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ISSN 1756-5979
(Issue 04)
May - June 2008
£2.00/€3.00
DAY-TIME WETTING
Alcohol consumption
and its consequences
for health: what can
nurses do to help?
RECRUITING NOW!
News
International and local news
What’s On
Find out what’s on in and around your area
18
Incontinence
Day-time Wetting
22
Mental Health
Alcohol consumption and its consequences
for health: what can nurses do to help?
26
Clinical Skills
28
Multiple Sclerosis
Evidence for the main management and
treatment strategies for spasticity in
multiple sclerosis.
31
Anne Diamond
Nutrition and Obesity
34
Recruitment - Canada
An insight into living and working in Alberta
38
Recruitment - Australia
39
Recruitment - New Zealand
42
Recruitment - Middle East
44
Recruitment - General
CONTENTS
4
16
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3
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News
RELIEF EFFORT IN MYANMAR INADEQUATE:
MSF emergency
teams in the
Delta call for
immediate and
unobstructed
escalation of
aid operations
14 days after Cyclone Nargis hit
Myanmar, international medical
humanitarian agency, Medecins Sans
Frontières/Doctors Without Border
(MSF), is urgently calling for an i
mmediate scale up of the overall relief
operation, which until now has been
deployed far too slowly and is
insufficient.
MSF teams are directly delivering
medical assistance and relief supplies
to tens of thousands of people.
However, the needs remain immense
in the Irawaddy Delta.
“Although MSF is able to provide a
certain level of direct assistance,
the overall relief effort is clearly
inadequate. Thousands of people
affected by the cyclone are in a critical
state and are in urgent need of relief.
The aid effort is hampered by the
government-imposed restriction on
international staff working in the
Delta region.
For example, despite the fact that
some MSF water-and-sanitation
4
specialists have been granted visas
to enter Myanmar, they have not been
permitted to travel into the disaster
area, where their expertise is
desperately needed because of the
contaminated water sources. An
effective emergency operation of
this magnitude requires coordinators
and technical staff experienced in
large-scale emergency response to
save lives,” explains Bruno Jochum,
MSF Director of Operations.
bringing relief directly to the
populations.
Hundreds of thousands of people
have lost their homes, and many are
gathered in makeshift camps. They are
in urgent need of clean drinking water,
food and other basic necessities.
Elsewhere, survivors are living among
the remains of their homes, surrounded
by floodwater and dead bodies.
MSF calls on the Government of
Myanmar to allow for an immediate
scale-up of the relief effort and to
ensure the free and unhindered access
of international humanitarian staff to the
cyclone-affected areas.
MSF teams are now working in more
than 20 different locations in Myanmar
and are managing to push further into
the outlying areas. MSF had medical
projects in Myanmar before cyclone
Nargis hit, which enabled its teams
to respond immediately in the Delta,
These MSF teams are treating several
hundred patients each day. In addition
to wounds, the main health problems
are respiratory infections, fever and
diarrhoea. Since the beginning of its
emergency operation, MSF teams have
distributed more than 275 tons of food
and flown in cargo planes with 140
tons of relief materials to Myanmar.
One in four older people in the UK have
become so worried about the future
that they are making themselves ill),
according to the third annual ‘Spotlight’
report produced by leading older
people’s charity Help the Aged. The
number of older people concerned
about their future to the extent that their
physical health has been affected has
risen by the equivalent of nearly a
million in the last year.
‘Spotlight 2008’ draws attention to the
issues faced by vulnerable older people
living in the UK today: ageism; neglect;
poverty; isolation and future deprivation.
With limited progress on many of the
issues in the past year, the Charity is
urging the Government to remedy the
long term neglect of older people.
Help the Aged is challenging Gordon
Brown’s Government to ease their
worries by ensuring they have equal
rights and are free from discrimination,
wherever it confronts them, from
hospitals to the high street.
Paul Cann, Director of Policy & External
Relations at Help the Aged, comments:
“This year’s ‘Spotlight’ report shines a
light on some of the worsening facts of
life for today’s pensioners. It’s appalling
that we live in a society where older
people feel sick with worry about the
future. The Government must ease
their concerns by banning the ageism
that continually sinks its poison right
into the heart of our society.”
Other key facts which show the reality
of growing older in the UK include:• Grinding poverty grinds on
In the past twelve months an estimated
200,000 extra pensioner households
have been plunged into fuel poverty.
The same number of older people are
living in poverty in 2008 as in the
previous year, with 21 per cent of
pensioners surviving below the poverty
line. 15 per cent of pensioners are
living in persistent poverty.
• Ageism rife
29 per cent of older respondents to
Help the Aged research – equivalent to
2.8 million people – agreed that health
professionals tend to treat older people
as a nuisance. The Charity’s ‘Just
Equal Treatment’ campaign has
highlighted the rampant age
discrimination faced by older people,
and called for a complete ban on age
discrimination and a new duty on public
bodies to promote age equality, as part
of the Equality Bill announced in last
week’s Draft Legislative Programme.
• Dignity shock
“That said, the Government has an
enormous job to do to improve the lives
of older people. As society ages, the
demands of older people will rightly get
louder and louder. The Government
must respond or run the risk of
alienating millions of voters as we
approach the next general election.”
As part of the launch of the 2008
‘Spotlight’ report, Help the Aged has
issued a series of key policy demands
from the Government. These are:• Include a complete ban on age
discrimination in the upcoming
Equality Bill;
The proportion of older people in
England who say they are not always
treated with dignity in hospital has
worsened from 21 per cent to 22 per
cent. Provision of low level social care
dropped dramatically with 11 per cent
fewer households - the equivalent of
well over a million people – receiving
care in England than in the previous
year.
• Outlaw mandatory retirement ages in
employment;
• Access denied
• A commitment to a new settlement for
funding a transparent, universal
method of delivering social care for
our ageing population.
One in ten people aged 75 or over
find it very difficult to get to their
local corner shop – a jump of three
percentage points in just a year. In
2008, an estimated 290,634 older
people in the UK do not get the help
they need to get out of their own
home, up by over 80,000 from 2007.
According to ‘Spotlight’, around one
million older people in the UK are
lonely – this is an improvement of just
three percentage points on 2007.
• The establishment of a targeted
strategy to reduce pensioner poverty;
• Introduction of a system of automatic
payments of benefits for older people;
• A set of clear plans for the
eradication of fuel poverty in
vulnerable households by 2010;
Paul Cannconcludes: “While the
report paints a rather dismal picture
of growing older in the UK, there have
been some steps forward. More people
aged 60 and over in Great Britain
are taking up their entitlement to
concessionary fares and the digital
divide seems to be narrowing with
people aged 65 and over now more
likely to have used the internet.
5
News
Older people sick at the
thought of their future,
according to landmark report
News
Mater Misericordiae University
Hospital and Mater Private Hospital
Win Irish Healthcare Innovation Award
for unique Public Private Partnership
Mater PET/CT Centre provides equal access
for public and private patients to innovative
cancer diagnostic facility
MaterMisericordiae University Hospital
and Mater Private Hospital were the
joint recipients of the “Public Private
Partnership in Innovation Award” at
the Irish Healthcare Innovation Awards
which were presented at a ceremony
in the Crowne Plaza Hotel, Santry,
recently. The award was in recognition
of the Mater PET/CT Centre, based in
Mater Misericordiae University
Hospital, which provides equal
access for public and private patients
to an innovative diagnostic facility.
The centre, located in the heart of
the Mater Misericordiae University
Hospital, is jointly owned by both
hospitals and managed by a distinct
board with representatives from both
organisations.
Speaking about the PET/CT Centre,
Brian Conlan, CEO Mater
Misericordiae University Hospital said
“We are delighted to have received
this award. As a result of our unique
partnership, patients with cancer,
neurological conditions and other
illnesses have access to diagnostic
testing which can change the course
of their treatment. 3,500 scans have
been carried out since the centre
opened in October 2005, with
approximately 40% being referred
from other Irish hospitals. Without this
unique collaboration many patients
would not have access to a PET/CT
at the same site as all of their other
investigations.”
Fergus Clancy, CEO, Mater Private
Hospital, said “Not only have we
achieved the development of a unique
diagnostic facility by combining the
technology and expertise from both
organisations. This collaboration
proves that public and private
hospitals can work very successfully
together for the benefit of all patients.
The innovative approach to the
development of this centre has also
been applied to the skill set of team
of medical experts involved and the
design of the facility. It offers:
• the only PET/CT fellow in Ireland,
Dr. Martin O’Connell
• a research team that has already
participated in a number of
significant oncology and
neurology projects
• the only quantitative brain PET
imaging and MRI fusion in Ireland
• faculty training for MMUH radiology
registrars
• international training for visiting
fellows from Greece, South Africa,
Oman
• design principals which ensure
minimal exposure to radiation for
staff
• an international reference site for
exceptional PET/CT facility design
Fergus Clancy, CEO, Mater Private
Hospital, and Brian Conlan, CEO,
Mater Misericordiae University
Hospital, are pictured here in the
PET/CT Centre located in Mater
Misericordiae University Hospital.
NHS Lothian pioneers
new procedure
A MEDICAL team in NHS Lothian has become
the first in Scotland to carry out a pioneering
new method of female sterilisation.
The team has carried out the first
hysteroscopic sterilisations in Scotland,
allowing patients to undergo a non-surgical
sterilisation.
The procedure, which uses the Essure
method of permanent birth control, involves
inserting micro-insert coils into the fallopian
tubes, creating a blockage which prevents
sperm from reaching an egg.
Four patients at the Royal Infirmary of
Edinburgh's Reproductive Health Outpatient
Department became the first in Scotland to
undergo the procedure on recently, as part of
a pilot project.
The department has now carried out over 20
procedures, and the project is to be evaluated
to assess its success.
Until now, sterilisation has been performed
laparoscopically through abdominal incision,
under a general anaesthetic. The procedure
usually leaves patients with two small abdominal wounds and recovering for up to a week.
Hysteroscopic Sterilisation by Essure is a
method of permanent birth control, which
does not require incision or general
anaesthetic.
The process is carried out by placing a
small tube with a camera on the end (a
hysteroscope) through the vagina and cervix
into the uterus, and inserting tiny coils into
the fallopian tubes.
During the next three months, tissue grows in
and around the micro-insert coils, thereby
blocking the fallopian tubes, and preventing
sperm from reaching an egg.
Dr Sue Milne, Associate Specialist in
Reproductive Medicine at the Royal Infirmary
of Edinburgh, said:
"Hysteroscopic sterilisation can be carried out
without patients being admitted to hospital,
and is completed within around 30 minutes.
"The new procedure means there is no longer
the need for an overnight stay in hospital and
recovery is more rapid."
Audrey Burnside, Clinical Nurse Manager,
Lothian Gynaecological Services, added:
"This procedure is a landmark achievement in
female sterilisation as it allows women to
undergo sterilisation with minimum pain and
disruption to their lives.
"We are delighted to become the first centre in
Scotland to offer the procedure, and we hope
to be able to offer it on a more permanent
basis within the next year."
6
British Cardiac Nursing
Awards 2008
Charles Bloe was short listed from
hundreds of nominations for the British
Cardiac Nursing Awards 2008. Charles
work in developing interactive online ECG
training programmes was one of three
short listed for the Innovation in Education
or Research Award and won First Prize at
the awards ceremony at Cafe Royal in
Londons Picadilly.
News
Charles is Clinical Editor of Skills for
Nurses and CEO of Charles Bloe Training
Ltd.
Charlies said:
"it is a tremendous honour to have won
this coveted award and is recognition for
the hard work that me and my team have
put in to online clinical education for
Nurses"
RCM inaugurates midwife with 30 years
NHS experience as new president
Liz Stephens, a passionate advocate
and activist for midwives, mothers and
babies, is the new president of the
Royal College of Midwives. Ms.
Stephens, a consultant/ caseload
midwife, has more than 30 years
experience in the NHS. Throughout her
career, Ms. Stephens has continued
in clinical practice and is an active
midwifery practioner.
She was inaugurated as the RCM
President at the RCM’s Annual General
Meeting in London recently, replacing
the out-going President Maggie (née
Elliott) O’Brien. She takes up the reins
of office as the profession faces staff
shortages, low morale and a lack
of jobs for student midwives. An
outspoken advocate for midwives,
she has worked in different clinical
settings – hospital birth centres and the
community and independent midwifery
sectors - as well as being employed in
midwifery teaching and management.
She was one of the first consultant
midwives in her former NHS trust at
St. Georges and has been an RCM
Council member for nine years.
Ms. Stephens said: “I am a strong
advocate for midwives and midwifery,
as well as women, mothers and babies.
As the new president, I will lobby for a
more woman-centred and midwife-led
approach to midwifery. I love my career
in midwifery and am passionate about
midwifery and its future. I am taking up
this role in a climate that is very difficult
for midwives. Midwives are struggling
to support women in the way they want
to leaving them frustrated and morale
across the profession at a very low
ebb.”
Commenting on the main issues facing
midwives and the college, she said:
“Our members’ workload is increasing
and their roles are becoming more
multi-faceted, yet midwives are torn
between the need to do their best
for women while juggling financial
restrictions and increased
administrative duties. Our members
are facing a tipping point: we need
more midwives; we have cut backs
in student places; and high student
attrition rates. Meanwhile, many
midwives are leaving the profession
because they cannot give the best
quality of care to women and babies.”
Speaking of Ms. Stephens
appointment, the RCM’s General
Secretary Dame Karlene Davis said:
“Liz has worked tirelessly and selflessly
as an RCM council member for nine
years. She holds passionate views
about the future of midwifery and is a
natural leader and advocate for our
members.”
Kate Acton, lead midwife at the
Mayday Birth Centre in Croydon, who
was mentored by Ms. Stephens as a
student, said: “She brings a passion
and commitment to everything she
does. She is not afraid of saying what
needs to be said. She is the most
woman-centred midwife I have met.
She has been in the profession a
long-time but she is still a hands-on
midwife and is a practising clinical
midwife, and will bring a really up-tothe minute perspective to the role.”
Addressing her goals for her tenure,
Ms. Stephens said: “I will use my
knowledge, skills and experience to
ensure that midwives and midwifery
are promoted locally, nationally and
internationally. With great power, comes
great responsibility and I believe I
have a tremendous responsibility to
the college’s 37,000 members. I am
known for speaking out on behalf of
midwives and I will continue to do so
from Whitehall to Stormont to Holy
Rood and the Senydd.”
7
RTX Healthcare Launch
Wireless Telehealth Monitor
With Built-in GSM/GPRS
Mobile Phone Technology
News
Remote Monitoring of Elderly People Suffering From
CHF, COPD, Diabetes and Other Chronic Diseases
now Becomes Easier and More Effective With a New
Interactive Telehealth Monitor Based on GSM/GPRS
Mobile Phone Technology.
