Nursing in General Practice March 2019

Issue 2 Volume 12 March 2019

The Journal of the Irish Practice Nurses Association

GESTATIONAL DIABETES

A GROWING PROBLEM

VITAMIN D AND CALCIUM KEY NUTRIENTS IN HEALTHCARE

CELLULITIS CARE IN THE COMMUNITY

HEARTWATCH SUCCESS AND FUNDING CUTS

PLUS COMPLETE OUR CROSSWORD AND WIN €50

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Size: 148 x 210 mm, Pages: 1 Colors: C M Y K (4 Color) Native File: Indesign CC Windows Generated in: Acrobat Distiller 11.0

umeclidinium/vilanterol

HAS POSITIVE HEAD-TO-HEAD DATA VS. ANOTHER ONCE-DAILY LAMA/LABA* 1 In symptomatic patients with moderate COPD *Anoro Ellipta compared to tiotriopium/olodaterol showed statistical superiority on pre-specified secondary endpoint of trough FEV1 at 8 weeks in the Intent to Treat population. ITT population n=236 (180mL vs. 128mL in trough FEV1; Difference 52ml (p<0.001, 95% CI:28,77).

The primary endpoint of non-inferiority on trough FEV1 at Week 8 in the PP population was met. Non-inferiority was met for the primary endpoint at Week 8 in the PP population (n=227) (175mL Anoro Ellipta and 122mL tiotropium/olodaterol, 95% CI: 26, 80; p<0.001)1

An 8-week, randomised, open-label, two-period crossover in symptomatic patients with moderate COPD (post bronchodilator FEV1 ≤70% and ≥ 50% of predicted value, mMRC≥2) and not receiving ICS at inclusion.1 COPD, chronic obstructive pulmonary disease; FEV1, forced expiratory volume in 1 second; LABA, long-acting beta2-agonist; LAMA, longacting muscarinic antagonist; mMRC, modified Medical Research Council scale; ITT, intent to treat. COPD, FEV PP, ITT

Learn more by visiting: www.anoro.ie/headtohead Anoro Ellipta is contraindicated for patients who are hypersensitive to the active substances or to any of the excipients. Anoro Ellipta is not indicated for the treatment of acute episodes of bronchospasm.

Cardiovascular events, such as cardiac arrhythmias, may be seen after the administration of muscarinic receptor antagonists and sympathomimeticagents, including umeclidinium/vilanterol.

Therefore, Anoro Ellipta should be used with caution in patients with severe cardiovasular disease.

Due to antimuscarinic activity (i.e. LAMA class activity), umeclidinium/vilanterol should be used with caution in patients with urinary retention or with narrow-angle glaucoma.2

Anoro Ellipta 55/22mcg is indicated as a maintenance bronchodilator treatment to relieve symptoms in adult patients with chronic obstructive pulmonary disease (COPD)2

▼This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information.

Anoro Ellipta▼ (umeclidinium bromide/vilanterol [as trifenatate]) Prescribing information (Please consult the full Summary of Product Characteristics (SmPC) before prescribing) Anoro Ellipta 55/22mcg (umeclidinium bromide/vilanterol [as trifenatate]) inhalation powder. Each single inhalation of umeclidinium bromide (UMEC) 62.5 micrograms (mcg) and vilanterol (VI) 25mcg provides a delivered dose of UMEC 55mcg and VI 22mcg. Each delivered dose contains approx.

25 mg lactose. Indications: COPD: Maintenance bronchodilator treatment to relieve symptoms in adult patients with COPD. Dose and administration: Inhalation only. COPD: One inhalation once daily at the same time of the day.

Contraindications: Hypersensitivity to the active substances or to any of the excipients (lactose monohydrate and magnesium stearate). Precautions: Anoro Ellipta should not be used in patients with asthma. Treatment with Anoro Ellipta should be discontinued in the event of paradoxical bronchospasm and alternative therapy initiated if necessary. Cardiovascular effects may be seen after the administration of muscarinic receptor antagonists and sympathomimetics therefore Anoro Ellipta should be used with caution in patients with severe cardiovascular disease. Anoro Ellipta should be used with caution in patients with urinary retention, narrow angle glaucoma, convulsive disorders, thyrotoxicosis, hypokalaemia, hyperglycaemia and severe hepatic impairment. No dose adjustment is required in

renal or mild to moderate hepatic impairment. Patients with rare hereditary problems of galactose intolerance, the Lapp total lactase deficiency or glucose-galactose malabsorption should not use Anoro Ellipta. Acute symptoms: Anoro Ellipta is not indicated for acute episodes of bronchospasm. Warn patients to seek medical advice if short-acting inhaled bronchodilator use increases, a re-evaluation of the patient and of the COPD treatment regimen should be undertaken. Interactions with other medicinal products: Interaction studies have only been performed in adults. Avoid -blockers. Caution is advised when co-administering with strong CYP3A4 inhibitors (e.g. ketoconazole, clarithromycin, itraconazole, ritonavir, telithromycin). Anoro Ellipta should not be used in conjunction with other long-acting 2-adrenergic agonists or medicinal products containing long-acting muscarinic antagonists.

Caution is advised with concomitant use with methylxanthine derivatives, steroids or non-potassium-sparing diuretics as it may potentiate possible hypokalaemic effect of 2-adrenergic agonists. Fertility, pregnancy, and breast-feeding: No available data. Balance risks against benefits. Side effects: Common: Urinary tract infection, sinusitis, nasopharyngitis, pharyngitis, upper respiratory tract infection, headache, cough,

References: 1. Feldman G.J et al. Adv Ther 2017; 34:doi 10.1007/s12325-017-0626-4.

2. Anoro Ellipta Summary of Product Characteristics. Available from: www.medicines.ie. Accessed: January 2019.

ANORO ELLIPTA was developed in collaboration with

Anoro_Advt_IE-9446912_D7.indd 1

oropharyngeal pain, constipation and dry mouth. Uncommon: Hypersenstivity reactions including rash, tremor, dysgeusia, dysphonia, atrial fibrillation, supraventricular tachycardia, rhythm idioventricular, tachycardia, supraventricular extrasystoles and palpitations. Rare: Anaphylaxis, angioedema, urticaria, vision blurred, glaucoma, intraocular pressure increased, paradoxical bronchospasm, urinary retention, dysuria and bladder outlet obstruction. Marketing Authorisation (MA) Holder: GlaxoSmithKline (Ireland) Limited, 12 Riverwalk, Citywest Business Campus, Dublin 24, Ireland. MA Nr: 55/22mcg 1x30 doses [EU/1/14/898/002]. Legal category: POM B. Last date of revision: February 2019. Job Ref: IE/UCV/0063/15 (8). Further information available on request from GlaxoSmithKline, 12 Riverwalk, Citywest Business Campus, Dublin 24, Tel: 01-4955000.

Adverse events should be reported to the Health Products Regulatory Authority (HPRA) using an Adverse Reaction Report Form obtained either from the HPRA or electronically via the website at www.hpra.ie. Adverse reactions can also be reported to the HPRA by calling (01) 6764971. Adverse events should also be reported to GlaxoSmithKline on 1800 244 255.

Anoro and Ellipta are registered trademarks of the GlaxoSmithKline group of companies

©2018 GSK group of companies.

All rights reserved.

IE/UCV/0006/17a(2) Date of Preparation: January 2019

2/15/2019 8:19:49 PM

nursingingeneralpractice

The Journal of the Irish Practice Nurses Association Issue 2 Volume 12 March 2019

Contents

News P2

Editorial As Ruth Morrow departs for Abu Dhabi with Special Olympics Team Ireland for the 2019 World Summer Games, she reveals how the capital has worked to foster a culture of inclusion in advance of the games

P 22

The Heartwatch programme has proved to be a huge success in preventing cardiovascular disease in the community.

GP Dr David Molony charts the programme’s achievements

P 26

Hospital admissions for cellulitis have increased in recent years. Theresa Lowry-Lehnen provides expert advice on how to care for cellulitis patients in the community

P 28

Spacer devices help to optimise drug deposition in the airways and are a vital tool in helping asthma patients control their symptoms, Ruth Morrow explains

P 30

Aislinn Dr Souza, in an informative article on vitamin D and calcium in health, explores how individuals are increasingly at risk of running low on these essential nutrients

P 4-12 News and NEC News P 13-15 Branch news

Articles P 16

P 18

Minister of State for Mental Health and Older People Jim Daly reveals how technology could help address recruitment and retention challenges in mental health Prof Fidelma Dunne and Dr Delia Bogdanet provide an excellent overview of gestational diabetes and how to optimise outcomes for mother and baby

EDITOR Niamh Cahill CONSULTING EDITOR Ruth Morrow DESIGNER Emer Keogh PUBLISHERS Graham Cooke Maura Henderson

Plus P 34

Product News

P 37

Crossword

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.

© Copyright GreenCross Publishing Ltd. 2019 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

Nursing in General Practice is published by GreenCross Publishing Ltd., Top Floor, 111 Rathmines Road Lr, Dublin 6 Tel: 01 4410024 Fax: 01 5472388 Email: maura@greenx.ie *GreenCross Publishing was established in 2007 and is jointly owned

by Graham Cooke and Maura Henderson.

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editorial

nursingingeneralpractice

Looking ahead to Abu Dhabi and the 2019 World Summer Games

B

y the time you are reading this month’s issue of Nursing in General Practice, I will be in Abu Dhabi with Special Olympics Team Ireland for the 2019 World Summer Games.

The decision to hold such a large-scale event and the largest humanitarian event in the world in 2019 was a significant one given that there is not a culture of inclusion or volunteerism in the United Arab Emirates (UAE). It has certainly been a huge challenge in preparing the team of 91 athletes who will be representing Ireland and competing in 12 sports from 7-22 March.

The world games will involve 7,500 athletes from 190 countries competing in 24 sports, 3,000 coaches/management teams and 20,000 volunteers who will be working at all sports venues to ensure all events run smoothly.

The UAE has been at the forefront in the Middle East in the protection and promotion of rights for people with intellectual disabilities – or people of determination, as they are called in the UAE. In December 2018, H H Sheikh Khalifa bin Zayed declared 2019 the Year of Tolerance. The announcement aimed to highlight the UAE as a global capital for tolerance.

Its approach is to be a bridge of communication between people of different cultures in a respectful environment that rejects extremism and places emphasis on the acceptance of others. The local organising committee of the Special Olympics World Games 2019 have rolled out an extensive community engagement programme to raise awareness, educate and inspire the public with the Special Olympics movement. It seeks to encourage tolerance in the community of people with intellectual disabilities. Initiatives have been running daily in schools and community spaces across Abu Dhabi and the UAE to create unity and understanding between the public and people with intellectual disabilities. Team Ireland have been linked up with a school in Dubai, which we will visit during the host town programme before the competition begins.

The ‘adopt a nation’ programme has been rolled out as a platform to engage students with Special Olympics by promoting the study of the values and cultures of the nations competing in the World Games 2019. Each school adopts a competing nation to study, which culminates in them cheering

2

Ruth Morrow

on that country at the games. The programme aims to leave a lasting legacy of diversity and inclusion in the schools, while also providing lots of enthusiastic fans to cheer on the athletes. The initiative is designed to engage the whole school, as well as the children who are typically sporty. This is achieved by integrating various aspects of the adopted nation into the school curriculum, including arts and crafts, technology and music. Schools have further embraced the movement by participating in 'Play Unified' sports activities by hosting sports matches for their students in teams which include people with intellectual disabilities.

The host town programme offers the opportunity to the delegations to enjoy Emirati hospitality, customs and traditions. It also creates public awareness of intellectual disabilities and promotes the Special Olympics spirit all over the UAE. Additionally, it helps familiarise athletes with their new environments before starting competitions through sports, cultural, artistic and community events. The host town programme will provide the athletes with a chance to experience the Emirati culture and hospitality while in turn providing every citizen of the UAE a life-changing and memorable experience with Special Olympics athletes.

Medication is one of the challenges I have had as medical coordinator. There are 160 drugs on the banned list, which include all psychotropic medication, HRT, OCPs, some analgesia and certain antibiotics. Any athlete who is on a medication on the prohibited list has to registered with the Ministry of Health in the UAE. Other team preparations have included addressing dietary requirements, preparing athletes for an eight-hour flight, some of whom have never flown before, and helping some athletes who have anxiety issues while flying.

I am looking forward to the madness, the fun, the challenges, the lack of sleep and the great friendships that are made when away with an international team. It will certainly be different because of the different culture of the UAE. Have a great St Patrick’s Day. We certainly will be celebrating it in Abu Dhabi.

Ruth Morrow Consulting Editor

BREASTFEEDING IS BEST FOR BABIES | INFORMATION FOR HEALTHCARE PROFESSIONAL USE ONLY

The importance of protein in infancy, in line with expert opinion The World Health Organisation recommends exclusive breastfeeding for the first six months of life.1 Protein and the importance of slower growth rates NEW LOOK, SAME FORMULA

The protein in breast milk is adapted to a baby’s needs.

The protein content decreases rapidly in the first month of lactation and declines much more slowly after that.1 Faster growth in infancy can be caused by overfeeding infants and/or feeding high protein infant formula.

Historically, formula-fed babies have been shown to grow faster than breastfed babies.2,3 This accelerated growth may contribute to a higher risk of overweight and obesity in later life.4

SMA® Nutrition has responded to expert opinion about protein levels in infant formula and developed SMA® PRO First Infant Milk.

For infants who are not breastfed, the FSAI recommends the use of a standard whey-based infant formula in the first 12 months of life5 Food Safety Authority of Ireland 20115

“Protein intakes of infants are generally well above the requirements, so protein content of Infant Formula and Follow-on Formula could be reduced”

››

SMA® PRO First Infant Milk has a whey to casein ratio of 70:306

››

SMA® PRO First Infant Milk is the lowest protein formula available at 1.25 g*/100 ml (1.87 g*/100 kcal)6

European Food Safety Authority 20147

“The breast milk content of amino acids is the best estimate of infant amino acid requirements” WHO/FAO/UNU 20078

SMA® PRO First Infant Milk is the only whey-dominant first infant milk clinically proven to achieve a growth rate comparable with a breastfed baby as defined by WHO growth standards.10

Visit us: smahcp.ie

*Powder only, liquids will vary

››

SMA® PRO First Infant Milk has an essential amino acid profile similar to that of breast milk9

Supporting you to support parents

References: 1. Lönnerdal B. Am J Clin Nutrition 2003; 77: 1537–43. 2. WHO UK Growth charts. Available at: https://www.rcpch.ac.uk/resources/ukwho-growth-charts-0-4-years (accessed July 2018).

3. Dewey KG et al. Growth of breast-fed infants deviates from current reference data: a pooled analysis of US, Canadian, and European data sets. World Health Organisation Working Group on Infant Growth. Pediatrics 1995; 96: 495–503. 4. Singhal A, Lucas A. Early origins of cardiovascular disease: Is there a unifying hypothesis? Lancet 2004; 363(9421): 1642–45. 5. Food Safety Authority of Ireland, 2011, Best Practice for Infant Feeding in Ireland. 6. SMA® PRO First Infant Milk datacard (accessed November 2018). 7. EFSA. Scientific Opinion on the essential composition of infant and follow-on formulae. EFSA Journal 2014; 12(7): 3760.

8. Protein and Amino Acid Requirements in Human Nutrition. Report of a Joint WHO/FAO/UNU Expert Consensus 2007. 9. Nestlé data on file, 2014. 10. Alexander DD et al. Am J Clin Nutr 2016; 104(4): 1083–92.

IMPORTANT NOTICE: The World Health Organisation (WHO) has recommended that pregnant women and new mothers be informed on the benefits and superiority of breastfeeding – in particular the fact that it provides the best nutrition and protection from illness for babies. Mothers should be given guidance on the preparation for, and maintenance of, lactation, with special emphasis on the importance of a well-balanced diet both during pregnancy and after delivery. Unnecessary introduction of partial bottle-feeding or other foods and drinks should be discouraged since it will have a negative effect on breastfeeding. Similarly, mothers should be warned of the difficulty of reversing a decision not to breastfeed. Before advising a mother to use an infant formula, she should be advised of the social and financial implications of her decision: for example, if a baby is exclusively bottle-fed, more than one can (400 g) per week will be needed, so the family circumstances and costs should be kept in mind. Mothers should be reminded that breast milk is not only the best, but also the most economical food for babies. If a decision to use an infant formula is taken, it is important to give instructions on correct preparation methods, emphasising that unboiled water, unsterilised bottles or incorrect dilution can all lead to illness. ®Reg. Trademark of Société des Produits Nestlé S.A

SMA79450_SMA_WIN_Growth_Advertorial_210x297mm_fa1.indd 1

ZRI 753/11/18

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news

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NATIONAL EXECUTIVE COMMITTEE NEWS DATE FOR YOUR DIARY IPNA Conference 2019 This year’s IPNA conference will be hosted by the Mayo branch on the 27 and 28 September, Galway Bay Hotel, Galway. The theme will be “Slán agus Follain” (well and healthy). Further details will be available on our website soon.

AWARDS AND EDUCATIONAL BURSARYS 2019 • IPNA Clinical Award - Cardiology (details available in this edition).

Closing date for applications 30 June 2019.

• IPNA Contribution to Practice Nursing Award.

Closing date for applications 31 July 2019.

• IPNA Educational Bursary Award.

Closing date for applications 31 July 2019.

• IPNA Loyalty Award.

Closing Date for applications 31 July 2019.

