust.
A key lesson from the resilience case studies is it is never too late. Strategies to boost staff morale, improve access and avoid austerity financing will pay dividends. Even if our health system was unprepared, much can still be achieved to save lives, secure a better functioning health system and protect livelihoods.
I was made for the lockdown, if I had been locked down, that is
DR PAT HARROLDHow was the summer for you? Quiet? No, mine wasn’t. I’m a GP you see.
Frontline without the backup, that’s us. If it was a film we would be in our far-flung outposts, dog tired and running out of ammunition, scanning the horizon for the cavalry.
I wouldn’t mind but I was made for the lockdown, if I had been locked down, that is. I was locked in alright, behind a closed door with big yellow and red signs, battered by an electronic barrage of phone calls and algorithms, emails and WhatsApps, until I thought that I should be locked up. But I missed out on the great lockdown experience.
I am a bit like one of those who went to Italy for Italia 90 and always felt that they had missed out on the true “we’re-allpart-of-Jackie’s-army” spirit of the thing.
You could not find anyone more suited to lockdown than me. I have a houseful of books I have not yet read, or want to read again. I have a garden that is half a rewilding project and half a work in
slow progress, which by itself would keep me fit and interested for years to come.
I have a guitar that could be better played and a dog who would appreciate more quality time with me loafing around in
They baked, they planted, they wove their own shawls from recycled organic seaweed. They had discovered the joys of reading real actual books, not screens
the woods. During the fabulous spring of 2020 the birds of the mid-west went about their lives unwatched by me, while my binoculars sat reproachfully on the shelf, as underworked as a sheepdog in a city apartment .
The radio and the papers were full of smiling, thoughtful people (the ones in the papers were smiling anyway. I am not so sure about those on the radio, but they seemed a damn sight happier than me at any rate) who had OMG realised that there was more to life than sitting in a traffic jam in Navan. They baked, they planted, they wove their own shawls from recycled organic seaweed. They had discovered the joys of reading real actual books, not screens. They learned how to plant vegetables and their eyes were opened to the beauty all around them. It took a while for me to be glad for them, for my eyes were open to the beauty all around me years ago. They were now green with envy for those who were freed from the bondage of the rat race, while I interrogated caller after caller about their sense of smell.
I am over it. The phrase now is the “new normal”. As if the old “normal” was not a foolish exploitation of the world’s dwindling resources. This virus might just be the first of many hiding away in the jungles and there is no vaccine for rising water levels.
The patients are coming back and we are glad to see them if they keep the mask on.
I had never thought I would have missed talking to clients so much. Often, in the old days, I would wonder when we could get round to talking about something apart from hurling. It was often a means of setting the scene, but sometimes I wonder was I the only one who spent more time on career advice for teens, gardening tips, and local politics than blood pressure. At meetings, bright young GPs would have the consultation down to an art, every slot supposed to pay for itself with maximum efficiency, while I seemed to be just enjoying the chat .
I even miss funerals. You know yourself. Deep down every doctor feels that the crowd might some day turn on them, but we went anyway. Looking back it meant a lot, especially if it was a long illness, as you turned away one last time from a person and family you had the privilege of helping.
There are positives. The scrubs and trainers are comfortable and practical and I wish I had switched over years ago. There will be no going back to the old normal on that one. The mask fogs up your glasses, but it has the great advantage that nobody can see your expression. You can be grinning like a loon and nobody can see you.
It is busy again, but the garden is looking well in a dishevelled way and I might get down to the Wexford Slobs for a spot of bird watching.
You will never have enough time, but you will always find time for what’s important.
The art of people with chronic diseases, such as epilepsy, can enhance our understanding of living with illness
GEORGELet’s begin with an ending: “The art of persons with epilepsy helps us understand what it means to have epilepsy, providing windows into its complexity and comorbidities.” That is Steven C Schacter’s conclusion to his exploration of “Epilepsy and Art …” in Epilepsy and Behaviour (2016, 57: 265–269). The art of individuals with epilepsy, says Schacter, helps doctors, scientists, and lay people develop an enriched understanding of the daily challenges facing those with the condition. Further, he speculates that research might reveal whether aspects of such art “correlate with side and location of the seizure focus/neural network, age of epilepsy onset, or cognitive and affective aspects”.
Schacter’s paper adds to the burgeoning evidence base supporting the role of art in medicine and one might wonder whether there is an ethics of aesthetics that dares to assert itself in the face of an increasingly science-based approach to medicine. In an Irish context it’s a question that should be asked… and answered in the bricks and mortar of the forthcoming All-Ireland Epilepsy Care and Research Centre. The centre – deserving the support of the medical and wider community – will “provide assessment, care, respite and education/training for individuals with epilepsy and related
disorders, and for family and carers, on the whole island of Ireland…”. I learned this from the Epilepsy Care Foundation Ireland, which in April 2019 bought 23 acres of land in north County Dublin. I also learned that Ireland is the only European country that does not have an epilepsy centre, so one might reasonably hope that once the centre is underway space will be made available to accommodate the artistic expression of those with epilepsy and related disorders.
Today, according to the charity Epilepsy Ireland’s Annual Report 2019, there are almost 40,000 people in the country living with the condition. And it is heartening to read on Epilepsy Ireland’s website that, “[m] ost people with epilepsy can live a full and active life working, playing sport, socialising, travelling, and taking up hobbies.” This is in stark contrast to the mood of grim portent evoked by the writer Graham Greene (1904–1991) who, in his first volume of autobiography A Sort of Life (1971), observed: “Epilepsy, cancer, and leprosy – these are the three medical terms which rouse the greatest fear in the untutored.…”
Another possible fear is that “the untutored” of today might include some of those who favour the headlong pursuit of evidence-based medicine at the possible expense of ignoring “The relationship between
the arts and medicine”. That is the title of a paper by Dr P Anne Scott in the Journal of Medical Ethics: Medical Humanities (2000, 26:3–8) in which she suggests not only that the arts may stimulate insight into shared human experiences and individual difference, but might also serve to enrich “the language and thought of the practitioner”.
Two examples illustrate the invaluable role that the arts can play among individuals with epilepsy and other conditions.
First, Spagno et al, writing in Epilepsy and Behaviour (2019, 93: 60–64), describe their work with adult patients to devise a contemporary dance based on a “qualitative study with patients with epilepsy, their families, and health professionals, called ‘Dialogue with Emotions’ to overcome barriers and to improve quality-of-life in epilepsy”. Second, the importance of the arts to children who are unwell is embodied by organisations such as Helium Arts, whose five-year plan (2017–2021) underlines their conviction that “the arts in healthcare make the strongest impact when a real and identified need is addressed through creative and artistic processes”, hence its aim to “grow the organ-
isation through striving to serve the 160,000 children living in Ireland with a chronic or serious illness”, such as epilepsy.
Interestingly, the arts can nourish both patient and physician. For example, the abstract art of distinguished neurologist Dr John Laidlaw (1920–2009) – who highlighted the “need for a multidisciplinary approach to the care of people with epilepsy” (https:// www.rcpe.ac.uk/obituary/dr-john-patrick-laidlaw-frcp-edin) – has recently been brought to a wider audience by award-winning photographer Graham Riddell (https:// www.grahamriddellphotography.co.uk/ blog/2020/3/dr-john-laidlaw-frcp-artist) , who was asked by Laidlaw to help archive his paintings, which can be viewed on Riddell’s blog. Noting that Laidlaw held his first exhibition in the Scottish Borders town of Peebles at the age of 87, Riddell comments: “It is interesting that he chose to specialise in epilepsy and one wonders what kind of brain he possessed to create such imaginative and beautifully colourful abstracts.”
With today’s global multiplicity of sameness threatening to deaden the senses, the importance of the arts in sparking the flame of creativity cannot be exaggerated, and there is no reason why those who are unwell should be denied access to opportunities to flourish in this way. However, this moral imperative can more easily be asserted within a healthy financial context. In which case it is timely to note the imminent arrival of Epilepsy Ireland’s fundraising Rose Week from 12 to 19 October (https://www.epilepsy.ie/ content/rose-week-2020). Whether we acknowledge it or not, we all have a need to express ourselves, and perhaps those who are unwell harbour a greater need than most.
Interestingly, the arts can nourish both patient and physicianRead more by Dr Pat Harrold at www.mindo.ie
JARDIANCE is indicated for the treatment of adults with insufficiently controlled type 2 diabetes mellitus as an adjunct to diet and exercise 1
- as monotherapy when metformin is considered inappropriate due to intolerance
- in addition to other medicinal products for the treatment of diabetes
* In addition to glucose lowering, JARDIANCE demonstrated reduction in weight and blood pressure; JARDIANCE is not indicated for weight loss or reduction of blood pressure.1
† EMPA-REG OUTCOME® was a randomised, double-blind, placebo-controlled cardiovascular outcomes trial. Patients were randomised to receive either JARDIANCE 10 mg once daily, JARDIANCE 25 mg once daily or placebo, on top of standard of care. Primary endpoint was 3-point MACE: Time to fi rst occurrence of cardiovascular death, non-fatal MI, non-fatal stroke. 14% relative risk reduction for combined endpoint of cardiovascular death, non-fatal MI, or non-fatal stroke (ARR 1.6%). 2
References
1. JARDIANCE (empaglifl ozin) Summary of Product Characteristics 2019. Available at: http://www.medicines.ie/medicine/16081/SPC/Jardiance+10+mg+and+25+mg+Film-Coated+Tablets
2. Zinman B, Wanner C, Lachin JM et al. Empaglifl ozin, cardiovascular outcomes, and mortality in type 2 diabetes. N Engl J Med 2015;373:2117-2128. (& Supplementary Appendix)
Prescribing Information (Ireland) JARDIANCE® (empagliflozin)
Film-coated tablets containing 10 mg or 25 mg empagliflozin. Indication: Jardiance is indicated for the treatment of adults with insufficiently controlled type 2 diabetes mellitus as an adjunct to diet and exercise: as monotherapy when metformin is considered inappropriate due to intolerance; in addition to other medicinal products for the treatment of diabetes. For study results with respect to combinations, effects on glycaemic control and cardiovascular events, and the populations studied, refer to the Summary of Product Characteristics. Dose and Administration: The recommended starting dose is 10 mg once daily. In patients tolerating empagliflozin 10 mg once daily who have eGFR ≥ 60 ml/min/1.73 m2 and need tighter glycaemic control, the dose can be increased to 25 mg once daily. The maximum daily dose is 25 mg. When used with sulphonylurea or insulin a lower dose of these may be considered to reduce the risk of hypoglycaemia. Renal impairment: The glycaemic efficacy is dependent on renal function. No dose adjustment is required for patients with an eGFR ≥60 ml/min/1.73 m2 or CrCl ≥60 ml/min. Do not initiate in patients with an eGFR <60 ml/min/1.73 m2 or CrCl <60 ml/min. In patients tolerating empagliflozin whose eGFR falls persistently below 60 ml/min/1.73 m2 or CrCl below 60 ml/min, the dose of empagliflozin should be adjusted to or maintained at 10 mg once daily. Discontinue when eGFR is persistently below 45 ml/min/1.73 m2 or CrCl persistently below 45 ml/min. Not for use in patients with end stage renal disease (ESRD) or on dialysis. Hepatic impairment: No dose adjustment is required for patients with hepatic impairment. Not recommended in severe hepatic impairment. Elderly patients: No dose adjustment is recommended based on age. In patients 75 years and older, an increased risk for volume depletion should be taken into account. Not recommended in patients 85 years or older. Paediatric population: No data are available. Method of administration: The tablets can be taken with or without food, swallowed whole with water. If a dose is missed, it should be taken as soon as the patient remembers; however, 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: Rare cases of diabetic ketoacidosis (DKA), including life-threatening and fatal cases, have been reported in patients treated with SGLT2 inhibitors, including empagliflozin.
Consider the risk of DKA in the event of non-specific symptoms such as nausea, vomiting, anorexia, abdominal pain, excessive thirst, difficulty breathing, confusion, unusual fatigue or sleepiness and assess patients for ketoacidosis immediately, regardless of blood glucose level. In patients where DKA is suspected or diagnosed, treatment should be discontinued immediately. Treatment should be interrupted in patients who are hospitalised for major surgical procedures or acute serious medical illnesses. Monitoring of ketones is recommended in these patients. Measurement of blood ketone levels is preferred to urine. Treatment with empagliflozin may be restarted when the ketone values are normal and the patient’s condition has stabilised. Before initiating empagliflozin, consider
factors in the patient history that may predispose to ketoacidosis. Use with caution in patients who may be at higher risk of DKA. Renal impairment: See under Dose and Administration; Monitor renal function prior to initiation and at least annually. Cases of hepatic injury have been reported with empagliflozin in clinical trials. A causal relationship between empagliflozin and hepatic injury has not been established. Haematocrit increase was observed with empagliflozin treatment. Osmotic diuresis accompanying therapeutic glucosuria may lead to a modest decrease in blood pressure.
