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The Journal of the Irish Practice Nurses Association
Issue 4 Volume 5 July / August 2012
Asthma in adults
Ruth Morrow
Tuberculosis
– role of the
practice nurse
Maria Kane
Twitter for
birdbrains
Lisa Nolan
Childhood
nutrition
Elizabeth Wallace
Supporting
patients to quit
smoking
Are your patients at risk?
chronic lung,
heart or renal
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age 65+
diabetes
weakened
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other at-risk
groups**
infant*
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* All infants are offered immunisation against pneumococcal disease as part of the National Immunisation Programme.
** See Immunisation Guidelines for Ireland www.immunisation.ie
09/11 IR00094c
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editorial
Minding the nurse
A
new IMO survey of 337 doctors reports “a crisis in general practice”. The study reported
that: 46% of doctors reported experiencing ill health in the last year. Working harder
and longer hours.
• 45% are working an extra 2 hour day.
• 78% have reduced their own annual leave
• 93% indicated that their work was negatively affecting their health
• 97% of general practitioners surveyed an increase in patient numbers presenting with
conditions directly attributed to the recession.
The results of the study were submitted to the DoH in light of further financial emergency
measures that Dr James Reilly may impose on general practice. Where does this leave the
practice nurse?
We were excluded from the submitted research despite our enormous contribution and
importance as a ‘role’.
Resources available in general practice have reduced whilst demands on the services
have increased. One in three people have a medical card secondary to a reduced salary,
unemployment, and reduced working hours and so forth. Those with medical cards attend
more commonly than those who have to pay. Those who need to pay – may not attend due to
financial strain or social circumstances. Black Report (UK).
It is clear that there are growing problems in an increasingly financially challenged and
distressed nation.
Doctor/Nurse workloads and patients demands have increased. Without addressing policy,
contracts, and the changing challenges of Primary Health Care, what about the nurse?
Don’t forget yourself! What about the carers? Even the strongest and healthiest nurse can
become ill in an unhealthy environment. It is often the most conscientious and perfectionist
nurses that get ill, stressed or burnt out.
Nurses often ignore their own health, yet as primary/shared care providers for many
patients it is paramount that we maintain our physical and emotional well-being. Only then
can we respond comprehensively to the needs of ourselves our families and our patients.
The bottom line is self-awareness and self-care. Some strategies of self-care include
colleague networking, meditation, mindfulness and reflective writing. We also need a
sustainable workload and a good supportive work environment and community.
Put yourself first!
Darina Lane
1
NE
W
Nutritional support
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Centrum Pregnancy Care is a specially formulated multivitamin-multimineral range for women planning
a baby and for pregnant and breastfeeding mums. Containing 19 vitamins and minerals, including Folic Acid
and Calcium, Centrum Pregnancy Care has been developed by the experts at Centrum to help support the
nutritional needs of you and your baby.
For more information ask at your local pharmacy or visit: www.centrum.ie
www.centrum.ie
Pfizer Consumer Healthcare, Citywest, Dublin 24.
* Trade Mark.
The Journal of the Irish
Practice Nurses
Association
Contents
Issue 5 Volume
2 September
October2009
Issue 4 Volume
5 July / August
2012
Reviews
9Supporting patients to quit smoking
Article contributed by quit.ie
Your work as a practice nurse can really influence
health behaviour change and the benefits of
smoking cessation are incalculable.
1
Editorial
4
News
8
Branch news
21
Asthma in adults
This article focuses on asthma in adults and examines
the recently updated Global Initiative for Asthma
guidelines from 2011 (with MCQs)
Ruth Morrow
27
Tuberculosis – role of the practice
nurse
in practice
15
Ireland has a very low incidence of TB but that is no
reason for complacency as even one infected person
can in turn infect 10 to 15 people per annum.
Maria Kane
Twitter for practice nurses
Lisa Nolan
Lisa Nolan gives a step by step guide
to setting up a twitter account – it
could be an invaluable source of clinical
information.
Editor
Maura Henderson
Consulting Editors
Darina Lane and Ruth Morrow
coMmissioning Editor
Judith Leavy
Designer
Barbara Vasic
30
Childhood nutrition from an nursing
perspective
The Practice Nurse is ideally placed advise mothers
Elizabeth Wallace
Advertorials
12
An ultimate cholesterol lowering
plan is needed
33
SMA tackles tummy troubles
34products
37
crossword
Publishers
Graham Cooke
Maura Henderson
© Copyright GreenCross Publishing 2012
The contents of Nursing in General Practice are
protected by copyright. No part of this publication
may be reproduced, stored in a retrieval system, or
transmitted in any form by any means – electronic,
mechanical or photocopy recording or otherwise
– whole or in part, in any form whatsoever for
advertising or promotional purposes without the prior
written permission of the editor or publishers
Disclaimer
The views expressed in Nursing in General Practice are not
necessarily those of the publishers, editor or editorial advisory
board. While the publishers, editor and editorial advisory
board have taken every care with regard to accuracy of
editorial and advertisement contributions, they cannot be held
responsible for any errors or omissions contained.
Nursing in General Practice is published by
GreenCross Publishing,
7 Adelaide Court, Adelaide Road, Dublin 2.
Tel: 4189799 Fax: 4789449
Email: [email protected]
*GreenCross Publishing was
established in 2007 and is
jointly owned by Graham
Cooke and Maura Henderson.
3
news
HIQA publishes National Standards
for safer better healthcare
New National Standards aimed at protecting patients and radically
improving services, and which will form the basis for future licensing of all healthcare facilities in Ireland, launched in June by the
Health Information and Quality Authority (HIQA).
Speaking at the launch of the Standards, HIQA Chief Executive
Dr Tracey Cooper said, “The National Standards are significantly important for patients, placing them at the heart of the care process,
with a major focus on dignity, respect, efficiency and safety. They
are a benchmark for change. Patients will have a clear expectation of the standard of care they can expect to receive and service
providers will be clear on what is expected of them. The Standards
provide, for the first time, a national and consistent approach to
improving safety, quality and reliability in our health service.”
“In our work we have found that strong leadership, governance
and management are essential for the delivery of safe care for
patients. Therefore, effective leadership and clear accountability,
responsibility, planning and management throughout each service
are among the requirements set out in these pivotal Standards.
These National Standards provide a roadmap for making this
vision for safer, better healthcare in Ireland a reality,” Dr Cooper
concluded.
The National Standards for Safer Better Healthcare contain 45
Standards, based on best international evidence, to ensure service
providers protect patients from risk and from harm, inform patients
of adverse events, acknowledge and support the key role of staff,
promote good governance and make the best use of information and resources to deliver high quality and safe care within the
resources available.
The Standards have been produced following an extensive
nec news
IPNA AWARDS 2012
Closing dates for this year’s IPNA Awards are fast approaching,
so please ensure you submit your entries in plenty of time!
Entries received after the closing dates will not be considered.
• Practice Nurse of the Year Award – closing date 31st July
2012. Any member can be nominated by any branch. Entry
forms are with branch committees.
• Clinical Award (based on Smoking Cessation) closing date is 10th
August. See previous issue of NiGP for the Case Study. It was also
e-mailed to all current members with a valid e-mail address.
• Educational Bursary – closing date 31st July 2012. Flyer is on
IPNA website.
• Valerie Mangan IPNA Loyalty Award – closing date 31st July
2012. Branch committees to send list of eligible names to
[email protected] Flyer is on IPNA website.
NEC MEETINGS 2012
• Wednesday 5th September 2012, Ashling Hotel, Parkgate
Street, Dublin 8.