Details and application forms for all IPNA awards can be found on www.irishpracticenurses.ie.

Contact: Caroline Daughton IPNA Administrator. Email: admin@irishpracticenurses.ie.

DEVELOPING CLINICAL PROCEDURES AND GUIDELINES The NEC are delighted to let you know that following our recent NEC meeting, approval has been granted for the IPNA to develop clinical procedure guidelines. The project lead on this will be Ms Ruth Morrow, ANP, Primary Care.

The aim is that IPNA members use these guidelines within their clinical areas following discussion and review at practice level to ensure that the CPGs meet the needs of the individual

practices.

Please ensure your branches have contacted Caroline (admin@irishpracticenurses.ie) identifying their top three CPGs to be developed to commence this project.

SPECIAL OLYMPICS The NEC would like to wish Ms Ruth Morrow (IPNA Cavan/ Monaghan branch) every success in her role as Medical Director for Team Ireland at the Special Olympics due to be held in Abu Dhabi next month.

SYMPATHIES The NEC would like to extend sincere sympathies to Winnie Quigley, National Membership Secretary, on the recent death of her mother, Una Quigley. May she Rest in Peace.

WEBSITE Regular updates/posts with regards to study days andpublications are available on our website: www. irishpracticenurses.ie.

NEC Meetings for 2019 • Wednesday 8 May, Ashling Hotel, Dublin, 11am.

• Wednesday 4 September, Ashling Hotel, Dublin, 11am.

• Friday 27 September, Galway Bay Hotel, Galway. Time to be confirmed.

• Saturday 28 September, AGM, Galway Bay Hotel. Time to be confirmed.

More than 100 posts vacant at CAMHS There are more than 115 vacant posts within the Child and Adolescent Mental Health Service (CAMHS), new figures show.

The figure, released following a parliamentary question (PQ), includes 15 vacant child psychiatrist posts nationally.

The news comes as it was revealed last month that 29 CAMHS psychiatrists are employed on a temporary basis.

A breakdown of the more than 115 vacant posts shows per community health organisation (CHO) area shows that the region with the most vacancies – 23.1 whole time equivalents (WTEs) in November 2018 was CHO 7, which covers Kildare, West Wicklow, Dublin West, Dublin South City and Dublin South West.

In CHO 8 (Laois, Offaly, Longford, Westmeath, Louth and Meath) there were 22.6 WTE vacancies in CAMHS. In Galway, Roscommon and Mayo (CHO 2) there were 19 WTE vacancies in November.

All of the posts were due for recruitment by the HSE National Recruitment Service, the HSE response to Fianna Fáil Deputy Fiona O’Loughlin states.

In a separate HSE PQ response to Fianna Fáil Deputy James Browne in December, the HSE outlined there were 103 approved

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consultant psychiatrist posts within the specialty of child and adolescent psychiatry nationally.

Of the 103, 88 consultants are employed on a permanent, fixed term or locum basis covering CAMHS teams, day hospital, inpatient units and specialist services.

Of the 15 consultant psychiatrist vacancies, three are in CHO 4 (Kerry, North Cork, North Lee, South Lee and West Cork), three are in CHO 5 (South Tipperary, Carlow, Kilkenny, Waterford and Wexford) and three are in CHO 6 (Wicklow, Dun Laoghaire and Dublin South East).

All of the remaining CHOs have one vacancy, except for CHO 3 (Clare, Limerick, North Tipperary and East Limerick), which has no vacancies.

The response warns that due to data processes there may be “variances and gaps in the data supplied to that held within hospitals”.

There are 70 multidisciplinary CAMHS teams nationally covering nine CHO areas. At the end of last year more than 2,600 children were on CAMHS waiting lists, with some waiting for over 12 months.

Grasping every opportunity, not gasping for air

THE DIFFERENCE IS

Symbicort is licensed for use in patients with asthma and COPD (FEV1 <70% predicted normal (post bronchodilator) and an exacerbation history despite regular bronchodilator therapy. Symbicort is not intended for the initial management of asthma.

ABRIDGED PRESCRIBING INFORMATION SYMBICORT® TURBOHALER® 100 micrograms/6 micrograms/ inhalation, inhalation powder. SYMBICORT® TURBOHALER® 200 micrograms/6 micrograms/inhalation, inhalation powder. SYMBICORT® TURBOHALER® 400 micrograms/12 micrograms/inhalation, inhalation powder. (budesonide/formoterol fumarate dihydrate). Consult Summary of Product Characteristics (SmPC) before prescribing.

Indication: Indicated in adults, adolescents aged 12 years and older and children aged 6 years and older (100/6 only), for the regular treatment of asthma where use of a combination (inhaled corticosteroid and long-acting ß2 adrenoceptor agonist) is appropriate: 1) patients not adequately controlled with inhaled corticosteroids and ‘as needed’ inhaled short-acting ß2 adrenoceptor agonists or 2) patients already adequately controlled on both inhaled corticosteroids and long-acting ß2 adrenoceptor agonists. Symbicort 100/6 is not appropriate for patients with severe asthma. Symbicort 200/6 and 400/12 only: Indicated in adults aged 18 years and older for the symptomatic treatment of patients with COPD with FEV1 <70% predicted normal (post-bronchodilator) and an exacerbation history despite regular bronchodilator therapy. Presentation: Inhalation powder.

Symbicort 100/6: Each metered dose contains budesonide 100mcg/inhalation and formoterol fumarate dihydrate 6mcg/inhalation. Symbicort 200/6: Each metered dose contains budesonide 200mcg/inhalation and formoterol fumarate dihydrate 6mcg/inhalation. Symbicort 400/12: Each metered dose contains budesonide 400mcg/inhalation and formoterol fumarate dihydrate 12mcg/inhalation Dosage and administration: Asthma: The dose should be titrated to the lowest dose at which effective control of symptoms is maintained.

Symbicort maintenance therapy: Patients should be advised to have their separate rapid-acting bronchodilator available for rescue use at all times. Adults (18 years and older): 100/6 and 200/6: The recommended dose is 1-2 inhalations twice daily. Some patients may require a maximum of 4 inhalations twice daily. 400/12: 1 inhalation twice daily. Adolescents (12-17 years): 100/6 and 200/6: The recommended dose is 1-2 inhalations twice daily. 400/12: 1 inhalation twice daily. Children 6-11 years (100/6 only): The recommended dose is 2 inhalations twice daily. Children under 6 years: Not recommended. Symbicort 400/12 is not recommended for children under 12 years. Symbicort maintenance and reliever therapy: 100/6 and 200/6 only (not indicated with 400/12 strength) Adults and adolescents (12 years and older): The recommended maintenance dose is 2 inhalations per day, given either as one inhalation in the morning and evening or as 2 inhalations in either the morning or evening. Patients should take 1 additional inhalation as needed in response to symptoms. If symptoms persist after a few minutes, an additional inhalation should be taken. No more than 6 inhalations should be taken on any single occasion. A total daily dose of more than 8 inhalations is not normally needed, a total daily dose of up to 12 inhalations could be used for a limited period.

Patients using more than 8 inhalations daily should be strongly recommended to seek medical advice. Children under 12 years: Not recommended. COPD (200/6): The recommended dose in adults is 2 inhalations twice daily. COPD (400/12): The recommended dose in adults is 1 inhalation twice daily. Elderly: No special dosing requirements required. Patients with hepatic or renal impairment: Increased exposure is expected in patients with severe liver cirrhosis. Contraindications: Hypersensitivity to active substance(s) or excipients.

Warnings and precautions: Recommended that the dose is tapered when the treatment is discontinued and should not be stopped abruptly. If treatment is ineffective, or exceeds the highest recommended dose, medical attention must be sought. Sudden and progressive deterioration in control of asthma or COPD is potentially life threatening and patient should undergo urgent medical assessment. Consideration should be given for increased therapy with corticosteroids, e.g. orally, or antibiotic treatment if infection present. Patients should have their rescue inhaler available at all times. Patients should be reminded to take their maintenance dose as prescribed, even when asymptomatic. The reliever inhalations should be taken in response to asthma symptoms but are not intended for regular prophylactic use e.g. before exercise, separate rapid-acting bronchodilator should be considered. Once asthma symptoms are controlled, consideration may be given to gradually reducing the dose. Patients should not be initiated on Symbicort during an exacerbation or if they have significantly worsening or acutely deteriorating asthma. Paradoxical bronchospasm may occur with an immediate increase in wheezing and shortness of breath after dosing. Symbicort should be discontinued immediately and an alternative therapy instituted if necessary. Systemic effects may occur, particularly at high doses prescribed for long periods e.g. Cushing’s syndrome, Cushingoid features, adrenal suppression, growth retardation in children and adolescents, decrease in bone mineral density, cataract and glaucoma, and more rarely, a range of psychological or behavioural effects including psychomotor hyperactivity, sleep disorders, anxiety, depression or aggression (particularly in children). Recommended that height of children receiving prolonged treatment is regularly monitored and if growth is slowed, therapy should be re-evaluated and consideration given to referring the patient to a paediatric respiratory specialist. If adrenal function is impaired from previous systemic steroid therapy, care should be taken when transferring patients to Symbicort therapy.

Patients transferring from oral steroids may remain at risk of impaired adrenal reserve for a considerable time.

HPA axis function should be monitored regularly. Prolonged treatment with high doses of inhaled corticosteroids may result in clinically significant adrenal suppression. Additional systemic corticosteroid cover should be considered during periods of stress such as severe infections or elective surgery. Rapid reduction in dose of steroids can induce acute adrenal crisis, symptoms may include anorexia, abdominal pain, weight loss, tiredness, headache, nausea, vomiting, decreased level of consciousness, seizures, hypotension and

hypoglycaemia. Treatment with systemic steroids should not be stopped abruptly. Transfer from oral steroid therapy to Symbicort may result in the appearance of allergic or arthritic symptoms such as rhinitis, eczema, muscle and joint pain. Specific treatment should be initiated for these conditions. In rare cases, tiredness, headache, nausea and vomiting can occur due to insufficient glucocorticosteroid effect and temporary increase in the dose of oral glucocorticosteroids may be necessary. To minimise risk of oropharyngeal candida infection, patients should rinse mouth with water after inhaling doses. Concomitant treatment with itraconazole, ritonavir or other potent CYP3A4 inhibitors should be avoided. Observe caution in patients with thyrotoxicosis, phaeochromocytoma, diabetes mellitus, untreated hypokalaemia, hypertrophic obstructive cardiomyopathy, idiopathic subvalvular aortic stenosis, severe hypertension, aneurysm or other severe cardiovascular disorders such as ischaemic heart disease, tachyarrhythmias or severe heart failure. Observe caution when treating patients with prolongation of the QTc-interval. Re-evaluate need for Symbicort in patients with active or quiescent pulmonary tuberculosis, fungal and viral infections in the airways. Hypokalaemia may occur at high doses of ß2 adrenoceptor agonists. Particular caution recommended in unstable or acute severe asthma.

Monitor serum potassium levels. As for all ß2 adrenoceptor agonists, consider additional blood glucose monitoring in diabetic patients. Visual disturbances may be reported with systemic and topical corticosteroid use. If a patient presents with these symptoms, consideration to ophthalmologist referral should be given to evaluate possible causes which may include cataract, glaucoma or rare diseases such as central serous chorioretinopathy. The excipient lactose contains small amounts of milk proteins, which may cause allergic reactions. 200/6 & 400/12: An increase in the incidence of pneumonia, including pneumonia requiring hospitalisation, has been observed in patients with COPD receiving inhaled corticosteroids. Physicians should remain vigilant as clinical features of such infections overlap with symptoms of COPD exacerbations. Risk factors include current smoking, older age, low BMI and severe COPD. Potential effects on bone density should be considered especially in patients on high doses for prolonged periods that have co-existing risk factors for osteoporosis. Drug interactions: Potent CYP3A4 inhibitors (e.g. ketoconazole, itraconazole, voriconazole, posaconazole, clarithromycin, telithromycin, nefazodone and HIV protease inhibitors) are likely to increase plasma levels of budesonide and concomitant use should be avoided. If this is not possible the time interval between administration should be as long as possible. Symbicort maintenance and reliever therapy is not recommended in patients using potent CYP3A4 inhibitors. Not to be given together with beta-adrenergic blockers (including eye drops) as can weaken or inhibit the effect of formoterol, unless compelling reasons.

Concomitant treatment with quinidine, disopyramide, procainamide, phenothiazines, antihistamines (terfenadine) and TCAs can prolong the QTc-interval and increase the risk of ventricular arrhythmias. L-Dopa, L-thyroxine, oxytocin and alcohol can impair cardiac tolerance towards ß2-sympathomimetics. Concomitant treatment with MAOIs, including agents with similar properties such as furazolidone and procarbazine, may precipitate hypertension reactions. Elevated risk of arrhythmias in patients receiving anaesthesia with halogenated hydrocarbons. Concomitant use of other beta-adrenergic drugs or anticholinergic drugs can have a potentially additive bronchodilating effect. Hypokalaemia may increase the disposition towards arrhythmias in patients taking digitalis glycosides. Hypokalaemia resulting from beta2-agonist therapy may be potentiated by concomitant treatment with xanthine derivatives, corticosteroids and diuretics. Pregnancy and lactation: Use only when benefits outweigh potential risks during pregnancy and breastfeeding. Budesonide is excreted in breast milk; at therapeutic doses, no effects on child are anticipated. Not known whether formoterol passes into human breast milk. Undesirable events: Consult SmPC for full list of side effects. Common: Headache, palpitations, tremor, candida infections in the oropharynx, coughing, mild irritation in the throat, hoarseness and pneumonia (in COPD patients using Symbicort 200/6) Uncommon: Tachycardia, muscle cramps, aggression, psychomotor hyperactivity, anxiety, sleep disorders, nausea, dizziness, blurred vision and bruises. Rare: Hypokalaemia, cardiac arrhythmias including atrial fibrillation, supraventricular tachycardia and extrasystoles, bronchospasm and immediate and delayed hypersensitivity reactions including exanthema, urticaria, pruritus, dermatitis, angioedema and anaphylactic reaction. Very rare: Depression and behavioural changes (predominantly in children), angina pectoris, prolongation of QTc-interval, hyperglycaemia, taste disturbances, Cushing’s Syndrome, Cushingoid features, adrenal suppression, growth retardation in children and adolescents, decrease in bone mineral density, cataract, glaucoma and variations in blood pressure. Paradoxical bronchospasm may occur in very rare cases. Package Quantities Each Symbicort Turbohaler 100/6 or 200/6 contains 120 inhalations. Each Symbicort Turbohaler 400/12 contains 60 inhalations. Legal category: POM. Marketing authorisation numbers: PA 970/28/1-3 Marketing Authorisation Holder: AstraZeneca UK Limited, 600 Capability Green, Luton, LU1 3LU, UK. Further information available on request from The MAH (address above), Freephone – 1800 800 899. SYMBICORT and TURBOHALER are trademarks of the AstraZeneca group of companies. Date of API preparation: 12/2017 API REF: IE-0607 Adverse events should be reported directly to: HPRA Pharmacovigilance, Earlsfort Terrace, Dublin 2.

Tel: +353 1 6764971 Fax: +353 1 6762517 Website: www.hpra.ie e-mail: medsafety@hpra.ie.

Adverse events should also be reported to AstraZeneca Medical Information on 1800 800 899.

Date of Preparation: January 2018. VEEVA ID: IE-0650

IPNA Clinical Award 2019

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The IPNA and Nursing in General Practice are delighted to announce the IPNA Clinical Award 2019. This year the award is focused on cardiology and the winner will receive an educational bursary of €1,000.

HOW TO ENTER Below is a case study accompanied by a set of questions that must be answered within a limit of 2,500 words. Please send your completed answers, along with your name, NMBI PIN, and full contact details to admin@irishpracticenurses.ie or by post to Caroline Daughton, c/o IPNA Administrator, Kilconlea Upper, Abbeyfeale, Co Limerick.

Closing date for receipt of entries is 30 June 2019.

The winner will be announced and presented with the award at the IPNA Annual Educational Conference at the Galway Bay Hotel on 27 and 28 September, 2019 The winner will also be announced on the IPNA website after the conference and the winning entry will be published in a future issue of Nursing in General Practice.

RULES • Entrants must be current IPNA members.

• Entrants must be on the current register of Nursing and Midwifery Board of Ireland (NMBI). They must include their name and NMBI PIN with their entry for verification.

• Entrants must be working as a practice nurse in the Republic of Ireland.

• Entrants must answer all questions.

• Word limit for entries is 2,500.

• Entrants must submit their entry on or before the closing date.

• Joint entries will not be accepted.

• The judges’ decision is final, and no correspondence will be entered into.

CASE STUDY – IPNA CLINICAL AWARD 2019 – Cardiology Background Bob is a 60 year old civil servant who presented to your surgery today for a routine checkup. During the consultation, he mentions that for the last few days he has been aware of his heart racing intermittently. You palpate his pulse and note that it is rapid and irregular.

Bob has no significance past medical history, has no known allergies and is not on any regular medications. He is a smoker, consuming approximately 30 cigarettes a day for the last 30 years and he drinks approximately 40 units of alcohol per week. On examination, you note: • • • • • • •

Blood pressure 135/70mmHg. Heart rate 185 beat/min.

Respiratory rate 15 breaths/min.

Oxygen saturations 99 per cent on room air.

Temperature 36.5 degrees celsius.

Lung sounds are normal.

Body mass index normal.

You perform an ECG (see below).