RTX Healthcare today announced a new member to
the family of interactive telehealth monitors, which
allows healthcare system integrators and disease
management companies to effectively monitor patients
at home. The RTX3371 GSM/GPRS Telehealth Monitor
collects vital signs wirelessly from external devices
and subjective patient information from patient
questionnaires and transmits the data directly to the
system integrator or disease management company's
own clinical information system. The collected vital
signs include weight, blood pressure, blood glucose,
peak flow, SpO2, ECG, blood coagulation and others.
All external devices are products from major third
party medical device manufacturers.
Bjarne Flou, CEO of RTX Healthcare says: "Expanding
our product portfolio to include a GSM/GPRS mobile
phone technology enabled Telehealth Monitor is a
natural next step in the progression of our vision
to become the preferred supplier of telehealth
equipment. Our Telehealth Monitors are extremely
simple and intuitive to use for elderly patients.
Furthermore, the flexibility of the device and our
business model, where RTX Healthcare sell the
RTX3371 Telehealth Monitor for a one-off fee without
a proprietary backend, makes our monitors an easy
and preferred choice for telehealth providers". Bjarne
Flou continues: "The RTX3371 GSM/GPRS Telehealth
Monitor is the second member of a family of telehealth
monitors, which also include the RTX3370 monitor with
built-in PSTN landline phone modem".
Hand drying: the
solution for all
reasons
Washroom operators have one
major consideration: to save on
ever-rising costs.
However, depending on where
that washroom is located, other
considerations might also apply:
to reduce cross contamination,
and to improve washroom
cleanliness by reducing the mess
caused by masses of paper
spilling over from used towel
waste bins.
Bay West Wave'n Dry and
Hands-Free hand towel
dispensers are the solution for
all reasons.
Unlike ordinary paper towel
dispensers where users take out
thick wads of paper at a time
(most of it thrown away) both
Bay West units deliver a
pre-measured amount of paper
with every dispensing, so paper
costs are not only reduced, but
wastage in the bin is also
minimised. This satisfies the desire
to reduce costs and limit waste.
In a healthcare environment, or
where the ready transfer of bugs
can easily infect a buildings
population with hugely disruptive
consequences, such as in schools
and colleges, the no-touch or
hands-free attributes of these
Bay West dispensers reaps
dividends all round.
Because the user does not have
to pull a lever or press a button
8
with wet hands in order to
dispense towels the chances
of cross contamination in the
washroom are considerably
reduced.
The Wave’n Dry dispenser
contains an electronic sensor
so that when the user passes
their hands in front of the unit a
measure of paper towel is issued.
If needed, another pass in front of
the sensor will issue another towel
but most users have by this time
dried their hands and moved on.
Observations show that indeed,
most users dry their hands whilst
on the move towards the door.
The Hands-Free dispenser
operates by the towel itself being
pulled – much like a traditional
linen towel unit, but without the
damp, bacteria laden cloth
remaining exposed to the
washroom atmosphere.
The result in both cases is that
user time in front of the dispenser
is cut down (compared to linen
towels or warm air dryers) due to
less lingering, but importantly, with
far fewer used paper towels being
thrown into the bin.
Wave’n Dry and Hands-Free
dispensers are part of the new
range of stylish and colourful
washroom dispensers from Bay
West. Ask for a catalogue.
Tel: +44 (0)1484 854460
www.disposablesukgroup.co.uk
Poll Reveals That Eight Out of Ten
Undergraduates Would be Proud to
Work in the NHS
Eight out of ten undergraduates would
be proud to work in the NHS, a NHS
Careers survey revealed today.
Although 78% still said the NHS would
not be their first choice employer and
54% would not even consider a career
in the NHS.
To view the Multimedia News Release,
please click:
http://www.prnewswire.com/mnr/nhsem
ployers/33027/
The poll was released as NHS Careers
celebrated the launch of a new website
- http://www.whatcanidowithmydegree.nhs.uk - for undergraduates and
recent graduates by giving away a
unique piece of graffiti painted by
internationally-acclaimed gallery,
Rare Kind.
The survey of 999 students (22%
were on clinical or healthcare related
courses) at fourteen English
universities also revealed that 81%
agreed the NHS would offer them good
training and career progression and
nearly two in five said it does not offer
careers to suit every graduate.
The website guides students and
graduates, based on their degree,
through the myriad of careers available
to them. The website shatters students'
misconceptions of the health service,
such as low pay and the unavailability
of careers for all graduates, while
giving an honest appraisal of working
in the NHS.
Other results from the survey include:
- 84% of students said that a career in
the NHS would challenge them
positively.
- 83% agreed the NHS would offer
them good training and career
progression.
- 82% said the NHS would allow them
to have a life outside of work.
- 1 in 3 students believes working
conditions are better in the NHS
compared to other employers.
- 59% believe the NHS pays poorly
compared to other employers.
Alan Simmons, a careers consultant for
NHS Careers, said: "It is clear
the NHS has a lot to do to get the
message to undergraduates that to
have a future career in the NHS, it
doesn't matter what degree you are
studying. With 350 different careers on
offer, there is a career for every graduate, whatever their degree.
"The launch of this website http://www.whatcanidowithmydegree.nh
s.uk - will be an important tool in this
battle. It doesn't pretend that working
for the NHS is all highs. But even when
the going gets tough, NHS staff know
they are doing a job that makes a real
difference to people's lives. In respect
of pay, a starting salary for graduates
can be just as good as the private
sector and in some cases it can be
better."
At the launch event at the University of
Brighton, the second character-driven
piece used photos of four real-life NHS
staff featured on http://www.whatcanidowithmydegree.nhs.uk. It has been
split and donated to four hospitals
across England.
EVERYBODY
DESERVES
A DIGNIFIED
DEATH
News
Launch of NHS Careers Website
www.whatcanidowithmydegree.nhs.uk
Celebrated With Opportunity to Win
Unique Graffiti
Help the Aged has today
responded to news of a new
£1 million programme funded by
the Department of Health, aimed at
transforming physical environment
in which the NHS cares for
thousands of dying patients
and led by the King's Fund .
Director of Policy, Paul Cann, said:
"Death is an unavoidable issue –
but what is avoidable is the
undignified and impersonal way
in which many older people die in
this country.
"Across society, there is a long way
yet to travel before people have a
clear understanding of what care
they are entitled to at the end of
their lives.
"This latest phase of the King's
Fund's Enhancing the Healing
Environment programme is a
welcome practical contribution
towards ensuring older people
will be able to die in comfort and
dignity with the very best care
available, wherever they die.
"Bringing the reality of death in
front of us and making mortuaries
part and parcel of hospital life is
part of challenging the taboo
around dying.
"As the Government plans its new
end-of-life strategy, Help the Aged
hopes that even greater attention
will be devoted to ensuring that the
final period of life is not marred by
poor support and a lack of dignity."
The artwork can be won at
http://www.whatcanidowithmydegree/pr
izedraw.
9
WWW.TRY-IT.IE – IRELAND’S
FIRST EVER ASSISTIVE
TECHNOLOGY
LIBRARY LAUNCHED
News
- 20,000 AT USERS TO BENEFIT FROM LOAN LIBRARY
www.try-it.ie, Ireland’s first every
Electronic Assistive Technology (EAT)
web based library bank was launched
today by a consortium of groups who
work with people with disabilities.
Assistive technology enables people
with disabilities to have greater control
over their lives. There are major
deficiencies in access, assessment
and provision of assistive technology
and this initiative allows centralised
access to people with disabilities and
their carers to the greatest array of
EAT available.
A consortium comprising the National
Rehabilitation Hospital, Enable Ireland
National Assistive Technology Training
Service, the NCBI, the Assistive
Communications Technology Officers
Network and the Irish Motor Neurone
Disease Association, who together
represent in excess of 20,000 service
users, has been awarded funding
byPOBAL (Enhancing Disability
Services scheme for social
inclusion)to establish and run the
web-based library of electronic
assistive technology (EAT) and to
provide a forum for education, training
and networking in this area.
The launch has been arranged in
conjunction with the Communication
Matters Roadshow who will hold a
range of workshops in communication
technology solutions in Croke Park on
the day.
Research shows that 75% of assistive
technology is abandoned due to the
lack of training and the portal aims to
address this issue by working with
training providers, carers and users
alike to, not only provide access to AT,
but access to education, training and
networking to maximise the benefits of
AT to users. As the website goes
live - members will be able to borrow
electronic aids, to allow themselves
and their users assess and try out a
range of assistive technology before
recommending purchase.
10
AT user, Michael Gogarty, who is
visually impaired, knows better than
most the impact that the right AT can
have. ‘‘I was born with a progressive
condition when there was no such
thing as AT. I now use among other
devices magnification software and
closed circuit televisions which enable
me to lead an independent life along
with other techniques and adaptions I
have learned.’’
background, knowledge and users
promises to enhance an exciting
collaboration where the needs of a
wide variety of individuals with
disabilities are recognized and
addressed.”
Henry Murdoch, Chairperson of the
NRH said, “I’m delighted to launch
try-it.ie, Ireland’s first centralised
Electronic Assistive Technology
library. I’m particularly pleased at
a consortium approach, which
recognises theneed for organisations
representing diverse and disparate
sectors of the disability community,
to work in a cohesive and integrated
manner to optimise the service
received by their clients. EAT is a
rapidly developing area and holds
huge for empowering, providing
independence, and increasing quality
of life for people with disabilities.”
An assistive technology (AT) device is
defined as ‘… any item, piece of
equipment, or product system, whether
acquired commercially off the shelf,
modified, or customized, that is used
to increase, maintain, or improve
functional capabilities of individuals
with disabilities.’ For individuals with
disabilities, AT is a necessity providing
independence, facilitating social
inclusion, and enabling participation in
opportunities that are taken for granted
by individuals who do not have
disabilities.
Glenna Gallagher, representing the
consortium said, “Research carried
out amongst users, carers and trainers
shows that there is an overwhelming
need for a service like try-it.ie.
Professionals who work with people
with disabilities throughout Ireland will
be able to borrow and trial new EAT
devices, receive feedback from other
users and AT assessors leading them
to make informed decisions about
what best suits their particular
circumstances prior to making
significant financial or time
commitments. They will also be
able to avail of assessments by
potentially more informed and highly
trained professionals as a result of
the education, training and support
dimension.
“This is the first time that these five
organisations have come together
and I believe that our diversity of
This website is modelled mainly on a
successful library operated by
Assistive Technology Partners
(Denver Colorado).
www.try-it.ie focuses specifically on
a subcategory of AT, Electronic AT.
Therefore the equipment available
for loan includes:
- Communication Aids, e.g. voice
amplification systems, speech
enhancers, and text-to-speech
devices.
- Computer Access, e.g. alternative
mice, keyboards, voice activation
software, etc.
- Leisure eg art/music/photography
- Memory Aids, e.g. task prompters,
visual assistants, voice cues.
- Switches, e.g. tactile pads, grip
switches, joy sticks, etc.
- Visual impairment, e.g. magnifiers,
CCTV systems, screen readers,
Braille-to-speech devices, etc.
SURGEONS at the Royal Infirmary of
Edinburgh have carried out Scotland's
100th pancreas transplant operation.
Stephen Proctor, 43, became the
100th patient to undergo the surgery
at the start of April.
The Transplant Unit at the Royal
Infirmary of Edinburgh is the only
centre in Scotland to offer the
pancreas transplant operation, and
has carried out 100 operations since
the programme started in April 2000.
Mr Proctor, of Portadown, County
Armagh, Northern Ireland, was
referred to the Transplant Unit in
Edinburgh by his Consultant, Dr
Hardy at Daisyhill Hospital, Newry,
because pancreas transplants are not
carried out at any hospitals in
Northern Ireland.
On April 10 he received a pancreas
and kidney double transplant,
becoming the 100th patient to receive
the pancreas operation.
Pancreas transplants are usually
combined with kidney transplants for
people with Type 1 diabetes and
established renal failure.
The combined transplant removes the
need for insulin injections and
dialysis.
Mr Proctor has been diabetic since
the age of 10, and suffered chronic
renal failure five years ago.
In 2005 he started Continuous
Ambulatory Peritoneal Dialysis
(CAPD), before being referred for a
pancreas and kidney transplant at the
beginning of this year.
Due to being the patient with his
blood type currently on the list, Mr
Proctor waited only three days after
being put onto the transplant list for
Scotland to receive his two new
organs.
Now, several weeks on from having
the operation, Mr Proctor has returned
home and is recovering well.
He said: "I have got a lot more energy
and it is brilliant not having to
take insulin any longer.
"The staff in the Transplant Unit have
been fantastic and every question I
have asked has been answered.
I can't thank them enough for the work
they have done.
"My thoughts and sympathies are with
the family of the donor and I would
like to thank them for donating the
organs which allowed me to undergo
my transplant.
"I would urge people to join the Organ
Donor Register and to carry a Donor
Card. Donating your organs could
save someone else's life."
John Forsythe, Director of the
Transplant Unit, said:
"This is a significant milestone for
pancreas transplantation in Scotland.
Not long ago pancreas transplant was
carried out sporadically across the
UK.
Now it is a very well established
treatment for diabetic patients who
have kidney failure and who are
suitable for this form of transplant.
"We are delighted that Stephen has
recovered so well and is able to go
back home to enjoy the success of his
transplant procedure. I know that he,
like the rest of us is very keen to
acknowledge the gift of the donor who
made this transplant possible."
MS Society Comments on
Social Care Consultation
Welcoming the launch of the consultation on social
care reform, Simon Gillespie, chief executive of the
MS Society, said: "We're acutely aware that most
people with MS feel the social care system is
failing them. The criteria for access to funding are
too tight - the funding shortfall isn't 20 years away,
it's with us right now.
"This consultation is a once in a generation
opportunity for the government to fix social care.
We need to make sure the young and disabled
aren't left out because current provision for them
is pitiful."
Background
There are 85,000 people with MS in the UK. Most
are diagnosed in their 20’s and 30’s and it affects
three times as many women as men. Symptoms
include loss of sight and mobility, grinding fatigue,
chronic nerve pain, depression, sexual dysfunction
and incontinence. MS is incurable and there are
few effective treatments.
The WI Dispense Clothes for a
Good Cause
Today, members of the Women's Institute dispense
clothes to urge people to check whether they have
sun damaged skin. Merely covered by a beach
towel the WI ladies, joined by well renowned GP
and media medic Dr Rob Hicks, are determined to
raise awareness of solar keratosis (SK) - a skin
condition resulting from cumulative sun exposure
and burning. These commonly occurring marks
can appear as small raised rough patches (often
pink, red or brown in colour) on the skin. If left
untreated, up to 1 in 10 can potentially develop
into squamous cell carcinoma (SCC) which is a
form of non melanoma skin cancer. In light of new
evidence that a quarter of Brits never check their
skin for signs of skin cancer this national health
campaign aims to encourage people to take a
closer look at their skin.
