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An evidence-based approach to helping prevent chronic disease

ASTHMA AND ALLERGIC RHINITIS How these two conditions are connected and latest treatment approaches


Presentation of pain in the older person with dementia


Cystitis, menopause, cervical screening, and heart disease


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Infantile colic commonly persists up to six months of age. True or false? Successful completion of this module will earn you 2 CPD credits visit www.medilearning.ie/nursecpd.ie Free CPD – accessible on android, iPhone and tablet



UPS AND DOWNS IN VACCINE ROLL-OUT Dear Readers, As we progress through the roll-out of Covid-19 vaccines, Ireland has done well in terms of its implementation. At the beginning of April, Israel had far outpaced the rest of the world when it comes to vaccinations, with 56 per cent of people having had the first dose of vaccine and 51 per cent having had two doses. No country in the EU is near that advanced level of roll-out. Ireland's vaccine roll-out is slightly above the European average with similar uptakes to Austria, Denmark, and France. General practice can be proud of their contribution to the vaccination programme roll-out, with GPNs and GPs having administered up to 60 per cent of vaccines despite challenges with availability and supply. Unfortunately, the downside to the success of general practice in the vaccination programme is the management of chronic disease and other essential services, which have had to be halted or delayed. In addition to this, staff burnout and fatigue are developing and as a result a number of practices have withdrawn from the vaccination of priority groups 4 and 7. The introduction of priority groups for vaccination has proved challenging to say the least. Introducing a mass vaccination programme in such a short space of time for 4.9 million people was undoubtedly going to raise debate and discussion with everyone having a ‘feeling of entitlement’ to receive the vaccine ASAP. Two of the most controversial groups – groups 4 and 7 – have raised a lot of discourse among patients and healthcare professionals. For example, people living with asthma and COPD have been identified by the HSE as very high-risk for severe Covid-19, but aren’t considered very high-risk when it comes to the vaccination programme unless they have severe asthma and are on biological therapy or have had multiple courses of oral steroids in the last 12

A message from Ruth Morrow, Consulting Editor

months. This has been so confusing for patients with many feeling that they should be in these groups as they are on long-term inhaled corticosteroids. No doubt these frustrations are being felt by general practice staff on a daily basis. Patients have frequently said to me that “they feel penalised for managing their asthma and looking after themselves” as they haven’t had oral steroids or acute asthma attacks in the last year. Given that most of these patients with severe asthma have been cocooning and are adhering to their medication regimes coupled with low circulation of influenza and other rhinoviruses, they haven’t been experiencing exacerbations and have not needed oral steroids, but are still on high doses of inhaled medications. Recent studies have shown that adherence to inhaled medication has improved since the beginning of the pandemic. Similarly, patients with diabetes who are well-controlled and have relatively normal HBA1Cs also feel they are being punished for looking after themselves. Given that there are so many high-risk groups, such as patients on renal dialysis and chemotherapy, patients with neurological conditions etc, deciding on these high-risk groups for prioritisation of vaccines has been difficult and the line has to be drawn

somewhere so as to offer vaccination to those at very high-risk of severe Covid-19. This inevitably has generated anxiety and distress for patients, which general practice staff have had to deal with on a daily basis. As the vaccination programme progresses through the age cohorts, pressure on general practice will, hopefully, ease somewhat and summer might have some sense of normality. New challenges have presented themselves in managing chronic disease. The emergence of long Covid, also known as post-acute sequelae of SARS-CoV-2 infection, post-acute sequelae of Covid-19 (PASC), chronic Covid syndrome (CCS) and long-haul Covid, will be a further challenge for GPNs. GPNs have demonstrated their skill and expertise in managing chronic conditions and can potentially support people through long Covid as they make significant adjustments to their lives as a result of this devastating virus. Once again, GPNs will rise to the challenge. However, I urge you all to have time off over the summer, have family time and ‘me’ time whether it’s at home or on a staycation. Hopefully, the weather will be kind to us and we will get out and about and enjoy our beautiful country.

MAY-JUNE 2021 1

Contents EDITOR Priscilla Lynch CONSULTING EDITOR Ruth Morrow SUB-EDITOR Emer Keogh emer@greenx.ie ADVERTISEMENTS Graham Cooke graham@greenx.ie





Dr Niall Davis and Dr Eoin MacCraith describe the presentation of cystitis, the latest management approaches, and when to refer to secondary care

ADMINISTRATION Daiva Maciunaite daiva@greenx.ie

Please email editorial enquiries to Priscilla Lynch priscilla@mindo.ie Nursing in General Practice is produced by GreenCross Publishing Ltd (est. 2007). © Copyright GreenCross Publishing Ltd. 2020

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

The contents of Nursing in General Practice are protected by copyright. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form by any means – electronic, mechanical or photocopy recording or otherwise – whole or in part, in any form whatsoever for advertising or promotional purposes without the prior written permission of the editor or publishers. DISCLAIMER The views expressed in Nursing in General Practice are not necessarily those of the publishers, editor or editorial advisory board. While the publishers, editor and editorial advisory board have taken every care with regard to accuracy of editorial and advertisement contributions, they cannot be held responsible for any errors or omissions contained.

2 MAY-JUNE 2020

NEC, regional branch, and Irish healthcare news




Key personnel from CervicalCheck outline the latest developments in the National Cervical Cancer Screening Programme, and the key role of smear takers



Theresa Lowry-Lehnen outlines potential symptoms and treatment options for menopause



Alexandra C Kelly, Clinical Nurse Specialist in Pain Management, gives expert advice on pain presentation and assessment in the older person with dementia


Ruth Morrow discusses the relationship between asthma and allergic rhinitis, and the latest evidence-based management approaches


05 HEART DISEASE IN WOMEN: P1 Priscilla Lynch speaks to cardiologist Dr Róisín Colleran about cardiovascular disease in women




The latest European Society of Cardiology data shows women with heart attack symptoms are often diagnosed and treated later than men


Theresa Lowry-Lehnen explains the rationale behind the HSE’s ‘Making every contact count’ approach to helping prevent chronic disease and empowering patients to lead healthy lifestyles, and the available training supports

44 46 47


Dr Alan Moran on all you need you know about buying an e-bike



An appreciation of olive oil by Tom Doorley



A round-up of the latest pharmaceutical-related news


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Please email your branch news to Priscilla Lynch priscilla@mindo.ie



Our branch started virtual educational meetings in May 2020, which was sponsored by Jane McGrath from Amgen. Nurse Col Conway introduced us with an IPNA osteoporosis update. Then we had a summer break. In September Dr Diarmuid Quinlan covered Chronic Disease Management. The sponsor was Flor O’Leary from Boehringer Ingelheim. Adrienna McKenna from AstraZeneca sponsored our October meeting. It was a very worthwhile and educational update on spirometry training by Ruth Morrow, respiratory nurse specialist. In November Dr Tony Folley, GP in Kinsale Medical Centre and lecturer in the Department in General Practice, UCC, covered a particularly important topic – 'Dementia care dilemmas in general practice'. The Zoom meeting was sponsored by Ann Marie Glyyn from GSK. The December meeting focused on our wellbeing. Dr Teesha Fitzgerald taught us about ‘Resilience in uncertain times’. Our sponsor was Margaret Byrne from Danone Nutricia. This year's first meeting and AGM meeting was in February, sponsored by Catherine O’Donnell, Thermo Fisher. Dietitian in paediatric allergy, CUH, Deborah Griffin talked about food allergy and gave a Coeliac disease update. After that followed the election of the officers. Angela Cashman stepped down as Chairperson and Jenny Nagle was elected. In March we had a meeting sponsored by Fiona Browne – Cow & Gate. She gave us a brief talk on the different milk products available from Cow & Gate. She discussed the nutrition solutions for common feeding issues, such as reflux and colic in infants. Our guest speaker Marie Courtney gave us a brief talk on what’s happening with the chronic disease management (CDM) programme. UCC are offering modules on cardiovascular and respiratory disease management and there is postgraduate funding available for anyone who is interested in applying for these courses. She also discussed the HSE Service Plan for 2021 for general practice. It involves a pilot programme of integrated diabetes care in north Cork called

4 MAY-JUNE 2021


network 9. It involves a multidisciplinary team approach to diabetes care including a diabetes nurse specialist, a podiatrist, and a community dietician. It aims to offer diagnostics, spirometry, and blood tests to patients without them having to go to hospital. There are plans to roll-out over 60 of these centres nationally eventually. It’s only available to patients with a medical card. The HSE is also running online a living well programme aimed at patients to help achieve best outcomes by looking after their physical, mental, and emotional health. In April our Zoom meeting was sponsored by Cathy O’Sullivan and Adrienne McKenna from AstraZeneca. Adrienne gave us a brief talk on Symbicort – now for use as rescue as well as maintenance therapy. Cathy spoke briefly on Forxiga for use in diabetics, but also now licensed for use in the treatment of heart failure, both for diabetic and non-diabetic patients. Dr James Dollard gave us a very interesting and informative talk on heart failure – on recognising the symptoms and the treatment for heart failure. The May meeting is scheduled for the second Wednesday by Anthea Rafter from Amgen. We will have speakers from Mná Feasa about domestic violence, what to look out for, and what can you do to help.

It's been a busy few months with Covid-19 vaccine clinics, webinars, online courses, etc. The monthly IGPNEA webinars are proving a great hit plus we continue to hold our local branch meetings over Zoom as well. Our March meeting was sponsored by BoehringerIngleheim and Norma Caples gave a presentation ‘Thinking beyond HbA1c, managing CVD risk’. This was followed by a talk from Kevin Morris, MPSI, on the topic ‘Environmental impact of inhalers’. A very thoughtprovoking presentation. Our April meeting was by Yvonne Breen, Besins Healthcare, on the topic of 'HRT transdermal gel –The where, when, how, who, when not, where not’. Very practical and informative. Our May meeting is scheduled for Wednesday 19 via Zoom. It is sponsored by Fiona Browne from Cow & Gate and will see Peri-natal Mental Health Midwife Mary Frisby from University Hospital Waterford give an overview of her service. Having personally seen the impact her interventions have made on some of my patients I expect this will be a hugely popular presentation. But we cannot survive on work alone... it is important to have a little self-care. So this month the Waterford Branch Members were asked to submit some of the hobbies/ interests/fun elements that help us keep our spirits up in these tiring and challenging times. Here are some of the things we get up to down here in the sunny southeast. (See photos on page 5). Stay safe everyone.


 Mary J had the first sighting of Mrs Covid - turns out she is a blond with green eyes, big ears, and in desperate need of a trip to the dentist #cavities

The Keogh Practice #working together

 Aisling stole the show with 'any excuse to get out of the vaccine clinics' #lockdownbaby  Mary L had a daughter graduate, following in mum's shoes #bigshoestofill

 Mary L after a long hard week of work still found time to walk and fundraise for the Irish Cancer Society #ontopoftheworld

Gillian sporting the latest in PPE fashion #toinfinityandbeyond  Mary McG was all geared up for the match #upthedeise

MAY-JUNE 2021 5



We now have over 900 members, our highest ever membership. A record 93 per cent of members renewed from last year, with over 200 new members in 2021.


Some 400 members are now using Siilo for secure messaging and news alerts and we are looking forward to the rest of our members joining us very soon so they can access specific daily broadcasts in relation to IGPNEA news, education, and events at a glance on their smartphones. Some useful quick ‘How to’ videos (how to use the CHAT and SPACES facilities on Siilo) and a manual can be found on our website, members can also email Barbara, membership@irishpracticenurses.ie, if they have any questions or need help with downloading it.


Our fourth Medcafe webinar took place on Tuesday, 11 May, titled ‘Post-acute sequelae of SARS-CoV-2 infection (PASC), long Covid care in general practice’. We were delighted to have Dr Noirin Herlihy and Dr Brian Osborne as our guest speakers. Thank you to Orla Loftus Moran for doing a super job as MC on the evening. We are pleased to have secured NMBI approval for this webinar. In June we will have two webinars, on Tuesday, 8 June, when Diane Bayliss of MPS will present on ‘The importance of good record keeping’ (the third in a series of four webinars). On Tuesday, 29 June, Patricia McQuillan (PDC) will present on 'Transactional analysis – Not my monkey – How well do we know ourselves'? In July we will be hosting another two webinars on 'Heart failure' and 'Polypharmacy'. We are collaborating with Medcafe to develop the technical requirements for issuing certificates for the webinars. We also will be issuing certificates for members who attended previous live webinars over the next couple of months.

conference on Friday 13 and Saturday 14, May 2022 in the Talbot Hotel in Waterford. Put the dates in your diaries; we are looking forward to an interesting programme and of course the chance to meet up at the conference.


Don’t forget to follow us on Twitter, @PracticeNurses. We now have over 1,600 followers.


Thank you to all the branch representatives who took the time to attend our virtual NEC meeting on 6 May, there was great attendance and discussion, no mean feat given how busy everyone is at the moment with the challenges of Covid and vaccine clinics.


We are delighted after months of hard work that we are able to use our new name (IGPNEA), which was voted on at our virtual AGM last November.



The Hub is the quick find resource centre on the IGPNEA website for our educational materials. There are currently 10 active areas in the Hub and resources continue to grow as more content is added regularly. The live sections are women’s health, immunisation, respiratory, gastro-intestinal, genito-urinary, dermatology, ENT, neurology, endocrinology, and health promotion. Each hub has a variety of learning resources, eLearning courses, links to webinars, and IGPNEA-produced educational material, including video presentations and articles. As each hub becomes active, notifications are sent out to members on Siilo and/or in the member’s newsletters.

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We are very appreciative that some great people represent us on both internal and external groups. As we have new members joining all the time we would like to set up a panel of members that may be willing to volunteer and represent IGPNEA. Please drop us an email or Siilo message if you are interested in being part of this panel. We can then email any requests to the panel and see who would like to take part. We are currently looking for volunteers for representation on the CervicalCheck clinical advisory group, an obesity special interest group, IGPNEA IR/HE task group, member’s digital handbook group, and a volunteer liaison person to support all our volunteer members.


The AGM this year will be held on Saturday, 16 October 2021, and it will be a virtual format similar to last year. We are delighted that the Waterford Branch will be hosting our next


We recently recorded a podcast with the Council.ie journal to promote the IGPNEA. Our PRO Theresa Lowry-Lehnen spoke to Editor Jack Mullen about the IGPNEA, new developments taking place within the association, Covid-19 challenges, the important role GPNs have played during the pandemic, and the future educational needs of GPNs. The podcast has received very positive feedback from our members and from other organisations and associations, such as the gardaí, emergency services, and the IMF (Irish Medical Formulary).

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International Nurses Day is celebrated across the world on 12 May each year, to mark the contributions that nurses make to society. It commemorates the birth of Florence Nightingale who was born on May 12, 1820 and celebrates the important role of nurses in healthcare. Following on from previous years the overarching theme for International Nurses Day 2021 was ‘Nurses: A voice to lead – A vision for future healthcare’, to show how nursing will look into the future as well as how the profession will transform the next stage of healthcare. To mark International Nurses Day, we sent a press release to various media outlets to highlight our new name, promote IGPNEA, and the pivotal role that GPNs play in the provision of healthcare for our practice populations. National PRO Theresa Lowry-Lehnen represented the IGPNEA on Tipp MidWest radio speaking about the IGPNEA, the contribution of GPNs during the pandemic and the effects of Covid-19 on general practice nursing, and the future needs of GPNs in Ireland. Joining other nurses in the south-east on International Nurses Day, Theresa also spoke about nursing and general practice nursing as a career choice on KCLR 97FM with Eimear Ní Bhraonáin.  We were also contacted by RTÉ news on International Nurses Day and IGPNEA Vice-Chair Una Butler represented GPNs by speaking on the Six:One news about the important contribution that GPNs have made during the pandemic and our key role in the Covid-19 vaccination programme in general practice.

8 MAY-JUNE 2021



he Irish Practice Nurses Association’ (IPNA) NEC proposed the motion at the 2020 AGM that the association's name IPNA be reviewed and replaced with a title that reflects the term ‘general practice nurse’ (GPN) and the educational objectives of the organisation. The motion was voted on by members and unanimously passed by 98 per cent of respondents. The new name chosen by our members is the ‘Irish General Practice Nurses Educational Association’ (IGPNEA). Our organisation’s remit is education and professional development for its members. The rationale for the name change was based on some misunderstanding about the role of the IPNA and an increase in queries being made in relation to industrial relations matters. The term ‘practice nurses’ has also become outdated and the title ‘general practice nurse’/GPN is now more commonly used. The name ‘Irish General Practice Nurses Educational Association’ reflects who we are; nurses working in general practice in Ireland and our association’s main role of education and professional development for GPNs. It no longer allows for any confusion regarding our purpose. Our logo remains the same and only the wording has changed. Our logo is long established and well recognised, has a history, and is a symbol of which we are very proud. The IPNA logo was originally designed in 1990 by Kate MacCormack (daughter of Netta Williams – one of the IPNA’s founding members and retired PDC), when she was a first year student at the National College of Art and Design. The four people represent a family and


the hand behind them represents the GPN supporting the family. The hand also symbolises the ‘hands-on’ clinical nursing care provided by GPNs. While our name has changed, our objectives, aims and values remain the same. Our objective is the advancement of education for GPNs. Our aim is that every GPN in Ireland will have equal access to appropriate quality education and that the specialist role of the GPN will be recognised, acknowledged, and valued. The IGPNEA works in partnership with key stakeholders and organisations and promotes excellence by providing information for members on all matters relevant to general practice nursing. It supports GPNs in building their competence and skills and assists with developing their scope of practice, by engaging in continuous professional development. It values collaborative working with its membership branches, officers, and members to ensure a robust and independent organisation that delivers good value. The IGPNEA has grown steadily over the years. There are now over 900 members, 18 branches nationwide, and a National Executive Committee (NEC) who oversee the role and function of the association and its members. Our members benefit from a vibrant association, which provides ongoing education and professional development, conferences, webinars, access to issues of our Nursing in General Practice journal, website, and educational hub with free online learning courses and resources and ongoing support and practical assistance, including annual educational awards and bursaries. See https://irishpracticenurses.ie for more information and support.

You can contact us at admin@irishpracticenurses.ie Mary Osakwe 087 130 4115 and membership@irishpracticenurses.ie Barbara Shanahan 086 263 4917




Frontline nurses and midwives experiencing long-term Covid symptoms are not getting the medical or employment supports they need, the 2021 INMO Annual Delegate Conference was told. The union’s conference heard from four nurses speaking of ongoing severe symptoms from a Covid-19 infection months later, including:  Extreme exhaustion;  Brain fog;  Difficulty breathing;  Heart problems;  Vision impairment. The conference, held on 6-7 May, debated two motions relating to long Covid. The

union is calling for Government and employer measures, including tailored medical supports, research into long Covid impacts, a guarantee that healthcare workers with long Covid won’t face income cuts, and flexible rehabilitation back into work. More than 7,500 nurses and midwives have contracted Covid-19 in Ireland – over a quarter of all Covid-19 cases among healthcare workers. INMO President and nurse, Karen McGowan said: “Long Covid is a condition that takes so much out of people and they’re simply not being treated fairly. “We are all looking forward to a time after this pandemic – but we cannot forget those

who took great risks to provide care and are being left in the lurch. “The very least they deserve is long-term certainty about their employment and income rights and a guarantee of medical care.” INMO General Secretary Phil Ní Sheaghdha said: “Covid can be a long-term, debilitating illness. People need to know where they stand, medically and in terms of work. “The HSE need to lead the charge on this and implement the measures that our members are calling for. This is a condition people are acquiring at work and their workplaces need to step up and give them the support they need.”


