NiGP Jan-Feb 2023

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ISSUE 1 VOLUME 16 JANUARY-FEBRUARY 2023 IRELAND’S INDEPENDENT JOURNAL FOR GENERAL PRACTICE NURSES INFANT FEEDING Preventing and managing lactational mastitis WOMEN’S HEALTH  CAM therapies in menopause  The A-Z of contraception ASTHMA UPDATE Modification of the GINA guidelines
References Dnord (calcifediol) 255 microgram soft capsules dnord.ie A step ahead in VITAMIN D deficiency1 FAST RESPONSE3 SIMPLE DOSING2 EFFECTIVE THERAPY2,3 PREDICTABLE RESULTS4

A message from Ruth Morrow, Contributing Editor, and the team at NiGP

Welcome to our first edition of 2023. We, at the editorial team, would like to wish you all a happy and healthy New Year, and thank you for the last 12 months of readership. As a fully independent journal, Nursing in General Practice (NiGP) is now brought to general practice nurses (GPNs) by fellow nurses, who understand the complex challenges and demands the role can bring. We are also acutely aware that life-long learning is a key element of both successful practise and clinical excellence, and that for GPNs, this learning frequently happens in your own time and at your own expense.

The team at NiGP would like to continue to make this, and other aspects of your professional and personal development, a little bit easier. We would, therefore, invite you as our readers, to send your suggestions, feedback, and opinions to us in the coming months, and tell us what you would like to discuss, read, and learn about. If you are interested in writing an article or sharing your experiences, we would also love to hear from you.

We kick off 2023 with special features in women’s health, sexual health, infant feeding, dermatology, and respiratory medicine. Our regular and valued contributor, Theresa Lowry-Lehnen, provides an in-depth update on contraception, that will enable you to provide evidenced-based and practical advice to women and their partners, about the best available and most suitable options for pregnancy prevention. Sticking with women’s health, we also explore the evidence regarding the efficacy of complementary and alternative medicine

(CAM) therapies in alleviating problematic menopause symptoms, and whether or not they should play a role in its management. Preliminary and anecdotal evidence is conflicting, but does warrant further investigation in several areas.

Still in women’s health, and extending into family health, this edition also brings you an exploration of lactational mastitis, the commonly encountered complication that can arise during breastfeeding. The evidence would suggest that early implementation of simple, effective, and evidence-based strategies, could prevent the condition exacerbating into more serious stages that can require hospitalisation. Find out what they are, and how you can continue to help your patients reduce their risks of developing the condition, or managing it if it arises. You will also find links to breastfeeding supports for you and your patients in the community.

Also in this edition, Dr David Buckley, Medical Director of the Kerry Skin Clinic, provides a detailed and evidenced-approach to managing acne in general practice. Refresh your memory and read about the common skin condition’s pathophysiology, prevalence, and management, to support patients through their experiences and treatment modalities. Dr Buckley outlines the recommended topical, systemic, and non-pharmacological approaches to care in general practice.

Finally, we examine what’s new in respiratory medicine as we advance into another year of scientific findings. Read highlights from the Irish Thoracic Society’s annual scientific meeting that took place in December, at the Killashee Hotel, Naas. Hot

topics included e-cigarettes, pulmonary hypertension, and the latest updates in asthma management guidelines. Our comprehensive article expands on these updates, and explores the evidence behind GINA’s latest recommendations, that call for changes to a 50-year-old approach in asthma management.

As always, we continue to bring you the latest in healthcare news from around the country. Read about escalating plans for industrial action by the INMO, the ongoing bed crisis, and a potential return to mandatory facemasks in congregated areas. We also deliver updates on the new Human Tissue Bill, and what it means for organ donation in Ireland, alongside the latest launches, innovations, and stories in healthcare.

The team looks forward to bringing you a wide variety of the most up-to-date evidence, recommendations, guidelines, and topics that you want to read about, for another year. We are also looking forward to hearing from, and connecting with you, our readers, so that we can meet your needs, while you meet the broad spectrum of needs your patients present with. Wishing you all a peaceful start to 2023.

NiGP is now a fully independent publication and is no longer the official journal of the IGPNEA. If you are interested in writing an article for NiGP, please email denise@greenx.ie

| EDITORIAL | | NURSING IN GENERAL PRACTICE | JANUARY-FEBRUARY 2023 | 1
Escalating plans for industrial action, the ongoing bed crisis, and a potential return to mandatory facemasks in congregated areas

C ONT ENTS

03 NEWS

All the latest in Irish healthcare news 13

IRISH THORACIC SOCIETY

Read highlights from the Irish Thoracic Society’s Annual Scientific Meeting in December and find out what’s new in respiratory medicine 18

RESPIRATORY MEDICINE

29

INFANT FEEDING

Exploring the best-practice recommendations for preventing and managing lactational mastitis in general practice 35 DERMATOLOGY

Dr David Buckley describes the optimal management of acne in general practice

EDITOR Denise Doherty denise@greenx.ie

CONSULTING EDITOR Ruth Morrow

SUB-EDITOR Emer Keogh emer@greenx.ie

CREATIVE DIRECTOR Laura Kenny laura@greenx.ie

ADVERTISEMENTS Graham Cooke graham@greenx.ie

ADMINISTRATION

Daiva Maciunaite daiva@greenx.ie

Please email editorial enquiries to Denise Doherty denise@greenx.ie

Nursing in General Practice is produced by GreenCross Publishing Ltd (est. 2007).

© Copyright GreenCross Publishing Ltd. 2023

CONTRACEPTION

Ruth Morrow reviews the evidence supporting the recent modifications of the GINA guideline for asthma management 23

WOMEN’S HEALTH

Examining the empirical evidence supporting CAM therapies in the alleviation of menopause symptoms and whether or not they should play a role

Theresa LowryLehnen provides a comprehensive overview of the available methods of contraception for women and men in Ireland 51 PRODUCT NEWS

The latest product news in healthcare 52 CROSSWORD

Try a 10-minute teaser on your tea break

Please email publishing enquiries to Publisher and Director, Graham Cooke graham@greenx.ie

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

DISCLAIMER

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

| IN THIS ISSUE | | NURSING IN GENERAL PRACTICE | 2 | JANUARY-FEBRUARY 2023
42

NEW PARTNERSHIP ANNOUNCED TO INCREASE ACCESS TO DIGITAL MENTAL HEALTH SUPPORTS

The HSE has announced a national partnership with the digital mental health platform SilverCloud to help address the growing need for access to mental health support in Ireland. Through this partnership, clinicians can refer to SilverCloud’s evidence-based digital cognitive behavioural therapy (CBT) programmes. Developed in Ireland in 2012, the multi-award-winning digital mental health platform is a result of nearly 20 years of clinical research with leading academic institutions. Today, SilverCloud is being used by more than 500 organisations globally to meet their populations’ mental health needs. Global experts have clinically proven the platform through fully randomised control trials and real-world data from over one million SilverCloud users. The platform is a leader in the industry, with its effectiveness, engagement, and range of clinical programmes that encompasses the spectrum of mental health needs.

The SilverCloud service operates within the guiding principles outlined in Sharing the Vision, Ireland’s national mental health policy to develop a broad based, whole system mental health policy for the whole population. The service is also closely aligned to both Connecting for Life, Ireland's national strategy to prevent suicide, and Healthy Ireland, the framework for action to improve the health and mental wellbeing of the population of Ireland. This service provides professionally

trained supporters in the area of mental health, who work with individuals to personalise the programme experience, and help them to reach their goals by providing weekly encouragement and ongoing support. The service has seen over 10,000 referrals from Ireland-based GPs, primary care psychologists and counsellors, and Jigsaw during its pilot. A new report published by SilverCloud reviewed the first 18-month application of the service in Ireland and shows:  89 per cent of people provided access to SilverCloud felt that digital CBT would work for them and their needs, prior to commencing a programme.  The overall programme satisfaction rate was 94 per cent post-use.  43 per cent of users with clinical levels of depression

showed reliable improvement.  63 per cent of users with clinical levels of anxiety showed reliable improvement.  Patient engagement with the programmes has seen a broad age range and a representation across all 26 counties.

Jim Ryan, Assistant National Director, HSE Mental Health Operations, said: “Research and recent experience continues to show that people engage well with digital mental health support. Access to an evidencebased programme, such as SilverCloud, to address anxiety and depression, is a really important and helpful addition to the range of supports being provided by the HSE. We have seen some really encouraging results in terms of mental health outcomes from the SilverCloud programme to date. Ken Cahill, Co-founder

of SilverCloud and Head of Behavioural Health, Amwell, said: “On behalf of the entire SilverCloud team, I am excited to see the announcement today of our successful tender award for the provision of guided digital CBT services, a testament to the work we have achieved in partnership with the HSE over the past number of years. Our initial rollout of the service in Ireland has proven to measurably reduce the depression and anxiety symptoms of Irish users. It has also dramatically increased access to mental health support to people right across the country, and we are now successfully supporting overburdened staff and services within our health system.”

You can learn about the programme at: www. silvercloudhealth.com/HSE.

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Derek Chambers, HSE; Ken Cahill, Co-Founder of SilverCloud; Anne Rabbitte, TD; Kevin Burke, service user

INMO calls on the Government to admit that current hospital overcrowding is a crisis, as consultation about industrial action begins

The Irish Nurses and Midwives Organisation (INMO) is calling on the Government and HSE to take immediate action amidst the ongoing overcrowding that continues to affect hospitals nationwide. That action it says, warrants an extraordinary response, and potentially, a return to wearing mandatory face masks in highlypopulated public areas as respiratory infections continue to rise. January 3 saw the number of patients without beds reach 931, the highest number on record since the trade union began counting trolleys in 2006. The IMNO says this crisis is affecting every hospital in Ireland, was avoidable, and had been predicted for months. The Irish Medical Organisation (IMO) has echoed these sentiments, voicing major concerns for doctors working in these environments and describing conditions in the healthcare system as dangerous, unacceptable, and comparable to a “war-zone”.

INMO General Secretary Phil Ní Sheaghdha stated that telling the public

to avoid hospitals is simply not an adequate response, and is calling for “supplemented emergency supports” until the end of February. Reiterating that staff simply cannot continue to withstand the unacceptable and challenging conditions, she warned that many will leave their posts if extraordinary action isn’t taken soon. She said: “Our members are treating patients in the most undignified conditions. This is not the type of care they should be providing in a country that has the resources to provide additional capacity and support. Nurses and other healthcare staff cannot continue to weather this storm without adequate support and protection from their employer. It will add to the increasing intention to leave of staff, which is exactly what this health service does not need…. We need Government to now make difficult decisions, including the return of mandated mask-wearing in congregated settings. We know that one of the main pressure points in our health service is the rise of respiratory infections. Asking people to return

to mask-wearing in busy congregated settings is a simple measure.”

Following an emergency meeting, the Executive Council of the INMO has sanctioned the beginning of a consultation with nurses on a campaign of industrial action over what they say is a crisis brought on by the Government itself. Safe staffing levels, safe skills mix, safe work environments, and solutions to the ongoing overcrowding crisis are priorities to be addressed.

INMO President Karen McGowan said: “We will now begin a period of consultation pertaining to industrial action. Nurses and midwives are being asked to crisis manage a situation that is of our employers’ own making. We know that levels of burnout are at an all-time high. We must now take whatever action is deemed necessary to ensure that we do not endure this level of danger in our workplaces in the coming months and years ahead on a continuous replay mode. We will now commence a series of information and consultation meetings with members over the next month.”

WHO SAYS PASSENGERS ON LONG-HAUL FLIGHTS SHOULD WEAR FACEMASKS

GIVEN RAPID SPREAD

According to the World Health Organisation (WHO), countries should recommend that passengers wear facemasks on long-haul flights in view of the rapid spread of the latest Omicron sub-variant of Covid-19 in the US. Ireland and the rest of Europe removed the requirement to wear

OF NEW VARIANT

masks on planes in May last year, but may see a return to this and other restrictions as the Government confirmed that all arrivals from flights originating in China will have to have a negative Covid-19 test result within 48 hours of travel and will have to wear masks on the flight. Random testing of passengers arriving from China

will also commence under new guidelines adopted by some European countries. In Ireland and Europe, the XBB.1.5 subvariant ‘Kraken’ has been detected in small numbers, but cases continue to increase. The new variant is expected to become dominant across the EU in coming weeks and months.

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HSE ROLLS OUT WALK-IN FLU VACCINATION CLINICS FOR CHILDREN, AS CASES RISE IN THE COMMUNITY

The HSE has announced that walk-in flu vaccination clinics for children aged twoto-17 years are being rolled out in community vaccination centres across the country in response to rising numbers of flu cases in children. No appointment is necessary and

the vaccine is free of charge. The children’s free nasal flu vaccine will be available up until 23 January. After this date, only children with preexisting medical conditions that are at risk of serious illness from flu will be eligible.

The HSE is encouraging parents to avail of this opportunity to vaccinate

their children against flu as it continues to spread. Almost 700 children under the age of 14 have been hospitalised with flu this winter to date, and the virus is predicted to continue circulating for a further number of weeks.

In Ireland, between 2009 and 2019, the HSE Health Protection Surveillance

Centre (HPSC) reported:  4,750 children needed hospital treatment because of complications of flu;  183 of these were admitted to intensive care;  41 children died.

A full list of vaccination centres and times can be found at: www2.hse.ie/ conditions/flu/walk-in/.

New facility for Cork GP Training Scheme officially opens

The Irish College of General Practitioners (ICGP) welcomed the official opening of its new, fit-for-purpose GP training facility for the Cork GP Training Scheme at St Mary’s Health Campus in Gurranabraher, Co Cork in December. The new facility coincides with the ongoing expansion of GP training in the region. The ICGP is leading an unprecedented increase in GP training numbers nationally to help meet the GP shortages, impending retirements, and the growing diversity of GP services in primary care. Last month, the ICGP received a record 968 applications for the 2023 GP Training Programme, reflecting the growing popularity of general practice as a career for medical graduates.

The ICGP’s National Director of GP Training Dr Martin Rouse

The new facility opened on December 7 at St Mary’s Health Campus in Gurranabraher, Co Cork

described the new facility as a “significant milestone” and a “tribute to the vision of past Directors of GP training in the region”. He also acknowledged the strong

links between the facility, the HSE, and University College Cork (UCC). Highlighting the growing numbers of trainee GPs, also said: “There are currently 932

trainees enrolled in the GP Training Programme across the country, and we have increased our training numbers by 60 per cent in the past six years.”

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Human Tissue Bill warmly welcomed as optout system for organ donation on the horizon

Minister for Health Stephen Donnelly TD has secured Government approval for the Human Tissue (Transplantation, Post-Mortem, Anatomical Examination, and Public Display) Bill. The composite Bill will provide a national legislative framework for operating donation and transplant services in Ireland for the first time. Separately, the Bill also introduces a regulatory regime for the conduct of post-mortems in hospital settings to be overseen by the Health Information and Quality Authority (HIQA), as well as safeguards to protect the integrity of the human body before and after death, and to prevent any organ retention without consent in the future. The major issues the Bill will address include:

 Provision of general conditions for the removal, donation, and use of organs and tissue from deceased and living persons for transplantation;

 Regulation of practices and procedures for post-mortems in hospital settings;  Provision of general conditions and regulations for anatomical examination;  Provision of general conditions and regulations for public display of bodies after death.

Under the new legislation, the proposal is to bring in an ‘opt-out’ register for organ donation. This means that when a person dies, it is presumed that they would wish to donate their organs after their death, unless they have otherwise stated to family members or registered to opt-out. If a person does register to opt-out, there will be no further discussion with their family. For those who do not opt-out, the family will continue to play a central role, but rather than being asked to consent to organ donation, they will be asked if they know any reason why their loved one would not consent to organ donation for transplantation. The legislation will bring Ireland into line with international best

practice for governance of human tissue matters, and help achieve national goals by increasing the potential number of donors through the implementation of the optout system and provision a framework for donation from living donors, including the establishment of pathways for non-directed altruistic living organ donation (which applies to kidney donation primarily).

The Irish Kidney Association (IKA) has warmly welcomed the Bill and stressed the importance of having conversations with loved ones about organ donation. Speaking about the landmark legislation, the IKA said: “It is important that the media play its part in communicating that families still play a central role in consenting to organ donation. This will reinforce the value of having the family organ donation conversation before the unthinkable happens.” The association looks forward to the upcoming changes in the current system and an increase in organ transplants across Ireland.

Cystic Fibrosis Ireland, part of the Irish Donor Network, has also welcomed Cabinet’s approval of the Bill. Philip Watt, CEO of Cystic Fibrosis Ireland and Chairperson of the Irish Donor Network, said: “Cystic Fibrosis Ireland today warmly welcomes Cabinet approval of the Human Tissue Bill and the Government’s stated commitment to increase organ donation and transplantation rates in Ireland, and to make organ donation the norm in Ireland. The five solid organs that have the potential to be transplanted are lungs, heart, kidneys, liver, and pancreas. With hundreds of people waiting for a transplant in Ireland, measures that increase the transplant rate are truly lifesaving and are to be welcomed, but they also need more resources.”

The End of Year Statement from HSE Organ Donation and Transplant Ireland (ODTI) revealed that 250 organ transplants took place in 2022, thanks to 86 deceased and 33 living organ donors and their families. Across the three national transplant

centres, 163 kidney, 10 heart, 18 lung, 51 liver, and eight pancreas transplants were completed. This includes kidney transplants from 33 living donors. Reflecting on the year, Dr Catherine Motherway, Clinical Lead, HSE ODTI, acknowledged the precious gift organ donors and their families give to recipients and their loved ones, describing both live and deceased donors as “the very essence” of transplant programmes. She said: “Behind each figure in this report are lives transformed by a transplant, by virtue of the enormous generosity of families who, in the most difficult circumstances, honour their loved one's wishes by choosing to donate their organs. Each and every time, we are humbled by the courage shown by our donor families. On behalf of ODTI, intensive care staff, transplant teams, and transplant recipients, I would like to offer my sincere gratitude and sympathy to the donor families. You are in our thoughts and prayers. Míle buíochas libh go léir.”

Speaking from real-life experience, transplant recipient Patrick Eustace said: “I received a life-changing kidney organ transplant 25 years ago as a child from an unknown donor. I’ve been incredibly lucky, and extremely grateful that it has allowed me to live a totally normal life since. My thoughts are always with the donor family who made such an altruistic decision in what must have been a very dark space for them. Organ donation can offer, either in the times of darkness or through the living donor program, a chance to beget new life to our friends, family, neighbours, and colleagues. It can offer a young girl or boy an opportunity at life that they might not otherwise have had. I would suggest that people have a conversation with their next-of-kin to ensure their immediate family are aware of their intentions regarding organ donation. It may seem like a difficult topic to broach with loved ones, but it can give reassurance to their family members in the event of their untimely passing.”