Dr Rob Hicks advises, "It is currently not possible
to tell which solar keratoses will develop into skin
cancer, it is therefore vital to check the skin for any
unusual marks and not to be frightened to seek
advice from your GP. There are currently various
treatments for solar keratosis, including topical
gels, freezing and scraping off the skin lesion."
Solar keratosis is primarily found in the older
generation however we are now seeing an
increase in younger age groups particularly as
more and more of us dedicate leisure time to
overseas trave. Clearly we are not paying attention
to the numerous warnings of the dangers of the
sun. The Suffolk West WI has pledged to reduce
the number of incidences of solar keratosis in
their region and they hope that the rest of the UK
will follow suit. Pat Collinson, Chairman of Suffolk
West WI said, "Awareness of this condition is
key and it is vital to spread the word of how
important it is to regularly check your skin, not only
for moles, but for any unusual marks or changes
and immediately consult your doctor if you have
any concerns. We hope by raising awareness of
this condition, we can prevent SKs being left
untreated and turning into something more
serious." For further info please visit
http://www.sundamagedskin.co.uk
11
News
NHS Lothian performs Scotland's
100th pancreas transplant
Next Generation Home
Monitoring Telehealth Platform
Launched by Evaware
- Advanced Technology Reduces Costs and Simplifies Installation
and Maintenance.
- Bluetooth Connectivity Simplifies User Interface and Operation.
News
- Links to a Web Browser Based Full Electronic Patient Record
(EPR) System Provides Clinicians With Comprehensive Analysis
Of Patient's History, Medication and Current Condition.
Evaware's Telehealth Platform enables clinicians to remotely
monitor the vital signs of their home-based patients on an almost
constant basis and automatically send alerts when any pre-determined clinical thresholds are breached.
The Telehealth Platform is easily configured to meet the needs of
each individual patient and has the capability of checking a range
of vital signs such as pulse rate, blood pressure, , temperature,
peak flow, blood glucose, weight (Even ECG) and many other
parameters regularly throughout the day and night. Whenever a
pre-determined threshold is breached an alert is automatically
relayed to the appropriate clinicians by email or text.
Nick Dyer, Managing Director of Evaware explains - "Telehealth
systemsare becoming an essential part of the mix in healthcare
services in that they keep constant surveillance on patients with
long term conditions and disabilities. Our Telehealth Platform
benefits patients, health authorities and doctors. Patients can
be monitored far more frequently and without the need to visit
their doctor or hospital; health authorities benefit from reduced
admissions & costs; and doctors have less patient visits and a
more manageable workload."
The RTX Telehealth Monitor supplied by Evaware is Bluetooth
enabled and integrates fully with Evaware's Project E-vita Patient
Record Solution together forming the Telehealth Platform. The
Monitor is EU Medical Device Directive EN60601 certified and
also United States FDA K510 approved.
The Platform's unique scripting functionality enables a series of
questions and answers to be configured, allowing the patient to
interact with the system using simple Yes/No buttons to describe
their symptoms/condition. The Telehealth Platform modifies each
question depending on the answer to previous questions, in much
the same way as a doctor would, thereby producing an accurate
assessment of the patient's condition. The patient's EPR is
updated immediately and available to all authorised clinicians..
Being integrated with a full EPR system gives clinicians the ability
to record all other data about a patient's treatment including visits
by healthcare professionals and admissions to hospitals. The
uploading of medical imagery and other documents provides a
complete and comprehensive picture of the patient's history and
current condition. The Telehealth Platform can easily and quickly
be reconfigured remotely without the need for on-site support.
About Evaware
Evaware is a Microsoft Certified Partner based in England and Isle of
Man.
About Project E-vita(TM) - http://www.projectevita.com
Project E-vita is a ground breaking product in the market of Healthcare
management systems and Electronic Patient Records. A feature rich
environment designed to meet the requirements of clinicians,
administrators and managers alike. The system architecture is shaped
to simplify the recording of all patient encounter data whether in Primary
Care, Community Care or even as an Outpatient/Inpatient in Secondary
(Hospital/Acute) Care environments.
12
Safefood welcomes the
publication of new
Broadcasting Bill
Safefood welcomes the publication of the new Broadcasting
Bill announced recently by the Minister for Communications,
Energy and Natural Resources, Eamon Ryan, and looks forward to the introduction of the proposed new codes to further
restrict unhealthy food advertising to children.
Evidence in respect of the patterns of consumption of
unhealthy food by children and teenagers clearly shows, that
there is an ever stronger need for action with regard to
promoting healthy eating among children, using whatever
means possible, including the limiting of advertising of
unhealthy foods to children.
Dr. Cliodhna Foley Nolan, Director of Human Health and
Nutrition, safefood said, "The time has come to restrict the
advertising of unhealthy foods to children. The marketing of
these foods to children is largely unrivalled in the broadcast
media. This prevalence undermines public health initiatives
designed to promote a healthy balanced diet among children.
Safefood believes that the provisions in the current Children's
Advertising Code are too limited.
"Evidence from the Children's Food Survey and the Teen
Survey show that with regard to healthy eating, the current
Children's Advertising Code is simply and clearly not having a
desired effect and further action is needed",
continued Dr. Foley-Nolan. http://www.wpp.com/WPP/About
STATEMENT BY WORK WISE UK
ON THE PRIME MINISTER'S RECENT
ANNOUNCEMENT TO EXTEND
FLEXIBLE WORKING PROVISIONS
FOR PARENTS OF OLDER CHILDREN
Phil Flaxton, chief executive of Work Wise UK, commented
on the Prime Minister's announcement of the extension of
the flexible working for parents of older children: "This
announcement coincides with National Work from Home
Day and the start of Work Wise Week, an initiative to promote
the wider adoption of smarter working practices, which
includes flexible working.
"Work Wise UK uniquely enjoys the backing of all sides of
industry, through support from the TUC, CBI and the British
Chambers of Commerce, and many organisations are already
reaping the benefits of adopting smarter working practices
with the associated improvements in productivity, staff
wellbeing through a better work-life balance, and associated
benefits through less need to commute or travel for work
reducing pollution, CO2 emissions, road congestion and
public transport over crowding.
"The Government's extension of its flexible working provisions
can only further the realisation of these benefits, and further
extend the adoption of smarter working practices across the
economy."
A new clinical study published today in Biological
Psychiatry adds weight to the growing body of
evidence that adults suffering from attention deficit
hyperactivity disorder (ADHD) may respond to
treatment.
ADHD has traditionally been perceived
as a childhood disorder, however,
existing studies have already
demonstrated that up to 65% of
paediatric ADHD cases will persist into
adulthood. It is estimated that between
two and four percent of adults in the
UK may have ADHD - the majority of
whom have not been diagnosed. Lack
of recognition of the existence of adult
ADHD has led to the misdiagnosis of
many adults with the condition, with
sufferers instead being diagnosed with
(and often treated for) other psychiatric
disorders such as anxiety, depression
and personality disorder.
One of the problems in recognising
ADHD in adults is that symptoms may
be confused with normal everyday
experiences such as irritability, lack of
motivation, disorganisation, impulsivity,
forgetfulness, and boredom. However,
for those diagnosed with adult ADHD
these symptoms start in early
childhood and may be more persistent
and severe than those without a
diagnosis.
Dr Marios Adamou, a psychiatrist
who runs a specialist ADHD clinic
for adults in Kent, commented that,
"ADHD is the most inherited
psychiatric condition. Approximately 1
in 20 adults in the UK need treatment
for ADHD but there are very few
services provided by the NHS.
Although there has been progression
in acceptance and understanding of
the condition over the last few years,
the tipping point for service provision
for ADHD in adults has not yet been
reached. It is vital to change public
perception and acceptance of this disorder so that those who are suffering
can get the help they need."
Treatment of adult ADHD in the UK
Currently, the majority of adults with
ADHD remain undiagnosed and
untreated.
There are relatively few clinics aimed
specifically at adult ADHD patients and
many sufferers entering adult life often
lose the necessary support and treatment they need. This can lead to
a greater reliance on the healthcare
system as untreated patients suffer
increased smoking-related disorders,
serious accidents, and alcohol and
drug misuse.
About the study published in Biological
Psychiatry
The new investigational study,
published today in Biological
Psychiatry, is the latest piece of
evidence to show that ADHD s
ymptoms continuing into adulthood
may be helped with treatment. The
Long-Acting Methylphenidate in
Adult ADHD (LAMDA) trial was carried
out across 13 European countries and
included 401 patients with a history of
ADHD symptoms extending from
childhood into adulthood. In this study,
prolonged-release OROS(R)
methylphenidate was shown to
improve adult ADHD symptoms.
In the UK OROS methylphenidate is
approved for the treatment of children
(over age 6) and adolescents with
ADHD, but is currently not approved
for the treatment of ADHD in adults.
About Janssen-Cilag
Janssen-Cilag has a long track record
in developing treatments for central
nervous system disorders, pain
management, oncology, fungal
infections and gastrointestinal
conditions. Products include
Concerta(R) XL (ADHD), Durogesic(R)
DTrans(R) (pain management),
Eprex(R) (anemia), Topamax(R)
(epilepsy, migraine prevention),
Risperdal(R) (schizophrenia, bipolar
disorder), Risperdal(R) Consta(R)
(schizophrenia) and Velcade(R)
(progressive multiple myeloma).
Healthcare
Professionals
Urged to
Listen and
Learn
From Patients with
Parkinson's Disease
Tom Isaacs, who famously walked 4,500
miles around Britain to raise the profile
of Parkinson's disease, is launching his
book "Shake Well Before Use". Taking
over the Royal Geographical Society
where many a travel tale has been
told, Tom will share an entertaining
description of his epic walk in 2002-3
to inspire healthcare professionals to
renew their approach to patients with
Parkinson's disease.
Tom hopes that by providing in depth
insights into his experiences, he will
be able to reach out to healthcare
professionals, enhancing their
understanding of the patients'
experience and driving standards of
care in Parkinson's disease even higher.
Tom's account of triumph over the
disease is one that newly diagnosed
patients can take comfort and inspiration
from. Doctors and specialist nurses can
help patients by driving them to The
Cure Parkinson's website for further
information and support.
Tom's book can also be bought online
at www.cureparkinsons.org.uk
priced £16.99 (excluding postage)
or by sending a cheque to Movers
& Shakers - 1 St Clement's Court,
London, EC4N 7HB (Charity number
1111816)
More information can be found at
http://www.janssen-cilag.co.uk
13
News
When ADHD Grows Up - New Study
Supports Growing Body of Evidence
for Adult ADHD
DRUG CALCULATIONS –
AVOIDING ERRORS
One in ten patients in UK Hospitals experience
harm or even death as a consequence of drug
errors.
This flexible online programme is suitable for any
healthcare professional who is involved in the
administration of medicines.
Cost: only £15 for 12 month access to this
programme.
CPD certificate issued after successful completion
of online drug calculations assessment.
Block licenses for larger groups of staff are also
available.
To register for this programme go to www.cb-training.com
For block booking licenses Tel. 01324 411013
14
Beaumont Hospital and Beacon Medical Group (BMG) are
pleased to announce that planning permission has been
received for a co-located hospital on the grounds of
Beaumont Hospital. The new facility will represent an
investment of 297m by BMG. When fully operational the new
hospital will directly employ over 504 staff, with additional
indirect employment of approximately 776 people.
The hi-tech, state-of-the-art hospital will comprise 170 single
rooms with 16 CCU beds, 6 operating theatres, ambulatory
surgery and full diagnostics incorporating some 26.4m
worth of new generation equipment. The gross floor area will
encompass approximately 38,815 sq metres. The hospital
will mirror the case-mix of the public hospital, in that all
specialities catered for in the public hospital will also be
catered for in the co-located hospital – both medical and
surgical. There will be a joint governance structure to
manage shared issues. The hospital will be operational
within 30 months from construction commencing.
Background to Co-located Private Hospitals Project
In July 2005, the Irish Government issued a policy direction
to the HSE under section 10 of the Health Act 2004 to
implement the Co-located Private Hospitals Project. The
project was aimed at freeing up additional beds for public
patients in public hospitals and the development of private
hospital facilities on public hospital sites.
No public land is being sold to successful bidders. The
hospitals will be privately operated hospitals for the provision
of health care to public and private patients alike and not
exclusive to private patients.
The new co-located hospitals will allow for 24/7 admission
from the public hospital, the public Emergency Department
(ED), primary care centres and through GP referrals. They will
have the capacity to treat all private patients currently catered
for in Public Hospitals thereby freeing up public beds for
additional public patients.
As part of the partnership approach between the public and
co-located hospitals, where the Public Hospital is full and the
Private facility has capacity, there will be a Service Level
Agreement (SLA) in place for the Private hospital to take in
Public patients. The reverse may also apply. Similarly, where
there is a deficiency of certain medical equipment and other
infrastructure in the public hospital, it has been agreed that
the Private hospital will supply and enter a Service Level
Agreement with the public facility to provide these.
New resource helps
patients make sense of
their pathology report
A groundbreaking new publication which offers vital information
topeoplewith breast cancer has been published by the charity
Breast Cancer Care in response totheneeds of patients.
Understanding Your Pathology Reportis the firstguideof its kind
in the UK, designed to help breast cancer patients overcome the
problems often presented to the non-professional by complex
pathology reports.
Thecomprehensivebooklet guides patients through their
pathology report, explaining medical terminology and treatment
implications in a clear and accessiblestyle.A selection of
suggested questions patients might want to ask their healthcare
team is also provided, encouraging a more collaborative
approach to treatment decision making.
Dr Emma Pennery, Clinical Director at Breast Cancer Care, was
part of the team of clinical experts and patients who designed
the resource. She commented:
“We often hear from patients who are struggling to make sense
of their pathology report and we know that this can cause a
great deal of anxiety. We also know that it can be difficult for
Health Care Professionals to explain these increasingly detailed
reports when there is limited time in an appointment.
“This booklet will help patients to make the most of their hospital
visits by giving them the knowledge and confidence to ask
questions and may help them to feel more in control of their
treatment.”
Professor Robert Coleman, Professor of Medical Oncology at the
Cancer Research Centre, Weston Park Hospital, Sheffield, said:
“This is an excellent, clear document which gives a
comprehensive explanation of a pathology report. It will be a
very useful resource for both patients and Health Care
Professionals.”
Patient Debbie Prosser, reviewed drafts ofUnderstanding Your
Pathology Reportandhas found the resource useful during her
treatment for breast cancer. She said:
“When you’re with the oncologist, sometimes you’re not in the
right state of mind and they can use a lot of technical language
which is difficult to understand. The clear language and pictures
in this booklet make your pathology report easier to digest and
takes some of the fear out of it.