QUESTIONS 1. Analyse the ECG and diagnose the arrhythmia. Discuss the incidence, prevalence and different types of this arrhythmia.

2. What other questions would you ask Bob, or what other assessments would you conduct?

3. What is the most significant risk associated with this arrhythmia? Explain why this is the most significant risk and also explain how this risk might be mitigated.

4. Describe how you would explain the goals of care to Bob. 5. With reference to the most appropriate drugs that Bob might be commenced on, discuss the pharmacological management of this condition.

6. Do you think that Bob should be referred to someone else?

If so, to who, when (how soon) and why? Provide a rationale for your answer.

7. Summarise the main points of care that need to be considered in the care of other patients who may present to your surgery with similar signs and symptoms in the future.

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More than half of GP practices closed to new patients, poll finds One-in-two GP practices are now closed to new patients, a poll conducted by medical directory website GPBuddy.ie has found.

Recently conducted on the website, the poll found that 55 per cent of GP practices were closed to new patients.

The finding is backed up by increasing anecdotal evidence from patients about difficulties acquiring a GP. Some 450 GPs voted in the poll. 249 said their practice was closed to new patients, 38 were “unsure” and 163 said their practices were open to receiving new patients.

Several GPs have taken to social media in recent months stating that more and more they are seeing patients at GP out-of-hours services who cannot access a GP. The practice of GPs closing their lists to new patients has increased in recent years following the introduction of FEMPI fee cuts and the absence of a new GP contract.

Results of the poll have been shared widely on social media amid calls from GPs for the reversal of FEMPI and increased investment in

general practice.

The poll comes as talks continue on a new GP contract between the IMO, HSE and Department of Health officials.

The IMO recently issued an update to its members on the talks, which look set to continue into March.

In correspondence to members, the IMO GP negotiating team said: “The priority is to finally and comprehensively address the FEMPI issue. GPs cannot be treated less equitably than their colleagues in the public service in terms of the reversal of FEMPI. While it is easy for others to set red lines such as full reversal of FEMPI without preconditions that is not negotiation, that is rhetoric which will not deliver anything tangible”.

“We hope that over the coming weeks we will be able to reach an agreement. However, it is important to state that we are also prepared to walk away from any deal that is not in the best interest of general practice.”

Minister Daly promises 24-hour mental health helpline by ‘end of year’ A 24-hour mental health helpline is due to launch in the second half of the year, Minister of State for Mental Health and Older People Jim Daly has announced.

Minister Daly said the phone line, which was due to roll out by the end of last year, would now be established in the latter part of 2019.

The delay occurred because the Department of Health has “changed track” on initial plans to launch the service using a private company, Minister Daly said.

The nationwide service would now be established using staff from the HSE National Ambulance Service (NAS), he said.

“They [NAS} get about 800 calls a month that are mental health related anyway and they really aren’t geared for it. There is no point sending an ambulance out to somebody who has a mental health episode…so what we’ve decided is we’re going to establish it within the National Ambulance Service, this 24/7 emergency phone line for mental health episodes,” Minister Daly remarked.

He revealed that funding and protocols had been agreed and said staff training, which will take 14 weeks, would commence in early February. He was unable to state an exact cost for the new service.

He explained that when a mental health call was made to the NAS a caller would be referred, using a register of national services, “to the appropriate nearest service”, which has not been happening heretofore.

“People are flailing around trying to discover where they should go. They don’t know whether they should go to Jigsaw or Pieta House or whatever. There are 1,027 different mental health services being funded by the HSE nationally,” he said.

“We need to know where they all are and have them on our database and they will need to have a clinical and corporate governance that’s acceptable and when all of that will be ticked they’ll all be set up on a register.”

EU Cross Border Directive costs triple in 2018 The cost of reimbursements under the EU Cross Board Directive (CBD) almost tripled last year as close to €12 million was paid out in patient care reimbursements, new HSE figures reveal.

In 2017 the cost of reimbursements amounted to €4.4 million but in 2018 this jumped to €11.8 million.

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The number of reimbursements processed under the European scheme, which began operating in Ireland in 2014, also rose significantly last year from 2,011 in 2017 to 3,763 in 2018.

The directive gives Irish patients the choice of receiving healthcare in another EU or European Economic Area (EEA) country.

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The cost of the treatment is refunded to the patient. The amount refunded is the cost of the treatment in Ireland or abroad, whichever amount is less. But travel, accommodation and other costs are not refundable under the scheme.

A HSE spokesperson said that the data supplied could change, as the CBD office was in receipt of about 1,500 pieces of post yet to be processed. “The office is currently working on post received between 25/10/2018 and 07/11/2018. Our normal turnaround timeframe to issue a response within 20 days is now 50 days due to volumes of activity versus resources,” the spokesperson said.

A review of staffing levels at the CBD office is underway due to the huge increase in work volumes at the office.

In reply to a recent Parliamentary Question by Deputy Róisín Shortall, Minister for Health Simon Harris said the HSE had acknowledged “their target of processing CBD reimbursements within 20 working dates has been exceeded due to the continued

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increase in the number of applications for reimbursement being received since the CBD Office was established in 2014.”

“Reimbursement applications have risen from 164 in 2015 (the first full year of the CBD) to in excess of 3,000 as of November 2018. Nevertheless, the HSE informs me that it remains committed to monitoring and reviewing this situation and providing reimbursement to CBD patients in a timely manner given the resources it has available.”

The CBD covers treatments that are publicly funded and available in Ireland, including inpatient and outpatient treatments. Some services are not included however, including organ transplantation, long term care, nursing home care and public health initiatives.

In 2014, when the scheme was first introduced, just seven reimbursements were processed in Ireland. This means that seven procedures were paid for under the directive, valued at €29,000, according to the HSE.

HSE spends almost €3 million on GP locums in 2018 Almost €3 million was spent by the HSE on employing GMS GP locums in 2018, the HSE has revealed.

The national average locum cost per annum for a GMS GP locum is €262,000, according to a HSE spokesperson.

The figure includes the cost of medical indemnity, travel, agency management fees, and VAT, the spokesperson added.

Last year, the HSE employed at least 11 GMS GP locums nationally as part of efforts to provide cover for 22 vacant GMS GP panels.

The HSE says 176 GMS GPs were awarded GMS contracts in 2018 while 101 GMS GPs retired in 2018.

“Out of the 101 retirements for 2018, 86 of these panels have been filled to date, 11 panels were dispersed to other GPs in the area and four panels are to be filled this year,” the spokesperson said.

“As of 1 December 2018, there were 22 vacant GMS panels with almost 3,000 GMS GPs in place nationally. All 22 vacant panels were

covered by another GP (including 11 locum GMS GPs) so that none of the vacant panels were without a GMS service.

“Currently there are less than one per cent of GMS panels vacant and in each case a locum or other appropriate arrangement has been put in place to maintain services to the communities in question.”

The HSE have struggled for many years to fill vacant GMS panels with a permanent GP replacement following State cuts enforced on GPs, which has contributed to a recruitment and retention crisis within the profession.

The failure to fill GMS panels caused by the loss of a GP has resulted in many GP practice staff, such practice nurses and receptionists, being forced to leave their roles.

In cases where a locum is found, the HSE usually offers existing practice staff a new contract of employment, but some staff are not prepared to take up an offer due to poorer terms and conditions.

HIV rapid testing for GP practices under consideration The Department of Health has said the expansion of HIV rapid testing to GP practices will be considered once there is a new HSE clinical lead for sexual health in place.

In response to a letter from NAGP President Dr Maitiu O Tuathail issued in December highlighting the lack of rapid HIV testing in general practice, the Department of Health said work on expanding rapid HIV testing was ongoing.

“Over the past two years, community HIV testing is expanding, in order to reach those most at risk of HIV and identify those living with undiagnosed HIV,” the Department’s response stated.

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“The initial approach taken by the HSE with the introduction of rapid HIV testing was to target to those most at risk of HIV. The 'Know Now' outreach project commenced in Dublin, Cork and Limerick in 2017, expanding to Galway in 2018.

“While the initial focus in Dublin was men who have sex with men (MSM) the target population in other cities has expanded to include other key target populations such as migrants, people who inject drugs and homeless communities.

“The HSE is currently scoping the expansion of rapid HIV testing in 2019 to target people living in direct provision centres and homeless communities.

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Call for immediate extension of cardiac cath lab services in Sligo The board of directors of the Saolta University Healthcare Group has urged Minister for Health Simon Harris to extend cardiac catheterisation laboratory services at Sligo University Hospital “as soon as possible”.

Dr John Kileen, Chairman of the Board of Directors for the Saolta University Healthcare Group, wrote to Minister Harris last September calling for the extension of services, stating the board’s wish to “progress this service as soon as possible”.

A copy of the letter was released following a Freedom of Information request.

To date no action has been taken to extend cardiac cath lab services in Sligo despite the submission of a business case by the group in August 2017 outlining the need for a five day cath lab service at the hospital, the letter notes.

Their view is based on the fact that the extension to services was recommended in the Henry Report - the HSE North West Cardiology Review Group Report 2013 - more than five years ago.

For elective cases there is a mobile cath lab unit operating just two days per week in Sligo, but the board feel an enhanced service is required for patients.

There are currently two cath labs based in Galway, which service the acute cardiac cases for Sligo and the Northwest.

A National Review of Specialist Cardiac Services is ongoing and is due to be completed by the end of June 2019.

“As set out in the National Development Plan 2018-2027, investment in cardiac catheterisation laboratories and other cardiac services infrastructure nationally will be informed by the outcome of the rational review,” a spokesperson for the Department of Health said.

“The aim of the national review is to achieve optimal patient outcomes at population level with particular emphasis on the safety, quality and sustainability of the services that patients receive by establishing the need for an optimal configuration of a national adult cardiac service.

This may consist of regional cardiac networks and network hospitals that are designated as general or comprehensive cardiac centres based on the clinical needs of the population.”

A spokesperson for Saolta outlined that they would like to see three fixed cath labs in Galway and one in Sligo, with a combined cardiology team from Galway, Sligo and Letterkenny providing invasive cardiac services to these four cath labs.

“This will allow for a fully integrated and sustainable service and will ensure timely access for acute and elective cardiac patients across the group,” the spokesperson said.

HSE staff endure over 15,000 assaults in three years HSE staff have suffered more than 15,000 physical and verbal assaults in the last three years, new data shows.

In 2016, 2017 and 2018 over 15,800 physical and verbal assaults occurred, according to information released by the HSE under Freedom of Information legislation.

The vast majority of assaults on HSE staff, more than 12,000, were physical in nature, the information, which is correct up to 12 December 2018, states.

The data reveals that physical and verbal staff assaults amounted to just over 6,000 in 2016 but fell to 5,500 in 2017 and 4,300 last year.

As the number of assaults decreased, so too did the number of payments issued to staff under the HSE’s Assault at Work Scheme.

In 2016, 158 individuals received payment under the scheme compared to 139 in 2017 and 135 in 2018.

Under the scheme, payment is issued to healthcare staff absent from work as a result of a serious physical assault incurred during the course of their duties.

The scheme provides for full pay, including allowances and

premium earnings for a period up to three months for general support staff grades, such as healthcare assistants. This goes up to six months for officer grades, such as nurses and medical staff.

But despite the fall off in assaults, the HSE says it predicts a rise in the number of recorded incidents in the future as a new system introduced in 2015 becomes further embedded in the system and the organisation continues to encourage reporting of all incidents.

At least 142 HSE staff were paid under the Assault at Work Scheme in 2015 at a cost to the State of €1.2 million. The HSE says it does not hold data on the cost of payments under the Scheme in more recent years.

In 2015 the National Incident Management System (NIMS) was introduced by the State Claims Agency for recording staff incidents.

Staff are encouraged to report all “near misses” and incidents, even those that do not result in harm, the HSE said.

“Hence, the number of incident reports should not be considered as indicative of a level of harm. There may also be multiple reports relating to the same incident.”

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IPNA

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2019 – a pivotal year for practice nurses IPNA PRO Pauline Kilcoyne recounts recent IPNA events and developments in practice nursing

L

ast December I attended the All Ireland Chief Nursing Officers’ Conference in Dublin Castle with Gillian Redmond.

The opening address from Dr Siobhán O’Halloran and Prof Charlotte McArdle focused on the “Road to Transformation – Routes to Reform of Nursing and Midwifery Care”.

The pivotal message of the address, and one stressed throughout the conference, was on the importance of all nurses working together to help with the implementation of Sláintecare.

Dr O’Halloran spoke about how she looks forward to working with all partners and stakeholders to ensure the successful integration of Sláintecare. The map is laid out for us and it sets the pathway for a new health service, so it is now up to us to work together successfully implement. The strategy sets out a very ambitious programme of work. These initiatives have the ability to maximise the potential which community nurses and midwives possess.

One of the speakers who stood out was Ms Joanne Shear, CEO and President of Primary Care Transformation Experts LLC. Ms Shear was recently appointed by Minister for Health Simon Harris as one of the 23 strong members of the Sláintecare Implementation Advisory Council.

Her excellent talk was titled: “Integrated Care: Answer to Ailing Healthcare Systems?” She spoke about nurse practitioners shaping the transformation with reference to her experience as national clinical programme manager for VA primary care in the US. She spoke about how she believed VA gave nurse practitioners full practice authority and how nurses are critical to the transformation model. I had the pleasure of meeting Ms Shear following the conference and from talking to her it was apparent to me how proud she is to be a nurse, which makes her a strong voice for representing nurses in Ireland. We discovered how the role of practice nurses was one that is part of a wide multidisciplinary team and how because of this, we too are on a journey on the “road to transformation”. Practice nurses are making a difference in their practices, but we also need to create career pathways. We need to think globally but act locally.

Another event to take place recently was the Donegal Diabetic Interest Group second meeting, sponsored by Astra Zeneca, which took place in January. Professor McHugh gave an enlightening presentation on drugs and kidney cardiovascular issues. As a direct result of the meeting, three new practice nurses joined the IPNA. This is another way of encouraging participation in events and involvement in the organisation.

News from around the country Supporting our branches across the country is my focus as PRO and I would like to share what has helped to increase the numbers in our local branches up and down the country.

We have an excellent and well organised branch committee comprising our Chairperson, Josephine Heward; Secretary, Breege Kirby; and Treasurer, Christine Doherty. We have an excellent committee who works tirelessly. The meetings are well organised and always start and finish on time. We are getting positive feedback from all our current members and this is evident through our increasing number of new members.

Since coming into the role of PRO and establishing a WhatsApp

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group for the Donegal Branch, we have noticed how it has helped to increase attendance at branch events and an increase in numbers in general. This is largely due to better communication throughout the organisation, with reminders sent out for events and an easily accessible platform to share ideas and get in contact.

We have nurses that have made the effort to travel from Sligo all the way up to Malin Head. They carpooled, making the journey so much more accessible, and we encourage other nurses to get in contact with each other to get more carpooling under way when attending events.

Attendance at branch meetings is a great way to keep up to date and assist in your professional development. The association is invaluable in terms of peer support and the strong bonds of friendship which arise because of it. It is a great way to network amongst fellow nurses as well as gaining experience from more seasoned practice nurses.

Gillian, our national Chairperson, wrote an excellent report in last month’s journal. She boldly asked: “Why not make 2019 the year of the branch meetings, and get out and support your local meetings”.

Together with our National Executive Committee (NEC) team we want you to get to know our branches better. We, the NEC team, are proud to promote the IPNA. As PRO, I will do my best to increase association membership.

Please note I am happy to be contacted at any time with queries about getting involved and I can meet with any branches having difficulties in finding their feet to offer support.

Updates on events from around the country The IPNA are represented on a national working group for point of care testing in communities with HIQA. The association is also involved in developing a certificate in respiratory care in Dundalk with the HSE and ICGP, the communication of critical lab results with the HSE and the roll-out of termination of pregnancy (TOP) services with the HSE and ICGP. UCD are in the process of introducing a practice model of care to general practice in Ireland. As part of this, UCD School of Nursing and the UCD Medical School of General Practice are proposing to support practice nurses in key roles in the area of preventative care in chronic disease. Providing access to care and other services will be included in the initiative. Many practice nurses have expanded and extended their scope of practice at an advanced level without professional recognition or parity, with no additional remuneration.

The initiative will provide an educational Masters programme level for those interested in becoming an ANP in general practice while enabling those with key skills and experience to receive recognition for prior learning and therefore get credit for their current experience and knowledge.

Participants will not have to undertake the complete Masters programme in order to become a registered ANP. Karen Canning, member of South Dublin IPNA, will be our representative for this exciting endeavour.

2019 will be a pivotal year for practice nurses in the advancement of their personal development. This will be an exciting journey for us and I am looking forward to seeing where it brings us in the coming year.

regional news

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News from IPNA branches countrywide Please send your branch notes to Niamh Cahill, Editor, NIGP, email: cahill.niamh@gmail.com

Members of Kilkenny IPNA present Kay Morrissey with a bouquet of flowers to mark her retirement

Kilkenny Last year we had some well attended and successful meetings.

Dorothy Moore, CNS Integrated Care for Diabetes; Christine Walsh, CNS Integrated Care for Heart Failure; Colette Walton, TVN; and Rosaleen Mhic Usitin, CNS Integrated Care for COPD; all came on various nights to deliver interesting talks on their specialty and services offered.

We recently held our AGM. We are fortunate to have an experienced committee to look after the branch this year.

Patricia McQuillan was thanked for organising meetings for the last two years and will continue as the NEC representative.

