The Journal of the Irish Practice Nurses Association

Issue 2 Volume 3 March / April 2010

Lung cancer: risk factors, presentation and diagnosis Eileen Byrne

A practical guide to the CervicalCheck call/re-call process Carrie Powles Niomh McCollam

Health significance of meningitis and fat quality of meningococcal Osteoporotic our diet disease fractures Dr Patricia Heavey Lisa M Slattery Melanie Fox

editorial

What a pity that some GPs insist on retaining their old ‘territory’

espite the demise of the Celtic Tiger there are some very positive developments of late. The National Cancer Screening Service's colorectal screening process has started its selection process. Mary Harney has decided to reverse her previous decision not to go ahead with the cervical cancer vaccine Dprogramme. The HPV vaccine will soon be available to around 30,000 first year secondary schoolgirls, free of charge. The minister has also launched guidelines for quality assurance in cervical screening. Also on a positive note, the National Screening Service is considering the introduction of a triage system of HPV testing for women with abnormal smear test results. All of this is very positive, however, in the midst of all these positive developments I was disappointed to spot the following headline: 'Death by a thousand cuts' by Dr Muiris Houston in the new fortnightly newspaper – the Medical Independent. Dr Houston’s article went on at length about all the hard work general practitioners carry out with little thanks from the Government and little negotiation over fees. His article also bemoans the future shortage of GPs :“a shortage of over 300 GPs by 2021”...(Medical Independent Issue 3 Vol. 1 p 29) “..the more astute GPs have realised what the collective agenda is: turn doctors into employers, expand nurse prescribers and encourage them to take over much of what doctors do”...he finished his attack by encouraging GPs to “stand up and shout stop”. His article returned us to the old professional territorialism about who does what and who ultimately maintains power. Until we all settle down and become more patient/people focused, disharmony will prevail. During the worst period in the history of Irish healthcare for doctors, patients and nurses alike, practice nurses have become an eminently reliable and responsible group. We were there for the swine flu, for the National Cervical Screening Programme, for the childhood vaccination programme 6 and 1, for the PCV catch-up programme, for the heart watch programme... I didn't hear many of our GP colleagues mouthing Muiris’s “Stop!” in relation to the above.

Darina Lane

Victoza Nurs in General A4 09(1):Layout 1 12/11/2009 14:19 Page 1

Once-daily Victoza® (liraglutide), in combination with metformin, impacts on multiple factors associated with type 2 diabetes providing, from baseline:1,2

Reductions in HbA1c: up to 1.30%1,2 Reductions in weight: up to 2.8kg1,2 Reductions in systolic blood pressure1,2 Improvements in beta-cell function1,2

Abbreviated Prescribing Information Hypersensitivity to the active substance or any of the excipients. Warnings and distension, dyspepsia, gastritis, flatulence, gastroesophageal reflux disease, Victoza® 6 mg/ml solution for injection in pre-filled pen (liraglutide). Please refer Precautions for use: Victoza® should not be used in patients with type 1 gastroenteritis viral, toothache, headache, dizziness, nasopharyngitis, bronchitis, to the Summary of Product Characteristics for full information. Victoza® 2 x 3 ml diabetes mellitus or for the treatment of diabetic ketoacidosis. Limited experience anorexia, appetite decreased, fatigue and pyrexia. Gastrointestinal adverse pre-filled pens. Victoza® 3 x 3 ml pre-filled pens. 1 ml of solution contains 6 mg in patients with congestive heart failure New York Heart Association (NYHA) reactions are more frequent at start of therapy but are usually transient. Very of liraglutide. Indication: Treatment of adults with type 2 diabetes mellitus in class I-II and no experience in patients with NYHA class III-IV. Due to limited few hypoglycaemic episodes observed other than with sulphonylureas. Patients combination with metformin or a sulphonylurea, in patients with insufficient experience Victoza® is not recommended for patients with inflammatory bowel >70 years or with mild renal impairment (creatinine clearance ≤ 60-90 ml/min) glycaemic control despite maximal tolerated dose of metformin or sulphonylurea disease and diabetic gastroparesis. Victoza® is associated with transient may experience more gastrointestinal effects. Consistent with medicinal products monotherapy; or in combination with metformin and a sulphonylurea, or gastrointestinal adverse reactions, including nausea, vomiting and diarrhoea. containing proteins/peptides, patients may develop anti-liraglutide antibodies metformin and a thiazolidinedione in patients with insufficient glycaemic control Other GLP-1 analogues have been associated with pancreatitis; patients should following treatment but this has not been associated with reduced efficacy of despite dual therapy. Dosage: Victoza® is administered once daily by be informed of symptoms of acute pancreatitis: persistent, severe abdominal Victoza®. Few cases reported of angioedema (0.05%), acute pancreatitis subcutaneous injection and can be administered at any time independent of pain. If pancreatitis suspected, Victoza® and other suspect medicinal products (<0.2%) and injection site reactions (approx. 2%). Injection site reactions usually meals however, it is preferable that Victoza® is injected around the same time should be discontinued. Thyroid adverse events, including increased blood mild. Causal relationship between Victoza® and pancreatitis can neither be of the day. Victoza® should not be administered intravenously or intramuscularly. calcitonin, goitre and thyroid neoplasm reported in clinical trials particularly in established nor excluded. Thyroid neoplasms, increased blood calcitonin and Recommended starting dose is 0.6 mg daily. After at least one week, the dose patients with pre-existing thyroid disease. Risk of hypoglycaemia in combination goitres are the most frequent thyroid adverse events and were reported in 0.5%, should be increased to a maintenance dose of 1.2 mg. Based on clinical with sulphonylureas; lowered by dose reduction of sulphonylurea. No studies on 1% and 0.8% of patients respectively. The Summary of Product Characteristics response, after at least one week the dose can be increased to 1.8 mg to further the effects on the ability to drive and use machines performed. Patients should should be consulted for a full list of side effects. Overdose: In the event of improve glycaemic control in some patients. Daily doses higher than 1.8 mg are be advised to take precautions to avoid hypoglycaemia while driving and using overdose, appropriate supportive treatment should be initiated according to the not recommended. When used with existing metformin therapy or in combination machines, in particular when Victoza® is used in combination with a patient’s clinical signs and symptoms. MA numbers: Victoza® 2 x 3ml pre-filled with metformin and thiazolidinedione therapy, the current dose of metformin sulphonylurea. Substances added to Victoza® may cause degradation; in the pens EU/1/09/529/002. Victoza® 3 x 3ml pre-filled pens EU/1/09/529/003. Legal and thiazolidinedione can continue unchanged. When added to existing absence of compatibility studies Victoza® must not be mixed with other medicinal Category: POM. For complete prescribing information please refer to The sulphonylurea therapy or in combination with metformin and sulphonylureas, a products. Pregnancy and lactation: Victoza® should not be used during Summary of Product Characteristics which is available on www.medicines.ie or reduction in the dose of sulphonylurea may be necessary to reduce the risk of pregnancy or during breast-feeding. If a patient wishes to become pregnant, or by email from [email protected] or from Medical department, Novo Nordisk hypoglycaemia. Victoza® can be used in the elderly (>65 years old) without dose pregnancy occurs, treatment with Victoza® should be discontinued; use of insulin Limited, 3-4 Upper Pembroke Street, Dublin 2, Ireland; www.novonordisk.ie. adjustment but therapeutic experience in patients ≥75 years of age is limited. is recommended instead. Undesirable effects: During clinical trials with Date created: July 2009 No dose adjustment is required for patients with mild renal impairment Victoza® the most frequently observed adverse reactions which varied according (creatinine clearance ≤60-90 ml/min). Due to lack of therapeutic experience to the combination used (sulphonylurea, metformin or a thiazolidinedione) were: ® Victoza is not to be recommended for use in patients with moderate (creatinine Very common: nausea, diarrhoea, hypoglycaemia when used in combination with Information about adverse event reporting is available at www.imb.ie. clearance of 30-59 ml/min) and severe renal impairment (creatinine clearance metformin and a sulphonylurea and headache when used in combination with Adverse events should be reported to the Novo Nordisk Medical department: below 30 ml/min), patients with end stage renal disease, patients with hepatic metformin; Common: hypoglycaemia when used in combination with a Tel: 1850 665 665. impairment and children below 18 years of age. Contraindications: thiazolidinedione, vomiting, constipation, abdominal pain, discomfort and

Further Information is available from: References: 1. Victoza® Summary of Product Characteristics, July 2009. Novo Nordisk Limited 2. Nauck M et al; for the LEAD-2 Study Group. Efficacy and safety comparison of liraglutide, glimepiride, and placebo, all in combination with metformin, 3/4 Upper Pembroke Street in type 2 diabetes: the LEAD (liraglutide effect and action in diabetes)-2 study. Diabetes Care 2009;32(1):84-90. Dublin 2, Ireland Tel: 01 678 5989 Victoza® is a trademark owned by Novo Nordisk A/S. Fax: 01 676 3259 Lo Call: 1850 665 665 Date of preparation: July 2009. IR/LR/0709/0268 www.novonordisk.ie The Journal of the Irish Practice Nurses Association Contents Issue 5 VolumeIssue 2 Volume 2 September 3 March / O /ctober2009 April 2010

1 editorial review 4 News 15 Meningitis and meningococcal 12 Branch news disease – adults get it too lisa M Slattery 22 lung cancer: risk factors, presentation and diagnosis eileen Byrne 28 A practical guide to the CervicalCheck call/re-call process carrie Powles Niomh McCollam 33 osteoporotic fractures Melanie Fox 40 health significance of fat quality of our diet dr Patricia Heavey Abstracts 44 Allergy 46 gAstroenterology Poster series Editor Maura Henderson 48 Maximising women’s health in Consulting Editors general practice Darina Lane and Ruth Morrow claire Bourke, Margaret Geoghegan, Sub Editor Ruth Morrow and Margaret O'Reilly. Tim Ilsley 50 wAlking in to primary care Designer linda Latham Barbara Vasic 51 Products Publishers Graham Cooke 53 Crossword Maura Henderson

*GreenCross Publishing is a recently established publishing house which is jointly owned by Graham Cooke and Maura Henderson. Between them Graham and Maura have over 30 years experience working in healthcare publishing. Their stated aim is to publish Nursing in General Practice is published by titles which are incisive, vibrant and pertinent to their readership. GreenCross Publishing, Lower Ground Floor, Graham can be contacted at 5 Harrington Street, Dublin 8. [email protected] Tel: 4789770 Fax: 4789764 Maura at Email: [email protected] [email protected] © Copyright GreenCross Publishing 2010 Disclaimer The views expressed in Nursing in General Practice are not The contents of Nursing in General Practice are protected by copyright. necessarily those of the publishers, editor or editorial advisory No part of this publication may be reproduced, stored in a retrieval board. While the publishers, editor and editorial advisory board system, or transmitted in any form by any means – electronic, have taken every care with regard to accuracy of editorial and mechanical or photocopy recording or otherwise – whole or in part, in advertisement contributions, they cannot be held responsible for any form whatsoever for advertising or promotional purposes without any errors or omissions contained. the prior written permission of the editor or publishers

3 news nec news Mater Private IPNA AWARDS 2010 The following Awards will be offered to members this year: IPNA Educational Bursary 2010 – closing date for entries is 31st July 2010. joins Healthlink.ie Practice Nurse of the Year Award 2010 – closing date for branch nominations is 31st July 2010. The Mater Private Hospital, one of Europe’s leading hospitals, Valerie Mangan IPNA Loyalty Award 2010 – closing date has become the first private hospital in the country to join the for branches to send names of members eligible to enter this highly acclaimed online National Healthlink Project; a web- award is 31st July 2010. based messaging service which allows the secure transmission Please see IPNA website and attend your upcoming branch of patient information such as results and referrals over the meetings for further details on all awards. internet. Healthlink.ie already has over 1800 General Practitioners IPNA CONFERENCE/AGM 2010 around Ireland and brings significant benefits and efficiencies 15th/16th October 2010, Ballybofey, Co Donegal – hosted by to general practice including reducing both the length of the IPNA Donegal Branch. time it takes to receive patients’ test results and the length of time spent contacting hospital departments, a reduction in POSTER DISPLAY administration and direct integration of results with practice If any current member created a poster that is relevant to management systems. Practice Nursing within the last three years and would like to GPs can now use Healthlink to send referrals electronically display it at the conference, please contact Lisa at admin@ to the Mater Private Specialist Breast Centre. The Mater Private irishpracticenurses.ie to book a poster display board, before Hospital’s Specialist Breast Centre offers a full range of services Monday 6th September 2010. Posters that have not been including rapid access to triple assessment, diagnosis and pre-booked by this date cannot be accommodated at the treatment for patients with breast cancer. Appointments are conference. confirmed by phone with the patient on day of referral receipt. Currently, for the Mater Private the range of services available 2010 NEC MEETINGS to GPs using Healthlink include: Wednesday 12th May 2010 – Ashling Hotel, Parkgate Street, • Radiology Results Dublin 7 - please note this has changed from original date of 5th • Cardiology Results (first hospital to send this message May. type) Wednesday 8th September 2010 - Ashling Hotel, Parkgate • Referral to the Mater Private Specialist Breast Centre Street, Dublin 7. • Death and Discharge Notifications Friday 15th October 2010 at IPNA Conference in Jackson's Hotel, Ballybofey, Co Donegal. It is planned to add additional services in the coming months • Laboratory Results Lisa Nolan, IPNA Administrator • Outpatient Appointment Messages Lisa Nolan, IPNA Administrator. • Prostate Referrals Tel: 042-9692403 • Cardiology Referrals e-mail: [email protected] • Diagnostic Imaging Referrals NUI Galway opens new nursing and midwifery library NUI Galway’s President, Dr James J. Browne, opened NUIG’s new Nursing and Midwifery Library on the 3rd February. The new library, which adjoins the James Hardiman Library on the main campus, provides a modern learning environment for over 700 nursing and midwifery students with group study rooms, computer suites, laptop-enabled study spaces, and wire- less access to the University’s networked services. The need for a new, purpose-built library was driven by changes in nursing education and the increase in student numbers, which resulted in greater pressure on space as well as a need for new types of learning resources. The new library has over 100 study places, and has been heavily used and much appreciated by students and staff since it opened. Over 700 nursing and midwifery students now have access to the full resources of the University Library, including a wide range of information sources and extensive opening hours, in a central location on campus. Previously, NUI Galway’s Nursing Library was located on the site of the former Nurses’ Home at At the opening of the Nursing and Midwifery Library at NUI University College Hospital and it relocated temporarily to the Galway were John Cox, Librarian, James Hardiman Library; IDA Business Park in Dangan in 2004. Professor Kathy Murphy, Head of Nursing and Midwifery, The library was developed at a total cost of €2 million. Of this NUI Galway; Dr James J. Browne, NUI Galway President; total, a sum of €1 million was provided by the Department of Mary McHugh, Director of Nursing, GUH; and Keith Health and Children. The balance has been provided from the Warnock, Vice-President for Capital Projects, NUI Galway. University’s own resources.

4 news CervicalCheck Smeartaker training unit clinical updates

The Smeartaker Training standards. The aim of the Clinical update meeting • 20 April Rochestown Park Unit of CervicalCheck – The Clinical Update Meetings is to dates: Hotel, Rochestown, Cork National Cervical Screening provide advice and assistance • 23 March Carlton Hotel, • 21 April Desmond Suite, Programme is holding a series to GPs and practice nurses in Dublin Road, Galway City Thomond Park, Limerick of CME accredited Clinical applying the Guidelines to • 25 March Bracken Court Ho- • 28 April Tullamore Court Update Meetings for Cervical- practice and the management tel, Balbriggan, Co Dublin Hotel, O’Moore Street, Tul- Check registered smeartakers of quality smeartaking. • 3 April Ramada Encore Ho- lamore Co Offaly (practice nurses and GPs) in CervicalCheck Clinical tel, Letterkenny, Co Donegal • 28 April Ramada Viking Ho- primary care. Updates also promote current • 14 April Best Western Ais- tel, Cork Road, Waterford The National Cancer best practice in the taking and ling Hotel, Parkgate Street, Screening Service recently management of quality smear Dublin 8 launched ‘Guidelines for tests and provide smeartak- • 14 April Brehon Hotel, Kil- Each meeting runs from Quality Assurance in Cervical ers with an opportunity to larney, Co Kerry 7.00-9.30pm and booking is Screening’. The Guidelines increase their knowledge and • 14 April Cavan General Hos- required. To book a place or for will help ensure that women understanding of Cervical- pital, Cavan, Co Cavan further information, contact in Ireland receive a quality as- Check. Each meeting will be • 15 April Stillorgan Park the Smeartaker Training Unit sured screening service in line followed by an in-depth ques- Hotel, Stillorgan Road, at [email protected] or call with the highest international tion and answer session. Dublin 18 061-461146 / 461234.

Labour publishes Bill to control spread of head shops and sex shops The Labour Party has published Under the terms of Labour’s month, specific planning expressed about the opening of a draft Private Members Bill to Planning and Development permission would be required both head shops and sex shops restrict the spread of so-called (Amendment) Bill, 2010, details for a change of use of a premises in locations that are particularly ‘headshops’. of which were published last to open either a head shop or a inappropriate, such as close to sex shop. schools. According to Ms Jan “These shops are selling O’Sullivan TD, Labour Spokes- products which are not covered person for Health: “The proprie- by the Misuse of Drugs Act, but tor of a grocery store, takeaway which clearly mimic illegal drugs or internet café must apply and and have damaging physical obtain planning permission to and psychological effects on open for business. However, that those who consume or inject same owner or a new owner those products. Because these can then decide to convert the shops are not illegal but are premises into a head shop or unlicensed and unregulated and a sex shop overnight without can sell their products to minors even having to apply to the local as well as adults there is serious authority for planning permis- concern in local communities at sion for change of use. In effect the failure of the authorities to there is nothing to stop a person take action.” from seeking and securing plan- Ms O’Sullivan added that the ning permission to open a sweet Bill was not a total solution to shop and then, overnight, turn- the problem of head shops, as ing it into a head shop. Because this would require the banning no specific planning permission of the dangerous substances on is required for change of use sale in these outlets, which she from one existing retail function said was “a complex and difficult to another, members of local procedure which may take communities have no opportu- some time”. However, she said nity whatsoever to express any it offered “an interim solution concerns they might have.” that would, if enacted, at a very Jan O’Sullivan, Labour Spokesperson for Health is Ms O’Sullivan added that minimum restrict the further seeking to restrict the spread of headshops particular concern had been spread of these outlets.”

5 news Continuing education in caring for children with life-limiting conditions A Palliative Care Needs Assessment for Children (Department symptom assessment and management, and ethical perspectives. of Health and Children and Irish Hospice Foundation, 2005), There is no fee for this programme. The programme dates for identified the “substantial need for further education and training 2010 are: for all professionals involved in caring for children with life- 24th March red Cow Moran Hotel, Dublin limiting conditions”. There are over 1,300 Irish children who live 3rd June Claregalway Hotel, Galway with a life-limiting illness and between 350 and 400 children die 7th September Hotel Kilmore, Cavan each year prior to their 18th birthday. 2nd November red Cow Moran Hotel, Dublin The report states that all providers of care for children with life-limiting conditions should have an opportunity to acquire Seven Day Programme additional knowledge, experiences and skills to assist them, as The seven day Level B programme is a more in-depth they support these children and their families. programme for registered nurses and midwives directly involved In response to this, two programmes are managed and co- in caring for children with a life-limiting condition. The aim is ordinated by the Centre of Children’s Nurse Education in Our to further develop the knowledge, skills and attitudes required Lady’s Children’s Hospital, Crumlin (OLCHC) and are funded by to enhance each child’s quality of life through meeting his /her the Irish Hospice Foundation. A one day awareness programme identified needs and to provide supportive and palliative care for – Caring for the Child with a Life-Limiting Condition Level A and these children and their families. The programme is facilitated in a seven day continuing education programme – Caring for the the Centre of Children’s Nurse Education at Our Lady’s Children’s Child with a Life-Limiting Condition Level B. Both programmes Hospital, Crumlin. Again there is no fee for this programme and have An Bord Altranais Post Registration Category 1 approval a bursary of up to €500 is available to support the participant’s (Feb. 2010). attendance. The programme dates are: Summer April 19, 20, 27 and May 4, 11, 18, 25. One Day Awareness Programme Autumn September 13, 14, 21, 28 and October 5, 12, 19. The one day Level A awareness programme is for nursing Winter November 10, 11, 17, 24 and December 1, 8, 15. and medical personnel, palliative care specialists (nursing and Nurses, midwives and other healthcare professionals are invited medical), psychologists, social workers and other personnel to attend either or both of these programmes. Early booking is from various voluntary and statutory organisations who are advisable as places are limited. occasionally required to provide care for children with life-limiting conditions and their families For further details and bookings please contact Fiona Woods, Topics addressed include healthcare provision for these Programme Co-ordinator. children, supporting social and psychological needs, pain and Phone: 01 4096605 and 087 7455952 or Email: [email protected] Workshop on female genital mutilation

“A practise that hurts is and girls have undergone FGM unacceptable” was the worldwide. It is estimated message delivered at a recent that 500,000 women victims workshop on female genital of FGM live in Europe while mutilation held in the Menlo the estimate for Ireland is Park Hotel Galway.. The aim of approximately 2,600. the workshop was to explore The Irish National Action the effects of FGM and Plan (NAP) to address FGM how men and women from was launched in November communities in which FMG 2008. To date AkiDwA, the is practised can contribute African and migrant women’s to the European and global network has developed campaign to end FGM. support for healthcare Speaking in advance of professionals by providing the meeting, the Consortium materials, information, of International Women research, lectures and training the new legislation that greater support and solidarity Leaders – a group that has to enhance knowledge. prohibits children being among all parties and those been established by active The organisation has, and taken outside Ireland for the who are committed to human African women leaders, continues to, deliver training procedure. rights. extended their support: “We to students, midwives and With financial support AkiDwA is also a partner believe both men and women, social workers and has been from the HSE, AkiDwA is with Amnesty International especially those from our calling for legislation in also progressing with the Ireland in Amnesty's European own communities should be Ireland to prohibit FGM. The implementation of the health Campaign to end FGM. heavily involved in efforts to organisation is also calling aspects of NAP. Speaking at For further information contact: end FGM .” for the introduction of an the meeting Salome Mbugua, Salome Mbugua, AkiDwA, 9B Over 140 million womenIN extraterritorialTE elementR into NDirectorA of AkiDw,T called forI OLower AbbeyN Street, DublinA 1. L DAY OF 6 ZERO TOLERANCE TO FEMALE GENITAL MUTILATION (FGM)

DATE Thursday 4th February TIME 10am - 1.30pm VENUE European Public Information Centre (EPIC) 18 Dawson Street, Dublin 2

A SEMINAR TO HIGHLIGHT THE WORK OF THE NATIONAL STEERING COMMITTEE AND WORK OVERSEAS BY IRELANDTO COMBAT FGM

Speakers include: Her Excellency Mrs Mannete Ramaili – AMBASSADOR OF LESOTHO Senator Ivana Bacik Colm O’Gorman - AMNESTY INTERNATIONAL (IRISH SECTION) Salome Mbugua - AkiDwA Sioban O’Brien Green - AkiDwA Eileen Morrow - WORLD VISION Ahmed Gadaf & Ifrah Ahmed - SOMALI COMMUNITY IN IRELAND Asiya Altawash - THE ISLAMIC CULTURAL CENTRE OF IRELAND

HOSTED BYTHE NATIONAL STEERING COMMITTEE

The National Steering Committee is comprised of AkiDwA, Amnesty International, UNICEF Ireland, Barnardos, Cairde, Children’s RightsAlliance, NationalWomen’s Council of Ireland, the HSE, Somali Community in Ireland, Integrating African Children in Ireland, Irish Aid, Integrating Ireland and Refugee Information Services, Christian Aid, Irish Family Planning Association and Others.