“Having a booklet which you can keep at home and refer back
to means that you can take the time to get to grips with what is
going on inside your body at your own pace.
“The section for questions is very helpful and would make me
feel more confident about asking questions in a consultation.
I wish I had have had this from the beginning!”
Understanding Your Pathology Reportis the latest in Breast
Cancer Care’s comprehensive range of award-winning free
information. To order a free copy,
visitwww.breastcancercare.org.uk or call0131 273 3198.
Health Care Professionals can be kept up to date with the latest
news from Breast Cancer Care’s email alert service – visit:
www.breastcancercare.org.uk/hcpor call 0845 070 0218.
15
News
Planning Permission
received for
co-located hospital
on the site of
Beaumont
Hospital, Dublin
Whats On
WHATS ON !
1-5 June 2008
ICM 28th Triennial Congress
SECC, Glasgow, Scotland
11-14 June 2008
EULAR, the European League Against Rheumatism
annual meeting - Paris, France.
[email protected]
The EULAR 2008 abstracts are now available online, under
embargo, to assist you in planning your coverage, and can be
accessed via: http://www.eular.org/congress_abstracts.cfm
Invitation to midwives from around the globe to participate in
the 28th ICM Triennial Congress 2008.
In one’s lifetime there are significant occasions that merit
being stored in our memory, the ICM 28th Triennial Congress
promises to be one of these. It is my honour, as President of
the ICM, to invite all midwives of the world to attend the
Glasgow Congress and as General Secretary of the host
organisation, the Royal College of Midwives, to extend a warm
welcome on behalf of the UK midwives. Midwives across the
world have demonstrated their perseverance to improve the
rights of women, their newborns and their families. As an age
old profession, midwifery has demonstrated its ability to face
challenges and accommodate to societal and cultural
changes. For further information visit the website at
www.midwives2008.org"
16
Press registration is still open online and is free of charge for
all holders of a valid press card / formal journalist credentials.
Press will have access to the onsite press facilities, including a
working room and interview areas, and the press office will be
able to assist you in organising interviews with relevant
experts. You can apply for press registration at:
http://www.eular.org/congress_press_registration.cfm
We look forward to seeing you at EULAR 2008 in Paris!
Rory Berrie and Camilla Dormer
EULAR Press Office
Email: [email protected]
Tel : +44 (0)207 331 5317
EULAR website: http://www.eular.org
There are more than a million people in the UK on long-term
warfarini and this number is set to increase by 10% year-onyear, due to the ageing population. Roche Diagnostics, a
pioneer in the development of monitoring systems for
anticoagulation, supported by the patient group
AntiCoagulation Europe (ACE), is conducting an educational
bus tour across the UK and Ireland to raise awareness of the
potential benefits of patient self-testing. The bus will be
stopping at 24 locations across the UK and Ireland and is
open to the public free of charge.
The CoaguNation Bus Tour will provide long-term warfarin
patients, and their family and friends, with an opportunity to
learn more about the practical aspects and potential benefits
of anticoagulation self-testing. This will include information on
how to simply and safely check their own blood coagulation
levels from home, providing more freedom for the patient.
A local anticoagulation nurse will be on board to give
practical advice and educational demonstrations on how to
use self-testing devices. The nurse will also be able to answer
any questions which patients, their family or friends may have
regarding warfarin medication and self-testing. There will also
be a local member of AntiCoagulation Europe on board to
provide first hand experience of self-testing, as well as a
number of educational patient support materials which visitors
can take away from the event.
The CoaguNation Bus Tour will stop at 24 locations in the UK
and Ireland on various dates from May to July 2008. Please
help to spread the word and inform your warfarin patients of
the UK–wide CoaguNation Bus Tour: For more information and
a full list of dates and locations / venues call the CoaguChek
helpline free on 0808 1007666 or visit www.onwarfarin.co.uk
Saturday 28 June 2008
Aylesbury Vale Education Centre, Stoke Mandeville
Hospital. Mandeville Road, Aylesbury, Buckinghamshire
Healthcare open event
11am to 1pm
Nursing and Midwifery Open Events
Want to Qualify for a Career in Nursing?
Or develop your career?
Come to a University open evening/day to discuss the benefits
of studying Nursing with the University of Bedfordshire.
Post registration opportunities are also available.
Nursing and Midwifery Open day
Contact Information: For further information, application, registration and booking fomrs, please apply to the event organiser:
Keren Roberts, 2 Acre Road, Kingston on Thames, Surrey
KT2 6EF Tel: 020 8541 1399
24th October 2008
Shelbourne Hall R.D.S. Dublin
Skills 4 Nurses 2008
Skills for Nurses are pleased to announce the latest
Nursing Exhibitions which will be held in Dublin,
Glasgow and Poland.
Seminars : Skills Zone : Training
Recruitment : Products : Services
As with all our events we have a full range of seminars
and workshops featuring prominent speakers and celebrities.
If you would like more information please contact:
Global Media Exhibitions on
tel. +44 (0)1292 525 970
email. [email protected] or log
onto: www.scottishirishhealthcare.com
6th November 2008
SECC Glasgow
Skills 4 Nurses 2008
Skills for Nurses are pleased to announce the latest
Nursing Exhibitions which will be held in Dublin,
Glasgow and Poland.
Seminars : Skills Zone : Training
Recruitment : Products : Services
As with all our events we have a full range of seminars
and workshops featuring prominent speakers and celebrities.
If you would like more information please contact:
Global Media Exhibitions on
tel. +44 (0)1292 525 970
email. [email protected] or log
onto: www.scottishirishhealthcare.com
6th - 15th November 2008
Africa
Bighearted Scotland is calling on adventure enthusiasts from
all over the country to take part in this year’s Livingstone’s
Footsteps Challenge in the heart of Africa to raise much
needed funds for charities across Scotland.
The challenge will take place from 6th – 15th November
2008.Places will be limited, so act now to avoid disappointment. For furtherinformation or an application pack please call
Lindsey Spowage on 0141 222 2333 or 07765 638687
or e-mail: [email protected]
To find out more info on Bighearted Scotland and the charities
involved go to: www.bigheartedscotland.org
2nd July 2008
Improving Maternal Mental Health
76 Portland Place, London
09:00 17:00 : 1 day
The conference focuses on ensuring a positive and holistic
approach to maternal mental health, identifying and managing
postnatal mental distress and working in partnership to improve
outcomes.
Programme sessions, themes and workshops
Fees:
£340 (plus VAT) NHS & Private Healthcare Organisations
£290 (plus VAT) Voluntary Sector/Charities
£475 (plus VAT) Commercial Organisations
17
Whats On
May - July 2008 (various dats)
Do you have patients on warfarin?
Incontinence
Day-time wetting
by June Rogers MBE
RN, RSCN, BA(Hons), MSc, ENB 216,978,N01
Paediatric Continence Advisor,
Director PromoCon,
Disabled Living,
Manchester
Introduction
There is a limited amount of data regarding the prevailance
of daytime wetting in children as many cases often go
unreported, however one study identified that at 7 years
approximately 4% of boys and 6% of girls have a problem
with day time wetting (Hellstrom et al 1991).Unlike nocturnal
enuresis however, day time wetting may have an organic
cause and is always worth investigating, and depending on
which professional initially see the child there can be wide
variation in the approach to the management of children with
this problem. For example, children identified at school as
having a day time wetting problem are often referred to the
educational psychologist who mainly take a behavioural
approach to management. Children seen by the family GP
may be either referred to the local hospital for a series of
investigations or reassured that the problem is some thing
the child will grow out of.
Also as daytime wetting can occur in association with
behavioural type problems some families feel that the
wetting is due to 'lazyness' or ‘naughtiness’ and not a sign
of an underlying problem so will therefore not seek any
advice. These children are often not identified until they
start school when the wetting becomes a problem. It is
important therefore that professionals are aware of the
standardised definitions of daytime wetting and treat the
child accordingly. As a result of these issues and some
confusion around some of the terms relating to day time
wetting the International Children's Continence Society (iccs)
has published guidelines relating to the standardisation of
18
terminology in relation to lower urinary tract function in
children and adolescents (Neveus et al 2006)
Classification of daytime wetting
In order to clarify any underlying problems it is useful to
classify the symptoms the child presents with in terms of the
storage and/or voiding phase of bladder function. (Neveus et
al 2006). All terminology is relevant from age 5 years
Storage symptoms
Increased or decreased voiding frequency is important with
3 or less times considered decreased and 8 times or more
considered increased urinary frequency. The completion of
a bladder diary will help to determine theses symptoms.
Any wetting is to be termed 'incontinence' even if it occurs
just once, with continuous incontinence, when the child is
wet all the time, being almost exclusively associated with
congenital malformation. Intermittent incontinence relates to
wetting occurring at intervals either during the day or night,
although wetting only at night (bedwetting) can also be
termed synonymously nocturnal enuresis. The term
‘enuresis’ however can no longer be used in relation to
wetting occurring in the day.
Urgency in this context relates to the sudden and
unexpected desire to void and nocturia means the child
wakes up in the night to void.
excluded. In this instance the ectopic orifice can open into
either the urethra, vestibulum or vagina ( Jaureguizar and
Pereira 1992). These children obviously require a surgical
referral.
Hesitancy denotes difficulty or delay in initiating a void and
straining is when the child has to apply abdominal pressure
to initiate and maintain the void. A weak stream is the one
term that is relevant from infancy. The term intermittency
relates to micturition occuring in several spurts (staccato)
rather than one continuous stream and is regarded as
physiological up to the age of 3 years if not accompanied
by straining.
Obstruction
This term is used for children who experience a mechanical
or functional impediment to urine flow which is characterised
by increased detrusor pressure and decreased urine flow
rate.
Other symptoms such as ‘holding on’ manoeuvres, to
postpone voiding, or post micturition dribble may also be
noted
Day time Conditions
There are a number of conditions which can affect the lower
urinary tract in children and in many occasions they can
overlap so children can present with a mixed picture or
develop further problems as time goes on. The following
conditions are the most commonest and are generally
applicable from the age of 5 years.
Over active bladder (OAB)
Children who present with urgency are said to have an
overactive bladder. In many cases these children also have
frequency, although fluid intake needs to be taken into
account as children who drink frequently may also void
frequently. The term ‘detrusor overactivity’ can only be
applied following cystometric evaluation.
Underactive bladder
This condition was previously termed ‘lazy bladder’ and is
used with children who present with low voiding frequency
with an often interrupted stream and who need to use
abdominal pressure to void.
Dysfunctional voiding
Dysfunctional voiding occurs when the urethral sphincter
contracts during micturition instead of relaxing so that child
almost invariable has to strain to void. The condition can
only be verified by repeated uroflow measurements which
identify the staccato pattern of voids. Children with
dysfunctional voiding may also have difficulty emptying
their bladders to completion with resultant residual urine
identified by a post micturition bladder scan.
Vaginal reflux
Vaginal reflux can occur (commonly in well built girls) when
urine refluxes into the vagina during a normal void which
then leaks out within a few minutes of the child leaving the
toilet. The condition is easily remedied by encouraging the
child sits correctly on the toilet with knees wide apart.
‘Giggle’ micturition
This is an uncommon form of wetting characterised by a
normally dry child experiencing complete bladder emptying
on giggling or laughing. These children have normal
bladder and sphincter control and no evidence of 'stress
incontinence'. In children with this condition it is thought
that detruser contractions are induced by centrally mediated
electrical discharges from the hypothalmus that occur with
laughter (Cisternino and Passerini-Glazel 1995).
Structural problems
For children that are always wet ( usually girls) with no period
of dryness, the possibility of an ectopic ureter needs to be
Stress incontinence
Children, notably girls, who report wetness following exercise
or abdominal straining could have stress incontinence due
to a wide bladder neck anomaly (Jaureguizar and Pereirra
1992).It must be remembered, however, that genuine stress
incontinence is extremely rare in neurologically normal
children.
Assessement
Nurses undergoing assessment of children need to ensure
they have the underlying knowledge and skills to do so.
A suite of competences in relation to continence have been
developed and are available to view on the Skills for Health
web site with CC01 relating to bladder and bowel
assessment (www.skillsforhealth.org)
History
A standardised, structured approach to history taking is
important. To provide grounds for clarification of the child’s
underlying problem it has been suggested that the
following four parameters are identified, the presence of
any incontinence, fluid intake, voiding frequency and also
volume.
Any underlying constipation should be excluded and a note
made of any previous urinary tract infections and relevant
surgery as well as a general history.
Demystification of the problem, with the wetting put in
perspective in relationship to the child's overall development,
should be discussed with the family.
Bladder diary
The bladder diary recording voiding and bladder symptoms
is crucial as part of the assessment and can be a vital tool in
determining the underlying cause of the wetting.
A baseline frequency volume chart gives an indication of
the degree of wetting and frequency of voidings. The iccs
suggests a minimum 48hours of measured recording of
fluid intake and output and 14 days of baseline recording of
any wetting episodes and bowel movements. However in
practice this can be difficult because of schooling.
The base line assessment also includes fluid intake and the
families are asked to record the amount, type and times the
drinks are taken. It has been found that the children don't
drink enough and when questioned about fluid intake during
the school day many report only one or two drinks taken.
It is generally recommended that children drink at least
6 drinks spread out evenly during the day.
Urinalysis, in the form of a dip-stick urine test should always
be carried out to exclude abnormalities. The child’s
functional bladder capacity can be estimated by asking the
child to pass urine into a jug, when they feel the urge to go,
and measure and record the contents. The bladder capacity
for age can be estimated by multiplying the child’ age by 30
and adding 30.
19
Incontinence
Voiding symptoms
The lack of clear voiding symptoms does not necessarily
mean they are not present as particularly in the younger
child they may not have been observed or reported
Incontinence
Uroflow measurement
The rate of urine flow can be easily measured by asking the
child to pass urine into a flow meter. This is an electronic
device, attached to a receptacle into which the child passes
urine, and it records the amount of urine passed per unit of
time.
Physical examination
A physical examination is important, particularly if the
child does not respond to simple interventions such as
fluid intake and regular toileting advice The general physical
assessment should include examination of the back to check
for malformations of the sacrum, presence of a hairy tuft or
asymmetry of the gluteal crease which may all be suggestive
of a neurological cause for the wetting. The external genitalia
also needs to be checked to exclude such things as labial
adhesions in girls and epispadias and meatal stenosis in
boys
Invasive investigations
Urodynamics
Cystometry tests assess the pressure, volume and flow rate
of the urine in the bladder. These tests involve inserting two
catheters into the child bladder and if tolerated one into their
bottom. This test checks that the bladder is filling and
emptying properly and by recording the test on video can
also detect if there is a problem at the opening (neck) of the
bladder.