Our new Chairperson is Una Stapleton. Joint secretaries are Anne Carpenter and Helen Fogarty, while Siobhan Carrigan will continue as treasurer.

Kay Morrissey, a longstanding member of the IPNA since 1993, retired recently. At our AGM she was presented with a bouquet of flowers to mark the occasion. We wish Kay all the best for a long and healthy retirement and thank her for all her years of service to practice nursing and to the IPNA.

Donegal Since you last heard from Donegal we have been very busy.

We had very good representation at the IPNA conference in Limerick and are extremely proud of Christine Doherty, who won the IPNA Clinical Award 2018. You can read her award winning entry in the January/February edition of this journal; you will see that she was a worthy winner. Congratulations to the Limerick/ North Tipperary committee for organising a very interesting conference.

We had a very well attended meeting in November and a very enjoyable Christmas gathering in December. We are most

grateful to Edwina Earles and Irene Walsh for their sponsorship and look forward to seeing them again in 2019.

Pauline Kilcoyne, supported by Kevin O'Donnell (Astra Zeneca representative), has established a Donegal Diabetes Interest Group for all practice nurses in the county. We had a full house to hear a very interesting presentation by Prof Cathy McHugh, Consultant Endocrinologist, Sligo University Hospital.

Much to our dismay this meeting found us saying farewell to Kevin as he is embarking on an exciting new career opportunity, and more exciting for him his new role as a doting Dad. Congratulations and best wishes to him from all of us.

We had no meeting in January, but we met up again on 13 February with a very good attendance for our AGM. Christine Doherty remains as Treasurer and Breege Kirby stays on as a Secretary. Josephine Heward, who has been our dedicated and hardworking Chairperson, has at long last been allowed to stand down and we are delighted to welcome Ann Marie Fogarty as our new Chairperson. We wish her every success and I know our members will give her lots of encouragement and support.

Josephine, we are so grateful to you for everything you have done to keep our branch vibrant and interesting for new and old members alike. Enjoy your well-deserved rest.

With so many changes happening in the delivery of primary care our meetings are so very important to help us support each other and to keep ourselves informed. Best wishes for 2019 to all the other branches.

Wicklow Wicklow resumed meetings after the Christmas break on Monday 14 January. We were delighted to have an attendance of 25 nurses, in spite of it also being the branch AGM. It was an excellent meeting on sexually transmitted infection

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News from IPNA branches countrywide

(STI) guidelines, diagnosis and treatment. The superb facilitator was Ann Moriarty, Emergency Department, Viral Screening Liaison Nurse, St James’s Hospital. Ann made this serious subject so interesting and even light hearted at times with her anecdotal stories. Thanks to Brenda Blewitt, Mirena representative from Bayer, for sponsoring Ann and for our lovely supper on the night.

The branch AGM followed the educational topic and the current chairperson, joint secretaries, and NEC representative were all re-elected. Our treasurer, Denise Breslin, has retired from practice nursing and stepped down as treasurer. Liz Given was elected to take over from Denise. A huge thank you to Denise for her many years as branch treasurer and for all her hard work and support over the years. She will be missed. All her colleagues and friends in Wicklow wish her a long, happy, healthy retirement.

Thanks, as always, for all the support from committee members and for agreeing to stand for re-election again this year.

Our planned meeting for 25 February had to be deferred one week at the booked speakers request for family reasons so the next branch meeting is on Monday 4 March.

The educational topic that night is: Essential rheumatology skills for practice nurses. The course aims to demonstrate core clinical skills for the assessment and diagnosis of patients with musculoskeletal and chronic inflammatory rheumatic diseases.

The evening is facilitated by Patricia Minnock, Madeline O'Neill, and Clara Bannon, ANPs in Rheumatology, Our Lady’s Hospice and Care Services, Harold’s Cross.

Thank you to Olive Kelly, Key Account Manager, Nordic Pharma, for kindly agreeing to sponsor the meeting and supper.

The next meeting is planned for 8 April, which will be a very interesting, extremely topical update from Carrie Powles, CervicalCheck.

The final meeting before the summer break is planned for Monday 13 May. Topic to be confirmed.

Thank you to all our members for supporting the branch and for the excellent attendance at meetings. We were delighted to welcome four new members in January and to also welcome back four previous members who have re-joined us this year.

It is encouraging to the committee, speakers and sponsors to have such great support and interaction at meetings. Thanks and we look forward to seeing you at upcoming meetings.

South Dublin The branch ended the year with a very interesting and informative presentation on rheumatology from Shona Lee, CNS, Tallaght University Hospital. We held our AGM after the meeting.

Mary Matthews stepped down as chairperson after three years.

Karen Canning was elected as Chairperson and we are delighted to welcome her back. Ciara Deegan stayed on as Treasurer. Mary Matthews offered to take up the secretarial position. Thank you to all. We are looking forward to a thriving 2019.

We kicked off in January with a meeting kindly sponsored by Sinead McSorley, Aptamil. Sinead gave a very good presentation on Aptamil products. This was followed by Mr Raymond Fenton, HSE Lead, Children First. Raymond discussed the Children First

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Act 2015 and our responsibilities as practice nurses. This was certainly thought provoking.

We held an extra meeting in early February on termination of pregnancy. We invited other branch members and were delighted to be joined by members from North Dublin and Wicklow branches. Karen Canning started with a presentation on the Health (Regulation of Termination of Pregnancy) Act 2018 and the new model of care.

Dr Mary Short, ICGP, discussed the ICGP Interim Guidelines, MyOptions helpline, consultations, medication, services in place and aftercare. Dr Caitriona Heinchion, Irish Family Planning Association, finished with a question and answer session on the consultation process.

Also in February we had a meeting kindly sponsored by Michelle Murphy, GSK. Michelle was accompanied by Aidan Egan. Both gave a talk on their products Relvar and Ellipta. Mary McDonald, ANP, Paediatric Asthma, Tallaght University Hospital, gave a very interesting talk on paediatric asthma. Mary covered the Under Sixes Cycle of Care and asthma management in primary and secondary care.

In March we will have an update from CervicalCheck. We are looking forward to the presentation from Carrie Powles.

Mayo The New Year started off with the January meeting facilitated by physiotherapist Neasa Canavan, who gave a presentation on physiotherapy and women's health. The meeting was held in Knockranny House Hotel, Westport and was sponsored by Deirdre O'Neill, Aptamil. The meeting was well attended and very enjoyable, highlighting the importance of pelvic floor exercises.

In February, Dr David Lappin, Consultant Nephrologist from Galway, gave a presentation on the significance of monitoring the estimated glomerular filtration rate (eGFR). The meeting was held at Mount Falcon Hotel, Ballina, sponsored by Amanda Dolan, Astra Zeneca. In March we will hold our AGM and elect new committee members.

The Mayo IPNA branch are busy planning and organising the 2019 IPNA conference to be held on 27 and 28 September in the Galway Bay Hotel, Salthill, Galway. The theme of our conference is “Slán agus Follain”, meaning “well and healthy”, highlighting our desire to help our patients to live healthy lives. The focus of the conference will be on factors that positively influence health and wellbeing through emotional health, including encouraging patients to manage stress more effectively and feel better about themselves.

A presentation on resilience will be delivered by Shane Martin. Another factor is the importance of sleep in maintaining wellness and health. Dr Harry Barry will deliver a presentation on sleep deprivation. This year the conference will hold practical workshops aimed at promoting health awareness through lifestyle factors and establishing healthier habits such as breast care and sexual health. We look forward to welcoming you all to the 2019 conference.

regional news

nursingingeneralpractice

News from IPNA branches countrywide

Cork

Roscommon Our first meeting of the year was held on 20 February. It was a great turn out at our usual venue of Gleeson's Hotel, Roscommon. We welcomed a new member, Barbara, and sent our congratulations to Marie on the birth of her baby girl, who was born in December. We had a great meeting sponsored by Catherine O'Donnell, Thermofisher.

Our speaker was Dr Edina Moylett, Paediatrician at NUI Galway. The subject was paediatric allergies and the talk was very relevant and informative. Dr Moylett talked about the management of common food allergies, eczema and allergic rhinitis. Tools on history taking from IFAN, SIGN and the iMAP milk ladder were highlighted.

It was very interesting to hear that more recent research is encouraging early introduction of peanuts into the weaning diet and how people suffering with severe nut allergy are in the early days of being introduced to small amount of nuts without suffering anaphylaxis. The talk lasted just over one hour ,which wasn't nearly enough.

Our next meeting will be on the 20 March on the topic of asthma and inhaler technique. We will all be thinking of some policy guidelines to feed back to the IPNA.

We have been busy as usual in the Cork branch. A very enjoyable pre-Christmas meeting was had by all in the Kingsley Hotel. We had an informative presentation from Louise Oâ&#x20AC;&#x2122;Neill on infant nutrition followed by a lovely meal.

The meeting was sponsored by Louise, Aptamil. A donation was given to a local charity by the branch members. We had no official meeting in January because we had a very informative presentation and tour at the Cork Fertility Clinic, which was a great success. Our first meeting of the year was held in February. We had a fantastic talk from Dr Zelie Gaffney on post reproductive health.

This meeting was also our AGM. Huge thanks to our outgoing committee for their very hard work over the last few years. The new committee are as follows: Chairperson, Angela Cashman; Vice Chairperson, Mary Mc Carthy; Secretary, Kay Poland; Treasurer, Ann Dunlea and NEC Representative Breda Looney Herlihy. Our next meeting is on 13 March, with the director of The Matt Talbot Centre, Douglas, to speak on the topic of teenage addiction. This promises to be another very relevant and informative meeting.

recruitment Part-time Practice Nurse Required Tralee Busy town centre general practice.

Fully computerised. Duties include Childhood/Travel Vaccinations/Cervical Smears & other general Nursing duties. Midwifery desirable but not essential.

Training will be provided.

Practice Nurse Required Glasnevin, Dublin Practice nurse required for GP practice in Glasnevin, Dublin City. Excellent pay rates for 3-4 mornings per week to cover a one year maternity leave. Longer term position may become available.

Call 01 830 7991 or email gpdublin7@hotmail.com for further information.

Applications please to The Ashe Street Clinic, Tralee or Email to maryb@asctralee.com

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interview

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Technology in mental health Niamh Cahill speaks to Minister of State for Mental Health and Older People, Jim Daly, about his aspirations for improving mental health services in Ireland

F

ine Gael politician and Minister of State for Mental Health and Older People, Jim Daly, was first elected to Dáil Éireann in 2011.

A former teacher, Minister Daly was re-elected in 2016 and has served as Minister of State for Mental Health and Older People, his first ministerial role, since June 2017.

At a time when the healthcare service faces ongoing criticism and when urgent improvements in mental health are being sought, his role is one brimming with challenge and expectation.

Minister Daly, in a recent interview, said the biggest issue

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facing mental health when he took over the role nearly two years ago was recruitment and retention.

Unfortunately, not much has changed in this regard as there are about 60 vacancies in psychiatry alone nationally.

The recruitment and retention model, he felt, on taking over the role, was not sustainable and since this time he has examined ways of addressing this.

He has looked internationally at best practice and discovered that a “global challenge” exists in recruiting consultant psychiatrists.

“Every country has a shortage of consultant psychiatrists,” he noted.

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While conceding that Ireland has its own, perhaps unique, issues relating to consultant entrant’s pay, he argued that globally countries were looking at new ways to relieve recruitment and retention difficulties.

So what are other countries doing?

According to Minister Daly, they are invoking the online space and embracing technology to address the recruitment shortage, which hasn’t been done in Ireland to date.

The Minister has big plans for mental health, with online psychology in primary care, tele-psychiatry for the Children and Adolescent Mental Health Service (CAMHS) and a 24hour mental helpline all due to commence this year. Telepsychiatry “hubs” in emergency departments (ED) are also planned.

“Prisons are another area where online psychiatry and counselling could work really well,” Minister Daly advised.

“This is the future of medical care full stop.”

Ideally, GPs should be able to access clinical consultancy services via a screen across all disciplines, not just mental health, he said.

Consultants, he maintained, could give GPs a lot of advice without the need for people to be “traipsing up to a clinic and waiting six months for an appointment”.

Psychology Some 114 assistant psychologists have been recruited this year to help boost patient access to psychology counselling services.

Minister Daly plans to roll out “two-to-three” online counselling pilots in primary care centres (PCCs) this year, beginning in Greystones, Co Wicklow shortly, and later this year in Cork, perhaps – Minister Daly was vague on locations and dates.

“Patients will be written to in batches of 100 that are waiting for a psychology appointment and told they can avail of online counselling free of charge [medical card holders only] if they want to contact the primary care centre,” he explained.

The new “screen to screen” service will eliminate the need for patients, and consultants, to travel long distances for psychology services, it is hoped.

Consultations will initially take place in primary care centres using newly purchased technology, with each piece of equipment (screen) costing about €2,000-3,000. The screen will allow clinician and patient to converse online.

“If it’s in a primary care centre, and it’s a one-on-one psychology session, you have no more resource implications than you have face to face.

"The only reason I would like it to be in a supported environment initially is that if somebody did get very upset, that they are not on their own in a remote, isolated area and are instead in an area where there is a nurse, doctor and people.”

As with all new tele-services proposed by the Minister, he does not believe more staffing or space will be required to roll out the service; space, he said, will not be an issue, while

interview

he also foresees no increase in workload for clinicians.

“Screen to screen doesn’t employ, necessarily, any more resources than face to face,” he said.

CAMHS and EDs At the start of December at least 29 CAMHS psychiatrists were employed on a locum/temporary basis due to ongoing difficulties in attracting permanent child and adolescent psychiatrists.

Last year, three high-profile consultant psychiatrist resignations from CAMHS occurred in the South East, with some clinicians siting grave operational and safety concerns for children trying to avail of CAMHS. In a bid to review practices across the country, Minister Daly recently met with “CAMHS leadership” in the Department of Health.

Clinical leads and HSE management leads of the nine CHO areas met to look at “what’s working well” and to share knowledge and find better ways of delivering the service.

It was the first time since taking office that Minister Daly had held such a meeting despite the ongoing recruitment and patient access challenges facing CAMHS. At the meeting, he advised that “there will be no waiting list initiative while I’m Minister… because dealing with waiting lists is only dealing with the symptom. I’m more interested in dealing with the structural causes of waiting lists”.

The single biggest issue raised at the meeting was obstacles to recruitment, with those present calling for a “localised recruitment” system, instead of the current national process, to help speed up recruitment.

Commenting on the situation in the South East, Minister Daly noted how tele-psychiatry could help address the problem.

“At the moment there is a high profile consultant psychiatrist vacancy in Wexford. A consultant from Galway travels to Wexford every weekend to do clinics and we’re very grateful to her to do weekend work and keep the system moving, but she’s in the car for seven hours every weekend doing that. There’s no reason why she couldn’t do that on screen. There is a CAMHS team in Wexford and the children are already in the CAMHS team, they just need clinical governance from a consultant psychiatrist.”

Minister Daly maintained that a hub and spoke model could be used, with the hub most likely in Dublin, to deliver care to patients.

“The hub will have a consultant psychiatrist there 24/7 and a camera and a screen there to connect into as many sites as we want around the country…it could connect into every site around the country.”

A psychiatrist could do assessments and provide governance to CAMHS teams, he advised, before adding “this is happening all over the world”.

Some 10 new advanced nurse practitioners will be introduced this year in CAMHS to help improve operations.

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gestational diabetes

nursingingeneralpractice

Optimising outcomes in gestational diabetes Dr Delia Bogdanet, SpR in Diabetes and Endocrinology; and Prof Fidelma Dunne, National University of Ireland Galway, examine the rise in gestational diabetes and highlight how best to treat the growing problem

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estational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy. This definition, however, does not exclude the possibility that the glucose intolerance might have been undiagnosed and may have antedated or begun at the same time as the pregnancy. So in 2014 the American Diabetes Association (ADA) redefined gestational diabetes as “diabetes diagnosed during pregnancy that is not clearly overt diabetes”.

Physiopathology In normal pregnancy, maternal tissues become progressively insensitive to insulin.

Skeletal muscle and adipose tissue are the main whole-body glucose disposable sites. In normal pregnancy, insulin-mediated whole-body glucose disposal decreases by 50 per cent and in order to maintain a euglycemic state, the woman must increase her insulin secretion by 200-250 per cent.

Some women have circulating immune markers (for example, anti-islet cell antibodies or antibodies to glutamate decarboxylase 65) that are diagnostic of evolving type 1 diabetes mellitus (T1DM); others have genetic variants that are diagnostic of monogenic forms of diabetes. These include genes for subtypes of maturity onset diabetes of the young (MODY) and maternally inherited diabetes.

GDM is a form of hyperglycaemia. Similar to other forms of hyperglycaemia, GDM is a disease of the pancreatic β cells, which do not produce sufficient insulin to meet the increased requirements of late pregnancy.

GDM is observed in obese as well as in lean women. However, the pathophysiology behind the disease is believed to differ between these groups. In obese women, the pathophysiology is primarily characterised by the pregnancy-induced insulin resistance being amplified by the already elevated pre-pregnant insulin resistance level. The elevated insulin resistance level is a known factor in the metabolic syndrome. In lean women, the same factors seem to play a role but a defect in the first-phase insulin response contributes to a larger extent. These defects culminate in a disruption of the action of insulin in maintaining glucose levels, resulting in maternal hyperglycaemia. Glucose is transferred via the placenta to the foetus. Maternal hyperglycaemia therefore

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stimulates a foetal hyperinsulinemia to counter the excess placental glucose transfer.