Therefore, caution should be exercised in patients with known cardiovascular disease, patients on anti-hypertensive therapy with a history of hypotension or patients aged 75 years and older. In case of conditions that may lead to fluid loss (e.g. gastrointestinal illness), careful monitoring of volume status and electrolytes is recommended. Temporary interruption of treatment with empagliflozin should be considered until the fluid loss is corrected. Elderly: See under Dose and Administration; special attention should be given to volume intake of elderly patients in case of co-administered medicinal products which may lead to volume depletion (e.g. diuretics, ACEinhibitors). Temporary interruption of empagliflozin should be considered in patients with complicated urinary tract infections. Cases of necrotising fasciitis of the perineum (Fournier’s gangrene), have been reported in patients taking SGLT2 inhibitors. This is a rare but serious and potentially life-threatening event that requires urgent surgical intervention and antibiotic treatment. Patients should be advised to seek medical attention if they experience a combination of symptoms of pain, tenderness, erythema, or swelling in the genital or perineal area, with fever or malaise. Be aware that either uro-genital infection or perineal abscess may precede necrotising fasciitis. If Fournier’s gangrene is suspected, Jardiance should be discontinued and prompt treatment should be instituted. An increase in cases of lower limb amputation (primarily of the toe) has been observed in long-term clinical studies with another SGLT2 inhibitor, counsel patients on routine preventative footcare. Experience in New York Heart Association (NYHA) class I-II is limited, and there is no experience in clinical studies with empagliflozin in NYHA class III-IV. Due to its mechanism of action, patients taking Jardiance will test positive for glucose in their urine. The tablets contain lactose and should not be used in patients with rare hereditary problems of galactose intolerance, total lactase deficiency, or glucose-galactose malabsorption. Interactions: Use with diuretics may increase the risk of dehydration and hypotension. Insulin and insulin secretagogues may increase the risk of hypoglycaemia therefore, a lower dose of insulin or an insulin secretagogue may be required. The effect of UGT induction (e.g. induction by rifampicin or phenytoin) on empagliflozin has not been studied. Co-treatment with known inducers of UGT enzymes is not recommended due to a potential risk of decreased efficacy. If an inducer of these UGT enzymes must be coadministered, monitoring of glycaemic control to assess response to Jardiance is appropriate.
Interaction studies suggest that the pharmacokinetics of empagliflozin were not influenced by coadministration with metformin, glimepiride, pioglitazone, sitagliptin, linagliptin, warfarin, verapamil, ramipril, simvastatin, torasemide and hydrochlorothiazide. Interaction studies conducted in healthy volunteers suggest that empagliflozin had no clinically relevant effect on the pharmacokinetics of metformin, glimepiride, pioglitazone, sitagliptin, linagliptin, simvastatin, warfarin, ramipril, digoxin, diuretics and oral contraceptives. Fertility, pregnancy and lactation: There are no data from the use of empagliflozin in pregnant women. As a precautionary measure, it is preferable to avoid the use of Jardiance during pregnancy. No data in humans are available on excretion of empagliflozin into milk. Jardiance should not be used during breast-feeding. No studies on the effect on human fertility have been conducted for Jardiance. Undesirable effects: Frequencies are defined 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), not known (cannot be estimated from the available data). Very common: hypoglycaemia (when used with sulphonylurea or insulin). Common: vaginal moniliasis, vulvovaginitis, balanitis and other genital infections, urinary tract infection (including pyelonephritis and urosepsis), thirst, pruritus (generalised), rash, increased urination, serum lipids increased. Uncommon: urticaria, volume depletion, dysuria, blood creatinine increased/ glomerular filtration rate decreased, haematocrit increased. Rare: DKA. Not known: necrotising fasciitis of the perineum (Fournier’s gangrene), angioedema. Prescribers should consult the Summary of Product Characteristics for further information on side effects. Pack sizes: 10 mg; 28 tablets, 25 mg: 28 tablets. Legal category: POM. MA numbers: 10 mg/28 tablets EU/1/14/930/013; 25 mg/28 tablets EU/1/14/930/004. 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 July 2020
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
Question 1
Cardinal symptoms, which should have been present for at least one month, for the diagnosis of schizophrenia include
A. Running commentaries in the third person.
B. Social phobias.
C. Thought insertion.
D. Use of neologisms (non-existent words).
E. Negative symptoms, eg, poor self-hygiene.
Question 2
A. Is normally administered twice weekly.
B. With full compliance will give 100 per cent protection.
C. Use is contraindicated in patients with epilepsy.
D. Recognised side-effects include diarrhoea.
E. Neuropsychiatric adverse reactions normally occur within the first two weeks of use.
Characteristic features of fibromyalgia include
A. Fatigue.
B. Widespread pain.
C. Increased sleep.
D. Weight loss.
E. Disability.
A. Invariably progresses.
B. Degree of oedema is closely related to lymph node damage.
C. Will develop within a few months or not at all.
D. Patient should be advised to massage the arm centripetally twice a day.
E. That is severe may be reduced by surgery.
E. FALSE. Normally in upper renal tract and need annual follow-up, with imaging and intervention considered after two-tothree years or earlier if growth >5mms, obstruction, infection, or pain.
D. TRUE. 95 per cent chance of spontaneous passage within 40 days.
C. FALSE. NSAIDs are first-line; oral and rectal routes provide equal analgesia.
B. TRUE. Though ultrasound indicated in children and pregnant women.
A. TRUE. Lifetime risk of getting stones is 10-to-15 per cent.
ANSWER 5
A. There is a recurrence rate of 50 per cent within 10 years.
B. First-line investigation in adults is non-contrast computerised tomography of the kidneys, ureters, and bladder.
C. Renal colic analgesic of choice is opioids.
D. Stones <4mms will nearly always pass spontaneously.
E. Asymptomatic stones can be safely ignored.
E. TRUE. Simple excisional (Homan’s) operation.
D. TRUE. Also wear good quality arm stocking and elasticated glove; raise arm on sling or pillows at night; use pneumatic compression.
C. FALSE. May begin many years after operation.
B. TRUE. As is restriction of arm movement.
A. TRUE. Whereas if caused by primary disease of the lymph nodes, often improves when they are irradiated.
ANSWER 4
E. TRUE. Commonplace though not invariable.
D. FALSE. Underlying problem of somatisation/pain catastrophising.
C. FALSE. Poor sleep is characteristic.
B. TRUE. For diagnosis must have been present for at least three months, involving both sides of the body.
A. TRUE. Overlaps with chronic fatigue syndrome.
ANSWER 3
E. TRUE. 69 per cent (78 per cent in first three weeks) and in most cases will resolve within two months of stopping the drug.
D. TRUE. With nausea often occurring within hours of taking the weekly dose.
C. TRUE. Or recognised psychiatric illness.
B. FALSE. Protective efficiency of about 90 per cent.
A. FALSE. Weekly.
ANSWER 2
anhedonia, social withdrawal.
DR THERESA LOWRY LEHNEN, PhD, Clinical Nurse Specialist Practitioner, RNP, Associate Lecturer at Institute of Technology Carlow, and Member of the Irish Student Health Association (ISHA)
Worldwide, bacterial meningitis is among the top 10 causes of infection-related death and it is important for clinicians to remain up-to-date on this potentially fatal disease
Meningitis is an acute inflammation of the meninges, the protective membranes that surround the brain and spinal cord. It is caused by bacterial, viral and less often parasitic and fungal infections however, the bacterial form of meningitis is the most severe. Viral meningitis can make people feel very unwell, but is rarely life threatening, usually resolves on its own and seldom causes longterm complications. Bacterial meningitis however, is a serious illness, a medical emergency and a public health concern. Bacterial meningitis is an infectious disease associated with substantial mortality and a risk of permanent disability in survivors. Mortality remains as high as 30 per cent in pneumococcal meningitis, 5-to-10 per cent in meningococcal meningitis and up to 50 per cent when untreated. Outcomes are improved by prompt recognition of symptoms and treatment with dexamethasone and intravenous antibiotics, which should be administered as soon as possible and preferably within the first hour.
Several types of bacteria can cause bacterial meningitis, including Streptococcus pneumoniae, Haemophilus influenza, Neisseria meningitides, Listeria monocytogenes, and Group B Streptococcus. The average incubation period is four days, but can range between two and 10 days. Early symptoms of meningitis include nausea and vomiting, fever, headache and a stiff neck, muscle pain, light sensitivity, confusion, cold hands or feet and mottled skin and in some cases, a rash that does not fade under pressure. These symptoms can appear in any order and only some may be present. Later symptoms can include seizures and coma. Infants are at higher risk of developing bacterial meningitis, and it spreads easily in areas with large gatherings of people such as schools and college campuses. Other factors that can increase the risk include an anatomical defect or trauma, such as a skull fracture or surgery, which could allow bacteria to enter the nervous system, an infection in the head or neck area, living in or traveling to high risk areas, a weak immune system, and working in laboratories and other settings where meningitis pathogens are present. There were 89 cases of bacterial meningitis reported in Ireland in 2018. Vaccination is key to preventing meningitis and it is important to follow the recommended vaccination schedule. H. influenza is the main cause of bacterial meningitis in children under five years of age in countries that do not offer the Hib vaccine.
Meningococcal bacteria live at the back of the throat and in the nose. Nasopharyngeal carriage of meningococci is common. About 10 per cent of the population carry meningococci at any given time, however, not all are virulent strains. Most carriers remain well, but they can spread the bacteria to others through coughing, sneezing, sharing personal items such as utensils, cutlery, and toothbrushes or through kissing and close or prolonged personal contact. Humans are the only natural hosts for meningococci and the organism dies quickly outside the human host. Meningococcal disease can occur at any age, but the highest rate occurs in children under five years. Group B streptococcus can pass from mothers to newborns during
delivery. Meningococcal B disease is most common in children under one year of age and the next highest risk group are young people aged 15-19 years. The risk of infection in Ireland is highest in winter and early spring. Of those who get meningococcal disease (the combination of meningitis and septicaemia), one-in-20 will die and onein-10 people who recover will have a major disability such as deafness, brain damage or loss of fingers, toes, hands, feet, arms, or legs. Neisseria meningitidis, often referred to as meningococcus, is a Gram-negative bacterium that causes meningitis and other forms of meningococcal disease such as meningococcaemia, a life-threatening sepsis.
Before the introduction of the meningitis C (MenC) vaccine in 2000, groups B and C caused most cases of meningococcal disease in Ireland. Since the introduction of the MenC vaccine the number of cases of meningococcal disease due to group C bacteria has fallen dramatically and most cases
are now caused by group B bacteria.
All children in Ireland are offered MenB vaccine at two and four months of age with a booster dose given at 12 months. For babies born on or after 1 October 2016, the administration of MenC vaccine changed from four months, to six months to allow the administration of the MenB vaccine at two and four months for earlier protection against meningococcal B infection, which is the most common type of meningococcal infection in this age group. A further dose of MenC vaccine is given to babies at 13 months as a combined Hib/MenC vaccine.
In addition, all students entering first year of secondary school from September 2020 will be offered a booster dose of the Meningococcal ACWY (MenACWY) non-live vaccine. The MenACWY booster vaccine is given to protect teenagers up to and including early adulthood from life-threatening meningococcal group A, C, W, and Y infection.
There are few exceptions to immunising children with the MenB and MenC vaccines, however – a child who has had a severe allergic reaction or anaphylaxis to a previous dose or any part of the vaccine including tetanus should not get the vaccines.
Meningococcal disease may present with clinical features that are indistinguishable from those associated with other acute self-limiting systemic illnesses. Meningitis due to Neisseria meningitides can begin with flu‐like symptoms such as fever, muscle aches and vomiting, before meningitis becomes clinically apparent. Symptoms such as pallor, altered mental state or limb pain should raise suspicion of meningococcal disease. Rapid onset and progression of symptoms over a period of hours is typical and can help to distinguish it from viral meningitis. A patient presenting with meningitis and a non‐blanching petechial or purpuric rash
strongly suggests meningococcal disease, although the rash may also be blanching, maculopapular or absent. The rash can appear rapidly on any part of the body including the palms of the hands and soles of the feet. The rash may go unnoticed unless the acutely unwell patient with a systemic febrile illness is completely undressed so that a thorough search for a haemorrhagic rash can be undertaken. Meningitis due to Streptococcus pneumoniae should be suspected in patients with predisposing conditions, such as sinusitis, otitis media, mastoiditis, cerebrospinal fluid leak, cochlear implants, asplenia, human immunodeficiency virus (HIV) infection, or other immunosuppressive conditions. Meningococcal disease usually presents as meningitis or septicaemia, or a combination of the two. Septicaemia, with or without meningitis, can be particularly severe and is associated with a considerably greater mortality rate than meningococcal meningitis without bloodstream infection.
Diagnosis and treatment of bacterial meningitis
A presumptive diagnosis of bacterial meningitis is a medical emergency and immediate referral to hospital is required. Antibiotic therapy should not be delayed while initiating referral. GPs and advanced paramedics should have benzylpenicillin available when attending patients and administer it without delay to patients with a systemic febrile illness and a petechial or purpuric rash. Ceftriaxone or cefotaxime are suitable alternatives if necessary. For optimal benefit, benzylpenicillin should be given intravenously. However, if unable to access the intravenous route, it can be administered intramuscularly. Benzylpenicillin should only be withheld if the individual has a proven history of penicillin anaphylaxis.