In some centres, with younger children, the tests are carried
out via a suprapubic catheter or while the child is sedated so
as to be less distressing for the child.
Treatment
Basic Advice
Meaningful advice should also be given regarding drinks
and regular toileting with written information. Star/incentive
charts may be appropriate in some instances, but it is
important to remember that the rewards should be given for
achievable processes such as increasing drinks rather than
the outcome of a 'dry day'.
Bladder Training (Urotherapy)
The basis for treatment for children with daytime wetting is
bladder re/training in the form of modified Cognitive Bladder
Training or urotherapy. Bladder training teaches the children
how to void, when to void and also the correct number of
voidings, by means of education, motivation and biofeedback ( Rogers 1996b).
Education
Relative to the age of the child basic information is given
regarding their bladder and kidneys. There are several 'My
Body' types of books available and I have always found
children fascinated about how their body works. A soft
bodied doll is also used with the younger child which has
been adapted by sewing a felt bladder and kidneys on its
tummy.
It is also explained to the children about the 'telephone' that
connects their bladder to their brain and what happens to
some children when they do not hear the 'telephone' ringing
because they are busy doing something such as playing out
or watching the television. If they do not hear it in time then
20
they have an 'accident' They must try and concentrate and
'listen' to the signals from their bladder which tells them
when they need to pass urine.
The child's bladder volume is estimated by the following
simple equation, multiply the child's age by 30 and add 30.
For example a child of 7 years would have an estimated
bladder volume of approximately 240 mls The child is then
aware about how much urine their bladder should hold .
The child is taught about the correct way to sit on the toilet
with their feet flat on the floor or a stool, to relax, not strain,
and to use their detrusor muscles not their abdominal
muscles to pass urine. The child is also told to try and
pass urine in one go. and not to stop and start.
For those children who may not empty their bladder
completely 'double micturition' is taught. This involves the
child going to the toilet to pass urine then going to their
bedroom sitting down, counting to 30 ( or waiting for 1-2
minutes depending on their age) then returning to the
toilet to try and pass urine again.
The children are also advised to drink regularly throughout
the day, taking extra drinks into school if necessary. Many
children restrict fluid in the mistaken belief that it will
reduce the wetting episodes.
Over the years many children have continuously suppressed
the urge to pass urine, the CBT programme teaches the
child to respond to the first signals to go to the toilet. They
are told to think about the signals they get from their bladder
by memorising the rhyme "1-2-3, do I need to wee ?" Writing
1-2-3 down on their pencil case, for example, serves as a
reminder when they are at school. An interval training chart
is also given to encourage the child to empty their bladders
regularly.
Motivation
The advantages of being dry are discussed with the child
and positive reinforcement is emphasised with the parents.
The child is also encouraged to follow the programme by
using stickers and 'incentive' charts. Hospital in patient
programmes are occasionally run and involve pairs of
children, of similar age and sex, who compete against each
other to see who can get dry first, although in the UK most
programmes are either run as outpatient or in the community.
Frequent contact is also made, either by telephone or home
visits, to ensure ongoing motivation and compliance with the
programme.
Biofeedback
Although initially the child is encouraged to go to the toilet
as soon as they get the urge, for some children the number
of times per day they pass urine is important. A number of
children, for example, do not go to the toilet often enough
instead will 'hold on' and put off going for as long as
possible until they finally wet. The aim is that the children
eventually learn to pass urine on average 7 times per day.
For those children that continue to pass urine an
inappropriate number of times, either too frequently or not
often enough, numbered stickers (from 1-7) can be given
to stick on a chart. The child is aware , for example, that they
have to have used sticker number 3 by lunch time. Counting
the number of times they pass urine acts as a feedback for
the child.
The child also measures the amount of urine they pass, by
calculating the expected bladder volume the child can see
whether they are passing a full bladder or just a partial
amount.
For those children who 'deny' being wet a wetting alarm can
be used. This is worn in the pants and signals when the
child starts to wet, the parent then sends the child to the
toilet straight away. (The alarm would only be used at home )
The Cognitive Bladder Training Programme was originally
developed for children aged seven years and older, however
it can be adapted and simplified for the younger child. The
family are made aware that the programme may have to be
followed for several weeks before any improvement is noted,
and it will then need to be continued until the child is
completely symptom free.
The aim of the Bladder Training Programme is to make the
child more aware of their bladder and to develop a basic
understanding of the normal voiding mechanism. The child
is taught to be aware of the urge to void and to react to
it appropriately. Those children who display holding
manoeuvres, for example, are taught to recognise the first
sensations of the desire to void and to react it immediately
instead of 'holding on’. In children who have 'urgency' they
learn to suppress the desire to void and reduce the number
of voidings. The child thus learns how to void correctly, when
to void by reacting to the correct signals, finally how often
to void.
References
Cisternino, A. Passerini-Glazel, G. (1995). Bladder
Dysfunction in children. Scandinavian Journalof Urology
and Nephrology, 173, 25-29.
Hellstrom A-L. Hansson E. Hansson S. Hjalmas K. Jodal U.
(1991 ) Association between urinary symtoms at 7 years old
and previous urinary infection. Archives of Diseases of
Childhood. 66: 232-234.
Hoebeke P, vande Walle JV (2002) Current management of
dysfunctional voiding. In RM Ehrilich (Ed) Dialogues in
Paediaric Urology, 25 (8 ) 2-3
Jaureguizar, E. Pereira, L. (1992). Structural incontinence.
Scandinavian Journal of Urology and Nephrology, 141, 20-25
Neveus T et al (2006) The tandardization of Terminology of
Lower Urinary Tract Function in Children and Adolescents:
Report from the Standardisation Committee of the
International Children’s Continence Society. The Journal of
Urology, 176, 314-324.
Rogers, J. (1996. Cognitive Bladder Training in the
Community. Paediatric Nursing, 8:8, 18-20.
Previous studies have highlighted the relationship between
bladder dysfunction and urinary tract infections (Hoebeke
and vand Walle 2002)). Although the causal relationship is
still unclear it is felt that incomplete emptying of the bladder
due to functional voiding problems is an important factor.
Therefore the development of a normal micturition pattern
should reduce the risk of the child developing further
urinary tract infections.
Medication
For those children with detruser instability, who fail to
respond to bladder retraining alone, a trial of an
anticholinergic can be tried, which decrease uninhibited
bladder contraction and increase functional bladder
capacity. Oxybutinin is an anticholinergic and
antispasmodic agent, and although some side effects
have been reported such as dry mouth, constipation and
drowsiness, it has been found to benefit a number of
children with day time wetting. Oxybutinin is also available
in a long acting formulation (Lyrinel XL) which is licensed for
children from age 6 and has been found to be beneficial in
combination with desmopressin for children who have night
time wetting particularly in association with an overactive
bladder.
Conclusion
Children with daytime wetting can present with a spectrum
of signs and symptoms so it is important that assessment
and implementation of treatments are undertaken in a logical
manner. Management of children with these problems takes
time and success is often dependent on the child and
families compliance. The nurse plays a key role in
working with the family, not only to develop and implement
management and treatment plans but also monitor
progress and provide continued motivation and support.
21
Incontinence
The child is told to listen to the sound as they pass urine,
does it come in one go, or does it spurt ? The child is made
aware that the urine should come in one go otherwise it is
wrong.
Mental Health
Alcohol consumption and its consequences for health:
what can nurses do to help?
Christopher Littlejohn RN, BSc(Hons), MSc : Primary Care Facilitator – Alcohol Liaison, NHS Tayside Alcohol Problems Service,
Constitution House, 55 Constitution Road, Dundee DD1 1LB Tel: 01382 424511 Email: [email protected]
The negative personal and societal consequences that can
accompany the consumption of alcohol are commanding
growing attention and concern. Following a brief overview of
alcohol-related harm and current drinking patterns in Scotland
this paper outlines what nurses can do to intervene effectively
with heavy drinking patients.
Alcohol-related harm in Scotland
The World Health Organisation has calculated alcohol to
be the third largest cause of disease and disability in the
developed world, behind only smoking and hypertension.
Alcohol has been associated with over sixty medical
conditions, including cardiovascular conditions (e.g.
hypertension, stroke), gastrointestinal conditions (e.g. liver
cirrhosis, pancreatitis, oesophageal varices), and cancers
(e.g. liver, mouth, pharynx, larynx, oesophagus, breast) as
well as depression, domestic problems, crime, relationship
breakdown, absenteeism, financial problems, accidents,
and suicide. Some alcohol-related harms (e.g. accidents,
assaults) can be explained in relation to intoxication , others
(e.g. illness and disease) by quantity and duration of alcohol
consumption. Many alcohol-related diseases are associated
with a daily consumption of as little as three units (see box 1)
per day , while cirrhosis requires an intake as low as four units
of alcohol per day over a number of years . While cirrhosis
deaths have nearly halved in the past decade across Europe,
they have more than doubled in Scottish men and increased
by more than 60% in Scottish women . Scottish women now
have the highest cirrhosis mortality rates in Europe, and
Scottish men the fourth highest. The annual costs to Scotland
arising from alcohol misuse have been calculated at over one
billion pounds per year . This includes over fifty million pounds
for alcohol-related hospitalisations, nearly ten million pounds
for alcohol-related accident and emergency visits, and over
three million pounds for GP consultations.
Box 1 : Calculating units of alcohol
Determine the quantity consumed. Calculate how much
pure ethanol (alcohol) is in the drink by multiplying by the
Alcohol By Volume (ABV%). 10mls of ethanol is one unit, so
divide the answer by ten.
Eg. A 750ml bottle of vodka, with an ABV of 37.5%:
750 x 37.5% = 281.25 mls of ethanol = 28.125 units of alcohol.
So, there are 28 units of alcohol in a 750 ml bottle of vodka.
Population drinking patterns
Large proportions of the population exceed recommended
weekly and daily consumption limits, although consumption
patterns vary by age and gender . Younger people tend to
drink on fewer occasions per week than older people, but are
more likely to drink heavily when they do so. Men are more
22
likely to drink – and drink heavily – than women. People from
more affluent groups are more likely to report drinking, and to
report exceeding daily recommended limits in the past week,
than those from less affluent groups . However, while drinkers
from less affluent groups are proportionately fewer in number,
their average daily consumption is higher than more affluent
drinkers (when compared by Scottish Index of Multiple
Deprivation score) . Younger drinkers are at increased risk of
intoxication-related harms, such as accidents, violence, and
self-harm , while chronic health consequences increase with
age. The highest emergency hospital admission rates in
Scotland (for intoxication/harmful use, alcoholic liver disease,
chronic liver disease, chronic pancreatitis, and oesophageal
varices) occur amongst men and women aged between 45
and 64. The second highest admission rates are amongst
those over sixty-five . Rates also increase alongside
socioeconomic deprivation, such that more people from
deprived populations are admitted compared to those
from more affluent populations.
Recognising when to intervene
Nurses come into contact with five types of drinkers. Low-risk
drinkers consume less than daily and weekly recommended
limits (box 2). Hazardous (‘at-risk’) drinkers consume enough
to be risking alcohol-related harm at some point in the future,
even if they have not experienced any alcohol-related harm
to date. SIGN 74 defines hazardous drinking as the regular
consumption of more than five units per day for men, and
more than three units per day for women . When this level of
drinking continues despite causing (or having caused) harm
to physical or mental health, this is termed harmful drinking
(synonymous with ‘alcohol abuse’ in the US). Alcohol
dependence is a behavioural diagnosis based on chronic
harmful drinking characterised by physiological symptoms
such as increased tolerance and withdrawal symptoms, and
psychological symptoms including craving, a sense of ‘loss
of control’ over consumption, increasing neglect of other
interests in favour of drinking, and continued drinking despite
the presence of alcohol-related problems and harm. Harmful
and dependent drinkers will often be exceeding daily and
weekly recommended limits. Binge drinking has been
operationalised in at least two distinct ways, although both
relate to the deliberate use of alcohol to achieve intoxication.
In one, binge drinking is defined as consuming at least twice
daily recommended limits in one session ; thus a man who
drinks four pints of 5% lager is a binge drinker. In the other,
favoured by specialist addiction journals, binge drinking is,
“an extended period of time (usually two or more days) during
which a person repeatedly administers alcohol…to the point
of intoxication, and gives up his/her usual activities and
obligations in order to use the substance”. Note that in the first
definition, it is quite possible for the binge drinker not to be
exceeding weekly recommended limits, even though the
risks to health are increased (e.g. higher risk of myocardial
infarction and hypertension in men).
Weekly recommended limits:
No more than 21 units per week for men
No more than 14 units per week for men
Two alcohol-free days per week are also recommended
Source: Erens & Moody, 2005
A number of validated screening tools exist that can assist in
quickly identifying which patients warrant further enquiry about
their drinking . Essentially these involve asking about quantity
and frequency of alcohol consumption in order to identify
those drinking at hazardous levels or higher (box 3).
Box 3 : Screening
Ask:
How much do you drink on an average drinking day?
How many days per week do you drink like that?
How much do you drink on your heaviest drinking day?
If more than twice the daily recommended limit, how
often do such heaviest days occur?
From answers record:
Average weekly alcohol consumption (from average
consumption x number of days per week plus additional
from heaviest drinking day(s) in week)
Whether patient ever drinks more than twice daily
recommended amount in one day
Positive screen if:
Drinking more than weekly recommended limit
Drinking more than twice daily recommended limit more
than once per month
Providing an effective intervention
According to current evidence-based guidelines, hazardous
and harmful drinkers should receive a ‘brief intervention’ from
their generic healthcare provider; harmful drinkers with more
serious problems and/or who are non-responsive to brief
intervention should receive counselling using motivational
interviewing; and patients with alcohol dependence should be
encouraged to receive specialist treatment. Brief intervention
tends to be used to refer to a single, ten-minute counselling
session in a general health setting, while motivational
interviewing tends to refer to longer, more comprehensive
multi-session counselling . Overall though, an effective
intervention involves the use of positive communication skills
to discuss a patient’s drinking with them. Indeed, one of the
strongest predictors of subsequent behaviour change is the
demonstration of empathy by the ‘counsellor’ .
Establishing alcohol on the clinical agenda
For any given patient, alcohol may be just one of any number
of issues requiring intervention. Following a positive alcohol
screening therefore, alcohol should be presented as one of the
subjects warranting attention. Alcohol’s priority for discussion
then requires to be negotiated with the patient. Some patients
are happy to address their drinking as a matter of urgency;
others fail to see any reason for concern, and it can be more
effective to build clinical rapport and trust by addressing other
issues first. Much depends on the setting (e.g. hospital ward,
primary care), duration of contact (e.g. in A&E there may only
be the one opportunity to intervene) and the patient (i.e. some
patients are more regular attendees than others).