• Friday 5th October 2012, Tullamore Court Hotel – time to be
decided later.
Lisa Nolan Tel: 042-9692403 e-mail: [email protected]
4
consultation process conducted by HIQA in which over 200 submissions were received from members of the public and interested
parties.
The Standards were sanctioned by the Minister for Health in May
2012 and they take immediate effect under Section 8 of the Health
Act 2007. Every service, including hospitals, primary care and ambulance services, will be able to use the Standards to improve the
service they provide to patients. From now on, service providers
will be expected to begin to implement the new National Standards, continue to improve the day-to-day experience and outcome
for patients and their families and begin to demonstrate compliance with them.
The Standards are a first step towards a licensing system for
the Irish healthcare system, both public and private. While HIQA’s
remit does not currently cover private healthcare, representatives
of this sector were involved in developing the Standards and the
Authority acknowledges the general desire from the independent hospital sector to be involved in the implementation of these
Standards. It is expected that private healthcare providers will
adopt these National Standards voluntarily in advance of proposed
statutory licensing.
Given that the National Standards are new to the healthcare
system in this country, HIQA will launch an awareness and education campaign with key stakeholders, publish guidance on the
Standards and work with other agencies to support the implementation of the Standards.
Later this year they will begin the process of monitoring how HSE
providers and HSE-funded providers are meeting the requirements
of the National Standards.
Agendas will be e-mailed to all NEC Reps before each
meeting.
IPNA CONFERENCE / AGM – 5th / 6th October 2012,
Tullamore Court Hotel.
Registrations are now open and all Practice Nurses currently
working in Ireland are invited to attend. Registration
Form and Conference Programme can be printed from
the IPNA website (from either ‘News’ or ‘Events’ pages).
Exhibitors who require information about stands can e-mail
[email protected]
IPNA IS NOW ON TWITTER
To complement existing IPNA communication channels, the
IPNA now has a Twitter account. If you have a Twitter account
you can follow the handle @PracticeNurses to receive IPNA
news, reminders and useful information from other groups –
directly to your timeline.
IPNA WEBSITE
The IPNA website, www.irishpracticenurses.ie is updated
constantly, so please log-in regularly to get the latest news on
study days, new posts in the Discussion boards and more…
news
Two new primary care programmes for community nurses
Two new primary care programmes are commencing in UCD
School of Nursing, Midwifery & Health Systems in September
2012* for registered nurses currently working in the community
setting or who wish to work in this area in the future.
1.Professional Diploma in Primary Care (Nurses &
Midwives) (30ECTS)
The programme aims to enable registered practitioners to
enhance their knowledge and skills in physical assessment,
community nursing practice, management of chronic illness
in primary care and health promotion and to integrate this
knowledge in the context of chronic disease management in
primary care.
The course aims to meet the needs of service in line with
current national policy on chronic disease management to
provide practitioners with the requisite knowledge, skills,
attitudes and professional values for the advancement of his/
her role in primary care.
The programme is offered on a part time basis and can
be completed over one academic year. The programme is
comprised of three modules in total. Two core modules must
be taken and a choice of optional module is offered:
Core modules:
• Health Assessment (Semester 1)
• Community Nursing: An applied approach (Semester 2)
Optional modules:
• Chronic illness across contexts (Semester 1) OR Promoting
Health and Well Being in Primary Care (Semester 1)
It is proposed that attendance in UCD for the programme
(1st semester) will be on Wednesdays for 8 weeks between
September and November 2012; attendance will be on five
Tuesdays between January and April 2013 (2nd semester).
On successful completion of all components of this
programme students will be granted a UCD Professional
Diploma in Primary Health Care (Nurses & Midwives) (30 credits
in total comprising 15 ECTS @ level 8 and 15 ECTS @ level 9).
Professional Certificate Promoting Health and Well Being
in Primary Care (Level 9 : 7.5 ECTS)
This course is designed primarily for health practitioners
currently working in the primary care setting (or who wish to
practice in primary care in the future) and is designed to build
upon existing knowledge and skills to effectively promote
health and well being in a variety of primary care contexts.
The programme aims to facilitate understanding of the
lifestyle influences on health to maximise health outcomes for
the population and to provide students with an opportunity to
explore, critically analyse and evaluate policies and practices
under pinning health promotion principles which empower
clients and enhance self efficacy. Key transferable skills
include accessing and applying health information resources
and evidence and application of motivational interviewing
techniques.
This is a single semester programme (September to
December period). Lectures will be delivered in University
College Dublin, on Wednesday afternoons for 8 weeks, using a
wide range of innovative teaching methods including lectures,
workshops and online media.
Further information
These UCD School of Nursing, Midwifery & Health Systems
accredited awards will provide recipients with professional
education experience which they can apply directly in clinical
practice. In addition, students can choose to continue their
education and build on a graduate foundation programme
and subsequently exit with a higher award including Graduate
Diploma or MSc.
Additional information on these programmes, entry
requirements and fees can be found at
http://www.ucd.ie/nmhs/taughtgraduateprogrammes/
or contact:
Dr Kate Frazer, T: +353 1 716 6479, E: [email protected]
Ms Yin Yin Sun (Administrator), T: +353 1 716 6448, E:yinyin.
[email protected] . *applications are now open.
Study Day – Topics of Interest in Primary Care
Some 50 nurses from primary and secondary care including 30 Practice Nurses and 20 Hospital Nurses from Sligo General
& Mayo General Hospital participated in the Topics of Interest in Primary Care Study Day which took place in Mayo in
May 2012 . The study day included: topics on updates in Asthma and Allergy Guidelines; updates in Asthma and Allergy
Symptoms and Management; Spirometry Interpretation and Workshops and Contraception: Options and Counselling.
5
news
Evolving patient care for people with dementias
The 2nd National Memory Clinic Conference themed Memory
Clinics, Intervention and Assessment took place recently in
Dublin. The purpose of the conference was to share best practice
experience of Memory Clinics operating in Ireland as well as
ensuring that they become an integral part of the diagnosis
and care for people living with Alzheimer’s disease and other
dementias. The keynote speech at the conference was delivered
by Professor Gordon Wilcock, founder of the Bristol Dementia
Research Group and currently chair of Geratology at the John
Radcliffe Hospital in Oxford. Prof Wilcock was joined by a number of experts who spoke at the conference including Professor Brian Lawlor, Director of the Memory Clinic at the Mercer’s
Institute for Research on Ageing and Consultant Psychiatrist, St
James’s Hospital, Dublin. The conference was supported by an
unrestricted educational grant from Lundbeck Ireland.
The meeting was attended by over 150 healthcare professionals working in the field of dementia and Alzheimer’s disease
including nurses, geriatricians, psychiatrists, neurologists, GPs,
psychologists, and social workers with a particular interest in
memory loss and dementia.
A Memory Clinic is a specialised service for people with memory loss and dementia. Through these clinics, diagnosis and intervention is provided for people concerned about changes in their
memory or who have noted other changes in cognitive functioning. While the specific set-up of each Memory Clinic varies, the
concept is to draw upon a range of multidisciplinary specialist
skills between professionals from medicine for the elderly and
psychiatry of later life, neurology, social work, nursing, psychol-
ogy and occupational therapy. It offers information, advice and
practical support about living with dementia for both the patient
and other family members. The social work service plays an active
part in the multi-disciplinary team at the Memory Clinic.