Doses of benzylpenicillin used for suspected cases of meningococcal disease are: Adults or children aged 10 years or over: 1200mg; Children aged 1-9 years: 600mg and for children aged <1 year: 300mg. GPs or advanced paramedics are not expected to carry an alternative antibiotic to benzylpenicillin, however, if unavailable a third generation cephalosporin such as ceftriaxone 80mg/kg (up to 2g) IM or IV for all ages or cefotaxime 50mg/kg (up to 2g) IM or IV for all ages can be used and are acceptable for the empirical treatment of suspected meningococcal disease prior to transfer to hospital. GPs or advanced paramedics should telephone and inform the emergency department and clinician at the referral hospital of the patient’s expected arrival so that delays in treatment are minimal. Clinical notes accompanying the patient should inform the hospital clinician which antibiotics have been administered and their dose.
When invasive meningococcal disease is suspected the diagnosis must be confirmed as quickly as possible (again, antibiotic treatment should not be delayed while initiating or awaiting results of diagnostic tests). The following samples should be taken at the time of initiating treatment in all suspected cases: Blood cultures; throat/pharyngeal swab; samples from other sterile sites as clinically appropriate, eg, joint, pericardial, or
Meningococcal disease can occur at any age but the highest rate occurs in children under five years
pleural effusions, CSF. Blood should also be taken for a full blood count and PCR testing for meningococcal DNA. Serology may occasionally be beneficial and consultation with a microbiologist should be considered.
Lumbar puncture is recommended for all cases with clinical meningitis, but should be deferred until the patient is haemodynamically stable and there are no contraindications such as cerebral oedema or raised intracranial pressure. CSF obtained from a patient with meningococcal meningitis typically has a high neutrophil count, low glucose and high protein content. However, low or absent white cells do not exclude meningitis and initial CSF tests can be normal in up to 5 per cent of cases. In some instances, imaging such as a computed tomography (CT) scan will be recommended before the lumbar puncture, to help determine if it is safe to perform the lumbar puncture and if another condition may be contributing to the patient’s symptoms such as a brain haemorrhage or tumour.
The treatment and long-term outlook of meningitis differ considerably based upon whether it is caused by a virus or bacterium. However, this distinction may not be clear until the culture results are available, usually 48 to 72 hours after they are obtained. The length of antibiotic treatment depends upon the results of the bacterial cultures. If the cultures are negative and the patient has improved, antibiotics may be discontinued after 48 to 72 hours. If cultures are positive, the length of treatment depends upon the bacteria identified and extent of complications that occur. The treatment course may range from several days to several weeks. Worldwide, bacterial meningitis is among the top ten causes of infection-related death. Although effective antimicrobial treatment is available and administered, fatality rates are still very high and 50 per cent of affected patients suffer long-term sequelae due to severe complications, such as hydrocephalus, cerebral oedema, cerebrovascular compli-
Chemoprophylaxis should be offered, irrespective of vaccination status, to those who have had prolonged close contact with the case in a household type setting during the seven days before onset of illness. Examples of such contacts would be those living and/ or sleeping in the same household including recent visitors who have stayed overnight, pupils in the same dormitory, boy/girlfriend, or university students sharing a kitchen in a hall of residence. Babysitters may also be included, depending on the level of contact.
Chemoprophylaxis should be considered if, during the seven days before onset of illness, the index case (adult or child) attended a house party for four hours or more with children under five years of age. If chemoprophylaxis is indicated, it should be offered to all attendees, both adults and children, who attended for four hours or more.
Special consideration should be given to situations in which there is greater than usual interactions between members of the extended family and an index case, particularly where overcrowded living conditions exist.
Other situations with possible close contact
Special consideration should be given to situations in which there is greater than usual interactions between members of the extended family and an index case, particularly where overcrowded living conditions exist.
Pre-school child-care facilities contacts in certain circumstances
Following risk assessment chemoprophylaxis should be considered in the following circumstances:
Family pre-school day care (where groups of children are cared for in a private home)
Pre-school child-care
Involving a group staying together in a single room for at least a four-hour session. Involving a group staying together in a single room for at least a three-hour session on more than one day. In this situation chemoprophylaxis may be considered if the setting is similar to a household, eg, if the children share meals and nap together.
Chemoprophylaxis among healthcare workers
Chemoprophylaxis is recommended only for those whose mouth or nose is directly exposed to large particle droplets/secretions from the respiratory tract of a probable or confirmed case of meningococcal disease during the acute illness until the case has completed 24 hours of systemic antibiotics. This type of exposure will only occur among staff who are working close to the face of the case without wearing a mask or other mechanical protection. In practice this implies a clear perception of facial contact with droplets/secretions and is unlikely to occur unless using suction during airway management, inserting an airway, intubating, or if the patient coughs in the HCWs face. General medical or nursing care of cases is not an indication for prophylaxis.
Pathologist and pathology technicians who may be exposed to aerosols during the performance of an autopsy should receive chemoprophylaxis when a face mask had not been worn and when the deceased patient did not receive antibiotics for a minimum of 24 hours antemortem.
Exposure of the eyes to respiratory droplets is not considered an indication for prophylaxis. Such exposure may, however, carry a low risk of meningococcal conjunctivitis and subsequent invasive disease. Staff should be counselled about the risk and advised to seek early treatment if conjunctivitis should develop with 10 days of exposure.
cations, and ventriculitis. Deafness, brain damage or loss of fingers, toes, hands, feet, arms, or legs are associated complications. Intracranial complications are associated with a worse outcome and are often the cause of long-term sequelae. The occurrence of hydrocephalus in patients with acute bacterial meningitis is associated with worse outcomes. The fatality rate of these patients reaches up to 46 per cent, whereas the fatality rate of patients without hydrocephalus is around 17 per cent. Arterial cerebrovascular complications such as stroke and cerebral haemorrhage, occur in approximately 15-20 per cent of patients with bacterial meningitis. Vasculitis and/or vasospasms are the most likely cause of these complications. Septic thrombosis of cerebral veins and sinus occurs in about 10 per cent of patients with bacterial meningitis. Epileptic seizures are a common complication of bacterial meningitis. In some cases they are the first presenting symptom, indicating impending herniation or the presence of an intraparenchymal abscess or cerebritis/encephalitis. Approximately 5 per cent of patients with acute bacterial meningitis experience seizures. Cerebritis and brain abscesses occur in approximately 1-to-5 per cent of patients with bacterial meningitis. On clinical examination the patients often presents a focal neurological deficit, such as partial paralysis or speech disorder, epileptic seizures or cephalgia, which is commonly one-sided. Abscesses can be the cause or the consequence of meningitis and are best detected by MRI or even MR spectroscopy.
Treatment for viral meningitis is mainly supportive. This includes rest, fluids or intravenous fluids if the patient is unable to drink, and medications to treat fever and/or headache. Most patients with viral meningitis recover with no long-term complications. Symptoms usually begin to improve within one week, although some will have fatigue, irritability, decreased concentration, muscle weakness and spasm, and difficulty with coordination for several weeks or more. Death is uncommon with viral meningitis.
The public health response to meningococcal disease includes identification of close contacts, arranging appropriate chemoprophylaxis and provision of appropriate information. Chemoprophylaxis is indicated only for those in close contact with a case in the seven days preceding the onset of illness. It reduces the risk to other susceptible individuals in the network, protecting them from acquiring the meningococcal strain from the carrier and possibly invasive disease. Chemoprophylaxis should be given to all identified as close contacts as soon as possible preferably within 24 hours after notification of the index case. However, it can be given up to a month after onset of illness in the index case. Three antibiotics, rifampicin, ciprofloxacin and ceftriaxone are currently used in Ireland for chemoprophylaxis of meningococcal disease. Depending on the serogroup of the index case, vaccination with MenC or MenACWY vaccine may be recommended for close contacts.
Healthcare workers in contact with cases of meningococcal disease are at increased relative risk of disease in the 10-day period following exposure.
Outbreaks of meningitis may occur in the general community or in settings such as crèches, schools, and colleges. The public health actions for each of these settings may vary and will depend on the identification of epidemiological links between cases and identification that the same organism is associated with the outbreak cases. The objective of public health management of such outbreaks of invasive meningococcal
disease is to interrupt transmission and prevent further cases. Once an outbreak is either suspected or recognised there is an immediate need to initiate a coordinated response. Following a case or outbreak of meningococcal disease, it is important for public health to disseminate information appropriately, as early detection, diagnosis, and treatment improves outcomes. Disseminating information to the community may require use of mass media, websites and community meetings and help lines.
Before the introduction of the meningitis C (MenC) vaccine in 2000, groups B and C caused most cases of meningococcal disease in Ireland
Vigilance for signs and symptoms among contacts is important especially in the immediate one-week high-risk period after the onset of symptoms in a confirmed case. Information disseminated should be sufficient to ensure public awareness of the situation while maintaining patient confidentiality. The family of a confirmed case should be informed that information will be distributed as appropriate. Leaflets or other printed material about meningococcal disease should be widely available and quickly distributed after reporting of a confirmed or clinical case.
Vaccination and patient education
Vaccination provides the best chance of protection against meningococcal disease. Opportunistic discussion in practice with patients helps reinforce the importance of vaccination programmes and adherence to the recommended schedules. Providing education to pregnant women and their partners about the importance of childhood immunisations programmes can help increase knowledge, vaccine uptake, and the timeliness of receipt of childhood vaccinations. Discussion involves debunking myths and addressing parental concerns about vaccine safety. Clinicians must continue to address the gaps in patient knowledge through detailed educational efforts and effective communication techniques. It is imperative that practice nurses and doctors are up to date on research and immunisation guidelines, and are able to communicate effectively the benefits and importance of vaccination. Effective communication techniques providing evidence-based information and best practice advice can address misconceptions and gaps in patient knowledge, leading to informed choices, patient education, and improved outcomes.
For reliable and up-to-date information about HSE immunisation programmes visit HSE NIO: https://www.hse.ie/eng/health/immunisation/
The global coronavirus pandemic has widespread implications for cardiovascular health. Since early in the course of the SARSCov-2/Covid-19 pandemic it was recognised that the clinical picture associated with the disease involved systemic illness and multisystem dysfunction. Cardiac complications in particular are relatively frequent. Moreover, patients with pre-existing heart disease appear to be at heightened risk of a severe clinical course if they develop Covid-19. In addition, some of the medications that were used for the treatment of patients with severe Covid-19 illness have cardiac side-effects, including QT-interval prolongation and cardiac arrhythmias. More recently, observational data suggests that a high proportion of patients who have recovered from Covid-19 had changes on cardiac MRI during follow-up. In a broader sense, the coronavirus pandemic has had most wide-reaching consequences in relation to service provision in patients without Covid-19 infection. Many studies documented a dramatic decline not just in elective cardiac procedures – which would not have been unexpected – but also in presentations with acute coronary syndrome and number of patients undergoing diagnostic and interventional catheter procedures for this indication.
Myocardial injury
Myocardial injury seems to occur in about 20-to-30 per cent of patients with severe Covid-19 who require admission to hospital. Importantly, adverse outcomes – in terms of proportion of patients with acute respiratory distress syndrome (ARDS) and death – are higher in patients whose illness is complicated by myocardial injury. The pathogenesis of myocardial injury in severe Covid-19 is multifactorial and includes injury due to:
(i) type 1 myocardial infarction (classical plaque rupture); type 2 myocardial infarction (including coronary artery supply/demand mismatch due to sepsis and shock, and microvascular dysfunction and thrombosis); (ii) viral myocarditis and myopericarditis; (iii) systemic inflammatory response syndrome or cytokine storm; (iv) right heart strain due to pulmonary embolism; and (v) stress (Takotsubo cardiomyopathy).
Emerging information
The management of patients with acute coronary syndrome (ACS) in the clinical circumstances pertaining during the first wave of Covid-19 proved extremely challenging, particularly in the worst hit regions. In certain areas, emergency systems were overwhelmed by large numbers of patients with advanced respiratory distress and patients had difficulties accessing care for other emergent conditions like myocardial infarction. As hospitals became significant amplifiers of the pandemic, triage protocols for ACS and care pathways had to be rapidly amended. Complicating this, evidence emerged to suggest that a proportion of patients with undiagnosed Covid-19 presented initially with ACS with atypical features. Data from the Milan region in Italy showed that a high proportion of patients (>60 per cent) who were admitted to the cath lab with ACS and subsequently testing positive for Covid-19 had no evidence of obstructive coronary artery disease despite extensive changes on ECG. This suggested that acute Covid-19 could masquerade as ACS.
With the passage of time, some explanations for this latter phenomenon have emerged. Firstly, it has become clear that Covid-19 illness that is severe is associated with a significant pro-
Consultant Cardiologist and Medical Director of the Irish Heart Foundation (IHF)
Priscilla Lynch: Are you/the IHF concerned about growing reports of cardiac issues such as myocarditis presenting in younger, healthier people related to Covid-19?
Dr Angie Brown: The Irish Heart Foundation are concerned about any patients who develop a significant illness from Covid-19, so the reports of patients being seriously unwell from direct cardiac involvement from Covid-19 is particularly worrying, especially as there seems to be a preponderance of young people affected. Whilst the primary focus of management for patients with Covid-19 remains close monitoring of respiratory function, there have been high levels of cardiac dysfunction in emerging cross-sectional and observational analyses, suggesting the need for heightened awareness in patients who may require cardiac input as part of a multidisciplinary approach.
Are you aware of such cases in Ireland?