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RISING CAESAREAN BIRTH RATES FOR FIRST-TIME MOTHERS MAY BE INFLUENCED BY CLINICIANS’ FEARS OF ADVERSE OUTCOMES ACCORDING TO STUDY

Anew study from the School of Nursing and Midwifery, Trinity College has found that factors influencing a clinician’s decision to perform a caesarean section (CS) on a first-time mother are complex and multifaceted. The team conducted one-to-one interviews with 20 obstetricians and 15 midwives who were involved in the decision-making process for CS in three maternity units in the Republic of Ireland. Researchers found that decisions are driven by a clinician’s fear of adverse outcomes and subsequent litigation, personal preference, their threshold to intervene, the culture of practice within the system, and by organisational guidelines and policies.

The researchers also highlight that rates of CS in Ireland are unacceptable and not in keeping with the expectations of pregnant women. More than one-third of first-time

mothers are giving birth by CS in the Republic of Ireland, despite evidence suggesting the procedure provides no additional benefits to mothers or babies. There has also been a notable and steady annual rise in CS birth rates over the last decade. It is suggested that a deeper insight into the factors influencing this practice will help to develop practical approaches to reduce the number of CSs safely and effectively. Sunita Panda, Assistant Professor in Midwifery, School of Nursing and Midwifery, and lead author of the study stated that most women wish for a natural birth and described the steady increase in CS as a “growing concern". She said: “It is crucial and timely to understand the factors that influence the decision-making and take action to stop the rising rates of caesarean sections safely and effectively.”

Prof Maeve Eogan, Obstetrician and Gynaecologist at the Rotunda Hospital

highlighted the importance of integrating the human factors identified in the study into in-service development of obstetrics. Dr Krysia Lynch, Maternity care expert and Chair of the Association for Improvements in the Maternity Services Ireland (AIMS) also commented on the study, calling it “an incredibly important piece of research". She said: “The most recent maternity safety statements available for 2022 show five of our units with a first-time mother caesarean birth rate of over 50 per cent, with another three having a rate of over 40 per cent. These rates are perhaps partially informed by our equally high induction of labour rates. Service users expect that our high caesarean rates reflect evidence-based practice and absolute need, this research paper has clearly shown that this is not the case.”

You can access the full study at https:// doi.org/10.1371/journal.pone.0279403.

Cancer Patient Advisory Committee announces call for expressions of interest for members

The Minister for Health Stephen Donnelly has announced a call for expressions of interest for membership of the Cancer Patient Advisory Committee. The committee was established in 2019 to provide input into the development of programmes for patients with cancer. It is primarily made up of people with direct experience of cancer treatment, either as patients, supporters of cancer patients, or those who support cancer patients as part of their work. The Committee is comprised of 15 members, plus a Department of Health (DoH) Chair. A representative of the National Cancer Control Programme also attends committee meetings.

The vacancies to be filled have arisen from an intended turnover in membership. The selection process will be undertaken

by a group comprising representatives of the Irish Cancer Society, the HSE’s National Cancer Control Programme, the DoH, and a member of the former Cancer Patient Forum. Membership of this committee will reflect the diverse nature of patients living with the effects of cancer and will ensure that the needs of cancer patients living in more remote areas are represented.

Launching the call for expressions of interest, Minister Donnelly said: “The input of the Cancer Patient Advisory Committee into policy formulation and planning helps to ensure that our cancer services continue to serve the needs of people living with and beyond cancer to the highest possible standard. I would like to thank committee members for their commitment and contribution to date. This has been invaluable in providing direct, effective

cancer patient input into the development of programmes and services.”

Committee member Michael Nowlan said: “Being a part of the Cancer Patient Advisory Committee has given me the chance to review new cancer policies and projects, afforded me the opportunity to speak directly to those creating them about my thoughts on how they could be improved, and given me the opportunity to bring the lived experience of cancer to the policy makers. I’d recommend applying for membership to anyone who wants to have their input on cancer services heard.”

The application period will run until 10 February 2023. The expressions of Interest form can be found on the Department of Health website at www.gov. ie/en/publication/677b8-cancer-patientadvisory-committee/.

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MINISTER FOR HEALTH ANNOUNCES

€9 MILLION IN ADDITIONAL SUPPORTS FOR STUDENT NURSES AND MIDWIVES

The Minister for Health Stephen Donnelly has announced his intention to provide significant additional supports for student nurses and midwives. The €9 million package of measures is in-line with recommendations from the McHugh Report. The report recommended an enhanced Travel and Subsistence Scheme for student nurses and midwives attending their supernumerary clinical practice placements. It also recommended a review of the pay for the 36-week internship final year student nurses and midwives serve as part of their training. Government has approved Minister Donnelly’s proposals and the enhanced Travel and Subsistence supports will be backdated for all student nurses and midwives to September 2022. Supports will include:

 An enhanced Travel and Subsistence Scheme for student nurses and midwives in years one-to-three of their studies will see each receive €500 per year as a targeted measure to contribute towards meeting the extra costs of meals associated with practice placements outside the student’s core placement site.

 A new rate of €80 for overnight accommodation is being introduced, along with an increased weekly cap of €300 for those students who require accommodation away from their normal place of residence while attending practice placements.

 Student nurses and midwives can also avail of, on a vouched basis, the reasonable cost of uniform laundry services during periods of overnight accommodation.

 Pay will be re-instated at 80 per cent of first year staff nurse/midwife pay scale

for internship students.  Two additional uniforms for student nurses and midwives at the start of their internship.

Acknowledging the contribution made by student nurses and midwives during their 36-week internship, Minister Donnelly said: “For student nurses and midwives on their final year internship, I am ensuring that their salary is set in line with the recommendation of the McHugh Report, by increasing their rate of pay to 80 per cent of point 1 of the staff nurse/midwife pay scale. This measure, worth €3.6 million, demonstrates further our commitment to retaining talent throughout our nursing and midwifery degree programmes, and our appreciation for the effort and dedication shown by students during their crucial final-year internships.”

Seventy per cent of Irish nursing homes have capacity to facilitate discharges from hospital, according to a survey by Nursing Homes Ireland. 210 nursing homes responded to the survey, with 147 of them stating that they are in position to receive discharges from hospitals. Within those homes, 760 beds are available. With 440 private and voluntary nursing homes operating across the country, NHI is suggesting that an excess of 1,000 beds are available across the sector.

Commenting on the findings, NHI CEO Tadhg Daly, emphasised what he called the “critical role” nursing homes fulfil. He said: “Approximately 60 per cent of the hundreds of people fit for

discharge from our acute hospitals require the specialised, round-theclock care provided by nursing homes, with nurses, healthcare assistants, therapeutic activities, and dayto-day living needs encompassed within the care. Post-hospital care, nursing homes specialise in providing convalescence and rehabilitative care that will support people’s transition back home. Long-stay care within a nursing home might also be most appropriate to their needs. We are engaged collaboratively with the HSE to inform of capacity within private and voluntary nursing homes to support timely discharge of patients back into the community where appropriate.”

Clonmel Healthcare is delighted to announce the launch of Pirfenidone Clonmel 267mg and 801mg film-coated tablets. Pirfenidone Clonmel is subject to medical prescription and is indicated in adults for the treatment of mildto-moderate idiopathic pulmonary fibrosis. Full prescribing information is available at www.clonmel-health.ie or from Clonmel Healthcare on 01 620 4000.

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760 beds available within private and voluntary nursing homes to support discharge of patients Clonmel Healthcare launches Pirfenidone for idiopathic fibrosis

INTERSTROKE STUDY UPDATE:

PSYCHOSOCIAL STRESS IS ASSOCIATED WITH AN INCREASED RISK OF STROKE

Psychosocial stress is associated with an increased risk of stroke, according to new University of Galway led research published in the Journal of the American Medical Association Network Open . The research is part of the ongoing INTERSTROKE study; one of the largest international studies of risk factors for stroke globally. It has been analysing data from 26,000 people in 27 countries since 2007. The latest research found that the occurrence of any stressful life event increased the risk of stroke by 17 per cent, with the occurrence of two or more stressful life events increasing the risk of stroke by 31 per cent.

The research was led by Dr Catriona Reddin, at University of Galway’s College of Medicine, Nursing and Health Sciences. It looked at levels of stress in more than 26,000 people in Europe, Asia, North and South America, the Middle East, and Africa. The research found that increased stress at home, stress at work, and recent stressful life events, such as marital separation or divorce, trauma, or major intra-family conflict were associated with an increased risk of ischaemic stroke and haemorrhagic stroke. Those who reported severe work stress were over twice as likely to have an ischaemic stroke, and over five-times as likely to have a haemorrhagic stroke compared to those who reported no work stress. The increased risk was lower in individuals who reported feeling more in control.

Dr Reddin said: “Approximately 7,500 Irish people have a stroke, an estimated 30,000 people are living in Ireland with disabilities as a result of a stroke and annually about 2,000 Irish people die as a result of stroke. In this latest INTERSTROKE study we looked at self-

reported stress. In people who reported severe home stress, the increase in stroke risk was lower in those who felt that what happens in life is determined by factors within their control. Similarly, in individuals who reported severe work stress, the increase in stroke risk was lower in people who felt that they had control over what happens in work, in most situations, compared to people who felt that they had little control over their work life.”

Prof Martin O’Donnell, Professor of Neurovascular Medicine at University of Galway and Consultant Stroke Physician at Galway University Hospitals, co-led the international INTERSTROKE study in partnership with Prof Salim Yusuf from the Population Health Research Institute at McMaster University, Canada. He stated

that stroke is the leading cause of adult disability in the world, highlighting the crucial nature of prevention.

Prof O’Donnell said: “The INTERSTROKE study is giving us a better understanding of the importance of conventional and emerging risk factors of stroke in different regions and ethnic groups globally, which are required to help prevention. We know that the best ways to prevent stroke are to eat a healthy diet, exercise regularly, and avoid smoking and drinking too much alcohol. In this latest study we got deeper insights into how work and life-related stresses can contribute to stroke. The findings suggest that higher locus of control is associated with lower risk of stroke and may be an important effect modifier of the risk associated with psychosocial stress."

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Dr Catriona Reddin, University of Galway’s College of Medicine, Nursing and Health Sciences, who led the research

VHI ENCOURAGES PEOPLE TO START THEIR PARKRUN STORY THIS JANUARY

Vhi has been the presenting partner of Parkrun Ireland for the past seven years and is calling on people to start 2023 by visiting their local Parkrun as a walker, jogger, runner, or volunteer. Parkrun is a free community event where anyone can walk, jog, run, volunteer, or just watch. A fivekilometre event takes place every Saturday morning for adults, while Junior Parkrun is a two-kilometre event that takes place every Sunday morning for four-to-14-yearolds and their families. There are currently 135 Parkrun events taking place around the country every weekend, with more locations being added frequently.

A previous survey by Parkrun, in

association with Vhi, outlined the mental and physical health benefits that can be gained from Parkrun participation. Key findings included:

 More than 90 per cent of participants reported a sense of personal achievement and improvements in physical health;

 83 per cent reported improvements to their mental health;

 85 per cent stated that participation in Parkrun improved their levels of happiness.

Matt Shields, Parkrun Ireland’s Country Manager said: “We all know how hard it is to follow through with New Year’s resolutions, but the beauty of Parkrun is the support you get as part of a community. Whether you start off walking, jogging, running, or as one

of our incredible volunteers, we’re certain that you will reap the mental and physical health benefits that Parkrun has already provided to thousands of people across the country.”

Vhi 360 health centres have also recently signed up to the ‘Parkrun practice’ initiative, which was set up by Parkrun Ireland in collaboration with the Irish College of General Practitioners (ICGP), to encourage GP practices across Ireland to develop close links with their local Parkrun, to encourage patients and carers to participate, and to help build local communities that are centred on wellness. Patients, families, and healthcare staff can register for their nearest parkrun at www.parkrun.ie.

New research shows genetic effect on the response to treatment for obesity

Collaborative research between the National University of Galway (NUIG) and Brunel University London has found that patients with severe and complicated obesity respond differently to a dietary weight loss programme based on their genes. The GERONIMO project studied patients attending the obesity clinic at Galway University Hospital (GUH), who were undergoing an intensive, short-term programme of medically-supervised dietary restriction in order to attempt to reverse some of the medical problems related to severe obesity. The research examined 93 patients who had volunteered for the study and who each weighed more than twice their maximum ‘healthy weight’. They were each then monitored while taking part in a meal replacement programme. The participants lost an average of 16 per cent of their body weight, or 21kg, after 24 weeks.

During the study, researchers were able

to analyse small variations in hundreds of genes that are known to be associated with obesity. The study found that that the ‘waist-to-hip ratio’ genetic risk score, which measures an individual’s genetic tendency to hold on to visceral or abdominal fat, was associated with less weight loss after the intervention. By combining information from these measured gene variations together, a genetic risk score was calculated for six different obesity-related traits.

Prof Francis Finucane, Senior Lecturer in the School of Medicine at NUIG and Consultant Endocrinologist at GUH, who led the clinical study, said: “Mechanistic studies like these, which help us to understand why some people respond better than others to the same intervention, are really important in providing more personalised and effective treatments for people with obesity. We know that in general, heritability and genetics play a huge

role in influencing body weight and the risk of obesity-related complications like diabetes, but finding the genes that account for this risk has been a challenge.”

Prof Alex Blakemore, Professor in Human Genomics at Brunel University, said: “Noone chooses their genes, so, as a society, we need to recognise that when it comes to maintaining a healthy weight, the challenge is greater for some people than for others. This study reveals just a small part of the picture of how our genes can help or hinder us in reaching our health goals.”

Speaking about next stages in the research, Prof Finucane said: “This work is exciting and important because it is the first Irish study to demonstrate a genetic effect on the response to a treatment for obesity. The genetic effects we found here were subtle, but we think it would be good to explore this further, in larger studies and with different obesity treatments, such as drug therapy or ‘metabolic surgery’.”

| NEWS | | NURSING IN GENERAL PRACTICE | JANUARY-FEBRUARY 2023 | 11

Ireland’s first internationally accredited medical hyperbaric oxygen treatment facility opens in Dublin

The Oxycare medical facility, Ireland’s only internationally accredited medical hyperbaric oxygen treatment centre, was opened by the Minister for Health Stephen Donnelly in December. In attendance were facility founders, Dr Gerry Molloy and Mr Declan Fleming, along with former patients and a group of Dublin-based medical professionals. Oxycare provides medical hyperbaric oxygen treatment to patients referred by consultants from around the country, is endorsed by the HSE, and accredited both nationally and internationally. Conditions suitable for medical hyperbaric oxygen treatment include, but are not limited to, the enhancement of healing in oxygen deprived wounds, skin

grafts and flaps post-surgery; healing of heat burns, radiation injuries, and crushrelated injuries; and the management of idiopathic sudden sensorineural hearing loss. Some evidence has also recently emerged to support the effectiveness of treating long Covid symptoms with medical standard hyperbaric oxygen therapy. The Oxycare hyperbaric oxygen chamber uses 100 per cent medical-grade oxygen that has been approved for medical treatments and certified by BOC gases, the same brand used in Irish hospitals. It is prescribed and administered to patients according to internationally-accepted treatment tables, in sessions that are approximately two hours long, or longer.

Dr Gerry Molloy, co-founder of Oxycare said about the results of the treatment:

“[They] are impressive, and are attested to in correspondence from various consultants who have referred their patients and who have now adopted this mode of treatment as an option to be considered for the most difficult cases. High-tech innovations do not always reduce healthcare costs, but this is the case for medical hyperbaric oxygen therapy. Overall healthcare spending in hospital and in the community is reduced, while outcomes for patients are enhanced. This centre represents a positive step forward in the advancement of Irish medical care, particularly for the patients, with stories of hope and healing embedded within the lives of patients who have been through our doors. We are proud to be able to offer this advanced treatment.”

RECRUITMENT

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l To work alongside present practice nurse. l Previous experience preferable, but not essential. l Training provided if necessary. l Duties to include, but not exclusive to: phlebotomy, childhood vaccines and other immunisations (eg, flu/covid vaccines etc), smear-taking, chronic disease management, ECG, 24 hour ABPM, removal of sutures/wound dressings, assist with minor surgical procedures (eg, Implanon insertion/removal, etc), diabetes care, telephone triage.

Please send CV or enquiries to: drpj@mcauliffemedicalcentre.ie

If you would like to place a recruitment advert in the next edition, please contact Louis@mindo.ie

| NEWS | | NURSING IN GENERAL PRACTICE | 12 | JANUARY-FEBRUARY 2023
GP PRACTICE NURSE REQUIRED FOR FRIENDLY PRACTICE IN BIRR, CO OFFALY To a dvertise, email Daiva Maciunaite at daiva@greenx.ie or Gemma Tyrrell at gemma@greenx.ie

IRISH THORACIC SOCIETY, ANNUAL SCIENTIFIC MEETING, KILLASHEE HOTEL, NAAS, 1-3 DECEMBER 2022

ITS meeting hears about changing nature of asthma therapy

The therapeutic face of asthma has changed remarkably for clinicians over the decades, the Irish Thoracic Society Annual Scientific Meeting 2022 was informed during a series of oral presentations.

The meeting took place from 1-3 December 2022 at Killashee Hotel, Naas, Co Kildare. It was the Society’s first inperson meeting since 2019.

In one oral presentation, the meeting heard about the Inhaler Adherence in Severe Unstable Asthma (INCA-Sun) randomised clinical trial.

Presenting on behalf of the trial’s research group, Prof Richard Costello from Beaumont Hospital, Dublin, delivered a talk entitled ‘Use of digital measurement of medication adherence and lung function to guide the management of uncontrolled asthma’.

Prof Costello said a number of members of the Society had taken part in the multicentre study. The study was carried out in 10 centres in Ireland and the UK. Patients older than 18-years-old were enrolled in the 32week single-blind randomised clinical trial, with an eight-week education period and three treatment adjustment phases.

Treatment decisions guided by the digitally acquired data on adherence, inhaler technique and peak flow were compared with current methods.

Prof Costello said that since he started in clinical practice the area of asthma “at least therapeutically” has changed “remarkably”.

He recalled the “massive change” that occurred with the introduction of inhaled corticosteroid (ICS) and long-acting beta-agonist (LABA) therapy and then the “dramatic” transformation brought by the introduction of monoclonal therapies.

“Despite these amazing drugs, there are a number of really important practical aspects of asthma management that need to be considered by us. And the first one is, many patients with asthma don’t take their treatment,” Prof Costello said, stating this figure was estimated to be about 50 per cent.