Early diagnosis is a critically important factor for people living
with dementia as it is a key contributor to improving quality of
life. It enables optimum clinical outcomes including detection of
potentially reversible causes of memory impairment, correction
of other associated conditions and early provision of medication
being used at the earliest possible opportunity to help maintain
independence. This enables the person with dementia, their
family members and caregiver’s, time to appropriately plan for
the future to ensure appropriate help and support is allocated.
Speaking at the conference, Prof Brian Lawlor, Director of the
Memory Clinic at the Mercer’s Institute for Research on Ageing
and Consultant Psychiatrist, St James’s Hospital, Dublin said, “As
the number of people with Alzheimer’s disease and dementia
increases with our ageing population, making provisions now for
the best possible diagnosis and care is more important than ever.
A Memory Clinic is one important part of the patient journey
and the conference today is a great opportunity to share best
practices and innovation from around the country. Looking to
the future, it is important that Memory Clinic’s are operated
by multi-disciplinary teams and that funding is made available
to ensure they are integrated into hospitals and care facilities
around the country.”
Videos of all the presentations made at the 2nd National Memory Clinic Conference are available at www.memoryclinics.ie
Practice nurse
required
Fairview Medical Centre, Dublin 3
• 1 full time or 2 part time optional
• permanent position
to support 4/5 Doctors with second nurse/phlebotomist.
Previous experience in practice nursing or similar role
an advantage; triage and midwifery desirable, some
training can be provided. Main duties include childhood
immunisations, cervical screening, general injections,
etc. Computer skills essential. CNM2 Rates. Please apply
with cover letter and CV to [email protected]
www.fairviewdoctors.com
Practice nurse
required
Practice nurse required to cover maternity leave from
16th July 2012. Fully computerised New Ross practice.
Previous experience desirable.
Phone: 087 9886078 during working hours.
Practice nurse
required
Practice Nurse required Dublin area, very reasonable hours.
Phone: 01 4578775 during office hours.
6
Safe Patient Care:
Healthcare-associated Infection
Prevention & Control for All:
A Foundation Course 2012
It gives us great pleasure to announce the third Royal
College of Surgeons in Ireland (RCSI) and the Health
Protection Surveillance Centre (HPSC) joint course on
Safe Patient Care - Healthcare-associated Infection
Prevention & Control for All - A Foundation Course.
The course will be held in the Cheyne Lecture Theatre,
RCSI St. Stephen’s Green, Dublin 2, for four days from
Monday 10th to Thursday 13th September 2012.
How to apply for the course:
Complete the online application form on the HPSC
website www.hpsc.ie
Payment of €100 fee to be sent by cheque/postal
order/bank draft or PO made payable to the RCSI
and posted to:
Siobhan Dowling
Health Protection Surveillance Centre
25- 27 Middle Gardiner Street
Dublin 1
news
Student health centre wins
award for STI campaign
The Dublin Institute of Technology (DIT) Student Health Centre
was amongst the winners at today’s Crystal Clear MSD Health
Literacy Awards for their project, ‘No Umbrella Campaign.’ At a
ceremony in Dublin, the DIT Student Health Centre team was
awarded for their project, which they developed after noticing
that many young men were not attending testing for sexually
transmitted infections (STIs) as they feared a painful and invasive
test called an ‘Umbrella Test.’ DIT won first place in the category,
‘Best Project in General Practice’ for developing a simple but
effective campaign to reassure the students that this test was
no longer necessary and that STI testing is simple and easier
than ever before. They did this by using a colourful, humorous
and clearly designed poster that dispels the ‘umbrella’ myth and
removes any fear associated with testing. Four other organisations were also recognised for their efforts to communicate
health information more clearly to the public. These organisations
are the National Cancer Control Programme, Arthritis Ireland, the
National Cancer Screening Service and RTE Radio 1.
Speaking about her team’s win, Louise O’Donnell, Practice
Nurse, DIT Student Health Centre, said, “We are delighted to have
won a Crystal Clear MSD Health Literacy award. It is an honour to
be recognised for our work. When we saw that uptake amongst
our target group was low, we knew that we had to communicate
in a way that would resonate with them.”
Conor McGinnity, Deirdre Adamson and Louise O’Donnell
are pictured celebrating their success at the Crystal Clear
MSD Health Literacy Awards with Dr Neil Boyle, Managing
Director, MSD and Ms Inez Bailey, Director of the National
Adult Literacy Agency (NALA).
Hospice nurse earns
top marks for children’s
palliative care programme
A hospice nurse working in the community in Cork who earned
top marks in the children’s palliative care programme at the
School of Nursing and Midwifery, Trinity College Dublin (TCD)
has received a prize to further her professional development.
The prize, funded by the Irish Hospice Foundation (IHF), was
awarded to Catherine Hyde of Marymount University Hospice
in Cork for demonstrating the most outstanding professional
aptitude in all three modules in the children’s palliative
care programme at TCD. Catherine took part in the first
interdisciplinary children’s palliative care education programme
in Ireland.
The IHF’s modest Children’s Palliative Care award will support
Catherine in attending or making a presentation at a relevant
conference. It can also be used to purchase books or journal
subscriptions relevant to children’s palliative care or cover the
costs of membership of a children’s palliative care organisation.
Dr Honor Nicholl of the School of Nursing and Midwifery,
Trinity College Dublin (TCD); Catherine Hyde of Marymount
University Hospice in Cork; Sharon Foley, CEO of the Irish
Hospice Foundation (IHF) and Dr Catherine Tracey of the
School of Nursing and Midwifery, TCD. Catherine earned
top marks in the children’s palliative care programme at the
School of Nursing and Midwifery, Trinity College Dublin and
received a prize to further her professional development
from the IHF.
Call for papers
The 13th Annual Interdisciplinary Research Conference (AIRC): Optimising Health in the 21st Century
• Conference Themes:
Adult Health; Children’s Health; Intellectual Disability;
Maternity Care; Mental Health
• Date:
7th and 8th November 2012
• Call for Abstracts:
Final submission deadline – 17th August
• Venue:
School of Nursing and Midwifery, Trinity College Dublin
• Event contact details:
Jeni Ryan, TCD School of Nursing and Midwifery, ryanjen@
tcd.ie | Tel: + 353 (0)1 896 3860 <tel:%2B%20353%20
%280%291%20896%203860>
• Website: http://airc2012.com/
7
regional news
Ne ws for IPNA br anches country wide
Cork
Elaine Goggin
Our last meeting before the summer break was held on May 23rd at Rochestown Park Hotel. There was a large turnout to
hear a very informative talk on allergies and their management by Claire Cullinane, Allergy CNS, CUH. This meeting was kindly
sponsored by Thermofisher Scientific. Thanks to our Chairperson, Una Quill for organizing the buffet food; it enhanced the
mingling.
Members have been busy completing the practical aspects of the Asthma Society web course, which was found to be very
helpful.
We would like to wish everyone a happy and healthy summer and here’s hoping that the sun will eventually shine. We would
like to thank again our members for their continued support and welcome new members. We look forward to our next meeting
on Wednesday September 12th.
Galway
Marianne Knight
We have been active in our Galway branch this year, but I had forgotten to put pen to paper. Our February meeting was held in
the Radisson Hotel and was sponsored by Deirdre O’Neill, Aptamil Infant Nutrition representative. We had a very interesting talk
on infant allergies given by Niamh Brannelly, Paediatric Dietitian.