An innovative practice in Abbeyfeale, Co Limerick requires an additional general practice nurse. Part-time position, approximately two-to-three days per week, sharing the week with our established practice nurse. Candidates must be a registered general nurse with An Bord Altranais. Previous experience in general practice is ideal, but not essential. Candidates will be welcomed into a very supportive environment. Induction and training will be offered to the successful candidate. Please forward CV and cover letter to cedarvillesurgery@gmail.com 


General practice nurse required for surgery in Sutton, Dublin 13. Five sessions a week. Experience with CervicalCheck desirable, but not essential. Please send CV to admin@suttonsurgery.ie


We are a unique general practice using a blend of conventional medicine and cutting-edge functional medicine to help our patients return to vibrant health. Mostly we see patients with a variety of conditions including CFS, IBS, fibromyalgia, severe hormonal imbalances, and life-wrecking autoimmune diseases. We also use innovative therapies including IV nutrition and ozone therapy. Our team is friendly, close knit, and enthusiastic. There is job satisfaction in buckets. The role will include patient care, phlebotomy, and administration of intravenous therapies. The hours are 8-12 pw, mostly afternoons, plus occasionally an extra 8-10 hours of morning work for colleague cover. Comprehensive training will be provided. You will be someone who enjoys variety at work, has a sense of humour, intellectual curiosity, and a kind heart. Please see www.drummartinclinic.ie, or to speak with our nurse, Kathryn, phone: 01 296 5993. Please send your CV with covering letter to vacancies@ drummartinclinic.ie with NURSE in the subject line.

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

MAY-JUNE 2021 9



The Irish Medicines in Pregnancy Service (IMPS), developed at the Rotunda Hospital, Dublin, “remains confident” funding will be allocated to develop the service nationally. “We remain in continual engagement with our primary funders, RCSI Hospitals Group/ HSE and the National Women and Infants Health Programme, to source recurring funding to sustain and develop IMPS services,” a spokesperson said in response to queries. The IMPS is a multidisciplinary service involving collaboration between specialist healthcare professionals in obstetrics, maternal-foetal medicine, and pharmacy. IMPS aims to support safe and effective use of medicines before, during, and after pregnancy. The IMPS leadership team was established through support from the Rotunda board’s own funds. A key component of the IMPS is an enquiry-answering service providing “objective, evidence-based information” on the use of medicines before, during, and after pregnancy to support effective risk communication and empower informed decision-making. As the scope of IMPS services is currently focused on patients attending the Rotunda, the majority of queries to date have originated from staff at the hospital (84 per cent), with most coming from consultants (37 per cent) and NCHDs (16 per cent), followed by pharmacists (24 per cent) and midwives (7 per cent). One-third of queries originated from outside the Rotunda, including from GPs (6 per cent), other hospitals (7 per cent), and members of the public (3 per cent). Most queries related to pregnancy (53 per cent) and breastfeeding (28 per cent). However,queries also related to preconception counselling (4 per cent), termination of pregnancy or unintentional medication

exposure in early pregnancy (6 per cent), and other issues including postpartum, gynaecology and miscellaneous queries (9 per cent). During the pandemic, the IMPS contributed to the development of national guidelines on the management of Covid-19 in pregnant women and education sessions for healthcare professionals. In addition, the IMPS, in collaboration with the RCPI Institute of Obstetricians and Gynaecologists, advocated for informed decision-making with respect to Covid-19 vaccination in pregnant and breastfeeding women. “Building on our experience with supporting and empowering informed decision-making on Covid-19 vaccines in pregnancy, our focus will expand to other medications and medical conditions including other vaccines, anti-epileptics, psychotropic medications, and medications used to treat autoimmune and inflammatory conditions. We aim to achieve this through the strategic priorities of information provision, multidisciplinary collaboration, advocacy, education, and research,” added the IMPS spokesperson.

10 MAY-JUNE 2021

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Demand for FFP2 masks for healthcare workers surged in January, prompting the opening of “additional supply lines to ensure continuity”, a meeting of the HSE’s National Crisis Management Team (NCMT) heard. On 12 January, the HSE’s Chief Clinical Officer Dr Colm Henry advised that due to the major rise of Covid-19 cases and “concern about increased potential for airborne transmission”, it was “appropriate to allow greater scope” for institutional and individual risk assessments with respect to wider use of respirator masks. Dr Henry’s advisory followed pressure from the Irish Nurses and Midwives Organisation for greater deployment of respirator masks, which were only recommended by the HSE for specific aerosol-generating procedures (AGPs) in line with

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World Health Organisation (WHO) guidance. A meeting of the NCMT on 29 January heard that demand for FFP2 masks had substantially increased. “Previously issued 130,000 units/week, now issuing in excess of one million units/week. 6.5 million units in stock. Additional supply being received. Opening additional supply lines to ensure continuity of supply,” outlined the minutes. Mr Sean Bresnan, HSE National Director of Procurement, told the meeting that funding and sanction was required for FFP2 masks’ expenditure, due to the scale of orders, with a letter to be submitted to the HSE board and Department of Health. HSE Clinical Lead on Infection Control Prof Martin Cormican advised that the guidelines for

of infants experience symptoms of regurgitation1

For bottle-fed infants with frequent regurgitation

ESPGHAN* March 2018


a stepped-care approach...

REVIEW the feeding history.

mask use were being reviewed to align with that of the European Centre for Disease Prevention and Control (ECDC). From the beginning of the pandemic, the ECDC had recommended respiratory masks when caring for suspected or confirmed Covid-19 patients, with surgical masks acceptable only where there were shortages of respirator masks. According to HSE guidance dated February 2021, healthcare workers “should have access” to a well-fitted FFP2 and eye protection when in contact with possible or confirmed Covid-19 cases and contacts. “In the context of a ward/unit-based outbreak it is appropriate to consider all patients in that setting as suspected or confirmed Covid-19 cases while active transmission is ongoing."

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12 MAY-JUNE 2021

IMPORTANT NOTICE: Aptamil Anti Reflux is a food for special medical purposes for the dietary management of frequent reflux and regurgitation. It should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. This product should not be used in combination with antacids or other thickeners and is not suitable for premature infants. Suitable for use as the sole source of nutrition for infants from birth and as part of a balanced diet from 6 months.

Ireland: www.nutricia.ie | Northern Ireland: www.nutricia.co.uk FOR HEALTHCARE PROFESSIONAL USE ONLY.

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Women's Health Authors: MacCraith E1, Davis NF1,2. 1 StAR MD Research Fellow, Blackrock Clinic and RCSI, Dublin 2 Consultant Urologist and Senior Lecturer, Beaumont Hospital and RCSI, Dublin



Cystitis is a common presentation in women, which can usually be diagnosed and managed in general practice, but onward referral is sometimes necessary

ystitis is defined as an infection and/or inflammation of the bladder. The presentation may involve frequent voiding of small volumes of urine, dysuria, urgency, odorous urine, suprapubic pain, haematuria, urinary incontinence or fever. Cystitis in the presence of infection may be classified as a urinary tract infection (UTI). An uncomplicated UTI is one occurring in a structurally and functionally normal urinary tract. This type of UTI accounts for the majority of cystitis cases in female patients and will typically resolve with a short course of antibiotics. Cystitis may also occur in the absence of a UTI. There are three main causes for non-infectious cystitis. It may occur after pelvic radiotherapy and is often referred to as radiation cystitis. It may also occur if the patient has a history of cyclophosphamide or ketamine use. Interstitial cystitis (or more recently known as bladder pain syndrome) is a chronic debilitating disorder with similar symptoms to infectious cystitis, but is diagnosed by excluding all other causes.

Risk factors and aetiology Risk factors for cystitis in females include; increasing age, reduced

oestrogen (menopause), previous UTI, diabetes mellitus, pregnancy, institutionalised elderly patients, stone disease, indwelling catheters, voiding dysfunction and genitourinary tract malformation. Risk factors in pre-menopausal patients include sexual intercourse, use of spermicide, new sexual partner, history of childhood UTI, and mother with a history of UTI.

The first investigation for cystitis should be a urine dipstick, which has several components to interpret

The most common causes of cystitis are Escherichia coli (E. coli), a Gramnegative bacillus, which accounts for 85 per cent of communityacquired and 50 per cent of hospitalacquired cystitis infections. Other common causative organisms include Staphylococcus saprophyticus, Proteus mirabilis, and Klebsiella. Bacteria from the bowel colonise the perineum, vagina, and distal urethra. From here the bacteria

ascend along the urethra and reach the bladder causing cystitis.

Investigations The first investigation for cystitis should be a urine dipstick, which has several components to interpret. Leukocyte esterase activity detects the presence of white blood cells (WBCs) in the urine. The presence of WBCs in the urine is referred to as pyuria and implies an inflammatory response of the urothelium (lining of the bladder) to a bacterial infection. This component of the urine dipstick has a sensitivity of 75-to-95 per cent for detection of infection. The next component is nitrites. These are not normally found in the urine and their presence suggests there is bacteria in the urine (bacteriuria). The sensitivity of this test is only 35-to-85 per cent (false negatives are common), but if nitrites are positive on a dipstick then it is highly likely there is an infection because the specificity is very high (>90 per cent). A mid-stream urine (MSU) sample which is collected for a dipstick test may also be sent to a lab for microscopy and culture. False positives on microscopy may occur due to vaginal commensal bacteria,

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Women's Health be prevented with general measures such as good fluid intake, avoiding constipation, cranberry juice, double voiding and wiping from front to back after voiding.

Recurrent UTIs

such as lactobacillus and Corynebacterium. To make a diagnosis of an uncomplicated UTI it is recommended that a urine culture would demonstrate >103 colony forming units per millilitre (cfu/mL).1 Usually a solitary episode of cystitis does not require any further investigations. However, further tests such as renal ultrasound, cystoscopy or CTKUB (kidney, ureter and bladder) may be necessary in certain clinical scenarios such as recurrent UTIs, unusual organisms on MSU, pregnancy or symptoms of pyelonephritis. Ultrasound may detect hydronephrosis, renal calculi, structural abnormalities and

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can be used to calculate the post-void residual volume in the bladder. CTKUB may detect renal, ureteric or bladder calculi. Cystoscopy may detect rare causes of recurrent UTIs such as urethral stenosis, bladder cancer, bladder calculi or a fistula.

Management Acute cystitis episode For acute uncomplicated cystitis, treatment with one of the following regimens is recommended: nitrofurantoin 50mg PO QDS for five days, trimethoprim 200mg PO BD for five days, or fosfomycin 3g PO single dose for one day.1, 2. Acute cystitis episodes may also

Recurrent UTIs are defined as >two infections in six months or three within 12 months.1 For recurrent UTIs, the European Association of Urology (EAU) guidelines panel recommends offering either three-to-six months of continuous low-dose antibiotic prophylaxis or postcoital antibiotic prophylaxis (single dose only).2 Continuous low-dose regimens include nitrofurantoin 50-to-100mg PO nocte, trimethoprim 100mg PO nocte, or fosfomycin 3g every 10 days. Patients with good compliance should be offered selfdiagnosis and self-treatment with a shortcourse regimen of antibiotics (the same regimens we discussed for acute cystitis episodes) for recurrent UTIs. It is important to avoid using unnecessarily long courses (>five days) of antibiotics for acute cystitis episodes in this group of patients in order to prevent reduced efficacy of antibiotics. There are a number of treatment measures for UTIs besides antibiotic prophylaxis effective lifestyle modification, particularly while at work, including avoiding habitual delayed urination and maintaining good fluid intake. It is important to avoid the spermicides which are present on condoms and the diaphragm. Post-menopausal women have a lack of oestrogen resulting in loss of protective lactobacilli. Topical oestrogen replacement with products such as Ovestin or Vagifem, but not oral oestrogen, has been shown to be effective at reducing recurrent UTIs.3 Proanthocyanidin (PAC) contained in cranberry products block bacteria adhering to the lining of the urinary tract and consumption of cranberry products has been shown to reduce the absolute risk of UTIs by 20 per cent.4. Applying natural yoghurt to the vagina may help to restore the natural protective flora. Probiotics (lactobacillus) are generally regarded as effective at reducing recurrent episodes of cystitis, however, studies have


Women's Health

CASE STUDY A 53-year old female presents to her GP with a three-day history of urinary frequency, dysuria and malaise. She has been treated for two previous UTIs this year at a different practice. She had no previous history of UTIs before this year. Her urine dipstick is positive for nitrites only. She is managed with a five day course of trimethoprim 200mg PO BD and her symptoms fully resolve. The MSU sample later showed E. Coli, which is sensitive to trimethoprim and nitrofurantoin. An outpatient referral is sent to a urologist because she is now classified as suffering from recurrent UTIs. The urologist organised an ultrasound kidneys and bladder which is unremarkable and shows that the bladder empties to completion. On examination the urologist noted some early evidence of atrophic vaginitis related to lack of oestrogen. The patient is commenced on local oestrogen therapy in the form of Vagifem.

At a 12-month follow up appointment with her urologist the patient reports an initial good response to the treatment for eight months, but in the last four months she has had three UTIs. Two of these episodes were associated with visible haematuria, and she is an ex-smoker. She undergoes a cystoscopy and CT urogram; both of which are unremarkable. The MSU on each occasion grows E. Coli, which is sensitive to trimethoprim and nitrofurantoin. The patient is commenced on low-dose continuous antibiotic prophylaxis in the form of trimethoprim 100mg PO nocte for six months as well as a probiotic in the form of Udo's Choice Super 8. She continuous to use Vagifem at the lowest effective dose as she found this to be beneficial. At a 12-month follow up appointment she is well and reports no UTIs for one year. She has been finished her low-dose antibiotic prophylaxis for six months and is maintained on probiotics and local oestrogen therapy.

colonises the perineum and vagina, and ascends the urethra to cause cystitis. Acute episodes should be treated with appropriate short-course antibiotics and patients given information on general preventative measures. No further investigations are required in on-off uncomplicated UTI episodes. Recurrent UTIs warrant referral to a urologist for further investigation, which may include imaging and cystoscopy to exclude structural or functional urinary tract abnormalities or underlying bladder pathology. Management of recurrent cystitis varies by age, but includes continuous low-dose prophylactic antibiotics, post-coital antibiotic prophylaxis, lifestyle modifications, topical oestrogen, cranberry products, probiotics and D-Mannose.

References failed to demonstrate this benefit.5 Udo's Choice Super 8 is an example of a probiotic that is commonly recommended by urologists and is available without prescription. D-Mannose is a product which can also be purchased without prescription and it has been shown that taking 2g of the powder dissolved in 200ml water daily reduces the risk of UTIs by 45 per cent.6 D-Mannose is thought to work in a similar manner to cranberry products by blocking the binding of bacteria to the urothelium. In diabetic patients with recurrent cystitis it is important to improve glucose control to reduce the frequency of episodes. Courses of Hiprex 1g PO OD have been shown to reduce UTI episodes but it is not commonly used. The efficacy of acupuncture has been investigated for recurrent UTIs, and in a small series it was shown to be more effective than placebo, but there is not strong enough evidence to recommend it as a treatment.7 Administration of hyaluronic acid (iAluril) into the bladder once per week for four weeks has been investigated for recurrent cystitis. A small series showed an 86 per cent reduction

1. Reynard J, et al. Oxford Handbook of Urology 4th Edition. Oxford University Press. 2019

There are a number of treatment measures for UTIs besides antibiotic prophylaxis - effective lifestyle modification, particularly while at work, including avoiding habitual delayed urination and maintaining good fluid intake

2. Bonkat G, Bartoletti R, and Bruyère F. EAU Guidelines on Urological Infections. Presented at the EAU Annual Congress Milan Italy 2021. ISBN 978-94-92671-13-4 3. Beerepoot MA, et al. Nonantibiotic prophylaxis for recurrent urinary tract infections: a systematic review and meta-analysis of randomised controlled trials. J Urol, 2013. 190(6): p. 1981-9 4. Kontiokari T, et al. Randomised trial of cranberrylingonberry juice and Lactobacillus GG drink for the prevention of urinary tract infections in women. BMJ, 2001. 322(7302): p. 1571 5. Schwenger EM, Tejani AM, and Loewen PS. Probiotics for preventing urinary tract infections in adults and children. Cochrane Database Syst Rev, 2015(12): p. Cd008772

in UTI episodes.8 This treatment option appears from small studies to be effective but is costly to administer in terms of healthcare resources.

Conclusion In summary, cystitis is a common condition in females which can be diagnosed with clinical history, examination and midstream urine collection. It is typically caused by E. coli from the bowel which

6. Kranjčec B, Papeš D, Altarac S. D-mannose powder for prophylaxis of recurrent urinary tract infections in women: a randomised clinical trial. World J Urol, 2014. 32(1): p. 79-84 7. Alraek T, et al. Acupuncture treatment in the prevention of uncomplicated recurrent lower urinary tract infections in adult women. Am J Public Health, 2002. 92(10): p. 1609-11 8. Damiano, R, et al. Prevention of recurrent urinary tract infections by intravesical administration of hyaluronic acid and chondroitin sulphate: a placebo-controlled randomised trial. Eur Urol, 2011. 59(4): p. 645-51

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Women's Health Authors: Dr Rachael Comer, Education and Training Manager, Screening Training Unit, CervicalCheck; Dr Noirin Russell, Clinical Director, CervicalCheck; Ms Gráinne Gleeson, Programme Manager, CervicalCheck; and Ms Fiona Ness, Communications Manager, National Screening Service

CERVICAL SCREENING IN IRELAND Covid-19 has affected every aspect of healthcare delivery, including the provision of cervical screening, which has undergone a number of important changes in recent years


he National Cervical Screening Programme, CervicalCheck, offers free cervical screening to women* aged 25 to 65 years in Ireland. Women are eligible for screening every three years from age 25 to 30 and every five years from age 45 to 65. The screening programme is based in primary care with more than 3,265 doctors, nurses, and midwives in primary care** registered with CervicalCheck. The primary care team, including general practice nurses (GPNs), is vital to the CervicalCheck programme. Their role includes identifying women who are eligible, encouraging women to participate, explaining the benefits and risks of screening, and counselling women when positive results are reported. This article will focus on cervical screening in primary care, the link between human papillomavirus virus (HPV) infection and cervical cancer, primary and secondary prevention, the influential role of sample takers, and CervicalCheck’s educational resources.