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Forticreme WIN Advert.indd 1 17/08/2009 14:08:02 news Colorectal Cancer Screening Hot topics in renal medicine Programme approved Abbott Educational Day for nurses

The National Cancer Screening screening for this age group Service (NCSS) today wel- on a two yearly cycle using comed receipt of approval to the faecal immunochemical proceed with the introduction test (FIT) which operates on an of a national population-based automated testing platform, colorectal cancer screening as the primary screening tool. programme for men and This will be one of the first in- women in Ireland. ternational population-based At a joint press conference screening programmes for with the NCSS, the Minister for colorectal cancer that utilises Health and Children, Ms Mary this technology as the primary Harney TD, today announced screening tool. approval of the NCSS to In order to develop capac- commence preparation and ity to implement a screening implementation of Ireland’s programme for the full 55-74 first colorectal cancer screen- population, the programme Abbott recently sponsored the fourth annual Renal Nurse Study ing programme. will be implemented on a Day, educating nurses in Ireland on the latest trends in renal The incidence of colorectal phased basis starting with men care. Dr Joe Eustace, Consultant Nephrologist, Cork University cancer increases with age and and women aged 60-69. Fifty Hospital, spoke to about 60 senior renal nurses about recent the highest rate of incidence is per cent of all cases of colorec- developments in cardio-renal syndrome. among men and women aged tal cancer in the 55-74 year age The event was Abbott’s fourth annual Renal Care Study Day, 55-74. The NCSS has recom- group are diagnosed in men providing a strong platform for the discussion of hot topics in mended the introduction of and women aged 60-69. renal nursing to an audience of approximately 60 senior renal nurses. The objective of the study day was to educate renal nurses on improvements in renal care and advances in this area First 2010 meeting of the Roche of medicine. Abbott's dedicated renal care business provides products aimed at improving the lives of patients living with Rheumatoid Arthritis Academy renal disease. Mind your head Kerry Councillor Michael Healy Rae swapped his trademark cap for a cycling helmet to raise awareness of the importance of wearing protective headgear in preventing head and brain injuries. The safety message was issued during Brain Awareness Week which ran from 8th – 14th March 2010.

Mary Breen (Clinical Nurse Specialist, Beaumont Hospital), Clara Bannon (Acting Clinical Nurse Specialist, Connolly Memorial Hospital), Sandra Griffin (Staff Nurse, Connolly Memorial Hospital) and Miriam Molloy (Clinical Nurse Specialist, St. Vincent’s University Hospital).

Ann Maria Curran (Clinical Nurse Specialist, Merlin Park Hospital Galway) and Trish Bewley (Clinical Nurse Specialist, Kerry Councillor Michael Healy Rae with Lucia Power, Galway Clinic). Regional Manager with Acquired Brain Injury Ireland.

8 GreencrossA4 11/03/2010 16:16 Page 1 NEW Onbrez® - fast action 1 with superior efficacy 2,3,4* A new first line once daily LABA for COPD 5

Onbrez® versus tiotropium provides •5 minute rapid onset of action1,6 •Less Breathlessness7 4* •Superior FEV1

ABBREVIATED PRESCRIBING INFORMATION Please refer to Summary of Product Characteristics (SmPC) before prescribing. Presentation: Onbrez Breezhaler 150mcg and 300mcg inhalation powder hard capsules containing indacaterol maleate, and separate Onbrez Breezhaler inhaler. Indications: For maintenance bronchodilator treatment of airflow obstruction in adult patients with chronic obstructive pulmonary disease (COPD). Dosage and administration: Recommended dose is the inhalation of the content of one 150mcg capsule once a day, administered at the same time of the day each day, using the Onbrez Breezhaler inhaler. Capsules must not be swallowed. Dose should only be increased on medical advice. The inhalation of the content of one 300mcg capsule once a day has been shown to provide additional clinical benefit with regard to breathlessness, particularly for patients with severe COPD. Maximum dose is 300mcg once daily. No dose adjustment required in elderly patients, for patients with mild and moderate hepatic impairment or for patients with renal impairment. No data available for use in patients with severe hepatic impairment. No relevant use in the paediatric population. Contraindications: Hypersensitivity to the active substance, to lactose or to any of the other excipients. Warnings/Precautions: Asthma: ◆ONBREZ BREEZHALER SHOULD NOT BE USED IN ASTHMA. Paradoxical bronchospasm: ◆If paradoxical bronchospasm occurs Onbrez Breezhaler should be discontinued immediately and alternative therapy substituted. Deterioration of disease: ◆Not indicated for treatment of acute episodes of bronchospasm, i.e. as rescue therapy. Systemic effects: ◆Indacaterol should be used with caution in patients with cardiovascular disorders (coronary artery disease, acute myocardial infarction, cardiac arrhythmias, hypertension), in patients with convulsive disorders or thyrotoxicosis, and in patients who are unusually responsive to beta2-adrenergic agonists. Cardiovascular effects: ◆Indacaterol may produce a clinically significant cardiovascular effect in some patients as measured by increases in pulse rate, blood pressure, and/or symptoms, ECG changes. In case such effects occur, treatment may need to be discontinued. Hypokalaemia: ◆ Beta2-adrenergic agonists may produce significant hypokalaemia in some patients, which has the potential to produce cardiovascular effects. In patients with severe COPD, hypokalaemia may be potentiated by hypoxia and concomitant treatment which may increase the susceptibility to cardiac arrhythmias. Hyperglycaemia: ◆Inhalation of high doses of beta2-adrenergic agonists may produce increases in plasma glucose. Upon initiation of treatment with Onbrez Breezhaler plasma glucose should be monitored more closely in diabetic patients. ◆During clinical studies, clinically notable changes in blood glucose were generally more frequent by 1-2% on Onbrez Breezhaler at the recommended doses than on placebo. Onbrez Breezhaler has not been investigated in patients with not well controlled diabetes mellitus. Pregnancy and Lactation: ◆No data available from the use of indacaterol in pregnant women. Onbrez Breezhaler should only be used during pregnancy if the expected benefits outweigh the potential risks. ◆Not known whether indacaterol / metabolites are excreted in human milk. A decision must be made whether to discontinue breast-feeding or discontinue Onbrez Breezhaler therapy, taking into account the benefit of breast-feeding for the child and the benefit of therapy for the woman. Interactions: ◆Concomitant administration of other sympathomimetic agents may potentiate the undesirable effects of Onbrez Breezhaler. Onbrez Breezhaler should not be used in conjunction with other long-acting beta2-adrenergic agonists or medicinal products containing long-acting beta2-adrenergic agonists. ◆Concomitant hypokalaemic treatment with methylxanthine derivatives, steroids, or non-potassium-sparing diuretics may potentiate the possible hypokalaemic effect of beta2-adrenergic agonists, therefore use with caution. ◆Indacaterol should not be given together with beta-adrenergic blockers (including eye drops) as these may weaken or antagonise the effect of beta2-adrenergic agonists. Where required, cardioselective beta-adrenergic blockers should be preferred, although they should be administered with caution. ◆Inhibition of the key contributors of indacaterol clearance, CYP3A4 and P-gp, does not raise any safety concerns given the safety experience of treatment with Onbrez Breezhaler. ◆Indacaterol has not been shown to cause interactions with co-medications. Adverse reactions: ◆The most common adverse reactions with Onbrez Breezhaler are: nasopharyngitis, upper respiratory tract infection, sinusitis, diabetes mellitus and hyperglycaemia, headache, ischaemic heart disease, cough, pharyngolaryngeal pain, rhinnorrhoea, respiratory tract congestion, muscle spasm, peripheral oedema. ◆Uncommon: paraesthenia, atrial fibrillation and non-cardiac chest pain. ◆Please refer to SmPC for a full list of adverse events for Onbrez Breezhaler. Legal Category: POM Pack sizes: Carton containing 30 capsules (3x10 capsule blister strips) and one Onbrez Breezhaler inhaler. Marketing Authorisation Holder: Novartis Europharm Limited, Wimblehurst Road, Horsham, West Sussex, RH12 5AB, United Kingdom. Marketing Authorisation Numbers: EU/1/09/593/002 & 007. Full prescribing information is available on request from Novartis Ireland Ltd, Beech Hill Office Campus, Clonskeagh, Dublin 4. Tel: 01 2601255 or at www.medicines.ie Date of Creation of API Text: Jan 2010 Date of Preparation: Feb 2010 NO1109471 References: 1. Balint et al. (ERS Poster) 2009. 2. Dahl et al. (ERS poster) 3. Kornmann et al. (Chest Poster) 2009 4. Fogarty et al. (ERS Poster) 2009 5. Onbrez Breezhaler SmPC 6. Spiriva® HandiHaler® SmPC 7. Mahler et al. (ERS Poster) 2009 * INHANCE Study comparitor Open Label Tiotropium news € Ronnie Whelan walks Irish pump 86m for Myasthenia Gravis

Former Ireland International footballer, into illicit medicines Ronnie Whelan, has announced his plans to take part in a 130km walk around More than 600,000 Irish people have offer (6.5 per cent); or in a nightclub/pub Ireland in an effort to raise awareness of admitted to buying prescription only (2 per cent.). Myasthenia Gravis. medicines from illegal sources according The report also revealed that the Ronnie Whelan is patron of the to new research. counterfeit medicines market in Ireland Myasthenia Gravis Association, and The Cracking Counterfeit Europe report may be worth more than €86 million a he became aware of the disease commissioned by Pfizer and published year contributing to the €10.5 billion when Elizabeth was diagnosed in last month, revealed that one in five or European wide black market. 2005. Myasthenia Gravis (MG) is an 21 per cent of 1,000 people in Ireland Until now putting a value on the size auto-immune disease, which causes a surveyed admitted to buying prescrip- of the counterfeit medicines market in breakdown between nerves and muscles, tion only medicines from illicit sources. Ireland has been difficult. However, the and results in loss of effectiveness in the Worryingly, the results suggest that ‘Cracking Counterfeit Europe’ research muscles of the arms, legs and eyes thousands of Irish people are turning revealed that a massive black market ‘Ronnie Whelan’s Rocky Road to Dublin to the internet to buy medicines that economy is generated by counterfeit Walking Challenge’ takes place from 29th should be prescribed by a healthcare medicines. This comes just weeks after April – 4th May and will cover four stages: professional – despite the fact that it has Gunter Verheugen, Vice-President of The Western Way, Slieve Bloom Moun- been estimated that between 50 and the European Commission, announced tains, Kevin’s Way in Glendalough and the 90 per cent of medicines bought online that 34 million fake tablets had been coastal route from Greystones to Dublin. are fake. According to the report, other seized on European borders in just two Walkers can choose to join Ronnie in sources where people are purchasing months. The number of counterfeit all stages of the challenge, or join him prescription medicines without prescrip- medicines uncovered at EU borders on one of the stages as he walks across tion include overseas or on holidays has increased from 560,598 in 2005 to Ireland. (16.6 per cent); through a friend (12 per 4,081,056 in 2007 – a seven-fold increase Eager walkers can visit www.rockyroad.ie cent); in response to an email or spam over two years. for more details and registration forms. Need for patient information tools after prostate cancer diagnosis Some 72% of prostate cancer patients on behalf of Astellas Pharma Co.Ltd other resources useful, mainly because felt the effect on their lifestyle was the 87% of patients rely solely on their of the language used can be difficult to most important factor when diagnosed specialist to provide information with comprehend. but 56% of those did not speak to their remaining numbers seeking further In response to the survey results specialist about it at the time of diagnosis, knowledge through websites or books Astellas Pharma Co.Ltd have according to a recent survey, carried out but only 10% found website and 3% find developed the website www. unitedagainstprostatecancer.com which provides a post diagnosis information tool for patients. “The website is an excellent aid for patients who can be overwhelmed when they are first diagnosed. It will help patients and their family members review the condition, treatments and expected lifestyle changes they may incur. It will be useful for patients to be able to digest the information given and help them prepare further questions for their subsequent consultations” said Mr Paul Sweeney, consultant oncologist Mercy University Hospital. Entitled “Silent Voices”, the survey took place in France, Italy, Spain, Poland, Germany and Ireland and researched 50 At the launch of www.unitedagainstprostatecancer.com were Jim Scott, prostate cancer patients in each country. chairman of MAC (Men Against Cancer); Olwyn Ryan, Irish Cancer Society; It was undertaken in Ireland with the Ms Aine Brady TD, Minister for Older People and Health Promotion; Dublin support of St. James’s Hospital Oncology football star of the ‘90’s Charlie Redmond and John Dowling, MAC. Dept, Mercy University Hospital Oncology Dept and MAC (Men Against Cancer).

10 news Readers offer In a world of drab and generic medical uniforms, what’s a fashionista nurse to wear? Happythreads is supplying the koi range of boutique scrubs, the Hejco range of tunics and Alegria ergonomic footwear. They have recently launched their website www. happythreads.ie, which offers a easy to use and fun method of purchasing and personalising uniforms online. Designed in California, the koi range of uniforms is made from a hardwearing, yet easy care, soft poly-cotton twill. With a great choice of colours and styles for both women and men and trousers that come in different styles and leg lengths every size and shape can get the correct fit. When people feel the soft fabric of the koi scrubs they fall in love with them, they don’t require ironing and hold onto their shape and colour very well. Happythreads is the exclusive distributer for koi in Ireland and the UK and are currently negotiating with Medical suppliers and retail outlets to supply the uniforms. New to Ireland are the Alegria range of ergonomic footwear designed for people who spend long hours on their feet. They feature a heavenly footbed padded with latex and memory foam and a rocker outsole reducing heal and metatarsal pressure. the koi Katelyn top in Navy and Karlie trousers. We just loved Happythreads also provide an embroidery service with a the soft fabric and feminine tailoring of the Katelyn top. The range of specially designed logos and will also embroider surgeons and doctors went for the koi steel grey Maxx top. specific practice names and logos. The embroidery service is Our logo is shocking pink and came out really well on the undertaken in Ireland, adding real value to the products. steel and navy uniforms” “Happythreads organised all the sizes we needed to allow Happythreads are offering readers of Nursing in General the staff to get the correct fit,” said Lorraine Power, Clinical Practice a special discount of 10% for the month of April, Nurse Manager of the Eccles Street Clinic. “The girls ordered please use promocode nurse10 when ordering online.

Anna May Driscoll Practice Nurse required Foundation Practice nurse required for our Presentation Dublin 7 general practice Approx 30+ hours in fully computerized surgery, previous practice nurse experience desirable.

Please email CV to [email protected] or call practice manager on 0871251815 for further information.

Practice Nurse required

2-3 mornings per week (extending to more sessions depending on demand ) Skills required: phlebotomy, ECG, spirometry, ability to do dressings, smeartaking, travel vaccinations. Sharon Cassidy, Staff Nurse, Theatres at I am also interested in extending the role of a suitable candidate to Galway University Hospitals, recipient perform the following: microdermabrasion, laser hair removal, after of the inaugural Learning Bursary from appropriate mentoring and training. the Anna May Driscoll Foundation with Damien Dyar, Emerge Education, the Experience essential. company which established the Anna May Driscoll Foundation. Please send CV to [email protected]

11 regional news N ews f o r I P N A b r anches c o unt r ywide

CLARE Aine Lally

As always our monthly meetings are held in the lovely Old Ground Hotel in Ennis on the third Tuesday of every month. We are really hoping this year the attendance will improve as the meetings prove an invaluable way to share and discuss any relevant issues. Practice nursing can be quite isolating so we do feel it is imperative for as many as possible to attend. It is also such a lovely get together. At the January meeting Carol McNamara and Elaine Buckley gave us great updates and answered many questions on the latest Cer- vicalCheck programme. All in all it all seems to be going well. For the February meeting, Hilda Clarke, diabetic nurse specialist at Portiuncula Hospital gave an excellent talk on diabetes. She works with Dr Maeve Durkin in Ballinasloe and her enthusiasm, practical and down-to-earth attitude encouraged us all to think about how we could improve the management and care of our diabetic clients in general practice. It was very kindly sponsored by Tommy O Donoghue from Merck Sharpe Dome. The annual conference in October is in Jacksons Hotel in Donegal and we encourage as many members as possible to attend.

Cavan/Monaghan Patricia Jenkins

‘Reducing Cardiovascular Risk in Type 2 Diabetes’ was the topic of our December meeting. This was kindly sponsored by Takeda and was well attended by our members. A scrumptious meal was served in the Old Post Restaurant at Clover Hill. Our January meeting held in Errigal Hotel, Cootehill, was sponsored by Allen and Hanbury. Jacqueline and Catriona, A&H Medical Representatives, introduced the COPD Assessment Tool (CAT questionnaire). Martina Carolan, Nurse Specialist, Navan Hosptial, gave a very informed talk on rheumatology and the importance monitoring patient’s treatments. Our March meeting was sponsored by Nutricia. Joanna Hovey, Paediatric Dietitian, gave a talk on Cow Protein Milk Allergy in Infants. For those nurses who completed the Bradford Diploma in Diabetes we were given a one day update provided by the HSE Cardiovas- cular Facilitator, Celine Croarkan. Recent national nurse’s conferences included Abracadabra’s Diabetes conference weekend in the Osprey Hotel, Naas and the Sexual Health Conference in the Strand Hotel in Limerick. If you attended any of these, I am sure you will agree the speakers at both conferences were only excellent. In April the Primary Care Diabetes Society has its annual conference in the Radisson Hotel in Athlone. This is well worth attending with health professionals from north and south and UK attending. It was with sadness we learned of the deaths of Maura Burke’s mother and Jennifer Wilson’s brother. May they rest in peace, Amen. If you wish to join the Cavan/Monaghan practice nurse branch please e-mail me and I will give you further details on how to apply. [email protected]

Cork Trish O’Connor

We in the Cork Branch had no scheduled IPNA January meeting but instead we had a very enjoyable and educational visit to ARC House where Dr Seamus O’Reilly (Consultant Medical Oncologist) gave a very informative talk on the oncology services. ARC House founded in 1994, is a registered charity offering professional support to men and women affected by cancer and those who care for them. The support is holistic and complements primary medical treatment with education and psychological care. The topic of February’s meeting was Nutrition and was very kindly sponsored by Carol Ann Notley, Abbott. GuestsSpeaker on the night Julie O’Sullivan, Nutritionist. Julie gave a very informative and interactive presentation on the Malnutrition Universal Screening Tool (M.U.S.T) & also provided us with very useful patient information packs. Pauline Lynch of the Diabetes Federation of Ireland also gave an informative presentation on CODE, the structured patient education programme. We hope to see you all at the next Cork Branch meeting which will take place in the Rochestown Park Hotel on Wednesday the 10th March at 7.30pm. The topic of the meeting is Urinary Incontinence and has been very kindly sponsored by Gretchen Kelleher, Janssen- Cilag.

Kerry Mary Brick

We braved the elements on Wednesday 20th January at our new venue, Carlton Hotel, Tralee. We were treated to an excellant educational evening given by Dr Beatrice Neufeldt, gynaecologist/obstetrician and specialist in psychosomatic medicine. Her topic on the night was The female menopause and is there a male menopause? The evening was sponsored by Eilish McGroarty of Bayer Health- care. Our February meeting was hosted by Ciara Leahy of Pfizer Nutrician. We were updated on the topic MUST by Sheila King, Commu- nity dietitian. Ciara Leahy shared her expertise regarding infant nutrition. Corina Corridan community dietitian and leader with X-Pert

12 regional news

shared with us the success of our primary care diabetic referrals to X-Pert. Dr Anna Clark travelled from Cork to emphasize the importance of health promotion in a primary care setting. She devotes her expertise to the Diabetic Federation of Ireland. A special thanks to the practice nurses who subscribed so generously to the Haiti appeal at our January meeting. A reminder to all practice nurses to complete the posted questionnaire before the forthcoming INMO Annual Delegate Conference in the Knightsbrook Hotel, Trim, Co Meath. Our March meeting is scheduled a week early Wednesday 10th so we can celebrate St Patrick’s day with our families.

Kilkenny Patricia McQuillan

Our first meeting of the year was on January 27th. It was sponsored by MSD and our local reps, Ray Farrell and Frank Tynan. Roseann Coughlan,the CNS/Cardiac in St. Luke’s General Hospital, Kilkenny came and gave an excellent presentation on the service that is offered in her hospital and the latest methods of treatment for cardiovascular patients. She reminded us about the Framingham Study,the Canadian Guidelines and the Reynolds Risk Score. The next meeting of the Kilkenny Branch was on Wednesday February 24th. Our sponsor on the night was Hannah Connolly from Schering Plough. Dr Chantelle MacNamara from the Keogh Practice in Waterford came with a trainee colleague. Dr MacNamara was as always forthright and entertaining in her talk. he covered many topics including the importance of health education, documentation and insurance. We had a light-hearted look at heart sink patients, however, we were reminded that we are the advocates for our patients coming into us.

Midlands Kerrie Martin

I’d first like to introduce myself as the new chairperson for the MidlandsB ranch and my colleague Gillian Redmond as vice chairperson. I would like to thank Una Ghee for all her hard work as chairperson over the last three years, hopefully myself and Gillian can keep up the high standard Una has set. Our first meeting of 2010 took place in the Tullamore Court Hotel. There was a great turn out for this meeting. The meeting was sponsored by Margaret Byrne, nutritionist for Milupa Aptamil. Margaret did an excellent presentation on infant feeding and weaning. Our next meeting is due to take place on 23rd March, again in the Tullamore Court Hotel. Topic dyslipidemia: update on new therapies by cardiology nurse specialist Rose Coughlan. Sponsor Caroline Johnston, MSD. We hope to see everyone there.