Yes, I am aware of some cases in Ireland occurring in younger people in their 20s and 30s.
thrombotic state. This seems to be dependent on the severity of the clinical illness. Heightened thrombotic risk is explained by a constellation of clinical risk factors including acute illness, reduced mobility, volume depletion, liver and kidney dysfunction and haemodynamic compromise. Amplifying this risk is the systemic inflammatory response associated with the illness which seems to contribute to pronounced diffuse endothelial dysfunction. Together these two factors can result in increased risk of venous thromboembolism (VTE) (including major pulmonary embolism), arterial thrombosis and/or embolism (including myocardial infarction), and disseminated intravascular coagulopathy. In fact, this double hit of intravascular thrombosis and microvascular dysfunction is likely a final common pathway for myocardial injury in a significant proportion of cases. Supportive evidence for this is emerging from autopsy studies. Although autopsy data has been somewhat slow to emerge due to logistical considerations associated with disease control, studies in selected patients reveal evidence of diffuse myocardial injury on macroscopic examination and microvascular thrombosis on light microscopy. On the other hand, myocarditis with viral infiltration of cardiomyocytes has been somewhat less frequent than clinically suspected. Heightened thrombotic risk may also manifest as stent thrombosis in patients with a recent or remote history of coronary stenting.
Management
Optimal management strategies for patients with cardiac complications of Covid-19 are a matter of debate. Patients with ACS and heightened risk remain best served by urgent diagnostic angiography with percutaneous in -
tervention as required. Whether more intense or prolonged antithrombotic therapy is beneficial remains to be demonstrated (eg, longer periods of therapeutic anticoagulation, use of more potent antiplatelet agents, more frequent use of intravenous glycoprotein receptor antagonists). In view of the pathogenic considerations discussed, however, such approaches appear clinically reasonable though dedicated trials are lacking. Observational studies suggest an association between anticoagulation and improved clinical outcome. Several large-scale trials investigating therapeutic anticoagulation in acutely unwell patients with Covid-19 in comparison with standard care conventional thromboprophylaxis are ongoing. Although primarily focused on prevention of VTE, they will likely be informative also in relation to arterial thrombotic events. Interestingly, clinical experience suggests that major bleeding is not a dominant feature of the clinical picture of severe Covid-19 infection.
Finally, interaction between investigational therapies for Covid-19 and anticoagulants including NOACs, vitamin K antagonists, and heparin, may be clinically relevant and must be considered in decision making.
In relation to chronic complications in patients who recover from Covid-19, recent interest has centered on myocardial abnormalities seen in a high proportion of patients undergoing cardiac MRI in a study conducted in Germany. Interestingly, most of the patients had a mild clinical course and did not require hospital admission. Analysis of signal intensity on cardiac MRI showed that 78 per cent of patients had abnormalities detected. Moreover, some evidence of reduced ejection frac-
Severe forms of myocarditis can lead to heart failure (impair the heart’s ability to pump blood) and arrhythmias. The presentation can be with chest pain and dyspnoea (breathlessness). Some of the people affected by this have needed treating on ITU and some have required ventilation and other forms of heart support. Other people may have milder forms of cardiac involvement with relatively few symptoms.
According to one study out of the University of Frankfurt in Germany, more than half of patients studied who had Covid-19 were found to have ongoing cardiac inflammation. Researchers noted that more than two-thirds of the patients who participated in the study had a mild illness and recovered at home from Covid-19.
We know that other viruses can affect the heart [but] the concern now is that even with a mild case of Covid-19, there’s a possibility that there could be inflammation and damage to the heart.
Do young people need to be more aware of the cardiac risks associated with the Coronavirus?
We all need to continue to be careful and continue to fol-
tion was seen in comparison with matched controls. Although the findings are intriguing and somewhat concerning, additional data to replicate these findings is awaited. Moreover, the clinical implications of changes that might be regarded as rather subtle remain unclear. In fact, our research institute is investigating the feasibility of a trial to confirm or refute these findings in an Irish population of Covid-19 recovered patients.
Finally, the impact of the coronavirus pandemic on heart disease is likely to be greatest in how it affects patients not suffering from Covid-19. Surveys of cardiologists across Europe and worldwide indicated a significant reduction in hospital admissions for myocardial infarction and a relative increase in patients presenting later with advanced complications of heart attack, less frequently seen in the contemporary era of reperfusion therapy. An analysis from the UK showed a 40 per cent reduction in ACS admissions in the initial phase of the pandemic, with a subsequent rebound in Q2 2020 albeit to a level that remained 16 per cent lower year-on-year when compared with historical data. Disruptions in upstream healthcare provision, including risk factor identification and management, opportunistic screening for uncontrolled risk factors, and referral for investigation and therapy of heart disease represents a significant clinical risk at a population level. It may well be that the impact of missed opportunities for care will be felt in a delayed wave of heart disease and heart failure in the months and years to come. One thing is sure, in relation to heart disease, in line with other areas of medicine and society, the impact of the Covid-19 pandemic will be indelible.
low the recommendations about hand hygiene, physical distancing, etc, and it is important for younger people to realise that though the vast majority will recover from Covid-19 should they contract it, that a small percentage of younger people will be seriously ill and may have a protracted recovery.
Do you have further comments on this issue?
There are a couple of studies that suggest that being infected with Covid-19 carries quite a high likelihood of having some involvement of the heart. We need further information so we know how long these changes persist. Since the pandemic began, people with underlying cardiovascular problems such as high blood pressure, coronary artery disease, or heart failure have been known to be at higher risk for infection and death.
The connection between Covid-19 and blood clots emerged later, after doctors began connecting the pulmonary embolisms, strokes, and heart attacks they were seeing to the virus. Taken together these findings indicate the need for ongoing investigation of the long-term cardiovascular consequences of Covid-19.
In the latest edition of its monthly publication Epi-Insight, the Health Protection Surveillance Centre (HPSC) has published an update on the 2020/2021 influenza season and influenza vaccination for children in Ireland.
The 2020/2021 influenza season presents a significant challenge to the delivery of healthcare services in the context of Covid-19, points out the HPSC. Every autumn and winter 200-to-500 people die in Ireland as a result of influenza (110 died in the 2019/20 season) and thousands of people need hospital admission, placing a considerable burden on the healthcare system.
For individuals, dual infection with influenza and Covid-19 is likely to lead to worse outcomes, particularly for those at-risk such as older people and those with underlying medical conditions.
To prevent cases of influenza in children and reduce the spread of influenza to others, the HSE’s National Immunisation Advisory Committee (NIAC) has now recommended influenza vaccine for all children in Ireland (aged two-to-17 years inclusive).
For the 2020/21 flu season, following recommendations from NIAC, the Department of Health is extending the influenza vaccination programme providing funding to the HSE to offer:
• Administration of Quadrivalent Live Attenuated Influenza (LAIV) vaccine free to all children aged two-to-12 years inclusive (to be administered intra-nasally).
• Administration of Quadrivalent Inactivated Influenza vaccine (QIV) free to all in at-risk groups, regardless of medical card or GP visit card status. This includes all those aged 65 years and over, pregnant women, children aged six-to-23 months and those aged 13-to-64 with long-term medical conditions, healthcare workers and carers.
The aim of the extension of the influenza programme to children aged two-12 years is to reduce:
• morbidity and mortality from influenza in children;
• transmission of influenza to the elderly and persons in risk groups;
• influenza cases and influenza-related hospitalisations;
• transmission of influenza to healthcare workers in families with children;
• absenteeism of children from school and their parents from work.
Children are among the most susceptible to influenza infection, notes the HPSC. It is estimated that 20-30 per cent of children develop influenza during each flu season compared to five to 10 per cent of adults. Children, because they have limited pre-existing immunity, are primary vectors of influenza transmission in the community and shed the virus at higher viral titres. Children transmit the flu virus for a longer period than adults. Children can transmit the influenza virus for 10 or more days, compared to six days in adults, therefore increasing spread of the disease.
Up to 10 per cent of children under 15 years attend their GP with influenza in an average flu season. Flu is an important cause of pneumonia, bronchitis, otitis media, croup and bronchiolitis in children. Incidence rates of influenza are highest in the younger age groups leading to high rates of excess outpatient visits, hospital admissions and antibiotic prescriptions.
In Ireland during the 2018/2019 flu season, 1,245 children were hospitalised with influenza. Children aged under five years had the second highest hospitalisation rates for influenza after those aged 65 years and older.
Between the 2009/10 and 2018/19 flu seasons, more than 4,750 children aged 0-14 in Ireland have required hospitalisation as a result of influenza, including 183 requiring critical care and sadly 41 children have died.
Nine European countries, the US, Canada and Australia already recommend influenza vaccine for children. The UK gives LAIV to children. Finland, US and Canada give LAIV or QIV to children.
Quadrivalent LAIV vaccine is egg-based and contains four vaccine virus strains as recommended by the World Health Organisation (WHO) for the Northern Hemisphere 2020/2021 influenza season.
In some studies, LAIV has been shown to be more effective in children compared with inactivated influenza vaccines. In addition, LAIV may offer some protection against strains not con-
tained in the vaccine, as well as virus strains that have undergone antigenic drift. A recent meta-analysis of LAIV suggested an efficacy against confirmed disease of 83 per cent.
The UK pilot primary school programme introducing LAIV was evaluated in 2014/2015 and showed:
• 94 per cent reduction in primary school-age children GP influenza-like consultations;
• 74 per cent reduction in primary school-age emergency department attendances with respiratory complaints;
• 93 per cent reduction in primary school-age confirmed influenza hospitalisations;
• 59 per cent reduction in adults GP influenza-like illness consultations.
The HSE National Immunisation Office (NIO) has developed an e-learning module for vaccinators ‘Live Attenuated Influenza Vaccine’ which is available at www.hseland.ie. The NIO has also produced information materials on LAIV for parents and healthcare workers, which will be distributed to GPs and pharmacists. These materials will also be available online from the NIO website www.immunisation.ie and www.hse.ie/flu
Reference: Tom Barrett, Chantal Migone, Lucy Jessop. National Immunisation Office. The 2020/2021 influenza season and influenza vaccination for children. Epi-Insight, Vol 21, Issue 4, September 2020.
This material is for healthcare professionals only
rapidly relieve cow’s milk allergy symptoms as quickly as 48 hours 2–4
successfully accelerate return to cow’s milk after 12 months of use**5
reduce the risk of future allergic manifestations by ~50%†6
*For the management of cow’s milk allergy vs. eHCF without LGG ®, rice, soy or amino acids (p<0.001) † During a period of 3 years vs. eHCF without LGG ® (p<0.001)
TRANSFORMING THE LIVES OF BABIES WITH COW’S MILK ALLERGY
et al. Br J Nutr 2012; 107:325–338.
Lothe L et al. Pediatrics 1989; 83:262–266. 3. Baldassarre ME et al.
Canani RB et al.
Pediatr 2013; 163:771–777. 6. Canani RB etal.JAllergyClinImmunol 2017; 139:1906–1913.
J Pediatr 2010; 156:397–401. 4. Nermes M etal.ClinExpAllergy 2011; 41:370–377.
Nutramigen with LGG ® is a food for special medical purposes for the dietary management of cow’s milk allergy and must be used under medical supervision. Nutramigen with LGG ® is not recommended for premature and immunocompromised infants unless directed and supervised by a healthcare professional.
IMPORTANT NOTICE: Breastfeeding is best for babies. The decision to discontinue breastfeeding may be difficult to reverse and the introduction of partial bottle-feeding may reduce breast milk supply. The financial benefits of breastfeeding should be considered before bottle-feeding is initiated. Failure to follow preparation instructions carefully may be harmful to your baby’s health. Parents should always be advised by an independent healthcare professional regarding infant feeding. Products of Mead Johnson must be under medical supervision.
Trademark of Mead Johnson & Company LGG © 2019 Mead Johnson & Company, LCC. All rights reserved. LGG ® and the LGG ® logo are registered trademark of Chr. Hansen A/S.
Date of Preparation: April 2020 (RB-M-04765)
Gutcast: Living Better with Inflammatory Bowel Disease (IBD) Feature Series
For someone living with Crohn’s disease or ulcerative colitis, collectively known as inflammatory bowel disease (IBD), getting the most out of their healthcare professional appointment is an important part of managing their condition.
Gutcast is a new podcast series developed by the Irish Society for Colitis & Crohn’s Disease (ISCC) in partnership with Janssen Sciences Ireland UC. In the fourth episode Dr Aoibhlinn O’Toole, Consultant Gastroenterologist at Beaumont Hospital, Dublin and Emma Anderson, IBD Nurse Specialist at Our Lady of Lourdes Hospital, Drogheda discuss how people can get the most out of their healthcare professional appointments with Gutcast host Amy Kelly, Director of ISCC.
Preparing for appointments and tracking symptoms
Dr O’Toole and Ms Anderson urge those with IBD to bring ‘a check list’ with them when attending an appointment. This should detail whether they have ulcerative colitis or Crohn’s disease; their medications and doses, reactions or intolerances; if they are in clinical remission; number of bowel movements; abdominal pain; blood in the stool; the impact of IBD on their quality of life; the challenges they’ve been facing; if they have missed school/college/or work as a result of their IBD; and how IBD has impacted their sleeping, eating and exercising. Dr O’Toole says, “If there something that’s bothering one of my patients, I want to know how often it’s happening so I can figure out if it is related to the patient’s Crohn’s or ulcerative colitis or if it’s a result of something else. I recommend my patients jot down their symptoms or use a symptom tracker in the form of an App. If someone with IBD really knows their disease, the meds they’re on, the complications they’ve had, that’s really going to help in guiding their healthcare professional through the appointment as well as possible.”