Purpose of screening * When we refer to ‘women’, we mean ‘women or people with a cervix’ ** Primary care refers to GP and other primary screening settings

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Cervical Screening

Screening identifies people in an apparently healthy population who have a higher chance of developing a health problem or a condition, so that an early treatment or intervention can be offered and thereby reduce the incidence and mortality of the health problem or condition within the population (World Health Organisation, 2020).

Ireland has introduced four quality assured, organised, population-based screening programmes under the management of the National Screening Service. These include BreastCheck, CervicalCheck, BowelScreen and Diabetic RetinaScreen. CervicalCheck was established in 2008 and since its introduction the incidence of cervical cancer in Ireland declined by 7 per cent year-on-year between 2010-2015 and over 100,000 cases of abnormal cervical cells have been detected and treated (NCRI, 2017).

The continuation of cervical screening and building trust in our CervicalCheck screening programme is of crucial importance in the coming months

On 23 March 2020, the programme changed from a primary cytology to a primary HPV programme. However, due to Covid-19 restrictions and on public health advice, CervicalCheck paused cervical screening in primary care on the same day. HPV primary screening resumed in primary care on 6 July 2020. Not surprisingly this led to a decrease in the number of women screened in 2020, although,

there was record attendance for November and December 2020. Covid-19 has affected every aspect of healthcare delivery, including the provision of cervical screening. Ensuring timely access to screening and results for women requires close collaboration between all elements of the programme, including the administrative call/ recall team, sample takers, cytology laboratories, colposcopy clinics and histology laboratories. In order to maintain a quality assured, timely service it is important that demand for screening is matched to downstream capacity as each component is inextricably linked.

Cervical cancer On average 300 women are diagnosed with invasive cervical cancer annually in Ireland. There were 84 deaths each year in 2015-2017, according to the latest National Cancer Registry Ireland (NCRI, 2020) report. Cervical cancer is the eighth most common cancer in women*, excluding non-melanoma skin cancer (NCRI, 2020). The age profile of invasive cervical cancer is younger than that for many other cancers, with almost half (47 per cent) of women aged less the 45 years when diagnosed (NCRI, 2017). There are two main types of cervical cancer; squamous cell carcinoma (77 per cent of cases) and adenocarcinoma (18 per cent) (Tjalma et al, 2013). The remaining 5 per cent of cervical cancers are due

Cervical Screening

Figure 1: Cervical cancer rate in Ireland - projected impact of screening. Reproduced with kind permission from NCRI

Women's Health to rarer histological types. Cervical screening with cytology and HPV testing is more effective at reducing the risk of squamous cell carcinoma than other histological types (Koliopoulos et al, 2017). Adenocarcinoma of the cervix is a more aggressive type of cancer associated with a poorer prognosis (Colombo et al, 2012). Cervical screening programmes internationally have had less impact on reducing adenocarcinoma than squamous cell carcinoma. It is now recognised that persistent HPV infection causes at least 92 per cent of cervical cancer in total and is responsible for 99 per cent of squamous cell cancers (Tjalma et al, 2013). HPV is easily spread through sexual skin-to-skin contact, and infections are very common, with the incidence of genital HPV infections peaking between 18 and 30 years of age (Smith and Travis, 2011). About 80 per cent of sexually active adults have been infected with one or more genital HPV strains at one time or another, but never know they have been infected because HPV is usually spontaneously cleared by the body’s immune system. Castellsagué (2008) estimates that more than 90 per cent of women clear the infection spontaneously. However, a small percentage of women do not clear the infection and it can remain dormant or persistent, sometimes for many years. (Muñoz N et al, 2009).

Primary and secondary prevention There are two approaches to preventing cervical cancer: Primary prevention through vaccination against HPV infection, and secondary prevention through effective screening and treatment programmes. In September 2010, a quadrivalent vaccination against HPV 6, 11, 16, and 18 was introduced in Ireland and administered to first-year girls aged 12-to-13 years in secondary schools. HPV 6 and 11 are associated with anogenital warts, while 70 per cent of squamous cell carcinomas are attributed to HPV 16 and 18 (Clifford et al, 2006). A nine-valent HPV vaccine was extended to boys in September 2019 after the Health Information and Quality Authority (HIQA) completed a positive health technology assessment (HTA). In relation to secondary screening, organised programmes deliver greater equity and access for all women and more efficient use of

Figure 2: How does HPV testing compare with the traditional cytology test (Scally, 2018)

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Women's Health

Cervical Screening This is significantly better than testing with cytology first, which detects 75 per cent of women at risk. However, the specificity of HR HPV testing is lower than cytology tests. This leads to an increase in false positive results, which increases the numbers of women referred to colposcopy services (Koliopoulos et al, 2017). As a result, women who test positive have a reflex cytology test and an earlier recall than those who test HPV negative (CervicalCheck, 2020).

CervicalCheck, our National Cervical Screening Programme

Figure 3: Colposcopy services for CervicalCheck resources within the most appropriate time frame, (Chrysostomou et al, 2018). The WHO (2020) compares screening to a sieve; it separates people who are more likely to have the condition from those who are less likely to have it. A screening test is never 100 per cent accurate; it is a blunt tool that divides the population into two cohorts, those with a higher chance and those with a lower chance of developing the condition.

HPV primary screening HPV testing is not new in Ireland, as it was first introduced by CervicalCheck as a ‘test of cure’ following excisional (LLETZ) treatment in colposcopy in 2012. In 2015, it was utilised as ‘HPV triage’ to determine how quickly to refer women with low-grade cytological abnormalities detected in primary care onwards to colposcopy. Also in 2015, CervicalCheck

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requested that HIQA perform a HTA of HR HPV testing as the primary cervical screening method. Following a detailed review, HIQA deemed the introduction of primary HR HPV testing as both clinically efficient and cost-effective (HIQA, 2017). This is in keeping with other high-income countries such as Australia, Italy, The Netherlands, New Zealand, Sweden, and the UK. In 2017, a Cochrane review included 40 studies with a total of 140,000 women and concluded that if 20 out of 1,000 women had precancerous changes, primary HPV screening would correctly identify 18 of these women whereas primary cytology screening would only identify 15 of these women (Koliopoulos et al, 2017). HPV as a primary screening test followed by reflex cytology in those that screen positive detects 90 per cent of women at risk of cervical cancer.

Collaboration between the administrative call/ recall team, primary care sample takers, cytology laboratories, colposcopy clinics and histology laboratories are essential to provide a qualityassured screening programme. It is important to note that CervicalCheck is an administrative programme, which is responsible for laboratory management recommendations. The clinical governance remains with the sample taker and colposcopy unit staff as they can perform a holistic clinical examination and also have access to the patient’s clinical notes. In order to ensure that the call/recall part of the programme functions effectively in a quality-assured manner, all three clinical arms of the programme (primary care, laboratories and colposcopy) need to be closely aligned. In order to ensure that the qualityassurance criteria are met, it is essential that when samples are taken, there is adequate downstream capacity to provide the necessary next steps. CervicalCheck is committed to ongoing education for all stakeholders. There are a number of supporting documents on the CervicalCheck website (www.cervicalcheck. ie/health-professionals.3800.html) and the National Screening Service online eLearning portal (www.NSSresources.ie). Healthcare professionals can refer to the HPV Primary Screening: Eligibility Framework (CervicalCheck, 2020) and Cervical Screening Results and Recommendations Table (CervicalCheck, 2020) to guide cervical screening requirements. Abnormal cytology and HPV test results can be monitored and treated in colposcopy clinics to prevent the development of invasive cancer. CervicalCheck has a memorandum of understanding with 15 strategically placed quality-assured colposcopy clinics (see Figure 3).

Women's Health

Cervical Screening

Screening coverage It is well documented that cervical screening can save lives, decrease morbidity, expand quality-of-life and deliver reassurance to individuals about their health (Arbyn et al, 2010; Sasieni, Castañón and Beer, 2013; Castañón et al, 2014; Arbyn et al, 2019). Screening coverage is defined as the proportion of the target population that has engaged in screening within a specific period, and directly correlates to the effectiveness of a screening programme (CervicalCheck, 2014). In keeping with the principles of screening, all screening programmes need a high target coverage to be effective. CervicalCheck’s objective is to obtain 80 per cent population coverage or more during a five-year period (CervicalCheck, 2016). CervicalCheck reports a five-year coverage of 77.4 per cent in the period 2018/2019 (CervicalCheck Report, 2020). Figure 4 stratifies the population coverage per age group for women and highlights that screening uptake in women over 50 years of age declines. This is a concerning trend that needs more investigation. Castañón et al (2019) state that the peak age of cervical cancer diagnosis will shift to the pre-HPV vaccination cohort, which suggests that as vaccinated cohorts become eligible for screening, the peak age group for cervical cancer diagnosis will move to older women. Castañón et al (2014) conducted a population-based case control study in the UK to examine cervical screening in women aged 50-to-64 and the risk

of developing cervical cancer in women aged 65-to-83. The study concluded that women are six times more likely to develop cervical cancer if not screened between the ages of 50 and 64. If adequately screened, screening protection was greatest from 65-to-69 years and decreased progressively since their last normal cytology test. According to Cancer Research UK (2019), the peak mortality rate for cervical cancer occurs between 85 and 89 years of age. Therefore, it is extremely important that women over 50 years engage with the cervical screening programme, as this will reduce their risk of developing cervical cancer and its associated mortality and morbidity in later life (Castañón et al, 2014; Castañón et al, 2018; Castañón et al, 2019).

The influential role of the sample taker Sample takers have a powerful role in making the cervical screening programme a success. Research shows that GPs and GPNs remain the most trusted source of information for most women, as shown in Figure 5 (Core, 2019). This emphasises the importance of making every contact count (MECC) with women. Regardless of women’s screening status, the relationship with general practice and how cervical screening is offered impacts cervical screening behaviours. Numerous Irish studies have reported that GPs and GPNs can have both a positive or negative impact on women’s cervical screening behaviour (Bowe, 2004; Walsh, 2006; O’Connor, 2014; Comer, 2020).

Education empowers sample takers, enabling them to give clear consistent information on the benefits and limitations of cervical screening. This helps women to make an informed choice and consent to participate in the CervicalCheck programme (See Figure 6). Even though every woman who receives an invitation to attend for cervical screening receives an information leaflet, the one-to-one consultation at each appointment is essential. Sample takers explain the possibility of a HPVpositive result and the potential of needing a repeat HPV test in one year or a referral to colposcopy. Sample takers are also skilled at providing cultural sensitivity to women and often use translated information videos in the woman’s native language (CervicalCheck, 2021). Explaining what is involved in the cervical screening procedure and answering questions in an unhurried, non-judgement manner while maintaining the dignity of the woman ensures that women report a positive screening experience. When sample takers are confident in engaging in the consultation process and normalise HPV infection, this avoids stigmatisation (Figure 6).

The importance of continuing professional development All sample takers are encouraged to participate in continuing professional development in order to keep up-to-date with changes in practice. CervicalCheck has developed a certificate in sample taking and delivers this stand-alone accredited training programme for healthcare professionals in line with the recommendations of the Cervical Screening Settings (2020), Standards for Quality Assurance in Cervical Screening (2020) and the CervicalCheck HPV Primary Screening: Eligibility Framework/ Reference Guide for GPs and Clinics 2020. The training opportunities available are provided in partnership with the ICGP, RCSI (Nursing Faculty), University College Cork, and the National University of Ireland, Galway. The education programme is underpinned by the HSE values of care, compassion, trust and learning, which encompasses self-direction, professional experience, inclusion and diversity. The applicant must work or be able to

Figure 4: Five-year coverage of eligible women by age group on the cervical screening register for period ending 31 August 2019 (CervicalCheck)

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Women's Health

Cervical Screening


STARTING THE CONVERSATIONA SAMPLE TAKERS GUIDE Normalising HPV infection and testing  Highlight the purpose of cervical screening –

differentiating between screening and diagnostic tests  Emphasise benefits of screening; screening saves

lives, it identifies HPV before it causes cancer and helps identify cell abnormal changes when it is easier to treat  Explain limitations of screening; it does not

prevent all cases of cervical cancer, which can develop in between screening tests, which is why symptoms should never be ignored  Explain what the risk factors for cervical cancer are;

smoking, early age at first intercourse, persistent HPV infection  Normalise HPV infection by making women aware

Figure 5: Trusted sources on cervical screening and cervical cancer. Research conducted by Core, 2019

that even being with one partner means that they still have an 80 per cent chance of contracting HPV infection and emphasise the ability of HPV infection to lie dormant for many years  Reassure that most people's immune system clears

get supervised experience in cervical screening consultations with a clinically responsible doctor (CRD) who holds a contract with CervicalCheck. A CervicalCheck-appointed clinical trainer is assigned to each candidate sample-taker to support the clinical aspects of training in the candidate sample-taker’s own clinical setting. Once the candidate sample-taker completes both the theoretical and clinical component of the sample taking programme, they can register as a certified sample-taker with CervicalCheck. There are 1,887 nurses/midwives that are registered sample takers. Nurses and midwives are accountable to the patient, the public, their regulatory body, the Nursing and Midwifery Board of Ireland (NMBI), their employer and any relevant supervisory authority (NMBI, 2015). Sample taking is an extension in the scope of practice for nurses and midwives. Nurses and midwives are accountable both legally and professionally for their practice, that is, for the decisions they make and the consequences of those decisions (NMBI, 2015). Nurses and midwives must be theoretically and clinically competent to expand their scope of practice to provide cervical screening consultations. Sample takers that need information on

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the HPV programme and how to consent effectively, can access an e-learning module with a number of video presentations, which is available on https://nssresources.ie website. CervicalCheck also circulates a monthly newsletter highlighting updates and changes to practice. We appreciate that general practice is extremely busy and endeavour to deliver bite-size pieces of education. Sample takers can register to receive this update by contacting carol.dermody@screeningservice.ie. To provide a quality approved programme, registered sample takers should participate in CervicalCheck clinical updates at least once every three years. Clinical updates may be delivered through face-to face meetings (national, regional, continuing medical/ nursing education [CME] or Cervical Check-led) or through the National Screening Service Learning Portal (https://nssresources.ie) and CervicalCheck website to maintain continuous professional development. All sample takers must maintain their professional registration for the period of time that they are registered with CervicalCheck. The clinically responsibility doctor should ensure that all sample takers in their service are appropriately educated and competent.

HPV from their body within 18 months without any treatment. For some people the infection remains and this is why a repeat test in 12 months will check if the infection has gone  Explain that in the absence of persistent HPV, it

is safe to repeat the next screening test in three or five years, depending on age. Without HPV infection, abnormal cells typically return to normal without intervention  Explain that if testing detects persistent HPV

infection, referral to colposcopy is initiated  Emphasise that regular screening between age

25 and 65 has a protective effect even after a woman completes cervical screening

Figure 6: Key points for sample takers Covid-19 Impact on cervical screening Cervical cancer screening programmes worldwide were affected by the Covid-19 pandemic. In 2020, due to the three month programme pause, travel and social distance restrictions, the CervicalCheck programme provided screening for approximately 143,000 women, which was significantly

It’s not too late to vaccinate against HPV Many adults continue to be at risk of new HPV infections throughout their lifetime1

Recommend Gardasil 9 to prevent future infections against 9 of the most common high risk HPV types


Gardasil 9 is available to order privately from MSD. msd@united-drug.com Freephone orderline 1800 200 845 Freefax orderline 1800 200 846

This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse reactions. See section 4.8 of the SPC for how to report adverse reactions. ABRIDGED PRODUCT INFORMATION Refer to Summary of Product Characteristics before prescribing. PRESENTATION Gardasil 9 is supplied as a single dose pre-filled syringe containing 0.5 millilitre of suspension. Each dose of vaccine contains highly purified virus-like particles (VLPs) of the major capsid L1 protein of Human Papillomavirus (HPV). These are type 6 (30 mg), type 11 (40 mg), type 16 (60 mg), type 18 (40 mg), type 31 (20 mg), type 33 (20 mg), type 45 (20 mg), type 52 (20 mg) and type 58 (20 mg). INDICATIONS Gardasil 9 is a vaccine for use from the age of 9 years for the prevention of premalignant lesions and cancers affecting the cervix, vulva, vagina and anus caused by vaccine HPV-types and genital warts (condyloma acuminata) caused by specific HPV types. The indication is based on the demonstration of efficacy of Gardasil 9 in males and females 16 to 26 years of age and on the demonstration of immunogenicity of Gardasil 9 in children and adolescents aged 9 to 15 years. The use of Gardasil 9 should be in accordance with official recommendations. DOSAGE AND ADMINISTRATION Individuals 9 to and including 14 years of age at time of first injection: Gardasil 9 can be administered according to a 2-dose schedule. The second dose should be administered between 5 and 13 months after the first dose. If the second vaccine dose is administered earlier than 5 months after the first dose, a third dose should always be administered. Gardasil 9 can be administered according to a 3-dose (0, 2, 6 months) schedule. The second dose should be administered at least one month after the first dose and the third dose should be administered at least 3 months after the second dose. All three doses should be given within a 1-year period. Individuals 15 years of age and older at time of first injection: Gardasil 9 should be administered according to a 3-dose (0, 2, 6 months) schedule. The second dose should be administered at least one month after the first dose and the third dose should be administered at least 3 months after the second dose. All three doses should be given within a 1-year period. It is recommended that individuals who receive a first dose of Gardasil 9 complete the vaccination course with Gardasil 9. The need for a booster dose has not been established. Studies using a mixed regimen (interchangeability) of HPV vaccines were not performed for Gardasil 9. Subjects previously vaccinated with a 3dose regimen of quadrivalent HPV types 6, 11, 16, and 18 vaccine (Gardasil or Silgard), hereafter referred to as qHPV vaccine, may receive 3 doses of Gardasil 9. The use of Gardasil 9 should be in accordance with official recommendations. Paediatric population (children <9 years of age): The safety and efficacy of Gardasil 9 in children below 9 years of age have not been established. No data are available. The vaccine should be administered by intramuscular injection. The preferred site is the deltoid area of the upper arm or in the higher anterolateral area of the thigh. Gardasil 9 must not be injected intravascularly, subcutaneously or intradermally. The vaccine should not be mixed in the same syringe with any other vaccines and solution. CONTRAINDICATIONS Hypersensitivity to any component of the vaccine including active substances and/or excipients. Individuals with hypersensitivity after previous administration of Gardasil 9 or Gardasil /Silgard should not receive Gardasil 9. PRECAUTIONS AND WARNINGS In order to improve traceability of biological medicinal products, the name and batch number of the administered product should be clearly recorded. The decision to vaccinate an individual should take into account the risk for previous HPV exposure and potential benefit from vaccination. As with all injectable vaccines, appropriate medical treatment and supervision should always be readily available in case of rare anaphylactic reactions following the administration of the vaccine. The vaccine should be given with caution to individuals with thrombocytopaenia or any coagulation disorder because bleeding may occur following an intramuscular administration in these individuals. Syncope, sometimes associated with falling, can occur before or after vaccination with Gardasil 9 as a psychogenic response to the needle injection. Vaccinees should be observed for approximately 15 minutes after vaccination; procedures should be in place to avoid injury from faints. Vaccination should be postponed in individuals suffering from an acute severe febrile illness. However, the presence of a minor infection, such as a mild upper respiratory tract

