24 minute read
FEATURE: CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Written by Deirdre Garvin, Respiratory CNS, Mayo University Hospital/Board Member, COPD Support Ireland
The health and life expectancy of the Irish population has improved, and with this comes a greater need for healthcare in chronic disease in Ireland.
The Slaintecare report (2017) of the Oireachtas Committee on the Future of Healthcare set out the vision for health service reform to improve the health of the nation.7 The aim is to provide a universal healthcare system and to move care delivery from the acute health care setting, which is unsustainable, to care closer to home which includes promoting health and wellbeing and meets the patients’ needs in a fair and equitable way.4,5,7 The integrated model of care for the prevention and management of chronic disease (IMPCD) is the essence of the national framework for integrated prevention and management of chronic disease in Ireland 2020-2025 and details how end to end care will be available in Ireland.4,5
Integrated care is the process of providing this Slaintecare vision for patients and integrated care has been shown to improve care by meeting population health need.4,5 Research shows patients with chronic diseases, including respiratory, when managed and cared for in primary care with good governance and clinical leadership have improved care and outcomes than if provided in acute services.7 Integrated care for chronic disease is care provided at the lowest level of complexity, close to home with services to support and empower individuals to optimise their health and minimise risk factors for developing or progression of their chronic disease.4,7 Health promotion and education by preventing illness in the first place and preventing progression is in line with Healthy Ireland policy which seeks to improve health through preventive strategies and supporting people to live healthier lives, which in turn reduces demand for hospital care.2,4,7 The framework is the mechanism of delivering care, which is person centred, holistic to the person and preventative.19 The various models of care and national clinical care programmes including the COPD model of care, have all adapted an integrated approach and are developing care around the framework which is line with policy.3,4,5,7 Slaintecare and the integrated framework detail the health reform including the development of 6 Regional Health Areas (RHA,). These are then further broken down into 96 Community Healthcare Networks (CHNs).4,5 CHN’s are geographical based units which serves a population of approximately 50,000 and three CHN’s will be served by a specialist ambulatory care hub for chronic disease serving a population of approximately 150,000. An ambulatory care hub will be a clinical site away from the hospital setting which will support access to diagnostic, specialists’ services and specialists’ opinions. Health care will primarily be delivered in the community with supports available to allow this by providing specialist care when needed within the community in chronic disease including COPD and this care will then be delivered closer to home.4,5,7
The treatment, burden and management of chronic illnesses account for a large share of health resources, including 80% of all general practitioner (GP) visits, 40% of acute admissions, 75% of hospital bed days and accounts for poorer quality of life.3,6,7,8,9 In the area of respiratory the true prevalence of respiratory conditions such as COPD in Ireland is unknown. It is estimated that 500,000 have COPD, however only approx. 200000 are diagnosed and many are unaware of their condition.1,8,9 COPD is a major health burden and causes morbidity and mortality in Ireland with over 1500 deaths and 15,000 patients admitted to hospital annually.3,8,9 Ireland has the highest rate of hospital admission with COPD of any country in the OECD.8,11
COPD Support Ireland & The Chronic Disease Management Programme
The ‘Integrated Model of Care for the Prevention and Management of Chronic Disease’ is at the heart of the ‘National Framework for the Integrated Prevention and Management of Chronic Disease’ and demonstrates how “end-to-end” care can be provided within the Irish health services. The Model of Care (Figure2) describes the five levels of service, and examples of each service, that need to be provided for a population in order to deliver integrated end-to-end care for chronic disease. These are the five levels of service that local areas need to strengthen and provide in an equitable manner to their population. Figure 2. Model of care for the Integrated Prevention and Management of Chronic Disease
Hospital Care
Care in the Community
4. Specialist Hospital Care
ED/ AMAU, Complex Care, Inpatient Care
Specialist Ambulatory Hub
3. Acute Specialist Ambulatory Care 2. Community Specialist Ambulatory Care 1. General Practice
Alternative OPD Pathways Respiratory Outreach Cardiac/Pulmonary Rehab Specialist Teams (CNS, Physio, Dietitians, Podiatrists) Structured Patient Education Diagnostics Assess Deteriorating Patient Scheduled Review Care Plan Virtual Clinics Telephone Triage Examples of Service Diabetes Prevention Making Every Contact Count Telehealth/Remote Monitoring Self-management Support