On March 22nd our meeting was held in the Clayton Hotel, Galway and was sponsored by Pamela Regan, MSD. David
Watterson, Podiatrist at University College Hospital Galway spoke about footcare in diabetic patients. Moira Noone, Clinical
Nurse Specialist, discussed clinical waste management. Moira explained how any practice can be inspected regarding waste
management. She gave all members present the required poster displaying the correct clinical waste containers and outlined
advice on how to bring one’s practice up to the required standard.
Our April meeting was held in The Claregalway Hotel and was sponsored by Laura Naughton, from Glaxo Smith Kline. Sarah
Mooney, DEXA Radiographer at Merlin Park Hospital, gave a very interesting talk and stressed the importance of ‘staling’ on
the referral form. She stressed that if such omissions are carried out this way and indicated merely as a ‘routine scan’, the scan
cannot be catered for.
Our final meeting before our summer break was sponsored by Michelle Cosgrove, from Grunenthal. Nancy Ruane and
Caroline Mitchell who work in the field of chronic pain at University College Hospital Galway outlined how they assess patient
care needs in the area of chronic pain.
Sally Whelan, our colleague Practice Nurse here in Galway is off to the Olympic Games in London. She is working as a
volunteer and did very well to be selected from a high volume of applicants. Sally will be working very hard but she stressed
that she will be following the tennis too. Sally will be mingling with Novak, Sharapova and the Williams sisters. Never mind the
tennis – some have all the luck!
Enjoy the summer…
Kildare
Margaret Clancy (087 9787142)
The new Kildare branch is now established, having survived the break with the Carlow branch – with great sadness at parting
after many good years as a joint branch.
The May meeting was our third, and was well attended. Many thanks to our sponsors; Brenda Blewitt of Berlipharm, and from
past meetings Fiona Hayde of Cow & Gate, Michelle Gray of Mullipa, and Sanam of MSD.
At our meeting this month Ann Moriarity was our speaker. Ann is a Practice Nurse and Sexual Health Advisor. She gave us a
very interesting and informative overview of sexual health topics in general practice.
As our AGM conference is looming in October in the Tullamore Court Hotel, we encourage members to book for the
conference now to avail of the early bird.
We are adjourning for the summer, but our next meeting will be Tuesday 18th September in the Maudlins Hotel. We welcome
new members to our branch. If you live close to Kildare, e.g. Dublin, Wicklow or Meath you might like to join us at the Naas
meetings.
We wish all the members a happy summer.
8
clinical review
Supporting patients
to quit smoking
Article contributed by quit.ie
The benefits of smoking cessation are incalculable; your work as a practice nurse can
bring about health behaviour change.
Y
our work as a practice nurse can really influence
health behaviour change. While acknowledging that
there are constant increases in patient numbers,
paperwork and other demands on your time, raising
the issue of smoking and giving brief advice can
become part of your work without adding too much to your
work load. It’s quick and easy to raise the issue of smoking
during your normal routine.
Smoking cessation guidelines recommend that all healthcare
professionals, including practice nurses, should check on the
smoking status of their patients/clients at least once a year
and advise smokers to quit smoking. This brief advice can be
delivered opportunistically during routine consultations, even
when smokers are not directly seeking help with stopping
smoking. Examples of opportunities for a brief intervention of
this kind would include:
• A discussion around smoking during the nursing treatment of
cardiology patients such as during an ECG or while taking bloods.
• Cervical screening, antenatal and postnatal appointments
are also opportune times to raise the issue. Cervical cell
changes are particularly exacerbated by tobacco use.
• Treating and dressing leg ulcers.
• Monitoring various chronic conditions such as diabetes,
COPD and asthma are also core roles and ideal opportunities
to raise the issue particularly since these conditions are
severely compromised by tobacco use.
Many practice nurses report reluctance to broach the
question of smoking with patients, however, it is worth
knowing that most smokers are happy for the topic to be
brought up by a health professional once it is done in a
supportive and non-judgemental manner. Remember 70% of
smokers WANT to quit so your question and your support and
advice can help them make a new attempt. Training is available
for those of you wishing to increase your confidence in asking
the right questions in a non confrontational way. Further
training can be provided to practice nurses and other health
professionals working in primary care by the HSE by emailing
[email protected]. This training is delivered by professional
tobacco cessation specialists and is free of charge.
The seven As?
A brief intervention consists of a number of As.
These are:
• Ask
• Advise
• Assess
• Assist
• Arrange
and you might like to add
• Applaud and
• Again
9
clinical review
Ask
Smoking is an important aspect of a client’s health status and
it is therefore important to maintain up-to-date records about
this. Two pieces of information are important: whether the
person smokes currently, and, if so whether they are interested
in stopping.
It is vital that smoking status and indeed exposure to second
hand smoke (i.e. family member/other smoking in the home) is
recorded in the medical and nursing notes both hard and soft
copies at every visit.
Advise
The health professional should ensure that if the patient does
smoke that they are aware of the benefits of stopping, and of
the health risks of continuing to smoke. An informed choice
should be made about whether or not to stop – and it is the
health professional’s responsibility to ensure that the choice is
properly informed by factual information.
Ask open-ended questions – using words such as ‘why’,
‘what’, where’, ‘who’, ‘when’ and ‘how’. Open-ended questions
will elicit a response about what the patient/client thinks, feels
or knows and will enable the helper to engage in discussion.
Assess
Assess the smoker’s readiness and willingness to stop. A useful
question to start with is “Have you ever thought of trying to stop
smoking?”
Assist
If the smoker does want to stop, a few key points can be
covered in a few minutes.
• Set a quit date and prepare to stop completely on that day.
• Review past experience and learn from it (what helped, what
hindered?).
• Make a personalised action plan.
• Identify likely problems and high risk situations and make a
plan of how you will cope with them.
• Ask family and friends for support.
Arrange
Follow-up is important in maintaining motivation and
providing support. For some smokers referral to a specialist
smoking advice service will be appropriate. Health
professionals therefore need to keep themselves well informed
about sources of more intensive help and about NRT and
pharmaco-therapies. It is important to remember that most
smokers make several attempts to quit before succeeding –
so on-going support will be needed. Follow-up provides an
opportunity to help prevent relapse and give support if and
when it occurs. The National Quitline 1850 201 203 can provide
ongoing support as can tobacco cessation specialist staff based
in many health promotion departments and hospitals around
the country. See quit.ie for lists of local specialist cessation
services.
Applaud
Don’t forget to offer praise and acknowledge endeavours.
Think about how difficult it is to change any behaviour, and
smoking is not only highly addictive, but also serves a number
of functions for the smoker, for which appropriate alternatives
need to be found. It’s tough trying to stop smoking and clients/
patients will need their efforts recognised and valued.
Again
Giving a brief intervention isn’t just a once only thing – you
need to make a note of your intervention and the patient’s
response in the case notes and check the patient’s needs every
time you see them. They may have changed their mind, or have
questions to ask you. Make sure that they know you will ask
them about smoking again next time you see them – and don’t
omit to do so, or the patient may think it isn’t that important.
Benefits of a brief intervention
Dr Fenton Howell (Director of Public Health) says: “There are
approximately 1 million smokers in Ireland. One in every two
of these smokers will die of a tobacco related disease. Look
around you – we all know someone who will be affected. We
can do something to prevent this. Brief advice along with
nicotine replacement therapy (patch, gum, inhaler etc) or
bupropion (zyban)/varenicline (Champix) is likely to double a
persons chances of quitting.”
Resources
While brief advice and follow through with smokers in their
quit attempt is helpful in itself, you may also wish to refer
people on for further help and advice.
• Smokers can be advised to talk to their GP within the practice
for support with medications such as nicotine replacement
therapy, buproprion and varenicline. Medical card holders
can be prescribed these and receive them through the GMS
scheme.