infection or low-grade fever, is not a contraindication for immunisation. As with any vaccine, vaccination with Gardasil 9 may not result in protection in all vaccine recipients. Gardasil 9 will only protect against diseases that are caused by HPV types targeted by the vaccine. The vaccine is for prophylactic use only and has no effect on active HPV infections or established clinical disease. The vaccine has not been shown to have a therapeutic effect and is not indicated for treatment of cervical, vulvar, vaginal and anal cancer, high-grade cervical, vulvar, vaginal and anal dysplastic lesions or genital warts. It is also not intended to prevent progression of other established HPV-related lesions. Gardasil 9 does not prevent lesions due to a vaccine HPV type in individuals infected with that HPV type at the time of vaccination. Vaccination is not a substitute for routine cervical screening. There are no data on the use of Gardasil 9 in individuals with impaired immune responsiveness. Safety and immunogenicity of a qHPV vaccine have been assessed in individuals aged from 7 to 12 years who are known to be infected with human immunodeficiency virus (HIV). Individuals with impaired immune responsiveness, due to either the use of potent immunosuppressive therapy, a genetic defect, Human Immunodeficiency Virus (HIV) infection, or other causes, may not respond to Gardasil 9. Long-term follow-up studies are currently ongoing to determine the duration of protection. There are no safety, immunogenicity or efficacy data to support interchangeability of Gardasil 9 with bivalent or quadrivalent HPV vaccines. PREGNANCY AND LACTATION There are insufficient data to recommend use of Gardasil 9 during pregnancy; therefore vaccination should be postponed until after completion of pregnancy. The vaccine can be given to breastfeeding women. No human data on the effect of Gardasil 9 on fertility are available. SIDE EFFECTS Very common side effects include: erythema, pain and swelling at the injection site and headache. Common side effects include: pruritus and bruising at the injection site, dizziness, nausea, pyrexia and fatigue. The post-marketing safety experience with qHPV vaccine is relevant to Gardasil 9 since the vaccines contain L1 HPV proteins of 4 of the same HPV types. The following adverse experiences have been spontaneously reported during post-approval use of qHPV vaccine and may also be seen in post-marketing experience with Gardasil 9: urticaria, bronchospasm, idiopathic thrombocytopenic purpura, acute disseminated encephalomyelitis, Guillain-Barré Syndrome and hypersensitivity reactions, including anaphylactic/anaphylactoid reactions. For a complete list of undesirable effects please refer to the Summary of Product Characteristics. PACKAGE QUANTITIES Single pack containing one 0.5 millilitre dose pre-filled syringe with two separate needles. Legal category: POM. Marketing authorisation number: EU/1/15/1007/002 (pre-filled syringe with two separate needles). Marketing Authorisation holder: MSD VACCINS, 162 avenue Jean Jaurès, 69007 Lyon, France. Date of revision: November 2019. © Merck Sharp & Dohme B.V. 2019. All rights reserved. Further information is available on request from: MSD, Red Oak North, South County Business Park, Leopardstown, Dublin 18 D18 X5K7 or from www.medicines.ie. Date of preparation: May 2021. II0033-R035 Adverse events should be reported. Reporting forms and information can be found at www.hpra.ie Adverse events should also be reported to MSD (Tel: 01-299 8700) References: 1. Centers for Disease Control and Prevention (CDC). Human papillomavirus In: Hamborsky J, Kroger A, Wolfe C, eds. Epidemiology and Prevention of Vaccine-Preventable Disease. 13th ed. Washington DC: Public Health Foundation; 2015:175-186

Red Oak North, South County Business Park, Leopardstown, Dublin D18 X5K7 Ireland


GARDASIL® 9 (Human Papillomavirus 9-valent Vaccine (Recombinant, adsorbed)).

Women's Health lower than the number projected at the start of the year (255,000). Although all women due their test in 2020 received their invitation before end of December 2020, there remains a significant number of women who were eligible for their screening test last year and thus will want to attend in 2021. As previously noted, it is extremely important to match the demand for screening with the downstream availability of laboratory and colposcopy services, both of which have been impacted by Covid-19. Attendance in March 2021 was 78 per cent above the projected monthly target. This is an extraordinary response at a time when primary care providers have so many other demands on their time, notably Covid-19 vaccination clinics. It is important to match the volume of sample taking in primary care to the capacity across the screening pathway. The programme needs to ensure a quality-assured service where results are returned to women and where referral to colposcopy is required and both are happening in a timely manner.

Conclusion The continuation of cervical screening and building trust in our CervicalCheck screening programme is of crucial importance in the coming months. This new approach of HPV testing will significantly improve the accuracy of the screening process, by increasing the chances of more cancers being prevented due to the detection of early changes. The challenging, but exciting prospect of turning cervical cancer into a rare disease in Ireland will require a strengthened focus and skilled leadership. We need to work together and make every contact count with women to promote screening. Healthcare professionals need to engage in continuing professional development in order to give consistent information to women and normalise the conversation around HPV infection. There are a number of CervicalCheck clinical updates available on the CervicalCheck website and the National Screening Service Learning Portal. CervicalCheck will endeavour to build trust through proactive communication with all our stakeholders and enhance our governance through robust processes, performance and structures.

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Cervical Screening

References Arbyn M, Weiderpass E, Bruni L, de Sanjosé S, Saraiya M, Ferlay J, and Bray F. 2019. Estimates of incidence and mortality of cervical cancer in 2018: A worldwide analysis. The Lancet Global Health. Bowe A. 2004. An evaluation of the first phase of the Irish Cervical Screening Programme from the woman’s perspective Castañón, A, Landy R, Cuzick J, Sasieni P. 2014. Cervical screening at age 50-64 years and the risk of cervical cancer at age 65 years and older: population-based case control study. PLoS Med, 11:e1001585 Castañón A, Landy R, Pesola F, Windridge P, Sasieni P. 2018. Prediction of cervical cancer incidence in England, UK, up to 2040, under four scenarios: A modelling study. The Lancet Public Health, 3(1), pp. e34-e43 Castañón A, Rebolj M, and Sasieni P. 2019. Is a delay in the introduction of human papillomavirus-based cervical screening affordable? Journal of Medical Screening, 26(1), pp. 44-49 Castellsagué X. 2008. Natural history and epidemiology of HPV infection and cervical cancer. Gynecologic Oncology, 110(3), pp. S4-S7 CervicalCheck, 2014. Guidelines for Quality Assurance in Cervical Screening, 2nd edn. National Cancer Services, HSE. Dublin: Stationery Office CervicalCheck (2020) HPV Primary Screening: Eligibility Framework. Available at Eligibility_for_Cervical_Screening_Framework.pdf (cervicalcheck.ie) Accessed on 20/04/21 CervicalCheck (2020) Cervical screening results and recommendations table. Available at CervicalScreeningResultsandRecommendations.pdf (cervicalcheck.ie) CervicalCheck (2020) Unpublished data Core Research (2019), HSE First Screening. Available at HSE HPV First Screening Report_Core Research_21.11.19.pdf Chrysostomou A, Stylianou D, Constantinidou A, and Kostrikis L. 2018. Cervical cancer screening programs in Europe: The transition towards HPV vaccination and population-based HPV testing. Viruses, 10(12), p. 729

Koliopoulos G, Nyaga VN, Santesso N, Bryant A, Hirsch M, Mustafa PP, Schünemann RA, Paraskevaidis HE, Arbyn M. 2017. Cytology versus HPV testing for cervical cancer screening in the general population. Cochrane Database of Systematic Reviews, 8 Lalkhen AG, McCluskey A. 2008. Clinical tests: sensitivity and specificity. Continuing Education in Anaesthesia Critical Care and Pain, 8(6), pp. 221-223 Muñoz N et al, 2009. Persistence of HPV infection and risk of high-grade cervical intraepithelial neoplasia in a cohort of Colombian women. British Journal of Cancer 100, 1184-11 National Cancer Registry Ireland (2020) CANCER IN IRELAND 1994-2018 WITH ESTIMATES FOR 2018-2020: ANNUAL REPORT OF THE NATIONAL CANCER REGISTRY. Available at NCRI_Annual Report_2020_01122020. pdf. Accessed on 20/04/21 National Cancer Registry in Ireland (NCRI), 2017. Cancer Trends No.35 Cervical Cancer. National Cancer Registry. Available at www.ncri.ie/sites/ ncri/files/pubs/CervicalCaTrendsReport_MP.pdf. Accessed on 20/04/21 NMBI 2014, Scope of Nursing and Midwifery Practice Framework NMBI. Available at www.nmbi.ie/nmbi/media/NMBI/Publications/Scope-ofNursing-Midwifery-Practice-Framework.pdf?ext=.pdf O’Connor M, Murphy J, Martin C, O’Leary J, Sharp L. 2014. Motivators for women to attend cervical screening: the influential role of GPs. Family Practice, 31(4), pp. 475-482 Petry KU, Menton S, Menton M, van Loenen-Frosch F, de Carvalho Gomes H, Holz B, Schopp B, Garbrecht-Buettner S, Davies P, Boehmer G, van den Akker E. 2003. Inclusion of HPV testing in routine cervical cancer screening for women above 29 years in Germany: results for 8,466 patients. British Journal of Cancer, 88(10), p. 1570 Sasieni P, Castañón A, and Beer H. 2013. Cervical Screening Wales Audit of Cervical Cancer (CSWACC) National Report: 1999-2009 Scally G. 2018. Scoping inquiry into the CervicalCheck screening programme. Dublin: Department of Health

Clifford G, Franceschi S, Diaz M, Munoz N, and Villa LL. 2006. HPV type-distribution in women with and without cervical neoplastic diseases. Vaccine, 24, pp. S26-S34

Smith GD, Travis, L. 2011. Getting to know human papillomavirus (HPV) and the HPV vaccines. Journal of the American Osteopathic Association, 111(3 Supplement 2), p. S29

Colombo N, Carinelli S, Colombo A, Marini C, Rollo D, Sessa C, and ESMO Guidelines Working Group, 2012. Cervical cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology, 23 (Supplement 7), pp. vii27-vii32

Wilson JMG, Jungner G, and World Health Organisation. 1968. Principles and practice of screening for disease

Comer, R Spiralling Vulnerabilities; Understanding the cervical screening behaviours of women over 50 years in the West of Ireland, unpublished. Available at https://aran.library.nuigalway.ie/handle/10379/16378 Health Information and Quality Authority (HIQA), 2017. HTA of HPV testing for cervical cancer screening. Available at www.hiqa.ie/ reports-and-publications/health-technologyassessment/hta-hpvtesting-cervical-cancer-screenin

World Health Organisation (2020) Screening Programmes; a short guide, World Health Organisation Regional Office Europe. Available at https://apps.who.int/iris/bitstream/hand le/10665/330829/9789289054782-eng.pdf Tjalma WA, Fiander A, Reich O, Powell N, Nowakowski AM, Kirschner B, Koiss R, O'Leary J, Joura EA, Rosenlund M, Colau B. 2013. Differences in human papillomavirus type distribution in high-grade cervical intraepithelial neoplasia and invasive cervical cancer in Europe. International Journal of Cancer, 132(4), pp.854-867

Women's Health Author: Theresa LowryLehnen (PhD), CNS, GPN, RNP, and National PRO, Irish General Practice Nurses Educational Association

Women's Health Menopause



If menopausal symptoms are discomfiting or causing concern, there are treatments that can help

he menopause can be defined as the end of a woman’s menstrual cycle and reproductive phase.9 The World Health Organisation (WHO) defines natural menopause as at least 12 consecutive months of amenorrhoea not due to physiological and pathological causes.11 The term menopause is often used to describe the transition phase during which a woman moves from the fertile to post fertile stage of her life, however, this phase should be referred to as peri-menopause or climacteric.9 Menstrual periods usually become less frequent over months or years before they finally end. The frequency and severity of menstrual periods during this transition can be irregular and vary. They may become light or very heavy, occur every two or t hree weeks, may not occur for months at a time and sometimes they can just stop suddenly. The menopause is a natural part of ageing that usually occurs between 45 and 55 years of age, as a woman’s oestrogen levels decline.10 Ovarian function declines with age. The onset of menopause features the decreasing production of oestradiol, as well as increasing levels of follicle-stimulating hormone (FSH).11 Menopause symptoms usually last around four year after the last menstrual period, although some women experience symptoms for longer. The average age for a woman to reach menopause is 52. When it

occurs before the age of 45 years, it is called premature menopause. It is estimated that premature menopause affects 1 per cent of women under the age of 40 and 0.1 per cent of women under the age of 30.1 Sometimes menopause is induced by invasive treatments, surgery including oophorectomy, and some breast cancer treatments, chemotherapy and radiotherapy. It can also be induced by underlying conditions such as Addison’s disease.10 The menopause transition is experienced by 1.5 million women globally each year and often involves vasomotor symptoms, vaginal

dryness, decreased libido, insomnia, fatigue, mood changes, lack of concentration, increased urinary tract infections, reduced bone and muscle mass, and joint pain.2, 10 Vasomotor symptoms affect most women during the menopausal transition, although the severity, frequency and duration varies. Hot flushes are reported by up to 85 per cent of menopausal women.3 Hot flushes and night sweats are present in as many as 55 per cent of women even before the onset of menstrual irregularity that define entry into

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Women's Health the menopausal transition. Their incidence and severity increases as women traverse the menopause, peaking in the late transition and tapering off over a number of years.4 The exact cause of hot flushes and night sweats is uncertain, but is thought to be due to the resetting and narrowing of the thermoregulatory system in association with fluctuations in or loss of oestrogen production.2, 7 The average duration of hot flushes occurring in women is 52 years, however, symptoms of lesser intensity may be present for longer.5 Approximately 25 per cent of women continue to have hot flushes up to five or more years after menopause. A meta-analysis of 35,445 women taken from 10 different studies confirmed a four-year duration of hot flushes, with the most problematic symptoms beginning one year before the final menstrual period and declining thereafter.6 Multiple population- and communitybased studies confirm that 27-to-60 per cent of women report moderate to severe symptoms of vaginal dryness or dyspareunia in association with menopause.8 In addition to vaginal atrophy, narrowing and shortening of the vagina, uterine prolapse can also occur, leading to high rates of dyspareunia. The urinary tract contains oestrogen receptors in the urethra and bladder, and as the loss of oestrogen becomes evident, women may experience increased urinary tract infections. Unlike vasomotor symptoms, vulvovaginal atrophy does not improve over time without treatment.2, 8 The menopause increases the risk of developing osteoporosis due to the lower levels of oestrogen in the body.10 During menopausal transition, the drop in oestrogen levels leads to more bone resorption than formation, resulting in bone loss. Osteoporosis is the most prevalent disease in menopausal women, and is strongly associated with a low quality of life.11 The prevalence of osteoporosis and related fractures are higher in postmenopausal women than in older men since oestrogen plays a key role in maintaining bone health. The fracture risk is higher in women than in men. The lifetime risk of fracture for a 60-year-old woman is close to 44 per cent, nearly double the risk for a man of the same

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age, which is 25 per cent.11 Since low oestrogen levels are the main cause of postmenopausal osteoporosis, hormone replacement therapy (HRT) is often considered as a first-line choice for prevention of osteoporosis and its effectiveness has been demonstrated by various studies. HRT is recommended for women who are aged below 60 years and/or less than 10 years post-menopausal. However, for those who are over the age of 60 and/or greater than 10 years postmenopausal, HRT is not recommended and other options should be considered.11

The menopause is a natural part of ageing that usually occurs between 45 and 55 years of age, as a woman’s oestrogen levels decline

Diagnosis and treatment There is no definitive test to diagnose the menopause, although measuring the level of follicle-stimulating hormone (FSH) in the blood can help confirm a diagnosis. FSH rises in women who are menopausal, however, a high level of FSH alone is not enough to make a diagnosis. A diagnosis of menopause can usually be confirmed in general practice by considering the woman’s age, whether or not they are still having periods and by asking questions about symptoms through a thorough history, which should also enquire about incontinence and sexual dysfunction.1,9 Blood pressure and BMI measurement and relevant blood tests should be included in the consultation and optional breast and pelvic examination, cervical smear test and mammography organised if required.9 The opportunity should also be taken to counsel and advise the woman with regard to general health screening, diet and exercise, bone health and contraception if required.9 Only one-in-10 women seek medical advice when going through the menopause and many do not require any treatment. If

menopausal symptoms are discomfiting or causing concern, there are treatments that can help. Treatment options include: HRT, tibolone which is similar to HRT, clonidine, vaginal lubricants and antidepressants. The type of treatment recommended depends on the symptoms, medical history, risks or sideeffects associated with the various treatments and the woman’s own preferences.1 HRT and tibolone do not provide contraceptive protection, and although fertility decreases during the menopause, it may still be possible to conceive. Therefore, continued use of contraception is recommended for one year after the woman’s last period if over the age of 50 and for two years after the last period if under 50 years of age.1

HRT HRT involves taking female hormones to restore the decline in the body’s levels during menopause. UK NICE (2015) guidelines state that HRT is effective and should be offered to women after discussing the risks and benefits. There are two main types of HRT:12  Combined HRT contains oestrogen and progesterone and can be taken by women who still have a womb.  Oestrogen-only HRT is available for women who have had a hysterectomy. HRT is available as tablets, transdermal patches, gels, intravaginal pessary or ring, nasal spray and implants. It is very effective at relieving menopausal symptoms, especially hot flushes and night sweats, but is associated with a number of side-effects including breast tenderness, headaches, and vaginal bleeding and is also associated with an increased risk of blood clots and breast cancer in some women.10 HRT has been the subject of much controversy and received negative press over the past two decades, leaving many women and some clinicians concerned about its use. Concerns about HRT are based on three main studies, which took place between 1998 and 2003. These three studies were the Heart Estrogen/Progestin Replacement Study (1998) US; the Women’s Health Initiative (WHI) study (2002) US; and the Million Women Study (2003) UK.9 The negative reports about HRT are largely due to the WHI study 2002, which has since been shown to be flawed. The