Prevalence Gestational diabetes mellitus (GDM) is increasing in prevalence in tandem with the dramatic increase in the prevalence of overweight and obesity in women of childbearing age. The criteria and cut off values for the diagnosis of GDM are different worldwide. Depending on the screening strategies being used (universal or selective) and diagnostic criteria, estimated prevalence rates have significant variation – with an increasing trend over the last decades; and even within a country’s population, depending on the racial and ethical composition of the residents the prevalence can vary. Globally, the prevalence of hyperglycemia in pregnancy (GDM and manifest T2D in pregnancy) is estimated to be approximately 15 per cent; for Europe, the prevalence is 12.6 per cent. A recent paper has studied the GDM prevalence for high risk women with a prepregnancy BMI ≥29kg/m2 and has found a GDM prevalence ranging from the lowest 24 per cent in the UK up to the highest prevalence of 52 per cent in Denmark. In Ireland, the prevalence of gestational diabetes is 12.4 per cent.

Screening and diagnosis Screening and diagnostic testing for GDM are very important in order to identify the women at risk of developing GDM and, in doing so, reducing or preventing the risk of adverse maternal and foetal complications.

Screening for GDM is usually done at 24-28 weeks of gestation because insulin resistance increases during the second trimester and glucose levels rise in women who do not have the ability to produce enough insulin to adopt this resistance.

Despite universal screening being the gold-standard, a large proportion of countries choose selective screening using parameters such as maternal age, previous GDM, previous large for gestational age babies, family history of diabetes, high pre-pregnancy BMI, belonging to an ethnic group associated with a high prevalence of GDM, hypertension, polycystic ovarian syndrome, women on long-term steroids, glucosuria or previously unexplained perinatal death. The argument for selective screening is that it helps concentrate medical

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resources on the patients with the highest risk of adverse events. However, by using selective screening, patients with GDM will be missed. Recent papers have shown that applying selective screening criteria would lead to up to 20 per cent of women with gestational diabetes being missed. Therefore, in 2011, the American College of Obstetricians and Gynaecologist (ACOG), ADA and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) recommended universal screening because of the beneficial effect from screening, diagnosis and subsequent treatment.

Also, what is important to note in the Avalos et al paper is that despite everybody being offered screening for GDM only 75 per cent consented and of those who consented only 44 per cent presented for testing. This highlights the imperative need to improve compliance with the screening method either by facilitating access to it or by improving or changing the screening test. New biomarkers are now emerging.

In pregnancy there is a higher physiological turnover of erythrocytes, rendering glycosylated haemoglobin (HbA1c) inadequate as a diagnostic tool, because of underestimation of the average glucose level - a reduction of HbA1c is typical in normal pregnancy.

A fasting plasma glucose level >7.0mmol/l or a casual plasma glucose > 11.1mmol/l meets the threshold for the diagnosis of diabetes, if confirmed on a subsequent day, and precludes the need for any glucose challenge. Otherwise, evaluation for GDM in women should follow one of two approaches: One-step approach: Perform a diagnostic oral glucose tolerance test (OGTT). The one-step approach may be cost-effective in high-risk patients or populations.

Two-step approach: Perform an initial screening by measuring the plasma or serum glucose concentration one hour after a 50-g oral glucose load (glucose challenge test [GCT]) and perform a diagnostic OGTT on that subset of women exceeding the glucose threshold value on the GCT. With either approach, the diagnosis of GDM is based on an OGTT. A variety of OGTT have been applied, but a consensus regarding screening for and classification of GDM is yet to be achieved globally. However, a 2-h 75g OGTT at 24-28 weeks of gestation is now being recommended both by the European Association for the Study of Diabetes, International Association of Diabetes and Pregnancy Study Group (IADPSG), ADA and World Health Organisation (WHO).

In 2010 the IADPSG outlined new diagnostic criteria for GDM based on the knowledge achieved in the Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study. This new guideline from IADPSG was adopted by the WHO in 2013 and ADA in 2014 and is based on the risk of adverse pregnancy outcomes. The threshold for a positive test is exceedance of one of the following three plasma glucoses; fasting plasma glucose ≥ 5.1mmol/L, 1 h ≥ 10.0mmol/L, or 2 h ≥ 8.5mmol/L. In comparison the WHO recommended threshold in 1999 was fasting plasma glucose ≥ 7.0mmol/L and in 1985 fasting plasma glucose ≥ 7.8mmol/L.

gestational diabetes

Complications Pregnancy complications - mothers Women with GDM are at higher risk of hypertensive disorders including gestational hypertension and pre-eclampsia. In the HAPO study, 5.9 per cent had gestational hypertension and 4.8 per cent had preeclampsia. The HAPO study also found a direct correlation between Caesarean section rate and maternal glycemia with an overall frequency of 23.7 per cent. In Ireland, the rates of complications amongst women with GDM were found to be as follows: 13.8 per cent developed maternal hypertension, 6.3 per cent developed pre-eclampsia 37.2 per cent underwent a caesarean section.

Pregnancy complications - infants Macrosomia in new-borns of diabetic mothers is characterised by increased body fat. The HAPO study found that percentage of body fat in new-borns maternal glycemia and foetal insulin levels estimated by cord C-peptide level were strongly positively correlated. Thus, maternal glycemia is directly related to neonatal adiposity. Although rare, shoulder dystocia is a serious complication of childbirth. A clear association between increased foetal size and the risk of shoulder dystocia has been shown once the birth weight exceeds 4kg. In Ireland, 7.1 per cent of infants of mothers with GDM were born prematurely, 24 per cent were macrosomic, 23 per cent were large for gestational age and 26 per cent required neonatal intensive care admission.

Long-term complications Women who are diagnosed with GDM are at high risk of developing diabetes mellitus later in life. An estimated ~10 per cent of women with GDM have diabetes mellitus soon after delivery. The rest appear to develop diabetes mellitus at rates of 20-to-60 per cent within 5-to-10 years after the index pregnancy in the absence of specific interventions to reduce their risk of diabetes mellitus.

The risk of diabetes mellitus in the mother after GDM is much higher than the risk of perinatal complications associated with GDM. Thus, GDM can be reasonably considered to be a form of prediabetes similar to impaired glucose tolerance in nonpregnant individuals.

The HAPO follow-up study analysed the data from 4,697 mothers, aged an average of 41.7 years and including 14.3 per cent who had experienced gestational diabetes, and their 4,832 children, who were aged an average of 11.4 years. Nearly a third (30.2 per cent) of the children were overweight or obese according to the International Obesity Taskforce criteria, and 11.2 per cent were obese. But the rates were higher if the children’s mothers had experienced gestational diabetes, at 39.5 per cent versus 28.6 per cent if they did not for overweight/obesity, and 19.1 per cent versus 9.9 per cent for obesity.

Gestational diabetes also affected the mothers’ longer-term outcomes, increasing their risk for dysglycemia. Specifically, diabetes was present in 10.7 per cent of those who had experienced gestational diabetes versus 1.6 per cent who had not, and the same was true of impaired fasting glucose, at 30.8 per cent versus 9.7 per cent, impaired glucose tolerance at 28.7 per cent versus 11.8 per cent, and any of the three measures, at 52.2 per cent versus 20.0 per cent. In Ireland, 25.9 per cent of

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gestational diabetes

women with previous GDM will develop glucose abnormalities post-partum compared to women with normal glucose tolerance during pregnancy who will only develop glucose abnormalities post-partum in only 3.6 per cent of cases.

All women with GDM should receive nutritional advice by a registered dietitian when possible. Individualisation of medical nutrition therapy (MNT) depending on maternal weight and height is recommended. MNT should include the provision of adequate calories and nutrients to meet the needs of pregnancy and should be consistent with the maternal blood glucose goals.

Compared to diet alone, exercise with dietary modifications has been found to lead to improved glycaemic control in one study.

The proposed mechanism for such an improvement in glycaemic control is heightened sensitivity of peripheral tissues to insulin.

Diet therapy has been focused on carbohydrate restriction.

Evidence from the randomised trials, however, supports the idea that women with GDM tolerate higher complex carbohydrate diets. In fact the data from randomised controlled trials would suggest that a diet which liberalises complex carbohydrates (using higher fiber and lower glycemic index carbohydrates) and limits saturated fats may be optimal in improving glycemia and preventing further insulin resistance. The recommended weight gain during singleton pregnancy is dependent on pre-pregnancy BMI: 12.5-18kg of weight gain for underweight women (BMI <18.5kg/m2); 11.5-16kg for normal weight (BMI 18.5-24.9kg/m2); 7-11.5 kg for overweight (BMI 25-29.9kg/m2), and 5-9kg for obese (BMI ≥30.0kg/m2).

As with screening and diagnostic recommendations, glucose testing and treatment goals differ among guidelines. All sources agree that elevated postprandial glucose is more predictive of negative outcomes, especially foetal macrosomia, compared with preprandial levels, with some indicating a stronger correlation with one-hour compared with two-hour postprandial levels. It is generally recommended that patients self-monitor seven times per day: Fasting glucose and before every meal (goal <5.3mol/L) and postprandial glucose one-hour (goal <7.8mol/L) after eating.

Pharmacological intervention in the management of GDM is usually employed when women fail to meet established goals with conventional therapy of diet and exercise. It is also indicated when elevated fasting glucose levels occur while on conventional therapy, because dietary modification has limited effect on these levels. Although most women achieve adequate glycaemic control with conventional therapy, 30-40 per cent do require the addition of pharmacologic therapy at some point during their pregnancies. The pharmacological options in this case include insulin or oral hypoglycaemic agents (metformin and glyburide).

Insulin is the pharmacologic therapy that has most consistently been shown to reduce fetal morbidities when added to MNT. Selection of pregnancies for insulin therapy can be based on measures of maternal glycemia with or without assessment of foetal growth characteristics.

The type and timing of insulin should be chosen based on the specific blood glucose elevation. If the fasting glucose is greater than 5.1mol/L then basal insulin, long-acting insulin analogue, or neutral protamine Hagedorn (NPH) should be started before bedtime. In cases where glucose level is elevated following a meal, rapid-acting insulin, or regular insulin should be prescribed before that specific meal, beginning with 2-4 units, or a dose

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of one unit per 10-15g of carbohydrates. If both fasting and PP glucose levels are elevated, a four-injections-per-day regimen “basal and meal time insulin regimen” should be prescribed.

When deciding how to dose insulin in pregnancy, the recommendations are not specific to GDM. The general principles for dosing insulin in pregnancy apply to pre-gestational and gestational diabetes. Although insulin sensitivity fluctuates throughout pregnancy, by the time insulin is needed for GDM, patients are often at the end of their second trimester or even in their third trimester. Insulin resistance increases throughout pregnancy, so the total daily dosing requirements are usually 0.8-0.9 units of insulin per kg of body weight. In a morbidly obese woman, the initial doses of insulin may need to be increased to 1.5-2.0 units/kg.

Insulin therapy decreases the frequency of foetal macrosomia and the risk of perinatal morbidity. Positive history of diabetes mellitus in a first-degree relative and multiple abnormal values in the OGTT were strongly found to predict the need for insulin management in women with GDM. Measurement of the foetal abdominal circumference early in the third trimester can identify a large subset of infants with no excess risk of macrosomia in the absence of maternal insulin therapy.

Metformin is another oral hypoglycaemic agent considered a potential substitute for insulin in GDM management. In a randomised controlled trial involving women with GDM, the use of metformin, whether alone or with supplemental insulin, was not associated with increased perinatal complications compared to insulin alone. Meanwhile, a 2013 meta-analysis found that metformin is comparable to insulin regarding glycaemic control and neonatal outcomes. In another recent study, metformin use was associated with similar desirable outcomes when compared to MNT and insulin use; its use was not associated with a higher risk of maternal or neonatal complications.

Post-partum follow-up The main emphasis of postpartum care should be the assessment of the future risk of diabetes mellitus and mitigating that risk.

Glucose tolerance testing one-to-four months postpartum is useful for the identification of additional women with diabetes mellitus and in stratifying the one-to-five-year risk of diabetes mellitus. In women who do not have diabetes mellitus at postpartum testing, the risk increases linearly for at least the first five-to-10 years, during which 30–50 per cent of women develop diabetes mellitus.

Several studies have looked at ways to prevent the development of type 2 diabetes (T2DM) in women with previous GDM. All these studies highlight and prove the importance of consistent, sustainable post-partum lifestyle change and interventions, through diet and exercise in preventing glucose abnormalities in later life. The purpose of these studies was to show that lifestyle interventions can prevent or at least postpone the development of T2DM. These interventions should be easily adopted and implemented in primary healthcare. A very important observation in these studies was that the intervention needs to be individualised, continuing and performed by skilled individuals in order to be effective.

References on request

INVOKANA® (canagliflozin) 100 mg & 300 mg film-coated tablets.

PRESCRIBING INFORMATION. Republic of Ireland. Please refer to Summary of Product Characteristics (SmPC) before prescribing.

INDICATIONS: The treatment of adults with insufficiently controlled type 2 diabetes mellitus as an adjunct to diet and exercise as monotherapy when metformin is considered inappropriate due to intolerance or contraindications, or in addition to other medicinal products for the treatment of diabetes. DOSAGE & ADMINISTRATION: Adults: recommended starting dose: 100 mg once daily. In patients tolerating this dose and with eGFR ≥ 60 mL/min/1.73 m2 needing tighter glycaemic control, dose can be increased to 300 mg once daily. For oral use, swallow whole. Caution increasing dose in patients ≥ 75 years old, with known cardiovascular disease or for whom initial canagliflozin-induced diuresis is a risk. Correct volume depletion prior to initiation. When add-on, consider lower dose of insulin or insulin secretagogue to reduce risk of hypoglycaemia. Children: no data available. Elderly: consider renal function and risk of volume depletion. Renal impairment: not to be initiated with eGFR < 60 mL/min/1.73 m2. If eGFR falls below this value during treatment, adjust or maintain dose at 100 mg once daily. Discontinue if eGFR persistently < 45 mL/min/1.73 m2. Not for use in end stage renal disease or patients on dialysis. Hepatic impairment: mild or moderate; no dose adjustment. Severe; not studied, not recommended. CONTRAINDICATIONS: Hypersensitivity to active substance or any excipient. SPECIAL WARNINGS & PRECAUTIONS: Not for use in type 1 diabetes. Renal impairment: eGFR < 60 mL/min/1.73 m2: higher incidence of adverse reactions associated with volume depletion particularly with 300 mg dose; more events of elevated potassium; greater increases in serum creatinine and blood urea nitrogen (BUN); limit dose to 100 mg once daily and discontinue when eGFR < 45 mL/min/1.73 m2. Not studied in severe renal impairment. Monitor renal function prior to initiation and at least annually. Volume depletion: caution in patients for whom a canagliflozin- induced drop in blood pressure is a risk (e.g. known cardiovascular disease, eGFR < 60 mL/min/1.73 m2, anti-hypertensive therapy with history of hypotension, on diuretics or elderly). Not recommended with loop diuretics or in volume depleted patients. Monitor volume status and serum electrolytes. Elevated haematocrit: careful monitoring if already elevated. Genital mycotic infections: risk in male and female patients, particularly in those with a history of GMI. Lower limb amputation: Consider risk factors before initiating.

Monitor patients with a higher risk of amputation events. Counsel on routine preventative foot care and adequate hydration. Consider discontinuing Invokana when events preceding amputation occur (e.g. lower-extremity skin ulcer, infection, osteomyelitis or gangrene). Urine laboratory assessment: glucose in urine due to mechanism of action. Lactose intolerance: do not use in patients with galactose intolerance, total lactase deficiency or glucose-galactose malabsorption. Diabetic ketoacidosis (DKA): rare DKA cases reported, including life-threatening and atypical presentation cases. Where DKA is suspected or diagnosed, discontinue Invokana treatment immediately. Interrupt treatment in patients who are undergoing major surgical procedures or have acute serious medical illnesses. Consider risk factors for development of DKA before initiating Invokana treatment. Necrotising fasciitis of the perineum (Fournier’s gangrene): post-marketing cases reported with SGLT2 inhibitors. Rare but serious, patients should seek medical attention if experiencing symptoms including pain, tenderness, erythema, genital/perineal swelling, fever, malaise. If Fournier’s gangrene suspected, Invokana should be discontinued, and prompt treatment instituted. INTERACTIONS: Diuretics: may increase risk of dehydration and hypotension. Insulin and insulin secretagogues: risk of hypoglycaemia; consider lower dose of insulin or insulin secretagogue. Effects of other medicines on Invokana: Enzyme inducers (e.g. St. John’s wort, rifampicin, barbiturates, phenytoin, carbamazepine, ritonavir, efavirenz) may decrease exposure of canagliflozin; monitor glycaemic control. Consider dose increase to 300 mg if administered with UGT enzyme inducer. Cholestyramine may reduce canagliflozin exposure; take canagliflozin at least 1 hour before or 4-6 hours after a bile acid sequestrant. Effects of Invokana on other medicines: Monitor patients on digoxin, other cardiac glycosides, dabigatran. Inhibition of Breast Cancer Resistance Protein cannot be excluded; possible increased exposure of drugs transported by BCRP (e.g. rosuvastatin and some anti-cancer agents). PREGNANCY: No human data. Not recommended LACTATION: Unknown if excreted in human milk. Should not be used during breast-feeding. SIDE EFFECTS: Very common (≥1/10): hypoglycaemia in combination with insulin or sulphonylurea, vulvovaginal candidiasis. Common (≥1/100 to <1/10): constipation, thirst, nausea, polyuria or pollakiuria, urinary tract infection (including pyelonephritis and urosepsis), balanitis or balanoposthitis, dyslipidemia, haematocrit increased. Uncommon (<1/100) but potentially serious: anaphylactic reaction, diabetic ketoacidosis, syncope, hypotension, orthostatic hypotension, urticaria, angioedema, necrotising fasciitis of the perineum (Fournier’s gangrene) (frequency not known), bone fracture, renal failure (mainly in the context of volume depletion), lower limb amputations (mainly of the toe and midfoot, incidence rate of 0.63 per 100 subject-years, vs 0.34 for placebo). Refer to SmPC for details and other side effects. LEGAL CATEGORY: POM. PACK SIZES & MARKETING AUTHORISATION NUMBER(S): Invokana 100 mg film-coated tablets: 30 tablets; EU/1/13/884/002. Invokana 300 mg film-coated tablets: 30 tablets; EU/1/13/884/006. MARKETING AUTHORISATION HOLDER: JanssenCilag International NV, Turnhoutseweg 30, B-2340 Beerse, Belgium. ® INVOKANA is a registered trade mark of Janssen-Cilag International NV and is used under licence. © 2017 Napp Pharmaceuticals Limited. FURTHER INFORMATION IS AVAILABLE FROM: Mundipharma Pharmaceuticals Limited, Millbank House, Arkle Road, Sandyford, Dublin 18. For medical information enquiries, please contact medicalinformation@mundipharma.ie UK/INV-18203(1) Date of Preparation January 2019.