“The other problem is patients don’t tell you that they have been non-adherent. This

means that you are liable to increase the treatment for someone when in fact you’d be better to address their adherence.”

Furthermore, inhaler technique was also poor for many people, which meant that “people can be adherent, but [are] not effectively getting the drug”. Another important factor was that asthma symptoms can be very non-specific.

“Think of the asthma patient who during the pandemic gained some weight and has started to reflux. They are going to have increased breathlessness, intermittent cough, particularly at night, and that is going to sound like asthma, unless you objectively assess and show that they have asthma,” Prof Costello said. “So there are a lot of practical problems with how we implement the treatment of asthma.”

He highlighted the INCA device, which records when and how the inhaler was taken. Each time the inhaler is opened and taken, an audio file is created, which can then be analysed and used to improve adherence.

Prof Costello said that a clinical decision tool has been developed, which encodes the decision for treatment adjustment, and he praised its creators.

“It formed the basis for this trial,” he said. “If you digitally assess adherence, if you digitally measure low function, and you then make the decisions objectively using

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Prof Richard Costello

a digital clinical decision-making tool, will you get a difference in outcome in poorly controlled severe asthmatics?”

In the study, the active group had personalised biofeedback on inhaler adherence, technique, and peak expiratory flow (PEF). Treatment decisions were informed by digital data. The control group had adherence coaching, inhaler training, and an action plan. Treatment was adjusted base on pharmacy refill rates, asthma control, and risk exacerbations. Both groups used a digitally-enabled inhaler and PEF.

Of the 220 patients that consented to participate, 213 were randomised, with 105 in the control group and 108 into the active group. Some 200 completed the 32-week study. The mean age was 47 years; 137 women participated. They had experienced high levels of exacerbations in the previous year.

At week 32, 11 of the active and 21 members of the control group required add-on biologic therapy. Some 16 per cent of the active group and 44 per cent of the control group who initiated fluticasone propionate (FP) 500mcg per day, had their dose increased to 1,0000mcg/day. Some 26 of the 83 (31 per cent) in the active group and 13 of the 73 (18 per cent) control patients

were reduced to FP 500mcg/day.

The study found that, despite a lower treatment burden, there were differences in asthma control, lung function, T2 inflammation, nor exacerbations between the two groups. It also meant that by not escalating treatment in non-adherent patients, there were no increased sideeffects, increased exacerbations, and loss of asthma control.

It concluded that evidence-based care informed by digital data safely led to a significantly lower treatment burden.

“Patients were 58 per cent less likely to be prescribed a biologic if you use the digital system,” said Prof Costello. “If you used the digital system you were 75 per cent less likely to have your ICS dose increased from a medium dose. And you were twice as likely to have your dose down escalated. About 40 per cent of patients were affected in a positive way by the digital system in terms of less treatment burden as opposed to increased treatment burden.”

In terms of cost-effectiveness, this led to a €3,000 per person savings for severe asthma cases. “We enrolled 200 patients, the overall study saved €500,000, if you did it as a direct cost model.”

Responding to questions from the

floor, the number of people with “truly refractory asthma is really very small”, Prof Costello said.

“What this system allows us to do is rapidly identify who has the refractory asthma, so we can get them to a biologic treatment quicker.”

Speaking on de-escalation, he cited a paper by Dr Vincent Brennan et al, “which indicated how dangerous high-dose inhaled cortical steroids are.”

“Some 20 per cent of people on highdose inhaled cortical steroids, that’s 500[mcg] BD, had adrenal insufficiency…. That is someone who has been taking 500 twice a day for a long time is extraordinarily, potentially harmful.

“One of the things that came out of the study is that if you make people adherent to high-dose inhaled steroids, and asthma isn’t the cause of their problem, you sure as hell are giving them a huge risk of adrenal insufficiency.”

Referencing COPD patients on a ward round who may have been on inhaled steroids for a long time, Prof Costello said “you look at the co-morbidities, cataracts, diabetes, and osteoporosis, and you start thinking they look like steroid-related side-effects”.

PAH outcomes in Ireland comparable with those in other European centres

The outcomes of pulmonary arterial hypertension (PAH) patients in Ireland are comparable with those in other European centres, the Irish Thoracic Society Annual Scientific Meeting 2022 was told.

During the meeting’s oral presentations, a study on the incidence and outcomes of PAH in the Republic of Ireland by Dr Sarah Cullivan of St James’s Hospital, Dublin, was delivered.

Dr Cullivan, who won the prize for best

oral presentation, was presenting on behalf of the national pulmonary hypertension unit (NPHU) at the Mater Misericordiae University Hospital, Dublin.

Pulmonary hypertension (PH) is a progressive disease of the pulmonary vasculature, which is characterised by premature morbidity and mortality. The study defined the characteristics of PH in the NPHU. The main objective was to examine PAH, which is a subgroup of pulmonary hypertension characterised by an elevated mean pulmonary artery

pressure and elevated pulmonary vascular resistance.

Cases of PH, which were referred to the NPHU between 2010 and 2020, were included in the study. PH was defined as a mean pulmonary artery pressure >25mmHg at right heart catheterisation.

Dr Cullivan said PH had an estimated prevalence in 1 per cent of the global population.

“PAH is a rare and progressive disease of the pulmonary circulation. The global incidence is estimated to be about six

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cases per million of the adult cases,” Dr Cullivan said.

“It was often considered a disease of young females, but as we know the demographics are changing. It’s increasingly diagnosed in older persons. There’s often equal sex distribution when patients are older and they often have concomitant co-morbidities.”

There were currently three main treatment pathways and double combination therapy was considered the standard of care for patients without significant cardiopulmonary comorbidities, she said.

“Outcomes were originally quite poor. The median survival… was 2.8 years in the 1980s, but this has improved in recent decades.”

She said that the retrospective study’s objective was to “address the paucity of data regarding the characteristics of PAH in Ireland” and it used the 2015 PAH definition by the European Society of Cardiology (ESC) and European Respiratory Society (ERS).

Some 415 cases of PH were identified by the study. Group 1 was made up of PAH patients and accounted for 39 per cent (n=163) of cases, with a calculated annual incidence of 3.11 per million population (95 per cent CI, 1.53-4.70).

“If you focus on the group as a whole you can see there was a female predominance at 77 per cent and a mean age of 56. Haemodynamics were quite severe…. The mean DLCO [diffusing capacity for carbon monoxide] was 49. The one, three, and five-year survival was 89, 75, and 65 per cent,” she said.

“In our cohort, the leading subgroup was PAH associated with connective tissue disease at 49 per cent or 80 cases. This was followed by IPAH [idiopathic pulmonary arterial hypertension] at 20 per cent or 33 cases, and then congenital heart disease-associated PAH.

“PAH associated with connective tissue disease, showed female predominance at 90 per cent, the mean age of diagnosis 64. Patients typically presented with quite symptomatic disease and haemodynamics were quite severe.

“Between 56 and 18 per cent of patients received double or triple combination therapies in the first 12 months following diagnosis.”

She said that there were a number of important points for discussion, including that there was a marked female predominance in this cohort and the mean age of diagnosis in this cohort was

quite young at 56.

“This could suggest that we might be missing the older cases of PAH in male cases,” said Dr Cullivan.

“We also see that patients typically present with quite advanced and symptomatic disease. This could suggest the need to improve disease awareness and case recognition at an earlier stage of the disease trajectory. This is once again reinforced by the incidence, which appears to be quite low relative to global estimates.”

She highlighted, from a treatment perspective, the revised ECS/ERS guidelines have recommended upfront double combination therapies “so in that sense we are ahead of the game”.

“Outcomes are quite good when we are compared to other European centres. It is widely accepted that the outcomes for those with systemic sclerosisassociated PAH are quite poor and certainly this

requires additional research and exploration,” she said.

In terms of limitations, she said that the study was retrospective and there was missing data.

“Furthermore, not all cases of congenital heart disease associated with PAH were referred to the unit as they are often managed by cardiology, which could mean the incidence of that cohort, and also the entire cohort, is underestimated,” Dr Cullivan said.

“In conclusion, this study highlights the outcomes of PAH in Ireland is comparable in other European centres; however, the incidence appears low.”

There was also the need to improve disease awareness and its evolving phenotype.

“Increasing access to diagnostics, which includes right heart [catheterisation], and a perspective national registry are important ways to address this,” she said.

She was asked from the floor what she thought about echocardiography as a tool to identify PH in this group.

“I know we had the detect algorithm for patients with systemic sclerosis…. But I think this data would suggest that we are not using that screening tool. That’s supposed to be done in asymptomatic patients and these patients are typically presenting with functional class 3 or 4 symptoms. Greater awareness of the high prevalence of PAH in that cohort by the rheumatologists who are managing those patients would be incredibly important."

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Prof Marcus Kennedy and Dr Sarah Cullivan

THE DEBATE – ‘E-CIGARETTES DO MORE HARM THAN GOOD’

Adebate on the pros and cons of e-cigarettes was one of the centerpieces of the Irish Thoracic Society Annual Scientific Meeting 2022.

Prof Luke Clancy of the Tobacco Free Research Institute chaired the debate, which proposed that ‘e-cigarettes are more harm than good’.

Prof Des Cox of Children’s Health Ireland spoke in favour of the motion, while Dr Emer Kelly of St Vincent’s University Hospital, Dublin, opposed it.

At the start of the debate, Prof Clancy asked for a show of hands on who agreed with the motion, which he described as a “nice contentious issue for debating”.

The majority of the attendees signaled they supported the motion.

Supporting the motion

Prof Cox said that a 2021 Health Research Board (HRB) systematic meta-analysis presented an overview from a number of studies, which had examined outcomes for nicotine replacement therapies (NRTs) versus e-cigarettes.

“They couldn’t find any effect from the time point of six months; in other words e-cigarettes weren’t that effective at helping people quit at the point of six months,” he said.

Bupropion has been shown to be very effective at smoking cessation, he said.

Prof Cox cited a Cochrane Review that using bupropion made it between 52to-77 per cent more likely that a person would stop smoking.

“There is conflicting evidence as to whether e-cigarettes are any good for tobacco cessation, but at best they are no better than NRT.”

Explaining why he believed e-cigarettes should not be used in smoking cessation, Prof Cox highlighted that a common phrase used by ‘provaping lobbyists’ was that e-cigarettes

were 95 per cent less harmful than tobacco cigarettes.

“That is one of the worst ‘factoids’ out there about this,” he said. “Where this statement came from was a 2013 paper from a group of 13 tobacco control experts looking at all the different products and how harmful they were compared with tobacco cigarettes. Actually, in the study itself, the authors said a ‘limitation of this study is the lack of hard evidence for the harms of most products on most of the criteria’. So even in the paper they said there was no hard evidence for what they were suggesting.”

In terms of the long-term impacts, Prof Cox cited research published earlier this year in the New England Journal of Medicine on ex-smokers who used e-cigarettes over a couple of years. Airway biopsies were taken from the ex-smokers and found areas of constricted bronchiolitis.

“They also found that when people stopped vaping, this regressed,” he said. “It is possible that this is what we might see in the next 20 years in the airways of people who chronically vape.”

He also highlighted that an ingredient

of e-cigarettes, diacetyl, had been linked with bronchiolitis.

Citing a study ‘The association between e-cigarette use and asthma among combustible cigarette smokers’, which had 3,000 participants, Prof Cox said it found a 39 per cent greater risk of asthma in the people who vaped who had never previously smoked.

“So again, there is an association with a chronic condition.”

In the European School Survey Project on Alcohol and Other Drugs (ESPAD) survey, which looked at 2019 data, 39 per cent of teenagers in the 15-to-16 age group had previously used e-cigarettes.

“A smaller proportion, about 14 per cent, were using them on a regular basis; this is a significant increase from the previous ESPAD survey in 2015. There is a rising incidence of the use of e-cigarettes among adolescents,” said Prof Cox.

Discussing e-cigarettes as a gateway to tobacco products, a HRB review published in 2020 found an over four-fold increased risk in teenagers, who vaped, of moving on to using tobacco products.

He concluded that e-cigarettes were not an effective tobacco cessation tool and that doctors should be promoting well known and proven smoking cessation products. He added its chronic use was likely to be damaging to the airways.

“There is experimental evidence of that. There are case reports coming through that there are harmful effects on the airways,” he said.

Against the motion

Opposing the motion, Dr Kelly, whose main research interest is chronic obstructive pulmonary disease (COPD), acknowledged that she had an “uphill battle”.

“Us humans have a very complex

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relationship with nicotine,” she said.

“It was in 1956 that the surgeon general report in the US stated a clear association with lung cancer and cigarettes. But in 2022 cigarettes are still freely available.”

She said that doctors detested cigarettes and they wished the product had never been invented.

“But they were and there are over a billion smokers in the world. There are six million deaths a year from smoking. We know that it is the single leading preventable cause of mortality. Aiding smoking cessation is the most valuable preventive medicine intervention that we can do.”

The majority of patients, 70 per cent, say they wished to quit and many seek medical advice on trying to quit, Dr Kelly said.

“So we need to keep our minds open, we need to at least consider e-cigarettes, if they can help at all.”

She said that “no matter what we do” about 9 per cent of pregnant women still smoke at the time of their delivery. Regarding teenage smoking, it was a multi-factorial issue, which included risk-taking behaviour, the meeting heard.

She said given it must be the case that many parents smoke given that approximately 20 per cent of adults are smokers.

“That means that kids, CF [cystic fibrosis] and asthma patients, they are being exposed to cigarette smoke,” Dr Kelly said. “We know for a fact that exposure to cigarette smoke is going to change lung development in a young lung, that it predisposes to obstructive lung disease and to cancer.”

She argued that anything that helped smoking cessation had to be good.

“There is literature about 800 smokers, half of them are put on nicotine replacement therapy, and half are put on e-cigarettes. About 10 per cent of those on nicotine replacement stopped and about 18 per cent of those on e-cigarettes stopped,” Dr Kelly said.

Dr Kelly also cited a 2021 Cochrane

Review, ‘Electronic cigarettes for smoking cessation,’ which found that people were more likely to stop smoking for at least six months using nicotine e-cigarettes than using nicotine replacement therapy.

“For every 100 people using e-cigarettes to stop smoking, nine-to-14 might successfully stop, compared with only six of 100 people using nicotine replacement therapy.”

She said there was a need to change the thinking in addressing smoking as a public health problem.

“We need to challenge our thinking in this. Smoking has become concentrated in the poorest sections of society. These people need our attention,” she said. “Also what we have to offer smokers has become reduced.”

She said that there was good data regarding varenicline (Champix), “but has anyone tried prescribing it recently?”

“It is not available since April of last year. I rang a pharmacy before I gave this talk and it is not going to be available for a while yet.”

In the UK, in November of last year, the National Institute for Health and Care Excellence guidelines brought out a “comprehensive document” on prevention and promoting quitting, “and discussing the vaping products with our patients.”

In his rebuttal, Prof Cox said Dr Kelly’s data came from the UK, which was an outlier internationally.

“Very few countries have taken such a pro-vaping tack as the UK,” he said. He continued that neither the World Health Organisation nor the European Respiratory Society supported the use of e-cigarettes as a cessation tool. He also said there had been no dramatic decrease in smoking rates in the UK. He highlighted that many e-cigarette users were also smoking, and that there was a slight uptake in the number of adolescent smokers, and there was a strong association with e-cigarette usage with this increase.

Dr Kelly said while she took Prof

Cox’s point on the UK information, “that doesn’t change the fact that it’s good information.” She added that bupropion was a “tough sell to patients with a sideeffect profile”, she said.

“Although Champix is a good option, it is just not out there.... The reality is in adult medicine our patients are smoking, and if they want to try e-cigarettes and if it works for them, we at least have to be the doctor that listens to them and brings them along that path,” Dr Kelly said.

During questions from the floor, the environmental impact of single-use, plastic e-cigarettes was highlighted.

“They are really bad for the environment,” Prof Cox agreed. “There’s been an upsurge in disposable vapes in the past year or two.”

As well as being single-use and plastic, they also had a lithium battery, Prof Cox said. “I think it’s certainly an argument for disposable vapes to be banned.”

Dr Kelly said she agreed that e-cigarettes should be regulated and that she does speak about both nicotine replacement therapy and e-cigarettes in her practice.

She cited one patient who was an inpatient in a psychiatric facility who was trying to give up smoking.

“He is not going to go cold turkey. He’s tried nicotine replacement before, so it is better for him than the 40 cigarettes a day he’s smoking. So I do discuss e-cigarettes with him, otherwise, we are ignoring the elephant in the room.”

Another question asked if there was any data on the length of time people vaped. Prof Clancy said that qualitative data from young adults found that users reported that a “big ‘advantage’” of e-cigarettes was they could be used any time and continuously.

“There is evidence that they are continuously using it and the levels of nicotine are quite high.”

Responding to another question, Prof Cox said that as far as he was aware there was very little evidence that there is a carcinogenic effect of e-cigarettes.

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AUTHOR: Ruth Morrow, Registered Advanced Nurse Practitioner (Primary Care); Respiratory Nurse Specialist (WhatsApp Messaging Service, Asthma Society of Ireland; and Nurse Educator and Consultant

MANAGEMENT OF STABLE AND ACUTE ASTHMA

RUTH MORROW PROVIDES A COMPREHENSIVE OVERVIEW OF THE MANAGEMENT OF STABLE AND ACUTE ASTHMA IN GENERAL PRACTICE AND PRESENTS THE EVIDENCE BEHIND RECENT CHANGES TO THE GINA GUIDELINES

Asthma is a heterogeneous disease, usually characterised by chronic airway inflammation, which is defined by the history of respiratory symptoms, such as wheeze, shortness of breath, chest tightness, and cough that can vary over time and in intensity, together with variable expiratory airflow limitation.1 The key to asthma management is educating and empowering patients to manage their asthma, as well as provision of the appropriate treatment for the patient’s asthma phenotype, symptoms, and lifestyle. The disorder is commonly managed in primary care settings, and the general practice nurse (GPN) is ideally placed to provide many vital components of optimal management and prevention.

Management of stable asthma

The goals of asthma management are:1

1. Symptom control: To achieve good control of symptoms and maintain normal activity levels.

2. Risk reduction: To minimise the risk of future exacerbations, fixed airflow limitation, and medication side-effects. Assessment of asthma control involves assessing symptoms over the previous four weeks using the Global Initiative for Asthma (GINA) Assessment of Asthma Control and the Asthma Control Test

(ACT), as well as assessing risk factors for poor outcomes. Treatment issues must also be addressed at every visit and should include:  Review of inhaler technique and adherence;  Asking about side-effects;  Reviewing the patient’s written asthma action plan;  Exploring the patient’s attitudes and goals for their asthma management. The treatment and management of asthma should incorporate the following elements:  Education on the disease process;  Management of triggers;  Medication management: Actions, inhaler technique, adverse events, and adherence;  Asthma action plan;  Management of acute flare-ups of asthma.