Ms Anderson suggests those with IBD should bring somebody with them to their appointment: “Some people tend to only hear the first thing that’s said to them when they go into their appointment. It can be a good idea for patients to have somebody
with them as well as having a little diary or the ISCC IBDWELL App to jot down their symptoms. A lot of time can be wasted during appointments asking about symptoms. I also suggest people have a list of questions, with the most relevant at the top, because they won’t always get to the bottom of the list. People shouldn’t be afraid to ask questions during their healthcare appointments or ask for clarity.”
Dr O’Toole says people often take a half day from school or college or work, to come for their appointments. “It’s a big deal. You want to get the most out of your appointment and you might feel rushed because the clinic is busy, or the doctor seems hassled. If you don’t understand something, just ask them to repeat it. It’s your appointment, you don’t want to feel rushed, you want to feel that you understand the plan. If you don’t understand something, just say so. I don’t want people leaving my clinic not having a clue what’s going on, so I tend to take a little bit of ownership over the consultation to try and ensure they actually understood the plan, or what’s going to happen.”
Dr O’Toole advises when looking at treatments, you have to look at the individual and their disease. ”Some medications work very well if you also have joint disease, or if you have skin disease or eye disease. Some treatments can be given as enemas or suppositories which can be very helpful for treating ulcerative colitis that just affects the lower part of the colon. We have to look at the individual, what infections they may have been exposed to, have they a cancer history, what stage they are at in their life, if it is easier to take a tablet or give themselves an injection at home. For example if someone has a needle phobia, is it better they to come into the hospital to get infusions?
Most of our patients get diagnosed when they are young. We have to think about what happens if they move away to college or they want to go to Australia with their friends for a year or maybe Canada when
they have finished college. We have to look at the individual, what suits that individual at all stages of their life, what other medical problems they might have, and this is what I would call shared decision making. We’re a team, we look at all the pros and cons and decide the best option for that person.”
Building relationships
Dr O’Toole and Ms Anderson emphasise how the entire multidisciplinary team work very closely together. Dr O’Toole said when people have an established relationship with their team, they knew what channels to use when they were unwell. “I think if someone with IBD is comfortable with their healthcare professionals - and this includes their GP, consultant, surgeon, other specialty doctors, IBD nurse, dietician, pharmacist, social worker, and/or psychologist - they’ll be a little bit more comfortable about explaining their symptoms. Someone with IBD can often encounter 20/30 different healthcare professionals throughout their journey.”
Ms Anderson says meeting so many different healthcare professionals through the IBD journey can be overwhelming, but the IBD nurse is the central point of contact. Unfortunately, not all hospitals have an IBD nurse and in that case the person needs to have a good relationship with their consultant, GP, or pharmacist. However, there are also many great stoma nurse services available. If a patient requires a stoma, they can be referred to the stoma nurse who can show them different types of stomas and help with their aftercare.
Dr O’Toole believes stoma nurses are fantastic at siting, so it minimises the cosmetic downside to having a stoma. For some people having a stoma is a relief. “I have patients who have trialled multiple courses of medications with their own side effects and ultimately they’ve gone on to surgery and they’re asking, why I didn’t send them for surgery years ago, as they
feel a new woman or a new man, and there are people who don’t want their stomas reversed as they are doing brilliantly.”
Talking about travelling or moving location, Ms Anderson says this doesn’t have to be a problem: “A patient can transfer to any hospital; we give them their information and we can contact their next hospital for them. However, if they are going abroad, we may need to give them some advice around medication and vaccinations. Sometimes it can be a little bit tricky travelling with medications, but we can advise on that. If they are going traveling maybe for a year and they’re on specific treatment, they need a plan. With IBD you can’t really go on a whim, especially if you’re on high-tech medication.”
The “Getting the most out of your appointments” episode of Gutcast provides patients with an important resource to take control of their IBD. It can also be helpful for friends and family to listen to in order to understand the condition and be able to support their loved ones.
Gutcast brings together healthcare professionals, and people living with the condition to give their opinions and advice on a variety of topics including mental health, fatigue, managing work and social life, sex and relationships and getting the most out of your healthcare appointments. Each Gutcast episode has been compiled in response to feedback from people living with IBD with the aim of providing practical advice and to address questions they may not feel comfortable openly discussing.
Please tune in to hear more on these topics and encourage people you are treating for IBD to go to ISCC.ie/gutcast where they can listen to the episodes and learn more about supports available. Or they can search ‘Gutcast’ on the Apple Pocast app, Spotify, Google Play music or wherever they listen to podcasts.
Date of Preparation August 2020, EM-35131
It's a big deal. You want to get the most out of your appointment and you might feel rushed because the clinic is busy, or the doctor seems hassled
The first podcast for people living with IBD in Ireland
Gutcast is a unique resource for patients that brings together experts and people living with Crohn’s disease and ulcerative colitis to provide information and advice on how to manage IBD.
Topics include:
IBD & COVID-19
What I wish I’d known
Mental Health
Work and social life
Sex and relationships
Getting the most from appointments
Managing fatigue
Personal stories of IBD
To access more information about Gutcast for HCPs open the camera on your phone and scan here:
Direct your patients to ISCC.ie/Gutcast to learn more or to listen wherever they get their podcasts.
Hosted by Amy Kelly, Director of ISCC and living with Crohn’s diseaseKEYTRUDA® (pembrolizumab)
ABRIDGED PRODUCT INFORMATION Refer to Summary of Product Characteristics before prescribing. PRESENTATION KEYTRUDA 25 mg/mL: One vial of 4 mL of concentrate contains 100 mg of pembrolizumab. INDICATIONS KEYTRUDA as monotherapy is indicated for the treatment of advanced (unresectable or metastatic) melanoma in adults. KEYTRUDA as monotherapy is indicated for the adjuvant treatment of adults with Stage III melanoma and lymph node involvement who have undergone complete resection. KEYTRUDA as monotherapy is indicated for the first-line treatment of metastatic non-small cell lung carcinoma (NSCLC) in adults whose tumours express PD-L1 with a ≥50% tumour proportion score (TPS) with no EGFR or ALK positive tumour mutations. KEYTRUDA, in combination with pemetrexed and platinum chemotherapy, is indicated for the first-line treatment of metastatic non-squamous NSCLC in adults whose tumours have no EGFR or ALK positive mutations. KEYTRUDA, in combination with carboplatin and either paclitaxel or nab-paclitaxel, is indicated for the first-line treatment of metastatic squamous NSCLC in adults. KEYTRUDA as monotherapy is indicated for the treatment of locally advanced or metastatic NSCLC in adults whose tumours express PD-L1 with a ≥1% TPS and who have received at least one prior chemotherapy regimen. Patients with EGFR or ALK positive tumour mutations should also have received targeted therapy before receiving KEYTRUDA. KEYTRUDA as monotherapy is indicated for the treatment of adult patients with relapsed or refractory classical Hodgkin lymphoma (cHL) who have failed autologous stem cell transplant (ASCT) and brentuximab vedotin (BV), or who are transplant-ineligible and have failed BV. KEYTRUDA as monotherapy is indicated for the treatment of locally advanced or metastatic urothelial carcinoma in adults who have received prior platinum-containing chemotherapy. KEYTRUDA as monotherapy is indicated for the treatment of locally advanced or metastatic urothelial carcinoma in adults who are not eligible for cisplatin-containing chemotherapy and whose tumours express PD L1 with a combined positive score (CPS) ≥ 10. KEYTRUDA as monotherapy or in combination with platinum and 5-fluorouracil (5-FU) chemotherapy, is indicated for the first-line treatment of metastatic or unresectable recurrent head and neck squamous cell carcinoma (HNSCC) in adults whose tumours express PD-L1 with a CPS ≥ 1. KEYTRUDA as monotherapy is indicated for the treatment of recurrent or metastatic HNSCC in adults whose tumours express PD-L1 with a ≥ 50% TPS and progressing on or after platinum-containing chemotherapy. KEYTRUDA, in combination with axitinib, is indicated for the first-line treatment of advanced renal cell carcinoma (RCC) in adults. DOSAGE AND ADMINISTRATION See SmPC for full details. Therapy must be initiated and supervised by specialist physicians experienced in the treatment of cancer. The recommended dose of KEYTRUDA as monotherapy is either 200 mg every 3 weeks or 400 mg every 6 weeks administered as an intravenous infusion over 30 minutes. The recommended dose of KEYTRUDA as part of combination therapy is 200 mg every 3 weeks administered as an intravenous infusion over 30 minutes. KEYTRUDA must not be administered as an intravenous push or bolus injection. When administering KEYTRUDA as part of a combination with intravenous chemotherapy, KEYTRUDA should be administered first. Treat patients until disease progression or unacceptable toxicity. Atypical responses (i.e., an initial transient increase in tumour size or small new lesions within the first few months followed by tumour shrinkage) have been observed. Recommended to continue treatment for clinically stable patients with initial evidence of disease progression until disease progression is confirmed. For the adjuvant treatment of melanoma, KEYTRUDA should be administered until disease recurrence, unacceptable toxicity, or for a duration of up to one year. KEYTRUDA, as monotherapy or as combination therapy, should be permanently discontinued (a) For Grade 4 toxicity except for: endocrinopathies that are controlled with replacement hormones; or haematological toxicity, only in patients with cHL in which KEYTRUDA should be withheld until adverse reactions recover to Grade 0-1; (b) If corticosteroid dosing cannot be reduced to ≤10 mg prednisone or equivalent per day within 12 weeks; (c) If a treatment-related toxicity does not resolve to Grade 0-1 within 12 weeks after last dose of KEYTRUDA; (d) If any event occurs a second time at Grade ≥ 3 severity. Patients must be given the
Patient Alert Card and be informed about the risks of KEYTRUDA. Special populations Elderly: No dose adjustment necessary. Data from patients ≥ 65 years are too limited to draw conclusions on cHL population. Data from pembrolizumab monotherapy in patients with resected Stage III melanoma, from pembrolizumab in combination with axitinib in patients with advanced RCC, and from chemotherapy combination in patients with metastatic NSCLC, and from pembrolizumab (with or without chemotherapy) in patients receiving first line treatment for metastatic or unresectable recurrent HNSCC ≥ 75 years are limited. Renal impairment: No dose adjustment needed for mild or moderate renal impairment. No studies in severe renal impairment. Hepatic impairment: No dose adjustment needed for mild hepatic impairment. No studies in moderate or severe hepatic impairment. Ocular melanoma: Limited safety and efficacy data exist. Eastern Cooperative Oncology Group (ECOG) performance status score ≥ 2: Patients with ECOG performance status score ≥ 2 were excluded from the clinical trials of melanoma, NSCLC, cHL, and HNSCC. Paediatric population: Safety and efficacy in children below 18 years of age not established. CONTRAINDICATIONS Hypersensitivity to the active substance or to any excipients.