Talking about drinking
Discussion of alcohol use should be on the explicit basis that
the patient is the most competent person to make decisions
regarding their own welfare (Miller & Rollnick, 2002). Simply
advising people to change does not work . Indeed, direct
attempts to persuade people to change risks entrenching
current behaviour, producing exactly the opposite result to
that which was intended . We all use a range of defence
mechanisms to justify our behaviour to ourselves in the face
of clear evidence of the need to change . Instead of trying to
directly persuade the patient to change, it is more productive
to give the patient the opportunity to talk about their drinking
behaviour, and encourage them to consider their own need to
change. Communication skills such as open questions and
reflective listening can be used to great effect, and a starting
point can be to simply ask the patient to talk about how
drinking fits into their life in an average day . This initial
discussion is likely to identify the things the patient enjoys
about drinking (e.g. it helps them relax). Generally, statements
from the patient regarding what they enjoy about drinking
should be met with understanding and empathy. Patients
may also highlight things that concern them about their
drinking. Concerns about drinking typically involve “the 4 L’s”,
namely Liver (their physical or mental health), Lover (their
relationships), Livelihood (their work or finances), or Law
(legal issues, such as arrest, or divorce). Statements regarding
concerns about drinking, or of desire or need to change,
should be encouraged by asking the patient to expand on the
detail of these. It is when patients begin to voice the reasons
for behaviour change, that positive outcomes become more
likely . During this introductory discussion, feedback using
objective assessment data can be offered. Thus elevated
laboratory tests (e.g. ?-GT, MCV), and comparison of the
patient’s current alcohol consumption levels with population
norms can be given. For example, tables 1 and 2 give weekly
consumption figures derived from the Scottish Health Survey .
It may be possible to highlight alcohol’s possible role in
causing or maintaining the patient’s current symptoms,
and/or highlight the future health risks of their current
consumption pattern.
Table 1: Alcohol Units per week, % of Scottish Men
16 - 24
25 - 34
35 - 44
45 - 54
55 - 64
65 - 74
75+
1 – 10
29
32
34
33
33
33
31
11 – 21
24
25
24
27
23
23
19
22 – 35
16
19
15
17
15
12
10
36 – 50
8
6
7
5
6
6
3
51+
8
6
6
7
7
4
3
*Source: Erens & Moody, 2005
Table 2: Alcohol Units per week, % of Scottish Women
65 - 74
75+
1–7
34
42
38
39
33
34
23
8 – 14
21
19
23
20
19
12
8
15 – 21
16 - 24
11
25 - 34
10
35 - 44
9
45 - 54
10
55 - 64
6
5
2
22 – 35
8
5
4
7
4
2
1
35+
4
2
2
2
1
0
0
*Source: Erens & Moody, 2005
The patient can be asked to self-rate the “importance to
change” from 1 to 10, and discussion can then occur
regarding the reasons for the self-rating, and what would need
to happen for importance to increase. The patient can also
self-rate their “confidence to change” from 1 to 10, and discussion can occur regarding their level of confidence.
23
Mental Health
Box 2 Recommended limits
Daily recommended limits:
No more than 4 units per day for men
No more than 3 units per day for women
Mental Health
Following a final summary of the whole discussion, permission
to provide a recommendation should be sought. Hazardous
drinkers should be encouraged to consider that all forms of
reduction (in amount consumed per occasion and number of
occasions per week) towards daily and weekly recommended
limits are positive. Further counselling is not indicated by
default, although the patient can be asked about progress a
few months later if contact allows. Harmful drinkers should be
encouraged to reduce to recommended limits, and attempts
should be made to ensure follow-up questions about progress
occur. For those who find it difficult to change but who
are responsive to offers to discuss their drinking further,
counselling with a practitioner trained in motivational
interviewing is indicated . For those with alcohol dependence,
the discussion should be aimed at having the patient consider
their need to seek specialist treatment, with referral made
when this is accepted. Follow-up questions about progress
should be ensured. As a rule, the entire discussion should
take up to a maximum of fifteen minutes .
Expected outcomes following brief intervention
Based on the randomised controlled trials of brief
intervention, and the meta-analyses of these trials, it has been
demonstrated that brief intervention is worthwhile . One typical
UK study found that one in five heavy drinkers who received
BI had become a low-risk drinker one year later, compared
to one in twenty who did not receive BI . There is a growing
evidence base that nurses can be as effective as medical
practitioners in enhancing lower-risk drinking patterns amongst
patients . Current calculations show that for every nine heavy
drinkers intervened with, one will be drinking in a low-risk
fashion one year later . Some of the rest will also be drinking
less on some occasions, and on fewer occasions than before.
Those with alcohol dependence are not usually influenced by
brief intervention, and instead the intention is to facilitate their
referral to specialist treatment services.
Conclusions
Heavy drinking is highly prevalent, and nurses in all areas are
likely to be coming into contact with hazardous, harmful and
dependent drinkers. It can be difficult to identify such drinkers
until significant medical and psychological harm has accrued,
unless time is taken to ask specific alcohol-related screening
and assessment questions. Having identified the heavy
drinking patient, the ideal intervention is to spend up to
fifteen minutes talking about their drinking, incorporating an
exploration of the patient’s concerns with health education
from the nurse.
Dillard, J. P. and Shen, L. (2005) On the Nature of Reactance and its
Role in Persuasive Health Communication. Communication
Monographs 72, 144-168.
Erens, B. and Moody, A. (2005) Alcohol Consumption. In The Scottish
Health Survey, Vol. 2, Bromley, C., Sproston, K. and Shelton, N. eds,
pp. 1-38. Scottish Executive, Edinburgh.
Hodgson, R., Alwyn, T., John, B., Thom, B. and Smith, A. (2002) The
FAST Alcohol Screening Test. Alcohol & Alcoholism 37, 61-66.
http://www.jsad.com/jsad/static/binge.html.
Leffingwell, T. R., Neumann, C. A., Babitzke, A. C. and Leedy, M. J.
(2007) Social Psychology and Motivational Interviewing: A Review of
Relevant Principles and Recommendations for Research and Practice.
Behavioural and Cognitive Psychotherapy 35, 31-45.
Leon, D. A. and McCambridge, J. (2006) Liver cirrhosis mortality rates
in Britain from 1950 to 2002: an analysis of routine data. Lancet 367,
52-56.
McBride, N., Farringdon, F., Midford, R., Meuleners, L. and Phillips, M.
(2004) Harm minimization in school drug education: final results of the
School Health and Alcohol Harm Reduction Project (SHAHRP).
Addiction 99, 278-291.
Miller, W. R. (2000) Rediscovering Fire: Small Interventions, Large
Effects. Psychology of Addictive Behaviors 14, 6-18.
Miller, W. R. and Rollnick, S. (2002) Motivational Interviewing:
Preparing People For Change. Guilford Press, New York.
Moyer, A., Finney, J. W., Swearingen, C. E. and Vergun, P. (2002) Brief
interventions for alcohol problems: a meta-analytic review of controlled
investigations in treatment-seeking and non-treatment-seeking populations. Addiction 97, 272-292.
Murray, R. P., Connett, J. E., Tyas, S. L., Bond, R., Ekuma, O.,
Silversides, C. K. and Barnes, G. E. (2002) Alcohol Volume, Drinking
Pattern, and Cardiovascular Disease Morbidity and Motality: Is There a
U-shaped Function? American Journal of Epidemiology 155, 242-248.
National Treatment Agency for Substance Misuse (2006) Models of
care for alcohol misusers (MoCAM). Department of Health, London.
NHS Quality Improvement Scotland (2005) Clinical indicators 2005.
NHS Quality Improvement Scotland, Edinburgh.
Ockene, J. K., Adams, A., Hurley, T. G., Wheeler, E. V. and Hebert, J.
(1999) Brief Physician- and Nurse Practitioner- Delivered Counseling
for High-Risk Drinkers: Does It Work? Archives of Internal Medicine
159, 2198-2205.
Prime Minister's Strategy Unit (2004) Alcohol Harm Reduction Strategy
for England. Cabinet Office, London.
References
ADDIN EN.REFLIST Anderson, P. and Scott, E. (1992) The effect of
general practitioners' advice to heavy drinking men. British Journal of
Addiction 87, 891-900.
Babor, T. F. and Higgins-Biddle, J. C. (2001) Brief Intervention: For
Hazardous and Harmful Drinking: A Manual for Use in Primary Care.
World Health Organization, Geneva.
Ballesteros, J., Duffy, J. C., Querejeta, I., Ariño, J. and Gonzàlez-Pinto,
A. (2004) Efficacy of Brief Interventions for Hazardous Drinkers in
Primary Care: Systematic Review and Meta-Analyses. Alcoholism:
Clinical and Experimental Research 28, 608-618.
Bellentani, S., Saccoccio, G., Masutti, F., Giacca, M., Miglioli, L.,
Monzoni, A. and Tiribelli, C. (2000) Risk factors for alcoholic liver
disease. Addiction Biology 5, 261-268.
Corrao, G., Bagnardi, V., Zambon, A. and Arico, S. (1999) Exploring
the dose-response relationship between alcohol consumption and the
risk of several alcohol-related conditions: a meta-analysis. Addiction
94, 1551-1573.
24
Rehm, J., Gmel, G., Sempos, C. T. and Trevisan, M. (2005) AlcoholRelated Morbidity and Mortality. Alcohol Research & Health 27, 39-51.
Rickards, L., Fox, K., Roberts, C., Fletcher, L. and Goddard, E. (2004)
Living in Britain. No 31: Results from the 2002 General Household
Survey. The Stationery Office, London.
Rollnick, S., Butler, C. and Hodgson, R. (1997) Brief Alcohol
Interventions in Medical Settings: Concerns from the Consulting Room.
Addiction Research 5, 331-342.
Rubak, S., Sandbœk, A., Lauritzen, T. and Christensen, B. (2005)
Motivational interviewing: a systematic review and meta-analysis.
British Journal of General Practice 55, 305-312.
Scott, H. K. (2000) Screening for hazardous drinking in a population
of well women. British Journal of Nursing 9, 107-114.
SIGN (2003) The management of harmful drinking and alcohol
dependence in primary care: A national clinical guideline. Royal
College of Physicians, Edinburgh.
Stockwell, T. (2006) Alcohol supply, demand, and harm reduction:
What is the strongest cocktail? International Journal of Drug Policy 17,
Stockwell, T., Hawks, D., Lang, E. and Rydon, P. (1996) Unravelling the
preventive paradox for acute alcohol problems. Drug and Alcohol
Review 15, 7-15.
The Academy of Medical Sciences (2004) Calling Time: The Nation's
drinking as a major health issue. The Academy of Medical Sciences,
London.
Varney, S. J. and Guest, J. F. (2002) The Annual Societal Cost of
Alcohol Misuse in Scotland. Pharmacoeconomics 20, 891-907.
Vasilaki, E. I., Hosier, S. G. and Cox, W. M. (2006) The Efficacy Of
Motivational Interviewing As A Brief Intervention For Excessive
Drinking: A Meta-Analytic Review. Alcohol & Alcoholism 41, 328-335.
WHO (2002) The World Health Report 2002. World Health
Organization, Geneva.
Wilk, A. I., Jensen, N. M. and Havighurst, T. C. (1997) Meta-analysis of
Randomized Control Trials Addressing Brief Interventions in Heavy
Alcohol Drinkers. journal of General Internal Medicine 12, 274-283.
Wright, S., Moran, L., Meyrick, M., O'Connor, R. and Touquet, R. (1998)
Intervention by an alcohol health worker in an accident and emergency department. Alcohol & Alcoholism 33, 651-656.
Brief Intervention: a summary
1. Screen
2. Negotiate a discussion of the patient’s drinking
3. Get the patient talking about their drinking (“a typical day”)
4. Empathise with functional aspects of drinking, encourage
elaboration about concerns
5. Offer objective feedback (liver enzymes, compare
population drinking norms)
6. Ask about importance to change/ confidence to change
7. Summarise: on the one hand things the patient enjoys/
values about drinking; on the other concerns the patient
has about drinking, plus health professional concerns from
assessment
8. Ask permission to give recommendation, and then deliver
Case study 1
Andrew is a 46-year-old manager with a local company. He is
married with three children. He and his wife usually drink one
bottle of red wine between them over dinner most nights
(750ml x 14% = 10.5 units per bottle = 5 units each x 5 nights
= 25 units).
Andrew also enjoys a generous scotch as a nightcap most
nights (2 units x 6 nights = 12 units), and meets with friends
for some real ale at the weekend (4 pints x 2 units = 8 units).
Andrew’s average daily consumption is 7 units and his
average weekly consumption is 45 units. This was calculated
when he visited his practice’s well man clinic. The clinical
agenda centred on Andrew’s borderline hypertension. The
nurse sought permission to discuss related issues of stress,
diet, alcohol and exercise. Andrew agreed to complete the
AUDIT, and scored 11. The nurse fed back that his drinking
was in the hazardous range, and that only 5% of men his age
drank as much as he did each week. The nurse clarified that
this did not necessarily mean he had an “alcohol problem”,
but that his long-term health was at risk.
The nurse also specifically highlighted the link between
alcohol consumption and hypertension. The nurse advised
Andrew of the daily and weekly-recommended limits and
encouraged him to consider reducing his consumption below
them. The nurse empathised about how his drinking helped
him relax after work, and stressed that any decision about
whether to change lay with him.
Andrew reflected on how playing football at weekends used
to help him unwind, and they went on to discuss the potential
of structured exercise to reduce his stress and his blood
pressure. Andrew received no further intervention for his
drinking. One year later he usually drinks one (large, 250ml)
glass of wine over dinner most nights, no longer has a
nightcap, and still meets his friends twice a month. His
average daily consumption is 3.5 units (within limits) and his
weekly consumption is 25 units (slightly above limits, but
improved on previous pattern).
(Adapted from Miller & Rollnick, 2002; Rollnick et al, 1997;
SIGN, 2003)
Box 4 Further resources
Brief intervention guidelines :
http://whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6b.pdf
http://pubs.niaaa.nih.gov/publications/Practitioner/Clinicians
Guide2005/guide.pdf
http://www.sign.ac.uk/pdf/sign74.pdf
Screening and assessment tools :
http://www.clintemplate.org/groups/9/
Alcohol-related websites for patients :
www.alcoholhelpcenter.net
www.downyourdrink.net
Alcohol-related websites for nurses :
www.nursingcouncilonalcohol.org
www.prodigy.nhs.uk/alcohol_problem_drinking
25
Mental Health
Silvia, P. J. (2006) Reactance and the dynamics of disagreement:
Multiple paths from threatened freedom to resistance to persuasion.
European Journal of Social Psychology 36, 673-685.
ECG
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COPD : PART 2 of 3
CAUSES OF COPD
Cigarette smoking
The primary cause of COPD is exposure to tobacco smoke.