The goal of asthma management is for the patient to be optimally controlled on the minimum amount of medication. GINA 1 provides healthcare

professionals with a management approach based on control, using the step-wise method outlined in Figure 1 . This assists healthcare professionals with the titration of medications as step-down or step-up approaches, while attempting to achieve this goal.

The cornerstone of asthma treatment is inhaled therapy, as medications are directly targeted at the airways, and therefore, are more effective. This also limits the amount of systemic absorption of drugs and reduces adverse events. Patients should be commenced on the appropriate step of the treatment guidelines, which is dependent on the severity of their symptoms.1 Each patient is assigned to one-of-five treatment steps and patients may move up or down the steps depending on individual symptoms and the amount of reliever therapy being used. Inhaled glucocorticosteroids are the cornerstone of asthma treatment and are the most effective controller

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THE PERCEPTION BY PATIENTS THAT THEIR RELIEVER PROVIDES MORE CONTROL OVER THEIR ASTHMA CAN MEAN THAT THEY OFTEN DON’T RECOGNISE THE NEED FOR OTHER TREATMENTS

FIGURE 1: GINA guidelines 2022

medications available. However, there are additional oral medications, such as leukotriene receptor antagonists, which can be added to drug regimes, and are useful in patients who have an allergic component to their asthma, experience cold air bronchoconstriction, and have exercise induced symptoms. These medications are also licensed for use in allergic rhinitis, a condition that 85 per cent of people with asthma also have. Sublingual immunotherapy is also now recommended at all steps of the guideline, depending on the patient’s asthma phenotype.

In 2019, GINA updated their strategy and outlined significant changes in best practice recommendations for asthma management in adults and adolescents. One of the most significant adaptations

was in relation to short-acting bronchodilators (SABA), which are no longer recommended as only-treatments at step one. They now recommend the introduction of combination therapy of inhaled corticosteroids (ICS) and long-acting bronchodilators (LABA) as a needed therapy at step one, and as a maintenance therapy at step two. Using a combination therapy as an asneeded therapy will require a significant change in the mindset and routine practices of healthcare providers and long-term sufferers, considering the long-standing use of SABAs in the alleviation of asthma symptoms.

Why this change?

Inhaled SABAs (Salbutamol, Terbutaline) have been first-line treatment for

asthma for 50 years. Traditionally, asthma was believed to be a disease of bronchoconstriction, with SABA being the primary drug of choice. Added to this, rapid relief of symptoms, reliance on, patient satisfaction, and their low cost have meant that SABAs were widely used, overused, and over-relied upon. The perception by patients that their reliever provides more control over their asthma can mean that they often don’t recognise the need for other treatments. Research over the past number of years has shown that regular and frequent use of SABAs actually decreases broncho-protection, increases rebound hyperresponsiveness, and decreases bronchodilator response. 2 Patients with apparently mild asthma are at risk of serious adverse events, such as near fatal

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asthma, acute asthma, and death from asthma. Regular or frequent use of SABAs is also associated with increased allergic response and increased eosinophilic airway inflammation.3 Patients who get three or more canisters of SABA per year (average 1.7 puffs/day) are associated with higher risk of attendance to the emergency department4 and patients who receive 12 or more canisters per year are associated with higher risk of death.5 A 2021 meta-analysis of four randomisedcontrol trials involving 9,565 patients demonstrated the benefits of LABA/ICS combination therapy, showing a 55 per cent reduction in severe exacerbations compared with SABA alone. Emergency department visits or hospitalisations were 65 per cent lower than with SABA alone, and 37 per cent lower than with daily ICS.6

In their review of the literature, GINA found no evidence to support a step one SABA-only approach. The lack of evidence for SABA-only treatment contrasted with the strong evidence for the safety, efficacy, and effectiveness of the treatments recommended in steps two-to-five of the strategy, such as ICS and ICS/LABA. Therefore,

GINA no longer recommends SABAonly treatment for step one. It is now recommended that all adults and adolescents with asthma should receive symptom-driven or regular low-dose combination LABA/ICScontaining controller treatment to reduce the risk of serious exacerbations. 1 Patients who have symptoms more than twice a month should be prescribed ICS/LABA twice daily (steps two-to-five) and patients

who have symptoms less than twice a month should use ICS/LABA on an as-needed basis (step one). Daily ICS is no longer listed as a step one option as it has a high probability of poor adherence. It is now replaced by a more feasible as-needed controller option at step one. Patients should be offered self-management plans with instructions on how to adjust their medications in response to worsening symptoms and/or worsening peak expiratory flow rate (PEFR). An example of a self-management plan is available at www.asthmasociety.ie.

Non-pharmacological management

The non-pharmacological management of asthma includes management of trigger factors, smoking cessation, management of obesity, and managing gastroesophageal reflux disease (GORD) if present. GORD can worsen asthma symptoms and treatment of reflux may improve them. Hormones can also play a significant role in asthma control. Some patients will experience worsening of their asthma symptoms pre-menstrually or during menstruation. During pregnancy, asthma control may improve, deteriorate, or stay the same as prepregnancy. Asthma may also develop in women who are menopausal, and very often requires high doses of inhaled corticosteroids as it can be more difficult to control. Influenza vaccination is also recommended for those with more severe asthma.

Adherence with medication regimes

in asthma management is adherence to medication, as many patients may be asymptomatic, and therefore, don’t feel the need to use their medication daily. Exploring the patient’s beliefs and attitudes can be useful in determining a rationale for nonadherence to medication regimes.

One of the biggest

| ASTHMA | | NURSING IN GENERAL PRACTICE | 20 | JANUARY-FEBRUARY 2023
challenges
consciousness No Agitated,
or
Oximetry on presentation (SaO2) >95% <92% Speech Sentences Words Pulse rate Pulse rate 100-120bpm Peak flow >50% predicted or best <50% of predicted or best Central cyanosis Absent Likely to be present
intensity Variable
ASTHMA MAY ALSO DEVELOP IN WOMEN WHO ARE MENOPAUSAL,
VERY OFTEN REQUIRES HIGH
AS
CONTROL
SYMPTOMS MILD SEVERE Altered
confused
drowsy
Wheeze
Chest may be quiet TABLE 1: Assessment of acute exacerbation of asthma (GINA, 2022)
AND
DOSES OF INHALED CORTICOSTEROIDS
IT CAN BE MORE DIFFICULT TO
K
CM MY CY
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CY CMY
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Saving medication until it is needed, fear of becoming addicted, or “the health professional didn’t listen” are amongst reasons given by patients in the INCA study.7 In the current climate, cost is a significant factor, even for the person who has a medical card, and should not be overlooked. Two proven ways to address non-adherence are shared decision-making between the health professional and the patient, and motivation interviewing. Using motivational interviewing, the GPN can assess the individual’s likelihood to adhere to their medication or to nonpharmacological interventions.

Assessment and management of acute asthma

Accurate and timely assessment of acute asthma exacerbations should be carried out to ensure a successful outcome. Table 1 differentiates between a mild and severe acute exacerbation. The management of acute asthma includes:

1. Oxygen therapy: 24 per cent delivered by face mask (usually one litre/min) to maintain oxygen saturation 93-to-95 per cent;

2. Inhaled short-acting bronchodilator:

Four-to-10 puffs of Salbutamol by spacer, or five milligrams by nebuliser, every 20 minutes for the first hour, then reassess severity. If symptoms persist, deteriorate, or recur, give an additional 10 puffs per hour and admit to hospital;

3. Oral corticosteroids should be given at a maximum of 50mg orally and continue for five-to-seven days;

4. Additional treatments for moderate or severe exacerbations can include ipratropium bromide 80mcg (or 250mcg by nebuliser) every 20 minutes. Criteria for immediate transfer to secondary care include:

1. Features of severe exacerbation at initial or subsequent assessment:  Patient is unable to speak or drink;  Cyanosis;  Subcostal retraction;  Oxygen saturation less than 92 per cent when breathing room air;  Silent chest on auscultation.

2. Lack of response to initial bronchodilator treatment.

3. Persisting tachypnoea after three administrations of inhaled SABA. 4. Unable to be managed at home.

Follow-up exacerbationpost

All patients should be followed up

regularly after an exacerbation until symptoms and lung function return to normal. Patients are at increased risk during recovery from a further exacerbation. This period also provides an opportunity to review and update the patient’s asthma management, review inhaler technique and adherence, and to ascertain if there was a cause or new trigger factors for this flare-up, which might be helpful in preventing future exacerbations.

At follow-up visit(s), the asthma review should include:  The patient’s understanding of the cause of the flare-up;  Modifiable risk factors, including smoking, weight loss if indicated, and addressing new triggers;  Adherence with medications and an understanding of their purpose;  Reliever should be administered as-needed rather than routinely;  If controller medication was increased, the increased dose should be maintained for three weeks and possibly longer, particularly during the winter or during hayfever season;  Inhaler technique skills;  Written asthma action plan. l

REFERENCES

1. GINA. Global Strategy for Asthma Management and Prevention, updated November 2022. Available at: https:// ginasthma.org/gina-reports/.

2. Hancox R J, Cowan J O, Flannery E M, Herbison G P, McLachlan C R, et al. (2000). Bronchodilator tolerance and rebound bronchoconstriction during regular inhaled B2-agonist treatment. Respiratory Medicine, 94 (8), 767-771. doi: 10.1053/rmed.2000.0820.

3. Aldridge R E, Hancox R J, Robin Taylor D, Cowan J O, Winn M C, et al. (2000). Effects of terbutaline and budesonide on sputum cells and bronchial

hyperresponsiveness in asthma. Am J Respir Crit Care Med, 161(5), 1459-64. doi: 10.1164/ajrccm.161.5.9906052.

4. Stanford R H, Shah M B, D'Souza A O, Dhamane A D, Schatz M. (2012). Shortacting beta-agonist use and its ability to predict future asthma-related outcomes. Ann Allergy Asthma Immunol, 109(6), 403-7. doi: 10.1016/j.anai.2012.08.014.

5. Suissa S, Ernst P, Boivin J F, Horwitz R I, Habbick B, et al. (1994). A cohort analysis of excess mortality in asthma and the use of inhaled beta-agonists. Am J Respir Crit Care Med, 149(3 Pt 1), 60410. doi: 10.1164/ajrccm.149.3.8118625.

6. Crossingham I, Turner S, Ramakrishnan

S, Fries A, Gowell M, Yasmin F, Richardson R, Webb P, O'Boyle E, Hinks TSC. Combination fixed‐dose beta agonist and steroid inhaler as required for adults or children with mild asthma. Cochrane Database of Systematic Reviews 2021, Issue 5. doi: 10.1002/14651858.

7. Sulaiman I, Mac Hale E, Holmes M, et al. A protocol for a randomised clinical trial of the effect of providing feedback on inhaler technique and adherence from an electronic device in patients with poorly controlled severe asthma. BMJ Open 2016; 6:e009350. doi: 10.1136/ bmjopen-2015- 009350.

| ASTHMA | | NURSING IN GENERAL PRACTICE | 22 | JANUARY-FEBRUARY 2023

DO COMPLEMENTARY AND ALTERNATIVE THERAPIES HAVE A PLACE IN THE

MANAGEMENT OF MENOPAUSE?

EXPLORING THE SYMPTOMS OF MENOPAUSE AND WHETHER ALTERNATIVE TREATMENT MODALITIES COULD AND SHOULD PLAY A ROLE IN THEIR MANAGEMENT

Menopause is a significant stage in every woman’s lifecycle. It occurs 12 months after the last period, but women may experience various symptoms in the years leading up to, during, and for many years after the transition.1 Menopause and its associated symptoms are gaining increasing awareness and support across Ireland because the overwhelming evidence would suggest that it is not well managed, talked about, or understood here. Less than 20 per cent of women currently experiencing menopause and perimenopause describe it as a positive experience, and 82 per cent agree that it is not openly discussed enough. 2 Women want more information, education, and understanding of the complex challenges and changes menopause brings physically, psychologically, emotionally, and socioeconomically.

In October 2022, Minister for Health Stephen Donnelly launched a national campaign to encourage everyone to talk about menopause and support those experiencing it. The campaign was launched in response to findings from The Radical Listening Exercise that was commissioned by the Women's Health Taskforce to improve women’s health outcomes and gauge their experiences of the healthcare system.2 Prior to the launch, research was carried out on behalf of the Department of Health (DoH) to quantify the

Three-quarters of women over the age of 35 have either entered perimenopause (19 per cent), are in menopause (18 per cent), or have completed menopause (37 per cent).

 While going through menopause, more than half describe their experience as being mainly negative.

 A third of women have almost constant symptoms.

perceptions around menopause in Ireland.3 The major findings are outlined in Table 1, and highlight the urgent need for better menopause management.

Alongside the campaign, several innovations have been implemented and achieved to enhance menopause care in Ireland, including:  Five specialist menopause clinics (in the National Maternity Hospital; Nenagh Hospital; the Rotunda; the Coombe; and University Hospital Galway) have opened to-date, with a further clinic in Cork planned to open later this year. 

One-in-seven women describe their symptoms as severe.

 Only a quarter of women have minimal or no symptoms.

 Main symptoms experienced are related to temperature regulation, fatigue, insomnia, menstrual changes, and brain fog.

The Irish College of General Practitioners (ICGP) has recently published its Quick Reference Guide on the Diagnosis and Management of Menopause in General Practice  Budget 2023 saw the removal of VAT from hormone replacement therapy (HRT).

Menopause symptom management

Most commonly, people are comfortable to talk to their GP, partner or spouse, or a close friend.

TABLE 1: Highlights from research on behalf of the DoH (October 2022)3

Data released in 2021 from Mental Health Ireland’s Menopause Report 4 is similar to the findings published by the DoH, and reinforces the need for improved symptom management strategies. Results published in the report include:  78 per cent of women report that menopausal symptoms interfere sometimes or often in their daily activities.

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 59 per cent of symptomatic postmenopausal women experience 13 or more symptoms, with vasomotor symptoms (VMS) being the most common.

 The most commonly reported symptoms are hot flushes (92 per cent of women), low sex drive (89 per cent of women), and night sweats (87 per cent of women).

 80 per cent of women experience weight changes during the menopause transition, with almost half of women finding weight management challenging. Less than one-third of women are using HRT in Ireland.4 Forty per cent of women have never considered HRT, 13 per cent are unsuitable candidates, 25 per cent do not wish to take hormones, and 12.5 per cent use other remedies for symptom alleviation.4 Only 29 per cent of women have never tried other remedies during menopause, meaning that more than twothirds have sought symptom relief from complementary and alternative medicine (CAM) treatments at some point during the menopause trajectory.4 The most commonly used CAM treatments are outlined in Table 2, along with their perceived effectiveness in symptom management.

Observational and anecdotal evidence, combined with the longevity and popularity of many CAM therapies, would suggest that they may provide effective adjuvant or stand-alone methods to

alleviate symptoms associated with menopause. However, many CAM therapies are poorly regulated, expensive, and lack a sound body of empirical data supporting their efficacy. The HSE does cite several of these treatments among its alternatives to HRT, with an acknowledgement of the lack of evidence supporting their use.5 Validated clinical research examining their role in the management of menopause symptoms is indeed scarce, but does gradually continue to emerge. Because menopause is primarily treated in general practice, general practice nurses (GPNs) are often a major support to this population of women. Therefore, examining the existing evidence supporting CAM therapies in menopause will help in the education, empowerment, and conversations these patients are calling for.

CAM therapies: The available evidence

In 2019, a critical review of the existing literature on the CAM treatments most commonly used for menopausal symptoms was published in the Journal of Evidence-Based Integrative Medicine 5 It included RCTs with a sample size of at least 10, including randomised pilot studies and systematic reviews. Observational, uncontrolled, nonrandomised data, and case studies did not meet the inclusion criteria.

The major findings of this review are outlined and discussed in relation to a wide range of popular CAM therapies.

Hypnosis

Hypnotherapy, an induced state of deep relaxation and altered awareness, was shown in the review to be associated with statistically significant improvements in menopause symptoms. Two randomised trials among breast cancer survivors showed a clinically significant reduction in hot flush severity and frequency that was comparable to drug therapy. The review also uncovered a separate study that found hypnosis to be as effective as venlafaxine 75mg in reducing both hot flush frequency and associated interference. Other data demonstrated associations between hypnotherapy and improved sleep quality and sexual function. No negative effects were reported and the reviewers concluded that hypnotherapy may act as standalone or adjuvant therapy in menopause, but that more investigation is required to validate the hypothesis.

Cognitive behavioural therapy (CBT)

The evidence supporting the talking therapy CBT as a therapeutic intervention for menopause is also inconclusive, but generally positive.

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CAM THERAPY BLACK COHOSH BREATHING TECHNIQUES SLEEP AIDS MINDFULNESS MIND-BODY RELAXATION TECHNIQUES CHIROPRACTOR/ SPINAL MANIPULATION Use (%) 38 26.1 21.6 24.1 34.3 7.1 Very effective (%) 36.1 20.7 36.4 25.6 25.9 60.6 Somewhat effective (%) 36.1 61.1 52.7 64.7 60.3 30.6 Not at all effective (%) 8.6 18.2 11.0 9.7 13.8 8.8 TABLE
2: CAM therapy use and perceived effectiveness for menopause symptom management in Ireland4

No RCTs reported clinically significant improvements in hot flush frequency, but several did demonstrate that the treatment may be beneficial in reducing hot flush distress and interference, as well as other psychological symptoms, such as depression and anxiety, that are associated with menopause. The HSE cites CBT as a potential treatment for low mood, anxiety, hot flushes, and sleep disturbances in menopause.7 Research in the field is still ongoing.

Biofeedback and relaxation techniques

Biofeedback uses a device to monitor autonomic bodily functions and provides ‘feedback’ about relaxation techniques to the patient. Some of the relaxation techniques examined in the reviewed RCTs included muscle relaxation, relaxation combined with thermal control biofeedback training, paced respiration, at-home relaxation audiotapes, guided imagery, and applied relaxation. Five trials indicated that relaxation techniques may reduce the frequency of hot flushes and improve psychological symptoms of menopause. However, these studies were considered low quality, with small sample sizes. Other studies also concluded that relaxation techniques may have a positive benefit on VMS, psychological issues, and stress, yet due to low-quality evidence and inconsistent findings, more evidence is needed to draw conclusions. Preliminary reports indicate these therapies may benefit some women.