The national framework for Integrated prevention and management of Chronic diseases which includes COPD is a whole system approach to integration that incorporated population health, wellbeing, preventative, acute, non-acute and community-based services.4,5 The framework is person centred, holistic proactive and preventative in endeavours to make care accessible and equitable for all. It will improve care for our COPD patients by providing access to diagnostic, specialist expertise, pulmonary rehabilitation, and COPD outreach across the country.3,4,5,10 The national framework for the integrated prevention and management of Chronic Disease in Ireland along with the accompanying 10 step guide document details how care will be delivered and details the 5 levels of care as seen in below diagrams.4,5 The MOC for COPD takes a holistic, person centred and life course approach to the provision of services.3,10 It reflects the principles of integrated care which in essence is to provide patients with the right care at the right time by the right team in the right place and to reduce inequalities and describes what services will be provided at each level of care.3
It is anticipated that patients through their journey will move through the levels of care, however primarily care will be provided in the community and a greater emphasis now is on primary prevention, health promotion and population health.3,10 Through early identification of risk factors through professionals using, Making every Contact Count (MECC) this will allow early detection and diagnosis, therefore appropriate management and in turn prevent or delay the onset of COPD.3,5,10 This will improve care for all patients across the levels of care as appropriate, allowing for specialist inpatient, specialist ambulatory care, specialist support to General Practice and chronic disease prevention and management in primary care, all supported by patient self-management with the aims of saving lives of people with COPD and in turn the reduction of hospitalisations and morbidity of COPD patients.3,4,5,10 The model of care details the 4 levels of service and level 0 care is included in the resource document on COPD integrated Service model.
In general terms level 0 care is about keeping communities healthy and to keep those with chronic disease living well.3,4,10 The integrated framework describes how services are being developed to support and empower individuals living in our communities to prevent and manage their chronic diseases.4,5 Services include education, support to manage their diseases and each RHA and CHN is tasked with mapping all services available including HSE funded, voluntary and community. This allows development of services that are lacking but also making best use of services that are in fact available. However, it is of paramount importance that all health care professionals (HCP’s) are aware of available services and can sign post patients and their families to these services The making every contact count (MECC) as a health promotion ensures health promotion is a focus of each HCP and patient encounter and should be a focus for us all.
This includes each patient encounter albeit in the GP’s surgery during an acute illness, during a structured chronic disease review, or a pharmacy visit. This requires staff to be aware of what’s available to support patients in their communities.
Level 0 care available and appropriate for COPD patients • Living Well with chronic disease programme • Self-Management programme • Stress management Programme • COPD Support Ireland Website • Social Prescribing, • Flourish programme • Sing strong programme • Making every Contact count • Tele-Health, remote monitoring • COPD support Groups • COPD support Ireland nurses phone line • Smoking Cessation services COPD Support Ireland (COPDSI) was established in 2013 as Irelands National COPD Support and Advocacy organisation and has established over 35 communitybased COPD exercise and peer support groups across the country. It supports patients and their families living with COPD throughout Ireland through various channels. The work of COPD Ireland supplements the work of the integrated framework for chronic disease and the model of care and can support patients and their families across all the 5 levels of care.
Patients can access information and services throughout their disease trajectory from diagnosis onwards. COPDSI work complements the work of the integrated care programme and model of care for chronic disease as much of its work focuses on providing services that supports those to live well and education on self-management. Equally it is a great source of knowledge for those who are undiagnosed and may want to learn a bit more about the disease and then seek help. Those who seek advice and are supported through various channels often are better equipped to manage their condition and COPDSI can support this. It is important that those of us working in healthcare are aware of supports available to our patients and can sign post patients and their families to the resources available. COPDSI has recently sent correspondence to Respiratory physicians of the valuable services it provides to help support their patients and this in turn can support the health service.
Services provided by COPDSI include:
COPD Adviceline 1800 83 21 46 is a HSE funded freephone service, delivered with the Asthma Society of Ireland; for people who want to discuss or learn more about their COPD and its Self-Management from a specialist respiratory nurse or physiotherapist. It is a valuable resource for patients and their families to learn more about COPD.