Wicklow Mary Finnegan

We held our AGM on 16th November in Grand Hotel Wicklow, and I am delighted to say, all the outgoing committee agreed to stay on for another year! All were duly proposed and elected, and thanks to everyone for coming forward again for election. I would like to say a personal ‘thank you’ to all the committee and branch members who have once again supported me in past year as Chair. Our guest speaker at the AGM was Aoife O Shea, Clinical Nurse Manager with Smith & Nephew, who gave us an excellent update on wound management, including use of Profore bandages. Our 1st meeting for 2010 was held on 25th Jan in the Ramada Hotel in Bray. Our speaker on that date was Ken O’Dwyer, an Advanced EMT, who gave us an excellent talk on medical emergencies and an overview of what his job entails. This talk was very well received and was very kindly sponsored by Maria Sheerin, from Cow & Gate, who opened the meeting with an update on infant feeding. She also held a raffle for some bottles of wine, which very nicely closed her presentation! That meeting was very well attended, as we had several members from Dublin branch joining us. Our tiny branch of just 20, has now increased to 38! We are delighted to welcome all our new members. We held the next meeting on 1st March, again. Our excellent speaker was Aideen Walsh, Clinical Nurse Specialist in Sexual Assault and Forensic examination, based in the Rotunda Hospital. The information regarding details of referral and exactly what the forensic exam involves. Again we welcomed several new members to our branch at that meeting. Our last meeting before the summer is scheduled for Monday 10th May, in the Ramada Hotel. The topic planned for that meeting is an overview on travel medicine, and will be sponsored by Niamh Bird from Sanofi Pasteur. Our meeting venue had been in Wicklow town for past seven years to try to facilitate those members living as far south as Arklow, but as their attendance has been falling off over past three years, and 80 per cent of our members are living in Bray or Dublin areas, we decided to move our meetings north of the county to try to encourage better attendance at meetings. The good news is there has been a huge increase in attendance, and very positive feedback regarding the convenience of the venue. At the meeting on 1st March, Rita Brown gave us a report from the recent NEC meeting, and details of the annual AGM. Deirdre Small will attend the next INMO meeting at end of March, and members were encouraged to return their questionnaire from the INMO re our pay, asap, as this is a contentious issue at present, with cuts imposed by some GPs on nurses salaries. It is hoped to arrange a BLS/Heartsaver/AED course for the branch in near future as certification has expired for several members. Pfizer are also very kindly sponsoring a course on Spirometry in Glenview Hotel in Wicklow on Monday 29th March. Course is limited to just 12 participant – on first come first served basis. As I close, can I once again extend a very warm welcome to all our new members, and a special thank you to all our ‘old’ ones.

13 A4 Ad COPD 0717:Layout 1 01/02/2010 12:43 Page 1

COPD patients with severe COPD (FEV1<50%), with a history of exacerbations and who are struggling with symptoms despite using a long- acting bronchodilator.

Good morning Symbicort®! (budesonide/formoterol)

Symbicort 400/12 bd + tiotropium: • Reduces severe exacerbation rates by 62% vs. tiotropium alone1

• Provides rapid improvements in morning symptoms1

PRESCRIBING INFORMATION(Refer to Full Summary of Product Characteristics before prescribing) Symbicort® Turbohaler® 400/12, Inhalation Powder (budesonide/formoterol) Presentations: Dry powder inhaler. Symbicort 400/12 Turbohaler : Each inhalation containing metered doses equivalent to 400mcg budesonide Turbohaler and 12mcg formoterol Turbohaler. Uses: Asthma: Treatment of asthma where the use of a combination (inhaled corticosteroid and long acting beta2-agonist) is appropriate. COPD: Symptomatic treatment of patients with severe COPD (FEV1 <50% predicted normal) and a history of repeated exacerbations, who have significant symptoms despite regular therapy with long-acting bronchodilators. Dosage and Administration: Asthma: (Symbicort maintenance therapy - regular maintenance treatment with a separate rescue medication) Adults (including elderly):1 inhalation twice daily. Some patients may require up to a maximum of 2 inhalations twice daily. Adolescents (12-17 years): 1 inhalation twice daily. Not intended for the initial management of asthma. Dose should be individualised. If an individual patient requires dosages outside recommended regimen, appropriate doses of beta2-agonist and/or corticosteroid should be prescribed. When symptoms are controlled, titrate to the lowest effective dose, which could include a once daily dosage. Lower strengths are available for the Symbicort maintenance and reliever therapy regimen. Children under 12 years: Not recommended. (A lower dose Symbicort 100/6 Turbohaler is available for use in children 6 – 11 years) COPD: Adults: 1 inhalation twice daily. Contraindications, Warnings and Precautions etc.: Contraindications: Hypersensitivity (allergy) to budesonide, formoterol or lactose (which contains small amounts of milk protein.). Warnings and Precautions: If treatment is ineffective, or there is a worsening of the underlying condition, therapy should be reassessed. Treatment should not be stopped abruptly. Sudden and progressive deterioration in control requires urgent medical assessment. Patients should have their rescue medication available at all times. Therapy should not be initiated during an exacerbation. Serious asthma-related adverse events and exacerbations may occur and patients should continue treatment but seek medical advice if asthma symptoms remain uncontrolled or worsen after initiation with Symbicort. As with any inhaled corticosteroid, systemic effects may occur, particularly at high doses prescribed for long periods. These may include adrenal suppression, growth retardation in children and adolescents, decrease in bone mineral density, cataract and glaucoma. Potential effects on bone should be considered especially in patients on high doses for prolonged periods that have co-existing risk factors for osteoporosis. Caution when transferring patients who have required high dose emergency corticosteroid therapy in the past or prolonged treatment with high doses of inhaled corticosteroid or oral corticosteroids or in a situation likely to produce stress (e.g. elective surgery). Recommend monitor height of children on long-term inhaled corticosteroids. Observe caution in patients with thyrotoxicosis, phaeochromocytoma, diabetes mellitus, untreated hypokalaemia or severe cardiovascular disorders. Re-evaluate use (dose/need for use) in patients with pulmonary TB or fungal/viral infections in airways. Observe caution in patients with prolongation of the QTc-interval. As with other beta2-agonists, hypokalaemia may occur at high doses. Particular caution recommended in unstable or acute severe asthma as this effect may be potentiated by xanthine-derivatives, steroids, diuretics and hypoxia. Monitor serum potassium levels. Hypokalaemia may increase the disposition towards arrhythmias in patients taking digitalis glycosides. In diabetic patients, consider additional blood glucose monitoring. Interactions: Concomitant treatment with itraconazole, ritonavir or other CYP3A4 inhibitors should be avoided unless the benefits outweigh the systemic side effect risks. Not to be given with beta adrenergic blockers (including eye drops) unless there are compelling reasons. Concomitant administration with quinidine, disopyramide, procainamide, phenothiazines, antihistamines (terfenadine), MAOIs and TCAs can prolong the QTc-interval and increase the risk of ventricular arrhythmias. L-Dopa, L-thyroxine, oxytocin and alcohol can impair cardiac tolerance. Concomitant administration with MAOIs, including agents with similar properties such as furazolidone and procarbazine, may precipitate hypertension. Risk of arrhythmias in patients receiving anaesthesia with halogenated hydrocarbons. May be potential additive effect when used concomitantly with other beta-adrenergic drugs. Pregnancy and Lactation: Should only be used when the benefits outweigh the potential risks. Side-effects: Common: Palpitations, candida infection in the oropharynx, headache, tremor, mild irritation in the throat, coughing, hoarseness. Uncommon: Tachycardia, nausea, muscle cramps, dizziness, agitation, restlessness, nervousness, sleep disturbances, bruises. Rare: Cardiac arrhythmias, e.g. atrial fibrillation, supraventricular tachydia, extrasystoles, immediate and delayed hypersensitivity reactions e.g. exanthema, urticaria, pruritus, dermatitis, angiodema and anaphylactic reaction, hypokalemia, bronchospasm. Very rare: Angina pectoris, signs and symptoms of systemic glucocorticosteroid effects e.g. adrenal suppression, growth retardation, decrease in bone mineral density, cataract and glaucoma, hyperglycemia, taste disturbances, depression, behavioural disturbances (mainly in children), variations in blood pressure As with other inhalation therapy, paradoxical bronchospasm may occur in very rare cases. Treatment with beta 2 – agonists may result in an increase in blood levels of insulin, free fatty acids, glycerol and ketone bodies. Package Quantities: Each Symbicort Turbohaler 400/12 contains 60 inhalations. Legal Status: Prescription only medicine (POM). Marketing Authorisation Number: PA 970/28/3. Marketing authorisation Holder: AstraZeneca UK Limited, 600 Capability Green, Luton, LU1 3LU, UK. Further information available on request from: AstraZeneca Pharmaceuticals (Ireland) Ltd., College Park House, 20 Nassau Street Dublin 2. Telephone: (01) AstraZeneca 6097100 Fax (01) 6796650. Abridged Prescribing Information prepared: 08/08. Symbicort and Turbohaler are Trade Marks of the AstraZeneca group of companies. Reference: 1. Welte et al. Am J Respir Crit Care Med 2009; 180 (8): 741- 50. Date of Preparation: December 2009. URN: 09/0717 clinical review

Meningitis and meningococcal disease – adults get it too Lisa M Slattery RGN BSc MA MSc, Community Services Nurse, The Meningitis Trust

eningitis is a serious and life-threatening disease. While under five year olds are most at risk of meningitis in Ireland and throughout Europe, it

is important to remember that adults contract Bacterial meningitis meningitis as well. Bacterial meningitis is a medical emergency which requires MThe aim of this article is to discuss meningitis in relation to early diagnosis, rapid transport to hospital and urgent medical diagnosis, transmission, treatment and after-effects for adults. treatment. It will also include two case studies, one bacterial and one viral. It is usually caused by infection with one of the following While most individuals recover with no after-effects, recovery organisms: Neisseria meningitidis (meningococcal) (see Figure from meningitis can take many months. Understanding 1), Streptococcus pneumoniae (pneumococcal) or Haemophilus the range of after-effects can help healthcare professionals influenzae B (Hib). The adult population, in particular those appreciate the true impact of the disease. aged over 64 years, are the second most at-risk group from

meningitis, more commonly pneumococcal meningitis. What is meningitis? Many of the bacteria that cause meningitis occur commonly Meningitis is an inflammation of the meninges, which are the and are often harmless commensals of the nose and throat membranous tissues surrounding the brain and part of the (Donovan & Blewitt, 2009). Transmission occurs between spinal cord. Bacteria, viruses and, more rarely, fungi are the individuals who have close, prolonged contact through main causes of meningitis. coughing, sneezing and intimate kissing. Approximately 10 Some bacteria that cause meningitis can also cause per cent of the general population will carry meningococcus septicaemia and the two (meningitis and septicaemia) can harmlessly in the nasopharynx, developing natural immunity occur separately or together. Meningococcal disease is the within 14 days. This increases to 25-30 per cent in teenagers term used when both meningitis and septicaemia are caused due to altered social behaviour, such as smoking (results in by Neisseria meningitidis. carriage of bacteria for longer periods of time) and intimate kissing (MacLennan et al, 2006). Carriage normally helps to improve natural immunity; however, in a small number of individuals, the bacteria crosses the nasopharyngeal membrane into the bloodstream where it multiplies rapidly and crosses the blood-brain barrier leading to inflammation of the meninges. In 2008, there were 253 reported cases of bacterial meningitis in Ireland, 168 cases of invasive meningococcal disease (IMD) (149 [89 per cent] of those were Neisseria meningitidis serogroup B), 22 cases of pneumococcal disease, 4 cases of Hib, 6 cases of Group B Strep and 38 others (HPSC, 2009). In 2008, four cases of meningococcal C meningitis were recorded, all four occurred in adults aged 17-46 years. Four (50 per cent) of the deaths due to IMD occurred in adults aged >20 years. The mortality rate for bacterial meningitis is 10 per cent with an estimated 15-25 per cent of survivors being left with Figure 1. Neisseria meningitidis. (Source: The Meningitis Trust.) varying degrees of after-effects (The Meningitis Trust, 2007).

15 clinical review

Viral meningitis refill (more than two seconds). Research has highlighted the Viral meningitis is more common than bacterial meningitis need to identify the early signs of sepsis (cold hands and feet, and is rarely life-threatening (Logan & MacMahon, 2008). leg pains, pale or blotchy skin). Thompson et al (2006) showed Many cases are mild and can be mistaken for influenza, but it that these signs and symptoms occur much earlier than the is important to remember that, in some cases, individuals can classic features of meningitis as described above. become very ill, resulting in a slow recovery. It is commonly The septicaemic rash occurs primarily with meningococcal caused by infection with enteroviruses, herpes simplex and septicaemia, so it is vital to remember not all types of mumps. Viral meningitis can occur in infants and children but is meningitis will produce a rash. The rash is a result of the high more commonly reported in adults. levels of endotoxins produced by the invading bacteria. This In 2008, 97 cases of viral meningitis were notified in Ireland leads to damage of the endothelial lining of the capillaries, (HPSC, 2009). Viral meningitis activity tends to be highest in resulting in capillary leakage and the classic haemorrhagic rash. the second half of the year. Figure 2 shows an image of the septicaemic rash with non- blanching petechiae. Recognition Where a rash is present with other signs of a febrile illness in Due to a high mortality rate and rapid deterioration prior a child or adult, it is important to make a thorough examination to admission to hospital, early recognition, diagnosis and as it is easy to miss one petechia amongst a widespread treatment are vital. Early treatment can also affect outcome maculopapular rash (Brogan and Raffles, 2000). The rash can in relation to the after-effects experienced by an adult who be difficult to see on darker skin and it may help to check the survives meningitis. conjunctivae, under the lower eyelid, palms of hands, soles of In the early stages, the symptoms of meningitis may be feet and palate. similar to other common illnesses, such as influenza and, more recently, swine flu. Differentiating between meningitis and swine flu in the early stages can be difficult. Meningitis can develop quickly and, in some cases, will become life threatening within hours of the first symptoms occurring. A high index of suspicion is vital to avoid missing anyone presenting with early flu-like, non-specific symptoms. Patients should be monitored every four to six hours for any changes or disease progression. There are, however, characteristic features of meningitis that may be easier to recognise. Adults may complain of neck stiffness, photophobia, muscle or joint pains and a severe headache. They may also be confused, be in respiratory distress or have impaired consciousness. Anyone developing these symptoms should seek medical advice. The signs and symptoms of viral meningitis are similar Figure 2. Septicaemic rash. (Source: The Meningitis Trust.) to those of bacterial meningitis thus making it difficult to distinguish between them without further investigation (Logan Adults may not appear severely ill in the early stages of and MacMahon, 2008). illness, but may rapidly deteriorate even following admission to hospital. Not all the symptoms appear at one time, and the rash Septicaemic rash may appear very late, if at all. It is therefore important to have Where septicaemia is present, adults will have signs of a high index of suspicion with patients who present with non- circulatory failure such as cool peripheries and delayed capillary specific signs and symptoms.

Surviving meningitis – Case 1 Nick’s Story My name is Nick. I’m 34 years old and I’m from Wales. I’ve lived make it through the night. Thankfully, I made it through. I’m in Ireland for almost seven years. Back in May 2006, I thought okay, but some people are not so fortunate. I’m a big, strong I was coming down with the flu. I was running the electrical boy, 5 foot 10 inches and 16 stone. The meningitis nearly killed side of a new development in Bray, Co Wicklow. I spent nine me. I’m an ex-boxer, and I’ve never lost a fight! days lying on my sofa, thinking I only had the flu, although I Since I got sick, I’ve developed epilepsy. The depression is have never felt so ill in my life. I went into work after the ninth something I’ve never known before. I’m a fun-loving guy, but day. I was sweating so badly, even my shins were soaking wet. this has changed my life in a very big way. I’ve had about eight I was shaking from head to foot. To make matters worse, I was fits to date and, as a result, I can’t work. I’ve only ever been working on top of a 13-foot stepladder all morning. an electrician, I don’t know anything else. I can’t do my job, At around 12.30pm, I took a delivery of cable tray and because I have to wait at least one year before I can go onto a trunking. I started to feel very ill. As I was waiting for the building site. second delivery van to reverse, I collapsed in the middle of the My last seizure was about four weeks ago, cooking dinner road. would you believe? One minute, I was making shepherd’s pie, I woke up talking to two paramedics. I didn’t know my the next, I was on the floor with my girlfriend Liz asking me to name, age, or where I was from. They took me to St Vincent’s talk to her. I’m getting there though. Hospital in Dublin with the blue lights going – that scared me! The Meningitis Trust has been there for me from day I knew something was very wrong. one. Lisa has been a fantastic help. I’ve been able to call her The doctor spoke to my sister and told her it was 50/50 if I’d whenever I’ve felt down.

16 For your patients with type 2 diabetes struggling to gain glycaemic control on oral monotherapy

Onglyza 5 mg improves the control

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1. DeFronzo RA, et al. Diabetes Care. 2009; 32(9):1649-55 2. Onglyza, Summary of Product Characteristics.

ONGLYZA™ 5mg film-coated tablets (saxagliptin). Abridged (NYHA class III-IV) or immunocompromised patients. Recommend dyslipidaemia and hypertriglyceridaemia. Laboratory tests: prescribing information. Consult Summary of Product monitoring for evidence of skin disorders. Interactions: Clinical Small decreases in absolute lymphocyte count were observed but Characteristics (SmPC) before prescribing.Presentation: 5 mg data suggest low risk for clinically meaningful interactions with were not associated with clinically relevant adverse reactions. saxagliptin (as hydrochloride) film-coated tablets. Uses: Adults: co-administered medicinal products. The metabolism of saxagliptin Key: Very common (≥ 1/10), common (≥ 1/100 to <1/10), For Type 2 diabetes mellitus patients to improve glycaemic is primarily mediated by cytochrome P450 3A4/5 (CYP3A4/5). uncommon (≥ 1/1,000 to <1/100) and rare (≥1/10,000 to control in combination with: metformin, when metformin alone, Caution with potent CYP3A4/5 inducers as glycaemic lowering <1/1,000).Consult SmPC for a full list of undesirable effects. Legal with diet and exercise, does not provide adequate glycaemic effect of Onglyza may be reduced. Pregnancy and lactation: Avoid Category: Prescription Only Medicine. Marketing authorisation control; sulphonylurea, when sulphonylurea alone, with diet and use during pregnancy unless clearly necessary. Risk to suckling number: EU/1/09/545/006. Marketing Authorisation holder: exercise, does not provide adequate glycaemic control in patients child cannot be excluded – either discontinue breast-feeding or Bristol-Myers Squibb / AstraZeneca EEIG, Bristol-Myers Squibb for whom use of metformin is considered inappropriate; and Onglyza therapy. Undesirable effects: In a pooled analysis, overall House, Uxbridge Business Park, Sanderson Road, Uxbridge, thiazolidinedione, when thiazolidinedione alone with diet and incidence of adverse events in patients treated with Onglyza 5 Middlesex, UB8 1DH, UK. Further information is available from exercise, does not provide adequate glycaemic control in patients mg was similar to placebo. Discontinuation of therapy due to Bristol-Myers Squibb Pharmaceuticals, Tel + 353 (1 800) 749 for whom use of a thiazolidinedione is considered appropriate. adverse events was higher compared to placebo (3.3% vs. 1.8%). 749. ONGLYZA™ is a trademark of the Bristol-Myers Squibb Dosage: Adults: 5 mg once daily as add-on therapy with or Common adverse reactions reported (regardless of causal / AstraZeneca group of companies. ©2009 Bristol-Myers without food at any time of the day. When used in combination relationship) in clinical trials: Upper respiratory infection; urinary Squibb. Abridged prescribing information prepared: 12-2009. with a sulphonylurea, consider a lower dose of sulphonylurea to tract infection; gastroenteritis; sinusitis; headache; and vomiting. reduce the risk of hypoglycaemia. Children and Adolescents: Not Nasopharyngitis was common in the add-on to metformin trial, recommended. Moderate Hepatic Impairment: Use with caution. hypoglycaemia was very common in the add-on to sulphonylurea Severe Hepatic Impairment: Not recommended. Moderate & Severe trial and peripheral oedema (mild to moderate only) was commonly Renal Impairment: Not recommended. Elderly ≥ 75 years: Use with reported in the add-on to thiazolidinedione trial. Hypersensitivity caution. Contraindications: Hypersensitivity to saxagliptin or to any and rash were more frequently reported in patients on Onglyza of the excipients. Precautions and warnings: Should not be used for compared to placebo. Adverse reactions considered to be the treatment of Type 1 diabetes mellitus or diabetic ketoacidosis or at least possibly related to Onglyza: Monotherapy: Common: in patients who have had any serious hypersensitivity reaction to a Dizziness and fatigue. Initial combination with metformin: DPP4 inhibitor. Contains lactose, not recommended in patients with Common: Gastritis. Uncommon: Arthralgia, myalgia and URN: 10/0025. rare hereditary galactose intolerance, the Lapp lactase deficiency or erectile dysfunction. Add-on to metformin: Common: Dyspepsia Date of Preparation: January 2010. glucose-galactose malabsorption. No experience in cardiac failure and myalgia. Add-on to sulphonylurea: Uncommon: Fatigue, Mercury Code – 422HQ09PM034(4)

Onglyza_245x340.indd 1 20/01/2010 17:13:35 clinical review

puncture is contraindicated and diagnosis should be made on While under five year clinical features and blood assays. Raised intracranial pressure can be treated with steroids, such as dexamethasone and, in severe cases, mannitol. olds are most at risk of Due to the necessity of early administration of antibiotics, it is not always possible to culture organisms from blood or meningitis in Ireland, it is cerebrospinal fluid (CSF). Other tests, such as polymerase chain reaction (PCR), make it possible to isolate minute quantities of important to remember bacterial DNA which is important for relevant treatment and also for accurate epidemiological data. Viral meningitis can be severe enough to cause raised that adults contract intracranial pressure and decreased consciousness. Otherwise treatment is primarily symptomatic. Once a diagnosis of viral meningitis as well. meningitis has been made, any early anti-biotic therapy is usually stopped. Treatment involves analgesia, hydration and nursing care to alleviate symptoms and discomfort. Unless there are complications, most cases of viral meningitis are self- Diagnosis, treatment and nursing care limiting with recovery occurring in 4-10 days. Initial diagnosis of meningitis and septicaemia is usually based on patient history and thorough clinical examination. Chemoprophylaxis If meningitis/septicaemia is suspected, patients should be Household contacts (i.e. those living/sleeping in the same transferred to hospital immediately. First-line treatment household as the index case up to seven days prior to with intravenous benzylpenicillin is recommended prior to commencement of illness) and those who have come into the patient being transported to hospital. This should be close contact with a case of meningococcal meningitis and/ administered by a GP or paramedic before the patient is or septicaemia require antibiotics. Work colleagues and school transferred to hospital. Although not as effective, it can be friends of the patient with meningococcal disease are not given intramuscularly in shocked patients. Benzylpenicillin at any increased risk unless there has been close, prolonged is only contraindicated where there is a history of penicillin contact. anaphylaxis (which is very rare). If more that one case occurs, antibiotics may be given to a wider group of contacts. Rifampicin is the drug of choice and Recommended dosage of benzylpenicillin: is given to eliminate the carriage of the organism from the • Adults and children >10 years 1,200mg network of close contacts of the case, thereby reducing the • Children 1-9 years 600mg spread of the organism to susceptible people. • Children <1 year 300mg After-effects Penicillin resistance is very rare in Ireland and meningococcus The majority of patients survive meningitis and septicaemia is also sensitive to third-generation cephalosporins. and make a full recovery; however, it is estimated that 15 per Depending on how the patient presents, they may require cent will be left with after-effects. These include complications treatment for shock and raised intracranial pressure. Circulatory that arise from damage to various areas of the brain, such as: shock is treated with volume replacement, oxygen therapy and, in severe cases, inotropic support. Where there are signs • Visual impairment/cortical blindness – visual impairment of raised intracranial pressure and circulatory collapse, lumber results from raised intracranial pressure which may cause