• Smokers can also be advised to log on to the HSE’s on-line
quit support tool at www.quit.ie , or to the quit smoking
facebook page at www.facebook.com/hsequit. Thousands
of smokers have logged on to these sites and they provide
valuable peer support to each other in their quit attempts.
• Professional counselling is also available from the National
Smokers Quitline at 1850 201 203 and from the local smoking
cessation services (details available at www.quit.ie).
Acknowledgements
Some of the above information was adapted from ‘Supporting
Change: Skills for Health Tobacco Module’
An informed choice
should be made about
whether or not to
stop – and it is the
health professional’s
responsibility to ensure
that the choice is
properly informed by
factual information.
11
advertorial
Sponsored by an educational grant from Alpro
An ultimate
cholesterol
lowering plan
is urgently
needed!
Linda Main BSc SRD, Dietetic Adviser, HEART UK – The Cholesterol Charity
C
ardiovascular disease is Ireland’s number one killer
accounting for 35% of all deaths and 20% of premature deaths.1 Despite recent reductions, which are
due to better treatments and an increase in smoking
cessation, coronary heart disease (CHD) still accounts
for over half these deaths.1 Elevated serum cholesterol level affects 4 out of every 5 ROI adults aged 45 and older and remains
one the biggest modifiable risk factors for CHD. 2 Dietary intervention should always be a first line treatment with or without
statin therapy. However, there is clearly a need for a diet renaissance – providing patients with a diet that is not only realistic,
but one that delivers impactful cholesterol lowering too.
What cholesterol levels should the ROI be aiming for?
Table 1. Target Cholesterol Levels (ROI)
Primary Care
Those at high risk
Total cholesterol
< 5mmol/l
< 4.5mmol/l
LDL cholesterol
< 3mmol/l
<2.5mmol/l with an
option of <2mmol/l
Every 1% drop in LDL-C is associated with a 12% decrease in all cause
mortality and a 21% decrease in cardiovascular events over 5 years.3
Aren’t statins enough?
Statin therapy has proven to be lifesaving, primarily as a result
of their 25-55% LDL-cholesterol reducing effect: 4
• In primary prevention, statins could reduce overall CHD
mortality by up to 7% and MI mortality by 27%.
• The impact in secondary prevention is far more impressive,
with some trials demonstrating a 30% reduction in overall
mortality and a 34% reduction in CHD incidence.
However, statins are not without their problems. Despite
clinical guidance strongly advocating the use of statin therapy
in higher risk patients, cholesterol levels remain high for the
majority of the population. In fact one third of those treated
with medication for cholesterol levels remain uncontrolled.2
Studies also show that large numbers of patients commonly fail
to take their statin therapy over the long term,5 with most not
complying in the first 12 months of treatment.6
Can diet replace statins?
Dietary intervention should always be a first line therapy
whether a patient is, or is not prescribed statins. The two
12
should be complimentary. However mounting scientific evidence suggests that dietary intervention can make a significant
impact on cholesterol levels.7,13
The Ultimate Cholesterol Lowering Plan (UCLP)
The UCLP owes is origins to David Jenkins, a researcher in
Toronto, Canada who developed a revolutionary dietary eating
plan. His diet could match the cholesterol lowering ability of a
low dose statin and exceeded the cholesterol lowering capacity
of the US National Cholesterol Education Program (NCEP) diet,
reducing LDL-cholesterol by up to 35%.9 The dietary regimen
was named “portfolio diet” and was made up of a number of
foods with proven cholesterol lowering properties. What Jenkins demonstrated, was that the combination of various cholesterol lowering foods resulted in an additive effect as each food
lowered cholesterol via a different mechanism.
Despite such promising results the portfolio diet is not
widely known and remains under used. Why? Probably because
of its inflexibility and the extent of the dietary changes that
are required. Luckily newer scientific evidence and positive
changes in food availability and taste acceptance point the way
to a new plan that is more practical and achievable.
Introducing the UCLP: simply put, it encompasses the ethos
of the portfolio diet but brings it up to date for better compliance. The diet is realistic, can be individualised for the needs
of each patient and the quantities of foods suggested are
evidence based.
Key to implementation is the use of techniques aimed at
motivating patients through gradual and realistic introduction
of dietary and lifestyle changes and the recognition of behavioural triggers.
Welcome to the UCLP Foods
The UCLP focuses on key dietary changes that are needed to
bring about significant cholesterol lowering results. The UCLP is
based on the Irish Healthy Eating Food Pyramid.14 The baseline
diet is low in saturated fat, containing 5+ fruit and vegetables
(daily), wholegrains (daily) and oily fish (twice per week). The
cholesterol lowering power is built by adding in soy protein,
nuts, plant sterol and sources of soluble fibre.
The practical application of the UCLP will be the focus of Part
2, explaining how achievable and motivational this eating plan
can be and what outcomes practice nurses and their patients
might expect.
Sponsored by an educational grant from Alpro
advertorial
Table 2: The UCLP Foods and their cholesterol lowering actions
UCLP Foods
Daily Intake
How they impact on cholesterol levels and cardiovascular
health
Low Saturated Fat Diet1,15-19
10% daily energy intake or less
Lowers LDL by increasing LDL uptake by liver
Fruit & vegetables14
5-a-day
Low in energy so aids weight control
Contain soluble fibres which can lower cholesterol
Soya protein12,20, 21
15-25g
1-3 servings
Lowers LDL cholesterol by interfering with liver LDL synthesis
Whole grain cereals22,23
3 servings
Associated with decreased CVD risk. Rich in polyphenolic
compounds, soluble and insoluble fibre, minerals, vitamins,
complex carbohydrates
Plant stanols and sterols24,25
1.5-2.4g
Lower cholesterol by interfering with biliary and dietary
cholesterol absorption from the gut
Nuts11,26,27
30g
Rich in mono-unsaturated fats which lower cholesterol when
substituted for saturated fats. Other mechanisms may relate to
fibre, flavonoids, vitamin E and mineral content.
Beta-Glucan and other
source of soluble fibre28-31
3g from oats
At least 10g from other
sources
Viscous fibres interfere with re-absorption of biliary cholesterol
Oily fish32
2 servings a week
Fish oils positively influence blood pressure, serum triglycerides,
inflammatory markers, coagulability and endothelial function,
and have anti-arrhythmic and plaque-stabilising effects. 32
References
1. DHC, Changing Cardiovascular Health: National Cardiovascular Health Policy
2010-2019, 2010, Government Publications: Dublin.
2. Morgan K, M.H., Watson D, Perry I, Barry M, Sheeley E, Harrington J, Molcho
M, Layte R, Tully N, van Lente E, Ward M, Lutomski J, Conroy R, Brugha R
SLAN (2008), SLAN, DHC 2007, The Stationary Office, Dublin.
3. Baigent, C., et al., Efficacy and safety of cholesterol-lowering treatment:
prospective meta-analysis of data from 90,056 participants in 14 randomised
trials of statins. Lancet, 2005. 366(9493): p. 1267-78.
4. Lardizabal JA, D.P., Benefits of statin therapy and compliance in high risk
cardiovascular patients. Vasc Health Risk Management 2010. Vasc Health Risk
Manag. 2010; 6: 843–853 6: p. 843-853.
5. Boggon R, E.S., Timmis A, Hemingway H, Gabriel H, Minhas I, van Staa TP,
Current prescribing of statins and persistence to statins following ACS in the
UK: a MINAP/GPRD study. British Journal of Cardiology, 2012. 19: p. 24.