Women's Health

Menopause WHI study mainly included older women who were given types of HRT that are no longer prescribed today. Women included in the study were aged from 50-to-79 years (average age 63 years) with only 3.5 per cent of participants in the 50-54 year age group. Women with severe symptoms were excluded and women with previous serious cardiovascular disease (CVD) were included in the study. When WHI published the study they documented that “a small increased RR in breast cancer (1.26) was observed, which did not reach statistical significance”, however, the following year a JAMA editorial said the WHI study had demonstrated that breast cancer rates were “markedly increased” in the HRT group. This continues to lead to controversy and negative press regarding HRT today.9 Most experts agree that if HRT is used on a short-term basis for no more than five years in women under the age of 60 years, the benefits outweigh the risks. HRT can help reduce a woman’s risk of developing osteoporosis as well as cancer of the colon and rectum.14 HRT does not increase the risk of heart disease in women under 60. Current data shows that HRT use before the age of 50 years carries no additional risk of breast cancer, while its use between the ages of 50-54 is linked to a small additional risk. HRT use in women over 60 is linked to an increased breast cancer risk with data showing 30 cases/10,000 in women who never used it, compared to 38 cases/10,000 women who used it.9, 12 Women with known CVD, angina, and myocardial infarction (MI) should avoid HRT as should women over 10 years post-menopause. Data also shows that women less than 10 years from the menopause or under 60 years of age may derive some cardio-protection from HRT use but further studies need to be carried out to confirm this.9, 12 Observational data also suggest that transdermal HRT may be less thrombogenic than oral preparations.12 In the first two years after commencing oral HRT the risk of developing a deep vein thrombosis (DVT) is slightly raised. HRT should be avoided in women with a current or recent past history of DVT and caution taken with women who had venous thromboembolism (VTE) around pregnancy

MENOPAUSE STILL SEEN BY MANY AS A TABOO SUBJECT IN IRELAND Priscilla Lynch Recently published research has found that 40 per cent of surveyed Irish women who are currently going through, or who have recently gone through, menopause still think it is a taboo subject. Of those surveyed, only 40 per cent discussed symptoms of menopause with their healthcare professional while 37 per cent of women did not discuss their symptoms with anyone. Of those who did not discuss their menopausal symptoms, embarrassment was a factor for 22 per cent.  Some of the most common menopausal symptoms reported by the women who have gone through the menopause included: Hot flushes (71 per cent), night sweats (69 per cent), sleeping problems (65 per cent), weight gain (57 per cent), mood changes (45 per cent), vaginal dryness (44 per cent), and urinary issues (27 per cent). The research showed that vaginal dryness impacts 51 per cent of women post-menopause. Lower levels of oestrogen can also cause urinary problems including frequency, burning when urinating and recurrent urinary tract infections, which was reported by 12 per cent of those surveyed. The research also aimed to understand the impact of menopause on a woman’s sex life. It found that of those surveyed, 77 per cent said sex was important to them, however, 41 per cent reported that their sex lives had disimproved following menopause, with almost half (45 per cent) of women claiming that they have

or while on the combined oral contraceptive pill (COCP). Women with a strong family history of or multiple risk factors for DVT would benefit from haematological review before treatment and it may be safer to use transdermal products.9 Women taking HRT must be regularly reviewed and monitored in general practice. A follow up review should take place three months after commencing HRT and at least once a year after that. Regular reviews help ensure that symptoms are under control, side-effects are checked for, and weight and blood pressure are monitored. The type and effectiveness of HRT used will be reviewed

experienced discomfort during sex with vaginal dryness being the main cause of the discomfort with over sixin-10 women (62 per cent) experiencing it. Almost the same proportion (58 per cent) claimed that they felt pain during sex, with just over a quarter (27 per cent) claiming that they experienced tightness during sex. Women’s health expert GP Dr Deirdre Lundy, Coordinator Sexual and Reproductive Health Courses, ICGP, commented: “Menopause is something all women experience and as we are now living longer, we live with the after-effects of menopause for much longer.  There are new treatments available that target specific issues of menopause, such as vaginal dryness, which can help treat chronic ongoing symptoms and can greatly improve a women’s quality-of-life. This research shows that many women are suffering in silence so I would urge all women to engage with their doctor or nurse to discuss any symptoms of menopause that they may be experiencing.” In relation to vaginal dryness Dr Lundy said: “Women should seek treatment earlier rather than later as the longer a woman suffers without treatment the more difficult it is to reverse.” The research was commissioned by Besins Healthcare UK Ltd, and carried out by Empathy Research, on a nationally representative sample of 300 female adults aged 45-to-60 years who have experienced the menopause or are currently going through the menopause (February-March 2020).

and changes made if necessary and discussion will also take place about when and how the treatment will eventually be discontinued.10

Alternative therapies Alternative therapies for hot flushes and sweats include alpha agonists such as clonidine HCl 50-75mcg BD. Side-effects can include insomnia, dry mouth, and drowsiness. Other alternative therapies for hot flushes and sweats include COC, the combined oral/TD/TV contraception, selective serotonin reuptake inhibitors (SSRIs) and gabapentin. NICE

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Women's Health guidelines suggest that 900mg daily of gabapentin has been shown to reduce vasomotor symptoms by approximately 50 per cent. Gabapentin may be of use in women with breast cancer.9 Cognitive behavioural therapy (CBT) has been found beneficial over placebo in several aspects of peri-menopausal management including vasomotor menopausal symptom relief. Mindful meditation practice is also recommended by NICE to help with low mood and anxiety.9 Oestrogen applied as a pessary, cream or vaginal ring directly into the vagina can be prescribed for vaginal pain, itch or dryness. This can be safely used alongside HRT, but may need to be used indefinitely as symptoms are likely to return when treatment stops. Over-the-counter vaginal moisturisers or lubricants can be used in addition to or instead of vaginal oestrogen.10 Some women experience mood swings, low mood and anxiety during the menopause. Self-help measures such as rest, taking regular exercise and relaxation activities may be beneficial. SSRIs may be used for the treatment of low mood or depression associated with menopause.10 Loss of libido is a common symptom during and post menopause. HRT can help, but if not effective a testosterone supplement may be considered. Testosterone can help restore sex drive. While it is not currently licenced for use in women, it can be prescribed off-label. Possible side-effects of testosterone therapy include acne and facial hair.10

Diet, physical activity, and bone health A healthy well balanced diet should be encouraged including oily fish, low GI fruits and vegetables, whole grains, soya and legumes. Excess red meat and simple sugars should be avoided. Regular physical activity is important for overall physical and psychological health. It improves the cardiovascular system and helps decrease LDLs and increase HDLs. Weight-bearing and resistance exercises help to strengthen bones and muscle mass and can help reduce the risk of falling by improving strength, flexibility and balance.9

26 MAY-JUNE 2021

Menopause Taking HRT can help prevent osteoporosis, although this effect does not last once treatment is stopped. A diet rich in calcium and vitamin D is important for bone health, and an intake of at least 400mIU (10 mgs) per day of vitamin D as a supplement should be considered given the prevalence of vitamin D deficiency in Ireland, and calcium 700-1200mg daily, ideally via diet.9 Stopping smoking and cutting down

Weight-bearing and resistance exercises help to strengthen bones and muscle mass and can help reduce the risk of falling by improving strength, flexibility and balance

References 1. HSE (2011). The Menopause. Health Service Executive. Dublin. Available at: www.hse.ie/eng/health/az/m/menopause/ 2. Santoro N, Epperson C, Mathews S. Menopausal (2015). Menopausal Symptoms and their Management. Endocrinol Metab Clin North Am. 2015; 44 (3) : 497 – 515 doi:10.1016/j. ecl.2015.05.001 3. ACOG (2014). Practice bulletin No. 141: Management of menopausal symptoms. Obstet Gynecol. 2014;123:202216. [PubMed]  4. Gold EB, Colvin A, Avis N, et al. (2006). Longitudinal analysis of the association between vasomotor symptoms and race/ethnicity across the menopausal transition: Study of Women’s Health Across the Nation. Am J Public Health. 2006 ; 96:1226-1235 5. Col N, Guthrie J, Politi M, et al. (2009). Duration of vasomotor symptoms in middle-aged women: a longitudinal study. Menopause. 2009;16:453–457. [PubMed] [Google Scholar] 6. Politi M, Schleinitz M, Col N. (2008). Revisiting the duration of vasomotor symptoms of menopause: a meta-analysis. J Gen Intern Med. 2008; 23:1507–1513. [PMC free article] [PubMed]  7. Freeman E, Sammel M, Lin H, et al. (2007). Symptoms

on alcohol if applicable is also good for maintaining general and good bone health.9, 10 Complementary and alternative therapies, such as herbal remedies and bioidentical hormones are generally not recommended for menopause symptoms, as it is unclear how safe or effective they are and some may interact with other medications and cause side-effects.10 With increased life-expectancy, women now spend at least a third of their lives postmenopausal. According to CSO statistics, almost 333,000 women in Ireland are potentially peri-menopausal at any one time and eight-out-of-10 women experience symptoms leading up to menopause.13 Once a taboo subject and rarely acknowledged in Irish society, it is reassuring to see the range of care and menopausal treatments now available in general practice and the growth of dedicated menopause clinics to help women manage their symptoms through the transition phase of what can be a very difficult time in their lives.

associated with menopausal transition and reproductive hormones in midlife women. Obstet Gynecol. 2007;110:230–240. [PubMed]  8. Santoro N, Komi J. (2009). Prevalence and impact of vaginal symptoms among postmenopausal women. J Sex Med. 2009;6:2133–2142.[PubMed] [Google Scholar] 9. Lundy D. (2018). Effective Solutions for Problems experienced by Women at the Menopause. ICGP AGM May 25, 2018. Dublin Convention Centre. Dublin 10. NHS (2018). Menopause Overview. National Health Service. UK. Available at: www.nhs.uk/conditions/menopause/ 11. Ji M, Yu Q. (2015). Primary osteoporosis in postmenopausal women. Chronic Dis Transl Med. 2015;1(1):9-13. Published 2015 Mar 21. doi:10.1016/j.cdtm.2015.02.006 12. NICE (2015) Menopause Full Guidelines. Clinical Guideline Methods, Evidence and Recommendations. Version 1.5. National Institute of Clinical Excellence. UK Available at: www.nice.org.uk/ guidance/ng23/evidence/full-guideline-pdf-559549261 13. CSO Statistics (2016). Central Statistics Office. Dublin 14. NHS Inform (2020). Hormone replacement therapy. National Health Service. UK. Available at: www.nhsinform.scot/tests-andtreatments/medicines-and-medical-aids/types-of-medicine/ hormone-replacement-therapy-hrt

Feature Author: Alexandra C Kelly BSc, MSc, P.G.Dip, RGN, RNT, RNP, RANP, Clinical Nurse Specialist in Pain Management, Beacon Hospital, Dublin and Adjunct Lecturer/ Assistant Professor, School of Nursing, Midwifery and Health Systems, University College Dublin

Feature Pain and Dementia



Concise, evidence-based information for GPNs regarding the common features of pain in the older person with dementia and its effective assessment

t is well established that the prevalence of both dementia and pain increases with age. One-in-14 people over the age of 65 years have dementia, and 50 per cent of those aged over 65 suffer from chronic pain. Concurrently, the age of Ireland’s population has been increasing since the 1980s. Indeed, from 2011 to 2016, the number of Irish adults over the age of 65 increased by 19.1 per cent. It is likely that this has a significant impact on patient care in general practice. Irish research conducted in 2016 found that nearly 22 per cent of encounters in general practice were with an adult over 70 years of age. Nurses in general practice are therefore very likely to encounter individuals of advancing age who are suffering from both dementia and pain. Your ability to work with your patient and their family or carers to perform an effective pain assessment is essential, as this is the first step in its effective management. The objective of this article is to provide practice nurses with concise, evidence-based information regarding the common features of pain in the older person with dementia and its effective assessment. It is outside the scope of this article to address the management of pain in this population, but some current open access literature on this topic is included in the bibliography section at the end of this article in order to guide independent learning.

What is pain? Pain is sometimes defined as ‘whatever the experiencing person says it is, existing whenever the experiencing person says it does’. This definition illuminates the subjective nature of pain; in other words, there is no objective test that can definitively establish whether a person is experiencing pain, or can measure the severity of that pain. You are therefore relying on your patient to provide you

People suffering from dementia typically have difficulty with memory, thinking and language, which are required to conceptualise and express pain

with the necessary information to perform a pain assessment. However, if an individual struggles to understand your questions, does not have the language to accurately communicate the sensations that they are experiencing, and does not have the abstract reasoning required to appreciate the effect that these sensations are having on their quality-of-life, pain becomes much more challenging to assess and treat. People suffering from

dementia typically have difficulty with memory, thinking and language, which are required to conceptualise and express pain. In addition, the older person may suffer from sensory impairment such as hearing and/or vision changes, which can impede effective communication. Unfortunately, pain in the older person with dementia commonly goes undetected for these reasons. Pain may also be defined as ‘an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage’. Here, it is stressed that in addition to the unpleasant physical sensations that arise as a result of pain, there are always emotional implications for the person. Older people who suffer from pain are more likely to experience loneliness and social isolation, depression and anxiety, and interference with activities of daily living such as impaired sleep and mobilisation. In order to assess pain, it is essential to have an understanding of the different types of pain your patient may experience. A visual breakdown of the types and aetiologies of pain outlined below can be seen in Figure 1. A patient may experience one type of pain, or a combination of types. One of the simplest ways of classifying pain is by duration. Acute pain is related to a specific injury that lasts for a limited time, such as pain from a fracture following a fall. Chronic

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Pain and Dementia

Figure 1: Types of pain pain persists beyond three months; this may be associated with long-term conditions, such as diabetic neuropathy. Pain may also be classified according to its site of origin. Nociceptive pain arises from non-neural tissue. Nociceptive pain may be further classified as somatic (arising from such structures as bone, muscle, ligament or skin) or visceral (arising from deep organs, such as the bowel, uterus or bladder). Acute nociceptive pain, which is somatic in origin, will arise following a fracture or a skin laceration. Patients with constipation may suffer from acute nociceptive pain, which is visceral in origin, as the bowel stretches due to faecal loading or colic. An example of chronic nociceptive pain, which is somatic in origin, is the pain associated with osteoarthritis. In this condition, thinning cartilage causes changes in the underlying bone. An example of chronic nociceptive pain, which is visceral in origin, is the pain associated with endometriosis, whereby growth of endometrial cells outside the uterine lining cause inflammation and scarring in the pelvic and abdominal organs and abdominal wall. Neuropathic pain occurs as a result of a problem with the nervous system itself and may arise in

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the peripheral and/or central nervous system. An example of acute neuropathic pain may be found in patients with shingles. In its initial presentation, reactivation of the varicella zoster virus in the peripheral nervous system causes blistering of skin and pain in the associated area. However, pain may persist long after the skin rash has healed. Some patients who have been diagnosed with shingles subsequently develop postherpetic neuralgia, a chronic neuropathic pain condition. It is important to remember that each type of pain can exist without tissue damage, and that tissue damage can exist without pain.

Holistic approaches to pain in the older person When assessing pain, it is important to consider not only the physical sensations experienced by the person, but also social, spiritual and psychological aspects. These will vary between younger and older populations. For example, with regard to the physical processing of pain in the older person, there is some evidence to suggest that changes in the nervous system over time result in a higher pain threshold. For this reason, clinicians often assume that older people feel less pain than their

younger counterparts. However, the body’s intrinsic mechanisms for pain control (such as the natural release of endorphins in response to a painful event) are also impaired, which can lead to increased pain intensity. Social differences may contribute to bias and misconceptions on your part and on the part of your patient, which can affect pain assessment. For example, stoicism is common in older populations. While this is seen as an individual coping strategy rather than a negative trait, it may lead to under-reporting of pain. You and your patient may also make assumptions about what the other is thinking and feeling. For example, your patient may assume that you know how much pain they are in, while you may be assuming that they will tell you if they have pain. Actively probing for pain is important in order to avoid this communication gap. Differences in language can also impede pain assessment. Often the older person will deny pain, but confirm that they are experiencing ‘soreness’ or ‘hurt’ when asked. For this reason, it is helpful to use a variety of different words to describe sensations when probing for pain. The spiritual component of pain is concerned with philosophy; in other words, the meaning that the person attributes to pain. For example, the older person may interpret pain as punishment or atonement for previous behaviours. They may assume that pain means advancing disease, and consequently may fear discussing this with you. Conversely, the older person may interpret pain as a normal feature of advancing age and assume that relief is not a possibility. Your patient may be concerned that a discussion about pain would serve as a distraction from their priority of treatment for the underlying condition. Open conversation about pain can help to identify and address such preconceptions. The psychological aspect of pain may be concerned with its common emotional effects such as sadness or fear, or associated psychopathology, such as depression or anxiety. It is also concerned with learning and knowledge development. Both you and your patient have spent a lifetime learning about pain. Beginning in early childhood, every previous pain experience builds on the last, leading up to the assessment that you will perform together.


Pain and Dementia sweeping motion of the hand. In order to assess pain quality, you can simply ask the patient what their pain feels like. Offering a few descriptors such as ‘dull, aching, sharp, or burning’ can help to prompt the person. The person’s chosen descriptors will aid you in diagnosing their pain type (see Figure 1). If the patient cannot speak, they may be able to nod or squeeze your hand in response to your questions. Perhaps most importantly, the person must be given adequate time to talk about their pain in order to maximise the possibility of obtaining a self-report.

Figure 2: Enhanced hierarchy of pain assessment (Source: ASPMN) A positive experience will have an impact on each subsequent experience of pain assessment for both of you.

Using an evidence-based framework to assess pain Given that the older person with dementia is at particular risk for under-recognition and undertreatment of pain, it is wise for your assessment to follow a systematic approach. The American Society for Pain Management Nursing (ASPMN) provides an evidence-based framework for guiding pain assessment in the patient unable to selfreport pain. This method of assessment follows a hierarchical approach, which prioritises selfreport where possible. The framework can be seen in Figure 2, and is applied to pain assessment in the older person with dementia, as outlined below.

Use the hierarchy of pain assessment techniques

Be aware of potential causes of pain As your patient may be unable to tell you that they have pain, it is important to be aware of any potential causes of pain. As mentioned above, chronic pain is very common in the older person, with the most frequent sites being the knees, hips and back. If the person’s visit requires a certain body position, such as lying laterally on a table, this may exacerbate their chronic pain. You should also consider the possibility of acute pain in the context of their presenting complaint. For example, if your patient has had a recent fall, recent surgery, been diagnosed with an infection such as in the urinary or respiratory tract, or has another acute condition such as constipation, they may experience pain as a result. Furthermore,

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acute pain may cause a period of exacerbation (or ‘flare’) of underlying chronic pain. Medical history may reveal other potential sources of pain such as cancer, diabetic neuropathy or multiple sclerosis. Pain may also be associated with procedures that you undertake in the practice, such as dressing changes or phlebotomy.