Mindfulness-based stress reduction (MBSR)

Mindfulness utilises the principles of non-judgemental awareness in the present moment and has been studied in a wide range of disorders. Research on its efficacy in menopause symptoms is, however, scarce. Only one RCT examining the effects of

MBSR for menopause symptoms in 110 women was examined in the review. Hot flush frequency, distress, and intensity failed to show statistically significant improvements. However, there was a clinically meaningful improvement in overall menopause-related quality-oflife and sleep quality. Perceived stress and anxiety also significantly improved in the MBSR group following treatment. More research is warranted before conclusions can be drawn, but initial indications are positive.

Yoga

There is high variability among yoga studies, which makes accurate datagathering and analysis difficult. This is likely in view of the multiple branches, methods, and styles of yoga, that range from physical body postures, to breath manipulation, and spiritual practices. The reviewers concluded that despite these challenges, there does appear to be moderate evidence supporting the short-term effects of yoga on psychological symptoms and fatigue in menopause, but no evidence was uncovered to support its application in the management of physical symptoms. Yoga is one of the relaxation techniques recommended by the HSE and may be beneficial for some women. 8

Aromatherapy

Aromatherapy involves the use of various essential oils in the promotion of healing. Again, drawing conclusions is difficult due to a lack of clinical trials, the vast selection and combinations of oils that may be used, and the frequent implementation of aromatherapy into other therapies. However, the limited available evidence is generally positive. RCTs included in the review reported that 12 weeks of lavender essential oil inhalation improved self-reported sleep quality compared with health education control, and reduced hot flush frequency by 50 per cent compared to a less than 1 per cent reduction in the control group. When

combined with massage, aromatherapy was reportedly more beneficial than massage alone in improving both physiological and psychological symptoms. Again, more clinical research is required to draw conclusions and make solid recommendations. Some women may experience benefits of aromatherapy alone, or combined with other CAM treatments.

Reflexology

Reflexology is a specific type of massage performed on the feet, hands, and other zones of the body that are believed to stimulate and regulate corresponding glands and organs. Again, valid and reliable data is scarce regarding its benefits in menopause, and the available literature is conflicting. Only two RCTs examining the use of reflexology for menopausal symptoms were included in the review. The earlier of the two found no significant differences between non-specific foot massage and reflexology on anxiety, depression, and VMS. A more recent RCT of 120 women did, however, find that 12 twice-weekly reflexology sessions significantly enhanced sexual dysfunction and improved hot flush frequency by 56 per cent compared to simple foot massage. In a separate investigation, the National Institute for Health and Care Excellence (NICE) has found that foot reflexology was more effective than control aromatherapy for hot flushes, sweats, and night sweats, but does state that a larger body of evidence is required to consider changing current guidelines. 9

Homeopathy

Homeopathy operates on the principles of hormesis, or ‘like-cures-like’, whereby patients are given micro-doses of natural substances that would be harmful in higher amounts to treat a disorder. The review uncovered only one study that found homeopathy to be beneficial in reducing distress in

| WOMEN’S HEALTH | | NURSING IN GENERAL PRACTICE | 26 | JANUARY-FEBRUARY 2023

menopause. Overall, researchers have concluded that there is no convincing evidence for the efficacy of homeopathy in menopause symptom management.

Acupuncture

Acupuncture is a popular form of traditional Chinese medicine (TCM) that involves light needle insertion into various points of the body, called acupoints. To-date, empirical data is conflicting regarding its role in menopause. Four trials included in the review found no statistical difference between acupuncture and placebo of superficially placed needles or needling at non-acupoints. However, six trials did report significant improvements in VMS, sleep, and other symptoms compared

sleep problems. Reviewers concluded that more precise trials are required to explore the reported benefits to-date and the various treatment combinations.

Chinese herbs

Chinese herbs come in a variety of combinations, preparations, and doses. It is, therefore, difficult to source accurate and comparable data, and again, available data was conflicting in the review. VMS, psychological symptoms, sleep quality, sexual functioning, and quality-of-life significantly improved with Chinese herbs when compared to placebo in several of the trials reviewed, while other RCTs reported no significant differences between treatment and placebo groups. Chinese herbs were not found to be

cohosh was combined with St John’s wort and examined against a placebo. In a study of 301 women, scores on the Menopause Rating Scale decreased by 50 per cent in the treatment group compared to 19 per cent in the control group. Depression also significantly decreased in the treatment group. A second RCT included in the review exhibited similar findings, making it difficult to conclude if black cohosh is beneficial by itself, or only in combination with other herbs. Sideeffects of black cohosh may include gastrointestinal problems, rash, and acute hepatitis. Both black cohosh and St John’s wort are cited by the HSE as potentially beneficial, but without sufficient supporting evidence. 5 Women may experience benefits, but should be aware of the potential side-effects and lack of empirical data.

Dong quai (Angelica sinensis)

to placebo. Like several other CAM therapies, acupuncture is sometimes combined with other techniques. The review included one study that found no benefit to acupuncture plus auricular acupressure in managing VMS over hormone replacement. Two studies investigating the effects of electroacupuncture (which involves the passing of a small electrical current between the acupuncture needles) found no significant differences between it and placebo. One study did report clinically significant improvements after electroacupuncture, but in mood only. An RCT using acupuncture in tandem with diet therapy and Tuina self-massage found that the combination significantly improved hot flush frequency, irritability, and

superior when compared to HRT in reducing VMS, anxiety, or depression. The drug Paroxetine was also shown to be more effective than Japanese herbs in a similar trial. More clinical trials are needed to draw conclusions.

Black cohosh

Black cohosh is a popular herbal remedy for menopause symptoms and multiple RCTs have been conducted to determine its efficacy. Of 16 RCTs that measured the effects of oral preparations on menopausal symptoms (that included VMS, sexual dysfunction, vulvovaginal symptoms, bone health, and quality-oflife), there was insufficient evidence to support its use, but enough evidence to warrant further investigation. Findings did become significant when black

As with black cohosh, Dong quai appears to be more effective when combined with other agents than individually. As a single treatment, the herb failed to show superiority over placebo for menopausal symptoms among 71 women in one of the reviewed RCTs. However, a combined preparation of Dong quai and Matricaria chamomilla in another trial demonstrated over 90 per cent improvements in the frequency and intensity of hot flushes, compared with less than 20 per cent in the placebo group. Combining Dong quai with other herbs, including black cohosh, milk thistle, red clover, American ginseng, and chastetree berry, also demonstrated improvements in hot flushes, night sweats, and sleep quality. In view of the safety concerns regarding Dong quai and its interactions with other medications and herbs (that include photosensitisation, anticoagulation, and possible carcinogenicity), the reviewers advocate for further trials before conclusions are reached.

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THE EVIDENCE SUPPORTING CAM THERAPIES IS INCONCLUSIVE TO-DATE, BUT THE EVIDENCE SUPPORTING EMPOWERMENT, INFORMATION SHARING, AND AWARENESS IN MENOPAUSE MANAGEMENT IS DEFINITIVE

Wild yam (Diascorea)

Only a small number of studies were uncovered by the authors, who also highlight that insufficient information exists regarding the long-term safety of wild yam use. The review did include an RCT of 50 women consuming 12mg of yam extract twice daily, who reported significant improvements in psychological symptoms compared with the placebo group. Topically, wild yam cream was no better than placebo in reducing menopause symptoms, or improving levels of oestrogen or progesterone. Again, more definitive data is required.

Evening primrose oil

No statistically meaningful benefit was associated with evening primrose oil at various doses, although symptoms did somewhat improve in one trial. When combined with marine fish oil and calcium, trials showed a 1 per cent increase in bone mineral density, which was not superior to calcium alone. The authors conclude that insufficient evidence exists to support the use of evening primrose oil in menopause at this time.

Phytoestrogens

Phytoestrogens are plant-derived compounds that are thought to mimic the effects of oestrogen in the body. The compounds are naturally found in soy, red clover, flaxseed, and hops. Fortythree RCTs, including one unpublished trial, were considered for the review. They demonstrated conflicting and inconclusive results that were difficult to evaluate. Only five trials investigating the effects of red clover extract on VMS were suitable for the meta-analysis. They did not demonstrate significant findings and the authors concluded that current evidence does not support the use of phytoestrogens to reduce the frequency or severity of VMS in menopause, but it does warrant further investigation.

Vitamin E

Vitamin E is poorly studied, but a popular choice for many women, according to the review. The authors uncovered a small number of clinical trials that found small, but clinically insignificant benefits of supplementation. They concluded that there is insufficient evidence to support the efficacy of vitamin E supplementation for menopausal symptoms at present.

Conclusion

Menopause is a challenging transition for many women. It can and does impact many or all aspects of their health and wellbeing, sometimes for a substantial period of time. It is also a deeply personal and individual experience, which necessitates and individualised and personal approach. The evidence supporting CAM therapies is inconclusive to-date, but the evidence supporting empowerment, information sharing, and awareness in menopause management is definitive.

Women want education, understanding, and support throughout the decisionmaking processes menopause brings. Some CAM therapies do appear to help alleviate many of the symptoms these women are experiencing. Others are not accumulating the same positive results in clinical trials. According to NICE, clinical guidelines regarding the use of these therapies are unlikely to change until more valid and reliable data emerges.9 However, their potential benefits and side-effects continue to be observed in ongoing trials. Sharing what we know so far is key to helping women find the right approach that meets their individual needs. l

REFERENCES

1. Currie H, Hamoda H, Fenton B. BMJ best practice: Menopause. 2015. [Updated 2021] Available at: https://bestpractice.bmj.com/topics/ en-us/194/pdf/194/Menopause.pdf.

2. Department of Health. Menopause. 2022. Available at: www.gov.ie/en/campaigns/ menopause/.

3. Department of Health. Understanding menopause: Highlights of Department of Health research carried out by B&A. Oct 2022. Available at: www.gov.ie/en/ campaigns/menopause/.

4. Lillis C, McNamara M, Wheelan

J, McManus M, Murphy M B, et al. Experiences and health behaviours of menopausal women in Ireland. 2021. Available at: www. mentalhealthireland.ie/wp-content/ uploads/2021/10/MenopauseReport-2021_Final.pdf?external=1.

5. Health Service Executive. Alternatives to HRT. 2022. Available at: www2.hse.ie/ conditions/hrt/alternatives/.

6. Johnson A, Roberts L, Elkins G. Complementary and alternative medicine for menopause. J Evid Based Integr Med . 2019 JanDec;24:2515690X19829380. doi: 10.1177/2515690X19829380.

7. Health Service Executive. Treatment: Menopause. 2022. Available at: www2.hse.ie/conditions/ menopause/menopause-treatment/.

8. Health Service Executive. Menopause: Things you can do. 2022. Available at: www2.hse.ie/ conditions/menopause/thingsyou-can-do/.

9. National Institute for Health and Care Excellence. Summary of evidence for 2019 surveillance of menopause (2015) NICE guideline NG23. 2019. Available at: www.nice.org.uk/ consultations/672/10/managingshort-term-menopausal-symptoms.

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RECOGNISING, MANAGING, AND PREVENTING LACTATIONAL MASTITIS IN GENERAL PRACTICE

MASTITIS IS A COMMON COMPLICATION DURING BREASTFEEDING, HOWEVER MANY BREASTFEEDING WOMEN DO NOT GET THE INFORMATION OR SUPPORT THEY NEED TO AVOID OR MANAGE IT

Lactational mastitis (LM) refers to inflammation of the breast that may or may not be accompanied by infection during breastfeeding. Lactational is the most commonly reported form of mastitis, but it can occur outside of breastfeeding in both men and women, which will require further and urgent investigation. LM is usually mild and easily managed at home by patients through a variety of simple techniques, support, reassurance, and adequate education. In a small proportion of women, LM can become more serious, and in severe cases, requires hospitalisation. A lack of understanding and inadequate knowledge about prevention and management of the disorder is associated with the development of severe complications and presentations. 1,2,3

Ireland has a high hospital admission rate for LM despite its notably low breastfeeding rates, and research suggests that these low rates of breastfeeding have contributed to low levels of expertise in the management of LM, and subsequently, higher rates of complications. 2 Similarly, data from Glasgow has found that a small number of breastfeeding women continue to receive inappropriate guidance from their healthcare providers that could lead to complications,

hospitalisation, and unnecessary cessation of breastfeeding. 3 The general practice nurse (GPN) is a vital link in the chain of breastfeeding support for many mothers, and in some cases, the primary one. An understanding of the condition, alongside education, support, and evidence-based interventions, are vital components of LM prevention and management, as well as knowledge of and collaboration with breastfeeding support organisations.

Causes and aetiology of non-infectious and infectious LM

The incidence of mastitis ranges globally from three-to-20 per cent, with the twoto-three weeks after birth being the most common timeframe for development.4 There is no consensus on the exact cause of LM in the literature. There appears to be a continuum from engorgement, to non-infective LM, to infective LM, to breast abscess formation.4 Engorgement

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or milk stasis, which may be linked to a decrease in the number of breast feeds given, often occurs postnatally between day three and 10, whereby one or both breasts can become overfull, tight, shiny, warm, hard, and painful.4 This period can also advance to LM and its associated complications if not managed correctly. Obstructed or sluggish milk ducts and/ or an excess milk supply that may block ducts if stagnant are also associated with LM development throughout the breastfeeding journey. A previous history of LM or breast trauma also increases the risk of development.4 Onset is usually gradual and unilateral for both noninfectious and infectious presentations.4,5

Non-infectious LM often begins with poor milk drainage and flow due to suboptimal removal of milk, sudden

 A bacterial infiltration through cracked nipples from the woman’s skin or infant’s mouth;  Pathogenic bacteria present in breastmilk;  A dysbiotic process resulting in overgrowth of some cultures and the extinction of others;  Virulence factors;  Production of biofilm;  Antimicrobial resistance;  Interaction with the host immune system.

Signs and symptoms

Early signs of LM include an erythematous, oedematous area on the breast that is usually tender or painful to touch and may present in a wedgeshaped formation. A breast lump or

collection of pus that lacks an outlet. Abscesses are more common in primiparous women, women aged over 30 years, and mothers who give birth post-term.4 Surgical intervention is frequently required to treat this complication. These more severe presentations of complicated infective LM will require immediate review by the GP and potentially hospitalisation for ultrasound, intravenous antibiotics, and further investigation and/or treatment.

Diagnosis

Diagnosis of non-infectious and infectious LM is based on breast examination, clinical history, and presenting signs and symptoms. History-taking should include a breastfeeding and obstetric history, symptom history, mother’s own history, and baby’s history. 4 Consent, hand hygiene, and reassurance will be required for the breast examination. Samples of breast milk may be sent for culture if infection is suspected and any indication of complicated or infectious LM should be reviewed by the GP. 4,7 Any breast lump, swelling, or abnormality that does not get significantly smaller within a week of treatment should also be examined by the GP and may be indicative of more serious disease or infection.7

changes in the baby’s feeding pattern, trauma, pressure from holding the breast incorrectly, or pressure from restrictive clothing and bras.4,5,6 These issues lead to an obstruction in the milk ducts and engorgement of the breast. Milk may then leak into breast tissue, exacerbating the inflammatory response, and in some instances, contributing to the development of infection.

Why infectious LM develops in some cases and not others is unclear, although there is evidence that certain bacteria, in particular Staphylococcus aureus , are more common in women with LM than those that do not develop the condition. 4,5,6,7 Theories behind the aetiology of infectious LM include:4,5,7

tissue thickening may or may not be palpable. The nipple may be pushed flat by oedema or engorgement and feel firm to touch. The patient might also experience a pain or burning sensation that is constant, or only during feeding. These symptoms do not necessarily indicate the presence of infection. Some women may feel generally unwell, but this is usually symptomatic of infectious LM, which may also be accompanied by pyrexia, chills, flu-like symptoms, and hot, painful areas on the breast.4,6,7 In more serious cases of acute infective LM, patients may also present with nipple inversion, thick nipple discharge, breast abscess, or draining fistulas.7 A breast abscess is a closed-in, localised

Management of non-infective LM

Women themselves have emphasised the importance of continuity, individualised care, and consistent information as vital elements of LM management. 1 Clinically, the continuation of breastfeeding is the core component of any approach. Therefore, the highest standards of care will encompass all of these elements. It’s important to be aware that one of the most common and adverse complications of LM is early termination of breastfeeding.7 Patients should always be encouraged to continue to breastfeed, pump,

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PATIENTS SHOULD ALWAYS BE ENCOURAGED TO CONTINUE TO BREASTFEED, PUMP, OR HAND EXPRESS AND ADVISED THAT AVOIDING FEEDING FROM THE AFFECTED BREAST WILL LEAD TO FURTHER MILK STASIS AND WORSENING SYMPTOMS

POSTNATAL INFECTION NO PENICILLIN ALLERGY NONIMMEDIATE PENICILLIN ALLERGY

Infective mastitis Flucloxacillin 500mg -1g QDS PO

Cephalexin 500mg TDS PO

TABLE 1: Medication Guidelines for Obstetrics and Gynaecology: Antimicrobial Prescribing Guidelines11

or hand express and advised that avoiding feeding from the affected breast will lead to further milk stasis and worsening symptoms. 1,3,4,5,6,7,8 Ultimately, breastfeeding is the preferred way to relieve blockages and symptoms of LM, but the process may be difficult and painful for patients. Therefore, many will need added reassurance, education, and support to continue feeding. Breastmilk may not release if the patient is in pain, and analgesia may also be required. Paracetamol and non-steroidal antiinflammatory drugs (NSAIDs), like ibuprofen, can be used for pain control in LM while breastfeeding.7,8

Evidence also exists to support the application of cold cabbage leaves in the reduction of pain and alleviation of symptoms of engorgement. 9 One tablespoon per day of oral granular lecithin has also been reported to relieve clogged ducts and help prevent LM recurrence. 4,10 Therapeutic ultrasound, which is administered by a trained lactation consultant or physiotherapist, is sometimes used to release obstruction and improve milk flow, and may be required daily for several days if symptoms persist. 6

It is important that patients are aware that the affected breast may produce less milk temporarily after an episode of LM and that regular, uninterrupted breastfeeding and skin contact with the baby will encourage milk production and flow to normalise. Educating patients about recognising

SEVERE OR IMMEDIATE PENICILLIN ALLERGY

Clindamycin 300450mg QDS PO

infectious LM include: 4,6,7

the signs and symptoms of infectious LM, such as pyrexia and chills, will help to reduce the risks of serious infection development and promote early intervention.