COPD & Me Exercise Programme
COPDSI developed a community-based COPD exercise programme delivered by fitness professionals. Classes take place weekly, either virtually, or in person at a local support group location. Participation in these classes has been shown to increase exercise capacity & gait speed and to reduce anxiety. You can refer patients to the COPD & Me exercise programme through the HCP referral link on www.copd.ie
COPD & Me Book
Is a comprehensive patient information and Self-Management education Book. Designed in collaboration with the Respiratory National Clinical Programme and supported by the Chronic Disease Management Programme, this book is now available to HSE COPD services nationally during 2022. To order copies, email info@copd.ie.
Sing Strong – Singing for better Lung Health
In COPD Self-Management, airway clearance and breathing control are taught to help control dyspnoea. Sing Strong is a novel, fun and popular way to learn and implement these techniques through singing. Created by vocal coach Ms. Ciara Meade and lecturer of cardiovascular and respiratory physiotherapy, Dr. Roisin Cahalan, SingStrong is delivered virtually or in person, over 10-weeks through COPDSI. In conclusion the rolling out of the national framework for integrated prevention and management of Chronic Disease and Model of care for COPD is a welcome development for those suffering and or at risk of developing COPD. Care and services which meets population health needs will be accessible and available and not a post code lottery service of services available in certain locations. COPDSI is a valuable resource to both HCP’s and patients and its work needs to be communicated to those who may benefit from its services.
References on request
Written by Dr Louise O’Toole, Consultant Medical Ophthalmologist, Bon Secours Hospital Glasnevin, Dublin Mater Private Network, Dublin
Macular oedema is the end common pathway for many prevalent ophthalmic conditions. It is one of the leading causes of central visual loss. The condition is characterized by the accumulation of fluid in the outer plexiform layer and the inner nuclear layer of the retina; it occurs secondary to the breakdown of the blood-retinal barrier. This causes an abnormal passage of proteins into retinal tissues resulting in osmotic water retention and consequent swelling. When macular oedema occurs, patients may be aware of a fall in their central vision, they may also experience distortion and reduced colour vision.
Macular oedema can be diagnosed at the slit-lamp using high magnification; however Ocular Coherence Tomography (OCT) imaging facilitates both detection and quantification of the oedema. In recent times, the availability of OCT imaging has increased, allowing patients to access this investigation through both optometric as well as ophthalmic practitioners. Depending on the aetiology of the macular oedema, it has a different nomenclature. A common cause of macular oedema is retinal vein occlusion (RVO). This may be secondary to a central, branch or hemiretinal vein occlusion. The prevalence of RVO increases with age. The most common association with RVO is undiagnosed hypertension. It is to be recommended that when patients are diagnosed with macular oedema secondary to RVO that they undergo 24-hour blood pressure monitoring. Open-angle glaucoma, diabetes mellitus, and hyperlipidemia have all been implicated as other primary risk factors for RVO. A hypercoagulable state also predisposes to the development of RVO. Conditions such as polycythemia, multiple myeloma, cryoglobulinemia, and Waldenstrom macroglobulinemia place patients at a higher risk of developing RVO. In a young patient who presents with a RVO a full systemic workup is mandated to detect such potential underlying causes. The primary treatment of macular oedema secondary to RVO is to address the underlying cause. Macular oedema secondary to advanced hypertension can resolve following adequate hypertensive control. Otherwise, patients are treated with a course of intravitreal therapy. The agents used may either be steroids or more commonly an anti-Vascular endothelial growth factor (VEGF) agent. Such agents include ranibizumab (Lucentis), aflibercept (Eylea), and bevacizumab (Avastin). Intravitreal steroids have a longer duration of action but are associated with an increased risk of cataract formation and can cause raised intraocular pressure. When the macular oedema resolves, the patient’s visual acuity generally improves unless there is associated non perfusion of the macula. Patients may require ongoing treatment for several months to years to preserve their vision. Patients with either Type 1 or Type 2 Diabetes Mellitus can develop diabetic macular oedema (DME). If the macular oedema does not involve the fovea, it can be treated by laser photocoagulation. However, laser scars can enlarge with time and encroach on the fovea leading to visual loss, so intravitreal therapy with either anti-VEGF agents or steroids is