Attempt to obtain a self-report of pain You should attempt to obtain a self-report of pain with every patient. This is the most accurate assessment strategy and safeguards the person’s autonomy in care. Assessment of present pain may be more reliable, as it may be difficult for the person to recall past painful experiences. While the severity of the person’s dementia will have an impact on the strategies used to assess pain, many older people with dementia can use pain assessment tools if they are facilitated to do so. To assess pain intensity, usually a simple verbal rating scale such as mild – moderate – severe will be preferred. The numerical rating scale 0-to-10 may also be used or pictoral scales such as the Wong-Baker FACES scale. It can be useful to show the scale to the patient, as this helps with abstract reasoning. The same scale should be used consistently when one is identified as appropriate for a particular patient, so their preference should be documented in their file. In order to assess pain location, the person may be able to point to the area of their body where they are experiencing pain. Different motions may be used depending on which type of pain the person is experiencing. For example, somatic pain is usually well localised and may be indicated by a pointed finger, whereas visceral pain is usually diffuse, indicated by a

Observe patient behaviours If the person is unable to self-report pain, assessment depends on the observation of painrelated behaviours. Importantly, while this kind of assessment may suggest that your patient has pain, it does not tell you how severe the pain is. It is also important to consider that pain behaviours may also overlap with fear-related behaviours. Behaviours commonly associated with pain include changes to facial expression, interpersonal interactions and activity patterns, and negative verbalisations such as groaning. Behaviours should be assessed at rest and on movement. Tools to standardise measurement of pain behaviours are mentioned below.

Solicit proxy reporting of pain and behaviour/activity changes In the process of assessing pain-related behaviours, it is important to be familiar with the patient’s routine activities. When you meet an older person with dementia for the first time, involving family members and caregivers will help you to detect changes from their baseline. To facilitate future assessments, it may be sensible to teach a proxy reporter about the different types of pain behaviours that may be observed. However, these reports should be used as one part of your pain assessment and should not be relied upon as a sole method of assessment.

Attempt an analgesic trial The type of analgesia used for a trial will depend on the patient. You may start with a nonpharmacologic treatment (such as ice or a heat pack), or a non-opioid drug such as paracetamol or ibuprofen. A mild opioid may be considered if there is no change in behaviour; thereafter doses can be adjusted slowly. However, if


Pain and Dementia neuropathic pain is suspected, the person may require analgesia specifically for this type of pain, such as gabapentin. It is essential to consider the patient’s medical history, gastrointestinal, renal and hepatic function, and to be aware of potential polypharmacy and drug interactions. Sources of more detailed guidance on the pharmacologic management of pain can be found in the bibliography section of this article.

ABBEY PAIN SCALE For measurement of pain in people with dementia who cannot verbalise

Utilise behavioural pain assessment tools There are a number of behavioural pain assessment tools available for use. The report of the second National Dementia Audit of Ireland recommends either the Abbey Pain Scale or the Pain in Advanced Dementia (PAINAD) Scale. The Abbey Pain Scale takes one minute, whereas PAINAD requires a five-minute observation period. Use of either tool helps to ensure consistency between assessments. Ideally assessments should be performed at rest and on movement.

Minimise emphasis on vital signs If your patient has changes in vital signs, this should only be taken as a prompt to complete a more detailed pain assessment. Vital sign changes do not indicate the presence of pain, nor does an absence of vital sign changes confirm that the person has no pain.

Assess regularly, reassess postintervention, and document As your pain assessment gives information about a single point in time, it is essential to reassess pain frequently. Reassessment provides important information regarding the effectiveness of your interventions to treat pain. Documentation of numerous assessments allows caregivers to glean more detailed information about pain, such as its temporal features and the overall impact of pain on the person’s quality-of-life.

Conclusion Pain and dementia are common among patients in general practice. An understanding of the types of pain your patient may experience will aid in its effective assessment. Holistic approaches to assessment are essential, and should take the physical, social, spiritual, and psychological aspects of pain into account. A systematic

Figure 3: Abbey Pain Scale approach to pain assessment in the older person with dementia will improve the validity of your assessment. Pain assessment should follow a hierarchical approach, with priority given to obtaining a self-report of pain where possible. Observation of pain behaviours can be standardised through the use of an evidence-based assessment tool. Family and caregivers should be included in the assessment process. Pain should be assessed and reassessed frequently, with documentation of results to enhance quality in pain assessment and its subsequent management. References on request

Bibliography 1. Abdulla A, Adams N, Bone M, Elliott AM, Gaffin J, Jones D, Knaggs R, Martin D, Sampson L, Schofield P. (2013) Guidance on the management of pain in older people. Age and Ageing 42, i1-i57. Retrieved from https://academic.oup. com/ageing/article/42/suppl_1/i1/9650?login=true on 21 February 2021 2. Schug S A, Scott D A, Mott J F, Halliwell R, Palmer G M, Alcock M. (2020) Acute Pain Management: Scientific Evidence (5th edn). Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine, Melbourne. Retrieved from www.anzca.edu.au/resources/collegepublications/acute-pain-management/apmse5.pdf on 21 February 2021

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Feature Author: Ruth Morrow, Registered Advanced Nurse Practitioner (Primary Care), Respiratory Nurse Specialist (WhatsApp Messaging Service Asthma Society of Ireland)




Allergic rhinitis is a risk factor for asthma, with 10-to-40 per cent of people who have allergic rhinitis also having asthma symptoms

sthma is a heterogeneous disease, usually characterised by chronic airway inflammation defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness, and cough that vary over time and in intensity, together with variable expiratory airflow limitation (GINA, 2020). Asthma affects over 380,000 people in Ireland; 7.1 per cent of Irish adults have asthma with 890,000 likely to experience it sometime in their lifetime. It is estimated that over 80 per cent of people with asthma have allergic rhinitis (AR). AR is a risk factor for asthma – 10-to-40 per cent of people who have AR also have asthma. AR is more likely to develop initially with asthma developing later. Therefore, people with AR should be assessed for asthma due to the increased of developing asthma. Similarly, patients with persistent asthma should be assessed for AR.

Symptoms of allergic rhinitis Typical symptoms of seasonal (hay fever) and perennial AR are:  Sneezing;  Itchy, blocked, or runny nose;  Red, itchy, or watery eyes;  Itchy throat, inner ear, or mouth;  Postnasal drip (a drip of mucus from the back of the nose into the throat);  Headaches;  Loss of concentration and generally feeling unwell;  Reduced sensation of taste and smell.

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For pollen levels in your area, see our pollen tracker on asthma.ie

Figure 1: Symptom chart

Patients may experience all or some of the above. Symptoms may be confused with symptoms of Covid-19. Figure 1 illustrates the differences between asthma, COPD, AR, Covid-19, the common cold, and flu.

Classification of AR In 2019, the classification of ‘seasonal’ and ‘perennial’ rhinitis was changed to ‘intermittent’ and ‘perennial’ rhinitis by the Allergic

Our pollen tracker is kindly supported by

Rhinitis and its Impact on Asthma (ARIA) initiative, which develops internationally applicable guidelines for allergic respiratory diseases. Intermittent rhinitis is classed as occuring less than four days per week or less than four weeks. Persistent rhinitis lasts more than four days and longer than four weeks. Both intermittent and persistent AR can be mild or moderate/severe (see Figure 2).



Figure 2: Classification of allergic rhinitis (ARIA, 2019) DRUG THERAPY OPTIONS


Oral H1 antagonists

Sneezing, rhinorrhoea, nasal itch, eye symptoms

Intranasal HI antagonist

Sneezing, rhinorrhoea, nasal itch

Intraocular HI antagonist

Eye symptoms

Intraocular cromones

Eye symptoms

Intranasal decongestants

Nasal blockage

Oral decongestants

Nasal blockage

Leukotriene receptor antagonists (LTRA)

Rhinorrhoea, nasal blockage, eye symptoms

Intranasal corticosteroids (INCS)

All symptoms

Oral corticosteroids

All symptoms


All symptoms

Table 1: Pharmacological treatment options for allergic rhinitis Presentation of the patient with AR The early response usually occurs within minutes of exposure to the allergen resulting in an inflammatory response. Mast call degranulation occurs resulting in nasal congestion, an increase in nasal secretions and nasal airway resistance. Several neural peptides, sympathetic and parasympathetic fibres are involved. The late response usually occurs hours later resulting in cellular inflammation. Symptoms recur at this this stage especially nasal congestion. T-cells and mast cells also produce cytokines during the late response. See Figure 3.

Pharmacological interventions (ARIA 2019) There are several treatment options available to the patient and a combination of these options may be required for optimal relief of symptoms. These are outlined in Table 1. Saline douching/nasal irrigation should also be encouraged and is available either as a saline rinse or saline spray. Saline rinsing involves high volume at a low pressure, whereas saline spray is a low volume delivered at high pressure. The advantages of saline douching include:  Direct cleansing;

 Removal of mucous and inflammatory mediators;  Reduces bacterial burden;  Reduces mucus thickness;  Improves mucociliary function by increasing ciliary beat frequency. Smoking cessation should be encouraged at every opportunity. Smoking increases the likelihood of chronic nasal symptoms and may be associated with the development of nasal polyposis. Passive smoking, environmental exposure, e-cigarettes, and vaping also increase the likelihood of chronic nasal symptoms and nasal polyposis. Mild intermittent AR treatment options include oral and nasal decongestants can be used as a rescue medication. These medications will reduce nasal congestion and should be used for no longer than seven days and should be avoided in pregnancy and breastfeeding. Oral H1 antagonists block the physiological effects from mast cell derived histamine. Second generation antihistamines are preferred due to their less sedating effect and are available over the counter. Antihistamines are also available intranasally or intraocular. Intranasal corticosteroids (INCS) are the first-line treatment for moderate/severe intermittent and persistent AR. These medications are used once or twice daily to each nostril and good technique is essential. If the nasal cavity is very obstructed, a nasal spray may not be effective. Nasal drops may be more effective in this scenario. Nasal spray and nasal drop technique can be viewed on www.asthma.ie/ about-asthma/resources/inhaler-technique-videos. Efficacy of INCS is not improved when used with oral corticosteroids (OCS). Figure 4 provides a stepwise approach to the management of AR. Sub-lingual immunotherapy (SLIT)/ allergen immunotherapy (AIT) is now recommended by GINA (2020) as a treatment option for patients with asthma who are sensitised and have AR. Immunotherapy is also recommended by ARIA (2019) for patients with AR who do not get an optimal response from oral H1 or INCS therapies. These medications are not available on the GMS and can be prescribed by GPs.

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Intermittent rhinitis: Persistent rhinitis:

Consider referral to allergist and ENT

Figure 3: Patient presentation with allergic rhinitis Non-pharmacological interventions Lifestyle intervention  Keep windows closed at night-time or

when the pollen count is high.  Monitor the pollen tracker on www.asthma.ie and minimise time spent outdoors when the pollen count is high.  Apply Vaseline around nostrils when outdoors to trap pollen.  Wear wraparound sunglasses to minimise levels of pollen irritating the eyes. Splash the eyes with cold water to help flush out pollen and soothe and cool the eyes.  Shower, wash the hair and change clothes if you have been outdoors for an extended period of time.  Exercise in the morning rather than the evening when there are higher rates of pollen falling.    Avoid drying clothes outdoors and shake clothes outside before bringing them inside – particularly bedclothes.  Minimise contact with pets that have been outdoors and are likely to carry pollen.   Put an Asthma Action Plan in place (Figure 5). An Asthma Action Plan contains all the information a person with asthma needs to keep their condition in

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 Be prepared – around Easter, patients should

have a review with GP and have a plan in place to optimise control of AR symptoms  Students should be advised to avoid sitting

near open window, if possible  Bring antihistamine/nasal spray to exam  Have optimal technique in using nasal spray/

nasal drops  Splash eyes with cold water before exam  Keep a supply of tissues to hand

Table 2: Exam time tips control. Every person with asthma should be offered a plan. It should be reviewed frequently and any time medication is changed. These can be downloaded for free from www.asthma.ie and should be filled out with the person’s healthcare professional.

Exam time tips Walker et al (2007) showed that students undertaking exams may drop a grade in

their exam results because of AR as a result of symptoms, sedating medication, and poor sleep. Having AR under optimal control cannot be underestimated. Some tips to help with exam time are listed in Table 2.

Endonasal phototherapy Endonasal phototherapy has an immunosuppressive effect by inhibiting allergen induced histamine released from mast cells. It also induces apoptosis in the T-lymphocytes and eosinophils. The procedure directs a combination of UV-B. UV-A and visible light into the nasal cavity. Endonasal phototherapy is generally welltolerated and effective and is a treatment option when pharmacological treatment is insufficient or contraindicated.

Surgical intervention It is considered that AR is a medical condition which requires medical intervention. However, if symptoms are unilateral; septal deviation, nasal polyps or tumour should be considered. Patients will still need to have an AR plan in place post-surgical intervention.

Dimensions: 214mm x 275mm (WxH)


KEEP ASTHMA TAMED Proactive asthma control that lasts1,2 RELVAR ELLIPTA

(fluticasone furoate/vilanterol)

*Relvar Ellipta is indicated for the regular treatment of asthma in adults and adolescents aged 12 years and older where use of a combination medicinal product (long-acting β2-agonist and inhaled corticosteroid) is appropriate: patients not adequately controlled with inhaled corticosteroids and ‘as needed’ inhaled short acting β2-agonists or patients already adequately controlled on both inhaled corticosteroid and long-acting β2-agonist2 For Healthcare Professionals only. Images used are for illustrative purposes only. Relvar is well tolerated. Most common adverse events are nasopharyngitis and headache2 PM-IE-FFV-ADVT-200005 December 2020 Relvar Ellipta was developed in collaboration with References: 1. Bernstein DI et al. J Asthma 2015; 52: 1073-1083. 2. Relvar Ellipta SmPC, 2019, available on www.medicines.ie

Relvar® Ellipta® (fluticasone furoate/ vilanterol [as trifenatate]) Prescribing information (Please consult the full Summary of Product Characteristics (SmPC) before prescribing) Relvar® Ellipta® (fluticasone furoate/vilanterol [as trifenatate]) inhalation powder. Each single inhalation of fluticasone furoate (FF) 100 micrograms (mcg) and vilanterol (VI) 25mcg provides a delivered dose of 92mcg FF and 22mcg VI. Each single inhalation of FF 200mcg and VI 25mcg provides a delivered dose of 184mcg of FF and 22mcg of VI. Indications: Asthma: Regular treatment of asthma in patients ≥12 years and older where a long-acting β2-agonist and inhaled corticosteroid combination is appropriate and where patients are not adequately controlled on inhaled corticosteroids and ‘’as needed” short-acting inhaled β2-agonists, or where patients are already controlled on both inhaled corticosteroid and long-acting β2-agonist. COPD (Relvar 92/22mcg only): Symptomatic treatment of adults with COPD with a FEV1<70% predicted normal (post-bronchodilator) and an exacerbation history despite regular bronchodilator therapy). Dosage and administration: Inhalation only. Asthma: Patients with asthma should be given the strength of Relvar Ellipta containing the appropriate fluticasone furoate (FF) dosage for the severity of their disease. Prescribers should be aware that in patients with asthma, FF 100 mcg once daily is approximately equivalent to fluticasone propionate (FP) 250 mcg twice daily, while FF 200 mcg once daily is approximately equivalent to FP 500 mcg twice daily. Adults and adolescents ≥12 years: one inhalation once daily of: Relvar 92/22mcg for patients who require a low to mid dose of inhaled corticosteroid in combination with a long-acting β2-agonist. If patients are inadequately controlled then the dose can be increased to one inhalation once daily Relvar 184/22mcg. Relvar 184/22mcg can also be considered for patients who require a higher dose of inhaled corticosteroid in combination with a long-acting β2-agonist. Regularly review patients and reduce dose to lowest that maintains effective symptom control. COPD: one inhalation once daily of Relvar 92/22mcg. Contraindications: Hypersensitivity to the active substances or to any of the excipients (lactose

Keep Asthma Tame 2021_PM-IE-FFV-ADVT-200005_214 x 275_D7.indd 1

monohydrate & magnesium stearate). Precautions: Pulmonary tuberculosis, severe cardiovascular disorders, heart rhythm abnormalities, thyrotoxicosis, uncorrected hypokalaemia or patients predisposed to low levels of serum potassium. chronic or untreated infections, diabetes mellitus. Paradoxical bronchospasm – substitute alternative therapy if necessary. In patients with hepatic with moderate to severe impairment 92/22mcg dose should be used. Acute symptoms: Not for acute symptoms, use short-acting inhaled bronchodilator. Warn patients to seek medical advice if short-acting inhaled bronchodilator use increases. Therapy should not be abruptly stopped without physician supervision due to risk of symptom recurrence. Asthma-related adverse events and exacerbations may occur during treatment. Patients should continue treatment but seek medical advice if asthma symptoms remain uncontrolled or worsen after initiation of Relvar. Systemic effects: Systemic effects of inhaled corticosteroids may occur, particularly at high doses for long periods, but much less likely than with oral corticosteroids. Possible Systemic effects include: Cushing’s syndrome, Cushingoid features, adrenal suppression, decrease in bone mineral density, growth retardation in children and adolescents, cataract, glaucoma. More rarely, a range of psychological or behavioural effects including psychomotor hyperactivity, sleep disorders, anxiety, depression or aggression (particularly in children). Increased incidence of pneumonia, including pneumonia requiring hospitalisation, has been observed in patients with COPD receiving inhaled corticosteroids. If a patient presents with visual disturbance they should be considered for referral to an ophthalmologist for evaluation of possible causes which may include cataract, glaucoma, or rare diseases such as central serous chorioretinopathy. Physicians should remain vigilant for the possible development of pneumonia in patients with COPD as the clinical features of such infections overlap with the symptoms of COPD exacerbations. Risk factors for pneumonia include: current smoking, older age, low body mass index and severe COPD. The incidence of pneumonia in patients with asthma was common at the higher dose of Relvar (184/22mcg). Patients with rare hereditary problems of galactose intolerance, the total lactase deficiency or glucose-galactose malabsorption

should not use Relvar. Interactions with other medicinal products: Interaction studies have only been performed in adults. Avoid β-blockers. Caution is advised when co-administering with strong CYP 3A4 inhibitors (e.g. ketoconazole, ritonavir, cobicistat-containing products). Concomitant administration of other sympathomimetic medicinal products may potentiate the adverse reactions of FF/VI. Relvar should not be used in conjunction with other longacting β2-adrenergic agonists or medicinal products containing long-acting β2-adrenergic agonists. Pregnancy and breast-feeding: Experience limited. Balance risks against benefits. Side effects: Very Common (≥1/10): Headache, nasopharyngitis. Common (≥1/100 to <1/10): Candidiasis of the mouth and throat, pneumonia, bronchitis, upper respiratory tract infection, influenza, oropharyngeal pain, sinusitis, pharyngitis, rhinitis, cough, dysphonia, abdominal pain, arthralgia, back pain, muscle spasms, fractures, pyrexia. Uncommon (≥1/1,000 to <1/100): Hyperglycaemia, vision blurred, extrasystoles. Rare (≥1/10,000 to <1/1,000): Hypersensitivity reactions including anaphylaxis, angioedema, rash and urticaria; palpitations, tachycardia, tremor, anxiety, paradoxical bronchospasm. Marketing authorisation (MA) Holder: GlaxoSmithKline (Ireland) Limited, 12 Riverwalk, Citywest Business Campus, Dublin 24, Ireland. MA Nrs: 92/22mcg 1x30 doses [EU/1/13/886/002]; 184/22mcg 1x30 doses [EU/1/13/886/005]. Legal category: POM B. Last date of revision: June 2019. Code: PI-2046. Further information available on request from GlaxoSmithKline, 12 Riverwalk, Citywest Business Campus, Dublin 24. Tel: 01-4955000.