Clinically significant COPD develops in 15% of cigarette
smokers. Age of initiation of smoking, total pack-years, and
current smoking status predict COPD mortality.(2) Overall,
tobacco smoking accounts for as much as 90% of the risk.
Second-hand smoke, or environmental tobacco smoke,
increases the risk of respiratory infections, augments asthma
symptoms and causes a measurable reduction in pulmonary
function.
• Air pollution
• Airway hyper-responsiveness
Diagnosis
Imaging Studies:
• Chest radiograph
• Computed tomography scan
Other Tests:
Pulmonary function tests which are essential for the diagnosis
and assessment of the severity of disease, and they are helpful
in following its progress. Carbon monoxide diffusing capacity
is decreased in proportion to the severity of emphysema.
Arterial blood gases reveal mild-to-moderate hypoxemia
without hypercapnea in the early stages. As the disease
progresses, hypoxemia becomes more severe and
hypercapnea supervenes. Hypercapnea commonly is
observed as the FEV1 value drops.
Treatment & Care:
The goal of management is to improve daily living and the
quality of life by preventing symptoms and the recurrence of
exacerbations by preserving optimal lung function. Once the
diagnosis of COPD is established, educate the patient about
the disease. Encourage the patient to participate actively in
therapy.
Smoking cessation continues to be the most important
therapeutic intervention. Most patients with COPD have
a history of smoking or are currently smoking tobacco
products. A smoking cessation plan is an essential part of a
comprehensive management plan. The success rates are low
because of the addictive power of nicotine, the conditioned
response to smoking-associated stimuli and psychological
problems, including depression, poor education and
campaigns by the tobacco industry.
27
Multiple Sclerosis
Evidence for the main management
and treatment strategies for spasticity
in multiple sclerosis.
by Paula Cowan, NHS Lothian, MS Specialist Physiotherapist, DCN Physiotherapy department
Western general Hospital, Crewe Road South EH4 2XU Tel: 0131 537 2113/ 07743861493
ABSTRACT. This short paper, which is the last in a series of
four looking at management of multiple sclerosis, will present
a treatment strategy for spasticity management in MS. This
strategy has been developed by a review of literature and
leads into a discussion of future improvements and research.
It will discuss issues in spasticity management raised in the
light of current practice. The indication for treating spasticity is
when it is causing harm (Ward AD 2002). An algorithm will be
put forward as a tool for evaluation, monitoring and treatment
of spasticity (Haselkorn JK et al 2005).The algorithm chosen
was adapted from Haselkorn et al 2005 as the review of
literature supported Haselkorns approach to the management
of spasticity. It was adapted to incorporate the essential
patient centred approach. A sequential, linear approach may
not apply to every individual but is intended to augment good
clinical reasoning. Guidelines can facilitate behavioural
changes in practice and research to minimise the often
devastating impacts of spasticity in MS. The author
recommends a thorough assessment of the impact of
spasticity on function in order to determine the need for and
effects of a treatment programme. Best practice treatments
and monitoring are discussed.
INTRODUCTION. An estimated 40-70% of individuals
who have multiple sclerosis (MS) report impairments and
disabilities that are due to spasticity (Haselkorn J, Loomis S,
2005). In recent years scientific advances in diagnosis and
improvements in treatment have dramatically increased the
knowledge and interest in MS. Nice guidelines (2003) have
tried to direct that all persons with MS have options to receive
treatments that may positively change their out look on life,
and improve their social and economic status. Therefore there
is an urgent need to optimise treatment strategies for patients
with MS in terms of spasticity due to its frequency in
occurrence and often debilitating consequences. In order
to treat spasticity, it is not always necessary to understand
the complexities of its pathophysiology. You are treating and
evaluating the effects the spasticity has on the body rather
than being concerned about the direct cause. It is also
important to note that spasticity can at times assist in the
rehabilitation process by assisting patients to stand who
otherwise could not (Ward AB 2002). Therefore spasticity only
needs to be treated when it is causing harm and that means
causing clinical symptoms or signs that are considered disabling. Or have the potential to become disabling. (Ward AB
2002, Stevenson VL & Jarrett L 2006).
Algorithms are presented by many authors for the treatment
of spasticity and are used as guidelines not as rules. They can
aid the clinician in their decision making by following a basic
step by step linear approach to treatment but there has to
be flexibility with the patient at the centre of treatment and
decision making. (Ward AB 2002, Stevenson VL & Jarrett L
2006, Haselthorn JK, Loomis S 2005.)
Spasticity is multifaceted and can range widely from a minor
annoyance to the initiation of a causal chain that results in
severe disabilities. The focus of this paper is to familiarise the
28
clinician with the management of spasticity in multiple
sclerosis.
METHOD. A computer assisted literature search was
performed on medical databases: Medline, Embase, CINAHL
and Cochrane. The following search terms were applied with
no limits: Spasticity management, Spasticity in MS, Treatment
of spasticity.
RESULTS. Evaluation of spasticity: The successful
individualised management of spasticity depends upon
investigation into the frequency, the intensity, and the
functional impacts of spasticity. Spasticity that interferes with
desired function is an indication for treatment (Haselkorn JK &
Loomis S 2005). The “clinical practice guidelines” in multiple
sclerosis by the multiple sclerosis council recommends that
spasticity be evaluated as part of a routine evaluation whether
or not the person with MS makes a specific complaint. The
importance of a thorough history cannot be over emphasised.
Management will only be successful if the person with MS
is allowed to express their own account of the impact of
spasticity and has time to express their expectations and
hopes (Stevenson VL & Jarrett L 2006).
It follows therefore that measurement or evaluation is essential
in order to monitor whether treatment has been successful.
This can be done in a number of ways depending on how
the spasticity is influencing the patient. In broad terms,
measurement instruments can be categorised into
neurophysiological methods (Voerman et al 2005),
biomechanical techniques (Wood et al 2005) and clinical
scales (Platz et al 2005). There is evidence in the literature
of spasticity evaluation which has been quantitatively
researched, and many different objective measurement
techniques have been employed ( Platz T et al 2005). A
selection of different measures is probably most appropriate
to reflect the different aspects of the condition. A battery of
measures to reflect different aspects of spasticity, such as
range of movement, resistance to movement (Ashworth scale),
strength, clonus and spasm frequency, as well as subjective
measures to capture the individuals perspective, such as VAS
(visual analogue scale) for pain, stiffness or comfort. Relevant
functional measures may be included eg timed walks, gait
analysis, nine hole peg. The measurements used should be
individualised for each patient. The limited use of outcome
measures in everyday assessment probably reflects the time
available, the varied nature of spasticity and complex nature
of the patients; this will reduce the effectiveness of the
management. (Stevenson VL & Jarrett L 2006). Although
present scales have limited ability, they are still routinely in
clinical practice, which is concerning for effective spasticity
management. However new evidence supports the use of the
MSSS-88 scale, a qualitative, patient based measure recently
developed and validated for MS. If spasticity management is
to be patient focused, clinical practice needs measurement
methods that capture patient’s experiences and perceptions
of spasticity. This scale claims to achieve this. (Hobart JC et al
2006).
Spasticity that is causing primarily focal problems can
frequently be treated with rehabilitation strategies and/or
neuromuscular blockade. Spasticity that is causing general
problems is likely to require more intense interventions.
Pharmacological treatments are available for both general and
focal types. Oral agents are given for generalised spasticity
while botulinum toxin or phenol injections are given for focal
spasticity. Along side those treatments skilled rehabilitation
strategies are employed such as self management techniques,
aids, splinting, posture/seating, stretching, functional electrical
stimulation, orthotics, splinting, exercise and thermal
modalities (Richardson D 2002). The final steps for some
patients in the algorithm are if the above interventions are not
effective and intrathecal treatment or surgical procedures are
an option. These options are not as commonly carried out
for many reasons. Cost of intrathecal pumps is a common
complaint but Ward AB 2002 points out that cost should be
set against ‘value’ of the treatment. If by treating the patient,
for example, reductions are made in their care management
costs i.e. less carers then overall it is cost effective. Surgery
can be painful and is irreversible. It is also seen as the end of
the line. In recent years there has been a marked reduction in
the amount of surgery but this is unclear as to whether that is
because management techniques have improved or some
other reason (Smyth MD & Peacock WJ 2000). The algorithm
at each stage concludes with evaluation and monitoring to
measure effectiveness.
CONCLUSIONS/RECOMMENDATIONS. Spasticity in MS
although a reported common problem can be under managed
in this population, resulting in some clients using significant
amounts of medication but still experiencing significant
residual functional limitations(Haselkorn JK & Loomis S 2005).
Spasticity in MS should not be treated with medication in
isolation, but instead a holistic approach should be available
for all clients. To successfully treat spasticity in MS then the
approach must be one that an individual accepts and is able
to incorporate into his/her life over many years, hence client
centred. Effective management of spasticity must begin with
education of available options to the client with MS, thus
allowing individuals to find treatment options which best fits
their own individual needs.
At outset, it is essential to identify the goals of treatment with
the client and have agreed outcomes which meet the client’s
needs. The adapted algorithm by Haselkorn et al is a useful
comprehensive guide supported by literature for the treatment
of spasticity. In the future clinicians should be cautious about
not substituting this algorithm for good clinical reasoning but
instead should use it in supporting treatment that can be
individualised to the client. This is best achieved in a
multidisciplinary team as tasks associated to agreed
outcomes can be shared between professionals; this allows
for the most appropriate professional working with the client to
affect the most change as efficiently as possible. Essential
changes must take place from the isolated GP consultation to
evolving team clinics to treat this complex multidimensional
symptom. Successful management requires follow-up and fine
tuning to meet the changing needs of the individual who has
MS, over the course of the disease. This follow up has been
lacking and through personal experience many patients have
been put on medications that have not been reviewed for
many years. There is also no evidence to suggest the best
time to introduce pharmacological treatments, hence requires
further investigation ( Basmajan JV 1975) The Nice guidelines,
although not compulsory in Scotland, have helped to
encourage open referral and close monitoring in spasticity
and other symptoms and empower the patient to be at the
centre of treatment decisions. Only recently has a measure
of the patient’s experience of spasticity become available
(MSSS-88) and as this becomes more widely used by
clinicians then this could be an exciting development to
find out more about spasticity in MS patients.
KEY POINTS:
•
•
•
•
•
Spasticity management is client centred
The use of an algorithm can be helpful
Only treat spasticity when it is causing harm
Set goals with the clients
Evaluate/ monitor with appropriate outcome measures for
each client
• Multidisciplinary team approach
KEY WORDS:
•
•
•
•
•
Spasticity
Management
Outcome
Measurement
Algorithm
REFERENCES:
Abbruzzese G (2002) The medical management of spasticity. European journal of
neurology 9 (suppl. 1 ) p30-34
Barnes MP, et al (2003) Spasticity in multiple sclerosis. Neurorehabil Neural Repair
vol 17(1): 66-70.
Basmajan JV (1975) Lioresal (baclofen) treatment of spasticity in multiple
sclerosis. Am J Phy Med 54(4):175-177
Brichetto G, et al (2003) Symptomatic medication in use in multiple sclerosis. Vol
9(5):458-60.
Haselkorn JK, Loomis S (2005) Multiple Sclerosis and spasticity. Phys Med Rehabil
Clin N Am 16. 467-481
Haselkorn JK (et al) (2005) Overview of spasticity management in multiple
sclerosis. Evidence-based management strategies for spasticity treatment in
multiple sclerosis. The journal of spinal cord medicine 28 ( 2) p167-199.
Hobart JC(et al) (2006) Getting the measure of spasticity in multiple sclerosis:
the Multiple sclerosis spasticity scale (MSSS-88) Brain 129, 224-234
Johnson GR (2002) Outcome measures of spasticity. European journal of
neurology 9 (suppl. 1) 10-16
Platz T et al (2005) Clinical scales for the assessment of spasticity, associated
phenomena, and function: a systematic review of literature. Disabil Rehabil 27:7-18.
Richardson D (2002) Physical therapy in spasticity European journal of
neurology 9 ( suppl. 1) 17-22
SmythMD, Peacock WJ (2000) The surgical treatment of spasticity. Muscle nerve
23:153-63.
Ward AB (2002) A summary of spasticity management- a treatment algorithm.
European journal of Neurology 9 p48-52
29
Multiple Sclerosis
TREATMENT STRATEGIES: The multiple sclerosis Council
for clinical practice guidelines published an algorithm for
management of spasticity (Haselkorn JK et al 2003). Although
algorithms are useful, a successful treatment strategy is one
that an individual accepts and is able to incorporate into
his/her life. This algorithm therefore can be used as a guide
and adapted to suit individual needs (see appendix 1). At
outset it is essential to set goals of treatment with the patient
and acceptable outcomes. Successful management requires
follow-up and fine tuning therefore any algorithm should
incorporate this requirement. When spasticity is presented as
either a new or aggravated symptoms then the algorithm by
Haselkorn et al 2005, guides the clinician to investigate and
treat provocative factors. These have been identified in part by
Stevenson VL & Jarrett L 2006, and clinical experience. They
are numerous and very individual to each patient and include
such aggravators as: infections, constipation, pain, drug
therapy, temperature, tight clothing, poor posture/positioning
and stress. Once these have been treated a client centred
approach to assessing any impairment or functional problems
are the next stage of the algorithm. Client centred participation
is essential as it minimises secondary complications and
helps to achieve the goals of a management programme.
This is highlighted in the algorithm. Spasticity then has to be
characterised into focal or general in order to treat properly.
30
Multiple Sclerosis
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31
Anne Diamond
Just in case you still think he’s a plonker
- let me tell you, I think John Prescott
has been very brave indeed to confess,
in his new, hot-off-the-bookshelves,
larger- than-life autobiography that he
has suffered from bulimia.
Okay, so many cynics reckon it’s a cheap way to grab headlines and
turn his book into a bestseller. But they underestimate the ferocity
of the storm into which Prezza has just willingly dived. Because if
he thought he got nasty headlines and malicious, snide comments
from press and people for his politics, he ain’t seen nothing yet.
For some reason, the media absolutely loathes fatties and almost
quite deliberately misunderstands the issues.
The day the news broke, I heard Radio 4’s Sue McGregor - “ by all
accounts an informed and intelligent person” comment: ‘I don’t
mean this unkindly, but his fight with bulimia seems to have been
one which he seems to have lost!’ The audience at Broadcasting
House guffawed. ‘I thought bulimics were, some of them, unbearably
thin, poor things!’ she added.