preferred by some for treating cases of DME with and without foveal involvement. Improving glycaemic control, regularising hypertension and treating hyperlipidaemia are known interventions to treat diabetic maculopathy. If DME has been present for some time, secondary structural changes can occur in the retina. These changes are termed disorganisation of retinal inner layers (DRIL). When these changes are seen, the visual prognosis for the patient is guarded. Neovascular age related macular degeneration (nAMD) is associated with swelling of the central macula. Choroidal neovascularisation leads to both subretinal and intraretinal leakage of fluid as well as haemorrhage. The presence of chronic intraretinal fluid is associated with a poorer visual outcome. Treatment of nAMD is with sustained intravitreal anti-VEGF therapy to dry up the intraretinal fluid and prevent the development of fibrosis. Patients are monitored with serial OCT imaging and their intravitreal treatment frequency adjusted accordingly. Cataract surgery is a recognised cause of macular oedema. When this occurs, it is termed pseudophakic cystoid macular oedema (CMO). The cataract surgery may have been either a complicated or an uncomplicated procedure. The patient may initially have good vision post cataract surgery which then falls in the following month, or else the vision may fail to improve vision at all post operatively. Many patients have subclinical CMO that is only detectable on OCT imaging and is self-limiting in nature. CMO is believed to be secondary to intraocular inflammation. The majority of patients with CMO will undergo resolution of their macular oedema following a course of combined topical NSAIDs and steroids. Sometimes intensive hourly treatment is required ab initio. A small subset of patients will require either a periocular or an intravitreal injection of steroid to settle this inflammatory condition. If cataract surgery is planned for their fellow eye, prophylactic anti-inflammatories are prescribed by many surgeons. Macular oedema may also occur as a complication of other intraocular procedures. These procedures include panretinal photocoagulation and YAG laser. Cryotherapy is another procedure which is known to cause macular oedema.
OCT image of left macular oedema
Uveitis, no matter where it is located within the eye -anterior, intermediate, or posterior can result in macular oedema and consequently reduced vision. The treatment of macular oedema secondary to uveitis is to treat the inflammatory cause with immunosuppressive agents. Chronic inflammatory changes at the macula can result in the development of choroidal neovascularisation.
Another cause of macular oedema is drug related. Fingolimid associated macular oedema (FAME) is well described. Fingolimid is an oral disease-modifying therapy indicated for the treatment of multiple sclerosis. The risk of FAME is dose dependent. A baseline OCT is required before commencing Fingolimid and the patients should undergo regular monitoring while on treatment. Latanoprost is a topical therapy commonly used to treat primary open angle glaucoma and CMO is a recognised side effect. CMO has been reported following nicotinic acid and niacin supplementation with doses of greater than 1.5g/day. Patients with retinitis pigmentosa have a reduced peripheral visual field. They may also develop CMO which will then further reduce their remaining central visual function. CMO in retinitis pigmentosa responds well to treatment with oral acetazolamide, topical dorzolamide or brinzolamide drops. Macular oedema has a disparate range of causes and accordingly treatments. It can cause mild to profound visual loss, if left untreated as in the case of nAMD the visual loss can be irreversible. OCT imaging facilitates the early detection of macular oedema and with early intervention, patients’ sight can be preserved.
TILDA publishes research on Brain Blood Oxygen
New research from The Irish Longitudinal Study on Ageing (TILDA) examined how blood oxygen levels in the brain (“cerebral oxygenation”) are affected when a person stands up. Blood flow to the brain provides oxygen and nutrients for normal function. A reduced supply has been associated with adverse events such as falls, depression and cognitive decline.
The group has previously studied the blood pressure response to standing, but in this study - published in the journal Experimental Gerontology - cerebral oxygenation was examined. The study used data from 2,764 community-dwelling participants. The size of the study enabled researchers to account for a range of confounding factors.
Key Findings:
• Women experienced a smaller drop in cerebral oxygenation compared to men. • Women took longer to return to their normal level.
• Older age groups had a larger initial drop in cerebral oxygenation and impaired stabilisation.
• Those taking blood pressure lowering medications took longer to recover. • Blood pressure levels also only partly explained some of the differences that we found.