PRECAUTIONS AND WARNINGS Assessment of PD-L1 status When assessing the PD-L1 status of the tumour, it is important that a well-validated and robust methodology is chosen to minimise false negative or false positive determinations. Immune-related adverse reactions Immune-related adverse reactions, including severe and fatal cases, have occurred in patients receiving pembrolizumab. Most immune-related adverse reactions occurring during treatment with pembrolizumab were reversible and managed with interruptions of pembrolizumab, administration of corticosteroids and/or supportive care. Immune-related adverse reactions have also occurred after the last dose of pembrolizumab. Immune-related adverse reactions affecting more than one body system can occur simultaneously. See SmPC for full details. Immune-related pneumonitis: Patients should be monitored for signs and symptoms of pneumonitis. Suspected pneumonitis should be confirmed with radiographic imaging and other causes excluded. Refer to SmPC for information on management of immune-related pneumonitis. Immune-related colitis: Patients should be monitored for signs and symptoms of colitis, and other causes excluded. Consider the potential risk of gastrointestinal perforation. Refer to SmPC for information on management of immune-related colitis. Immune-related hepatitis: Patients should be monitored for changes in liver function (at the start of treatment, periodically during treatment and as indicated based on clinical evaluation) and symptoms of hepatitis, and other causes excluded. Refer to SmPC for information on management of Immune-related hepatitis. Immune-related nephritis: Patients should be monitored for changes in renal function, and other causes of renal dysfunction excluded. Refer to SmPC for information on management of immune-related nephritis. Immune-related endocrinopathies: Severe endocrinopathies, including adrenal insufficiency, hypophysitis, type 1 diabetes mellitus, diabetic ketoacidosis, hypothyroidism, and hyperthyroidism
receiving pembrolizumab. For signs or symptoms of SJS or TEN, pembrolizumab should be withheld and the patient should be referred to a specialised unit for assessment and treatment. If SJS or TEN is confirmed, pembrolizumab should be permanently discontinued. Caution should be used when considering the use of pembrolizumab in a patient who has previously experienced a severe or life-threatening skin adverse reaction on prior treatment with other immune- stimulatory anticancer agents. Other clinically significant immune-related adverse reactions: The following additional clinically significant, immune-related adverse reactions, have been reported in clinical trials or in post-marketing experience: uveitis, arthritis, myositis, myocarditis, pancreatitis, Guillain-Barré syndrome, myasthenic syndrome, haemolytic anaemia, sarcoidosis and encephalitis. Refer to SmPC for information on management of significant immune-related adverse reactions. Solid organ transplant rejection has been reported in the post-marketing setting in patients treated with PD-1 inhibitors. The benefit of treatment with pembrolizumab versus the risk of possible organ rejection should be considered in these patients. Complications of allogeneic Haematopoietic Stem Cell Transplant (HSCT): Allogeneic HSCT after treatment with pembrolizumab: Cases of graft-versus-host-disease (GVHD) and hepatic veno-occlusive disease (VOD) have been observed in patients with classical Hodgkin lymphoma undergoing allogeneic HSCT after previous exposure to pembrolizumab. Until further data become available, careful consideration to the potential benefits of HSCT and the possible increased risk of transplant-related complications should be made case by case. Allogeneic HSCT prior to treatment with pembrolizumab: In patients with a history of allogeneic HSCT, acute GVHD, including fatal GVHD, has been reported after treatment with pembrolizumab. Patients who experienced GVHD after their transplant procedure may be at an increased risk for GVHD after treatment with pembrolizumab. Consider the benefit of treatment with pembrolizumab versus the risk of possible GVHD in patients with a history of allogeneic HSCT. Infusion-related reactions: For severe infusion reactions including hypersensitivity and anaphylaxis, stop infusion and permanently discontinue pembrolizumab. With mild or moderate infusion reactions, infusion may continue with close monitoring. Premedication with antipyretic and antihistamine may be considered. Overdose: There is no information on overdose with pembrolizumab. In case of overdose, monitor closely for signs or symptoms of adverse reactions and treat appropriately. INTERACTIONS No formal pharmacokinetic drug interaction studies have been conducted with pembrolizumab. No metabolic drug-drug interactions are expected. The use of systemic corticosteroids or immunosuppressants before starting pembrolizumab should be avoided because of their potential interference with the pharmacodynamic activity and efficacy of pembrolizumab. Corticosteroids can be used as premedication, when pembrolizumab is used in combination with chemotherapy, as antiemetic prophylaxis and/or to alleviate chemotherapy-related adverse reactions. FERTILITY, PREGNANCY AND LACTATION Women of childbearing potential Women of childbearing potential should use effective contraception during treatment with pembrolizumab and for at least 4 months after the last dose of pembrolizumab. Pregnancy No data on use in pregnant women. Do not use during pregnancy unless the clinical condition of the woman requires treatment with pembrolizumab. Breast-feeding It is unknown whether pembrolizumab is secreted in human milk. A risk to newborns/ infants cannot be excluded. Fertility No clinical data available. SIDE EFFECTS Refer to SmPC for complete information on side effects. Pembrolizumab is most commonly associated with immune-related adverse reactions. Most of these reactions resolved with appropriate medical treatment or withdrawal of pembrolizumab. The most serious adverse reactions were immune-and infusion-related adverse reactions. Monotherapy: Very Common: anaemia, hypothyroidism, decreased appetite, headache, dyspnea, cough, abdominal pain, nausea, vomiting, constipation, musculoskeletal pain, arthralgia, asthenia, oedema, pyrexia, diarrhoea, rash, pruritus, fatigue. Common: pneumonia, thrombocytopaenia, lymphopaenia, hyponatraemia, hypokalaemia, hypocalcaemia, insomnia, neuropathy peripheral, lethargy, dry eye, cardiac arrhythmia (including atrial fibrillation), hypertension, hyperthyroidism, insomnia, dizziness, dysgeusia, pneumonitis, colitis, dry mouth, severe skin reactions, vitiligo, dry skin, alopecia, eczema, dermatitis acneiform, erythema,
myositis, pain in extremity, arthritis, influenza like illness, chills, AST and ALT increases, hypercalcaemia, increase in blood alkaline phosphatase, blood bilirubin increased, blood creatinine increased, infusion related reaction. Frequency not known: solid organ transplant rejection Combination with chemotherapy: Very Common: anaemia, neutropaenia, thrombocytopaenia, hypokalaemia, decreased appetite, dizziness, neuropathy peripheral, dysgeusia, headache, dyspnoea, cough, abdominal pain, alopecia, diarrhoea, nausea, vomiting, constipation, rash, pruritus, musculoskeletal pain, arthralgia, pyrexia, fatigue, asthenia, oedema, blood creatinine increased. Common: pneumonia, febrile neutropaenia, leukopaenia, lymphopaenia, infusion related reaction, hypothyroidism, hyperthyroidism, hyponatraemia, hypocalcaemia, insomnia, lethargy, dry eye, cardiac arrhythmia (including atrial fibrillation), hypertension, pneumonitis, colitis, dry mouth, severe skin reactions, erythema, dry skin, myositis, pain in extremity, arthritis, nephritis, acute kidney injury, chills, influenza-like illness, hypercalcaemia, ALT increase, AST increased, blood alkaline phosphatase increased. Combination with axitinib: Very Common: hyperthyroidism, hypothyroidism, decreased appetite, headache, dysgeusia, hypertension, dyspnoea, cough, dysphonia, diarrhoea, abdominal pain, nausea, vomiting, constipation, palmar-plantar erythrodysaesthesia syndrome, rash, pruritus, musculoskeletal pain, arthralgia, pain in extremity, fatigue, asthenia, pyrexia, alanine aminotransferase increased, aspartate aminotransferase increased, blood creatinine increased. Common: pneumonia, anaemia, neutropaenia, leukopaenia, thrombocytopaenia, infusion related reaction, hypophysitis, thyroiditis, adrenal insufficiency, hypokalaemia, hyponatraemia, hypocalcaemia, insomnia, dizziness, lethargy, neuropathy peripheral, dry eye, cardiac arrhythmia (including atrial fibrillation), pneumonitis, colitis, dry mouth, hepatitis, severe skin reactions, dermatitis acneiform, dermatitis, dry skin, alopecia, eczema, erythema, myositis, arthritis, tenosynovitis, acute kidney injury, nephritis, oedema, influenza like illness, chills, blood alkaline phosphatase increased, hypercalcaemia, blood bilirubin increased PACKAGE QUANTITIES KEYTRUDA 25 mg/mL: 4 mL of concentrate in a 10 mL
Type I clear glass vial. Legal Category: POM. Marketing Authorisation numbers EU/1/15/1024/002 Marketing Authorisation holder Merck Sharp
5 October 2020
Q1 Which golfer won the Dubai Duty Free Irish Open?
Q2 For the first time ever two of cycling’s grand tours will overlap, when staged this month. They are the Giro d’Italia and which other event?
Q3 Who won the Russian Grand Prix in Sochi last month?
Q4 Which Italian club knocked Shamrock Rovers out of the Europa League last month?
Q5 The All-Ireland GAA Championship will finally commence in the coming weeks. Who are the defending hurling champions?
Q6 Name the Cork teenager who knocked World Champion Ronnie O’Sullivan out of the European Masters Snooker Championships last month?
The winner of the 14 September Sporting Quiz Competition is Dr Ken Ruigrok, Skerries, Co Dublin
The winner of the 14 September 2020 Crossword is Dr Charles O’Toole, Co Wexford
Q1 Who won the second tennis major, the US Open women’s singles championship?
A: Naomi Osaka
Q2 Arsenal added the FA Community Shield to their recent FA Cup victory last month. Name the Arsenal manager who guided them to this success?
A: Mikel Arteta
Q3 Who is the Irish cyclist currently contesting the sprinters green jersey in the Tour de France. A: Sam Bennett
Q4 What year did Team Jordan have a 1-2 finish in the Belgian Grand Prix? A: 1998
Q5 Who scored Ireland’s equaliser in Stephen Kenny’s opening fixture as Ireland manager? A: Shane Duffy
Q6 Who shocked Dylan White in a recent world heavyweight bout, knocking him out in the 5th round? A: Alexander Povetkin
DOWN
1 Small deliberative assembly (9)
5 Writer (6)
6 Equine animal (5)
12 Corridor (7)
16 - Propel with force (6)
TITLE: ‘Psychopath? Why We Are Charmed by the Anti-Hero’
AUTHOR: Dr Stephen McWilliams
PUBLISHER: Mercier Press 2020
REVIEWER: Prof Brendan Kelly
In real life, psychopaths commonly leave a trail of terrible destruction in their wake: Emotional chaos, financial ruin and – in the worst cases – the obliteration of innocent lives. In fiction and film, however, the cutting edges of psychopaths’ actions are transformed into surprising narrative turns, thrilling psychological twists and complex stories of manipulation and deceit that fascinate as much as they repel. All too often, we find ourselves siding with the fictional psychopath or, at the very least, longing to see more of their fiendish goings on. Why?
The reasons underpinning this state of affairs lie at the heart of Dr Stephen McWilliams’ wonderful new book, Psychopath? Why we are charmed by the anti-hero. A graduate of the RCSI, McWilliams is a consultant psychiatrist at Saint John of God Hospital, associate clinical professor at UCD School of Medicine and Medical Sciences, and medical editor of Hospital
Doctor of Ireland. In addition to his medical degree, McWilliams holds a masters degree in medical education (MMEd) and a doctorate in medicine (MD).
Readers of the medical press will be very familiar with McWilliams’ writing. He has authored or co-authored over 250 articles, contributed to three books and written four books himself, including The witchdoctor of Chisale, The China trials, and Fiction and physicians: Medicine through the eyes of writers. The latter is an especially interesting collection of essays, brief biographies and reviews that relate to medicine in the context of literature and looks at doctors writing fiction, ranging from Nostradamus to Oliver Wendell Holmes to Robin Cook.
McWilliams’ encyclopaedic knowledge of literature is evident again in his new book about psychopaths and the vital roles that they play in fiction, film, and television. With grace and assurance, McWilliams takes us through the history of the concept of psychopathy and, especially, the “Psychopathy Checklist” devised by Canadian psychologist Robert D Hare.
This checklist has become the gold standard for diagnosing psychopathy and McWilliams makes excellent use of it throughout his book.
So, what are the key features of psychopathy? These include, but are not limited to: Glibness, grandiosity, pathological lying, manipulation, shallow affect, lack of empathy and remorse, no sense of responsibility, parasitic lifestyle, need for stimulation, promiscuity, and poor behavioural controls. There is often also juvenile delinquency and criminal versatility, among other undesirable and troubling characteristics.
Having armed us with this knowledge, McWilliams then guides us through a bewildering array of fictional psychopaths ranging from Amy Elliott Dunne in Gone Girl to Hannibal Lecter in The Silence of the Lambs, from Tom Ripley in The Talented Mr Ripley to Tony Soprano in the television series The Sopranos, and from James Bond in the Ian Fleming novels to the deplorable Frank Underwood in the television series House of Cards. McWilliams’ cast of characters is both deeply interesting and oddly disturbing –a perfect reflection of the psychopaths that they all seem to be.
Despite the psychopathic traits that all of these characters share, there is still great diversity in the bunch. Some psychopaths are “amazing” while others are “gothic” or “sinister” and some are “secret psychopaths” – a concept to send desperate chills up the sturdiest of spines. And, then, some are just “gangsters”.
Throughout this parade of loveliness and awfulness combined, McWilliams remains consistently focused on why, precisely, these characters can be considered psychopaths and what it is about them that makes them so likeable to readers and viewers.
Towards the end of the book, McWilliams finishes his journey by expressing views about which of his fictional psychopaths are the most psychopathic and which are the most likeable. You will need to buy and read this excellent book to find out the answers to these ultimate questions. But there is also much to treasure along the way, as McWilliams parades his rich and dizzying array of psychopaths from fiction and film, ranging from the socially adjusted, highly skilled professionals who save our lives to
the criminal predators who repel us, fascinate us, and occasionally kill us.
One of the many points that this book demonstrates is that psychopaths are, as McWilliams writes, utterly essential in fiction. As a result, McWilliams’ book is a glorious compendium of raffish, seductive, destructive characters who charm their way into our hearts and then destroy us from the inside out. And we love to read about them, watch them, and experience the vicarious thrill of proximity to fictional danger, destruction and, on occasion, pure evil.
Psychopath? is the perfect book for anyone who has ever been charmed by an anti-hero, rooted for a villain or fallen in love with a character who was just bad news from the get-go. It is also essential reading for anyone who knows, or is, a psychopath. As Dr Maurice Guéret comments on the front cover, it is “the perfect read to go with fava beans and a nice Chianti...”.
Prof Brendan Kelly is Professor of Psychiatry at Trinity College Dublin and author of The Doctor Who Sat For A Year (Gill, 2019)
Mr Paul Redmond outlines the financial support options available to GPs during the Covid-19 crisis
Covid-19 has affected all sectors of our lives. In particular, our economy and our financial lives have been impacted severely, with those within our public health service and our GP practices now on the frontline tackling the crisis.
Many busy GP practices who were used to regular sustainable income from private patients were suddenly affected by a nationwide lockdown and patients were unable to attend the practice for routine appointments. This may have impacted the cashflow.
GP practices would, pre-Covid-19, have enjoyed healthy cashflows and profits each year and accessing funding was never needed or considered. With this unexpected drop in income:
• What course of action is needed?
• Is finance required?
• What is available to a GP?