Surviving meningitis – Case 2 Deirdre’s story (meningococcal meningitis and septicaemia) It was 11 February 2007 and I had recently flown home from Monday, 12 February and I woke up on Sunday, 18 February a ski trip in Canada. I didn’t sleep well. My feet were cold. I around 6am. I had meningococcal septicaemia type B and, tossed, turned and had a vague recollection of being sick a during those days, my family members were told I was couple of times as the night wore on. The vomiting wasn’t extremely ill and had less than a four per cent chance of severe but it wasn’t right. I went to a local GP’s practice and survival. Later I found out I had received the last rites twice. luckily was seen by one of the doctors immediately. Within I remember nothing of that week, a week that is lost in minutes, he had diagnosed potential meningitis, called an time forever and the fact that family and close friends went ambulance and administered a shot of penicillin. through a different experience than mine makes it very hard From there, my memory of what happened gets a little to understand or know exactly what happened and how it hazy. I do remember the ambulance staff constantly talking was. to me so I would remain conscious, and I was wondering why The days following were filled with blood tests, chest x-rays, they were saying this when I felt fine and there was no way I dialysis, visits by medical teams, dietitians and, of course, visits was going to sleep! The fact that the doctor had said potential from my family. Tubes for dialysis were inserted, removed, meningitis had not sunk in at all. To be honest, like many inserted again, I had a kidney biopsy, an ultrasound of my others, I thought that it was a disease that affected children heart and MRI scans. The worst were the canulas – no words and not adults, and certainly not me – I was 39 years old. can describe the distress and agony they caused. There were We arrived at A&E but I have little memory of what lots of medication and bloods taken each day. Apart from the happened next. All of what I have described happened on antibiotics, there were tablets to avoid ulcers, anti-coagulant

18 clinical review

neuronal damage to the visual cortex and/or the posterior Since I got sick, I’ve visual pathways. Visual impairment may be partial or result in cortical blindness. • Hearing impairment/sensorineural deafness – post-meningitic developed epilepsy. hearing impairment is an important cause of acquired sensorineural deafness. Hearing impairment may be mild The depression to moderate as well as permanent. It is recommended that all patients should have a hearing test, before or soon after discharge from hospital. is something I’ve • Neurological complications – including epilepsy, cerebral palsy, hydrocephalus and cranial nerve palsies are also never known. associated with damage to various parts of the brain, including the cranial nerves. • Behaviour problems – these can include mood swings, Nick aggression and, occasionally, violent temper tantrums. • Learning difficulties – problems can range from subtle issues, such as a mild reduction in IQ and short-term difficulties in concentrating and reading, to severe long-term learning The after-effects of meningitis and septicaemia are very difficulties. often complex and affect the whole family. A multidisciplinary team may be required to provide ongoing care and support. The complications of septicaemia and shock can lead to areas of necrotic tissue and skin loss which may require skin grafting. Prevention In more severe cases, limb loss, organ damage and neurological Vaccination is the only way to prevent meningitis. There is damage can occur. currently no vaccine available to protect against all types Alongside the physical complications, anyone who has of meningitis but the following vaccines protect against contracted meningitis may experience other difficulties, such meningitis caused by the relevant bacteria/virus. as depression, fatigue and short-term memory loss. These may affect their day-to-day activities including being unable to Meningococcal C return to work on a full-time basis, or at all. A meningococcal C vaccine is available to everyone up to the The intense tiredness can be very debilitating and recovery age of 23 years and is included in the childhood immunisation involves rest, good diet and gradually increasing exercise. schedule. While the risk of the disease is generally low in adults, Returning to work too early can lead to exhaustion and can there is a greater risk for people up to the age of 23 years and slow down recovery. During this time, patients and their again at the age of 64 years and above. Travel vaccines are families require a great deal of patience and understanding recommended for people travelling to areas where other types from themselves and the professionals involved in their care. are more prevalent. Travel vaccines include: A&C; A; C; W135 & Y. Due to the fact that viral meningitis is rarely life-threatening, There is currently no vaccine to protect against many sufferers can feel that their illness is taken less seriously meningococcal group B (Men B), the most common cause of and the after-effects they suffer are not always acknowledged. bacterial meningitis in adults in Ireland. Recovery from viral meningitis can be very slow but is normally complete. However, sufferers can still suffer headaches, Pneumococcal tiredness, depression, memory loss and concentration Two vaccines are currently available, a conjugate vaccine problems. is available for those aged under five years and is currently

injections, anti-seizure medication, high-blood pressure attending. My last hurdle was to get the all clear and be able tablets and, at one stage, the most disgusting anti-potassium to drive again following the seizure. A year later, I did just that. powder drink. There were also high-protein drinks along with When I returned home I got in touch with The Meningitis unappetising food. Trust and their support and understanding was invaluable I retained a lot of fluid, I had no appetite, had some – they listened, they understood, they supported. They still diarrhoea and always felt nauseated. I would be sick mostly do and somehow I think they will be in my life forever. I will in the mornings and evenings. When I came off the IV drips, I be always grateful for the support I’ve received and the lost about 10kg – the fluid was retained no more! friendship that has been shown. All I wanted, probably like most patients, was to go home, At the end of June, I felt well enough to go back to work. to my own bed and some home cooking. I knew I would Initially on a part-time basis and gradually built up to going recover better there. They let me out on the afternoon of back full time in late July. I still get very tired very quickly and Monday 12 March – exactly a month to the day that I entered have to take regular, short breaks. I have also managed to the hospital. negotiate a condensed week where I work five days in four, The following weeks were spent taking it very easy but allowing me Fridays off or, if not, allowing me to work from I was also in and out of both the renal clinic and a general home. This takes its toll but gives me a much-needed three- medical clinic and, of course, had regular visits for dialysis. day weekend and does make a difference. Gradually things became good, my kidneys improved and I have been though an incredible experience. I survived. the dialysis sessions ended. Only five small physical scars I still ask the question ‘why?’ but know I’ll never have the remain. The days became my own again and gradually I was answer. I am just thankful for every day and pray that I’ll make discharged from the various outpatient clinics I had been the most of each one that presents itself.

19 clinical review

included in the immunisation schedule. A polysaccharide vaccine is also available and is currently recommended for The after-effects...are all adults over the age of 65 years. It is also recommended for adults and children who have experienced any of the following: • Diabetes mellitus. very often complex and • Chronic heart, respiratory or liver disease. • Chronic renal disease or nephrotic syndrome. affect the whole family. • Sickle cell disease. • Those with missing or non-functioning spleens. A multidisciplinary • Those with immunodeficiency due to disease or treatment. • Persons with HIV infection or AIDS. • Vaccination is not recommended for healthy young adults, as team may be required there is little risk of pneumococcal infection. (Source: HSE, 2008.) to provide ongoing

Hib An effective vaccine against Hib disease was successfully care and support. introduced into the childhood immunisation programme in 1992. Most recently, there has been a catch-up booster campaign targeted at those aged under five years due to a slight increase in the incidence of Hib meningitis in the last few years. This vaccine does not protect against any other type of Family days – a fun day and an opportunity for families meningitis. affected by meningitis to meet and share their experiences.

MMR The Trust also provides education programmes for the public Prior to the introduction of MMR, mumps was the most and healthcare professionals and all training sessions can be common cause of viral meningitis in children aged under five tailored to suit the needs of any audience. years. It produces a wide range of literature which can be obtained free of charge, including symptoms cards, factsheets, posters, BCG leaflets, early years guides for childminders, a teacher BCG is routinely offered at birth to all babies. Unlike other handbook, employers’ packs and a children’s book called When types of meningitis that develop quickly, TB meningitis usually Monty had Meningitis for families with a child that has survived develops slowly with vague symptoms, such as aches and meningitis. pains, loss of appetite and tiredness, usually with a persistent headache. These vague symptoms can last for several weeks before the more specific symptoms of meningitis, such as severe headache, dislike of bright lights and neck stiffness, occur. The slow progression of the disease makes it difficult to diagnose and it is often advanced before treatment begins.

Support for life – The Meningitis Trust References The Meningitis Trust is a registered charity which focuses on 1. Brogan PA, Raffles A. The management of fever and providing 24-hour support through a range of professional petechiae: making sense of rash decisions. Archives of Disease services nationwide for people of all ages affected by in Childhood 2000; 83 (6): 506-7. meningitis. The Trust’s support services include: 2. Donovan C, Blewitt J. An overview of meningitis and 24-hour nurse-staffed helpline – that provides information and meningococcal septicaemia. Nursing Standard 2009; 23 (45) emotional support (Tel. 1800 523 196). 42-9. Professional counselling and bereavement support – 3. HPSC (2009). Health Protection Surveillance Centre Annual confidential face-to-face counselling and bereavement support Report 2008. http://www.hpsc.ie/hpsc/AboutHPSC/ for people who have had meningitis and their families. AnnualReports/File,4080,en.pdf (last accessed: support in people’s homes. 15 February 2010. One-to-one contacts – these provide an opportunity for 4. HSE (2008). Immunisation guidelines. http:// individuals to share their experience with others affected by www.immunisation.ie/en/AdultImmunisation/ meningitis. Pneumococal/#Who_is_at_risk_of_pneumococcal_disease (last accessed: 15 February 2010). Contact details and further information 5. Logan SA, MacMahon E. Viral meningitis. British Medical If any readers would like to avail of a training session, order Journal 2008; 336 (7634): 36-40. literature for your workplace or would like to find out more 6. MacLennan J, Kafatos G, Neal K et al. Social behaviour and about support services please contact: Lisa M Slattery RGN meningococcal carriage in British teenagers. Emerging BSc MA MSc, Community Services Nurse, The Meningitis Infectious Diseases 2006; 12 (6): 950-7. Trust, Tel. (01) 845 9488 or email: support@meningitis-trust. 7. The Meningitis Trust (2007). After Meningitis, leaflet. http:// ie www.meningitis-trust.ie/Leaflets%20etc., last accessed 15th For further information, please contact the Meningitis February 2010. Trust’s 24-hour Freephone nurse-staffed helpline on 1800 8. Thompson NJ, Ninis N, Perera R et al. Clinical recognition 523 196 or visit: www.meningitis-trust.ie of meningococcal disease in children and adolescents. The Lancet 2006; 367 (9508): 397-403.

20 For Diabetes No coding makes blood glucose testing even easier For Type 1 and Type 2 patients on insulin

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FreeStyle is a trademark of the Abbott Group of companies in www.abbottdiabetescare.ie various jurisdictions. Print code: IADV28092009 September 2009 clinical review

Lung cancer is likely to eclipse breast cancer as the leading cause of cancer mortality in Irish women in the near future Lung cancer – risk factors, presentation and diagnosis

Eileen Byrne, Lung Cancer Co-ordinator, Midland Regional Hospital, Mullingar, Co Westmeath

n Ireland, 2,340 people die from lung cancer each year.1 This Risk factors equates to approximately 20 per cent of all cancer deaths. Smoking Incidence in Irish men has fallen slightly in recent years and The incidence of lung cancer is strongly correlated with is below the EU average. However, in Irish women, lung cigarette smoking, with about 90 per cent of lung cancers cancer is on the increase. Lung cancer is likely to eclipse arising as a result of tobacco use. The risk of lung cancer Ibreast cancer as the leading cause of cancer mortality in Irish increases with the number of cigarettes smoked over time. This women in the near future and has already done so in some risk is referred to in terms of pack-years of smoking history (i.e. countries.3 the number of packs of cigarettes smoked per day multiplied Despite the enormous burden of disease, the prevailing by the number of years smoked, a ‘pack’ being a pack of 20 attitude to lung cancer, even among healthcare professionals, cigarettes). For example, a person who has smoked two packs is one of pessimism, or at worst, absolute nihilism. This reflects of cigarettes per day for 10 years has a 20 pack-year smoking poor overall survival rates, even in the minority of patients who history. While the risk of lung cancer is increased with even a present with apparent early-stage disease who are treated with 10-pack-year smoking history, those with 30-pack-year histories intention to cure. or more are considered to have the greatest risk for the Overall five-year survival is less than 10 per cent and, despite development of lung cancer. advances in radiotherapy and chemotherapy, surgery remains Pipe and cigar smoking can also cause lung cancer, although the only effective curative treatment for lung cancer. the risk is not as high as with cigarette smoking.

22 clinical review

The risk of developing lung cancer decreases each year Types of lung cancer following smoking cessation as normal cells grow and replace Most lung cancers can be divided into two main types: non- damaged cells in the lung. In former smokers, the risk of small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). developing lung cancer begins to approach that of a non- The types behave in different ways and have their own special smoker about 15 years after cessation of smoking. treatment needs.

Passive smoking NSCLC subtypes Passive smoking is an established risk factor for the Squamous cell carcinoma development of lung cancer. These cells are usually found in the centre of the lungs, lining Asbestos fibres the bronchi, and do not spread quickly. This is the most Asbestos fibres are silicate fibres that can persist for a lifetime in common type of lung cancer in Ireland. lung tissue following exposure to asbestos. The workplace is a common source of exposure to asbestos fibres, as asbestos was Adenocarcinoma widely used in the past as both thermal and acoustic insulation. These cells are usually found at the edges of the lung where Today, asbestos use is limited or banned in many countries, mucus is made. including Ireland. Both lung cancer and mesothelioma (cancer of the pleura Large cell carcinoma of the lung as well as the peritoneum) are associated with These are large, round cells that may appear in any part of the exposure to asbestos. Cigarette smoking drastically increases lung and tend to spread quickly. the chance of developing an asbestos-related lung cancer in exposed workers. SCLC These cancers have small round cells that tend to grow quickly. Radon gas They form large tumours and spread to lymph nodes and other Radon gas is a natural, chemically-inert gas that is a natural organs such as the brain, bones, adrenal glands and the liver. decay product of uranium. Uranium decays to form products, This type of cancer often starts in the bronchi near the centre of including radon, which emit a type of ionizing radiation. As the chest. with asbestos exposure, concomitant smoking greatly increases the risk of lung cancer with radon exposure. Other types of lung cancer Radon gas can travel up through soil and enter homes A rare type of lung cancer is mesothelioma which is a cancer through gaps in the foundation, pipes, drains or other of the pleura cells. Usually it occurs after someone has been openings. Despite the fact that radon gas is invisible and exposed to asbestos. odourless, it can be detected with simple test kits. Signs and symptoms of lung cancer Lung diseases Symptoms of lung cancer are varied and depend on where and The presence of certain diseases of the lung, notably chronic how widespread the tumour is. Warning signs of lung cancer obstructive pulmonary disease (COPD), is associated with are not always present or easy to identify. an increased risk for the development of lung cancer, even after the effects of concomitant cigarette smoking have been No symptoms excluded. In up to 25 per cent of people who get lung cancer, the cancer is first discovered incidentally on a routine chest x-ray or Prior history of lung/other cancer computed tomography (CT) scan as a solitary small mass. These Survivors of lung/other cancer have a greater risk than the patients with small, single masses often report no symptoms at general population of developing lung cancer. the time the cancer is discovered.

Symptoms related to the cancer The growth of the cancer and invasion of lung tissues and surrounding tissue may interfere with breathing, leading to symptoms such as cough, shortness of breath, wheezing, chest pain and haemoptysis. If the cancer has invaded nerves, for example, it may cause shoulder pain that travels down the outside of the arm (called Pancoast’s syndrome) or paralysis of the vocal cords, leading to hoarseness. Invasion of the oesophagus may lead to dysphagia. If a large airway is obstructed, the collapse of a portion of the lung may occur and cause infections (abscesses, pneumonia) in the obstructed area. Chest infections, especially in patients with a smoking history, which do not resolve with treatment should be investigated.

Symptoms related to metastasis Lung cancer that has spread to the bones may produce excruciating pain at the sites of bone involvement. Cancer that has spread to the brain may cause a number of neurological symptoms that may include blurred vision, headaches, seizures or symptoms, such as weakness or loss of sensation in parts of Figure 1. Anatomy of the lungs. the body.

23 clinical review

Paraneoplastic symptoms Chest x-ray Lung cancers frequently are accompanied by symptoms that The chest x-ray is the most common first diagnostic step when result from the production of hormone-like substances by any new symptoms of lung cancer are present. Chest x-rays the tumour cells. These paraneoplastic symptoms occur most may reveal suspicious areas in the lungs but are unable to commonly with SCLC but may be seen with any tumour type. determine if these areas are cancerous. A common paraneoplastic syndrome associated with SCLC is the production of a hormone called adrenocorticotrophic CT scan hormone (ACTH) by the cancer cells, leading to oversecretion A CT scan of the chest may be ordered when x-rays do not of the hormone cortisol by the adrenal glands (Cushing’s show an abnormality or do not yield sufficient information syndrome). about the extent or location of a tumour. CT scanning of the The most frequent paraneoplastic syndrome seen with abdomen may identify metastatic cancer in the liver or adrenal NSCLC is the production of a substance similar to parathyroid glands and a CT scan of the head may be ordered to reveal the hormone, resulting in elevated levels of calcium in the presence and extent of metastases in the brain. bloodstream. Positron emission tomography Non-specific symptoms Positron emission tomography (PET) Non-specific symptoms seen with scanning is a specialised imaging technique many cancers, including lung cancers, Warning signs that uses short-lived radioactive drugs to include weight loss, weakness and produce three-dimensional coloured images fatigue. Psychological symptoms, such of lung cancer of those substances in the tissues within the as depression and mood changes, are body. also common. While CT scans look at anatomical are not always structures, PET scans measure metabolic Indications for immediate chest activity and functioning of tissue. PET scans x-ray present or easy can determine whether a tumour tissue is Rapid access to appropriate actively growing and can aid in determining multidisciplinary care improves the the type of cells within a particular tumour. outcome in lung cancer. For GPs, where to identify. In PET scanning, the patient receives there is a genuine clinical suspicion, a a short half-lived radioactive drug and chest x-ray should be available at their receives approximately the amount of local hospital within one week and preferably on a walk-in radiation exposure as two chest x-rays. The drug discharges basis. Indications for urgent/immediate chest x-ray in the over- particles known as positrons from wherever they are taken up 40-year age group, particularly smokers/ex-smokers, are shown and used in the body. As the positrons encounter electrons in Table 1. within the body, a reaction producing gamma rays occurs. A scanner records these gamma rays and maps the area where How is lung cancer diagnosed? the radioactive drug is located. History and physical examination may reveal the presence For example, combining glucose (a common energy source of symptoms or signs that are suspicious for lung cancer. In in the body) with a radioactive substance will show where addition to asking about symptoms and risk factors for cancer glucose is rapidly being used, for example, in a growing development, such as smoking, signs including breathing tumour. difficulties, airway obstruction or infections in the lungs may be detected. Cyanosis suggests a compromised function of the Bronchoscopy lung and, likewise, changes in the tissue of the nail beds, known Examination of the airways by bronchoscopy may reveal areas as clubbing, may also indicate lung disease. of tumour that can be biopsied. A tumour in the central areas of the lung or arising from the larger airways is accessible to sampling using this technique. Bronchoscopy may be performed using a rigid or a flexible fibre-optic bronchoscope and can be performed in a same-day outpatient bronchoscopy suite or an operating room. Some patients may cough up dark- brown blood for one to two days after the procedure. More serious but rare complications include a greater amount of bleeding, decreased levels of oxygen in the blood and heart arrhythmias as well as complications from sedative medications and anaesthesia.

Fine needle aspiration Fine needle aspiration through the skin is most commonly performed with radiological imaging for guidance. Needle biopsies are particularly useful when the lung tumour is peripherally located in the lung and not accessible to sampling by bronchoscopy. A small amount of local anaesthetic is given prior to insertion of a thin needle through the chest wall into the abnormal area in the lung. A small risk (three to five per Figure 2. Clubbing. cent) of a pneumothorax accompanies the procedure.

24 Danone Actimel, an ally for the elderly in winter*

Age-related immunoscenescence

As we get older, the immune systems ability to react & adapt declines due to an age-related phenomenon in the body’s defences called immunoscenescence. This involves both the host’s capacity to respond to infections and the development of long-term immune memory, especially by vaccination.

How can Actimel help?

Actimel is a food product scientiﬁ cally proven in 24 published clinical trials to help strengthen your natural defences. New research suggests that probiotics can also exert a beneﬁ cial effect not only within the gastrointestinal tract but more widely within the immune system.

NEW NEWS Effect after seasonal ﬂ u vaccination

Emerging evidence suggests that Actimel (2x100ml) improves the immune response to seasonal ﬂ u vaccination in the elderly. Placebo controlled studies showed1; Higher antibody titres to seasonal ﬂ u strains Effect maintained on seroconversion for H1N1**, H3N2 and B in the Actimel group B strain over time under Actimel consumption compared to the control and remained higher at 3, 6 and 9 weeks post vaccination. at 9 weeks after vaccination.

Antibody titre at 3, 6 and 9 weeks after vaccination. Boge T. et al 2009. A. B. C. H1N1 H3N2 B

120 120 120 100 100 100 80 80 80 60 60 60 GTM GTM

GTM Actimel 40 40 40 20 20 20 Control 0 0 0 Baseline 3w 6w 9w Baseline 3w 6w 9w Baseline 3w 6w 9w Time post vaccination Time post vaccination Time post vaccination “Vaxigrip, Sanofi-Pasteur MSD, season 2006-2007” A/New Caledonia/20/99 (H1N1) / A/Wisconsin/67/2005 (H3N2) B/Malaysia/2506/2004.

These results are further evidence that Actimel has a measurable impact on the immune system. Further research is needed to understand the beneﬁ ts of probiotic for different applications, in particular for how probiotics could help improve the immune response to vaccination.

For more information on probiotics and Actimel, please visit www.probioticsinpractice.co.uk

* Actimel is scientifically proven to help strengthen the natural defences when consumed daily as part of a healthy diet & lifestyle. Studies on Actimel collectively demonstrate that L. casei Imunitass survives in the gastrointestinal tract and exerts a beneficial effect on each of the 3 lines of “natural defence” (1)The intestinal flora, (2)The intestinal mucosa and (3)The intestinal immune system or gut-associated lymphoid tissue (GALT) when consumed daily as part of a healthy diet & lifestyle. ** This is a seasonal H1N1 strain not the swine flu strain.