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

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Figure 4: Stepwise pharmacological treatment for allergic rhinitis

Figure 5: Asthma Action Plan

Special considerations in AR Children under four years

Figure 6 illustrates the typical age of onset of allergies in children. Outdoor allergens are unusual in children under two years of age. Type 2 sub-endotype IL4/IL-13 are associated with AR in children. IL-5 is associated with asthma. Treatment of children under four years should focus on allergen avoidance and saline spray. Cetirizine is the oral H1 antagonist of choice. Cetirizine is licensed from two years, but good safety is reported from six months of age. For moderate/severe persistent AR, intranasal corticosteroids such as fluticasone or mometasone should be considered first-line treatment. Longterm follow-up studies suggest no growth retardation if used as a once-daily dose. Caution should be taken in children who are also using inhaled or topical corticosteroids for asthma or dermatitis. In children with resistant symptoms and those with co-existing asthma, leukotriene receptor antagonists should be considered. Parents should be educated in relation to possible side-effects of sleep disturbance and mood disorders.

Pregnancy AR affects 20 per cent of pregnancies and women with pre-existing AR can experience an increase in symptoms. Medications should be avoided where possible and should be used if benefits to the mother are greater than risk to foetus. Medication should be avoided

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Figure 6: The allergic march in children in the first trimester if possible. Topical administration of medication should be firstline where possible.

Conclusion This article has explored the relationship between asthma and AR. Pharmacological and non-pharmacological interventions for the management of AR have been discussed. Special considerations in children and pregnancy have been addressed. The impact of AR on health and well-being is significant, with many people experiencing impairment of daily activities, learning and cognitive function, as well as reduced productivity at work and school. Optimal control of symptoms through pharmacological and non-pharmacological treatment regimes in combination

with education, self-management, and empowerment are paramount to manage this distressing condition.

References 1. Bousquet JJ, Schünemann HJ, Togias A, et al. Nextgeneration ARIA care pathways for rhinitis and asthma: a model for multimorbid chronic diseases. Clin Transl Allergy. 2019, 9, 44 2. Global Initiative for Asthma, 2020. Global Strategy Management and Prevention. Available at www.ginasthma.org 3. Walker S, Khan-Wasti S, Fletcher M, Cullinan P, Harris J, Sheik A. Seasonal allergic rhinitis is associated with a detrimental effect on examination performance in United Kingdom teenagers: case-control study. Allergy Clin Immunol. 2007 Aug;120(2):381-7

Women's Health

Cardiovascular Disease Author: Priscilla Lynch



ardiovascular disease is often perceived as a man’s disease, but it impacts men and women equally; almost 5,000 women in Ireland die from heart disease and stroke annually, making it the leading cause of death for women. In fact, women are almost seven times more likely to die from cardiovascular disease than breast cancer, yet the traditional image of a heart attack is a man clutching their chest. Moreover, the literature shows that women can experience delays in being diagnosed correctly, being less likely to get the required diagnostics or be treated as quickly and aggressively as their male counterparts. The warning signs of a myocardial infarction (MI) can be more subtle in women than men, noted Dr Róisín Colleran, Consultant Interventional Cardiologist for the Mater Private Network, who has helped raise public awareness of this issue, encouraging women in Ireland to “listen to their heart” and to look out for the early signs and symptoms of heart disease. The most common presenting symptom of angina or MI in both women and men is central chest discomfort, often described as a pressure, intense heaviness, tightness or squeezing. However, in women, symptoms can be more subtle or atypical than in men, making the diagnosis more likely to be delayed or missed, sometimes being attributed to anxiety, menopause, stress or over-exertion, she told NIGP. Women are more likely than men to experience symptoms such as stomach, back, shoulder or throat pain, indigestion, nausea or vomiting, shortness of breath, or fatigue rather

Dr Róisín Colleran

than chest pain. “When people don’t have those typical symptoms there isn’t the same index of suspicion. So studies have shown that heart attack, coronary heart disease, or angina may be underdiagnosed or at least be delayed diagnosed in women because of this tendency towards atypical presentation,” Dr Colleran said. In addition, “women tend to develop heart disease about 10 years later than men, because we are generally protected by oestrogen before menopause. So with younger women your index of suspicion would be less, but over the lifetime, the risk of death from cardiovascular disease in men and women is in fact equal. Women live longer and have more time to develop it after menopause.”

Prevention Up to 90 per cent of cardiovascular disease is preventable. Given the increasing rise of cardiovascular risk factors, such as obesity, diabetes and the metabolic syndrome in the population, prevention through addressing lifestyle issues, such as quitting smoking, healthy diet, and regular exercise is key, said Dr Colleran. “While we can’t change some risk factors, such as age and family history of early heart disease, there is

something we can do at every stage of life to reduce our risk of heart disease and stroke. Smoking is such a preventable risk factor; it really increases the risk of heart disease and stroke.” People should get to know their heart health numbers and risk factors – blood pressure, cholesterol, blood sugar levels – and work with their doctor to make sure these are at target, “and be proactive and take responsibility for it rather than it just being a passive process. “In addition, screening for conditions, such as diabetes and high blood pressure, is also important. We often see dramatic drops in blood pressure in those who lose a few stone, without medication, so it really is a big risk factor across the board.” However, Covid-19 is having an ongoing negative impact, in both slower presentation of patients with MI symptoms, leading to poorer outcomes, and less chances for opportunistic diagnosis of issues like high blood pressure, given the huge reduction in physical GP and outpatient appointments, pointed out Dr Colleran.

Female-specific risk factors A history of pre-eclampsia, high blood pressure during pregnancy, gestational diabetes, and PCOS are risk factors for heart disease specific to women, noted Dr Colleran. If a woman has had any of these conditions, they should take extra care to try to control other risk factors for cardiovascular disease. Women who go through premature menopause, either naturally or because they have had their ovaries removed, are twice as likely to develop heart disease as women of the same age who have not yet gone through menopause, she added.

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Women's Health


Heart Disease


Women with chest pain are more likely than men to wait over 12 hours before seeking medical help

hest pain is misdiagnosed in women more frequently than in men, according to research presented at the European Society of Cardiology (ESC) Acute CardioVascular Care 2021 congress, held recently. The study also found that women with chest pain were more likely than men to wait over 12 hours before seeking medical help. “Our findings suggest a gender gap in the first evaluation of chest pain, with the likelihood of heart attack being underestimated in women,” said study author Dr Gemma Martinez-Nadal, Spain. “The low suspicion of heart attack occurs in both women themselves and in physicians, leading to higher risks of late diagnosis and misdiagnosis.” This study examined gender differences in the presentation, diagnosis, and management of patients admitted with chest pain to the chest pain unit of an emergency department between 2008 and 2019. Information was collected on risk factors for a heart attack including high blood pressure and obesity. The researchers recorded the physician’s initial diagnosis after the first evaluation of each patient, which is based on clinical history, physical examination, and an electrocardiogram (ECG) and occurs before other examinations like blood tests. A total of 41,828 patients with chest pain were included, of which 42 per cent were women (median age 65). The median age in men was 59 years. Women were significantly more likely (41 per cent versus 37 of men) to present late to the hospital (defined as waiting 12 hours or longer after symptom onset). “This is worrying since chest pain is the main symptom of reduced blood flow to the heart (ischaemia) because an artery has narrowed,” said Dr Martinez-Nadal. “It can lead to a myocardial infarction, which needs rapid treatment.”

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In the physician’s initial diagnosis, acute coronary syndrome (ACS) was more likely to be considered the cause of chest pain in men compared to women. Specifically, in 93 per cent of patients, the ECG did not provide a definitive diagnosis. In those patients, the doctor noted a probable ACS in 42 per cent of cases – when analysed according to gender, probable ACS was noted in 39 per cent of women and 44.5 per cent of men (p<0.001). The significantly lower suspicion of ACS in females was maintained regardless of the number of risk factors or the presence of typical chest pain. Dr Martinez-Nadal said: “In the doctor’s first impression, women were more likely than men to be suspected of a non-ischaemic problem. Risk factors like hypertension and smoking should instil a higher suspicion of possible ischaemia in patients with chest pain. But we observed that women with risk factors were still less likely than men to be classified as ‘probable ischaemia’.” In women, 5 per cent of ACS were initially misdiagnosed, whereas in men, 3 per cent of ACS were initially misdiagnosed (p<0.001). After multivariate analysis, female gender was an independent risk factor for an initial impression of non-ACS.

Hypertension symptoms in women often mistaken for menopause Cardiologists, gynaecologists and endocrinologists have laid out recommendations on how to help middle-aged women prevent later heart problems in a new ESC consensus document published recently in the European Heart Journal. The document provides guidance on how to manage heart health during menopause, after pregnancy complications, and during other conditions, such as breast cancer and polycystic ovarian syndrome (PCOS). The important role of a healthy lifestyle and diet is

recognised – eg, for optimal management of menopausal health and in women with PCOS who have elevated risks of high blood pressure during pregnancy and type 2 diabetes. “Physicians should intensify the detection of hypertension in middle-aged women,” states the document. Up to 50 per cent of women develop high blood pressure before the age of 60, but the symptoms – for example, hot flushes and palpitations – are often attributed to menopause. “High blood pressure is called hypertension in men, but in women it is often mistakenly labelled as ‘stress’ or ‘menopausal symptoms’,” said first author Prof Angela Maas. “We know that blood pressure is treated less well in women compared to men, putting them at risk for atrial fibrillation, heart failure and stroke – which could have been avoided. “There are several phases of life when we can identify subgroups of high-risk women,” said Prof Maas. “High blood pressure during pregnancy is a warning sign that hypertension may develop when a woman enters menopause and it is associated with dementia many decades later. If blood pressure is not addressed when women are in their 40s or 50s, they will have problems in their 70s when hypertension is more difficult to treat.” While menopausal hormone therapy is indicated to alleviate symptoms, such as night sweats and hot flushes in women over 45, the authors recommend assessment of cardiovascular risk factors before initiation. Therapy is not recommended in women at high cardiovascular risk or after a stroke, heart attack, or blood clot. The document also provides advice for transgender women. “These women need hormone therapy for the rest of their lives and the risk of blood clots increases over time,” said Prof Maas.

Feature Author: Theresa Lowry-Lehnen (PhD), CNS, GPN, RNP, and National PRO, Irish General Practice Nurses Educational Association

Healthy Feature Lifestyle

MAKING EVERY CONTACT COUNT ‘Making Every Contact Count’ is an evidence-based approach that aims to relieve the pressure on the health services by helping prevent chronic disease and empowering patients to lead healthy lifestyles.


aking Every Contact Count’ (MECC) was established by the HSE in 2016 to support the implementation of Healthy Ireland in the health services, enable people to make healthier lifestyle choices and reduce health inequalities. Implementation of the framework is a key strategic action in reducing the burden of chronic disease in Ireland. Comprising of cancer, cardiovascular disease, chronic obstructive pulmonary disease (COPD) and diabetes, chronic diseases are the leading cause of mortality globally, representing 60 per cent of all deaths worldwide and 76 per cent of deaths in Ireland (DoH, 2016). At least 42 per cent of cancers can be prevented and adopting healthy lifestyle behaviours is a significant factor in achieving this. In addition, 80 per cent of heart disease, stroke and type 2 diabetes can be prevented through a healthy diet, regular physical activity, reduction in alcohol consumption, and avoidance of smoking and tobacco products (HSE, 2017). There are approximately 30 million contacts to the Irish health service annually and 14 million of these are with GP services (HSE, 2017). About 80 per cent of GP consultations and 60 per cent of hospital bed days in Ireland relate to chronic illnesses. Treatment and management of chronic disease puts unsustainable pressure on

health services in acute hospitals and primary care and has many personal implications for those affected with a chronic condition. Evidence shows that health advice and interventions have the potential to produce significant behaviour change for patients (HSE, 2017). Our services and healthcare teams have enormous potential to

Healthcare professionals are asked to take the opportunity during daily contacts with patients and service users to ‘make every contact count’

influence the health and wellbeing of the people for whom we provide care. Addressing the prevention and management of chronic disease is a main priority for the health service both in Ireland and internationally. The publication of Healthy Ireland – A Framework for Improved Health and Wellbeing 2013–2025 and the publication of Healthy Ireland in the Health Services: National Implementation

Plan 2015–2017 provided a blueprint on how prevention should be addressed. Engaging healthcare professionals in preventative activities as part of routine clinical consultations is an essential element in both primary and secondary healthcare services in addressing the prevention of chronic illnesses. MECC is an evidence-based approach that aims to relieve the pressure on the health services by helping prevent chronic disease and empowering patients to lead healthy lifestyles. Healthcare professionals are asked to take the opportunity during daily contacts with patients and service users to make every contact count and support patients to make lifestyle choices that help prevent chronic diseases and promote self-management of existing chronic diseases. Through these contacts, health professionals can enable patients to achieve positive longterm behaviour change. Development of chronic illnesses is greatly influenced by lifestyle behaviours. The reasons unhealthy lifestyle behaviours are adopted is complex and can be best illustrated through the social determinants of health model (Dalghren and Whitehead, 1991), which explores the range of underlying factors that impact on an individual’s health and wellbeing. These include social and

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Healthy Lifestyle

Healthy Lifestyle


Table 1: Model for making every contact count in the Irish health services

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Healthy Lifestyle on addressing the wider social determinants of health and wellbeing (NHS, 2014). Life expectancy rates in Ireland for males are currently 79 years and 83.5 years for females. However, the number of healthy years is considerably less, on average 71 years for men and 72.5 years for women (HSE, 2017). These findings suggests that approximately eight years of life for men and 11 years for women are impacted significantly by poor health and disability, largely due to chronic illnesses. A focus on chronic illness prevention both in society and in health services is essential in addressing this issue. Health behaviour change is complex and health professionals are in a unique position to support people towards making changes that will have long-term health gains for individuals and for society as a whole (HSE,2017). Making positive changes such as stopping smoking, improving diet, increasing physical activity, losing weight, and reducing alcohol consumption can help people to reduce their risk of poor health significantly. Understanding the impact of the wider social determinants of health and wellbeing is important as these factors may prevent an individual from engaging in health promotion intervention programmes.

Figure 1: The social determinants of health

Figure 2: Model for making every contact count in the Irish health services

family support networks, level of education, employment, in addition to wider socioeconomic, cultural and environmental factors and conditions. Tackling the social determinants of health requires a whole government approach with multi-agency input at local, regional and national level to identify solutions as outlined in the Healthy Ireland framework (HSE, 2017). Chronic illnesses impact negatively on a

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person’s quality-of-life and affect the socially disadvantaged disproportionately, contributing to widening health gaps within society. They represent substantial financial costs not only to those affected and their families, but also to the health and social care system, and result in a significant loss of productivity to the economy. There is a need for systemic change towards proactive prevention and a greater emphasis

MECC training The HSE MECC e-Learning training programme is available to all healthcare professionals in Ireland. The programme consists of six 30-minute e-Learning modules. The health behaviours, which are the focus of attention, are the four main lifestyle risk factors for chronic disease; tobacco use, physical inactivity, harmful alcohol consumption, and unhealthy eating (HSE, 2016). The training modules include an introduction to behaviour change covering the foundations in behaviour change theory and techniques including the underlying principles of a patient-centred approach. Four topic modules are available on smoking, alcohol and drugs, healthy eating and active living, and a skills into practice module, which demonstrates the skills of how to carry out a brief intervention across a range of topics through a suite of video scenarios using real-life healthcare professionals. Following successful completion of the online modules, healthcare professionals


Healthy Lifestyle can download a certificate and there follows an opportunity to complete an ‘Enhancing your brief intervention skills’ workshop. This training programme has been approved by a range of healthcare professional bodies for continuous professional development (HSE, 2016). The faceto-face training workshops on enhancing brief interventions skills are currently unavailable due to Covid-19 and other options are being explored to support health professionals to enhance their skills after completing the e-learning programme (HSE, 2020). By completing the full training programme, online and workshops, health professionals learn how to structure brief interventions, adopt a patient-centred approach, build rapport and advise patients, assess a patient's readiness to change, arrange further support for patients who wish to change, and how to manage challenging intervention situations (HSE, 2017). MECC improves the health and wellbeing of patients and the general public and contributes to the reduction of health inequalities in society. It cannot be viewed as a separate public health issue, but as a role that all health professionals have a responsibility and a requirement to adopt. This approach allows movement to a position where discussion of lifestyle behaviour is routine, non-judgmental and central to everyone’s role in healthcare provision, and by doing so supports better clinical outcomes and patients' quality-of-life. The model for MECC is presented as a pyramid with different levels (Figure 2). Each level represents an intervention of increasing intensity with the low intensity interventions at the bottom and specialised services at the top of the pyramid. Implementing the MECC approach begins with the basic levels of brief advice and brief intervention. In practice this means that all health professionals and healthcare assistants are trained to a level that enables them to conduct a brief intervention with patients. Brief interventions involve discussion, negotiation and encouragement with or without follow-up and applies the 5As of a brief intervention – Ask, Advise, Assess, Assist and Arrange. MECC brief advice and brief intervention takes a matter of minutes and is not intended to add to existing busy workloads, rather it is structured to fit into and complement existing engagement approaches.