The Government has implemented financial supports to assist GPs during this crisis with a view to being able to keep their practices open, staff employed, and cashflow managed.
How to decide if finance is required?
Cashflow analsysis
Speak to your accountant and work on a cashflow plan. Be flexible and
open minded to changing your existing habits and procedures; new ones may be needed to guide you through this crisis. Your accounts may show a decrease in revenue that is needed to continue to practice. It may show that a short-term finance option is needed to get through.
Who do I contact?
There are a multitude of websites and social media articles highlighting these options. However, these can be overwhelming and contradictory. Keep it simple. Research official Government websites, citizens advice, and official bank websites or your own accountant. Try to avoid overloading yourself with information.
First stop should be your own bank where you are a valued customer. They have relationship managers available who have likely been in contact already. They have updated all their websites with specific Covid-19 helplines and have measures in place to assist.
Supports available are as follows
General help
• Commercial rates: The commercial rates are being waived for six months from March 2020 to September 2020. This is available from
your local rates office within the county council.
• Annual returns and tax returns: Revenue has advice for practices experiencing trading difficulties in all areas including tax returns, late payments, debt enforcement, and tax clearance. The Revenue website contains all links and information.
• Warehousing of tax liabilities: Covid-19-related VAT and payroll tax debts, due from 1 March 2020 to the date when sectoral restrictions are lifted, will be deferred for a period of 12 months. There will be no debt enforcement action taken by Revenue and no interest charge accruing for warehoused debit.
Cashflow supports
• Restart grant: Grant available based on 2019 rates already paid up to a maximum of €25,000, available to all businesses and can be applied for through local county council. This will be paid to your bank account as clear funds, not used against other rates due. These are available to medical practices whose
income has been reduced by 25 per cent as a result of Covid. The Government has also added an additional 20 per cent top up to businesses in Laois and Offaly known as Restart Grant Plus and an additional 40 per cent for those in Kildare as a support.
• SBCI Covid loan: Available from SBCI to businesses negatively impacted by 15 per cent, providing bank finance supported by Government. Loans up to €2.5 million are available through high street banks. The interest rate is fixed and there are no early penalties for repayment.
• Microfinance Ireland loan available to companies with 10 or fewer employees. A three-year loan up to €50,000 is available for businesses impacted negatively by 15 per cent due to Covid.
• Business continuity voucher: These are available from your Local Enterprise Office for any practices with up to 50 employees. There is a funding support of €2,500 available towards third party consultancy costs to assist in developing strategies to respond to the crisis.
• Online trading voucher: These are available from your local enterprise office and are for the value of €2,500. These funds are to be used to update websites and are invaluable for GPs with health information changing so regularly from HSE and the National Public Health Emergency Team.
All these supports are available readily and statistics released by the Government on 22 July 2020 show the exact amount of these funds already paid to date. These are unprecedented times and regardless of your financial situation pre-Covid-19, every sector of the economy has been impacted negatively. Apply for the supports and remember, if any borrowings are not used, they can be returned to the lender, often without penalties.
If you wish to receive further information on any item within the article, contact your accountant or financial advisor.
Mr Paul Redmond (CPA,QFA, FAIA) is Managing Partner of RDA Accountants Limited. He is a member of the Institute of Certified Public Accountants. He is also a Fellow of the Association of International Accountants and a qualified financial advisor
When I was handed the keys to the allnew SEAT Leon, the brand-neutral delivery agent said, “it’s so good, I can’t believe Volkswagen let them build it.”
Well if that isn’t high praise, I don’t know what is. I’ve been a fan of new SEATs for a number of years now; the cars have been stylish and sporty in a way that SEAT just wasn’t, back in my day. With the help of their German overmasters, Volkswagen-Audi Group, they have brought the marque on in leaps and bounds, akin to the trajectory Skoda have seen over the past 20 years.
This new Leon has its sights set firmly on the mothership’s hit record, the Golf, and this time around, it looks like it might have more to offer than the champ. First things first; it looks great, better than a Golf, aside from the shoddy font they used to write Leon across the back, which resembles something from a nightclub in Playa del Ingles. Whoever
in SEAT signed off on that needs to walk the plank. Aside from that little blip, the Spanish Golf gobbler looks and drives very, very, well, especially considering its price-point when compared to Volkswagen’s superstar.
The model I was given the keys to is the 1.5 litre, eTSI, petrol-powered Leon NF FR, which boasts a new mild electric hybrid set up. I’ve yet to meet a mild hybrid system that I’ve noticed, but I’m sure it was working away in the background. The FRs are sportier versions and mine was in stunning ‘desire red’. The car has the tried and tested DSG automatic gearbox with flappy paddles and the 1.5 litre sTSI engine produces 150hp, which, I must admit, feels adequate. Something I rarely say about a car under 180hp that isn’t
a bantamweight. The steering felt tight and responsive and altogether well sorted. The FR models come with sports suspension as standard, giving the car oodles of grip on windy, soggy, leaf-logged autumn roads. The FR models also come with goodies like LED headlights, electric door mirrors, wireless phone chargers and rain-sensing wipers, as standard. Sitting in the Leon is perfectly comfortable, the plastics used in the cockpit are of a high standard and the overall layout feels ergonomic without feeling cluttered. The infotainment system is intuitive and simple with an acceptable user experience for an in-car computer. There’s also loads of rear legroom, more than a Golf or Ford Focus, and a sizeable enough boot for golf clubs,
shopping or a few Labradors.
The new Leon is offered with five engine options, two of which are petrol, including a 1.0 litre (110hp) and 1.5 litre (150hp) motor. For diesel lovers, the options are a 2.0 (115hp) or a 2.0 (150hp), while the newest edition to the range, the mild electric hybrid 1.5 petrol (150hp) is also available. I’ve yet to meet a mild hybrid system I thought was impressive, but I’m always open to being proven wrong.
Some of the other things the Leon FR comes with are: 18-inch rims; air conditioning; a fully digital cockpit; some very cool dynamic rear indicators; the all-important parking cameras; and SEAT’s Connect service that allows you to remotely access your car’s data via the SEAT App.
The SEAT Leon’s party piece though, is that it starts at €23,910 or €239 on PCP.
However, that is the starting price and bottom of the range cars are often bought by people who don’t understand what they’re doing and only want new reg-plates to show the neighbours.
The FR model I tested, with the 1.5 litre eTSI engine, sits at the other end of the price range at €30,890 or €35,674 if you get all the bells and whistles I had. But for that you are getting a quality car that you will enjoy spending time in. Even at that price, it’s still a bargain compared to the Volkswagen Golf (€27,305 for the entry-level).
Test drive this car and prepare to be surprised by how good it is.
1.5
Colour: Desire Red
Co2: 109g/km
Vehicle Price: : €30,890
Option Price: €4,784
Total €35,674
National Intensive Care Covid-19 Research and Scientific Conference, 5 September 2020
By combining genomic testing and next generation sequencing technology, a new partnership led by RCSI researchers aims to advance predictive tests for multiple myeloma (MM), the second most common blood cancer in Ireland.
The study will be carried out at Beaumont Hospital, Dublin, and run through the Blood Cancer Network Ireland with several other cancer hospitals in Ireland participating. It represents a collaboration between RCSI University of Medicine and Health Sciences and SkylineDx with funding support from Amgen; Celgene, a Bristol Myers Squibb company; and Janssen.
Multiple myeloma is a cancer of plasma cells in the bone marrow that normally produce antibodies to help fight infection. Approximately 250 patients are diagnosed with this condition in Ireland every year. Globally the incidence of this disease is rising, due to population growth, an aging world population and a rise in age-specific incidence rates. Due to the complex nature of the disease, patients often require multidisciplinary medical input and myeloma drugs are amongst the highest cost therapies worldwide.
Due to improvements in new treatments for multiple myeloma, the outlook for patients has greatly improved with survival times and treatment free intervals increasing. However, in 2020 multiple myeloma is still considered an incurable disease, with the majority of patients following a relapsing course and requiring further treatment. According to the National Cancer Registry Ireland, the five-year survival of multiple myeloma patients is approximately 50 per cent, in keeping with international best standards, but greater advances in therapy and knowledge is required to improve this figure.
Predicting the course of the disease and guiding treatment choice in newly diagnosed patients is one of the major challenges in this cancer. Currently available tests at diagnosis fall short of providing this information to patients and haematologists. Newly developed tests over the last number of years are helping to do this and an example is a minimal residual disease test. This is a test performed on the patient’s DNA at diagnosis by next generation sequencing, which can detect if there are trace amounts of the cancer remaining in a patient after treatment, and has been shown to be highly predic-
tive of long-term outcomes in several studies. Another test that can help to predict patients outcomes has been developed by SkylineDx, which uses a novel gene expression based test to guide prognosis called the ‘MMprofiler’.
At Beaumont and RCSI, in collaboration with SkylineDx, scientists have implemented these novel gene-based tests SkylineDx for the testing of MM patients in order to guide prognosis. This test called ‘MM profiler with SKY92’ establishes if patients have a high risk of relapsing and has been increasingly adopted in global clinical trials as a more predictive and robust marker than older tests like fluorescence in-situ hybridization. This study at RCSI and Beaumont aims to combine these two highly predictive modalities to provide a personalized medicine approach for patients.
This in-depth analysis of genetic risk could enable doctors to identify which patients are at highrisk of relapse after a stem cell transplant. With this knowledge, it may in the future be possible to refine treatment for individual patients based on their specific disease molecular signature.
“If our study can definitively determine which patients will benefit from certain treatments, and when, it will provide clinicians with invaluable information that will lead to better outcomes for patients with multiple myeloma,” said Dr Siobhan Glavey, Honorary Senior Lecturer at RCSI, Consultant Haematologist at Beaumont Hospital and the project’s Principal Investigator.
“As we move toward personalised medicine, studies like ours will hopefully become more and more common and will help to target high cost-effective therapies with greater precision. The study will initially enrol a small number of patients and follow them over time to test this theory.”
THERAPY PROGRAMME IN LIGHT OF COVID-19
Saint John of God Hospital has launched a new online therapy programme for people whose mental health has been impacted by Covid-19 and associated restrictions.
The hospital recently reported a dramatic increase in admissions and referrals from new and existing patients with mood and anxiety disorders, addictions and issues relating to severe social isolation and relationship tensions, with up to half of admissions and referrals since May related to Covid-19 anxiety and restrictions. Acute work-related stress has also seen a number of healthcare workers being admitted to the hospital.
‘Living Well in the New Normal’ is a cognitive behavioural therapy-based programme which has been designed and written by Dr Keith Gaynor, Senior Clinical Psychologist, author and academic. Speaking about the programme, Dr Gaynor said: “Normally anxiety management courses have the message that we are too anxious and that the risks we face are small. In the middle of this international health emergency, it is clear that this isn’t true. The risks are real and very serious. If we haven’t been impacted medically, then we probably have been affected economically or socially. We must create new
ways of understanding ourselves in this new normal.”
Chief Executive of the hospital, Ms Emma Balmaine, said: “We have felt compelled to design and deliver appropriate interventions aimed at providing substantial responses to the intense pressure that Covid-19 restrictions continue to place on people. We are fortunate to have specialist and committed clinicians who have risen to this challenge and who are delivering creative and responsive therapeutic responses.
“We are seeing that such responses are absolutely necessary and we expect that demand for our services will intensify in the months ahead as many aspects of life stabilise and the country continues to reopen. Additional planning has been necessary to ensure that Saint John of God Hospital is in a position to respond to the mental health needs of our patients at this time.
“Current admission patterns suggest that those who have long standing mental health issues may need increased support at this time, but we are also seeing a lot of new referrals from people experiencing mental health challenges as a result of the Covid-19 crisis.”
A startup company developing treatments for inflammatory diseases based on a research partnership between the University of Queensland (UQ) and Trinity College Dublin has been acquired in a landmark deal, one of the largest in Australian and Irish biotech history.
Inflazome has been acquired by Roche for an upfront cash payment of €380 million, plus additional payments based on the achievement of certain milestones.
The company was founded in 2016 following a research collaboration between UQ and Trinity, with UQ’s technology transfer company UniQuest leading the commercialisation of the resulting intellectual property.
Headquartered in Dublin, the company is developing drugs to address clinical unmet needs in inflammatory diseases by targeting inflammasomes, which are understood to drive many chronic inflammatory conditions. The acquisition gives Roche full rights to Inflazome’s portfolio of inflammasome inhibitors.
UQ Vice-Chancellor and President Prof Deborah Terry welcomed the acquisition and congratulated those involved.
“This is an outstanding outcome for the company, both universities, the researchers and the investors.
“Now more than ever, the value of research translation to support the recovery of our economies cannot be understated. This deal reinforces the importance of research collaboration and shows what can be achieved through commercialisation.”
Trinity College Dublin Provost Dr Patrick Prendergast added his congratulations.
“This is wonderful news, first for the many people across the world with diseases like
Parkinson’s who stand to benefit from these discoveries.
“It is also a boost for the Irish scientific community and for Trinity College Dublin, where the ideas originated that led to the collaboration with UQ and the subsequent foundation of Inflazome. Investigator-led research drives the innovation economy, and this news offers tangible evidence of its importance and what can be achieved through partnership. We congratulate all the researchers involved for their tireless commitment to discovery and innovation and for making a real difference in society.”