6. Bandolier Patient compliance with statins. Bandolier.
7. Jenkins, D., et al., Direct Comparison of a Dietary Portfolio of Cholesterollowering Foods with a Statin in Hypercholesterolemic Participants American
Journal of Clinical Nutrition, 2005. 81: p. 380-387.
8. Jenkins, D., et al., Assessment of the longer-term effects of a dietary
portfolio of cholesterol-lowering foods in hypercholesterolaemia. American
Journal of Clinical Nutrition, 2006. 83: p. 582-591.
9. Jenkins, D., et al., The effect of combining plant sterols, soy protein, viscous
fibers, and almonds in treating hypercholesterolemia. Metabolism, 2003.
52(11): p. 1478-1483.
10. Jenkins, D., et al., Effects of Dietary Portfolio of Cholestetrol-Lowering Foods
vs Lovastatin on Serum Lipids and C-Reactive Protein. Journal of American
Medical Association, 2003. 290: p. 502-510.
11. Jenkins, D., et al., Dose Response of Almonds on Coronary Heart Disease
Risk factors: Blood Lipids, Low density Lipoproteins, Lipoprotein(a),
Homocysteine and Pulmonary Nitric Oxide: A Randomised, Controlled,
Crossover Trial. Circulation, 2002. 106: p. 1327-1332.
12. Jenkins, D., et al., Soy Protein Reduces Serum Cholesterol by Both Intrinsic
and Food Displacement Mechanisms. The Journal of Nutrition, 2010.
13. Jenkins, D.J.A., et al., Effect of a dietary portfolio of cholesterol lowering
foods given at 2 levels of intensity of dietary advice on serum lipids in
hyperlipideamia JAMA, 2011. 306(8): p. 831-839.
14. DHC, Health Eating Pyramid, 2012: online.
15. NICE, Lipid Modification, N.C.C.f.P. Care, Editor 2008 (revised 2010).
16. Astrup, A., et al., The role of reducing intakes of saturated fat in the
prevention of cardiovascular disease: where does the evidence stand in
2010. American Journal of Clinical Nutrition, 2011. 93: p. 684-688.
17. FAO/WHO, Interim summary of conclusions and dietary recommendation on
total fat and fatty acids – From the Joint FAO/WHO Expert Consultation on Fats
and Fatty Acids in Human Nutrition 10-14 November 2008, WHO Geneva 2008.
18. FAO, Fats and fatty acids in human nutrition: Report of an expert
consultation, 2010.
19. Fernandez, M. and K. West, Mechanisms by which Dietary Fatty Acids
Modulate Plasma Lipids. J Nutr, 2005. 135: p. 2075-2078.
20. Harland, J. and T. Haffner, Systematic review, meta-analysis and regression
of randomised controlled trials reporting an association between an intake
circa 25g soy protein per day and blood cholesterol. Atherosclerosis, 2008.
200: p. 13-27.
21. Reynolds, K., et al., A Meta-analysis of the effect of soy pritein
supplementation on serum lipids. American Journal of Cardiology, 2006. 98:
p. 633-640.
22. Seal, C., Wholegrains and CV Risk. Proceedings of the Nutrition Society, 2006
65(1): p. 24-34.
23. Miller-Jones J, E.J., Whole Grains: Benefits and Challenges. Annual Review of
Food Science and Technology 2010. Vol 1: p. 19-40.
24. EFSA, Plant Sterols and Blood Cholesterol: Scientific substantiation of a
health claim related to plant sterols and lower/reduced blood cholesterol
and reduced risk of (coronary) heart disease pursuant to Article 14 of
Regulation (EC) No 1924/20061. Official Journal of the European Union Food
Safety Authority 2008. 781: p. 1-12.
25. EFSA, Plant stanol esters and blood cholesterol Scientific substantiation
of a health claim related to plant stanol esters and lower/reduced blood
cholesterol and reduced risk of (coronary) heart disease pursuant to Article
14 of Regulation (EC) No 1924/20061. Official Journal of the European Union
Food Safety Authority, 2008. 825(1-13).
26. Kris-Etherton, P., et al., The Role of Tree Nuts and Peanuts in the Prevention
of Coronary Heart Disease: Multiple Potential Mechanisms. Journal of
Nutrition, 2008. 138(9): p. 1746S.
27. Mukuddem-Petersen, J., W. Oosthuizen, and J. Jerling, A systematic Review
of the Effects of Nuts on Lipid Profiles in Humans. Journal of Nutrition, 2005.
135: p. 2082-2089.
28. Kelly S, S.C., Brynes A, Whittaker V & Frost G, Wholegrain cereals for coronary
heart disease, in Cochrane Review 2009
29. EFSA, Scientific Opinion on the substantiation of a health claim related to oat
beta-glucan and lowering blood cholesterol and reduced risk of (coronary)
heart disease pursuant to Article 14 of Regulation (EC) No 1924/20061.
Official Journal of the European Union Food Safety Authority, 2010. 8(12): p.
1885.
30. Brown, L., et al., Cholesterol Lowering Effects of Dietary Fiber: A metaanalysis Americal Journal of Clinical Nutrition, 1999. 69: p. 30-42.
31. Theuwissen E, M.R., Water-soluble dietary fibers and cardiovascular disease.
Physiology and Behaviour, 2008: p. 285-292.
32. Begg A, C.S., Halcox J, Kaba A, Main L, Ray K, Purcell H, Williams H, Yellon D
Omega-3 fatty acids in cardiovascular disease: re-assessing the evidence.
British Journal of Cardiology, 2012. 19 p. 79-84.
13
@alpro_uk
#plantpower
The 3-step programme that is changing cholesterol lowering advice.
Two thirds of the UK population have elevated
cholesterol levels - one of the biggest risk factors for
coronary heart disease.
l
NUTS – Just a handful. Due to their high
unsaturated fat content – all nuts have
demonstrated some cholesterol lowering properties.
The Ultimate Cholesterol Lowering Plan (UCLP),
is a revolutionary dietary and behaviour change
programme underpinned by a wealth of compelling
clinical evidence. The UCLP was developed in
collaboration with HEART UK - The Cholesterol Charity
- and seven leading health and diet experts.
l
BETA-GLUCAN – the unique fibre mainly found in
oats and barley, can reduce cholesterol absorption
from the gut. 2-3 servings of oat-based bread
slices, oat-based cereals, oat bran or oat cakes.
l
STANOL/STEROL containing products can lower
serum cholesterol by up to 10% at 1.5g - 2.4g per day.
There are many formats now available for
consumers including one shot
drinks, spreads and milks.
Combining the science with behavioural strategies,
the patient-led programme is practical, flexible and
motivational – resulting in a minimum cholesterol drop
of 5% and with a potential 24% cholesterol drop.
STEP 1 – Motivational interviewing is integral to the
process. It enables the patient to identify their
motivational triggers and work through their barriers.
STEP 2 – Building strong foundations: Reducing
Saturated Fat – 5-a-day – Oil-Rich Fish.
STEP 3 – A pick ‘n’ mix of four cholesterol lowering
foods all proven to lower cholesterol on their own
and when combined result in a cumulative cholesterol
lowering effect.
l
SOYA FOODS – as little as 15g of soya protein has
been clinically proven to lower serum cholesterol
levels by around 4-10%. This equates to 2 glasses of
soya milk alternative, a handful of soya nuts (roasted
Edamame beans) or 20g unhydrated soya mince.