Uncontrolled blood sugar can’t wait

INVOKANA is indicated for the treatment of adults with insufficiently controlled type 2 diabetes mellitus (T2DM) as an adjunct to diet and exercise.1

Lower HbA1c levels In patients with HbA1c higher than 9%, INVOKANA reduces HbA1c by 1.57% and 1.80% with its 100mg and 300mg doses respectively.3

Long-term cardiovascular benefits† 14% reduction in the risk of cardiovascular death, nonfatal myocardial infarction and nonfatal stroke (3-point MACE) HR 0.86 (95% CI 0.75-0.97).4 33% reduction in risk of hospitalisation for heart failure HR 0.67 (95% CI 0.52 - 0.87).4

Improved renal outcomes† 47% relative risk reduction in time to first adjudicated nephropathy event (doubling of serum creatinine, need for renal replacement therapy, and renal death) HR 0.53 (95% CI 0.33 - 0.84).5 27% reduction in the progression of albuminuria in patients with normo- or micro-albuminuria HR 0.73 (95% CI 0.67-0.79).4

Adverse events should be reported to: HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517. Website: www.hpra.ie; E-mail: medsafety@hpra.ie.

Adverse events should also be reported to Mundipharma Pharmaceuticals Limited on drugsafetyireland@mundipharma.ie or by phone on 01 2063800 (1800 991830 outside office hours) References: 1. Invokana SmPC www.medicines.ie 2. Davies MJ et al, Diabetes Care. 2018 Oct: 10.2337/dci18-0033 (http://diabetologia-journal.org/wp-content/ uploads/2018/10/Consensus-Report-ADA-EASD.pdf). 3. Wilding JP et al J Diabetes Complications 2015; 29;438-44. 4. Neal B. et al. N Engl J Med 2017; 377:644-657.

5. Perkovic V. et al Lancet Diabetes Endocrinol. 2018 Sep;6(9):691-704 INVOKANA® is a registered trade mark of JanssenCilag International N.V. and is used under licence.

MUNDIPHARMA® and the ‘mundipharma’ logo are registered trade marks of Mundipharma AG. Date of Item: November 2018. IRE/INVK – 18273 Distributed in Ireland by: Mundipharma Pharmaceuticals Limited, Millbank House, Arkle Road, Sandyford, Dublin 18, Ireland. Phone +353-1-2063800 www.mundipharma.ie

The recommended starting dose of INVOKANA is 100mg once-daily. * an SGLT2i for treatment of T2DM patients with ASCVD, HF, CKD and for use in patients where there is a compelling need to minimise hypoglycemia and those with a compelling need to minimise weight gain or promote weight loss † Compared to standard of care

Seize the moment to make years of difference

heartwatch

nursingingeneralpractice

Preventing cardiovascular disease in primary care Cork GP Dr David Molony documents the success of Heartwatch in primary care to date but bemoans the lack of investment in the programme, which is no longer recruiting patients

H

eartwatch is the National Programme in General Practice for the secondary prevention of cardiovascular disease (CVD) in Ireland as patients with established cardiovascular disease have a high risk of subsequent CVD events, including myocardial infarction (MI), stroke, and death.

In Ireland, CVD accounts for 35 per cent of all deaths and 20 per cent of premature deaths in those under 65 years of age.

Heartwatch was set up in 2003, as a pilot programme, to provide chronic disease management and secondary prevention of a defined population who had previous MI, CABG, PTCA. Some 20 per cent of doctors nationally were involved, but all doctors enrolled in the Midlands Diabetes Care programme were included in the programme.

The aim of the programme was to reduce morbidity and mortality from cardiovascular disease in post cardiac event patients, to study risk factors and therapeutic interventions over time, to examine the patient processes in implementing the processes of referral and retention and to record the incidence of cardiovascular events in the patients participating in the programme. The programme was based on the second European Joint Task Force recommendations for secondary cardiac prevention.

The gathering of data is a fundamental aspect of this programme and this was overseen by a large national infrastructure with a National Steering Committee, Data Management Committee, Independent National Data Centre (for receiving practice data and distributing quality anoymised data reports appropriately), and National Programme Centre. The GP practices involved were supported by GP Coordinators and Nurse Facilitators.

Initially data was collected through an interim software commissioned for the programme but the accredited GP software suppliers in Ireland developed integrated in-house software solutions allowing GPs to use their practice software to link with INDC etc. Data management was reviewed and independently reported with ongoing learning and improvement in quality of data.

The Heartwatch programme was a success from the very start in that it brought together most of the medical bodies involved in general practice to deliver a patient care study and preventive programme, namely HSE (Health Boards initially), Department of Health and Children, ICGP, IMO and the Irish Heart Foundation. This process followed best international advice that this, post cardiac

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event care, should take place in GP primary care and be measured to best international standards of the time, as up to this time, post cardiac event management and rehabilitation took place in the hospital setting.

This model was designed on the basis of the need to move chronic care into the community and would have been in keeping with the Primary Care Strategy, launched two years previously.

The basis of this model comes from Wagner et al who developed and described the Chronic Care Model (CCM) in the mid-1990s.

CCM was to enable better care for patients with chronic conditions and comprises six key elements to promote high quality care in healthcare settings and target populations. The primary goal of the CCM is healthier patients, more satisfied healthcare providers and cost savings.

Six predominant aspects of the CCM include: 1) Self-management support – promoting patient autonomy in their care plan, linking patients to appropriate community resources, use of evidence based programmes to provide emotional support in addition to strategies for living with chronic conditions.

2) Clinical information systems – effective data management of patient files can improve patient care (eg, providing timely reminders for appointments and tests or other services that may be required). Data management can also facilitate performance monitoring and quality improvement strategies.

3) Delivery system redesign – incorporating a multidisciplinary approach, where tasks could be delegated/shared with other members of the team (eg, pharmacists, practice nurses, external agencies) in terms of patient follow-up, support for selfmanagement and behaviour change.

4) Decision support – Utilisation of evidence-based guidelines in practice, information sharing and patient participation in the use of evidence-based guidelines in addition to liaison with specialists in the field.

5) Healthcare organisation – Effective leadership, leadership support where changes have been implemented within an organisation for quality improvement purposes. Communication and interagency collaboration between health care workers across services may break down barriers that patients often encounter during their trajectory of care.

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6) Community resources – Collaboration between clinicians and external agencies, encouraging patients to utilise appropriate community-based resources.

For the practices, there was a significant learning curve to get the programme up and running and excellent support was given by GP Coordinators and Nurse Facilitators. New organisation in practices was developed, large amounts of information and patient support material had to be managed, patients identified, registers organised, detailed information collected from patients and relayed to INDC. Some of the personal lessons learned on this pathway in providing a chronic disease programme now seem very obvious and simple, but need to be repeated.

To deliver a sustainable programme for any group of people you must first: 1) Identify the patients.

2) Set up a register of the patients.

3) Set up a recall system for the patients.

4) One person in the practice must have primary responsibility for each programme.

5) That person must review and follow up defaulters monthly.

The GPs and practice nurses were provided with a useful and detailed handbook to explain the log in and operation of Heartwatch and this had to be followed to the letter or payment would not be forthcoming. This was to ensure quality and consistency of data but was indeed a learning curve.

The process is straightforward, with initial detailed registration with all the boxes being filled and then maintenance of four visits to the GP annually, following the protocol screens and compulsory fields (see copy attached forms). This has been a learning curve for each clinician entering data, either nurse or doctor, and these fields are to follow all major risk factors for deterioration.

The data is loaded by the GP practice monthly (for the programme but only three monthly for individual patients), sent directly to the

heartwatch

Independent National Data Centre (based in ICGP headquarters, Lincoln Hse) where the data is independently and confidentially stored and only anoymised data can be used by certified agencies.

When the data is verified, sanction for payment is sent to PCRS and this is returned to GP practices as a separate payment on ‘pink sheets’.

Unfortunately, this payment was severely hit by FEMPI and is still paid at the reduced rate of €39.18 down from €50. Over 90 per cent of data is returned electronically, reflecting the state of computerisation of general practice in Ireland over many years.

Data reflects the patient risk and collection includes gender, systolic BP, diastolic BP, T cholesterol, LDL, smoking, exercise (minutes per week of activity), BMI, medication, including groups on aspirin or other anti platelet drugs, anticoagulant, beta-blocker, statin or other lipid lowering drugs, ACE or ARB, especially any changes, smoking habits, OPD visits and diabetic factors, if diabetic, and objective risk assessment using Heartscore is carried out at the time to give more objective data of care.

It is expected that as well as recording data, that lifestyle advice be given where necessary and that easy referral to community dieticians, smoking cessation support and access to physical activity officers etc would be offered. Patient support leaflets are provided to support the role and give accurate information to the patient. Some consideration has to be given to the literacy level of the patient, taking into account that approximately 10 per cent of the Irish population have low literacy levels.

It is at the lifestyle discussion stage with the patient that knowledge of behaviour modification and brief intervention techniques are useful and prevent confrontation with patients on targets. Firstly, the target must always be apparent to the patient or no change will take place. The majority have to be supported and here the Wheel of Change model is a useful guide. Going from one stage to the next is a useful gain and just reassuring the patient and offering support, when they are ready themselves for change, is greatly beneficial.

Using the Wheel of Change, such as in the Smokers Guide, is useful for the doctor or nurse to gauge where the patient is at as regards changing their lifestyle in specific areas, but clinicians always have to remember to deal with the patients own concerns first, and then only approach the clinical concerns for the patient if appropriate at the time. This is a slow process of informing self-management and supporting the patient on their clinical pathway.

Another aspect which is not measured, but which those of us operating this and other chronic disease illness programmes know, is the importance of relationships and trust built up in the practices between GPs, practice nurses and practice staff and their patients.

The sending of reminders to patients about their visits is a positive reinforcement to the patients that someone is watching and cares about their health and outcomes and we all take pride in delivering a complete service to our patients.

After some time in operation, it is noticeable that a new therapeutic relationship/bond develops between patient and practice team supported by consistency etc, as per the six rules of CCM above. This relationship often opens up avenues of further support for the families of Heartwatch patients, as relatives are the most likely to be at risk of developing CVD in the future and the opportunity for education and behaviour change of family members is important.

23

heartwatch

Further on the ground learning with these patients with chronic disease is that they need our support and not criticism. When they fail to reach targets we must have a positive, forward looking approach, without blame and give reassurance that “the next visit will be better”, as we cannot do anything about the past.

By 2005, 11,400 Heartwatch patients were recruited by 470 GPs, approximately 24 patients each, rising to 12,358 patients in 2011.

17,399 patients by 2014 had 185,855 consultations and 22,000 patients and over 400,000 consultations occured by 2016, according to the ICGP. 400,000 consultations over the last 15 years of Heartwatch must have contributed significantly to the improvement in cardiovascular disease morbidity and mortality of the Irish population. But imagine what might have been done if the “pilot programme” had been rolled out nationally to the other 80 per cent of GP practices in the country.

Results Bennet et al (2008) noted “Substantial decreases in several of the risk factors from baseline to the one-year follow-up time point were observed. It showed a statistically significant decrease in systolic and diastolic blood pressure, total and LDL cholesterol, BMI and smoking.” Also they noted a “statistically significant decrease in HbA1c levels for those with diabetes at one year”. Also noted was an increase in the diagnosis of diabetes due to close monitoring, with 170 additional patients with diabetes at year two.

They also noted a marked increase in appropriate medication prescribing with more aspirin, statins, ACE and ARBs being used, especially with diabetic patients.

By year two further substantial decreases in several of the risk factors from baseline were noted, ie, statistically significant further reductions in systolic, diastolic BPs, total and LDL cholesterol, BMI and smoking prevalence. So continuing with the programme meant continuing improvement at year two.

Furthermore the improvements seen in Heartwatch at this time reflect other international studies, in particular the National

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Swedish Programme where the results and gains were very similar, showing that the Irish medical system can achieve as much as our international colleagues, if supported.

Further still in 2011, Fitzpatrick et al showed “Studies of cardiac rehabilitation without any follow-up programmes show that over time patients revert in part to previous lifestyle habits; this primary care-delivered programme (Heartwatch) has shown sustained improvements in major risk factors, particularly smoking, blood pressure and cholesterol, and treatments for CHD. Weight management presents a greater challenge.”

The interactions are also not lost on the families who see the need for care and compliance with both the programme and the medication. Families can become more aware of risk to other family members and support siblings and parents, hopefully subliminally themselves with an eye on the future.

The physicians also gain from the close working relationships with the practice nurses and having objective risk assessment tools applied to their patient population, where objective risk assessment often prompts an intervention that might otherwise be missed for some time and this benefit is clearly demonstrated in Heartwatch. Supported systems work for patients and practice staff alike.

Heartwatch is a study which brings hope and despair because it demonstrates that Irish practice is at least as good as any other medical system if it is supported. We see equivalent measures to other countries and gains from Heartwatch have been demonstrated clearly and scientifically from at least 2008, yet this successful programme is now no longer recruiting and has had much of the GP resources removed in the last number of years.

A conservative figure shows that over 90,000 people at any one time over the last 15 years would have benefited from this simple but effective programme.

The evidence here reflects all the other chronic disease programmes that could decrease expensive morbidity in our young cardiac and diabetic patients and also death in our national population.

Chronic disease is what we GPs and practice nurses deal with in the main and the Heartwatch programme showed unequivocally that we can do this to best international standards. But we need support, IT and infrastructure to succeed.

References Heartwatch: A secondary prevention programme in primary care in Ireland. Bennet et al European Journal of Cardiovascular Prevention and Rehabilitation 2008, 000-000.

Heartwatch: The effect of a primary caredelivered secondary prevention programme for cardiovascular disease on medication use and risk factor profiles. Fitzpatrick, Patricia and Fitz-Simon, Nicola and Lonergan, Moira and Collins, Claire and Daly, Leslie (2011). European Journal of Preventive Cardiology, 18, (1), pp. 129-136.

A Survey of GP awareness and use of Risk Assessment Tools in Cardiovascular Disease Prevention Guidelines. D Byrne et al, IMJ July/Aug 2015 Volume 18 Number 7, 204.

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Free independent CPD for Irish nurses

A

B

Latest module

Heart failure and iron deficiency was devised by Dr Pat Oâ&#x20AC;&#x2122;Callaghan MD FRCP, Cardiologist, University Hospital Waterford.

In heart failure iron deficiency is predominantly due to increased iron loss from the body. True or False?

Check your answer against the latest module on nursecpd.ie.Successful completion of this module will earn you 1.5 CPD credits Free CPD â&#x20AC;&#x201C; accessible on android, iPhone and tablet

cellulitis

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Caring for cellulitis patients Theresa Lowry-Lehnen, Clinical Nurse Practitioner and Associate Lecturer at Institute of Technology Carlow, looks at the management and treatment of the often hard to diagnose condition cellulitis

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ellulitis – a potentially serious skin and soft tissue infection – occurs when streptococcus and staphylococcus bacteria enter the body through a break or wound in the skin. Cellulitis is among the most frequent infections requiring hospitalisation, and the incidence of methicillin-resistant Staphylococcus aureus (MRSA) cellulitis is increasing (Quirke, 2017).

Cellulitis can occur anywhere on the body but the most common location is the lower leg. Bacteria enter the body through broken areas of skin such as scratches, cuts, bites, puncture wounds or ulcers and can also enter through areas of dry, flaky, or swollen skin such as athlete's foot or dermatitis.

Cellulitis develops rapidly. The first signs may be a flu-like illness with the person developing a high temperature and feeling cold and shivery before the local signs appear. The skin becomes red, hot, swollen and painful with a clear line of demarcation between normal and affected skin (HSE, 2018).