1Boge T, et al. A probiotic fermented dairy drink improves antibody response to influenza vaccination in the elderly in two randomised controlled trials. Vaccine (2009),doi:10.1016/j.vaccine.2009.06.094

101442_actimel WOIN_A4.indd 1 18/08/2009 12:23:36 clinical review

Table 1. Urgent referrals for chest X ray for suspected lung cancer.2

Patient presents with

Symptoms • Stridor • Haemoptysis • Superior vena caval obstruction • New onset unexplained cough or alteration in character of chronic cough SVOC symptoms and signs • Hoarseness • Sensation of fullness in the face when patient bends over • Unexplained persistent chest and/or shoulder pain • Breathlessness • Dyspnoea • Headaches, which worsen on leaning forward or • Weight loss bending over • Features suggestive of metastasis from lung cancer (e.g. • Facial swelling, with a dark red look to the complexion brain, bone, liver or skin) • Swollen neck • Unresolved chest infection • Swollen arms and hands • Visible swollen blue veins on the chest Signs • Dizziness • Clubbing • Chest signs • Hepatomegaly • Cervical and/or supraclavicular lymphadenopathy

Chest X ray. Report should be back in 1 week

Normal chest X ray but Suggestive of lung high suspicion of cancer cancer; e.g.: • Slowly resolving consolidation • Pleural effusion • Mass

Urgent referral Immediate referral

Adapted from the National Institute for Clinical Excellence, Guideline 24: Lung Cancer, 2005.

Thoracentesis to the bones. Likewise, elevated levels of certain enzymes Sometimes lung cancers involve the pleura and lead to a normally present within liver cells, including aspartate pleural effusion. Aspiration of a sample of this fluid with a aminotransferase and alanine aminotransferase, signal liver thin needle (thoracentesis) may reveal the cancer cells and damage, possibly through the presence of a metastatic establish the diagnosis. As with the needle biopsy, a small risk tumour. of a pneumothorax is associated with this procedure. Conclusion Major surgical procedures The best strategy for combating lung cancer remains If none of the aforementioned methods yield a diagnosis, prevention. Eradication of smoking in the population has surgical methods must be employed to obtain tissue for the greatest potential for reducing the risk of lung cancer; diagnosis. These can include mediastinoscopy (examining the however, this task requires the commitment of several chest cavity between the lungs through a surgically-inserted organisations including the Government, education probe with biopsy of masses or lymph nodes that may professionals and healthcare professionals. contain metastases) or thoracotomy (surgical opening of the chest wall for the removal or biopsy of a tumour). With a thoracotomy, it is rare to be able to completely References remove a lung cancer, and both mediastinoscopy and 1. Donnelly DW, Gavin AT, Comber H. Cancer in Ireland 1994- thoracotomy carry the risks of major surgical procedures 2004: a comprehensive report. Northern Ireland Cancer (complications such as bleeding, infection and risks from Registry/National Cancer Registry of Ireland, Ireland, 2009. anaesthesia and medications). 2. National Institute for Clinical Excellence. Lung cancer: the While routine blood tests alone cannot diagnose diagnosis and treatment of lung cancer. National Institute lung cancer, they may reveal biochemical or metabolic for Clinical Excellence, London, 2005. abnormalities in the body that accompany cancer. For 3. O’Connell F et al. Guidelines for clinical management of example, elevated levels of calcium or of the enzyme alkaline, lung cancer. Irish Medical Journal 2004; 97 (2): supplement. phosphatase, may accompany cancer that is metastatic

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A practical guide to the CervicalCheck call/re-call process

Carrie Powles, RGN, Regional Smeartaker Co-ordinator, East and Midlands, CervicalCheck, the National Cervical Screening Programme, Niomh McCollam, RGN, Regional Smeartaker Co-ordinator, South East, CervicalCheck

successful national programme in Ireland has the Despite the significant efforts of all potential to reduce mortality rates from cervical cancer by as much as 80 per cent over time. concerned over the last 30 years Since its launch, CervicalCheck has proved in Ireland, opportunistic-based successful with high levels of uptake among eligible Awomen. During its first 12 months, CervicalCheck operated cervical cancer screening has failed an open access system of screening to ensure that initial interest from women in the programme could be effectively in terms of making any population accommodated. impact on cervical cancer mortality. Benefits of an organised screening programme CervicalCheck, the National Cervical The EU recommends that cancer screening should be only Screening Programme, became offered on a population basis in organised, quality-assured screening programmes.1 As proven internationally, the basis available to in excess of 1.1 million for a successful population-based screening programme is an eligible women aged 25 to 60 years active call/re-call system of invitation. On 1 September 2009, CervicalCheck moved from open on 1 September 2008. access entry for women to an organised call/re-call method of invitation to maximise uptake amongst all eligible women

28 in practice

in Ireland. A key point is that all eligible women on the CervicalCheck screening register will be called for a free smear test within the three yearly screening round. In Finland and Iceland, a reduction of approximately 60 per cent in cervical cancer mortality rates has been observed since the introduction of an organised screening programme.2 Peto et al, estimated that the NHS Cervical Screening Programme in England and Wales was credited with reducing cervical cancer incidence by 42 per cent since it introduced an organised call, re-recall system of invitation in 1988.3 Smeartakers in primary care have been pivotal to the programme’s success thus far. There are 4,367 active registered smeartakers in over 1,170 screening locations in primary care, of which 1,388 are practice nurses. The current priority for CervicalCheck is to encourage and invite those women who have not yet proactively attended for screening, to increase the Cervical cancer cells likelihood that the 80 per cent target uptake is met over the full three-year screening round. There are additional exemptions to invitation-only screening Women who have already attended for a CervicalCheck for women, including: smear test will be re-called according to management • Women who have had a CervicalCheck smear test result recommendations based on programme policy. The recent requiring repeat. move to a call/re-call approach has implications for the • Women over 60 years who have never had a smear test. management of cervical screening in practice. • Women of any age who require post-colposcopy surveillance. Call/re-call process in practice • Women post hysterectomy in certain circumstances. CervicalCheck provides free smear tests to women aged 25 to • Women aged 20 years and over on renal dialysis. 40 every three years and every five years to women aged 45 • Women aged 20 years and over with HIV infection. to 60, following two consecutive ‘no abnormality detected’ • Women aged 20 years and over post organ transplant. results. CervicalCheck has a national register of in excess of 1.1 If the woman presents or rings the surgery and does not million eligible women aged 25 to 60 years and over the three- have an invitation letter (or is not eligible for follow-up after an year screening round every woman on this register will be abnormal result, or under the criteria listed above) she should invited by letter for a free smear test. register with CervicalCheck and wait for a letter of invitation. The process required to access programme smear tests is outlined below: Helping women register with CervicalCheck 1. A woman phones to make an appointment for a There are three ways in which a woman can register for CervicalCheck smear test. If she has received a CervicalCheck CervicalCheck: invitation or re-call letter, she is eligible for a free smear test. An appointment can be scheduled and the woman should 1. Register online at www.cervicalcheck.ie by clicking on the ‘self-register’ tab and 2. A woman presents at the surgery without a CervicalCheck providing the details required. All fields marked with an invitation or re-call letter. If a woman has participated in asterisk on the registration form are obligatory, including CervicalCheck and requires follow-up or routine re-call a woman’s first name, surname, surname at birth, mother’s but does not have a CervicalCheck letter with her, or if you maiden name and address. The form must be validated by are uncertain as to whether a woman is eligible, contact matching the colours seen on screen at the end of the page. CervicalCheck on Freephone 1800 45 45 55 to check. The registration form also asks if the woman has had a smear test in the last three years. 2. Register by phoning CervicalCheck on Freephone 1800 45 45 55 and giving registration details over the phone. 3. The woman can fill in a self-registration form (available Smeartakers have from Inform Display Systems – Tel. [061] 338 580) and send it to CervicalCheck by Freepost. It helps to ensure that self- a professional registration leaflets are readily available in the surgery.

To ensure easy access to the programme for any woman responsibility to aged 25 to 60 years who has not had a smear test in three years or more, CervicalCheck has established a fast-track facility for keep their skills invitation. Women can avail of this by highlighting at the time of registration (online, by Freephone or Freepost) that they and knowledge have not had a smear test in the last three years or more. Following this, CervicalCheck will issue an invitation to the woman inviting her to make an appointment with a current in the area of registered smeartaker of her choice. Over 30,000 letters of invitation in response to opt-in requests have been issued cervical screening. since 1 September 2009 and the current waiting time for such an invitation is three weeks; however, this may vary slightly according to demand.

29 in practice

Helping women avail of free smear tests CervicalCheck will facilitate a smear test on a woman who Smeartakers can help women by providing them with is new to the programme and who has not yet been invited clear information about the smear test and ensuring they at the discretion of the clinically responsible doctor in some understand the process involved. Also it is important to explain exceptional cases if it is believed by the doctor that the woman the potential results of a smear test and to ensure that a woman is at risk of not responding to a CervicalCheck invitation letter. is comfortable throughout the procedure. If a woman has In such cases, CervicalCheck will provide the smeartaker with a positive experience, she is more likely to attend for future the consumables required for taking the smear test and will routine screenings. process it. However, the test will not, at this time, generate Practices that have operated their own cervical screening re- payment to the smeartaker. call systems for women can integrate these systems within the CervicalCheck national re-call process by: Results and re-call Once a woman has had her first smear test with CervicalCheck, • Checking if a woman is due for practice or clinic re-call. she will require two negative results three years apart before • Checking if she is eligible for a smear test within going on to age appropriate re-call. When complete, a letter CervicalCheck criteria. about her result will be posted to her. If the result is normal, she • If yes, advising her to register with CervicalCheck or will automatically be re-called when her next smear is due (in registering on her behalf. three or five years, depending on her age). If the result is abnormal, she will be advised to contact her smeartaker. If a three or six month follow-up is required, she will be advised of this in the result letter sent from the programme and she will not receive a further invitation letter Even if the woman is on this occasion. Smear tests requiring a three month follow-up should not be anxious, it is not good taken prior to three months. Even if the woman is anxious, it is not good practice to repeat a smear test prior to three months as this may result in a sub-optimal sample as the epithelial cells practice to repeat a may not have fully regenerated in this time. Women required to have a six-month follow-up should smear test prior to not have a smear test repeated prior to five months. Women required to have yearly follow-up should not have a smear test repeated prior to 10 months. three months as this Smear tests should be dispatched a minimum of once weekly to avoid delayed receipt at the cytology laboratory, which may may result in a sub- cause increased turnaround time for results. Such delays may also result in expired sample vials necessitating a repeat smear optimal sample. test for a woman. Expired samples will not be processed and will be destroyed by the laboratory.

30 Keeping updated Smeartakers have a professional responsibility to keep their skills and knowledge current in the area of cervical screening and best practice in smeartaking. The CervicalCheck Smeartaker Training Unit facilitates training and education initiatives in cervical screening on a national basis, including Clinical Updates for GPs and NUI-accredited modules of smeartaker training for health professionals. Clinical updates for registered smeartakers are Practice Nurses offered annually. Training is also available for non-medical practice staff. Details of all of these courses are available from the The Smeartaker Training Unit of CervicalCheck – Smeartaker Training Unit by emailing: [email protected] The National Cervical Screening Programme, is or Tel. (061) 461 234/146, and also on the CervicalCheck website (www.cervicalcheck.ie). holding a series of free CME accredited Clinical In addition to this information, the website is a useful resource for supporting and updating smeartaker knowledge Update Meetings for CervicalCheck registered and evidence base. smeartakers (GPs and practice nurses) in primary care.

The Clinical Update Meetings will:

Provide advice and assistance to GPs and practice nurses in applying the ‘Guidelines for Quality Assurance in Cervical Screening’ to practice Promote current best practice in the taking and management of quality smear tests Provide smeartakers with an opportunity to increase their knowledge and understanding of CervicalCheck

Each meeting will be followed by an in-depth question and answer session.

Clinical Update Meetings are taking place from 7.00-9.30pm as follows:

23 March Carlton Hotel, Dublin Road, Galway City 25 March Bracken Court Hotel, Balbriggan, Co Dublin 25 March Lecture Hall, Mayo General Hospital, Castlebar, Co Mayo 13 April Ramada Encore Hotel, Letterkenny, Co Donegal 14 April Best Western Aisling Hotel, Parkgate Street, Dublin 8 14 April Brehon Hotel, Killarney, Co Kerry 14 April Cavan General Hospital, Cavan, Co Cavan 15 April Stillorgan Park Hotel, Stillorgan Road, Dublin 18 20 April Rochestown Park Hotel, Rochestown, Cork 21 April Desmond Suite, Thomond Park, Limerick References 28 April Tullamore Court Hotel, O’Moore Street, Tullamore, Co Offaly 1. IARC. European guidelines for quality assurance in cervical cancer screening, second edition. Luxembourg: European 28 April Ramada Viking Hotel, Cork Road, Waterford Commission; 2008. Report no. ISBN 978-92-79-07698-5 2. Sigurdsson K, Sigvaldason H. Effectiveness of cervical Booking is required. To book a place or for further information, cancer screening in Iceland, 1964-2002: a study on trends in contact the Smeartaker Training Unit at [email protected] or incidence and mortality and the effect of risk factors. Acta call 061-461146 / 061-461234. Obstet Gynecol Scand 2006; 85 (3): 343-9 3. Peto J, Gilham C, Fletcher O, Matthews FE. The cervical cancer epidemic that screening has prevented in the UK. Lancet 2004 Jul 17-23; 364 (9430): 249-56. Bonviva: Licensed for the treatment of postmenopausal osteoporosis

ABRIDGED PRESCRIBING INFORMATION if creatinine clearance <30 ml/min. Potential for dysphagia, oesophagitis and oesophageal or gastric (For full prescribing information refer to the Summary of Product Characteristics [SmPC]) ulcers. Follow dosing instructions especially if history of prolonged oesophageal transit time. Monitor Bonviva® (ibandronic acid) 150mg film-coated tablets for signs or symptoms of possible oesophageal reactions – instruct patients to discontinue therapy Indication: Treatment of osteoporosis in postmenopausal women at increased risk of fracture. A and seek medical attention if symptoms of oesophageal irritation develop. Caution with concomitant reduction in the risk of vertebral fractures has been demonstrated, efficacy on femoral neck fractures administration of NSAIDs. Patients with rare hereditary problems of galactose intolerance, the Lapp has not been established. Dosage and Administration: No relevant use in children. Not studied in the lactase deficiency or glucose-galactose malabsorption should not take the tablet presentation. Drug paediatric population. Not recommended where creatinine clearance <30 ml/min. Patients should Interactions: Observe fasting requirements for food, drink and oral medicinal products/supplements. receive supplemental calcium and/or Vitamin D – see SmPC. 150 mg once a month swallowed Pregnancy and Lactation: Do not use. Side Effects and Adverse Reactions: Common adverse reactions whole (the tablet should not be sucked or chewed) with plain water only (180-240 ml) whilst sitting or (≥ 1/100 to <1/10): Headache, oesophagitis, gastritis, gastro-oesophageal reflux disease, dyspepsia, standing in an upright position. Take after overnight (≥6 hours) fast and one hour before the first food, diarrhoea, abdominal pain, nausea, rash, arthralgia, myalgia, musculoskeletal pain, muscle cramp, drink (except water) or any other oral medicinal products or supplements (including calcium). Patients musculoskeletal stiffness and influenza-like illness. Refer to the SmPC for a full listing of adverse events must not lie down for 1 hour after administration. Refer to SmPC for missed doses. Contraindications: including post marketing experience. Legal Category: Limited to sale and supply on prescription only. Hypocalcaemia, hypersensitivity to any ingredient. Warnings and Precautions: Treat hypocalcaemia Presentation and Marketing Authorisation Numbers: 1 tablet blister pack EU/1/03/265/003. and other disturbances of bone and mineral metabolism before starting Bonviva. Ensure adequate intake Marketing Authorisation Holder: Roche Registration Limited, 6 Falcon Way, Shire Park, Welwyn of calcium and vitamin D. Osteonecrosis of the jaw reported. A dental examination with appropriate Garden City, AL7 1TW, United Kingdom. Further information is available from Roche Products (Ireland) preventive dentistry should be considered prior to treatment in patients with concomitant risk factors. Avoid Limited, 3004 Lake Drive, Citywest, Naas Road, Dublin 24. Telephone: (01) 4690700. Fax: (01) invasive dental procedures if possible during treatment. Refer to SmPC for full details. Not recommended 4690791. Bonviva is a registered trade mark. Date of Preparation: July 2009.

P11/12/09 clinical review

Osteoporotic fractures Melanie Fox, Fracture Liaison Service CMN2, Waterford Regional Hospital

Osteoporosis is a skeletal disorder characterised by compromised bone strength predisposing a person to increased risk of fracture.1 Osteoporosis places huge economic and social burdens on societies worldwide.

steoporosis is a preventable disease that is usually Osteoporotic fracture sites not managed until the disease becomes evident, Common sites for osteoporotic fracture are the spine, hip, i.e. the patient sustains a low-trauma fracture. distal forearm and proximal humerus, but they also occur at Fracture liaison services (FLS) are being developed other sites including the pelvis, ribs, distal femur and tibia. in many hospitals in Ireland. These nurse-led The remaining lifetime probability in women who are at the Oservices liaise between primary and secondary care. FLS assess menopause of a fracture at any one of these sites exceeds that people over the age of 50 years who have sustained a low- of breast cancer (approximately 12 per cent) and the likelihood trauma fracture to determine their risk of further fractures of a fracture at any of these sites is 40 per cent or more in and, if appropriate, they are referred for a diagnostic scan developed countries.2 (dual-energy x-ray absorptiometry; DXA) and recommended Osteoporotic fractures are associated with increased appropriate treatment. mortality.4 With hip fractures, most deaths occur in the first Low-trauma fractures are described as fractures that have three to six months following the event, of which 20–30 per occurred easily, e.g. following a fall from standing height. cent is causally related to the fracture event itself. The estimates Treatment recommendations are made to the patient’s GP. This of deaths from Sweden that are causally related to hip fracture simple and straightforward process has been proven to prevent suggest that more than one per cent of all deaths are due to hip further fractures. fracture.5

33 clinical review

Bone mineral density measurements and diagnosis of If a person is frail and frequently falls, then hip protectors osteoporosis should be considered. A number of randomised trials have DXA is a non-invasive test that uses low-dose radiation and is shown that wearing hip protectors can markedly reduce hip the gold standard for measuring bone mineral density (BMD). fracture risk; however, it should be kept in mind that other trials The objectives of BMD measurements are to provide diagnostic have cast doubt on their value as a preventive measure.12,13 criteria and prognostic information on the probability of future Medications that can cause sedation and alcohol should be fractures. This is traditionally expressed as the increase in the avoided if possible. In the home, safety measures should be relative risk of fracture per standard deviation (SD) decrease in encouraged. For example, the use of a non-slip bath mat in the BMD measurement. shower and bath, removal of loose mats, trailing flexes, broken The units of measure computed from the BMD are T-scores steps and highly-polished floors. (recommended reference range is the NHANES III reference The lifting of heavy objects is discouraged and do-it-yourself database for femoral neck measurements in women aged jobs around the home should be left to younger members of 20-29 years). For the prediction of hip fracture, the gradient of the family. If it is necessary to get up to go to the bathroom at risk provided by hip BMD is 2.6, i.e. the fracture risk increases night, a landing light should be left on. 2.6-fold for each SD decrease in hip BMD.6 The incidence of osteoporotic fractures is increasing more than would be expected from the ageing of the population. This may reflect changing patterns of exercise or diet in recent General descriptive categories (WHO) decades. • Normal: T-score >-1 SD • Low bone mass (osteopenia): T-score – 1 to –2.5 SD Nutrition • Osteoporosis: T-score < – 2.5 SD Calcium and vitamin D supplements decrease secondary • Established osteoporosis: < – 2.5 SD with one or more hyperparathyroidism and reduce the risk of proximal femur fragility fractures. fracture. Intakes of at least 1,000mg/day of calcium, 800 IU of vitamin D and of 1g/kg body weight of protein can be General management recommended in the general management of patients with osteoporosis.3 Mobilty and falls The correction of poor protein nutrition in patients with a The prevention of falls is very important, especially for those recent hip fracture has been shown to improve the subsequent already at risk. Improving muscle strength and coordination by clinical course.14 physiotherapy and adequate exercise is paramount to those already in the osteoporosis risk category. Pharmacological interventions Exercise forms an integral component of osteoporosis The most commonly used agents in Europe are the selective management.3 A positive relationship between both current oestrogen-receptor modulators (SERMs), raloxifene, the physical activity, physical activity in adolescence and BMD has bisphosphonates, alendronate, ibandronate and risedronate, been shown in young female Canadians (aged 18-35 years)7 agents derived from parathyroid hormone and strontium and in Italian middle-aged women.8 Current exercise has ranelate. been associated with higher bone density in postmenopausal English women9 and in Norwegian women aged 50-75 years SERMs with fractures.10 Consideration for risk of fracture must be given to • Raloxifene 60mg daily (Evista) immobilised patients who may lose as much bone in a week when confined to bed as they would otherwise lose in a year. Raloxifene reduces the risk of vertebral fractures by 30-50 per Adequate annual eye testing for persons aged over 50 years is cent in postmenopausal women with low-bone mass.15 The recommended. only severe (but rare) adverse event reported was an increase in deep vein thrombosis (DVT). There is a significant and sustained decrease in the risk of invasive breast cancer (by about 60 per cent).16 Consideration for risk Bisphosphonates of fracture must be Oral bisphosphonates • Alendronate (70mg) once-weekly. • Risedronate (35mg) once-weekly. given to immobilised • Ibandronate given (150mg) once-monthly.

patients who may lose Bisphosphonates produce their effect by reducing the recruitment and activity of osteoclasts and increasing their as much bone in a apoptosis. Oral bioavailability is low, between one and three per cent of the dose ingested, and is impaired by food, calcium, iron, coffee, tea and orange juice. week when confined Bisphosphonates are quickly cleared from plasma (50 per cent being deposited in bone and the remainder excreted to bed as they would in urine). Their half-life in bone is very prolonged. Oral bisphosphonates are associated with mild gastrointestinal disturbances and some aminobisphosphonates (alendronate otherwise lose in a year. and pamidronate) can rarely cause oesophagitis.