The outcome of this engagement could be providing information, signposting to further support, referring to a lifestyle service or even just listening to whether or not the individual is ready to make a change (NHS, 2014). Extended brief intervention are conducted by health professionals with greater capacity to carry out more lengthy interventions, because of their specialist role or due to the specific service that they work in. This intervention is delivered to patients requiring

Evidence points to brief interventions being effective for one-in-eight people in relation to alcohol and one-in-20 individuals in relation to tobacco

more intensive support in their behaviour change efforts or who may be self-managing an existing chronic disease. Specialist services are delivered by practitioners who use specialised or advanced approaches to support patients to change behaviour. These services include smoking cessation and dietetic services, along with services delivered by staff with in-depth counselling skills in the wider arena of

References 1. Dahlgren G, Whitehead M. (1991). Social Determinants of Health Model. Stockholm 2. DoH (2013). Healthy Ireland: A Framework for Improving Health and Wellbeing 2013-2025. Department of Health 3. DoH (2015). Tobacco Free Ireland Action Plan. Department of Health 4. DoH (2016). Healthy Ireland Survey 2016; Summary of Findings. Department of Health 5. DoH (2016). A Healthy Weight for

supporting people to change (HSE, 2017). In summary Evidence points to brief interventions being effective for one-in-eight people in relation to alcohol and one-in-20 individuals in relation to tobacco. When applied in the population context where there are 30 million contacts every year throughout the Irish health services, MECC has the potential to have a substantial impact, make a real difference, and have a very positive effect on the health and wellbeing of individuals, communities and the population as a whole (HSE,2017). Frontline staff are well placed and have the opportunity to recognise appropriate times and situations in which to engage with individuals and practice populations to help improve their health and wellbeing and reduce the burden of chronic disease, which is crucial to improving the quality of people’s lives and making every contact count successfully. MECC is available at: www.hse.ie/eng/about/ who/healthwellbeing/making-every-contact-count/ MECC resources are available to download at: www.hse.ie/eng/about/who/healthwellbeing/ making-every-contact-count/order-resources/ making-every-contact-count-client-record.pdf MECC promotional resources, for use in both staff facing areas and onsite in hospital and community healthcare settings, are available to order from: www.healthpromotion.ie

Ireland. Obesity Policy and Action Plan 2015-2025. Department of Health

Service. HSE

6. DoH (2016). Get Ireland Active! National Physical Activity Plan for Ireland. Department of Health

count. Training Programme. COVID-19

7. HSE (2015). Healthy Ireland in the Health Services National Implementation Plan 2015- 2017. HSE


8. HSE (2016). Making Every Contact Count. HSE

Using every opportunity to achieve health

9. HSE (2017). Making Every Contact Count. A Health Behaviour Change Framework and Implementation Plan for Health Professionals in the Irish Health

12. NICE (2014). Behaviour change:

10. HSE (2020) Making every contact Update. HSE. Available at: www.hse.ie/ eng/about/who/healthwellbeing/making-

11. NHS (2014). An Implementation Guide and Toolkit for Making Every Contact Count: and wellbeing. National Health Service. UK

individual approaches. National Institute for Health and Clinical Excellence. Public Health Guidance no 49. NICE, UK

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Dr Alan Moran looks at the increasingly popular world of e-bikes

bout four years ago I wrote an article on e-bikes that made me a big fish in a small pond. Normally I write about cars and have been doing so for over 20 years. But I decided I’d write about the latest upcoming trend mainly because my wife had bought one and to say she loved it was an understatement. By the way, I have one car, two motorbikes, and four bikes, plus one tandem. So we are a cycling family in a way.  At the time e-bikes were sensible, which means heavy. Bike batteries remain heavy, which any electric car manufacturer will tell you as they spend sleepless nights worrying about the weight of their cars. With heavy batteries the bike needs a heavier frame, heavier tyres and heavier brakes. But over the last few years they’ve been using different aluminium alloys and the bikes have become lighter. So much so it is possible to have one that would be hard to tell from a conventional bike.

before they need replacing, unlike chains. And they don’t need chain oil, hence they don’t get messy and greasy leaving stains on your clothes. Range is dependent on the size of the battery and how you use it. It is possible to have a battery that will last 80km, but using it on hilly terrain (they don’t recharge going downhill) with max assistance will see it run flat in 30-40km, and then you’ll have a heavy bike to pedal home. 

How they work

Bicycle or MPV?

Anyway, e-bikes essentially are bicycles that come with motors in three different places: The front hub, the rear hub, and the centre. The centre works out best for weight distribution as it is best to have the centre of gravity in the, em, centre. Batteries can be in the back on a carrier, or attached to, (or within, better again) one of the down tubes. Again, the down tubes are best but it means batteries are not as easily interchangeable. Disc brakes, preferably hydraulic, are best. Gears can be derailleur like a racing bike, or hub. Rohloff are the best (and cost about an extra €1,000), but Shimano make a very good second best, for a significantly reduced cost. With hub gears it is possible to get an e-bike with a belt drive, a bit like the fan belt of a car. These can last up to 25,000km

Which brings me to an important point. Generally what is available in Ireland is ‘pedal assist’. When you’re pedalling, it assists. Stop pedalling and the help disappears. E-bikes are also available that assist by twisting a throttle, rather like a motorbike. Some members of An Garda Síochána will argue that a pedal assist bike is a mechanically propelled vehicle (MPV) and hence needs a licence and insurance. Whenever I looked for insurance for a motorbike I was always asked for the registration. So until the day I can register the bike, and get a registration plate, I would suggest to the gardaí that if they could tell me where I could register the bike then I’d be happy to comply. In February the Government confirmed

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... e-bikes essentially are bicycles that come with motors in three different places: The front hub, the rear hub, and the centre

that, under current Irish law, e-bikes are not classed as MPVs or as pedal bicycles, but announced its approval to draft legislation on e-scooters and e-bikes in the forthcoming Road Traffic (Miscellaneous Provisions) Bill. This, the Government says, will allow for the introduction of appropriate regulations for these types of vehicles. E-bikes will be legislated for using EU standards as a reference point and will be treated mainly in the same way as pedal cycles while the more powerful models of e-bikes will be treated as light mopeds.

What’s on the market With all that in mind, let’s have a look at some of the e-bike brands currently on the market. To my mind one of the best looking bikes is the Van Moof. It has a 250 watt (powerful enough) front motor, with four power levels, and a range of 60-120km. It can get to a 50 per cent charge in 80 minutes with its integrated battery, with full charge in four hours, and looks brilliant. Only problem is you’ll probably have to go to the Netherlands, Germany or the US to buy one. Available in Ireland, Cannondale (called the Cannondale Quick Neo) would be known for their quality frames in the racing fraternity, but not for their value for money. The battery is hidden in the down tube, and hence is small. Range is described as up to 75km.  Also at the upper end of the price spectrum is the Gocycle GXi. Designed by an ex car designer, it features many ‘why didn’t we think of those before’ features. It can vary the amount of assistance given, so you can configure that unless you’re hitting 200 watts, it sits and watches you do the work. Once you’ve reached your limit it gently kicks in. For those living in apartments who don’t want to leave an expensive e-bike in the bike park or shed, it folds up neatly. (By



the way, for a seriously good folding bike, not an e-bike, look no further than the Brompton.... Another day’s work). If you thought these were expensive there’s the Trek Madone SLR eTap. Not just electric pedal assist, it has electric gear changes. Priced at around €12,000 these could easily be mistaken for a proper road racing bike. Don’t worry, Trek has bikes from €2,000 upwards too. The best description of their range of e-bikes is ‘vast’.  Raleigh has made great bikes over the years. Their current e-bikes tick a lot of the boxes as above with a central motor and comfortable ride. We, as in ‘the Royal We’, rented one during our summer holidays (staycation) in Ireland last year (when the

lockdown eased) and I have to say I was not impressed by the motor. Maybe there was some tidying up to do with the pedal sensors. As with all e-bikes, try before you buy.

especially what is known in the sport as the LBS, or the local bike shop, who always appear to have a friendly face with a greasy rag and a spanner to help out in emergencies.

Where to buy

So in conclusion

Now I cannot leave this article without mentioning two sources from which to buy your bikes. One is recently established in Dublin; Decathlon. They seem to have bikes when no one else does, and they have a range of e-bikes now for sale. The range of their lowest cost model is 20-35kms, with the higher cost model having a range of 50-90kms. The other source is Easy Motion, a Dublin based e-bike specialist. I am a great believer in supporting locally-based businesses,

E-bikes are a great addition to a family’s transport needs. We need more cyclists on the road to increase our cardiovascular health, reduce pollution, and, dare I say it, take my beloved cars from our cities. Our lungs need it, our cities need it, as does our planet. And the more people we have cycling, the more people we have who understand the needs of cyclists, who will convince selfish motorists that we need to share our roads as well as our atmosphere.

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AN APPRECIATION OF OLIVE OIL There are people who can produce detailed tasting notes for individual olive oils, writes Tom Doorley

ust as there are wine snobs, there are olive oil snobs. When I was growing up, my mother used to buy Goodall’s olive oil in tiny bottles. I can still remember the attractive, fruity smell of this pretty basic stuff (we’re talking the early 1970s here) as it warmed in the pan. She was ahead of her time as far as cooking was concerned. At that stage most olive oil in Ireland came from the pharmacy and was used, warmed, to loosen stubborn ear wax. And now, take a look at the shelves of a well-stocked deli and marvel at how many forms of it you can buy; and some of them are dearer than a lot of perfectly decent wine, litre-for-litre. Some even come in very small bottles, suggesting that they should be used by the drop rather than the glug. There are certainly people who can produce detailed tasting notes for individual olive oils and the language used is often much the same as is used to describe wine. Common phrases would be peppery, fruity, grassy, tomato leaves, nutty, green apple, floral, etc. Our daily cooking oil is the basic olive oil from Aldi, not too strongly flavoured, but nice and stable and, as it happens, a very good base for homemade mayonnaise. The olive oils we use to dress salads and vegetables, to drizzle on grilled meats or on to burrata, are the serious stuff. We buy a Spanish organic extra virgin olive oil, five litres (roughly the yield from one tree) at a time, direct from the producer, Campillo de Julia near Jérica in Valencia. Through CrowdFarming.com this costs €65, delivered to Ireland. It is fairly pungent – peppery is the word

46 MAY-JUNE 2021

of 200ºC, and that Avonmore Irish Ghee, or clarified butter, has a smoke point of 210ºC.

that comes to mind, but there’s a fruitiness too, and it’s quite delicious and amazingly well-priced. Mark Shannon, of Bistro One in Foxrock, usually bilocates between south Dublin and Tuscany where he has an olive grove of 100 trees. In normal times, when the olive crop is harvested, usually in early November, and it has been taken to the frantoia for pressing, Mark is on the next flight home with the first five litres and it is on the tables in the restaurant that evening. Sometimes I’m lucky enough to get hold of a bottle and I can report that it is superb. Brand new freshly-pressed extra virgin olive oil (EVOO) is an experience like no other. We occasionally buy Azouro EVOO from Portugal, green and fruity, which offers very decent value at €12.95 from Fallon & Byrne; and when we can get it, the EVOO from the very Fonterutoli estate in Chianti Classico, is a treat. Omega I really can’t quite understand the fuss people make about rapeseed oil. It has the advantage, I suppose, of being local, but I’m not attracted by the taste and I find it can develop a

fishy aroma when heated. True, its omega-6 to omega-3 PUFA content is a desirable 2:1, compared to olive oil’s 9:1, while sunflower oil, which I avoid like the plague, weighs in at a rather shocking 40:1. The fact is that the Western diet is too rich in omega-6 and very light on omega-3 (hence the advisability of fish oil supplements for heart health). Sunflower oil has a relatively low smoke point of 107ºC, as against 160ºC for EVOO and 177ºC for rapeseed, a chastening thought as so many people think of it as the healthiest option when deep-frying. When used for frying, it releases 20 times the amount of aldehydes considered relatively safe by the World Health Organisation. By contrast, saturated fats are relatively stable at high temperatures. Lard, for example, at 39 per cent saturated fat, comes out best for deep-frying, in good company with ghee or clarified butter with 50 per cent saturated fat. Goose fat and coconut oil, 27 per cent and 86 per cent respectively, are highly stable too. It is worth noting that refined olive oils (as distinct from EVOO) can have a smoke point in excess

Butter Our armoury of fats in the kitchen is very traditional (well, depending on where in the world you are, but we consider ourselves to be global citizens). Our main cooking fats are butter and olive oil, but we also have a packet of James Whelan Butchers’ beef dripping in the fridge – essential for steaks and for Yorkshire pudding. On the very few occasions that we cook chips – usually birthday steak feasts, featuring Béarnaise sauce – dripping or lard is the fat of choice. We usually have some goose or duck fat knocking around but, to be honest, I often forget to use it. Yes, it knocks out a serious roast potato, but so does beef dripping, and – a Richard Corrigan trick – a mixture of butter and olive oil. It is interesting to compare the ingredients of a pack of butter and a pack of 'spread'. The butter contains cream and salt, the spread has water, plant oils (30 per cent) (sunflower, palm, linseed, rapeseed), plant stanol esters, salt, emulsifiers (monoglycerides and diglycerides of fatty acids, sunflower lecithin), natural flavourings, vitamins A and D. Butter is, of course, naturally rich in vitamin A and D, plus E, B12, and K2. But, much more to the point, butter is naturally delicious. Imagine melting that 'spread' over a new potato? Or having the first of the new season asparagus with 'spread'. Can you even make a Béarnaise with 'spread', if you were deranged enough to try?

Product News

PRODUCT NEWS WOMEN’S HEALTH MATTERS – A NEW WEB HUB RESOURCE FOR HEALTHCARE PROFESSIONALS IN IRELAND GOES LIVE Bayer has launched a dedicated hub for healthcare professionals on women’s health. The website, www.womenshealthmatters.ie, brings together key resources in a central location to support healthcare professionals on topics related to women’s health with a focus on contraception, menorrhagia, and endometrial hyperplasia. The hub houses a range of materials including online training, such as e-learning modules, on-demand training, and GP buddy tutorials. It will contain recordings of webinars and meetings and it enables healthcare professionals to register for upcoming events. Supports for counselling patients, such as a counselling checklist and a video to counsel patients in seven minutes; inserter resources for inserting IUSs including a video;

and information materials that can be downloaded and given to patients, all can be found on the new hub. It also contains Bayer product information including clinical data and FAQs.

“Listening to the feedback from healthcare professionals, we learnt that there was a real need for a one-stopshop for busy healthcare professionals to access valuable and up to date resources on women’s health in Ireland,” said Caitriona Doherty, Therapeutic Area Manager, Women’s Health, Bayer. “For instance, the Bayer Women's Health team recognises the impact that Covid-19 is having on customers’ opportunities for education and interactions with patients. In light of this, we have provided on the site a variety of new and relevant on-demand clinical and educational content, such as training for effective phone and video consultations and checking for understanding in a digital consultation,” Ms Doherty added.

ASTELLAS RECEIVES POSITIVE CHMP OPINION FOR XTANDITM (ENZALUTAMIDE) FOR PATIENTS WITH METASTATIC HORMONE-SENSITIVE PROSTATE CANCER Astellas Pharma Inc has announced that the Committee for Medicinal Products for Human Use (CHMP) of the European Medicines Agency (EMA) has adopted a positive opinion recommending an additional indication for the oral once-daily therapy Xtanditm (enzalutamide) for adult men with metastatic hormone-sensitive prostate cancer (mHSPC, also known as metastatic castration-sensitive prostate cancer or mCSPC). Men diagnosed with mHSPC tend to have a poor prognosis, with a median survival of approximately three-to-four years, underscoring the need for new treatment options. If approved by the European Commission (EC), enzalutamide will be the only oral treatment approved by the EC to treat three distinct types of advanced prostate cancer — non-metastatic and metastatic castrationresistant prostate cancer (CRPC) and mHSPC. The CHMP decision is based on data from the pivotal phase 3 ARCHES trial investigating

enzalutamide in men with mHSPC. “This positive opinion from the CHMP is testament to our continuing commitment to addressing unmet needs for men with advanced prostate cancer,” said Andrew Krivoshik, MD, PhD, Senior Vice President and Global Therapeutic Area Head, Oncology Development, Astellas. “We are excited to be another step closer to approval of enzalutamide for the treatment of men with metastatic hormone-sensitive prostate cancer in Europe.” Data from the ARCHES trial showed that enzalutamide plus androgen deprivation therapy (ADT) significantly reduced the risk of radiographic progression or death by 61 per cent versus placebo plus ADT in men with mHSPC (n=1,150; hazard ratio [HR]=0.39 [95% CI: 0.30-0.50]; P<0.0001). The safety analysis of the ARCHES trial appears consistent with the safety profile of enzalutamide in previous clinical trials in CRPC. In ARCHES, grade 3 or greater adverse events (AEs) (defined as severe/

disabling or life-threatening) were similar for patients receiving both enzalutamide plus ADT and those who received placebo plus ADT (24.3 per cent vs 25.6 per cent). The positive opinion from the CHMP will now be reviewed by the EC, which has the authority to approve medicines for European Union member countries, as well as Iceland, Norway, and Liechtenstein. Enzalutamide is currently approved in the EU for the treatment of adult men with high-risk non-metastatic castrationresistant prostate cancer (nmCRPC) and adult men with metastatic castrationresistant prostate cancer (mCRPC) in whom chemotherapy is not yet clinically indicated, or following disease progression on or after docetaxel therapy. In the US, enzalutamide is approved in non-metastatic and metastatic CRPC as well as mCSPC also referred to as mHSPC. In Japan, enzalutamide is indicated for the treatment of prostate cancer with distant metastasis, which includes mHSPC and CRPC.

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16 17 18




Across ACROSS1 - Perhaps (8) DOWN 1 Perhaps (8) 1 Opposite of fail (4) 5 Not5as- much (4) much (4) 2 Figure with four equal Not as 8 Cram (5) straight sides (6) 9 One-of-four equal 3 Have an effect on another (9) 8 - Cram (5) parts (7) 4 Neither gas nor solid (6) 10 Acquire from a relative (7) 6 Complete (6) 9 - One of four equal parts (7) 12 Imaginary (7) 7 Plan of action (8) 14 Treatment room (7) 11 Cyclone (9) 10 - Acquire from a relative (7) 16 Compress (7) 12 Pertaining to the body (8) 18 Remark (7) 13 Peak (6) 12 - projectile Imaginary 19 Pointed (5) (7) 14 End a dispute (6) 20 Tardy (4) 15 Come into view (6) 14 -(8)Treatment room (7) 21 Acutely 17 Not at home (4)

Down 1 - Opposite of fail (4)


2 - Figure with four equal straight sides (6) 3 - Have an effect on another (9) 4 - Neither gas nor solid (6) 6 - Complete (6) 7 - Plan of action (8) 11 - Cyclone (9)

16 - Compress (7)

12 - Pertaining to the body (8)

18 - Remark (7)

13 - Peak (6)

19 - Pointed projectile (5)

14 - End a dispute (6)

20 - Tardy (4)

15 - Come into view (6)

48 MAY-JUNE 2021

For all that matters in medicine AVAILABLE IN PRINT AND DIGITAL

Toddler Milk


APTAMIL TODDLER MILK New FSAI Guidelines 2020 Fortified foods and drinks can contribute to the recommended intakes of Vitamin D, Iron & Omega 3 in toddlers2 Just 2 beakers a day (300ml) of Aptamil Toddler milk provides toddlers with 93% of the RDA3 for Vitamin D and 45% of the RDA3 for Iron Available in 800g powder, 200ml & 1 litre liquid

For more information, call our dedicated freephone on 1800 22 12 34 or visit nutricia.ie This information is for healthcare professional use only. Aptamil Toddler Milk should be used as part of a varied and balanced diet from 1 year. Recommended serving per day is 300ml. 1. Irish Universities Alliance (IUNA), National Pre-school Nutritional Survey. Further analysis for Danone Nutricia (data available on request). Main survey available at: https://www.iuna.net/surveyreports 2. Food Safety Authority of Ireland (FSAI), Scientific Recommendations for Food-Based Dietary Guidelines for 1 to 5 Year-Olds in Ireland. Available at: https://www.fsai.ie/Dietary_Recommendations_1-5_Year_Olds/ 3. Food Safety Authority of Ireland (FSAI), Recommended Dietary Allowances for Ireland 1999. Available at: https://www.lenus.ie/handle/10147/44808

May 2021

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Nursing In General Practice (NIGP) May June 2021  

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