Old age, diabetes, obesity, deficiencies in skin integrity, immunity and vasculature are risk factors for the development of cellulitis and are often seen in patients who are hospitalised with cellulitis. The biggest risk factor, however, is a positive history for cellulitis. Old age is associated with skin atrophy, poor circulation, immunosenescence, and comorbidities such as diabetes or congestive heart failure. Malnourishment causes impaired wound healing, decreased skin elasticity and integrity, and relative immunosuppression. Incidence, complications (bacteraemia, osteomyelitis, endocarditis) and hospitalisation rates are all higher in diabetic patients. Most cases of cellulitis in diabetic patients can be attributed to diabetic foot associated skin defects, but more than a quarter of the cases of culturepositive diabetic cellulitis occur on non-foot locations. In morbid obesity, the skin is more susceptible to damage and takes longer to repair (Cranendonk et al, 2017).

Recurrent infections occur in up to 57 per cent of patients with cellulitis, predisposing to post-cellulitic oedema and further episodes of recurrence (Quirke, 2017). Almost 30 per cent of hospital admissions for cellulitis are for recurrent cellulitis.

Lymphoedema is the most important risk factor for recurring cellulitis, and 25-60 per cent of recurrent cellulitis patients suffer from chronic oedema. Obese patients have more recurrences and CRP and leucocyte counts are higher in these recurrences (Linder et al, 2014).

Studies of antibiotic use in Irish and other European hospitals have shown that skin, wound or soft tissue infections are second

26

only to lower respiratory tract infections as the most common indication for inpatient antibiotic treatment. In Ireland, hospital admissions for cellulitis and erysipelas increased by 25 per cent during the period 2009-2014 (Quirke, 2017). Erysipelas is a distinct form of superficial cellulitis with notable lymphatic involvement and is raised, sharply demarcating it from uninvolved skin.

Diagnosis of cellulitis can usually be made on medical history and examination, although culture and molecular diagnostic procedures should be performed if cellulitis is associated with a purulent wound or pustular focus. The clinical presentation of cellulitis is mimicked by a range of diseases. One recent study (Cohen et al, 2016) revealed that 31 per cent of patients hospitalised with cellulitis were misdiagnosed, the most frequent mimickers being stasis dermatitis, stasis ulcers, gout, congestive heart failure, non-specific oedema and deep venous thrombosis (DVT).

Patients with mild cellulitis (Class I) are usually treated with oral antibiotics for seven-to-14 days. Flucloxacillin is usually the drug of choice. Clarithromycin is used for patients allergic to penicillin, Clindamycin is used with Clostridium difficile and Co-amoxiclav for facial cellulitis (HSE, 2018) (www.antibioticprescribing.ie). Class II cases and above are treated with intravenous therapy to benefit from a rapid increase of antibiotic in the blood. Class III and IV should be referred to hospital.

For leg ulcers and recurrent cellulitis the treatment is different.

The HSE Expert Advisory Committee advises that antibiotics do not improve healing unless infection is active. Culture swabs and antibiotics are only indicated if there is evidence of clinical cellulitis; increased pain; enlarging ulcer or pyrexia. Antibiotics should be reviewed after the culture results are available and specialist opinion sought in severe infection. Initial treatment is usually flucloxacillin 500mg QDS for seven days and review, or clarithromycin 500mgs BD for seven days and review. Doses are usually oral unless indicated otherwise.

Considerations • Is it cellulitis?

• Bilateral cellulitis is uncommon.

• Is it chronic changes of venous stasis and chronic ulceration?

• Don’t swab unless atypical organisms are suspected.

• Colonisation is likely in leg ulcers.

• Two or more episodes of proven cellulitis may benefit from low dose prophylactic penicillin (in non-penicillin allergic patients).

• PATCH I and II clinical trials: 250mgs of penicillin six-to-12 months reduced episodes of cellulitis.

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• •

antibioticprescribing.ie

www.

Exclusion criteria for cellulitis (OPAT) (TCP, 2016) •

•

•

•

• •

•

•

•

•

•

•

C diff

• • •

CREST (Clinical Resource Efficiency Support Team)

https://www.hse.ie/eng/services/list/3/cits/managcellcomm.pdf

References

et al

JAMA Dermatol

The Netherlands Journal of Medicine

https://www.hse.ie/eng/services/list/2/gp/ antibiotic-prescribing/conditions-and-treatments/ skin-soft-tissue/recurrent-cellulitis-and-leg-ulcers/ leg-ulcers.html.

BMC Infect Dis

https://epubs.rcsi.ie/cgi/viewcontent.cgi?article=1 088&context=mdtheses.

http://www.tcp.ie/opat/.

Nursing Times

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spacer devices

nursingingeneralpractice

Guidance on inhaler and spacer device use Advanced Nurse Practitioner Ruth Morrow highlights the importance of spacer devices and looks at how best to utilise them in asthma control

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pacer devices are reservoirs or holding chambers which are held between the metered-dose inhaler (MDI) and the patient’s mouth. They are used with MDIs to assist patients to optimise drug deposition in the airways and therefore reduce and control their asthma symptoms.

Maximising airway deposition of a pMDI-delivered drug requires a slow (30L/min) deep inhalation commencing immediately after activation of the device followed by holding the breath for four-to-10 seconds (Newman et al, 1982). Even with optimal technique and modern hydrofluoroalkane propellants, pMDIs deliver approximately only 20 per cent of the emitted dose to the lower airways, leaving 80 per cent in the oropharynx (Newman et al, 1982). With incorrect technique, the deposition to the lower airways is further reduced, potentially to zero. The concept of activating the pMDI into a spacer or a valved holding chamber (VHC) (a reservoir with a one-way valve permitting airflow into, but not out of, the patient’s mouth) prior to inhalation was developed in the 1950s to address some of the problems and potentially critical errors when using a pMDI (Franklin et al 1958, Stein et al 2016). Using a spacer/VHC slows down the particles emitted from the pMDI, which may further increase lung deposition of the respirable fine particles, although the clinical significance of this effect is not well established. It certainly significantly filters out and thereby reduces oropharyngeal deposition of the larger particles emitted from a pMDI and therefore reducing the risk of side effects (Newman et al 1986).

What are the different kinds of spacers?

There are different types of spacers – small, medium and large volume holding chambers. Some spacers have a mask attached which are suitable for young children. It is important that the child’s face is measured for the mask as there are different sizes of masks. If the mask is too big, then medication may get into the eyes.

Who should use spacers?

Everybody who is prescribed a metered dose inhaler should also be prescribed a spacer device to maximise drug deposition in the lungs (Vincken et al, 2018).

Why do we recommend them?

Spacers are recommended to ensure the optimum amount of medication reaches the airways thereby reducing asthma symptoms. By using a spacer device the risk of side-effects from some inhalers is reduced. These side effects are oral candidiasis and dysphonia which are associated with inhaled corticosteroid inhalers.

How should an adult or a child use their spacer and inhaler?

There are two techniques which may be used – the single breath technique and the multiple breath technique or tidal breathing.

The multiple breath technique is more suitable for children and also during a flare-up (emergency), but can also be used by adults.

Using a spacer using the single breath technique 1. Assemble spacer (if necessary).

2. Remove inhaler cap.

3. Check dose counter (if applicable).

4. Hold inhaler upright and shake well.

5. Insert inhaler upright into spacer.

6. Put mouthpiece between teeth without biting and close lips to form good seal.

7. Breathe out gently, into the spacer.

8. Hold spacer level and press down firmly on inhaler canister once.

9. Breathe in slowly and deeply.

10. Hold breath for five-to-10 seconds or as long as comfortable.

11. While holding breath, remove spacer from mouth.

12. Breathe out gently.

13. If a second dose is needed, repeat steps three to 13.

14. Replace cap and disassemble spacer.

28

spacer devices

nursingingeneralpractice

Using a spacer using the multiple breath technique or tidal breathing 1. Assemble spacer (if necessary) .

2. Remove inhaler cap.

3. Check dose counter (if applicable).

4. Hold inhaler upright and shake well.

5. Insert inhaler upright into the spacer .

6. Put mouthpiece between teeth without biting and close lips to form good seal.

7. Breathe out gently, into the spacer.

8. Hold spacer level and press down firmly on inhaler canister once.

9. Breathe in and out normally for three or four breaths.

10. Remove spacer from mouth.

11. Breathe out gently.

12. Remove inhaler from spacer.

13. If a second dose is needed, repeat steps three to 12.

14. Replace cap and disassemble spacer.

How do I care for my spacer?

Spacers should be cleaned weekly and after a chest infection.

Spacers should not be shared. To clean the spacer: • The spacer should be disassembled.

• Immerse the parts in lukewarm tap water and detergent such as washing-up liquid.

• Shake the parts in the water and rub them with a soft cloth.

• Leave the parts soaking for 15 minutes, then take them out of the water.

• Do not rinse or dry rub the inside of the parts.

• Rinse soapy water off the mouthpiece.

• Place the parts on a clean towel to air-dry overnight.

• Reassemble the parts the next morning and check that the valve is not stuck.

Spacers/VHCs are potentially subject to microbial contamination and, since they come into contact with mucous membranes.

Bacterial contamination of spacers/VHCs appears to be common; for example, in one study, contamination with Pseudomonas aeruginosa, Staphylococcus aureus and Klebsiella pneumoniae was detected in 35 per cent of spacers/VHCs used by children with asthma (Cohen et al, 2005).

How often do I need to change my spacer?

According to manufacturers’ leaflets, the lifetime of a spacer/VHC varies between six and 12 months. Spacers/VHCs should, therefore, be replaced at least annually (Vincken et al 2018) How can I get my child to use their spacer?

• You can make your spacer ”child-friendly” by putting stickers of their favourite characters on it.

• You can also leave it in their toy box and let them play with it so that they become familiar with it and are not afraid of it – spacers are not easily broken.

• Use the spacer on their favourite teddy/ toy as pretend play.

If a child is crying when using a spacer does the medication get

into their lungs?

If a child is crying when using their spacer, most of the medication ends up in their stomach. So, it is better that the child is co-operative and relaxed when using their spacer to ensure the optimum amount of medication reaches the airways.

Advantages and disadvantages of a spacer/valved holding chamber (VHC) (Vincken et al 2018} Advantages • Slows down the aerosol cloud as it emerges from the pMDI. • Reduces impact of hand–breath (activation–inhalation) coordination problems.

• Longer propellant evaporation time reduces particle size (increases respirable fine-particle fraction) and improves lung deposition.

• Filters out larger aerosol particles. Reduces oropharyngeal impaction/deposition and local side-effects (inhaled corticosteroids).

• Reduces fraction of swallowed drug, gastrointestinal absorption, systemic bioavailability and thus extrapulmonary unwanted effects (β-adrenergic agonists).

• VHCs can be used with tidal breathing, administered by a care giver.

• For the very young (using a face mask) and any patient where coordination is a challenge.

• During acute exacerbations (replacing nebulisers).

• • • •

Disadvantages Require regular cleaning.

Large-volume spacer/VHC devices are bulkier and less portable.

Electrostatic charge may reduce the respirable aerosol fraction.

More expensive (but may save medication).

Conclusion This article has addressed the importance of using spacers with pMDI devices to optimise the deposition of medication to the lower airways thereby gaining control of respiratory symptoms and reducing the risks of side-effects from medications.

References Cohen HA, Cohen Z, Pomeranz AS, et al, 2005, Bacterial contamination of spacer devices used by asthmatic children. J Asthma, 42: 169–172.

Franklin W, Lowell FC, Michelson AL, et al, 1958, Aerosolised steroids in bronchial asthma. J Allergy, 29: 214–221.

Newman S P, Pavia D, Garland N, et al, 1982, Effects of various inhalation modes on the deposition of radioactive pressurised aerosols. Eur J Respir Dis 63: Suppl. 119, 57–65.

Newman S P, Woodman G, Clarke SW, et al, 1986, Effect of InspirEase on the deposition of metered-dose aerosols in the human respiratory tract. Chest; 89: 551–556.

Stein SW, Thiel C G, 2016, The history of therapeutic aerosols: a chronological review. J Aerosol Med Pulm Drug Deliv; 30: 20–41.

Vincken, W, Levy, M L, Scullion, J, Usmani, O S, Dekhuijzen, P N R and Corrigan, C J, 2018, Spacer devices for inhaled therapy: why use them, and how? ERJ Open Research, 4(2).

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vitamin D and calcium

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Vitamin D and calcium â&#x20AC;&#x201C; Key nutrients for modern times Aislinn De Souza, Nutrition Coach, explores the role vitamin D and calcium play in optimising health and wellbeing

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itamin D and calcium work interdependently in promoting health. However, indoor lifestyles and the rise of dairy free food trends means that we are increasingly at risk of running low on these essential nutrients.

It is well established that vitamin D and calcium are nutrients that we ingest to regulate phosphorus metabolism, in order to ensure our bones, muscles and teeth are healthy. What is not common knowledge is that vitamin D is, in actuality, a prohormone produced in our bodies, for example, when UVB rays from the sun strike uncovered skin. The hormone version of vitamin D is so critical to our overall health, that almost every cell on our body has a thirsty receptor for its nourishing effects. Aside from its bone building activities, vitamin D exerts anti-inflammatory effects by bolstering neuromuscular activity and immune function. Indeed, research is rising steadily around the associative role vitamin D plays in protecting against hypertension, cardiovascular disease, type 2

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diabetes, depression, Parkinsonâ&#x20AC;&#x2122;s disease, cognitive impairment, depression and autoimmune diseases, such as multiple sclerosis, type 1 diabetes, rheumatoid arthritis and hashimoto thyroiditis.

Vitamin D and calcium â&#x20AC;&#x201C; A deficiency of the modern era Ironically, as we become more attuned to the multipronged benefits of vitamin D, our levels are plummeting at a population level due to indoor lifestyles, increased use of sunscreen protection, processed diets and the rising levels of obesity. Indeed, rickets, a deficiency of vitamin D and calcium (thought to be eradicated in Ireland) alarmingly re-emerged in recent decades in Ireland, where as many as 23 cases were reported. These identified cases preempted investigative action, resulting in the Food Safety Authority of Ireland (FSAI) recommending a national policy on vitamin D supplementation for infants in Ireland in 2007. Rickets is a paediatric bone disorder which can cause severe bone deformities, such as

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bowed legs. Adults who do not get enough vitamin D and calcium can develop osteomalacia, a condition which makes bones softer with consequent bone pain and muscle weakness. The prevalence of osteomalacia in Europeans is cited to be as high as 25 per cent.

Osteoporosis, a condition which makes bones brittle and fracture easily, affects approximately over 300,000 people in Ireland, with the risk of incidence increasing in postmenopausal men and women.

Who is at risk of low levels of vitamin D? • Adults with BMI >30kg/m2 (adiposity sequesters vitamin D); • South Asian and African populations; • Chron's disease, liver disease, cystic fibrosis (which present with fat malabsorption); • Home bound populations with limited sun exposure and unbalanced diets.

How to assess vitamin D levels?

Vitamin D status can be investigated through the 25-hydroxy vitamin D blood test. Given the potential role vitamin D plays in protecting against chronic disease, focus at a research level has shifted to ascertaining sufficiency (ie, vitamin D levels that are required for optimal overall health) as opposed to assessing deficiency.

Optimal serum 25-hydroxy vitamin D for sufficiency has not been standardised globally, with definitions of sufficiency of serum 25-hydroxy vitamin D ranging from >50 to 100nmol/litre.

Vitamin D deficiency is widespread across Europe with on average 13 per cent of Europeans having vitamin D serum levels <30nmol/l.

With respect to vitamin D insufficiency, it is purported that this affects almost 50 per cent of the population worldwide, a staggering figure considering the potential role vitamin D plays in the amelioration of the incidence of chronic disease.

How much vitamin D is required?

Pregnancy and breastfeeding The FSAI recommends that a pregnant or breastfeeding woman should be encouraged to take vitamin D rich foods and if considering a vitamin supplement, a low dose supplement of five micrograms vitamin D should be taken.

vitamin D and calcium

not more than 10 micrograms of vitamin D are consumed, due to the risks of toxicity.

What are the food sources of vitamin D? Natural food sources of vitamin D A food first strategy should always be encouraged in order to meet total energy and nutrient requirements, due to the matrix of nutrients in food that work synergistically to promote health, as opposed to a vitamin supplement working in isolation, which can have potential serious side effects of toxicity in high doses. However, only a small amount of foods naturally contain an appreciable level of vitamin D, as illustrated in Table 1.

Clearly, oily fish (fresh, frozen or tinned) is a rich source of vitamin D, with, for example, wild salmon having more vitamin D than farmed salmon. Oily fish clocks in as the most bio available source of EPA and DHA omega 3 essential fatty acids and is a good source of selenium.

Indeed, the current public health message is to consume oily fish at least two to three times per week for its cardio protective health benefits. Oily fish is indeed a super food required for super health.

Fortified food sources of vitamin D The global research interest from food industry into the potential role of vitamin D in optimising health has witnessed a concomitant rise in foods being fortified with vitamin D. Some examples are illustrated in Table 2.

Vitamin D supplementation Many multivitamins and fish oils contain vitamin D and it is wise to be aware of the amount being consumed. The FSAI are aware that there are currently many high dose vitamin D supplements on the market and have recently published recommendations that taking more than five times the recommended amount of vitamin D is unsafe for children and taking more than 10 times the recommended amount of vitamin D is unsafe for adults. As the adage goes, always check the label.

What about calcium?

Over 90 per cent of peak bone mass is laid down by the age of 19 years with the remaining bone mass built up right into the age of mid- to late-30s, declining after the age of 50 years. Calcium is a necessary bone building companion for vitamin D, their effects augmented by regular weight bearing physical activity.