THE EXTREMELY POPULAR UCLP TEACHING TOOLKIT IS NOW AVAILABLE FREE
to all health professionals. The toolkit comprises of: A deskTop flip chArT to help take your
patient step by step through the Uclp process, providing you with the detail whilst
your patient views simple images and food portion photography. A pATienT Uclp
informATion sheeT. A summary of the Ulcp, with practical examples and
allowing for tailored advice. Your patient can record their motivational triggers
and barriers discussed and fill in the food, drink, mood and hunger score diary.
TO ORDER SIMPLY EMAIL ‘UCLP TOOLKIT’ to [email protected]
THE UCLP: EATING TO OUR HEARTS CONTENT, SAVING LIVES AND MONEY.
The authoritative report presenting an overview of the Uk cholesterol dilemma and its current
management and the compelling evidence for the Uclp’s impact on the health of the nation and the
nhs economic burden. electronic version available free to all health professionals.
SIMPLY EMAIL ‘UCLP REPORT’ to [email protected] or download from
http://health.alprosoya.co.uk/uclp.html or http://www.heartuk.org.uk/healthprofessionals/index.php/uclp/
in practice
Twitter for Practice Nurses
Time to tweet – how to set up
your own Twitter account
It’s time to step into the 21st century. Lisa Nolan gives you a step-by-step guide to
setting up a Twitter account. Twitter can be whatever you want: a source of up to the
second ‘gossip’ or a virtual library of instant clinical information at your finger tips.
Lisa Nolan, Virtual Administrator at IPNA and Aslan Virtual Admin,
tweets from @AslanVA
U
nless you’ve been on a career break in a galaxy
far, far away – or have been trapped under
something heavy in a room with no internet
access (in which cases, welcome back!) you will
be aware of the phenomenon that is Twitter.
What started out in 2006 as an SMS service to deliver ‘short
bursts of inconsequential information,1 has become a global
communications tool. It has half a billion registered users, 100
million of whom are active every month.
So far, it seems that there are two distinct groups: fullyfledged Tweeps (Twitter users) and those who drop their
shoulders and arms in bored disinterest whenever it is
mentioned. If you are one of those from the village of
orangutan arms, I’m guessing it’s because you think Twitter is
just an unnecessary, gossipy forum of fluff, only relevant for
teenagers and the hip-and-happening crew.
But Twitter is not just about who is getting divorced today. It
has evolved and morphed in ways that would transfix a social
anthropologist. It has been argued that it is catalyst for great
change when, by its nature (largely uncensored worldwide
instant messaging), it facilitated free speech in places where
this may be curtailed (Arab Spring 2011-20122). On the flip side,
it is also a very effective vehicle for cyber-bullying (football
players after Euro 2012, TV presenters), uncorroborated
information growing legs (Presidential election anyone?!) and,
rightly or wrongly, a method of circumventing the legal process
(have you tried to enforce a super-injunction recently?!).
SO, WHAT USE IS TWITTER TO PRACTICE NURSES?
It may surprise you to learn that there is a lot of useful
information in the Twittersphere for healthcare professionals
– it’s just a matter of creating the right community of followers
and people to follow. It’s a great forum to interact with and
learn from your peers, educators and influencers around the
world. There are virtual chat rooms (searchable by #hashtags)
where you can watch online conversations about specific
healthcare topics, e.g. #diabetes, #MMR. Another example is
#Nurchat which is a fortnightly Twitter chat in the UK that is
worth one hour of CPD activity.
You can manage your Twitter feed so that it only shows
what’s relevant. You can follow live feeds of speakers’
presentations at healthcare conferences worldwide.
15
in practice
Healthcare professionals are using it to chat informally about
best practices and to discuss latest research or news. Most
healthcare agencies and groups are on Twitter now, streaming
news, announcements, disease alerts, etc, in real time. Some
Twitter accounts aim to be informative, such as the IPNA’s, @
PracticeNurses; others are interactive, actively engaging in
conversations and replying directly to messages from followers.
IN A NUTSHELL
Benefits of Twitter:
1. Global Networking. You can connect with people whom
you might never meet otherwise. By carefully following the
right people, you can create your own online community of
like-minded people. And you get to ask questions. In fact,
you are encouraged to engage with other users – that’s
what it’s for!
2. It is often the place to hear breaking news. About anything.
3. It’s free!
Potential Pitfalls:
1. Every tweet is visible to the entire planet, forever. The term
for this is ‘evergreen’ and Twitter users are often reminded
that ‘what happens in Vegas, stays on Twitter’. The rules,
manners and common courtesy that apply in everyday life
are especially important when comments are evergreen.
Obviously, the usual rules of confidentiality and data
protection apply, so you should never discuss or identify
real patients on Twitter.
2. On a less serious note, it’s a little bit addictive! 
If you are shy about being visible on the internet, don’t
worry. You don’t have to use your own name or photo on your
profile. You can follow whoever you like and quietly watch their
tweet/banter/heated discussions. Bear in mind though that
Twitter closes inactive accounts so be sure to tweet (or retweet
someone else’s message) at least every 6 months.
Figure 1.
Figure 2.
Getting started
To set up a Twitter account from scratch, you will need:
• Computer, smartphone or tablet.
• An e-mail address.
• An unquenchable thirst for knowledge/updates/ gossip/
networking.
It’s a good idea to have a second tab open in your browser
with your e-mail account open in one of them, as you will need
it during the registration process.
Figure 3.
1. Go to www.twitter.com
2. Click on Sign up for Twitter. (Figure 1)
3. Fill in name and e-mail address. Note: the name you enter
here will appear on your Twitter profile. (Figure 2)
4. Select a password and username. Username is what your
Twitter ‘handle’ will be and will appear beside the name
you chose in step 3.
5. Click Create My Account
For demonstration purposes, the graphics show a Twitter
account that has the name HCP2012 and Twitter handle @
hcpireland . Other users will see it as follows: HCP2012 @
hcpireland
Figure 4.
16
in practice
6. The next screen will show a sample tweet from Twitter.
(Figure 3)
7. Click Next.
8. The next screen is where you can build your timeline, i.e.
follow people so that their tweets appear in your timeline.
(Figure 4)
9. You will get an e-mail from Twitter to your e-mail address,
asking you to confirm your Twitter account by clicking on
the link within the e-mail. Click on that link. (Figure 5)
10. This will open a new tab on your browser, where you can
adjust your privacy settings. (Figure 6)
11. When you have adjusted your privacy settings, click
on Save Changes. You will be prompted to enter your
password to confirm the settings.
12. Click on your username name in top left of screen. This will
display your Twitter profile, i.e. what other users will see.
13. To edit your profile, click on Edit Profile in top right corner.
The profile editing page appears. (Figure 7)
Picture: This is your profile picture. You can upload a photo
of yourself, or your pet, or a cartoon or any image you have a
licence for. If you want to, you can leave it as the ‘egg-head’
although Twitter users like to be able to identify people, so
consider using your photo if you want to build up a network of
followers.
Bio: This is where you can describe yourself in 160
characters or less, e.g. Healthcare professional, cat/dog/
iguana-owner, frustrated [team] supporter, parent, master of
the sphygmomanometer, coffee-junkie, chocoholic, Olympic
Tiddlywinks hopeful, advocate for senior moments, bedmaking expert, dish-washing manager, light bulb engineer,
proprietor of in-house laundry facility...
14. When you have made all your changes, click Save Changes.
15. To customise your profile further, click on Design (from list
on left side of screen).
16. Select a suitable background, or upload/customise your
own background.