Then someone else made a stupid comment about Prezza’s two
Jags being to blame for his obesity - and so started day after day
of cheap shots at Prezza’s expense in the newspapers, on tv and
radio. And who would believe there were so many hundreds of
pictures of him scoffing his face! Here he was cradling an enormous
pack of fish and chips, there he was biting into a pie. Here he was
sitting at a banquet, knife and fork at the ready and napkin tucked
into his collar, there he was nibbling a sausage roll whilst on the
campaign trail. The picture editors had a never-ending supply. And
the vocabulary, unacceptable for any other medical condition, was
vicious ‘greedy’, ’lardy’, ’Fat boy’ and everywhere, the inevitable
question which is, in itself, a massive insult: "Did Blair know he
had left a sick man in charge?" For ‘sick’, read no compassion, just
the assumption that a bulimic may not be mentally unstable, and
therefore unable to do his job.
Bulimia and anorexia wreck lives - “ whether they affect painfully
thin schoolgirls or a middle aged politicians. Are they part of the
obesity epidemic we’re trying to fight right across the world? Is
over-eating, like anorexia and bulimia, an ‘eating disorder’ I’d say
yes. Are these conditions a sign of mental instability? As you cannot
control your eating, and your obsession with food may actually be
controlling you, does that mean you are mentally incapable of
dealing with the rest of your life?
On my website, www.buddypower.net, we have hundreds of men
and women who vehemently disagree with the idea the’re mentally
unbalanced! They lead busy lives, juggling work with bringing up
families. Many have big deal jobs, managing companies, people,
money. Many are nurses!
Eating disorders - “and I include overeating in this” are thought to
be a symptom of stress. Stress is clearly a 21st century disease,
and shows itself differently in different people. Some turn to drink
or drugs, or compulsive shopping or gambling. Others, like John
Prescott, turn to food - even when the’ve just got home from a five
course banquet in the City. Apparently, when his bulimia became
known within his immediate circle of family and friends, one close
aide told him to simply ‘eat less’. Fat lot of good that did.
After much nagging from the wife, Prezza did eventually go to see
the House of Commons doctor, who referred him to a specialist in
eating disorders. He nearly turned tail when he saw the waiting
room, full of anxious young women. “Luckily, none of them
shopped me to the press” he remarked.
That’s the first thing I thought of, too, when I tried to seek medical
help for my weight problem. I was terrified that someone would
recognise me, and tell the papers. In the end, they did. When I was
nervously awaiting obesity surgery in a Belgian clinic, some fellow
British sufferer decided to shop me to the Sunday papers - which is
how my gastric band became a public fascination rather than my
own private worry!
Now if that’s not a sign of stress, tell me what is! It’s one thing to
have a weight problem, or a suspicion that you’re out of control with
your food intake, but it’s quite another to face the contempt of the
media.
Yet I know a great many Fleet Street writers, photographers and
editors, many of whom have weight problems, and even more who
are near-alcoholics. I dread to think how many may have drugs
problems, too. In the various broadcasting centres I have worked
in, I have been only too aware of snorting going on in the loos, and
performers who go in looking hangdog and miserable and who,
moments later, emerge wide-eyed and buzzing. But they’re okay,
you see, because their problem is hidden rather better than the fatty
bulimic or the anorexic.
We sophisticated, 21st century humans seem to have such a weird
relationship with food. In India, as we all know, the poor are starving.
So the emerging middle class, as a sign of success and wealth,
found it desirable to become fat. Now they realise they’ve gone too
far, and are queueing up for obesity surgery, some 20,000 women
in New Delhi alone.
In the little island of Puerto Rico, the governor has declared
childhood obesity an ‘island-wide emergency’. A whole generation
of kids are presenting with high blood pressure, diabetes and heart
disease. Yet still their culture celebrates ‘pudginess’ as a sign of a
healthy child. One top paediatrician there says 40 to 50 percent
of the infants he treats are overfed. "The older generations, the
grandmothers, are the ones who have this idea everyone needs
to be chubby." he said.
Genetics have been blamed for fuelling the epidemic in Puerto Rico
and other Latin American countries, where people's indigenous
ancestors evolved to survive without a reliable food supply.
Those genes plus an overabundance of food is a deadly
combination. At the moment, it seems to be more prevalent in the
Hispanics and African-Americans. Almost unbelievably, 78 per cent
of African American women are obese, that’s a whole population of
mums and grans who could die early. But one day it’s going to show
in most of us worldwide throughout all races and kinds.
According to one geneticist I recently interviewed at the University
of Oxford, we have bodies that were created for a time of need, and
we now live in a world of plenty. (Most of us, anyway). Genetically,
we cannot evolve quickly enough to stop us dying from obesity.
So we need to find other ways. Quickly. Like getting our head
around the problem.
As John Prescott is going to discover, with the impending launch
of his book, the media still thinks it’s funny, pathetic and worthy of
ridicule and scorn. Years of political bear-baiting may have prepared
him for malicious attacks. But this is so personal, I fear for his
strength. If it were me, it would send me right back to the biscuits
and ice-cream.
The National Obesity Forum
(NOF) recently announced the
appointment of TV personality,
Health Campaigner and
Journalist, Anne Diamond,
as its Patron.
During her career, Anne Diamond has helped launch
awareness drives concerning cervical cancer screening,
autism, dyslexia and vaccination programmes. Her proudest
achievement was the spearheading of the 1991 “Back To
Sleep” campaign to prevent cot death, which earned her the
Medal of the Royal College of Paediatrics and Child Health.
She is the only non-medic to ever receive this accolade.
Now she has turned her attention to the obesity epidemic,
since her own well-publicised battle with her weight and has
accepted the role of Patron with The National Obesity Forum
and is writing a book about the global obesity epidemic.
The Government recently announced plans for new
standards and guidelines in Children’s Centre’s - to tackle
Britain’s obesity problem for children up to the age of five.
Today, 1 in 5 children in Britain are overweight or obese.
Responding to this strategy www.grub4life.org.uk, Britain's
first on-line family nutrition service has been launched in
tandem with this initiative to help make feeding pre school
children easier, less complicated, less stressful – and
healthier. www.grub4life.org.uk is an on-line family nutrition
service designed by childhood dietitian Nigel Denby for
parents, carers, child care workers, and health professionals.
In announcing the Government's Strategy, "Healthy Weight,
Healthy Lives" The Rt. Hon Alan Johnson MP. Secretary of
State, Department of Health said "Tackling obesity is the most
significant public and personal health challenge facing our
society. The core of the problem is simple - we eat too much
and we do too little exercise. The solution is more complex.
The first key element of the strategy is the healthy growth and
development of children.”
Responding to the Government strategy and announcing
the launch of www.grub4life.org.uk TV Dietitian and founder of
the on line service, Nigel Denby, says “www.Grub4life.org.uk
has been created on two very simple principles- "Good
nutrition should start from an early age and good health is
the foundation for Good Learning. We are passionate about
supporting the Government’s initiative through Children’s
Centres and have provided access to our extensive
resources through www.grub4life.org.uk".
www.grub4life.org.uk has a comprehensive database of fact
sheets and family recipes, which have been tried and tested
on over 10,000 pre school children which are available to all;
daily updated news and research updates on children's
nutrition; a panel of experts include leading dietitians, chefs
and child care specialists as well as parents who share a
passion for feeding their children; On line Forums and chat
rooms offer a chance to share triumphs, worries as well as
every day real stories of how to help children eat well.
Registration is free for parents and carers by going to
www.grub4life.org.uk.
For more information please call Nigel Denby or
Tony Fitzpatrick on 07941 396610 or email at
[email protected]
The NOF was established by clinicians in late 2000 to
raise awareness of the growing health impact that being
overweight or obese was having on patients and the National
Health Service (NHS). Ms. Diamond’s role will be to increase
awareness of the growing prevalence of obesity and its
dangers, and to call for urgent action from health care
professionals so that sufferers can be helped.
Announcing the appointment, Dr. Colin Waine, Chair of the
National Obesity Forum said today, ”The National Obesity
Forum is delighted to announce that Anne Diamond has
kindly agreed to become a valued patron. We look forward
to working in collaboration with her to tackle issues relating to
obesity and its impact on health and health resources.”
Anne Diamond said, “I am delighted to become Patron of the
NOF, and I hope to help make a difference. What we need
is greater understanding from the medical establishment,
action from the politicians, and compassionate help for the
individuals whose lives are being impaired and shortened by
this debilitating condition. It’s not a laughing matter, it’s an
enormous tragedy in the making. I used to be known as the
“elfin queen of breakfast television”, so if obesity happened
to me it can happen to almost anyone! I am gradually
winning the war against fat, and I hope to help others, too.”
Obesity can shorten life.
It can wreck quality of life.
Currently, 1 in 4 women,
1 in 5 men in the UK is
obese.
We have the fattest
children in Europe.
Obesity has trebled
since the 1980s and
costs the UK £2.3
billion a year in health
and other costs - a
figure expected to rise
to £2.6 billion by 2010.
(NOF)
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Anne Diamond
New on-line family nutrition
service launches this week
to support Government's
Child Obesity strategy
34
Canada Feature - Alberta
Relocating to
Canada Feature - Alberta
ALBERTA
If you are considering Alberta
as a place to work and live,
then you are moving towards
a bright future
Alberta is a province in Canada
Alberta is one of the best places in the world to work and live. The economy is
booming, so there are lots of job opportunities not only for you, but also for your
family members. Alberta has no provincial sales tax and the lowest rate of
provincial income tax in the country. We have an excellent public education
system, first-class health care and other social services, a comfortable standard
of living, clean air, beautiful scenery and welcoming people.
If you are considering Alberta as a place to work and live, then you are moving towards a bright future. Alberta's
unprecedented economic growth has opened up many opportunities for immigrants to start a new life with access
to first-rate education, health care and recreation. Alberta Employment, Immigration and Industry can provide you
with information about the immigration process for Canada and Alberta, as well as about programs and services
designed to help immigrants before and after they arrive.
LIVING IN ALBERTA : : :
Alberta offers a high standard of living and quality of life that is among the best in
the world. Alberta’s strong economy places it in high demand for those looking for
a new home in Canada.
Before you decide to come, make yourself familiar with what life is like in Alberta,
to see if it is the right place for you. In particular, you should learn more about:
• Housing: Alberta’s booming economy has placed enormous demand on the
supply of housing.
Alberta Facts :
Population: As of April 1, 2007, Alberta's
population is estimated to be 3,455,062.
This represents a yearly increase of
approximately 102,800 persons (or 3.07%
growth) for the twelve months ending
April 1, 2007.
Source: Alberta Finance
Capital City: Edmonton
• Transportation: There are lots of ways to get around in Alberta, including
public buses, trains and personal vehicles.
Currency: Canadian dollar
• Childcare: Learn about the childcare options available for you.
Weather: Current weather in Alberta
• Education in Alberta: Alberta has a world-class educational system.
If you’d like to improve your English language skills, Alberta offers English
language training.
Telephone Area Codes: 780 in the northern
part of the province, 403 in the south
• Healthcare: Alberta has a strong and responsive public healthcare system
that offers preventative, emergency, and long-term care.
Proclaimed a Province: September 1, 1905
• Money and banking: Alberta offers banking and financial services to help
you make the most of the money you earn.
• Laws and the legal system: The justice system is designed to ensure that
people live in safety and security.
• Participating in your community: The best part about living in Alberta is that
it has wonderful opportunities to get involved in your community and have fun.
Time Zone: Mountain Time (two hours
behind Toronto or New York; one hour
ahead of Vancouver, Seattle or
Los Angeles; seven hours behind
Greenwich Mean Time (GMT); and six hours
behind GMT during Daylight Savings Time)
Log onto: http://alberta.ca/home
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Canada Feature - Alberta
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Canada Feature- Alberta
Recruitment - Australia
MIGRATE TO AUSTRALIA
We assist Registered Nurses with hospital or age care
experience to process their Australian Permanent Residency
(Migration) Visa application, Australian Nursing Registration,
Employment and Settlement in Australia.
Please email your details to:
Varghese Puthussery, CPA, MMIA (MARN 0209861)
Email: [email protected] Web: E-VISA.COM.AU
e-Visa Australia Pty. Ltd., 2A Doric Street,
Shelley WA 6148, Perth, Australia
Ph: + 6189354 2285 / 6140208 7675 Fax: +6189354 2618
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39
Recruitment - New Zealand
40
Recruitment - New Zealand
Recruitment - Middle East
CURRENTLY RECRUITING FOR INTERVIEWS IN JUNE
Great opportunities in the Kingdom of Saudi Arabia!
The Saudi Aramco Medical Services Organization
(SAMSO), is currently recruiting world class staff: nurses,
supervisors and nursing personnel, across all disciplines
and specializations
Saudi Aramco is the national oil company of the Kingdom
of Saudi Arabia, and for 75 years has been a reliable and
responsible supplier of energy to the world.
SAMSO itself is a world class organization with a proud
history. It provides excellent medical care for Saudi
Aramco employees and their dependants - currently a total
patient population of over 180,000. SAMSO is accredited
by the Joint Commission on Accreditation of Health
Care Organizations (JCAHO) and the Joint Commission
International (JCI). SAMSO maintains the highest level of
professionalism in medical services by using state-of-theart equipment, investing in modern facilities and continually
developing employees to meet the highest international
standards.
What can SAMSO Employees Expect?
Salary
Saudi Aramco offers compensation that simply cannot
be matched because your salary is tax free. Current
take home salaries for Staff Nurses range from £35,100 £43,500, whilst Supervisors can earn from £48,800 £56,000.This could enable you to save a significant
proportion of your earnings while enjoying a great lifestyle.
Leave
As a single person working for Saudi Aramco, you'll
be eligible for a repatriation allowance, which covers
round-trip airfare for you to return home. An additional
25% payment on top of this allowance is also provided
to cover miscellaneous travel expenses.
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Personal Effects Shipment
When you join us, we pay for and arrange the shipment
of all your personal belongings to Saudi Arabia. We also
cover the cost of returning them if and when you decide
to stop working with us.
Lifestyle
This lifestyle includes living in desirable residential
accommodation in established Saudi Aramco communities
with swimming pools, gyms, tennis courts, libraries shops
and beaches.
Aside from a minimal rent, you'll have no bills to worry
about - electricity, water and local telephone service are
all free. That leaves you free to spend your spare time
indulging in whatever leisure activity takes your fancy relax on our private beach, try out a range of exciting water
sports or take advantage of Saudi Arabia's ideal location
to travel to previously far-flung destinations.
Generous vacation allowances and a central location
provide fantastic opportunities for travel. In short,
successful candidates receive a full package of salary,
benefits, lifestyle – and the time to enjoy it all. Most
importantly, you’ll be part of an extraordinary medical
organization that will enhance your career.
We are currently short listing candidates for our
nursing interview workshop in June.
Send your CV to
[email protected]
Or contact one of
our recruiters on
0800 0684916
For more
information visit
www.jobsataramco.com/eu
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Recruitment - Middle East
44
General Recruitment
45
Education & Training