Management of infectious LM

The management techniques discussed for non-infectious LM can be implemented for infectious presentations too. In particular, continuation of breastfeeding remains the cornerstone of management. 1,3,4,5,6,7,8 Fully emptying the breasts of excess milk regularly has been shown to decrease the duration of symptoms in patients treated with and without antibiotics.4 Hand hygiene should also be recommended for all the family and the importance of skincare and hygiene of the breasts should be reinforced to the patient. Any equipment, such as breast pumps, should be sanitised to minimise further microbial invasion. In the absence of breast abscess or serious infection requiring intravenous therapy and/or surgical input, antibiotic therapy is usually commenced orally, as outlined in Table 1

Practical advice and education

Providing reassurance, education, and advice on how to manage both forms of LM is key to optimal recovery and the continuation of breastfeeding. Simple, natural interventions that may make breastfeeding easier during episodes of non-infectious and

Gentle breast massage before and during feeding, primarily focused on the affected area and surrounding tissue to help unblock ducts.

Using a warm, moist compress on the affected breast for two-tothree minutes (or up to 20 minutes if required) before feeding may also improve flow.

 Cold packs applied to the breast after emptying can help reduce oedema and pain.

 While in the shower, patients can lather and massage the breast with a steady, but gentle pressure behind the affected area, pressing toward the nipple.

 Starting a breastfeeding session on the affected breast is advisable. If the milk doesn’t release or feeding becomes too uncomfortable, recommend that the patient switch to the unaffected breast for a period, then try again and continue to alternate as tolerated.

 Positioning the baby with its chin facing the blockage of the affected breast may also promote improved drainage.

 Advise patients to try gentle hand expressing or using a breast pump if feeding is too painful or not possible.

 Reinforce the importance of staying adequately hydrated and rested.

Prevention of LM

Prevention of LM can be enhanced when pregnant and breastfeeding mothers receive adequate education about how to recognise and minimise their risks of developing the condition. The promotion of exclusive breastfeeding will in itself promote prevention. A variety of potential risk factors for LM development have been identified by experts and include:4,5,6,7,8

Poor positioning and/or attachment of the infant to the breast;

Damaged skin integrity of the nipple or breast;

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Use of bottles or pacifiers;  Too rapid weaning, infrequent feeds, or missing feeds; 

Uneven breast drainage, incorrect attachment during feeding, and problems with baby sucking;  Distractions that prevent or delay the baby or mother breastfeeding;  Illness in mother or baby;  Sustained pressure on the breast from sources that include ill-fitting bras, breast shells worn for too long in a bra with too small cups, slings with straps that press into the breast, and stomach sleeping;  Stress and fatigue; 

Nipple piercings and scar tissue could interfere with milk transfer and contribute to blocked ducts and mastitis;

 Use of antifungal and other nipple creams.

Conversations about these modifiable risk factors will be

paramount in preventing LM development. Ideally, education should start in the antenatal stages and continue postnatally throughout the breastfeeding journey. Support from family members and other healthcare providers is also an important element of both prevention and management. The optimal approach will be a multidisciplinary one.

Conclusion

There are many resources available to help GPNs and breastfeeding parents to prevent, recognise, and manage LM effectively. Knowing what services are available from statutory and voluntary organisations will help guide care and decision-making. Specialist supports are available in the community, including public health nurses (PHNs) and International Board-Certified Lactation Consultants (IBCLCs). Becoming familiar with the

breastfeeding and antenatal classes available in local maternity units, as well as the booking systems for them is also an important element of patient education. Voluntary groups, such as La Leche League, Cuidiu, Friends of Breastfeeding, and The Breastfeeding Supporter can also provide valuable resources and support GPNs and patients. 4

The nationwide database of hospital, public health and voluntary breastfeeding support is available at: www.breastfeeding.ie/Support-search/.

To find an IBCLC and a host of valuable resources and information, visit the Association of Lactation Consultants in Ireland (ALCI) at: www.alcireland.ie/find-a-consultant/.

Information about support groups for breastfeeding patients in the local area is available from the HSE at: www2.hse.ie/services/breastfeedingsupport-search/. l

REFERENCES

1.Tøkje I K, Kirkeli S L, Løbø L, Dahl B. Women's experiences of treatment for mastitis: A qualitative study. Eur J Midwifery. 2021 Jun 29;5:23. doi: 10.18332/ejm/137356.

2. Cooney F, Petty-Saphon N. The burden of severe lactational mastitis in Ireland from 2006 to 2015. Ir Med J . 2019 Jan 15;112(1):855. PMID: 30719896.

3. Scott J A, Robertson M, Fitzpatrick J, Knight, C, Mulholland, S. Occurrence of lactational mastitis and medical management: A prospective cohort study in Glasgow. Int Breastfeed Journal . 2008 3, 21. Available at: https://doi. org/10.1186/1746-4358-3-21.

4. Health Service Executive. Mastitis: Factsheet for healthcare professionals. Available at: www.hse. ie/file-library/mastitis-factsheet-for-

healthcare-professionals.pdf.

5. Wilson E, Woodd SmL, Benova L. Incidence of and risk factors for lactational mastitis: A systematic review. Journal of Human Lactation . 2020;36(4):673-686. doi:10.1177/0890334420907898.

6. Health Service Executive. Mastitis while breastfeeding. 2022. Available at: www2.hse.ie/ conditions/mastitis/.

7. Blackmon M M, Nguyen H, Mukherji P. Acute mastitis. [Updated 2022 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan. Available at: www.ncbi.nlm. nih.gov/books/NBK557782/.

8. National Health Service Northern Ireland. Mastitis. 2022. Available at: www.nidirect.gov.uk/ conditions/mastitis.

9. Boi B, Koh S, Gail D. The effectiveness of cabbage leaf

application (treatment) on pain and hardness in breast engorgement and its effect on the duration of breastfeeding.

JBI Libr Syst Rev. 2012;10(20): 1185-1213. doi: 10.11124/01938924201210200-0000.

10. Drugs and Lactation Database (LactMed) Bethesda (MD). National Institute of Child Health and Human Development. Lecithin. 2006 [Updated 2022 Sep 19]. Available at: www.ncbi.nlm.nih.gov/books/ NBK501772/.

11. Health Service Executive Clinical Programme in Obstetrics and Gynaecology. Medication guidelines for obstetrics and gynaecology

- Antimicrobial prescribing guidelines. 2017. Available at: www. hse.ie/eng/services/publications/ clinical-strategy-and-programmes/ antimicrobial-safety-in-pregnancyand-lactation.pdf.

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MANAGING ACNE IN GENERAL PRACTICE

ACNE IS PROBABLY THE MOST COMMON DERMATOLOGY PROBLEM SEEN IN GENERAL PRACTICE, YET MANY PATIENTS STILL STRUGGLE TO MANAGE THEIR ACNE

Acne is a very common, chronic inflammatory skin disease. It occurs in 90 per cent of teenagers and half of them continue to have acne as adults. About 20 per cent of young people have moderate or severe acne.

Acne is probably the most common dermatology problem seen in general practice. The diagnosis is usually obvious and the treatment for the majority of patients is simple and straightforward. Despite this, many patients still struggle to manage their acne, which occurs on the worst part of their body (face) at the worst time of their life (teenagers and young adults). Left untreated or partially treated, acne may lead to physical and /or psychological scarring.

Pathophysiology

Acne is a disease of the pilosebaceous unit. There are four major contributing factors ( Table 1). It usually occurs at puberty or in early adult life when there is a surge of hormones. Patients with acne do not usually have too much or too little hormones (apart from polycystic ovary syndrome (PCOS) patients).

The problem with acne sufferers is end-organ hypersensitivity to the normal fluctuations in hormones that occur at this time of life and this may be genetically determined. This causes

FIGURE 1: Types of acne pimples

the pilosebaceous unit to over-produce oil, leading to blocked pores called ‘comedones’. Comedones may be almost invisible (micro-comedones), closed comedones (whiteheads) or open comedones (blackheads). These comedones become colonised by the commensal bacteria known as Cutibacterium acnes (C. acnes), which causes inflammation in the area, resulting in the inflammatory features of acne, such as papules, pustules, cysts or nodules ( Photo 1 and Figure 1).

Treating the inflammatory features of acne with oral or topical antibiotics without treating the underlying problems of excess oil and comedones will only partially help and the patient will relapse quickly once the treatment is stopped.

Topical treatments

The first-line treatment for acne sufferers should be to tackle the excess oil and comedones ( Photo 2). Acne washes containing salicylic acid, 0.5to-2 per cent, may help. However, most

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AUTHOR: Dr David Buckley, FRCGP, MICGP, Medical Director of the Kerry Skin Clinic, Tralee, Co Kerry, www.kerryskinclinic.ie

patients will also need a topical retinoid such as topical isotretinoin (eg, Isotrex), or a retinoid-like agent, such as adapalene (eg, Differin Gel), or a combination of a retinoid-like agent, such as adapalene with benzoyl peroxide (eg, Epiduo).

These topical agents can be irritating and patients need careful counselling on how to use them properly. These products should be put all over the acne-affected areas and not just onto the individual spots since they are designed to reduce oil production, prevent the build-up of comedones, and avoid the development of papules and pustules. These agents should be applied sparingly on alternate nights for the first week or two until the patient gets used to the drying effects before increasing to nightly use.

Some patients may need to use a lightweight, non-greasy, noncomedogenic moisturiser in the morning to counteract the drying effects of topical retinoids or retinoid-like agents.

Patients with sensitive skin or a history of eczema may not be able to tolerate these topical agents and may have to try a less irritating topical treatment, such as azelaic acid 20 per cent (Skinoren Gel) instead.

These topical retinoids and retinoidlike agents are very slow to work. It can take weeks or months to see an improvement in the acne. Results can be enhanced by logical combinations, such as a topical retinoid or a retinoidlike agent in association with an antiinflammatory agent, such as benzoyl peroxide (BPO), or antibiotics either topically or orally ( Table 2).

BPO, like topical retinoids and retinoid-like agents, can be quite irritating and should be used sparingly and on alternate days initially before increasing to daily use. Because BPO is cheap and available without prescription, it is sometimes used first-line on its own with an anti-acne wash when there is primarily inflammatory acne without too much oiliness or comedones. BPO is also useful as it does not make the patient sensitive to sunlight and it can be used in

THERE ARE FOUR MAIN MECHANISMS IN THE AETIOLOGY OF ACNE:

A. Excessive production of sebum (under hormonal control)

B. Follicular plugging causing micro-comedones and comedones

C. Overgrowth of micro-organisms especially C. acnes (formerly Propionibacterium acnes), which causes release of inflammatory cytokines

D. Inflammation causes the pylosebaceous cyst wall to rupture, resulting in an intense foreign bodylike reaction, which leads to further development of inflammatory lesions (papules, pustules, nodules, cysts)

TABLE 1: Aetiology of acne

pregnancy. In addition, it can be useful for treating large areas, such as the back and chest, as it comes in relatively large tubes (eg, Acnecide Gel 60 grams). Apart from its drying effects, the other disadvantage of BPO is that it can bleach clothing, so it is best to advise patients to apply it at night, if they are putting it on their chest or back, they should use a white T-shirt at night, white sheets, white pillowcases, and white towels.

BPO does not have any anticomedonal effects so it is best used in combination with topical retinoids or retinoid-like agents for more moderate-to-severity acne, especially if there are many comedones.

For most patients with acne, combining BPO with adapalene (a retinoid-like agent), such as Epiduo Gel is very convenient as it only has to be applied once at night all over the acne-affected areas of the face and neck. However, this combination of two potentially irritating agents can be drying and somewhat irritating, especially at the start of treatment. Applying it alternate nights for the first week or two can help with the irritation

PHOTO 2: Oily acne in a 15-year-old prior to oral isotretinoin

and most patients can then increase up to nightly use. One bottle (45g) should usually last two-to-three months when applying it to the face. If this combined agent causes too much irritation, it might be necessary to apply a topical retinoid or retinoid-like agent, such as topical isotretinoin or adapalene at night and BPO in the morning, but this involves twice-daily treatments, which may reduce compliance, especially in men.

BPO can have as good an anti-bacterial effect on acne as topical antibiotics without the risks of developing resistance. It has the advantage over topical antibiotics in that it can be used long-term for weeks, months or years without losing its effect.

Patients with more moderate to severe

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PHOTO 1: Acne features. Blue = blackhead (open comedone). Yellow = whitehead (closed comedone). Red = papule. Purple = pustule. Pink = excoriation from picking

Decrease sebum production

Reduce follicular plugging

Reduce propionibacterina

inflammation

TABLE 2: Mode of action of various anti-acne therapies (adapted table)10

acne may need an antibiotic added to the above mentioned topical treatments to get the acne under control ( Table 3). While topical antibiotics offer some antibacterial effects, resistance can develop quickly and they are only licensed to be used for three months, which is a very short time in an acne sufferer’s life. Acne can lasts years, not months, so topical antibiotics have a very limited role in the overall management of acne.

Systemic treatments

Oral antibiotics used for a maximum of three-to-six months have useful antibacterial effects, but products, such as lymecycline 405mg daily or doxycycline 100mg daily, also have powerful antiinflammatory effects, which is probably their primary mechanism of action in acne. However, like BPO, antibiotics have no anti-comedonal effects, so they should never be used alone to treat acne. It is best to combine antibiotic treatments with anti-comedonal

treatments, such as topical retinoids or retinoid-like agents. The combination of a topical retinoid or a retinoid-like agent with an oral antibiotic for three-to-six months should clear up 90 per cent of acne in 90 per cent of patients who can tolerate this treatment. Lymecycline is usually the first-line systemic treatment as doxycycline occasionally causes photosensitivity or oesophagitis. Tetracyclines should not be used in children under the age of 12 years.

INDICATIONS FOR ORAL ISOTRETINOIN (ROACCUTANE)

Severe nodulocystic acne

Acne unresponsive to standard oral and topical treatments especially if scarring

Acne relapsing after repeated courses of oral and topical acne therapies

Acne associated with severe psychological upset

Gram-negative folliculitis

Conglobate acne

Acne fulminans

Pyoderma facialev

TABLE 4: Indications for oral isotretinoin

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MODE OF ACTION SALICYLIC ACID WASH BENZOYL PEROXIDE TOPICAL RETINOIDS AZELAIC ACID (SKINOREN) TOPICAL ANTIBIOTICS ORAL ANTIBIOTICS HIGH-DOSE OESTROGENS AND/OR ANTIANDROGENS
ROACCUTANE
++ ++
+ ++ + + ++
acnes ++ + ++ ++ ++
Reduce
+ + + + ++ ++
ACNE CAN LASTS YEARS, NOT MONTHS, SO TOPICAL ANTIBIOTICS HAVE A VERY LIMITED ROLE IN THE OVERALL MANAGEMENT OF ACNE

Acne is a chronic disease

Acne should be considered a chronic disease. Like many other chronic diseases, such as asthma or rheumatoid arthritis, treatment should be aimed at settling the acute symptoms (papules, pustules, nodules and cysts) and preventing relapse. Once the patient’s acne is under control (90 per cent or clearer) they can stop their oral therapy, but should continue with their topical retinoids or retinoid-like agent indefinitely to prevent relapse until such time as they are convinced that they have grown out of their acne. This can be months or years if necessary. Oral tetracyclines and topical retinoids or retinoid-like agents should be avoided in pregnancy. BPO and erythromycin 500mg twice a day for three-to-six months are safe in pregnancy if required for troublesome acne. Adapalene (a topical retinoid-like

agent) combined with BPO (Epiduo Gel) is a very useful product as it can be used both to control acute flare ups of acne (with a course of oral antibiotics for three-to-six months if necessary) and it can also be used as a maintenance treatment once the acne is under control to prevent relapse. With these combinations it may be possible to explain to the patient how to manage the acute phase of their moderatelysevere acne (eg, Epiduo Gel and an oral anti-acne tablet for three-to-six months) and the maintenance treatment (eg, stop the tablet and use Epiduo Gel alone) in one single visit.

Lifestyle, cosmetics, and medication

Acne is primarily hormonally driven. However, poor diet, inappropriate use of cosmetics, stress, and picking can all aggravate acne. There is some evidence

that excessive sugar and excessive dairy in the diet may aggravate acne. When seeing a young person with acne, it is a good opportunity to give them lifestyle advice about diet and exercise. Try to talk directly to the young teenager who comes with their parents. Encourage them to stay on a low-sugar diet and they should be encouraged not to consume excessive dairy products. Protein powders that are used for sports or bodybuilding should be avoided as they contain excessive amounts of whey protein and often make acne worse. While there is no hard evidence that exercise helps acne, it is a good opportunity to advise young people to take vigorous physical exercise for one hour at least five times a week, which may help their overall health and feeling of wellness.

Young women in particular are bombarded with misinformation about skin care and cosmetics. They are encouraged to “cleanse, tone, and

| ACNE |
www.citrinehealthcare.com | Tel: 01 445 7206 Protect the skin you’re in Targeted skin care for dry and irritated skin. 1 00% I R I S H OWNE D 1 %00 I R I S H ENWO D

ACNE

A. ALL CASES

Use a salicylic acid wash; avoid oily products and no picking

B. MILD

Continue A and add in: 

Comedonal acne: Topical retinoid or azelaic acid

C. MODERATE

Inflammatory acne: BPO or topical antibiotics*

For mixed type acne use combinations of above

WORSE BETTER

Topical retinoid = adapalene or isotretinoin

BPO = benzoyl peroxide

Oral antibacterial agents = lymecycline, doxycycline or erythromycin

Anti-androgens = Dianette, OCP containing progestins with anti-androgenic properties (eg, drospirenone, chlormadinone acetate) or spironolactone

*Topical antibiotics should only be used for a maximum of 12 weeks, never with oral antibiotics

TABLE 3: A stepwise approach to acne

moisturise” even if they don’t need it. Moisturising already oily, acne-prone skin is like “adding fuel to the fire”. Young people should be informed that moisturising does not prevent wrinkles or ageing of the skin. However, some acne cleansers and topical acne treatments may dry the skin, so some patients may need a light-weight, oilfree, non-comedogenic moisturiser in the mornings to control the drying effects of their acne treatments. Makeup and sun blocks should be oil-free and non-comedogenic.

Underlying hormonal issues, such as women using ultra-low-dose oestrogen combined contraceptive pills,

Continue with A and B and add in oral treatments: Eg, anti-bacterials x 3-6 months (+/- antiandrogens x 6-12 months in females)

WORSE

D. SEVERE Refer for Roaccutane

CURED (33% may relapse)

progesterone-only pills, progesterone implants or progestogen containing intrauterine devices (IUDs) (eg, Mirena or Kyleena) may aggravate acne. Women with resistant acne or acne with signs of other hormonal problems, such as irregular periods, obesity or hirsutism should be investigated for PCOS. Women with PCOS and acne may do well with hormonal treatments, such as the contraceptive pill Dianette for up to 12 months or spironolactone (a diuretic that has been used off-label in women with acne for over 30 years due to its antiandrogenic properties) (50-100mg daily), which can reduce oil production and comedones. These hormonal treatments

are best combined with topical antiinflammatory agents, such as BPO or azelaic acid. Women on spironolactone should not become pregnant, due to potential risk of birth defects.