From age 0 to 12 months Since 2011, Ireland’s national infant feeding policy recommends that all infants under the age of 12 months receive a vitamin D3 only supplement of five micrograms (200IU) per day, whether they are breastfed or formula-fed, taking solids (or a combination of these). If Natural food sources of calcium the infant was born premature or is receiving on-going medical care, It is a truism that dairy foods are the most bio available form they may need extra vitamins or a higher dose of vitamin D. Fortified Food Amount Vitamin D From age five years upwards Trout 100g The most recent 2019 Mackerel 100g recommendations from the FSAI is that everybody, aged five years Salmon 100g upwards, should consume 10 micrograms of vitamin D every Sardines 100g day from food (and if needed, Eggs 2 supplements). It is important to check other multivitamins and Table 1: Vitamin D content of natural food sources fish oil supplements to ensure

10 micrograms 8.6 micrograms 8 micrograms 5 micrograms 4 micrograms

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vitamin D and calcium

Fortified Food

Amount

Vitamin D

Milk fortified with Vitamin D

500mls

20 micrograms

Yoghurt fortified with Vitamin D

125ml

1.5 to 5 micrograms

Cheese string fortified with Vitamin D

1 portion

1.3 micrograms

Cereals fortified with Vitamin D

30g portion

1 to 3 micrograms

Table 2: Vitamin D content of fortified foods Food

Amount

Calcium (mg)

Milk

200ml

240mg

Yoghurt

125g

260mg

Cheese

30g

220mg

Yoghurt drink

200mls

270mg

Fromage Frais

70g

60g

Table 3: Calcium content of common dairy food sources (general estimation)

Life Stage

Amount of dairy servings per day

Pregnancy and Breastfeeding

3

Age 9 to 18 years (Male & Female)

5

Age 19 to 50 years (Male & Female)

3

Age 51 + years (Male & Female)

3

Table 4: Servings of dairy foods recommended to meet calcium needs

Food

Amount

Calcium

Sardines (with bones)

60g (1/2 tin)

258mg

Pilchards (with bones)

60g

150mg

Tinned salmon (with bones)

30g

50mg

Orange

1 medium

75mg

Broccoli

2 spears (85g)

34g

Table 5: Calcium content of non dairy food sources

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of calcium. Dairy foods have an unparalleled matrix of nutrients that work synergistically to promote overall health, as opposed to a supplement solely containing calcium.

Adults require, on average, 800mg calcium per day, with older children and teenagers requiring up to 1,000mg calcium per day in order to promote peak bone mass. People with coeliac disease require at least 1,000mg calcium per day and those with inflammatory bowel disease and osteoporosis may higher doses of calcium, as defined by the treating medical and dietetic team.

What about dairy free and cow’s milk protein free alternatives?

Current consumer food trends towards cow’s milk free drinks and dairy free foods are reflected in supermarket aisles being lined with a variety of cow’s milk free drinks and other food products. Cow’s milk allergy in adulthood and primary lactose intolerance should be verified medically before embarking on a cow’s milk free diet. Children under 4.5 years of age should not consume rice milk as a replacement for cow’s milk and dietetic supervision is required for children consuming cow’s milk free diets arising from medially confirmed cow’s milk allergy.

Iodine is a necessary mineral to produce thyroid hormones, the requirement for iodine increasing in pregnancy. A recent study of over 900 teenage girls

by Safefood found that Irish teenage girls aged 14-15 years of age have iodine levels at the lower end of the required range identified by the World Health Organisation. Those who reported consuming soya based drinks had the lowest urinary iodine concentration.

Cow’s milk and dairy products have the highest rates of iodine and are the main sources of iodine for most people. It is important to note that most cow’s milk free drink alternatives are not fortified with iodine.

Cow’s milk is not only rich in calcium and vitamin B12 but it is an inexpensive form of high biological value protein with the added bonus that many natural versions may contain live bacteria, called probiotics, which increase the level of beneficial bacteria in the gut, required for optimising immunity.

On balance, vitamin D and calcium are key drivers in promoting health. We should look to food sources (natural and/or fortified) as much as possible to meet requirements, and use a vitamin and mineral supplement with prudence, as required.

References on request

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product news

Rhinex Relief launched by Rowex Ltd Rowex Ltd has announced the launch of Rhinex Relief 50 micrograms/actuation nasal spray, suspension.

Each actuation of the pump delivers a metered dose of 50 micrograms of mometasone furoate (as mometasone furoate monohydrate). The total weight of one actuation is 100mg.

Rhinex Relief is indicated for use in adults to treat the symptoms of seasonal allergic rhinitis, after a seasonal allergic rhinitis has been diagnosed by a physician.

Allergic rhinitis is a common IgE (Immunoglobulin E) mediated disease associated with both nasal and ocular symptoms. Common presenting nasal symptoms include congestion, itching, rhinorrhoea and sneezing. Nasal symptoms are frequently accompanied by ocular ones, such as itchy eyes, watery eyes and redness.

NUI Galway Bacterial Infection Project Awarded SFI Funding NUI Galway has been awarded almost €420,000 in funding for developing new technology for faster clinical detection and

Pictured L-R: Prof Mark Ferguson, Director General of Science Foundation Ireland and Chief Scientific Adviser to the Government of Ireland; and Dr Joseph Byrne, School of Chemistry, NUI Galway

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diagnosis of bacterial infections.

Dr Joseph Byrne from NUI Galway received his award as part of a Government investment of €10.8 million in Irish research funding through Science Foundation Ireland’s (SFI) Starting Investigator Research Grant (SIRG).

With awards ranging from €376,000 to €425,000 over four years, the projects funded will support 20 researchers and a further 20 PhD students in the research areas of health, energy, environment, materials and technology.

Dr Byrne’s research will develop novel devices that will indicate the presence of specific bacteria through colour changes, caused by the interactions of their proteins with laboratory-produced sugar-based chemical compounds on the surface of newly-designed materials.

This will provide a convenient visual strategy to identify diseasecausing bacteria. 3D-printing will be used to create these compact diagnostic devices, which will benefit patient outcomes and qualityof-life. This new technology could also be deployed in other scenarios such as detecting bacterial contamination of water supplies.

New Phase 3 data demonstrates superiority of Tremfya vs Cosentyx New results from the ECLIPSE study recently announced by the Janssen Pharmaceutical Companies of Johnson and Johnson show that Tremfya (guselkumab) is superior to Cosentyx (secukinumab) in treating adults with moderate to severe plaque psoriasis for the primary endpoint assessed at week 48.

Almost 85 per cent of patients receiving Tremfya (guselkumab) achieved the primary endpoint of a PASI 90 response at week 48 compared with 70 per cent of patients receiving Cosentyx (secukinumab).

ECLIPSE is the first Phase 3 head-to-head study to compare efficacy between first-in-class IL-23 inhibitor, guselkumab, and the IL-17 inhibitor, secukinumab.

The data was presented at the 3rd Inflammatory Skin Disease Summit (ISDS) in Vienna recently.

ECLIPSE is Janssen’s fourth Phase 3 study for guselkumab in plaque psoriasis and is part of a comprehensive clinical development programme that also includes ongoing Phase 3 studies in psoriatic arthritis and Crohn’s disease.

“The response-over-time curves show that maximum response rates with guselkumab are achieved after six months and are maintained over time through one year, achieving superiority at the primary endpoint of the study,” lead study investigator Prof Richard Langley, Division of Clinical Dermatology and Cutaneous Science, Department of Medicine, Dalhousie University, Canada, said.

“Results of the study confirm a slightly more rapid onset of response with secukinumab, but importantly in a chronic disease like psoriasis, these data provide new insights into comparative longer-term efficacy.”

Laurent de Saint Sernin, General Manager Commercial Operations, Janssen Sciences Ireland UC said: “The results of this study provide invaluable insight into the efficacy of guselkumab.

This treatment offers patients high levels of skin clearance and our three-year data shows a consistent maintenance of efficacy.”

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Dr Vincent Carroll appointed

Chairman of ARC cancer support centres

product news

on his appointment as Chairman of the Board at what is a very dynamic time for ARC as we celebrate 25 years. Last year, more than 2,300 people came through the doors of ARC’s centres, a number that has increased by 27 per cent since 2014. In response to ever-increasing demand, this year we plan to enhance the range of supports and programmes provided to meet the growing needs of people who wish to access ARC’s services. We are delighted to have Dr Carroll at the helm to guide us through ARC’s next exciting chapter.”

Roscommon University Hospital’s first Endoscopy Registered Advanced Nurse Practitioner ARC Cancer Support Centres have announced the appointment of Dr Vincent Carroll as Board Chairman. From its drop-in centres at Eccles Street on Dublin’s Northside, and South Circular Road on Dublin’s Southside, ARC provides psychological, emotional, educational and practical support, complementary therapies and counselling services, free of charge to people with cancer and their loved ones.

A serving member of the ARC Board, Dr Carroll is a graduate of medicine from University College Dublin, from which he also holds a Master’s in Public Health Medicine. Dr Carroll has always had a keen interest in complementary medicine too, studying acupuncture and traditional Chinese plant-based medicines, leading to his current role as College Director of the Lansdowne College of Acupuncture and Complementary Medicine. He is also a Fellow of the Royal Society of Tropical Medicine.

Commenting on his appointment, Dr Carroll said: “The genesis of ARC was in the realisation at the time that even when a doctor’s work in treating a person with cancer is done, there is still a real need to provide ongoing psychosocial support to that person into the future.”

“ARC has also always adopted a community-based approach, recognising that cancer impacts more than just the individual; it impacts their families, friends and wider community too. It supports its clients in providing them with the tools to navigate their present and their future, whether these be through counselling, support groups, psychoeducational programmes and complementary therapies, as well through peer support and friendship.

“This year, ARC celebrates 25 years and I look forward to working with my Board colleagues, staff, volunteers, and, most importantly, our clients, in ensuring that the ARC of tomorrow continues to respond nimbly to the needs of its clients in ways which make a profound and meaningful difference to people’s lives.”

Ms Deirdre Grant, Chief Executive, ARC Cancer Support Centres, added: “I am delighted to congratulate Dr Carroll

The endoscopy service at Roscommon University Hospital has been developing year on year with a corresponding increase in activity with almost 3900 procedures conducted in 2018.

One of the latest developments has been the appointment of Amy Forde as a Registered Advanced Nurse Practitioner (RANP) in Gastroenterology at the Ms Amy Forde hospital, joining the growing group of nurse endoscopists nationally. Since her registration in September 2017, Amy has completed over 1000 procedures, including gastroscopies, colonoscopies, sigmoidoscopies and proctoscopies at Roscommon University Hospital and she has attained the quality indicators to become a registered endoscopist with BowelScreen – the National Bowel Screen Programme.

Amy completed her general nursing training in Galway University Hospitals in 2007 and has since gained experience working with patients with colorectal conditions in both Oxford in the UK and in St Vincent’s Private Hospital, Dublin.

In 2012, Amy completed a Graduate Diploma in Cancer Nursing (Colorectal) in UCD to advance her knowledge and skills in caring for this cohort of patients. She started working at Roscommon University Hospital in 2014 when it became one of the 14 Bowel Screening colonoscopy units in Ireland.

Since the commencement of BowelScreen in Roscommon, Amy has co-ordinated the care of all patients referred for colonoscopy to the hospital from the programme.

In 2014, Amy commenced her training in endoscopy, and under the mentorship and guidance of surgeons Mr Liam McMullin, Mr Mohammed Eldin and Mr Tapas Chatterjee, undertook her Clinical Practicums in endoscopy in Roscommon University Hospital. In 2017 Amy completed a Master of Science Nursing Advanced Practice (Gastroenterology).

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product news

Half of all COPD sufferers remain undiagnosed Some 250,000 of the 500,000 people with chronic obstructive pulmonary disease (COPD) in Ireland remain undiagnosed, according to the Asthma Society of Ireland.

COPD Support Ireland is calling on people in Ireland living with undiagnosed COPD to see a doctor and get an official diagnosis.

The free COPD and asthma adviceline can play a key role in helping a person who has recently had a COPD or asthma diagnosis.

The phone number is 1800 832 146 and callers can to speak to a respiratory nurse about a number of topics on managing and improving their condition.

Callers can book a free call back appointment by calling the free phone number between 09:00 and 17:00 Monday to Friday. The asthma society facilitates a call back from the nurse at a time that suits the patient.

Professor JJ Gilmartin, Chairperson of COPD Support Ireland, said: “If you find yourself experiencing COPD symptoms like shortness of breath, persistent coughing, coughing up mucus/phlegm and wheezing, you should see a doctor who can help you investigate if you may have COPD especially if you are over 40 years old. Being diagnosed with COPD will allow you to get in control of your condition and avail of all our COPD services which includes the COPD and asthma adviceline.”

Sarah O’Connor, CEO of the Asthma Society of Ireland, said: “It is so important that people with COPD and asthma properly control their conditions and the joint COPD and asthma adviceline is the perfect way for them to do so.”

Mundipharma biosimilar Pelmeg (pegfilgrastim) now available in Ireland Pelmeg, a pegfilgrastim biosimilar, indicated for the reduction of the duration of neutropaenia and incidence of febrile neutropaenia in adults treated with chemotherapy, is now available in Ireland.

Developed by Cinfa Biotech, part of the Mundipharma network of independent associated companies, Pelmeg is the fourth biosimilar in Mundipharma’s portfolio.

The Mundipharma network of independent associated companies recently announced the launch of Pelmeg (pegfilgrastim), a biosimilar of Neulasta in Ireland following authorisation by the Health Products Regulatory Authority (HPRA). The launch follows European Commission (EC) approval in November 2018.

Pelmeg is indicated for the reduction of the duration of

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nursingingeneralpractice

neutropaenia and the incidence of febrile neutropaenia in adult patients treated with cytotoxic chemotherapy for malignancy (with the exception of chronic myeloid leukaemia and myelodysplastic syndromes).

“We are delighted that Pelmeg is now available in Ireland.

The launch of the treatment builds on our proven commercial excellence in biosimilars over the past three years.

"Pelmeg has the potential to play an important role in improving the lives of patients affected by chemotherapyinduced neutropaenia and febrile neutropaenia,” Mr Donagh O’Leary, Commercial Lead at Mundipharma Pharmaceuticals Limited, said.

The acquisition of Cinfa Biotech provides Mundipharma with global reach and expanded development capabilities.

Mundipharma will continue to leverage partnerships to develop its expanding portfolio of biosimilars, reinforcing its biosimilars leadership in Europe and extending its geographical footprint.

Cystic Fibrosis Ireland gets set to host national conference for CF community Registration is now open for Cystic Fibrosis Ireland’s (CFI) annual conference, which will take place in the Mount Wolseley Hotel, Carlow, on Saturday 30 March.

Titled “2009-2019: A Decade of Progress, but many Challenges Ahead”, the event will be of particular interest to family members, friends and the wider CF community.

Registration is now open online at www.cfireland.ie.

The conference takes place ahead of CFI’s annual fundraising flag day, 65 Roses Day, on Friday 12 April, when people are urged to buy a purple rose for €2 or donate online at www.65RosesDay.ie.

The conference will provide a chance to reflect on a decade of progress, as well as serving as an opportunity to look to the future and the challenges that lie ahead for people with CF in Ireland.

Among the speakers are Prof Barry Plant, Cork University Hospital, who will address new CF drug therapies in the pipeline. Dr Michelle Murray, Mater Hospital, will update delegates on transplants and organ donor consent developments.

Other topics will include an update on CF treatment centres, difficulties posed by hospital superbugs for CF patients, and challenges faced by parents of children newly diagnosed with CF and supports available.

A number of people will also share their experience of living with CF and how significant strides over the past decade have changed their lives, including well known CF campaigner Ms Jillian McNulty. More than 1,300 people have CF in Ireland, which has the highest incidence per capita in the world, and some of the most severe types of CF.

crossword

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Across 1 - Early version of a document (5) 1 Early version of a document (5) 4 - Next after after sixth (7) 4 Next sixth (7) 7 Twenty (5) 7 - Twenty (5) 8 Very large animal (8) 8 - Very large animal (8) 9 Apart from (5) 9 - Apart from (5) (8) 11 Abruptly 15 Free from error (8) 11 - Abruptly (8) 17 Produce as a fruit (5) 15 -19 Free frominfluential error (8) or important (8) Most 20 Only just to be seen (5) 17 - Produce as aable fruit (5) 21 Use again (7) 19 - Most influential or important (8) 22 Increase in size (5)

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Down 1 - Variety (9) 1 Variety (9) 2 - Before or by (7) now (7) 2 Before or by now 3 Become tense (7) 3 - Become tense (7) 4 Gesture (6) 4 - Gesture (6) 5 Forgive for a fault (6) 5 - Forgive for a fault (6) 6 Weary (5) 10 Indispensable (9) 6 - Weary (5) 12 Inquisitive (7) 10 - Indispensable 13 Emotional stability (7)(9) 14 Lots of (6) 12 - Inquisitive (7) 16 Selection (6) 13 - Emotional stability (7) 18 Picture (5)

20 - Only just able to be seen (5)

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16 - Selection (6)

22Congratulations - Increase in size (5) to the winner of the last crossword: 18 - Picture (5)

Caithriona Monnelly, Maynooth, Co Kildare.

Please post or email your answers to: Editor, Nursing in General Practice, GreenCross Publishing Ltd, Top Floor, 111 Rathmines Road Lr, Dublin 6.

Email: cahill.niamh@gmail.com Closing date for entries: 25 March 2019.

Winner will receive €50.

Please note: The winners’ cheque will be sent out within 60 days.

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