Louise Newman is the lead author of the study and Research Assistant in Medical Gerontology at Trinity. She said, “We know that age affects how quickly blood pressure recovers when a person stands up, but we didn’t know if it was the same for cerebral oxygenation. "We used novel equipment, nearinfrared spectroscopy, to measure the change in blood oxygen in the brain during a standing task. We found that women experienced a smaller drop in cerebral oxygenation compared to men, but women took longer to return to their normal level. We also found that those taking antihypertensive medications took longer to recover. “However, there were no differences in the cerebral oxygenation response in those who told us they felt dizzy, light-headed or unsteady when standing up. Blood pressure levels also only partly explained some of the differences that we found.”
She explained, “The study highlights the need for standing cerebral blood measures to be assessed in older patients, regardless of symptoms.” Professor Rose Anne Kenny, TILDA’s Principal Investigator, added, “Brain cells survive and function according to how much oxygen they receive and how quickly the cells and circulation can clear toxins from the brain cells. We stand up 30-50 times per day and each time our bodies must react quickly to ensure that the flow of blood and therefore oxygen is kept constant. For the first time in such a large adult study we have measured such brain blood flow when TILDA participants stood up and demonstrated that the ability to react quickly and maintain flow is impaired year on year over 50 years. “Furthermore, men and women react differently. Muscle strengthening exercises and other interventions can change in a beneficial way these responses, so early recognition of problems, using this novel technology, should trigger treatments and lifestyle behaviour changes. As a result of this research, we have started to use the new technology in clinical settings to improve patient management.” The study, Age and sex related differences in orthostatic cerebral oxygenation: Findings from 2764 older adults in the Irish Longitudinal Study on Ageing, is published in the journal Experimental Gerontology and is freely available to all online.
Professor Rose Anne Kenny, TILDA
Exciting Developments at Uniphar
Uniphar are very excited to welcome Martin Slattery to the Uniphar Supply Chain & Retail division. Martin joins Uniphar as Wholesale Commercial Director having spent the last 15 years in senior leadership roles across both the retail and FMCG wholesale sectors so brings with him a wealth of experience in driving good business and the importance of customer partnerships.
He spent the last 8 years at the head of Musgrave MarketPlace overseeing a period of significant sales growth having led a complete brand transformation and customer offer across their nationwide sites.
Prior to this Martin was part of Lidl Ireland’s early success across a period of 7 years working in various key roles and divisions finishing as Sales Director. He also spent 2 years working in marketing in the Financial sector. He holds a Masters in Marketing from NUI Galway. Uniphar have also confirmed the appointment of Louise Martin as the new Retail Director for Uniphar Supply Chain & Retail. Louise joined Uniphar 2 years ago as Consumer Business Unit Manager. Prior to Uniphar, Louise held several senior commercial positions in McKesson UK, Lloyds Pharmacy Ireland and Tan Organic. During her time as Head of Category Management for McKesson UK, Louise built a strong team, grew retail sales in what was a challenging retail environment at the same time as managing an aggressive store refit programme. Over the last two years during Louise’s management the Consumer business has doubled its turnover and profit. Louise has brought an energy and passion for pharmacy retail, customer focus, brilliant basics and cross functional collaboration to the Consumer business. She has fostered a positive work culture within Consumer, focused on building a commercially focused and highly motivated team. Louise leaves the Consumer team in an excellent place for success as they are embarking on a new phase of growth and opportunity.
Martin Slattery, Wholesale Commercial Director, Uniphar Supply Chain & Retail Louise Martin, Retail Director, Uniphar Supply Chain & Retail
Fighting Blindness to Host Leading International Eye Researchers
Retina, the annual gathering of international eye experts organised by Fighting Blindness, returns to Dublin this November for the first time since 2019.