Patients with severe nodulocystic acne, scarring acne, and acne that does not respond or relapses as quickly to six months of an oral anti-acne agent combined with appropriate topical agents as outlined above may need a course of oral isotretinoin ( Table 4). This should only be prescribed by doctors with experience of prescribing systemic retinoids (eg, GPs with a special interest in dermatology or consultant dermatologists). l

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REFERENCES

1. Dawson AL, Dellavalle RP Acne vulgaris. BMJ . 2013; 346:f2634.

2. Bhate K, Williams HC. Epidemiology of acne vulgaris. Br J Dermatol 2013; 168(3):474-85.

3. Mallon E, Newton JN, Klassen A, et al. The quality-of-life in acne: A comparison with general medical conditions using generic questionnaires. Br J Dermatol 1999; 140(4):672-6.

4. Teen Acne Survey; Harris Poll. Conducted between July 13 and 31, 2017 by www.theharrispoll.com/.

5. Grossi E, et al. The

constellation of dietary factors in adolescent acne: A semantic connectivity map approach.

J Eur Acad Dermatol Venereol 2016 Jan; 30(1):96-100. doi: 10.1111/jdv.12878.

6. Nast A, et al. European evidence-based (S3) guideline for the treatment of acne –update 2016 – short version.

J Eur Acad Dermatol Venereol 2016 Aug;30(8):1261-8. doi: 10.1111/jdv.13776.

7. Henehan M, Montuno M, De Benedetto A. Doxycycline as an anti-inflammatory agent: Updates in dermatology.

J Eur Acad Dermatol Venereol. 2017,31,1800-1808. doi: 10.1111/jdv.14345.

8. Tan J, Humphrey S, Vender R, et al. A treatment for severe nodular acne: A randomised investigator-blinded, controlled, non-inferiority trial comparing fixed-dose adapalene/BPO plus doxycycline vs oral isotretinoin.

Br J Dermatol . 2014;171:1508-16.

9. Buckley D, Yoganathan S. Can oral isotretinoin be safely initiated and monitored in primary care? A case series.

Ir J Med Sci 2017 Jan 9. doi: 10.1007/s11845-016-1540-5.

10. Gollnick H, Cunliffe W, Berson D, et al. Management of acne: A report from a global alliance to improve outcomes in acne. J Am Acad Dermatol .2003 Jul;49(1 Suppl):S1-37.

| ACNE |
Free independent CPD for Irish nurses nurse CPD A B C Successful completion of this module will earn you 2 CPD credits An overview of the latest approaches and evidence in treating iron deficiency in patients with cardiovascular issues Iron deficiency in cardiology – 2022 Scan here or visit www.medilearning.ie/nursecpd

A-Z OF CONTRACEPTION

EXAMINING THE VARIETY OF CONTRACEPTION METHODS AVAILABLE IN IRELAND TO HELP YOUR PATIENTS MAKE THE RIGHT DECISIONS FOR THEM

Contraception is the act of preventing pregnancy. Although hormonal contraceptives and intrauterine devices (IUDs) are highly effective at preventing pregnancy, they do not protect against sexually transmitted infections (STIs). The correct and consistent use of condoms, in addition to helping prevent pregnancy, reduces the risk of contracting HIV and other sexually transmitted infections. Condoms offer the best protection from STIs if used correctly, and using dual protection, ie, condoms with another method of contraception, is recommended.1,2

There are many different types of contraception available. Choosing the right method is a personal decision and involves finding what works best for the individual. Contraceptive counselling with a health professional is a marked contributor to the successful use of contraception. When considering contraceptive methods, counselling should include efficiency, safety, acceptability, and availability, including accessibility and affordability.

Some 17-to-25-year-olds can now get free contraception in Ireland. The free scheme is to be extended to 26-yearolds from January 2023, and to 26-to30-year-olds in September 2023. The

free contraception scheme covers the full cost of prescription contraception, including the cost of consultations with medical professionals to discuss suitable contraception options and enable prescription of same. The scheme provides a wide range of contraceptive options, including contraceptive injections, implants, IUDs, intrauterine systems (IUSs), the contraceptive patch and ring, and various forms of oral contraceptive pill, including emergency contraception. It also includes fitting and removal of long-acting reversible contraception (LARC), plus any necessary checks by medical professionals certified to insert or remove them. This is a major step forward for sexual and reproductive health in Ireland, and a progressive step towards promoting women’s health. 2

Methods of contraception

Combined hormonal contraceptives (CHCs)

Combined hormonal contraceptives (CHCs) containing synthetic oestrogen and progesterone are among the most commonly prescribed and wellresearched types of contraceptive medication in use. CHCs can be delivered through a pill, patch, or vaginal ring. In CHCs, both progestins and oestrogen inhibit the hypothalamic–

pituitary–ovarian axis, which controls the reproductive cycle. Progestins prevent pregnancy by inhibiting the luteinising hormone (LH) surge, suppressing ovulation, thickening the cervical mucus, lowering fallopian tube motility, and causing the endometrium to become atrophic. Oestrogens prevent pregnancy by suppressing folliclestimulating hormone (FSH) production, which prevents the development of a dominant follicle. Progesterone is responsible for most contraceptive action and side-effects, and the addition of oestrogen helps prevent irregular or unscheduled bleeding.4

The combined pill is more than 99 per cent effective with perfect use and 91 per cent effective with ‘typical use’. Advantages are that it does not interrupt sex, often reduces bleeding and period pain, and may help with premenstrual symptoms. Disadvantages are that it can be less effective if a pill is missed, if there is vomiting or severe diarrhoea, or by taking certain medications. It is not suitable for smokers over 35 years of age or those who are obese. It may not be suitable for women who are breastfeeding and medical advice should be obtained. The combined pill may not be suitable for women with hypertension, circulatory disease, blood clots, breast cancer (current or within

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AUTHOR: Theresa Lowry-Lehnen, RGN, PG Dip Coronary Care, RNP, BSc, MSc, PG Dip Ed (QTS), M Ed, PhD,and Clinical Nurse Practitioner and Associate Lecturer, South East Technological University

mycontraception.ie (2022)

the past five years), migraine with aura, gallbladder or liver disease, or diabetes with complications. 5 On commencing the combined pill, some women may experience breast tenderness, skin irritation, mild headaches, a bloated feeling, or have some breakthrough bleeding between periods. These symptoms should settle within the first few months of using the combined pill. In healthy women who do not smoke, the combined pill can be used up to menopause. However, as the risks of cardiovascular disease increase with age, doctors often recommend changing

after the age of 40. Long-term use of the combined contraceptive pill does not affect fertility, but once stopped, it may take some time for the body's natural hormones to go back to their normal levels. 2,3,5

The CHC transdermal patch is a thin adhesive square about 4-5cm wide, containing synthetic oestrogen and progesterone. It can be placed on the stomach, upper arm, buttock, or back, and must be completely attached to the skin to be effective. The patch is replaced every week for three weeks. During the fourth week, no patch is

worn and a withdrawal bleed occurs. It is over 99 per cent effective with perfect use, and 91 per cent effective if not always used correctly. 2,4 Advantages are that it does not interrupt sex and may be easier to remember than taking a pill every day. Unlike the pill, the CHC patch is not affected by vomiting or diarrhoea. It may protect against cancer of the ovaries and the uterus. 5 Effectiveness may be reduced by taking certain medications. It is not suitable for people who are obese, or for smokers over the age of 35. It may not be suitable for women who are breastfeeding, and

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medical advice should be sought. 2,3 It is a very effective method when used correctly, however, pregnancy can occur if an error is made using the patch, especially if it becomes loose or falls off for more than 24 hours, or the same patch is left on the skin for more than one week. 5

The CHC vaginal ring (NuvaRing) is a clear, flexible ring about two inches in diameter containing synthetic oestrogen and progesterone that is placed in the vagina for 21 days, and removed for seven days to allow for withdrawal bleeding. It is replaced monthly. Users can place the ring in the vaginal canal themselves. As with the patch, the less frequent applications can be appealing and can lead to increased adherence. The ring’s internal placement ensures the steady delivery of hormones, which allows for lower serum concentrations than occur with either the patch or pills. As a result, the ring generally has milder side effects than seen with other CHC delivery methods. Some users may experience increased vaginal irritation and discharge. There is also some evidence of reduced vaginal dryness, which may appeal to perimenopausal women and others who tend to experience such dryness. 4 It is over 99 per cent effective with perfect use, and 91 per cent effective if not always used correctly. Advantages are that it can be self-inserted, does not interrupt sex, and stays in place for 21 days before removal. Its effectiveness may be reduced by taking certain medications, and it is not suitable for people who are obese or smokers over 35. It may also be unsuitable if breastfeeding and medical advice should be sought for same. 2,3

Ring users may have concerns about their risk for pregnancy if the ring is removed intentionally or accidentally. The ring can be removed for up to three hours without diminishing its contraceptive effect. The manufacturer recommends rinsing the device in cool or lukewarm water prior to reinsertion. If

the ring is out for more than three hours, users should take extra steps to protect (condoms or abstinence from sex) against pregnancy. As with any device, users should consult the package insert for more specific instructions.4

Progesterone-only pill (POP)

POPs are generally made with firstgeneration progestins and dosage amounts are substantially lower than those found in any CHC. POPs must be taken at the same time every day. They are used continuously, with no hormone-free interval.4 Progestogenonly pills are considered safe in many clinical scenarios where CHCs are contraindicated. Progestogen-only

35. It can also be used while breast feeding. 2,3 The progestogen-only pill may not be suitable for women with liver, heart disease or stroke, breast cancer (current or in the past), systemic lupus erythematosus (SLE) or lupus, or irregular vaginal bleeding. However, in healthy women with no medical conditions that make it unsuitable, it can be taken until menopause or age 55. 5

There are two types of progestogenonly pills available in Ireland, Noriday and Cerazette, which differ in the way they work and instructions for what to do if a pill is missed. If a pill is forgotten, it should be taken as soon as remembered, and the next one at the correct time. This may mean taking two pills in one day. If the Noriday

PROGESTOGEN-ONLY PILLS, HOWEVER, HAVE A HIGHER FAILURE RATE WHEN NOT TAKEN AT THE SAME TIME EVERY DAY BECAUSE EFFECTIVE DRUG LEVELS ARE ONLY MAINTAINED IN THE BLOODSTREAM FOR 22 HOURS

pills, however, have a higher failure rate when not taken at the same time every day because effective drug levels are only maintained in the bloodstream for 22 hours. The progestogen-only pill may be commenced at any time. Another method of contraception should be used if vaginal intercourse takes place during the first 48 hours of pill use. Protection will begin after two days. 5 The most common side-effects of POPs are unscheduled bleeding and spotting, likely due to the shorter daily window of efficacy and the absence of oestrogen. Its effectiveness may also be reduced by taking certain medications, missing a pill, or having vomiting or severe diarrhoea. Advantages are that it does not interrupt sex and can be used by smokers over the age of

pill is taken more than three hours late, the woman is not protected. She should continue to take the pill as soon as possible and will be protected again after two days of taking the pill normally. Until then, using condoms or abstinence from sex is required. If the Cerazette pill is more than 12 hours late the woman is not protected against pregnancy. Protection against pregnancy will return after two days of taking the pill normally. Until then using condoms or abstinence from sex is required. 5 It is unlikely that taking the pill during early pregnancy will increase the risk of defects in the foetus. However, although it is rare, the likelihood of ectopic pregnancy is greater if pregnancy occurs while taking the progestogen-only pill. 5

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Long-acting contraceptionreversible (LARC)

LARCs are a group of contraception methods that provide very effective contraception, are long-acting, and reversible when removed or stopped. They include injections, IUDs, IUSs, copper coils (IUCDs), and subdermal contraceptive implants. LARC are the most effective reversible methods of contraception because their efficacy is not reliant on patient compliance.

LARC needs to be inserted and removed by a specially trained doctor or nurse. Most are more than 99 per cent effective. An exception is the injection, which can have lower efficacy. LARC can be used by most women of any age, including those who cannot use contraception containing oestrogen; experience side-effects with oestrogen, such as nausea or breast tenderness; have migraines; smoke; have never had a baby; are breastfeeding or have recently had a baby; have recently had a termination of pregnancy; are overweight; have diabetes or epilepsy; are living with HIV; or have inflammatory bowel disease. Different LARC work in different ways.6

Implant (Implanon)

The contraceptive implant is a small flexible plastic rod, which is implanted by minor surgery under the skin in the inner part of the upper arm. Local anaesthetic is used to numb the skin before insertion. The implant slowly releases progesterone hormone and gives contraceptive protection for three years. It can be removed at any time with minor surgery, and it can be used by women of all ages, whether they have had children or not. A pregnancy test will be performed before insertion to confirm the woman is not pregnant. The implant is suitable for women who are breast-feeding or who do not tolerate oestrogen. Fertility returns to normal once the implant is removed. In the first three-to-six months of use, many

women have irregular bleeding. After this, most women will have lighter or less frequent periods. Some will have regular monthly periods and some will not bleed at all. 3,7

The implant will begin to work within one week. If there are no medical problems, the implant can be used as a method of contraception until menopause. Each implant will have to be changed every three years, but there is no limit to the number of implants that can be fitted. Removal may leave a small scar. The implant is not affected by common antibiotics, but is affected by enzyme-inducing medication, such as HIV treatments or epilepsy medication.7,8

An implant can be inserted three weeks (21 days) after giving birth. If the implant is inserted on or before day 21, the woman will be protected from pregnancy immediately. If the implant is put in later than day 21, an extra method of contraception is required for seven days. The implant can also be used immediately after a miscarriage or termination of pregnancy.7,8 There is no evidence that there is a delay in return to fertility after the removal of an implant. Over 90 per cent of women will have returned to a normal cycle within three-to-four weeks.7

IUS hormonal coil

The hormonal coil, also called an IUS, is a small, T-shaped device that is placed in a woman’s uterus. It is made of flexible plastic, which contains a slow-releasing hormone called levonorgestrel. It has two soft threads on the end that hang through the opening at the entrance of the cervix into the top of the vagina. An IUS works by changing the conditions in the uterus and cervix. These changes prevent sperm fertilising an egg and may also prevent a fertilised egg implanting in the womb. 9

There are three types of IUS available; the Mirena, which lasts for eight years Kyleena for five years, and Jaydess for three years. 2,9 An IUS can be fitted

at any time during the menstrual cycle, once it is confirmed that the woman is not pregnant. An internal examination is carried out before the IUS is inserted and the insertion visit takes approximately 15-to-20 minutes. Insertion can be uncomfortable and some women experience a periodtype pain and light bleeding for a few days afterwards. Some women may experience common hormonal sideeffects, such as headaches, breast tenderness, and abdominal discomfort. There is a small risk of infection and of expulsion. The risk of perforation is very low when the IUS is fitted by an experienced healthcare provider.

A check-up is required four-to-six weeks after insertion, to check the strings, make sure the device is properly in place, and that there are no problems. The woman is taught to feel for the strings and should check them monthly to make sure the IUS is in place. Normal fertility returns as soon as the IUS is removed. Another IUS can be inserted directly after the old IUS has been removed. If the woman is not going to have another IUS inserted, is sexually active and does not want to become pregnant, an extra contraceptive method, such as condoms, should be used for seven days once the IUS is removed. An IUS can be put in within 48 hours of giving birth, but fitting of an IUS is usually deferred until at least eight-to-12 weeks after the birth. Another contraceptive method will need to be used until then. An IUS can be used safely while breastfeeding and does not affect milk supply. 9

IUCD- copper coil

An IUCD, also known as the IUD, loop, or copper coil, is a small T-shaped contraceptive device that is placed in a woman’s uterus. It is made of flexible plastic with a coating of thin copper wire. It has one or two soft threads on the end, which hang through the opening at the cervix into the top of the vagina. An IUCD works by preventing

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sperm from surviving in the cervix, uterus, or fallopian tubes. It may also work by stopping a fertilised egg from implanting in the uterus.10

The IUCD acts as an effective method of contraception for five-to-10 years, depending on the device used. There are several different types of IUCDs. The newer devices contain more copper and are more than 99 per cent effective. Older IUCDs have less copper and are less effective. An IUCD can be fitted at any time during the menstrual cycle, once it is confirmed that the woman is not pregnant. An internal examination is carried out before the IUCD is inserted. Insertion can be uncomfortable and some women may experience a periodtype pain and light bleeding for a few days after insertion.10 There is a slight risk that an IUCD might perforate the uterus or cervix during insertion. This may cause pain, but there are often no symptoms. If this happens the IUCD may have to be surgically removed. The risk of perforation is very low when the IUCD is fitted by an experienced practitioner. There is also a small risk of pelvic infection in the first three weeks after insertion.10

An IUCD can be inserted within 48 hours of giving birth, but fitting is usually deferred until at least eightto-12 weeks after the birth. Another contraceptive method will need to be used until then. An IUCD can be used safely while breastfeeding.10

If another IUCD is not being inserted following removal of a device, and the woman does not want to become pregnant, an extra contraceptive method, such as condoms should be used for seven days before the IUCD is removed. Sperm can survive for up to seven days inside the body and could cause pregnancy once the IUCD is removed.10 If a woman becomes pregnant with an IUCD in place, the doctor will usually remove the device, if possible. While there is a risk of miscarriage following removal of the device, leaving it in could cause

miscarriage later in the pregnancy. If the woman does not have a miscarriage, the IUCD will not harm the baby. An IUCD can be put in immediately after a miscarriage or termination of pregnancy if the woman was pregnant for less than 24 weeks. The IUCD is also a very effective form of emergency contraception used after unprotected sex or contraceptive failure.10

Injection (Depo-Provera)

The contraceptive injection, DepoProvera, contains the hormone progestogen. It is effective for 12 weeks. The hormone is injected into a muscle, initially during the first five days of a woman’s period, and further injections are required every 12 weeks. The injection acts primarily by preventing ovulation. Less often, it works by thickening cervical mucus to prevent sperm from fertilising an egg, or by altering the lining of the uterus, which may prevent implantation of a fertilised egg. The contraceptive injection may be associated with weight gain and other side-effects, such as acne, breast tenderness, bloating, and changes in mood. For some women, use of DepoProvera may be associated with an increase in weight of up to two-to-three kilograms over a one-year period.11,12

Some medical conditions may make the injectable contraceptive unsuitable. These can include breast cancer; unexplained vaginal bleeding; thrombosis; heart attack or stroke; diabetes with complications or for more than 20 years; active liver disease; and risk factors for osteoporosis. As with any injection, there is a risk of a small infection at the site of the injection. Prolonged Depo-Provera use for more than three-to-four years is associated with a small loss of bone mineral density, which is largely recovered when the contraceptive injection is stopped. 11,12

The injection can be started immediately after a termination of pregnancy or miscarriage if the

woman was pregnant for less than 24 weeks. Protection against pregnancy is immediate. If a woman has just had a baby, delaying the injection for six weeks often makes irregular bleeding less likely. Contraceptive injections can be used while breastfeeding. A small amount of hormone enters the milk, but is not harmful for the baby. There could be a delay of up to one year in the return of fertility after discontinuing the use of injectable contraceptives, so this method of contraception may not be suitable for women who are planning on conceiving a baby within the next year.11

Emergency contraception

Emergency contraception is a safe, effective, and responsible method of preventing pregnancy when regular contraception has failed, no contraception was used, and in the event of sexual assault. Emergency contraception will usually prevent pregnancy if taken on time.13

Emergency contraception, also known as post-coital contraception, is available in two forms, the emergency contraceptive pills (ECPs) progesterone (taken within three days of unprotected sex) and ulipristal (taken within five days of unprotected sex), or insertion of an IUCD.