34 Help Protect Your Post-Menopausal Patients From IU Osteoporotic 5600 Fractures With of Vitamin D

The Only Osteoporosis Therapy With 5600 IU of Vitamin D That Provides Demonstrated Fracture Prevention at the Hip and Spine,1,2-4 in one tablet Actual size

Updated NOF a guidelines recommend 800–1000 IU of vitamin D per day for adults ≥50 years 5

FOSAVANCE® 70 mg/2800 IU Tablets (70 mg alendronic acid as alendronate sodium trihydrate and 70 micrograms (2800 IU) colecalciferol (vitamin D3) Patients should be instructed that if they miss a dose of ‘Fosavance’ , they should take one tablet on the morning after they remember. They should not take two tablets on the same day, but should return to taking one tablet FOSAVANCE® 70 mg/5600 IU Tablets (70 mg alendronic acid as alendronate sodium trihydrate and 140 micrograms (5600 IU) colecalciferol (vitamin D3) once a week, as originally scheduled on their chosen day. Cause of osteoporosis other than oestrogen deficiency and ageing should be considered. Hypocalcaemia must be corrected before initiating therapy with 'Fosavance'. ABRIDGED PRODUCT INFORMATION Refer to Summary of Product Characteristics before prescribing. Other disorders affecting mineral metabolism (such as vitamin D deficiency and hypoparathyroidism) should also be effectively treated before starting 'Fosavance'. The content of vitamin D in ‘Fosavance’ is not suitable for PRESENTATION FOSAVANCE®70 mg/2800 IU Tablets. Capsule-shaped, white to off-white tablets marked with an outline of a bone image on one side, and ‘710’ on the other, containing 70 mg alendronic acid as alendronate correction of vitamin D deficiency. In patients with these conditions, serum calcium and symptoms of hypocalcaemia should be monitored during therapy with ‘Fosavance’. Due to the positive effects of alendronate in increas- ® sodium trihydrate and 70 micrograms (2800 IU) colecalciferol (vitamin D3). FOSAVANCE 70 mg/5600 IU Tablets Modified rectangle-shaped, white to off-white tablets, marked with an outline of a bone image on one side, ing bone mineral, decreases in serum calcium and phosphate may occur especially in patients taking glucocorticoids in whom calcium absorption may be decreased. Colecalciferol: Vitamin D3 may increase the magnitude of and '270' on the other, containing 70 mg alendronic acid as alendronate sodium trihydrate and 140 micrograms (5600 IU) colecalciferol (vitamin D3). USES Treatment of postmenopausal osteoporosis in patients at risk of hypercalcaemia and/or hypercalciuria when administered to patients with disease associated with unregulated overproduction of calcitriol (e.g. leukaemia, lymphoma, sarcoidosis). Urine and serum calcium should be moni- vitamin D insufficiency and for 'Fosavance' 5600 for patients not receiving Vitamin D supplementation. ‘Fosavance’ reduces the risk of vertebral and hip fractures. DOSAGE AND ADMINISTRATION The recommended tored in these patients. Patients with malabsorption may not adequately absorb vitamin D3. Excipients: Patients with rare hereditary problems of fructose intolerance, galactose intolerance, the Lapp lactase deficiency, glucose- dosage is one- tablet once weekly. Due to the nature of the disease process in osteoporosis, ‘Fosavance’ is intended for long-term use. Patients must be advised to follow the instructions below: For adequate absorption of galactose malabsorption or sucrase isomaltase insufficiency should not take ‘Fosavance’.Drug interactions If taken at the same time, it is likely that food, beverages (including mineral water), calcium supplements, antacids, alendronate: ‘Fosavance’ must be taken with water only (not mineral water) at least 30 minutes before the first food, beverage, or medicinal product (including antacids, calcium supplements and vitamins) of the day. Other and some oral medicinal products will interfere with absorption of alendronate. Therefore, patients must wait at least 30 minutes after taking alendronate before taking any other oral medicinal product. Since NSAlD use is beverages (including mineral water), food and some medicinal products are likely to reduce the absorption of alendronate. The following instructions should be followed exactly in order to minimise the risk of oesophageal associated with gastrointestinal irritation, caution should be used during concomitant use with alendronate. Colecalciferol Olestra, mineral oils, orlistat, and bile acid sequestrants (e.g. cholestyramine, colestipol) may impair irritation and related reactions: the absorption of vitamin D. Anticonvulsants, cimetidine and thiazides may increase the catabolism of vitamin D. Additional vitamin D supplements may be considered on an individual basis. Use in pregnancy and lactation: • Swallow ‘Fosavance’ only upon arising for the day with a full glass of water (not less than 200 ml or 7 fl.oz.). 'Fosavance' is only intended for use in postmenopausal women and therefore it should not be used during pregnancy or in breast-feeding women. There are no adequate data from the use of 'Fosavance' in pregnant women. • Patients should only swallow FOSAVANCE whole. Patients should not crush or chew the tablet or allow the tablet to dissolve in their mouths because of a potential for oropharyngeal ulceration. It is not known whether alendronate is excreted into human breast milk. Colecalciferol and some of its active metabolites pass into breast milk. SIDE EFFECTS The following adverse experiences have been reported during • Do not lie down until after the first food of the day which should be at least 30 minutes after taking the tablet. clinical studies and/or post-marketing use of alendronate. No new adverse reactions have been identified for ‘Fosavance’. Common (≥ 1.0% and <10%) Gastro-intestinal disorders: Abdominal pain, dyspepsia, constipation, • Do not lie down for at least 30 minutes after taking ‘Fosavance’. diarrhoea, flatulence, oesophageal ulcer, dysphagia, abdominal distension, acid regurgitation.Musculoskeletal and connective tissue: Musculoskeletal (bone, muscle or joint) pain. Nervous system disorder: Headache. Uncom- • Do not take at bedtime or before rising for the day. mon (≥ 0.1% and <1%) Gastro-intestinal disorders: Nausea, melaena, vomiting, gastritis, oesophagitis, oesophageal erosions. Skin and subcutaneous tissue disorders: Rash, pruritus, erythema. Rare (≥ 0.01% and <0.1%) Patients should receive supplemental calcium if intake from diet is inadequate. Additional supplementation with vitamin D should be considered on an individual basis taking into account vitamin D intake from vitamins and Immune system disorder: Hypersensitivity reactions including urticaria and angioedema. General disorders and administrative site conditions: Transient symptoms as in an acute-phase response (myalgia, malaise and rarely, dietary supplements. Equivalence of 2800IU of vitamin D3 weekly in ‘Fosavance’ to daily dosing of vitamin D 400 IU has not been studied. Equivalence of intake of 5600 IU of vitamin D3 weekly in FOSAVANCE to daily dosing fever), typically in association with initiation of treatment. Metabolism and nutrition disorders: Symptomatic hypocalcaemia, often in association with predisposing conditions. Gastro-intestinal disorders: Oesophageal stric- of vitamin D 800 IU has not been studied. Use in the elderly: No dosage adjustment is necessary. Use in renal impairment: No dosage adjustment is necessary for patients where GFR is greater than 35 ml/min. Alendronate is ture, oropharyngeal ulceration, upper gastro-intestinal PUBs (perforation, ulcers, bleeding). Skin and subcutaneous tissue disorders: Rash with photosensitivity. Eye disorders: Uveitis, scleritis, episcleritis. Very rare (<0.1%) not recommended for patients with renal impairment where GFR is <35 ml/min. Use in children and adolescents: Not recommended. CONTRAINDICATIONS Oesophageal abnormalities and other factors which delay Skin and subcutaneous tissue disorders: Severe skin reactions, including Stevens-Johnson syndrome and toxic epidermal necrolysis. Post-marketing experience: The following reactions have been reported (frequency unknown) oesophageal emptying, such as stricture or achalasia. Inability to stand or sit upright for at least 30 minutes. Hypersensitivity to alendronate or to any of the excipients. Hypocalcaemia. PRECAUTIONS Alendronate can cause during post-marketing experience: Nervous system disorders: dizziness, dysgeusia. Ear and labyrinth disorders: vertigo. Skin and subcutaneous tissue disorders: alopecia. Musculoskeletal, connective tissue and bone disorders: local irritation of the upper gastro-intestinal mucosa and potentially worsen any underlying disease. Because there is a potential for worsening of the underlying disease, caution should be used when alendronate is given to Osteonecrosis of the jaw has been reported in patients treated by bisphosphonates. The majority of the reports refer to cancer patients, but such cases have also been reported in patients treated for osteoporosis. Osteone- patients with active upper gastro-intestinal problems, such as dysphagia, oesophageal disease, gastritis, duodenitis, or ulcers, or with a recent history (within the previous year) of gastro-intestinal disease such as peptic ulcer, crosis of the jaw is generally associated with tooth extraction and/or local infection (including osteomyelitis). Diagnosis of cancer, chemotherapy, radiotherapy, corticosteroids and poor oral hygiene are also deemed as risk or active gastro-intestinal bleeding, or surgery of the upper gastro-intestinal tract other than pyloroplasty. In patients with known Barrett's oesophagus, prescribers should consider the benefits and potential risks of alendronate factors; joint swelling, stress fractures of the proximal femoral shaft. General disorders and administration site conditions: asthenia, peripheral oedema. Laboratory test findingsIn clinical studies, asymptomatic, mild and transient on an individual patient basis. Oesophageal reactions (sometimes severe and requiring hospitalisation), such as oesophagitis, oesophageal ulcers and oesophageal erosions, rarely followed by oesophageal strictures, have decreases in serum calcium and phosphate were observed in approximately 18 and 10%, respectively, of patients taking alendronate 10 mg/day versus approximately 12 and 3% of those taking placebo. However, the incidences been reported in patients receiving alendronate. Physicians should be alert to any signs or symptoms of a possible oesophageal reaction, and patients should be instructed to discontinue alendronate and seek medical atten- of decreases in serum calcium to < 8.0 mg/dl (2.0 mmol/l) and serum phosphate to ≤ 2.0 mg/dl (0.65 mmol/l) were similar in both treatment groups. PACKAGE QUANTITIES ‘Fosavance’ 70 mg/2800 IU Tablets 4 tablets.‘Fosavance’ tion if they develop symptoms of oesophageal irritation such as dysphagia, pain on swallowing, retrosternal pain, or new or worsening heartburn. The risk of severe oesophageal adverse reactions appear to be greater in 70 mg/5600 IU Tablets 4 tablets. POM Date of review: November 2009. Marketing Authorisation numbers: ‘Fosavance’ 70 mg/2800 IU Tablets, EU/1/05/310/002. ‘Fosavance’ 70 mg/5600 IU Tablets, EU/1/05/310/007. patients who fail to take alendronate properly and/or continue to take alendronate after developing symptoms suggestive of oesophageal irritation. It is very important that the full dosing instructions are provided to, and Marketing Authorisation Holder: Merck Sharp & Dohme Limited, Hertford Road, Hoddesdon, Hertfordshire EN11 9BU, UK. ® denotes registered trademark of Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., understood by the patient. Patients should be informed that failure to follow these instructions may increase their risk of oesophageal problems. While no increased risk was observed in extensive clinical trials with alen- Whitehouse Station, N.J., U.S.A © Merck Sharp & Dohme Limited 2009. All rights reserved. API.FOS. (II/13) Nov 09 Additional prescribing information available on request or from www.medicines.ie dronate, there have been rare (post-marketing) reports of gastric and duodenal ulcers, some severe and with complications. Osteonecrosis of the jaw, generally associated with tooth extraction and/or local infection (including References: 1. Data on file, MSD 2. Liberman UA, Hochberg MC, Geusens P, et al. Hip and nonspine fracture risk reductions among antiresorptive agents: evidence from randomised controlled trials. Int J Clin Pract. osteomyelitis) has been reported in patients with cancer receiving treatment regimens including primarily intravenously administered bisphosphonates. Many of these patients were also receiving chemotherapy and corticos- 2006;60:1394–1400. 3. Cranney A, Guyatt G, Griffith L, et al. IX: Summary of meta-analyses of therapies for postmenopausal osteoporosis. Endocr Rev. 2002;23:570–578. 4. Papapoulos SE, Quandt SA, Liberman UA, teroids. Osteonecrosis of the jaw has also been reported in patients with osteoporosis receiving oral bisphosphonates. A dental examination with appropriate preventive dentistry should be considered prior to treatment with et al. Metaanalysis of the efficacy of alendronate for the prevention of hip fractures in postmenopausal women. Osteoporos Int. 2005;16:468–474. 5. NOF Scientific Statement. National Osteoporosis Foundation’s Up- bisphosphonates in patients with concomitant risk factors (e.g. cancer, chemotherapy, radiotherapy, corticosteroids, poor oral hygiene, periodontal disease). While on treatment, these patients should avoid invasive dental dated Recommendations for Calcium and Vitamin D3 Intake, October 2008. Available at www.nof.org/prevention/calcium_and_VitaminD.htm. Accessed 9 September 2009. a NOF=National Osteoporosis Foundation. procedures if possible. For patients who develop osteonecrosis of the jaw while on bisphosphonate therapy, dental surgery may exacerbate the condition. For patients requiring dental procedures, there are no data available to suggest whether discontinuation of bisphosphonate treatment reduces the risk of osteonecrosis of the jaw. Clinical judgment of the treating physician should guide the management plan of each patient based on individual benefit/risk assessment. Bone, joint and/or muscle pain has been reported in patients taking bisphosphonates. In post-marketing experience, these symptoms have rarely been severe and/or incapacitating. The time to onset of symptoms varied from one day to several months after starting treatment. Most patients had relief of symptoms after stopping treatment. A subset had recurrence of symptoms when rechallenged with the same medicinal product or another bisphosphonate. Stress fractures (also known as insufficiency fractures) of the proximal femoral shaft have been reported in patients treated long-term with alendronic acid (time to onset in the majority of cases ranged from 18 months to 10 years). The fractures occurred after minimal or no trauma and some patients experienced thigh pain, often associated with imaging features of stress fractures, weeks to months before presenting with a completed femoral fracture. Fractures were often bilateral; therefore the contralateral femur should be examined in bisphosphonate-treated patients who have sustained a femoral shaft fracture. Poor Pelham House, South County Business Park, Leopardstown, Dublin 18, Ireland healing of these fractures was also reported. Discontinuation of bisphosphonate therapy in patients with stress fracture is advisable pending evaluation of the patient, based on an individual benefit risk assessment. 12-10-FSP-2009-IRL-2868-J clinical review

A number of randomised trials have shown that wearing hip protectors can markedly reduce hip fracture risk; however, it should be kept in mind that other trials have cast doubt on their value as a preventive measure.

Intravenous bisphosphonates Strontium ranelate

• Ibandronate (3mg) every three months is also approved • Protelos 2g scahet once-daily. for postmenopausal osteoporosis.17 • Yearly IV infusion of zoledronate (5mg) for three years. Strontium ranelate both inhibits bone resorption and Loading with 100,000 IU ergocalciferol (vitamin D) IM stimulates bone formation and the decrease in fracture five days pre infusion. rates is of similar magnitude to that described for oral bisphosphonates.18 Food, milk and its derivative products Intravenous aminobisphosphonates can induce a transient reduce the absorption of strontium ranelate. acute phase reaction with fever, bone and muscle pain The most common adverse events are nausea and diarrhoea, that ameliorates or disappears after subsequent courses. which are generally reported at the beginning of treatment Osteonecrosis of the jaw has been described in cancer and usually disappear after the third month of treatment. patients receiving high doses of intravenous pamidronate An increase in the incidence of DVT (relative risk [RR] 1.42; or zoledronate. The incidence in osteoporotic patients confidence interval [CI] = 1.02, 1.98) has been reported. treated with oral and intravenous bisphosphonates is in the order of 1/100,000 cases, and its causal relationship with Treatment thresholds bisphosphonate therapy has not been established. Treatment is justified without measurement of BMD, for example in patients with fragility fractures and other strong risk Peptides of the parathyroid hormone family HITECH scripts) factors. Measurement of BMD is indicated in individuals who have a high fracture probability, provided that it will influence • 20μg teriparatide (1-34) (Forsteo S/C daily over 24 the management decision. months). Treatment with calcium and vitamin D3 and a • 100μg parathyroid hormone (PTH) (1-84) (Preotact S/C bisphosphonate or strontium ranelate is recommended with daily over 18-24 months).19 a T-score of – 2.5 or less, or with a T-score of – 1.5 in patients with a fragility fracture or a high probability of fracture. PTH is PTH adverse effects considered in patients with a T-score of – 3 SD or less or in the The most commonly reported adverse events with PTH or presence of vertebral fractures. teriparatide are nausea, pain in the limbs, headache and Guidelines are being developed by the Joint Initiative on dizziness. The change in serum calcium with PTH is small and Bone Health on the management of patients on steroids. routine monitoring during therapy is not required. Isolated episodes of transient orthostatic hypotension are also reported Assessment of fracture risk but typically resolve within minutes to a few hours and do not Low-trauma fractures indicate a substantial independent preclude continued treatment. increase in risk of future low-trauma fracture of the order of

36 for longer lasting bones

†

SWALLOWTABLET †

Convenient to take more expensive s more calcium than the market leader s20% 41% sMarket leader is

ABBREVIATED PRESCRIBING INFORMATION calcium & vitamin D3 (Please refer to Summary of Product Characteristics before prescribing)

CALTRATE* 600 mg/400 IU, fi lm-coated tablet Presentation: Each tablet contains 600 mg of calcium (as calcium carbonate) & 10 micrograms of cholecalciferol (equal to 400 IU vitamin D3). Contains sucrose & partially hydrogenated soya bean oil. Indications: Correction of combined vitamin D & calcium defi ciencies in the elderly. As an adjunct to specifi c treatments for osteoporosis, in patients where combined vitamin D & calcium defi ciencies have been diagnosed or those at high risk of defi ciency. Dosage & Administration: Adults & Elderly: One tablet twice a day (morning/ evening). Pregnant women One tablet a day. Oral (Swallow with 200mls water). The elderly or patients with known diffi culties in swallowing, may break the tablet into two parts before taking with water. Do not suck or chew. Contraindications: Hypersensitivity to any ingredients including peanut or soya. Patients who now have, or have had renal failure, kidney stones, hypervitaminosis D, hypercalciuria & hypercalcaemia & diseases &/or conditions that lead to hypercalcaemia &/or hypercalciuria. Precautions: In prolonged treatment, check calcaemia & renal function, particularly in the elderly (see interactions). If renal function deteriorates, the dose must be reduced or treatment interrupted. Caution is advised in immobile patients. This product contains vitamin D; further administration of vitamin D or calcium must be medically supervised with regular monitoring of calcaemia & calciuria. Patients with sarcoidosis calcaemia & calciuria must be monitored. Risk of soft tissue calcifi cation must be considered. In severe renal insuffi ciency, vitamin D3 as cholecalciferol is not metabolised normally & other forms of vitamin D3 must be used. Cases of asphyxiation due to tablet choking have been reported. This product contains sucrose; patients with sugar intolerance should not take this medicine. Not intended for use in children & adolescents. Interactions: Thiazide diuretics & systemic corticosteroids (calcium monitoring required). Orlistat, combined ion-exchange resins (cholestyramine) or laxatives (paraffi n oil) can reduce the GI absorption of vitamin D3. Take tetracycline 2 hours before or 4 to 6 hours after taking calcium. Cardiac glycosides (monitor patients regularly with ECG check & calcaemia). Phenytoin or barbiturates (may reduce the activity of vitamin D3). Iron, zinc or strontium preparations, estramustin or thyroid hormones should be spaced at least 2 hours from calcium medicines. Bisphosphonate, sodium fl uoride or fl uoroquinolone administration, Caltrate should be spaced by at least 3 hours from these medicines. Oxalic acid (found in spinach & rhubarb) & phytic acid (found in wholegrain cereals) can inhibit calcium absorption by forming insoluble compounds with calcium ions. Patients must not take calcium containing-products in the two hours after consumption of foods rich in oxalic acid & phytic acid. Pregnancy & lactation: Caltrate may be used during pregnancy & breastfeeding. Daily intake in pregnancy should not exceed 1500mg calcium & 600IU cholecalciferol. Avoid prolonged use as hypercalcaemia can aff ect the developing foetus. Calcium & vitamin D3 pass into breast milk, this should be considered when vitamin D3 is given concomitantly to infants. Side-eff ects: Hypercalcaemia, hypercalciuria, constipation, fl atulence, nausea, abdominal pain, diarrhoea, pruritis, rash & urticaria. Legal Category: P. Pack Size: 90 tablets. PAH: Whitehall Laboratories Ltd T/A Wyeth Consumer Healthcare, Taplow, Berks, SL6 0PH, United Kingdom. PA number: PA172/38/1. Further information is available upon request from Wyeth Consumer Healthcare, Blanchardstown Corporate Park 2, Dublin 15 or look up, www.medicines.ie PCRS Reimbursable. Date of preparation: December 2009. † Source: MIMS September 2009. * Trade Mark.

Dec 09 Ref: Ca 09 108 Med. clinical review

two-fold. Low BMD increases the risk of future fracture again References (one SD from peak BMD doubles the risk of future fracture). 1. Consensus development conference. JAMA 2001; 285: The fracture risk varies markedly in different populations, e.g. in 785-95. WHO Study Group, WHO Technical Report Series women with a T-score of – 2.5 SD, the probability of hip fracture 843/1994. is five times greater at the age of 80 years than at the age of 50 2. Kanis JA, Johnell O, Oden A et al. Long-term risk of years. osteoporotic fracture in Malmo. Osteoporos Int 2000; 11: The ability of BMD to predict fracture is comparable to the 669–74. use of blood pressure to predict stroke and is significantly 3. Kanis JA, Burlet N, Cooper C et al. European guidance better than serum cholesterol to predict myocardial for the diagnosis and management of osteoporosis in infarction.19 Age contributes to risk independently of BMD, i.e. postmenopausal women. Osteoporos Int 2008; 19 (4): 399- for any BMD, fracture risk is much higher in the elderly than in 428. the young. 4. Cooper C, Atkinson EJ, Jacobsen SJ, O’Fallon WM, Melton LJ. A population-based study of survival after osteoporotic Clinical risk factors3 fractures. Am J Epidemiol 1993; 137: 1001–5. 1. Body mass index (BMI) /= 3 units daily are associated with a bone mineral density in Italian middle-aged women. Eur J dose-dependent increase in risk. Epidemiol 1998; 14 (2): 153-7. 7. Rheumatoid arthritis causes a fracture risk independently of 9. Coupland C, Cliffe S, Bassey E et al. Habitual physical activity BMD and the use of glucocorticoids. and bone mineral density in postmenopausal women in England. Int J Epidemiol 1999; 28 (2): 241-6. Secondary causes of osteoporosis 10. Omland LM, Tell GS, Ofjord S, Skag A. Risk factors for low • Rheumatoid arthritis. bone mineral density among a large group of Norwegian • Untreated hypogonadism in men and women. women with fractures. Eur J Epidemiol 2000; 16: 223-9. • Inflammatory bowel disease. 11. Watts NB. Fundamentals and pitfalls of bone densitometry • Prolonged immobility. using dual-energy x-ray absorptiometry (DXA). Osteoporos • Organ transplantation. Int 2004; 15: 847-54 • Type I diabetes. 12. Sawka AM, Boulos P, Beattie K et al. Do hip protectors • Thyroid disorders. decrease the risk of hip fracture in institutional and • Chronic obstructive pulmonary disease. community-dwelling elderly? A systematic review and meta- • Case-finding strategies. analysis of randomized, controlled trials. Osteoporos Int 2005; 16: 1461-74. FRAX tool 13. Kiel DP, Magaziner J, Zimmerman S et al. Efficacy of a hip The FRAX tool, which was developed by the WHO Collaborating protector to prevent hip fracture in nursing home residents: Centre for Metabolic Bone Diseases in Sheffield, UK, computes the HIP PRO randomized, controlled trial. JAMA 2007; 298: the 10-year probability of hip fracture or a major osteoporotic 413-22. fracture, i.e. clinical spine, hip, forearm or humerus. It uses 14. Rizzoli R, Bonjour JP. Dietary protein and bone health. J Bone algorithms that integrate the weight of clinical risk factors for Miner Res 2004; 19: 527-31. fracture risk with or without BMD. The risk factors include age, 15. Delmas PD, Bjarnason NH, Mitlak BH et al. Effects of gender, BMI, prior fracture, paternal hip fracture, smoking, raloxifene on bone mineral density, serum cholesterol alcohol, glucocorticoids and rheumatoid arthritis. concentrations, and uterine endometrium in The tool can be used online (http://www.shef.ac.uk/FRAX) postmenopausal women. N Engl J Med 1997; 337: 1641-7. or paper charts can be downloaded that provide fracture 16. Cummings SR, Eckert S, Krueger KA et al. The effect of probability according to the number of clinical risk factors. raloxifene on risk of breast cancer in postmenopausal women: results from the MORE randomized trial. Multiple Conclusion Outcomes of Raloxifene Evaluation. JAMA 1999; 281: 2189-97. Although BMD and clinical risk factors are important 17. Delmas PD, Adami S, Strugala C et al. Intravenous components of risk of fracture, a variety of non-skeletal factors, ibandronate injections in postmenopausal women with e.g. liability to fall and force of impact, contribute to fracture osteoporosis: one-year results from the Dosing Intravenous risk. Attention has focused on the identification of patients at Administration Study. Arthritis Rheum 2006; 54: 1838-46. high risk of fracture rather than the identification of patients 18. Reginster JY, Seeman E, De Vernejoul MC et al. Strontium with osteoporosis. ranelate reduces the risk of nonvertebral fractures in postmenopausal women with osteoporosis: Treatment of Peripheral Osteoporosis (TROPOS) study. J Clin Endocrinol Metab 2005; 90: 2816-22. 19. World Health Organisation. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Technical Report Series 843. WHO, Geneva, 1994.