Dr Ellen Moran, Research Manager, Fighting Blindness
The scientific stream of the conference takes place from November 3-4 and brings together leading clinicians and scientists at the vanguard of ophthalmology research. Now in its 14th year, Retina aims to enable participants share the advances they are making with their peers, to offer a springboard for ideas, and to provide an opportunity for collaboration in the collective human effort to find treatments and cures for vision impairment and blindness. With latest figures showing that there are approximately 272,000 people in Ireland living with blindness or vision impairment, this event will be of interest to all those working in eye healthcare, from researchers working at the bench, to clinicians working at the bedside. Registration for the conference, which is taking place in the Radisson Blu Royal Hotel, Golden Lane, Dublin 2, will open on October 1 at www.retina.ie
Day 1 – StarT Symposium
The first day of the conference, Thursday November 3, features a StarT symposium, organised by StarT, a European Training Network, established to advance diagnosis, understanding and treatment of Stargardt disease. Among the speakers will be Professor Mariya Moosajee, Francis Crick Institute London, whose work ranges from developing new therapies for inherited retinal diseases (IRDs) to developing patient understanding with the creation of the Gene Vision online resource on rare genetic eye disorders.
Day 2 – Scientific Conference
The second day of the conference, Friday November 4, features a wide range of speakers who will offer perspectives on topics such as the use of adaptive optics in Age-Related Macular Degeneration (AMD), developments in gene editing for inherited retinal diseases, and the use of artificial intelligence in offering precision diagnosis for eye disease. Speakers include: • Professor Catherine Bowes
Rickman, Duke University,
USA, one of the world’s leading experts on AMD who will speak on the pathobiology of AMD and her work to find a cure • Professor Austin John
Roorda, University of
California, Berkeley, USA, inventor of the Adaptive
Optics (AO) Scanning Laser
Ophthalmoscope, who will address the use of AO in studying AMD and evaluating treatments to slow its progression • Dr Alessandra Recchia,
Associate Professor in
Molecular Biology, University of Modena and Reggio Emilia,
Italy, who will update on gene editing in inherited retinal diseases and her application of the CRISPR/Cas gene therapy tool in retinitis pigmentosa • Professor Rando Allikmets,
Columbia University, New York, who discovered the first gene associated with AMD, among other discoveries, will speak on precision ophthalmology and using state-of-the-art genetic testing for personalised treatment of Stargardt/ABCA4 disease
Dr Abigail Fahim, Assistant Professor, Kellogg Eye Centre, Michigan, USA
‘Back in the Room’
For Dr Ellen Moran, Research Manager with Fighting Blindness, Retina 2022 provides an opportunity for the international eye research community to come together, share ideas and develop partnerships: “We are delighted to welcome some of the world’s foremost thinkers in ophthalmology research to Dublin for what promises to be the most inspiring Retina conference yet. It was 2019 when the eye research community last had an opportunity to gather in-person for Retina and the intervening period has been particularly challenging for the IRD community, with several potential therapies not making it through clinical trials. Many in the community feel some of these therapies have indeed shown promise, but that success is perhaps only being judged in improving, as opposed to maintaining vision, and that keeping current levels of sight should also be deemed a win. The unfortunate reality is that while mutations have now been identified in over 300 genes for IRDs, therapies continue to elude us. We owe it to the approximately 5,000 people in Ireland with an IRD to put our shoulders to the wheel in driving forward innovation in this area.
“That’s why Retina 2022 provides such a valuable opportunity to allow people to get ‘back in the room’, to meet face-to-face, and to showcase the positive scientific research advances being made, as well as to address some of the challenges before us and how these can best be overcome. Retina is unique in providing earlystage researchers and established experts a joint platform to share their insights and develop personal connections and collaborations.”
Unlocking Retinal Cells
One of the conference speakers, Dr Abigail Fahim, Assistant Professor, Kellogg Eye Centre, Michigan, USA, adds: “Retinal pigment epithelial cells, or RPE cells, form a supportive layer adjacent to the light-sensing cells of the retina. RPE cells are critical for the health of the retina and the health of the underlying blood vessels, called the choroid. In certain inherited retinal dystrophies, such as choroideremia, dysfunction of RPE cells can disrupt this support system and can lead to damage of the adjacent retina and choroidal vasculature, causing irreversible vision loss. My lab examines abnormalities of protein transport and release from RPE cells in choroideremia, and how these released proteins may be damaging neighboring tissues. We hope to establish a platform for testing new treatments in choroideremia and other diseases with RPE dysfunction. This is the next step to give these patients hope.” Retina 2022 is supported by AbbVie, Novartis, Roche and Specsavers. For more information on the conference proceedings and to register, visit www.retina. ie, or follow on Twitter @fight_ blindness #RetinaDublin