In a joint statement, UniQuest CEO Dr Dean Moss and Trinity Research and Innovation Director Mr Leonard Hobbs said the deal echoed global market confidence in the quality of research at Trinity and UQ. “This is one of the largest Australian and Irish biotech deals and follows the company’s Series B capital raise of A$63 million in 2018. It’s wonderful to see it eventuate, bringing much-needed treatment options a step closer to reality.”
Two of the company’s drug candidates are in clinical trials for the treatment of debilitating conditions such as cardiovascular disease, arthritis and neurodegenerative diseases such as Parkinson’s, Alzheimer’s and motor neuron disease. The intellectual property behind Inflazome’s drug candidates is based on a research partnership between Prof Matt Cooper, Prof Kate Schroder, Dr Rebecca Col, and Dr Avril Robertson from UQ’s Institute for Molecular Bioscience and Prof Luke O’Neill from Trinity College Dublin. Inflazome is supported by a syndicate of investors, including Novartis Venture Fund and Fountain Healthcare Partners, Longitude Capital and Forbion.
MALLOW GENERAL HOSPITAL APPOINTS FIRST ADVANCED NURSE PRACTITIONER IN HEART FAILURE
Mallow General Hospital (MGH), which is part of the South/South West Hospital Group, has announced the registration of Ms Mairead Lehane as the hospital’s first Advanced Nurse Practitioner (ANP).
Ms Lehane, who has been working at MGH since 2001, will be based in the heart failure clinic and is the third ANP to be appointed to a heart failure post in Ireland.
Prior to her new role, Ms Lehane completed her ANP training in MGH and Cork University Hospital (CUH), which involved 500 hours of supervised clinical practice. As an ANP working in the heart failure clinic, Ms Lehane will work with the cardiology teams based in MGH and CUH to deliver a hub and spoke model of heart failure care. Patients will receive heart failure care in CUH and then access out-patient heart failure treatment locally in MGH.
Commenting on the appointment, Ms Claire Crowley, General Manager at MGH, said: “Management at Mallow General Hospital would like to congratulate Mairead Lehane on her registration as the first ANP in heart failure in the hospital. This appointment is significant, particularly given that Mairead is the third ANP to work in this area in Ireland. The heart failure clinic has been operating in the hospital since 2013, and internationally, heart failure clinics have a profound impact on mortality rates and hospital avoidance. Against the backdrop of an aging population and an increase in chronic disease, Mairead’s new role is responsive to the government policy of Slaintécare, bringing care closer to the patients.”
Ms Lehane completed her general nurse training in CUH in 1994 and undertook a diploma in high dependency nursing and high-
er diploma in coronary care nursing while working in London in Charing Cross Hospital and St Mary’s Hospital. During her time as a Clinical Nurse Specialist in MGH, she developed a range of innovative and forward-thinking cardiac services. These include a cardiac rehabilitation service in 2001, Cardiac Support Group North in Cork in 2008 and a heart failure clinic in 2013. Ms Lehane also graduated with a first-class honour in nurse prescribing in 2014, won an innovation award to develop a complex behavioural intervention, graduated with a master’s by research degree from University College Cork in 2018 and attained a PG Certificate in Advanced Practice in 2020.
Ms Lehane is also a co-founding member of the Irish Association of Heart Failure Nurses, a member of the Executive Committee of the Irish Nurses Cardiovascular Association and is currently one of five Irish nurses collaborating with heart failure nurse leaders in the UK, Scotland and Wales to research the impact of Covid-19 on heart failure service delivery.
Welcoming the new ANP to her post, Ms Patricia Moloney, Director of Nursing, said: “Advanced Nurse Practitioners are highly experienced and autonomous practitioners. They use advanced specialist knowledge and critical thinking skills to independently provide optimum patient caseload management. Mairead has never accepted the status quo; always striving to positively and compassionately impact service delivery while working to the patient-centred ethos of a model two hospital. Using her leadership, knowledge translation and research skills, she will be a strong role model for the other clinical nurse specialists, nurse prescribers, and nurses in MGH.”
Advertise today, email louis@mindo.ie
GP REQUIRED FOR CORK CITY PRACTICE
GP required for busy Cork City centre practice. Fully computerised. Fully supported with 2 doctors, 2 nurses, admin staff, and practice manager. No house calls. Parking provided. 4-to-6 sessions available per week.
Please contact Maria for more details at maria.odriscoll@gtv.ie
GP REQUIRED WITH INTEREST IN WOMEN’S HEALTH IN DUNDALK
GP required on a long-term basis either full-time or part-time. Full computerised. We have full nursing and administrative support with no out-of-hours or weekend work. We are a long-established family-friendly progressive practice. If interested and would like more information:
Please email to: parkavenuesurgery@gmail.com
GP REQUIRED – ATHLONE TOWN
Vocationally trained GP required for a fully computerised (Socrates) urban/rural teaching practice in Athlone town.
We are offering an excellent salary with a view to early Partnership for the right candidate. We have full nursing and administrative support. We are part of MIDOC out-of-hours service with minimal on-call hours.
We are a vibrant, progressive, family-friendly practice. The position would suit someone looking to work in the area long-term. We will cover Medisec, ICGP or NEG’s subscriptions for the successful candidate.
Athlone is a lovely town situated on the river Shannon within easy access of Galway and Dublin. There are great schools, restaurants, shopping, arts, cycle way, sports, hotels, and all the usual amenities.
We have a fantastic quality-of-life.The commute time to work and to the countryside is approximately 10 minutes.
If interested please email your CV to Della Kenny, Practice Manager at info@towncentresurgery.ie
FULL-TIME ASSISTANT REQUIRED FOR PLEASANT RURAL PRACTICE IN COOLE, CO WESTMEATH.
1 hour from Dublin. Attractive terms and conditions on offer. Please forward CV and references to drpatcullen@gmail.com
GP REQUIRED LONG-TERM – CO LOUTH
• Permanent GP required in an established, well located, busy and growing practice
• Partnership opportunity with immediate profit-share option for the right person
• Immediate start available with long-term potential
• Between 6 – 8 sessions available immediately and increasing
• Excellent nurse and admin support
• Fully computerised using Socrates
• MICGP/MRCGP or equivalent essential Contact: dundealgandoc@gmail.com
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.
These suites would suit many uses due to the high footfall passing the door every day. The suites are 5 minutes walk from Grafton Street with several amenities close by. There is direct access from all areas of Dublin to the suites via the Dart and Bus and The Luas runs to Dawson Street, 5 minutes walk away. There is a big concentration of new businesses in the area. Trinity College, Merrion Square and Pearse Street are on the doorstep. Very favourable and flexible terms.
2 Suites available ❚ self-contained ❚ bathroom/waiting room/consulting rooms ❚ 440sq feet and 690sq feet ❚ both newly renovated ❚ high speed broadband, etc.
Please contact Mary Anne on 087 6394946 for further information or to arrange viewing
If you have anything you would like to share, please email: info@mindo.ie
Doug Witherspoon
When discussing the SARS-CoV-2 pandemic, it has become obligatory to add the phrase ‘at time of writing’. This is done in the full knowledge that what is written in the current context now may be a historical footnote in two weeks’ time.
And so, ‘at the time of writing’, the rates of infection are still creeping up, as are ICU admissions, while restrictions on movement are being more tightly applied, particularly in Dublin and Donegal. Most pubs have had to pull the shutters down again and health authorities are, as the saying goes, ‘not ruling out’ another general lockdown in an attempt to slow the spread of the virus.
Perhaps therein lies the rub — lockdown does not kill the virus, but rather merely slows down the spread, although in
certain media outlets, the narrative has changed and instead of ‘flattening curves’, it’s sometimes being suggested that lockdown can ‘crush’ or ‘eliminate’ the virus. As I have written previously, certain media sources could be a bit more responsible when it comes to the melodramatic rhetoric they employ.
Details of the adverse health consequences of the first lockdown are emerging in drip-feed fashion. The most obvious of these consequences and perhaps the most difficult to evaluate metrically, are of course the effects on people’s mental health. The isolation of the first lockdown has of course hit the elderly hard, a demographic of people who were dealing with an epidemic of loneliness before people
▼This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse reactions.
***Co-primary endpoints were change from baseline in trough FEV1 and SGRQ at week 24 (n=1810). A subset of patients (n=430) remained on
Ellipta SmPC 2019. 2. Lipson DA et al. Am J Respir Crit Care Med 2017; 196:438–446. 3. Lipson DA et al.N Engl J Med 2018; 378:1671–1680.
and vilanterol as trifenatate (VI) 25 mcg provides a delivered dose of 92 mcg FF, 55 mcg UMEC and 22 mcg VI. Indications: Maintenance treatment in adult patients with moderate to severe COPD who are not adequately treated by a combination of an inhaled corticosteroid (ICS) and a long-acting ß -agonist (LABA) or a combination of a LABA and a long acting muscarinic antagonist. Dosage and administration: One inhalation once daily at the same time each day. Contraindications: Hypersensitivity to the active substances or to any of the excipients (lactose monohydrate & magnesium stearate). Precautions: Paradoxical bronchospasm, unstable or life-threatening cardiovascular disease or heart rhythm abnormalities, convulsive disorders or thyrotoxicosis, pulmonary tuberculosis or patients with chronic or untreated infections, narrow-angle glaucoma, urinary retention, hypokalaemia, patients predisposed to low levels of serum potassium, diabetes mellitus. In patients with moderate to severe hepatic impairment patients should be monitored for systemic corticosteroid-related adverse reactions. Eye symptoms such as blurred vision may be due to underlying serious conditions such as cataract, glaucoma or central serous chorioretinopathy (CSCR); consider referral to ophthalmologist. Increased incidence of pneumonia has been observed in patients with COPD receiving inhaled corticosteroids. Risk factors for pneumonia include: current smokers, old age, patients with a history of prior pneumonia, patients with a low body mass index and severe COPD. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take Trelegy. Acute symptoms: Not for acute symptoms, use short-acting inhaled bronchodilator. Warn patients to seek medical advice if short-acting inhaled bronchodilator use increases. Therapy should not be abruptly stopped without physician supervision due to risk of symptom recurrence. Systemic effects: Systemic effects of ICSs may occur, particularly at high doses for long periods, but much less likely than with oral corticosteroids. Interactions with other medicinal products: Caution should be exercised with concurrent use of ß-blockers. Caution is advised when co-administering with strong CYP3A4 inhibitors (e.g. ketoconazole, ritonavir, cobicistat-containing products), hypokalaemic treatments or non-potassium-sparing diuretics. Co-administration with other long-acting muscarinic antagonists or
long acting ß2-adrenergic agonists is not recommended. Pregnancy and breast-feeding: Experience limited. Balance risks against benefits. Side effects: Common (≥1/100 to <1/10): pneumonia, upper respiratory tract infection, bronchitis, pharyngitis, rhinitis, sinusitis,
even knew the abbreviation ‘NPHET’, before Drs Holohan and Glynn were famous nationwide and before the concept of ‘social distancing’ was ever heard of.
Some of the elderly defied the lockdown and decided to take their chances and if another lockdown is imposed, it’s reasonable to expect that the numbers of elderly people who defy it will increase.
And then there are the effects on physical conditions — the delayed diagnoses, the missed treatment appointments, the near-empty emergency departments, and the cancellation/postponement of elective procedures, which are considered non-essential, but many of which have had a significant impact on people’s quality-of-life.
In all of this, it must be kept in mind that people with chronic illness are by their nature more vulnerable to psychological distress and for many of them, lockdown provided a sort of ‘tipping point’, a phrase the UK government has become very fond of using lately. A study published in Frontiers in Psychology in August highlighted that estimates predict approximately 18,000 excess cancer deaths over the next 12 months as a result of the Covid-19 emergency, with the authors pointing out that “across eight hospitals in the UK, a majority of patients with cancer or suspected cancer were not accessing healthcare services, with major declines in chemotherapy attendances (60 per cent reduction) and urgent referrals for early diagnosis (76 per cent reduction)”. Needless to say, early diagnosis and treatment are vital in a range of conditions, not least cancer.
And then there is the number of people with cardiovascular disease who have been slipping through the cracks. A European Society of Cardiology (ESC) survey earlier this year comprised 3,101 healthcare practitioners involved in the treatment of STEMI patients in 141 countries. Among the main findings were that fewer severe heart attack patients attended hospitals — 78.8 per cent of the respondents spoke of a decrease in the number of STEMI patients coming to their hospitals and overall, the number of patients admitted to hospital had decreased by 50 per cent on average.
A further 62.3 per cent of the ESC survey respondents stated that at the height of the pandemic, STEMI patients presented later, beyond the window for percutaneous coronary intervention/thrombolysis and overall, the percentage of patients presenting later than usual was estimated to be 48 per cent on average.
No doubt the specialties of rheumatology, neurology, psychiatry, dermatology, paediatrics, and many more have their own tales to tell on how the lockdown affected their clinics and patient care.
All of the above do not even touch on the serious impact the lockdown had on increased rates of domestic violence, higher prevalence of alcohol abuse, and the consequences for an already battered economy; recession and economic hardship themselves are known to have adverse health consequences. All of that, as they say, is beyond the scope of this article.
In life, everything is a trade-off and if another lockdown is being pondered, it should be thought about very carefully indeed to make sure that, for some people at least, the cure doesn’t turn out to be more harmful than the disease.