38 Dog Lady A4 26/01/2009 09:47 Page 1

HELPPROTECTTHE FRAGILE ELDERLY

Calcium and/or vitamin D deficiency in the elderly can lead to loss of muscle tone and an increase in falls and osteoporotic fractures.1-5

Calcichew-D3 Forte is indicated for the treatment and prevention of calcium and vitamin D deficiency.6

Their strength is our forte

CALCICHEW-D3 FORTE CHEWABLE TABLETS PRESCRIBING INFORMATION 2 hours before, or 4 to 6 hours after Calcichew-D3 Forte), bisphosphonates or Adverse events should be reported to the Pharmacovigilance Unit at (Please refer to full Summary of Product Characteristics when prescribing) sodium fluoride (take 3 hours before Calcichew-D3 Forte), thiazide diuretics, the Irish Medicines Board (IMB) ([email protected]). Presentation: Chewable tablet containing 1250mg calcium carbonate (equivalent corticosteroids, cardiac glycosides, ion exchange resins (cholestyramine), laxatives to 500mg of elemental calcium) plus 400IU colecalciferol (equivalent to 10 (paraffin oil). Calcichew-D Forte should not be taken within 2 hours of eating Information about adverse event reporting can be found on the IMB 3 website (www.imb.ie). Adverse events may also be reported to Shire micrograms vitamin D3). Uses: Treatment and prevention of vitamin D/calcium foods high in oxalic acid (e.g. spinach and rhubarb) or phytic acid (e.g. whole deficiency. Supplementation of vitamin D and calcium as an adjunct to specific cereals). Side effects: Hypercalcaemia, hypercalciuria, constipation, flatulence, Pharmaceuticals Ltd on +44 1256 894000. therapy for osteoporosis, in pregnancy, in established vitamin D dependent nausea, abdominal pain, diarrhoea, pruritus, rash, urticaria. Use in pregnancy and osteomalacia and in other situations requiring therapeutic supplementation of lactation: Can be used in case of calcium and vitamin D deficiency. Daily intake References: 1. Perez-Lopez FR. Maturitas 2007;58: 117-137. 2. Dawson- malnutrition. Dosage and administration: Oral (suck or chew). Adults and elderly: in pregnancy should not exceed 1500mg calcium and 600IU colecalciferol (15 Hughes B & Bischoff-Ferrari HA. J Bone Miner Res 2007; 22: S2; v59-v63. Two tablets daily. Children: Not intended for use in children. Hepatic impairment: micrograms vitamin D ). Avoid overdose as permanent hypercalcaemia affects 3 3. Lin JT & Lane JM. Phys Med Rehabil Clin N Am 2005; 16: 109-128. No dose adjustment required. Renal impairment: Should not be used in patients developing foetus. Calcium and vitamin D3 pass into breast milk so consider this with severe renal impairment. Contraindications: Diseases and/or conditions when giving additional vitamin D to the child. Pharmaceutical precautions: Do 4. Heaney RP. Endocrinology and Metabolism Clinics 1998; 27(2): 255-265. resulting in hypercalcaemia and/or hypercalciuria, renal stones, hypervitaminosis not store above 30°C. Keep container tightly closed. Legal category: Pharmacy 5. Hunter DJ & Sambrook PN. Arthritis Res 2000; 2(6): 441-445. 6. Calcichew- D, hypersensitivity to ingredient(s) especially soybean oil and peanut. Precautions: product. Product Authorisation No: 535/1/3. Product Authorisation holder: D3 Forte. Summary of Product Characteristics. July 2007. Monitor serum calcium and creatinine levels, particularly in elderly patients on Shire Pharmaceuticals Ltd., Hampshire International Business Park, Chineham, Date of preparation: January 2009. IRE/CDF/09/0001 cardiac glycosides or diuretics and in patients with high tendency to calculus Basingstoke, Hampshire RG24 8EP UK. Distributed in Republic of Ireland by: Cahill formation. Use with caution in patients with impaired renal function. Take into May Roberts, P.O. Box 1090, Chapelizod, Dublin 20, Republic of Ireland. Further account risk of soft tissue calcification. Avoid in patients with phenylketonuria or information is available on request. Date of revision: July 2007. sugar intolerance. Prescribe with caution in patients with sarcoidosis. Use with CALCICHEW is a registered trademark of Shire Pharmaceuticals Ltd in the caution in immobilised patients. Additional doses of calcium or vitamin D should Republic of Ireland. only be taken under close medical supervision. Interactions: Tetracyclines (take nutrition

Health implications of fat quality of our diet Dr Patricia Heavey, DPhil, RNutr, Flora Consultant Nutritionist Diet plays a critical role in obtaining and maintaining good health, and research indicates that the quality of dietary fats is a crucial element in this. However, studies have shown that consumers do not understand dietary fat, either the importance of the quality or the quantity of fats needed for health.

Role of fat in the diet Fats are oxidised to provide energy and are the most concentrated form of dietary energy (9kcal/g). They also provide essential fatty Fats provide essential acids and help in the absorption of the fat-soluble vitamins A, D, E and K and antioxidants. Fats insulate against heat loss by means of subcutaneous fat stores and provide a protective layer around fatty acids and help essential organs. Fats also serve as building blocks of membranes; for example, in the absorption forming the structural component of brain tissue and the myelin sheath around nerves and forming phospholipids, the principal of the fat soluble component of cells’ membranes. Fats are a substrate for hormone and prostaglandin synthesis and play a key regulatory role in many other biological functions. vitamins A, D, E and In addition, the type of fat consumed makes a difference to heart health and the total amount of fat in the diet is also important. K and antioxidants.

40 nutrition

Trans fats are found in many processed foods that contain shortening or partially hydrogenated fats such as biscuits, cakes, some fast food meals and takeaways.

Monounsaturates Monounsaturated fats are found in olive oil, rapeseed oil, some nuts and avocados. These fats also have a beneficial effect on cholesterol levels and are good for heart health.

Dietary fat and cardiovascular disease The risk of cardiovascular disease (CVD) is closely related to the intake of dietary fat. Saturated fatty acids are known to increase the risk of CVD, whereas unsaturated fatty acids have been Fat cells. The type of fat consumed makes a difference to shown to protect against diseases of the heart. heart health. CVD is the leading cause of mortality in Ireland, accounting for approximately 10,000 deaths a year or 36 per cent of all deaths.1 Twenty-two per cent of premature deaths (under the age of 65 years) are from CVD.1 In Ireland, the mean daily intake Types of fat of fat in men and women (37 per cent of food energy) exceeds current recommendations for fat (for a maximum intake of 35 Saturates per cent of food energy).2 Saturated fats can raise low-density lipoprotein (LDL) In addition, the mean daily intake of saturated fat in men and cholesterol levels, which can have an adverse effect on heart women is 14 per cent of total energy2 which greatly exceeds health. Saturated fats are often solid at room temperature and the World Health Organisation’s recommendation of less than are mostly found in dairy products such as hard cheeses and 10 per cent of total energy from saturated fat intake.3 butter, meat products such as sausages and burgers and the fat on meat. Consumer research Consumer surveys have shown that fat consistently ranks at Trans fats the top of the list of consumer nutrition concerns. The 2008 In terms of heart health, trans fats are considered to be worse Food and Health Survey4 of the International Food Information than saturated fats, as they can raise LDL cholesterol and lower Council found that 70 per cent of those surveyed were high-density lipoprotein (HDL) cholesterol. However, in the concerned with the amount of fat they consume. One change Irish diet, we consume much more saturated fats than trans in recent surveys is an increased recognition of the role of trans fats and so reducing saturated fats should be the focus for our fats in overall health. patients. More recently, a consumer study conducted by Diekman and Trans fats are found in many processed foods that contain Malcolm5 was carried out in 16 countries and included 6,426 shortening or partially hydrogenated fats such as biscuits, respondents. The survey was conducted by phone, internet pastries, cakes, some fast food meals and takeaways. They are and face-to-face interviews depending on the acceptable also found in butter and fatty meat, such as lamb. method for different populations. Participants were aged between 18 and 70 years and were the main family shopper. Polyunsaturates The results from the survey indicated that knowledge about Polyunsaturates are found in oily fish, nuts, seeds and certain fat is conflicted, including which fats have health benefits. Fifty- plant oils including sunflower oil and some spreads and soft nine per cent of respondents felt that fat should be avoided, margarines. Two important polyunsaturates are omega 3 65 per cent felt that a low-fat diet was a healthy diet and 38 per and omega 6 oils. Omega 6 fats play an important role in cent claimed to avoid foods containing fat. maintaining blood cholesterol levels, while omega 3 fats have Respondents were aware of the different types of fats but did been shown to keep hearts healthy. Omega 6 fats and omega not know which ones were healthier. Omegas had the greatest 3 from plants are essential fats, which means they must be level of recognition but, at the same time, many did not realise provided in the diet as the body cannot make them. that they were fats.

41 nutrition

Conference on nutrition and health There was also a call on scientists, healthcare professionals Confusion about the role of fat in the diet and recognition and media around the world to advocate simple, consistent of the different types of fats needs to be addressed in order and effective messages to improve the fat quality of the diet for consumers to make educated choices regarding their and promote such changes for the prevention of chronic diet. In February 2009, 40 leading world experts from the disease and to achieve optimal health. field of nutrition and health, originating from 25 countries, For further information on the outcomes of this meeting, came together in Barcelona. There they discussed the critical please visit the following website: www.theIEM.org importance of an optimal fat intake. They indicated that the goal of dietary recommendations is to meet nutritional needs References and, at the same time, prevent the development of chronic 1. The Central Statistics Office. Available online: www.cso.ie disease and support optimal health and wellbeing. The 2. North South Ireland Food Consumption Survey (IUNA). quantity of fat is an important factor determining energy intake Available online: www.iuna.net which should be balanced with energy expenditure to achieve 3. WHO/FAO. WHO Technical Report Series No 916. Diet, and maintain healthy weight. nutrition and chronic disease. 2003. Geneva, WHO. In addition, the quality of fat in the diet is important for 4. International Food Information Council Foundation: normal growth and development and it has a marked impact Food and Health Survey. Consumer attitudes towards on blood cholesterol and the occurrence of coronary heart food, nutrition and health. Washington, International disease and stroke. In line with authoritative international Food Information Council, 2008. http://ific.org/research/ health bodies and current evidence, the committee made the foodandhealthsurvey.cfm following recommendations on the quality of fat in the diet for 5. Diekman C, Malcolm K. Consumer perception and insights on optimal health across the life course worldwide, from an age of fats and fatty acids: knowledge on the quality of diet fat. Ann about two years onwards: Nutr Metab 2009; 54: supplement 1, pp25-32

Fat may provide up to 30-35 per cent of the daily energy intake; • Saturated fat should provide no more than 10 per cent of the daily energy intake; • Essential polyunsaturated fats (omega 3 and omega 6) should contribute 6 to 10 per cent of the daily energy intake; • The intake of trans fats should be less than one per cent of the daily energy intake; and • The remainder of the energy from fat can be provided by monounsaturated fats.

42 abstracts

focus on: allergy

Environmental and occupational allergies Peden D, Airborne allergens are the major cause of allergic rhinitis and asthma. Daily exposure comes Reed CE from indoor sources, chiefly at home but occasionally at schools or offices. Seasonal exposure J Allergy Clin Immunol to outdoor allergens, pollens and moulds is another important source. Exposure to unusual 2010 Feb; substances at work causes occupational asthma, accounting for approximately five per cent of 125v (2 suppl 2): S150-60 asthma in adults. Indoor and outdoor air pollutants trigger airway inflammation and increase the severity of asthma. Diesel exhaust particles increase the production of IgE antibodies. The identification and reduction of exposure to allergens is a very important part of the management of respiratory allergic diseases. This US study from the Department of Pediatrics, University of North Carolina, discusses domestic allergens, arthropods (mites and cockroaches), moulds, and mammals (pets and mice). Indoor humidity and water damage are important factors in the production of mite and mould allergens, and discarded human food items are important sources of the proliferation of cockroaches and mice. Means of identifying and reducing exposure are presented. The study’s two authors also discuss outdoor allergens: pollens and moulds. The particular plants or moulds and the amount of exposure to these allergens is determined by the local climate, and local pollen and mould counts are available to determine the time and amount of exposure. Climate change is already having an important effect on the distribution and amount of outdoor allergens. The study finishes with a discussion on indoor and outdoor air pollution and methods that individuals can take to reduce indoor pollution in addition to eliminating cigarette smoking.

Management of nut allergy influences quality of life and anxiety in children and their mothers Cummings AJ, Nut allergy is known to impact on the quality of life (QoL) and anxiety of both the allergic child Knibb RC, Erlewyn- and their parents, but little is known about how the management of food allergy is associated Lajeunesse M et al with these variables. This study from the Infection Inflammation and Immunity Department, Pediatr Allergy Immunol, School of Medicine, University of Southampton, UK, aimed to investigate the impact of nut 14 January 2010 allergy on QoL and anxiety in mothers and children with nut allergy in order to identify management strategies that may influence these factors. Forty-one nut-allergic children aged 6-16 years and their mothers completed questionnaires to assess maternal and children’s QoL (Paediatric and Quality of Life Inventory [PedsQL], World Health Organisation Quality of Life BREF (WHOQOL-BREF), Food Allergy Quality of Life-Parental Burden questionnaire [FAQL-PB]), anxiety (Spence Children’s Anxiety Scale [SCAS], State-Trait Anxiety Inventory [STAI]) and perceived stress scale (PSS). Children also completed a nut allergy-specific QoL questionnaire. Demographic data, details of previous reactions, test results and management plans were collected using parent report questionnaires and hospital notes. Children with nut allergy had poorer emotional (p=0.004), social (p=0.043) and psychological (p=0.006) QoL compared to healthy normative data. Maternal and child QoL and anxiety were not influenced by the severity of previous reactions. Mother and child reported lower anxiety (p=0.043 and p<0.001 respectively) when the child was prescribed an epinephrine auto-injector. Anxiety was not associated with whether the child carried the auto-injector or whether they strictly avoided traces of nuts in foods. Prescribing auto-injectors is associated with reduced anxiety for food-allergic children and their mothers, but is not associated with improved adherence with medical management or reduced risk-taking behaviour.

44 New

75µg desogestrel ...when Oestrogen isn’t right 1

Pregnancy Protection1 1 Comparable to a COC Oestrogen-FREE

Primarily Inhibits1 Ovulation

Introducing new oestrogen-free1 Cerazette for a star performance

Reference with a history of thromboembolic disorders. Consider discontinuation if Adverse reactions: Refer to SmPC for full details. Common: irregular bleeding, 1. Cerazette Summary of Product Characteristics. hypertension develops. Benefi t/risk assessment should be made in women amenorrhoea, headache, weight gain, breast pain, nausea, acne, mood Cerazette® 75 microgram fi lm-coated tablets Desogestrel Abbreviated with liver cancer. Monitor patients with diabetes during the fi rst months of changes, decreased libido. Breast discharge may also occur. Other less Prescribing Information (Refer to Summary of Product Characteristics use. Effects on bone density are unknown. Despite the fact that Cerazette common and rarely reported side effects are listed on the SmPC. Overdose: No before prescribing) Presentation: One sachet containing 1 strip of 28 tablets, consistently inhibits ovulation, ectopic pregnancy should be taken into account serious effects have been reported. Symptoms may include nausea, vomiting each tablet containing 75mcg desogestrel. Uses: Contraception. Dosage: in the differential diagnosis if the woman gets amenorrhoea or abdominal and in young girls, slight vaginal bleeding. Treatment should be symptomatic. One tablet daily at about the same time. There is no pill-free week between pain. Chloasma may occasionally occur. Cerazette contains less than 65mg Legal category: Prescription Only Medicine. Product licence number: PA strips. Contraindications: Known or suspected pregnancy, active venous lactose, and therefore should not be administered to patients with rare 61/27/1 Price: 1 carton Cerazette containing 28 tablets - €5.90 Product thromboembolic disorder, presence or history of severe hepatic disease hereditary problems of galactose intolerance, the Lapp lactase defi ciency, licence holder: Organon (Ireland) Limited, P.O. Box 2857, Drynam Road, with current abnormal liver function tests, known or suspected sex-steroid or glucose-galactose malabsorption. Use in pregnancy and lactation: Not Swords, Co. Dublin, Ireland Further information is available from: Schering- sensitive malignancies, undiagnosed vaginal bleeding, hypersensitivity to any recommended during pregnancy. Cerazette does not infl uence the production Plough Ltd, Shire Park, Welwyn Garden City, Hertfordshire, AL7 1TW, UK. ingredients. Precautions and warnings: Women currently using combined or quality of breast milk. Small amounts of the metabolite etonogestrel are Telephone +44 (0) 1707 363636 Date of revision of Prescribing Information: oral contraceptives (COCs) have a slightly increased risk of having breast excreted with the milk. Limited long term follow-up data (up to 2.5 yrs) on July 2009 cancer diagnosed. The risk in users of progestogen only pills is possibly of children who were breast-fed do not indicate any differences compared to similar magnitude to COCs. This risk is low compared to the risk of getting those whose mother used a copper IUD. However development and growth Please refer to the full SmPC text before prescribing this breast cancer ever in life. The increased risk in COC users may be due to of the nursing infant should be carefully observed. Interactions: Interactions product. Adverse events should be reported. Reporting forms an earlier diagnosis, biological effects of the pill, or a combination of both. may lead to breakthrough bleeding and contraceptive failure. This may be and information can be found at www.imb.ie Adverse events Refer to a specialist if acute or chronic disturbances of liver function occur. seen with enzyme inducers such as hydantoins, barbiturates, primidone, with this product should also be reported to Schering-Plough Epidemiological studies have associated the use of COCs with an increased carbamazepine, rifampicin, oxcarbazepine, topiramate, rifabutin, felbamate, incidence of venous thromboembolism (VTE, deep venous thrombosis and ritonavir, nelfi navir, griseofulvin and products containing St John’s Wort. Drug Safety Department on +44 (0) 1707 363773. pulmonary embolism). It is unclear whether desogestrel used alone carries Reduced absorption of etonogestrel may be seen with medical charcoal. the same risk. Discontinue in the event of a thrombosis. Consider stopping Hormonal contraceptives may interfere with metabolism of other drugs, prior to long term immobilisation due to surgery or illness. Caution patients and therefore increase or decrease their plasma or tissue concentrations.

Date of preparation: August 2009 Schering-Plough employs 1700 people in Ireland involved in the manufacturing, distribution and sales of our products. CZT09/34b

H53253 CZT Nurse in GP 210x297.indd 1 27/8/09 16:07:12 abstracts Focus on: Gastroenterology Role of the primary care provider in the diagnosis and management of heartburn Patients with heartburn re able to recognise symptoms and self-treat; however, patients with more per- Kushner PR sistent and/or troublesome symptoms should be evaluated by a physician or other healthcare provider. Curr Med Res Opin This review from the Department of Family Medicine, University of California at Irvine, California, USA, 22 January 2010 focuses on the role of the primary care provider in the diagnosis and treatment of heartburn. A search was conducted on PubMed (to November 2009) and articles relevant to the management of heartburn by a primary care provider topic were selected. Diagnostic tools, such as endoscopy and ambulatory pH monitoring, were recommended for advanced assessment of patients with frequent heartburn to avert misdiagnosis and to identify complications of reflux disease. Over-the-counter and prescription treatments for frequent heartburn symptoms include antacids, histamine(2)-receptor antagonists (H[2]RAs), antacid/H(2)RA combinations, and proton pump inhibitors (PPIs). Among these, PPIs represented the mainstay of acute and maintenance treatment regimens in reflux disorders and were more effective than H(2)RAs for long-term use due to the development of tolerance to the latter therapy. While once-daily PPI therapy may be sufficient in most patients, a few may require twice-daily PPI therapy to alleviate their symptoms. This review was limited by its relatively narrow focus on articles cited in PubMed. The primary care provider is ideally situated to advise patients on the best treatment option for their condition and to provide follow-up care if required. Reflux and cough Reflux is a significant contributor to cough in otolaryngology practice; cough is just one marker of its Merati AL many negative effects on the upper aerodigestive tract. Reflux causes cough both by direct irritation/ Otolaryngol Clin inflammation and by increasing sensitivities to other noxious agents. North Am 2010 Feb; Detailed and diligent clinical evaluation, including laryngoscopy, is useful in advancing the working 43 (1): 97-110, ix diagnosis of reflux-associated cough, according to this study from the Department of Otolaryngology, University of Washington School of Medicine, St Louis, Missouri, USA. Supplemental testing, including impedance monitoring of oesophageal refluxate, can be important to evaluate for both acidic and non-acidic reflux exposure. The mainstay of treatment continues to be dietary and other lifestyle interventions and drug therapy. Although proton pump inhibitor therapy is effective in most patients, especially those with acid reflux disease, prokinetic therapy is probably very important with those with combined acid and non-acid disease and those with pure non-acid disease. It is likely that failure to improve can be due to behavioural and drug compliance issues. Anti-reflux surgery can yield long-lasting positive outcomes in carefully selected patients despite the lower efficacy of treatment for primary upper aerodigestive tract symptoms (cough, hoarseness, sore throat), compared with heartburn and regurgitation.