The progesterone ECP is available from pharmacies without a prescription, and from a doctor or family planning clinic. It must be taken within 72 hours of unprotected sex, but is most effective the sooner it is taken.

The main brand of the ulipristal ECP in Ireland is ellaOne. It is also available from pharmacies without a prescription, GPs, and family planning clinics. It must be taken within 120 hours of unprotected sex, but is more effective the sooner it is taken. Evidence suggests that the ulipristal ECP (ellaOne) is more effective than the progesterone ECP. Both methods of the ECP work by preventing or delaying ovulation, thereby preventing

| CONTRACEPTION | | NURSING IN GENERAL PRACTICE | 46 | JANUARY-FEBRUARY 2023

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fertilisation. There are no long-term side-effects from using the ECP. 13 It is important to take the ECP as soon as possible after unprotected sex, and the doctor or pharmacist should be informed if the woman is taking any other medication. A small number of medications may reduce the effectiveness of the ECP, and the woman may need a different dosage or an IUCD. If vomiting occurs within three hours of taking the ECP, it is important that patients return to their healthcare provider as soon as possible for a second dose or further advice. Taking different kinds of the ECP during the same cycle is not recommended as they work in different ways. If a second dose is required during the cycle, the same ECP must be used as the first dosage. Other methods of contraception are recommended after taking the ECP as it does not provide contraception for the remainder of the cycle. There is a small risk of failure with the ECP and the woman may still become pregnant. The ECP does not work if a woman is already pregnant. 13

Barrier methods of contraception

Condoms

Condoms are a barrier method of contraception which work by preventing semen from entering the vagina. A male condom is made from very thin, natural latex rubber, which is soft and stretchy. It is closed at one end, with a teat to collect sperm, and fits over an erect penis. A female condom is made of very thin polyurethane plastic. It is closed at one end, and designed to form a loose lining to a woman’s vagina with two flexible rings, one at each end, to keep it in place. 14

Advantages are that condoms help prevent the spread of HIV and STIs, are easily accessible, only need to be used when having sex, and have very few or no side-effects. Male condoms come in a variety of shapes and sizes. A female condom can be put in any time before

sex. Disadvantages are that the male condom can sometimes slip off or split. Some people are sensitive to latex, though this is rare. Female condoms may be noisy and may slip during sex. Female condoms are not suitable for women who have an infection in their vagina or cervix. 14

Male condoms are 98 per cent effective with perfect use every time, but 82 per cent effective when the method is not used correctly every time. Using condoms correctly requires practice. They can get damaged if handled roughly or used with an oilbased lubricant. They too must be

diaphragms are 92-to-96 per cent effective. They are only 71-to-88 per cent effective if not always used correctly, and it is important that patients are made aware of this. They should receive an examination for the initial fitting and correct sizing, as well as education regarding correct insertion.17,18

Advantages are that the diaphragm can be put in place anytime before sex, reused after careful washing and drying, and it is a useful method if the woman wants to avoid taking hormonal contraception. 18

Disadvantages are that it can disrupt sex; may not be suitable for people

used before the expiry date on the packet. Female condoms are 95 per cent effective with perfect use every time, and 79 per cent effective when not always used correctly.15

Using condoms every time during sex reduces the risk of getting an STI. Condoms offer the best protection from sexually transmitted infections if used correctly. Using dual protection, ie, condoms with another method of contraception is recommended. 2

Diaphragm

A vaginal diaphragm is a barrier method of contraception that fits into the woman’s vagina. Vaginal diaphragms are domes made of thin, soft silicone with a flexible rim. The diaphragm covers the woman’s cervix and prevents the sperm from reaching the egg. To be effective, diaphragms need to be used with a contraceptive gel to inactivate any sperm that are present. If used according to instructions and with the gel, latex

who are sensitive to the chemicals in contraceptive gel; annual checks are required to make sure it still fits; a different size may be needed if more than three kilograms of body weight has been gained or lost; it must be left in place for at least six hours after sex, but not longer than 24 hours; extra spermicide must be used if sex occurs more than once; and it does not protect against STIs. Cystitis can also be a problem for some women who use a diaphragm. It may not be a suitable method of contraception for women with weak vaginal muscles, an unusual shaped cervix, repeated urinary tract infections, or a history of toxic shock syndrome.17,18

Other methods of contraception

Spermicides

Spermicides are not very effective when used on their own and are best combined with a barrier method, such as a condom or a diaphragm. There are many different types available,

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IT IS IMPORTANT TO TAKE THE ECP AS SOON AS POSSIBLE AFTER UNPROTECTED SEX, AND THE DOCTOR OR PHARMACIST SHOULD BE INFORMED IF THE WOMAN IS TAKING ANY OTHER MEDICATION

from foams to creams and gels, but they all work in similar ways. Spermicide needs to be applied prior to intercourse, every time. 22

Chemicals in spermicides make it difficult for sperm to move in the vagina. Since spermicides are best used with another form of contraception, the directions on how to use them will depend on the barrier method they are applied to. Spermicides must be left in the vagina for at least six hours after sex. Close attention must be paid to the spermicide's expiry date. Some people experience allergic reactions or irritation caused by the chemicals in spermicide products. They do not protect against sexually transmitted infections. 22

The withdrawal method

The withdrawal method pre-dates science and is not a reliable method of contraception. It involves the man removing his penis from the vagina before ejaculation. It requires a lot of self-control and it can be a very undependable method of contraception. Withdrawal does not protect against sexually transmitted infections. 23

Natural planning

Natural planning, sometimes referred to as fertility awareness, is a technique of tracking exactly which stage of the menstrual cycle the woman is at, and only having sex on non-fertile days. Natural planning methods vary in terms of how much attention they need, but it’s important to be aware of fertile days and to use additional contraception on these days. It is about 76 per cent effective with typical use. 24

Permanent methods of contraception Vasectomy - male sterilisation

Vasectomy (male sterilisation) offers a safe, convenient, and effective permanent method of family planning for men (or couples) who are certain

that their family is complete and/or who do not want (any more) children. Before carrying out the procedure counselling is recommended to ensure it is the best method of family planning for them. The operation is a minor procedure carried out under local anaesthetic and involves cutting and sealing the spermatic tubes. The doctor will make either a small cut or puncture in the scrotum. The tubes will be cut and re-joined by tying the ends together or sealing them with heat. The opening in the scrotum is very small and sutures may not be needed. If sutures are required, dissolvable stitches or surgical tape will be used.

Female sterilisation (tubal occlusion)

Female sterilisation, or tubal occlusion, is a surgical procedure carried out under anaesthetic to permanently prevent pregnancy. The fallopian tubes are blocked or sealed to prevent the sperm from reaching the egg and becoming fertilised. 20 Sterilisation is for people who have completed their families or who are sure that they never want to have children. It should not be undertaken at a time of stress or crisis, and consideration should be given to alternative forms of long-term contraception during the decision-making process. Counselling will be recommended before the procedure. Female sterilisation cannot be easily reversed. 21

The operation takes approximately 10to-15 minutes to complete.19

There is a small risk that the procedure may not be successful. Semen tests should be performed 16 and 18 weeks after the vasectomy to ensure there is no sperm left in the tubes and that the operation has been successful. Until two negative semen tests have been confirmed, another method of contraception should be used. More than two semen tests may be required. There is also a very small risk, (one-in-2,000) of late failure. 19

Vasectomy is a minor procedure with very little risk involved. However, a small number of men can experience bleeding, swelling, or infection, and occasionally sperm can leak out of the tube and collect in the surrounding tissue causing inflammation and pain. Vasectomy should not affect the man’s libido or sex life. 19

A pregnancy test will be taken to confirm the woman is not pregnant before the procedure. There is a slight risk that the operation will not work. Although it is rare for fertility to return, the tubes do sometimes re-join. The risk of failure is about three-in-1,000, depending on the procedure used. All operations carry some risk, including the risk of wound and other infections, but the risk of serious complications with tubal occlusion is low. Wound sutures will need to be removed at a follow-up appointment, unless dissolvable sutures were used. 20,21

It is very unlikely that pregnancy will occur after a tubal occlusion. If pregnancy does occur, there is a chance that the pregnancy will develop in the fallopian tube (ectopic pregnancy) rather than in the uterus. Contraception will need to be continued for four weeks after the operation or until the woman’s next period after the procedure. Sex can resume as soon as it feels comfortable. Sterilisation should not affect the woman’s libido or sex drive. The woman can usually return to work after five days, but this will depend on her general health and type of work. Heavy lifting should be avoided for a week. 20,21

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VASECTOMY IS A MINOR PROCEDURE WITH VERY LITTLE RISK INVOLVED

Outlook

Effective contraception provides social and health benefits by reducing unplanned pregnancies, termination of pregnancies, and facilitating family planning. Optimal contraceptive selection incorporates safety, efficiency, reliability, availability, accessibility and affordability, and should include the individuals’ preferences and values. Oral contraceptive pills are the most commonly used form of reversible female contraception. LARCs, including intrauterine devices and subdermal implants, have the highest levels of effectiveness. Progestin-only and non-

hormonal methods carry the lowest risks. LARCs, which include IUDs, IUS-hormonal coils and IUCD-non-hormonal coils, and implants, offer women a safe, long-lasting choice for preventing pregnancy. They are highly reliable and more effective than birth control pills, the patch, or the vaginal ring. The injection is also a reliable method of LARC for many women, but can be less effective than other LARC methods, and is not suitable for all.2,25 There are currently no approved contraceptive options for men, except condoms and vasectomy. Research exists on hormonal forms of birth control for men, including a daily pill,

however, no male birth control pill is currently available. Ongoing research is exploring further safe and effective contraceptive options for men. The two main areas of research are hormonal contraception using synthetic hormones to block the effect of testosterone on sperm development; and non-hormonal contraception using other techniques to prevent sperm from entering the vagina, such as injections into the vas deferens. Current male contraceptive methods under evaluation attempt to supress sperm count to <1 million/ml and include a testosterone plus progestin topical gel. 25 

REFERENCES

1. Bansode O, Sarao M. (2022). Contraception. In Statpearls publishing. Available at: www.statpearls.com/ ArticleLibrary/viewarticle/19940.

2. HSE Sexualwelbeing.ie (2022). Contraception. Available at: www. sexualwellbeing.ie/sexual-health/ contraception/free-contraception/.

3. Mycontraception.ie (2022). Smart alternatives to taking the pill every day. Available at: www.mycontraception.ie/ sites/g/files/vrxlpx28156/files/2021-11/ ie_wh_ius_2019_larc_smart_ alternatives_to_the_pill_-_design_ changed.pdf.

4. Britton L, Alspaugh A, Greene M, McLemore M. (2020). An evidencebased update on contraception. Am J Nurs. 2020 Feb;120(2):22-33. Available at: www.ncbi.nlm.nih.gov/pmc/articles/ PMC7533104/.

5. IFPA. (2021). The combined pill. Irish Family Planning Association. Available at: www.ifpa.ie/factsheets/ combined-pill/.

6. FPNSW (2022). Long-acting reversible contraception. Available at: www. fpnsw.org.au/factsheets/individuals/ contraception/long-acting-reversiblecontraception-larc.

7. Irish Family Planning Association (2021). Contraceptive implant. Available at: www.ifpa.ie/factsheets/implant/

8. Implanon NXT Summary of Product Characteristics. Available at: www.medicines.ie.

9. Irish Family Planning Association (2021). IUS hormonal coil. Available at: www.ifpa.ie/factsheets/hormonal-coil/.

10. IFPA (2021). IUCD Copper Coil. Irish Family Planning Association. Available at: www.ifpa.ie/factsheets/copper-coil/.

11. IFPA (2021). Injectable contraception. Irish Family Planning Association. Available at: www.ifpa.ie/ factsheets/injection/.

12. Depo-provera Summary of Product Characteristics. Available at: www.medicines.ie.

13. IFPA. (2021). Emergency contraception. Irish Family Planning Association. Available at: www.ifpa.ie/ factsheets/emergency-contraception/.

14. IFPA (2021). Condoms. Irish Family Planning Association. Available at: www. ifpa.ie/factsheets/condoms/.

15. Sexualwellbeing.ie (2022). Male condom. Available at: www. sexualwellbeing.ie/sexual-health/ contraception/your-choices/condoms/ male-external-condom.html.

16. Sexualwellbeing.ie (2022). Female internal condom. Available at: www. sexualwellbeing.ie/sexual-health/ contraception/your-choices/condoms/ female-internal-condom.html.

17. IFPA (2021). Diaphragm. Irish Family

Planning Association. Available at: www. ifpa.ie/factsheets/diaphragm/.

18. Sexualwellbeing.ie (2022). Diaphragm. Available at: www. sexualwellbeing.ie/sexual-health/ contraception/your-choices/diaphragm/.

19. IFPA (2021). Vasectomy. Irish Family Planning Association. Available at: www. ifpa.ie/factsheets/vasectomy/.

20. HSE (2021). Female sterilisation. Health Service Executive. Available at: www2.hse.ie/conditions/femalesterilisation/.

21. IFPA (2021). Tubal occlusion. Irish Family Planning Association. Available at: www.ifpa.ie/factsheets/ female-sterilisation/.

22. Mycontraception.ie (2022). Spermicides. Available at: www. mycontraception.ie/contraceptionmethods/the-spermicide.

23. Mycontraception.ie (2022). Withdrawal method. Available at: www. mycontraception.ie/contraceptionmethods/withdrawal.

24. Mycontraception.ie (2022). Natural planning. Available at: www. mycontraception.ie/contraceptionmethods/natural-planning.

25. Teal S, Edelman A. (2021). Contraception selection, effectiveness, and adverse effects. A review. JAMA 2021;326(24):2507-2518. doi: 10.1001/ jama.2021.21392.

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Nordic Pharma launches Dnord for the treatment of vitamin D deficiency

Nordic Pharma Ireland are pleased to announce the launch of Dnord, a prescription only treatment for vitamin D deficiency. Dnord is available in 255mcg soft gel capsules of calcifediol as calcifediol monohydrate, which come in a pack of 10. Dnord is indicated for the following:

 Treatment of vitamin D deficiency in adults.

 Prevention of vitamin D deficiency in adults with identified risks, such as in patients with malabsorption syndrome, chronic kidney disease mineral and bone disorder (CKDMBD), or other identified risks.  As adjuvant for the specific treatment of osteoporosis in patients

with vitamin D deficiency, or at risk of vitamin D deficiency.

Dnord is a one capsule, once a month dosing for patients with vitamin D deficiency and prevention of vitamin D deficiency in patients

with identified risks or adjuvant for the specific treatment of osteoporosis. Higher doses may be necessary in some patients after analytical verification of the extent of the deficiency. In those cases, the maximum dose administered should not exceed one capsule per week.

Dnord should not be administered with a daily frequency. Dnord is reimbursed under the General Medical Services and Community Drugs Scheme, and is available from 1 January 2023. Please refer to the summary of product characteristics for further information, which is available at www.hpra.ie, or from Nordic Pharma Ireland on 01 468 8998.

ACCORD HEALTHCARE IRELAND LAUNCHES

ANOTHER PATIENT SUPPORT APP

Accord Healthcare Ireland is launching its new mobile app, Me & My Methofill, for patients with rheumatoid arthritis that are on methofill. Methotrexate is one of the most incorrectly dosed medicines, and the Health Products Regulatory Authority (HPRA) adopted the recommendations issued by the European Medicines Authority (EMA) to prevent serious potential errors with dosing, which included more prominent warnings on product packaging and providing educational materials for patients and healthcare providers.

The Me & My Methofill mobile app supports rheumatoid arthritis patients to take care of their own health and wellbeing, by providing weekly medication reminders to

support correct dosing, how to inject animations, patient materials, and adverse event reports information.

Ms Tracy Kivlehan, Head of Hospitals and Speciality Brands, Accord Healthcare Ireland, said: “We are delighted to be rolling out our second patient-centred app to Irish patients, which continues to demonstrate our support to patients across therapy areas with app technology. This new app will allow patients prescribed methofill to help manage their self-dose treatment from the comfort of their own home. We are committed to supporting the patients and healthcare providers of Ireland, and we believe our Me & My Methofill app will do just that.”

The app is available to download free of charge from iTunes and Google Play.

| CROSSWORD | | NURSING IN GENERAL PRACTICE | 52 | JANUARY-FEBRUARY 2023 ACROSS 1 Right to enter (6) 7 Manual of instruction (8) 8 Thee (3) 9 Conduct reconnaissance (6) 10 Neat in appearance (4) 11 All (5) 13 Room used for preparing food (7) 15 Lack of success (7) 17 First appearance (5) 21 Not bumpy; level
22 Celestial body
23 Nine plus
24 Advocate of representative government
25 Be attractive
SCRIBBLE BOX DOWN 1 A person in general (6) 2 Pair (6) 3 Work of fiction (5) 4 Give reasons for (7) 5 Something in the way (8) 6 Law enforcers (6) 12 Connection; link (8) 14 Get ready (7) 16 Not awake (6) 18 Liquid container (6) 19 Passageway through rock (6) 20 Flour dough used in cooking (5) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Across 1 - Right to enter (6) 7 - Manual of instruction (8) 8 - Thee (3) 9 - Conduct reconnaissance (6) 10 - Neat in appearance (4) 11 - All (5) 13 - Room used for preparing food (7) 15 - Lack of success (7) 17 - First appearance (5) 21 - Not bumpy; level (4) 22 - Celestial body (6) Down 1 - A person in general (6) 2 - Pair (6) 3 - Work of fiction (5) 4 - Give reasons for (7) 5 - Something in the way (8) 6 - Law enforcers (6) 12 - Connection; link
14 - Get ready (7) 16 - Not awake (6) 18 - Liquid container (6) 19 - Passageway through rock (6)
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