A preliminary report on the efficacy of the Multicare AR-Bed in three-week, three-month old infants on regurgitation, associated symptoms and acid reflux The aim of this preliminary study from the Universitair Ziekenhuis Brussel Kinderen, Brussels, Belgium, Vandenplas Y, was to evaluate the efficacy of a 40-degrees supine body position on infant regurgitation, reflux-asso- De Schepper J, ciated symptoms and acid reflux. Verheyden S et al Thirty of 52 consecutive infants presenting with frequent regurgitation and reflux-associated Arch Dis Child symptoms occurring mainly during feeding were evaluated in the Multicare AR-Bed. I-GERQ-R 2010 Jan; (Infant-Gastro-oesophageal Reflux Questionnaire-Revised) and an oesophageal pH monitoring were 95 (1): 26-30 performed at inclusion and after one week. Eight out of 30 (27 per cent) infants did not tolerate the 40-degrees positioning and had to be taken out of the study within the first two days. However, in 22/30 (73 per cent) of the infants, the I-GERQ-R and acid reflux decreased significantly with the Multicare AR-Bed. The mean duration of use of the Multicare AR-Bed was 3.2 months. The results of this pilot study suggest that a specially-made bed that nurses the infant at 40-degrees supine body position reduces regurgitation, acid reflux and reflux-associated symptoms. However, the intervention was open, the sample size small and the withdrawal rate was substantial. Larger trials are needed.

46 for a long-term contraceptive solution

A highly reliable, compliance-free, 3 year contraceptive option 1

No pills to remember or forget 68mg etonogestrel Well-accepted, discreet subdermal method 2,3 Forgettable freedom

References 1. Otero Flores JB et al. Int J Gynecol and Obstet 2005;90:228-33. 2. Implanon – Summary of Product Characteristics. 3. Long-acting reversible contraception: the e ective and appropriate use of long-acting reversible contraception, National Collaborating Centre for Women’s and Children’s Health October 2005.

Implanon® (See SPC before Prescribing) Etonogestrel. Presentation: Preloaded liver function. Hypertension. Diabetes. Chloasma. Physicians may need to consider earlier pain, ovarian cyst, painful menstruation, ¡ u-like illness, pain, fatigue, weight decrease, applicator with a non-biodegradable implant containing 68mg of etonogestrel. Uses: replacement of the implant in heavier women. Ectopic pregnancy should be ruled out insertion site pain or reaction and hot ¡ ushes. Other less common and rarely reported Contraception. Dosage and Administration: One implant should be inserted subdermally if a women presents with abdominal pain and amenorrhoea. History during pregnancy side e ects are listed in the SPC. Overdose: Remove previous implant before inserting a after pregnancy has been excluded. Each implant will last for up to 3 years. Implanon or previous use of sex steroids: jaundice and/or pruritis related to cholestasis, gallstone new one. There are no data on overdose with etonogestrel. Legal Category: Prescription should only be inserted or removed by physicians familiar with the insertion and removal formation, porphyria, SLE, HUS, Sydenham’s chorea, herpes gestationis, otosclerosis. Medicine. Product Authorisation Number: PA 61/28/1. Product Authorisation technique. Insertion, removal and replacement instructions must be strictly followed. Expulsion may occur if the implant is not inserted correctly or as a consequence of local Holder: Organon Ireland Limited, a part of Schering-Plough, P.O. Box 2857, Drynam Contraindications: Active venous thromboembolic disorder, known or suspected in¡ ammation. In rare cases the implant may migrate from the insertion site. Pregnancy Road, Swords, Co. Dublin, Ireland. Date of revision of prescribing information: April 2009 sex-steroid sensitive malignancies, presence/history of severe hepatic disease with and Lactation: Not indicated during pregnancy. Exclude pregnancy prior to insertion. Implanon IRE/4-09/3 current abnormal liver function tests, undiagnosed vaginal bleeding, hypersensitivity Implanon may be used during lactation, growth and development of the child should be to ingredients. Precautions and Warnings: Risk of having breast cancer diagnosed in carefully followed. Interactions: Possible interactions with phenytoin, phenobarbital, Please refer to the full SPC text before prescribing this product. users of progestogen-only preparations is possibly similar to the slightly increased risk primidone, carbamazepine, rifampicin, oxcarbazepine, topiramate, felbamate, ritonavir, Adverse events should be reported. Reporting forms and associated with combined OCs. This may be due to earlier diagnosis, the biological e ects nel£ navir, nevirapine, griseofulvin and St John’s Wort. Implanon may also interfere with the information can be found at www.yellowcard.gov.uk (UK) and of the OC, or a combination of both. Some epidemiology studies have associated combined metabolism of other drugs - consult their prescribing information for details. Undesirable www.imb.ie (Ireland). Adverse events with this product should OC use with an increased incidence of VTE, DVT and PE. It is unclear whether etonogestrel e ects: Very Common: Vaginal Infection, headache, acne, irregular bleeding, weight carries the same risk. Remove implant in the event of a thrombosis and prior to long-term increase, breast tenderness and pain. Common: Alopecia, dizziness, depressed mood, a ect also be reported to Schering-Plough Drug Safety Department on immobilisation. Caution patients with a history of thromboembolic disorders. Abnormal lability, nervousness, nausea, ¡ atulence, libido decreased, increased appetite, abdominal +44 (0)1707 363773

Date of preparation July 2009 Schering-Plough employs 1700 people in Ireland involved in the manufacturing, distribution and sales of our products. IMP09/07f

H52325 IMP Nurs in Gen Prac - 210x297.indd 1 14/7/09 14:47:35 poster series Maximising women’s health in general practice

omen’s health incorporates conditions, “that are either unique to women or affect women MaxiMising in a different way to men.” (McPherson and WoMan’s HealtH in Waller 2003) The Cavan/Monaghan branch general Practice poster presentation aims to identify how the WWomen’s Health Management in Primary Care course which was undertaken in the North East has impacted on clinical practice in a positive manner. Twenty practice nurses and two general practitioners participated in the course. Six of these were from the Cavan/ “Women’s Health Incorporates Conditions that are either unique Monaghan branch. to women or affect women in a different way to men” McPherson and Waller 2003

advise & support Menopause Health Promotion & education The learning outcomes included: Bereavement Principles of HRT Information Giving Domestic Violence Natural Therapies Cardiovascular Risk Assessment • A critical understanding of the common pathophysiology of Crisis Pregnancy Lifestyle Interventions Understanding of Anatomy & Physiology Symptom Management the female reproductive system Family Planning screening & Prevention Natural Methods osteoporosis Cervical Screening • The principles underpinning approaches to assessment Hormonal Methods Lifestyle Interventions Mammography Barrier Methods / Chemical Methods Medication Management Breast Self Examination Emergency Contraception Identify at Risk Groups Vaccination and management of the care of women’s sexual health, the Sterilization Promotion of Compliance continence Promotion menopause and the impact upon relationships. sexual Health lifestyle Modifications Symptom Management STI’s Screening Smoking Cessation Education The ability outcomes focused on the selection and formula- Use of Condoms (Safe Sex) Alcohol Consumption Referal Pathway to Appropriate Service Education Physical Activity tion of an appropriate prescription of care and management Referal to Appropriate Services Healthy Eating interdisciplinary team Stress Management CNS’s in Continence Promotion alternative therapies Smoking Cessation according to the individual women’s sexual health needs. It also Menopause accessibility of service PHN’s Premenstrual Syndrome Walk in Service GP enabled the course participants to demonstrate a critical and Stress Management Same Day Apts Hospital Consultants Preconception advice Recall Systems Mental Health Team reflective approach to the management and care of menopau- Physiotherapist scope of Practice code of Professional conduct continuing Professional Development sal and post menopausal women. An Bord Altranais, 2000 Medico-legal The need for a women’s health course was highlighted by equity Accountability evidence Based care many members of the branch. Once the cervical screening training programme had been completed many practice nurses were faced with ‘other issues’ when attending to these women. Issues such as incontinence, prolapse, depression, hot flushes, irisH Practice nurses association sexual health needs, to name but a few, were highlighted as cavan/MonagHan areas that we were not fully equipped to deal with. BrancH The advent of this course was met with great enthusiasm with regards to bridging the gap (in terms of extra knowledge Copy of original poster and skills that were required). There was equally a feeling of dread at the prospect of a written exam and two written assignments. The assignments included a reflective journal Outcomes for Practice Nurses on a specific women’s health issue and a summary of how • An increase in our knowledge base and confidence in women’s health needs were managed in each individual issues surrounding women’s health. practice. The primary focus of the assignments was to evaluate • It has enabled us to ask the women the appropriate our clinical practice. questions therefore ensuring a comprehensive assessment. How does it impact on the patient/client? • It has given us the ability to assess risk factors and has • Easy access to a women’s health service in their own armed us with more practical skills. An example of this locality. can be in relation to assessing pelvic floor muscles and to • Problems may be identified earlier therefore leading to explain appropriate exercises to the client. swifter referral to appropriate service. • The referral pathway can now be direct from the practice • Embarrassment barrier may be reduced as a result of nurse following appropriate protocol. avoiding male practitioner with no compromise in • It has aided in relation to continuing professional outcome for client. development. • Facilitates opportunistic screening. • It is cognisant of accountability, scope of practice and code • Provides a choice of practitioner. of professional conduct. • Patient safety ensured with adherence to scope of practice and infection control protocols. References • Provision of evidence based, accountable, up-to-date McPherson & Waller (2003) Women’s Health 5th Edition Oxford knowledge and care. University Press . ISBN 0192632868 (Pbk).

Abstract submitted by Claire Bourke, Margaret Geoghegan, Ruth Morrow and Margaret O’Reilly

poster series

Walking in to primary care

his study investigated the attendances and outcomes of a Walk-In Advanced Nurse Practitioner (ANP) – led service in general practice from the period of 1st February 2006 – 31st August 2006. There has been no research in the Republic of Ireland in relation to this new nurse led service initiative. This resource provides first ‘point of contact care’ for the patients of the Liberties Primary Care Team, caring for patients of all ages, from theT cradle to the grave. The practice provides medical care for an underprivileged population of a (GMS) current patient listing of approximately 2500. The Primary Care Strategy (Department of Health & Children 2001) advocates that the ease of access to services, the quality, responsiveness and timeliness of the treatment and care received by individuals within their own communities are fundamental indicators for how well their needs are being served. Lessons learned from walk-in primary care centres internationally point to a lack of continuity of care between such centres and general practices (Jones 2000). The ANP in Primary Care has the potential to provide continuity of care, immediate access (Perry et al. 2005) and direct referrals to other health professionals where necessary within a general practice setting.

Aim of the study To review the number of consultations, range of symptoms and presenting problems managed by the ANP at a daily morning walk-in clinic in general practice.

Methodology A retrospective analysis of all the consultations managed by the ANP at the walk-in clinic was studied. All consultations were assessed using computerized notes relative to presenting complaint and outcomes of each episode of care were monitored. The need for referral to a secondary care service was also documented. In order to inform the study findings, booked consultations and telephone consultations with the ANP were also recorded highlighting the impact of a walk-in clinic on management of a concurrent case load in general practice.

Findings The data to date highlights the variety of acute illnesses managed by the ANP in Primary Care. The demographics of the attendees were predominantly female and young children. Only two patients to date were referred to A/E. This study describes the workload of the ANP and demonstrates the range of clinical acumen required in order to set up and manage a walk-in service for this population group.

References Department of Health and Children. (2001) Primary Care: A New Direction. Government of Ireland Stationary Office. Myers PC, Lenci B, Sheldon M (1997) A Nurse Practitioner as the first point of contact for urgent medical problems in a General Practice setting. Family Practice 14,(6) 492-497 Jones M (2000) Walk-in primary medical care centres: lessons from Canada. British Medical Journal; 321:928-931 Perry C, Thurston M, Killey M, Miller J (2005) Nurse-led care. .The nurse practitioner in primary care: alleviating problems of access? British Journal of Nursing 14(5):255-9

This was an entry for the branch poster award 2006 Abstract submitted by Linda Latham, ANP in Primary Care.

50 product news

Onglyza (saxagliptin) 5mg tablets for type Cozatan ( Losartan Potassium ) 50mg & II diabetes launched 100mg film-coated tabs launched

Bristol-Myers Squibb and AstraZeneca recently announced Clonmel Healthcare is delighted to announce the launch of that Onglyza (saxagliptin) 5mg tablets have been launched in Cozatan (Losartan Potassium ) 50mg & 100 mg film-coated Ireland. Onglyza is indicated as a once-daily 5 mg oral tablet tabs. This product will join the other cardiovascular medicine dose in adult patients with type II diabetes mellitus to improve product listings within the Ethical Prescription Division of glycaemic control: Clonmel Healthcare. • in combination with metformin, when metformin alone, Cozatan is an Angiotensin-II Antagonist and indications are; with diet and exercise, does not provide adequate glycaemic • Essential hypertension control; • Renal disease in patients with hypertension and type 2 • in combination with a sulphonylurea, when sulphonylurea diabetes mellitus with proteinuria ≥0.5g/day as part of an alone, with diet and exercise, does not provide adequate antihypertensive treatment. glycaemic control in patients for whom use of metformin is • Chronic heart failure (in patients ≥ 60 years), when treatment considered inappropriate; or with ACE inhibitors is not considered suitable due to • in combination with a thiazolidinedione, when the incompatibility, especially cough, or contraindication. thiazolidinedione alone, with diet and exercise, does not • Reduction in the risk of stroke in hypertensive patients with provide adequate glycaemic control in patients for whom left ventricular hypertrophy documented by ECG. use of a thiazolidinedione is considered appropriate. Cozatan 50 mg & 100 mg film-coated tabs are 48% cheaper Marketing authorisation is based on data submitted from a than the brand originator. comprehensive clinical development programme that included Cozatan is available on the GMS from 1st March 2010. GMS six core Phase III registrational trials. The registrational trials codes are; Cozatan 50mg – 65035 & Cozatan 100mg 65036. assessed the safety and efficacy of Onglyza and involved 4,148 Full prescribing information is available on request or go to patients with type II diabetes, including 3,021 patients treated www.clonmel-health.ie . Product is subject to prescription. with Onglyza. Please Onglyza is the first medicine to be launched in Ireland contact Clonmel through the worldwide collaboration of Bristol-Myers Squibb Healthcare on and AstraZeneca to enable the companies to research, develop 01-6204000 and commercialise select investigational medicines for the if you require treatment of type II diabetes. any additional Onglyza belongs to the class of dipeptidyl peptidase-4 information on (DPP-4) inhibitors. These are designed to enhance the body's Cozatan (Losartan ability to decrease blood sugar (glucose) when it is elevated Potassium) 50mg & by acting on the incretin hormones, thereby increasing insulin 100mg film-coated production, and by reducing the liver's production of glucose. tabs.

Onbrez, the first once daily dronchodilator to demonstrate 24 hour symptom control in COPD

Novartis has launched Onbrez (Indacaterol) as a new once-daily improved lung function1 and provided clinically relevant maintenance bronchodilator in adult patients with chronic improvement in symptoms of breathlessness compared to obstructive pulmonary disease (COPD). This follows European tiotropium8. Recent data presented at the American College approval which was received in December (2009). of Chest Physicians (ACCP) Chest Conference showed once- Onbrez, containing the active ingredient indacaterol daily Onbrez also achieved significant improvements in lung maleate, is the first new inhaled compound for the treatment function compared to twice-daily salmeterol. In addition, of COPD to be made available for EU patients in seven years. Onbrez provided better health status* and improved Additionally, it is the first and only treatment to demonstrate in breathlessness compared with salmeterol3. clinical studies both 24-hour bronchodilation and a rapid onset Onbrez has shown good overall safety and tolerability, which of action within five minutes of inhalation. is comparable to placebo and current treatments. The most "The trial results for Onbrez show greater improvements in common adverse drug reactions were nasopharyngitis, cough, lung function, breathlessness and quality of life together with upper respiratory tract infection, and headache. These were in a reduction in COPD exacerbations," said Dr Tim McDonnell, the vast majority mild or moderate and became less frequent Consultant Respiratory Physician, St. Vincent’s Hospital. "This as treatment was continued. Onbrez is available in 150mcg provides a valuable new treatment option for Irish doctors and 300mcg strengths and represents a significant cost saving and their patients enabling better symptom control which will compared to the standard treatment for COPD in Ireland. greatly help people with COPD maintain active and productive “Given the considerable health burden arising from COPD, the lives despite the condition." Irish Thoracic Society (ITS) welcomes any new therapies which The EC based its approval of Onbrez on an extensive clinical help to alleviate brethlessness and improve quality of life in trial programme with data from over 6,000 patients. This data patients with this disease” Dr Terry O’Connor, President, Irish included pivotal Phase III results showing Onbrez significantly Thoracic Society. www.yourmedicines.ie

51 product news

Salbuvent (Salbutamol) 2.5mg/2.5ml, New study shows alli significantly 5mg/2.5ml Nebuliser Solution reduces visceral fat

Breathe Pharmaceuticals are delighted to announce the launch A new study presented at the International Congress of an additional nebuliser solution in the family of respiratory on Abdominal Obesity that used state-of-the-art MRI drugs for delivery by a nebuliser from Breathe Pharmaceuticals technology reveals that taking alli (orlistat 60 mg) in Ireland; Salbuvent (Salbutamol 2.5mg/2.5ml, 5mg/2.5ml while following a reduced calorie, lower-fat diet can nebuliser solution). Salbuvent is indicated for use in the routine lead to a significant reduction not only in weight but management of chronic bronchospasm unresponsive to also in dangerous visceral fat. conventional therapy and the treatment of acute severe asthma. The research, carried out over three months at Salbuvent completes the range of respiratory drugs Europe’s largest imaging centre, illustrates the for delivery by a nebuliser now available from Breathe changes taking place inside someone’s body as they Pharmaceuticals in Ireland, joining Ipravent, Combineb and take alli. It reveals that overweight adults (BMI over Budesitan. All nebuliser suspensions and solutions by Breathe 28 kg/m2) using alli in conjunction with a reduced Pharmaceuticals can also be administered using the same calorie, lower-fat diet not only lost 5 per cent of their nebuliser as the originator brands. body weight, but importantly, 10 per cent of this Breathe Pharmaceuticals is a joint venture between Breath dangerous visceral fat versus baseline. Results also Ltd, specialists in the anti-asthmatic field who sell their nebule showed that at week 12 alli significantly reduced products around the world, including the UK, Europe and the waist circumference, the best practical marker for USA and Clonmel Healthcare Ltd, who have been providing high visceral fat. quality, affordable medicines in Ireland since 1970. Together as Commenting on the new study, Community Breathe Pharmaceuticals, we will build on the vast experience Pharmacist and Honorary Senior Lecturer at Queen’s of both companies to provide the best levels of service and care University in Belfast, Dr Terry Maguire said; “The possible in this specialist field. results of this study are significant, particularly as we Salbuvent is available on the GMS from 1st March 2010 – codes have an ever increasing problem with overweight 44905 and 44906. Full prescribing information is available on and obesity in Ireland. We know that a loss of 5% request or go to www.clonmel-health.ie. Product subject to of body weight is an important and a considerable prescription. achievement for anyone that is overweight or If you require obese, more importantly the health benefits of this any additional weight loss are considerable, particularly as this information on any weight loss leads to a reduction in visceral fat and a nebule from Breathe reduction in the risk of chronic diseases such as type Pharmaceuticals please II diabetes and heart disease, both of which account contact Clonmel for considerable illness and death each year. Not Healthcare on all fat is the same and visceral fat, which is found 01 620-4000. around in the abdomen, is more dangerous and a strong predictor of premature death. Just a little extra visceral fat increases the risk of serious disease, but modest weight loss decreases it considerably. Although it is a hidden fat, waist circumference is a good indictor of visceral fat hence people who are ‘apple shaped’ as opposed to ‘pear shaped’ may be at greater risk.” Fucidin H Ointment 15g & 30g These latest findings, when considered with discontinued – March 2010 existing data, suggest that alli plus diet not only helps people lose 50 per cent more weight than Leo Pharma will be discontinuing Fucidin H Ointment 15g and 30g dieting alone, but also improves health. Dr Rexford from the Irish market in March 2010. This discontinuation is not Newbould, GSK study investigator and scientist at the due to any safety or quality issue therefore allowing pharmacists Clinical Imaging Centre in Hammersmith Hospital, UK and patients to continue to dispense or use the Fucidin H said: “While it’s well-known that overall weight loss of Ointment that they currently have. 5-10 per cent is beneficial, what is not so well-known Please note that Fucidin H Cream 15g and 30g will continue to is that the health benefits occur because visceral fat, be available. the fat stored deep within the abdomen, is lost. This If you require any further information, contact the LEO Pharma new research shows that when people lose weight Sales and Marketing department at (01) 490 8924 or email the LEO using orlistat 60 mg in conjunction with diet, they Pharma Medical department at: [email protected] lose visceral fat.” www.yourmedicines.ie

52 crossword

Across 1 2 3 4 5 6 1. If a bull loses its tail and goes crazy, a leg bone emerges (6) 7 4. be up against an overturned tuba! (4) 8. Fly-by-night of low origin (3)

8 9 9. Illness of stormy seaside (7) 10. Mona is confused about Middle East state (4) 11. and 22 across. Pop venue by the Boyne (5,6) 14. Group of cattle, it is said, are audible (5) 16. Gradual injection from a leaky tap? (4) 18. See 2 down 10 11 12 20. It’s for hearing - and in hearing! (3) 21. Departed, like Christy Brown’s biographical

13 foot! (4) 22. See 11 across

14 15 16 Down 1. Amphibian - Kermit perhaps (4) 2. and 18 across. Weight control illness distorts 17 verminous labia (7,7) 3. Loaded a sick eland? (5)

18 19 20 5. Underwear from a dingy bar! (3) 6. T.P.? Sound as a wigwam! (6) 7. Is twice a goddess! (4) 12. It nourishes a deformed ailment (7) 13. It’s no help exploding carbolic acid (6) 15. Computer game reverses mood (4) 21 22 16. Theatre production in Drumcondra Manor (5) 17. Lough for a sea eagle! (4) 19. Umpire, in short (3)

Answers to last month’s crossword Caltrate is a trademark. PA 172/38/1. Across: 6. cocaine 7. rebut 9. Oslo 10. eye tooth 11. singer 13. Full prescribing information available from hell 15. yale 16. ice age 18. cicatrix 21. apes 22. camel 23. satanic Wyeth Consumer Healthcare, Plaza 254, Ballycoolin, Dublin 15 Down: 1. morse 2. caroline 3. knee 4. nero 5. pustule 8. hearse or from www.medicines.ie 12. goitre 13. hogmanay 14. Vatican 17. tepid 19. amen 20. x-ray

Congratulations to the winner of last month’s crossword, Name: Josephine Heward, Health Centre, Lifford, Co Donegal. Please send your answers to the Editor, Address: Nursing in General Practice, GreenCross Publishing, Lower Ground Floor, 5 Harrington Street, Dublin 8. Closing date for entries: 3rd May 2010. Winner will receive v50. Please note: the winners’ cheques will be sent out Email: within 45 days.

53 Breakthrough for very dry to atopic-prone skin NEW LIPIKAR BaLm aP With La Roche-Posay Thermal Spa Water

1st Lipid replenishing care 24hr anti-scratch efficacy, Quick-dress texture.

Proven clinical efficacy*: 57% Reduction of pruritus** 72% Reduction of loss of sleep

Use Test: 85% Observe moisturising effect all day long 82% Observe a reduction in the desire to scratch 94% Observe product spreads easily 76% Observe it is easy to use

* Protocol: multicentre clinical study, conducted in Canada on 73 patients aged from 3 to 12 years old suffering from light to moderate atopic dermatitis

** Itching

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