17. Save Changes
18. If you want to adjust how you receive updates from Twitter
e.g. each time you are mentioned or retweeted, click on
Notifications in the list on the left of the screen and choose
the settings you want.
19. To set up notifications to your mobile phone or to get a
Twitter App for your smartphone, click on Mobile in the list
on the left (Figure 8). Follow the instructions on screen.
Twitter will send a confirmation text to your mobile phone
to ensure it is linking with the correct number.
So now you are ready to jump out of the nest and explore the
Twitterverse. To learn more, check out the Help sections on the
Twitter website. Have fun!
Figure 5.
Figure 6.
Figure 7.
References
1. Jack Dorsey, founder of Twitter
2. ‘Affective News and Networked Publics: The Rhythms of
News Storytelling on #Egypt’, Journal of Communication
Volume 62, Issue 2, pages 266–282, April 2012
Figure 8.
17
IPNA Conference 2012
IPNA Conference 2012 Registration Form
Closing Date for Registration Friday 21st September 2012
Personal Details
Please fill in your name and place of work as you would like them to appear on the delegate list.
If you do not wish to appear on the delegate list please tick here.
Please use BLOCK CAPITALS.
Full Name
Branch
Place of Work
Daytime Phone
Email Address
Correspondence Address
An Bord Altranais Pin No.:
Conference Booking Fees
Conference fee early-bird IPNA members (Before Friday 11th August). Conference fee IPNA members:
Day rate Saturday only
Non Members
€75
€90
€60
€110
(Includes Conference material, refreshments, Gala dinner Friday, lunch Saturday).
***Please ensure email address is provided for conference receipt***
Conference Accommodation contact hotel: Tullamore Court Hotel. 057 9346689
Single room 1 night single
Double / Twin per person sharing 1 night Please contact the hotel directly for room bookings.
€75
€55pps
Workshops
Choose 2 of the following:
Ear careDiabetic Foot AssessmentWarfarin treatment
Payment
I enclose a cheque / postal order for a total of € made payable to Irish Practice Nurses Association
Please return Booking Form and Fee to: Tracey Rooney, Membership Secretary, Dundrockan, Donaghmoyne,
Carrickmacross, Co. Monaghan Phone No: 086 2634917 E-mail [email protected]
Cancellations must be received in writing by post or email no later than Friday 27th September 2011 after this date fees
cannot be refunded.
18
IPNA Conference 2012
IPNA CAVAN/MONAGHAN BRANCH
NATIONAL CONFERENCE – OCTOBER 5/6TH 2012
TULLAMORE COURT HOTEL
An Bord Altranais Approval 5 CEUs
PROPOSED AGENDA
FRIDAY 5th
2-4.30p.m. Registration & Exhibition open
5-6.30p.m.Workshops:
Ear Irrigation & Otoscopy
Ms Toni Finnegan, Practice Nurse
Vascular Assessment of the Lower Limb
Mr Declan Campbell, Podiatrist
Caring for patients on Warfarin therapy Ms Margaret McFadden, Practice Nurse
7pm.
Conference Gala Dinner
8.30pm.Key note speaker
Dr Tony O’Sullivan, GP, Irishtown, Dublin
Physician, heal thyself – growing up with diabetes
9.30p.m.Awards
Research Bursary Award
Clinical Award
Practice Nurse of the Year Award 2012
SATURDAY 6th
8.00a.m.Exhibition
9.30amOpening remarks
9.45am
Conference Address
Ms Roisin Shortall, TD., Minister of State, Department of Health with responsibility for Primary Care.
10.00a.m
Dr Deirdre Lundy, GP, Family Planning Course Co-ordinator ICGP
“Managing the menopause”
10.45
Ms Susan McKenna, RN, BNS, RNP, Post graduate Cert. Management of Chronic Kidney Disease.
Chronic kidney disease
11.30-12.30
Coffee and Exhibition
12.30-1.15p.m Ms Martina Carolan, CNS Rheumatology
Rheumatoid arthritis
1.15pmValerie Mangan IPNA Loyalty Award
2.30pmA.G.M.
Conference close
19
Onbrez ® Breezhaler ®
• Superior Bronchodilation
versus tiotropium
• 5 minute rapid onset of action
1,2,*
A first line once daily
maintenance treatment for COPD
3
1
ABBREVIATED PRESCRIBING INFORMATION
Please refer to Summary of Product Characteristics (SmPC) before prescribing.
Presentation: Onbrez Breezhaler 150mcg and 300mcg inhalation powder hard capsules containing indacaterol maleate, and separate Onbrez Breezhaler inhaler. Indications: For maintenance bronchodilator treatment of airflow
obstruction in adult patients with chronic obstructive pulmonary disease (COPD). Dosage and administration: Recommended dose is the inhalation of the content of one 150mcg capsule once a day, administered at the same time
of the day each day, using the Onbrez Breezhaler inhaler. Capsules must not be swallowed. Dose should only be increased on medical advice. The inhalation of the content of one 300mcg capsule once a day has been shown to
provide additional clinical benefit with regard to breathlessness, particularly for patients with severe COPD. Maximum dose is 300mcg once daily. No dose adjustment required in elderly patients, for patients with mild and moderate
hepatic impairment or for patients with renal impairment. No data available for use in patients with severe hepatic impairment. No relevant use in the paediatric population. Contraindications: Hypersensitivity to the active
substance, to lactose or to any of the other excipients. Warnings/Precautions: Asthma: ◆ONBREZ BREEZHALER SHOULD NOT BE USED IN ASTHMA. Paradoxical bronchospasm: ◆If paradoxical bronchospasm occurs Onbrez
Breezhaler should be discontinued immediately and alternative therapy substituted. Deterioration of disease: ◆Not indicated for treatment of acute episodes of bronchospasm, i.e. as rescue therapy. Systemic effects: ◆Indacaterol
should be used with caution in patients with cardiovascular disorders (coronary artery disease, acute myocardial infarction, cardiac arrhythmias, hypertension), in patients with convulsive disorders or thyrotoxicosis, and in patients
who are unusually responsive to beta 2 -adrenergic agonists. Cardiovascular effects: ◆Indacaterol may produce a clinically significant cardiovascular effect in some patients as measured by increases in pulse rate, blood pressure,
and/or symptoms, ECG changes. In case such effects occur, treatment may need to be discontinued. Hypokalaemia: ◆ Beta 2 -adrenergic agonists may produce significant hypokalaemia in some patients, which has the potential to
produce cardiovascular effects. In patients with severe COPD, hypokalaemia may be potentiated by hypoxia and concomitant treatment which may increase the susceptibility to cardiac arrhythmias. Hyperglycaemia: ◆Inhalation of
high doses of beta 2 -adrenergic agonists may produce increases in plasma glucose. Upon initiation of treatment with Onbrez Breezhaler plasma glucose should be monitored more closely in diabetic patients. ◆During clinical studies,
clinically notable changes in blood glucose were generally more frequent by 1-2% on Onbrez Breezhaler at the recommended doses than on placebo. Onbrez Breezhaler has not been investigated in patients with not well controlled
diabetes mellitus. Pregnancy and Lactation: ◆No data available from the use of indacaterol in pregnant women. Onbrez Breezhaler should only be used during pregnancy if the expected benefits outweigh the potential risks. ◆Not
known whether indacaterol / metabolites are excreted in human milk. A decision must be made whether to discontinue breast-feeding or discontinue Onbrez Breezhaler therapy, taking into account the benefit of breast-feeding for
the child and the benefit of therapy for the woman. Interactions: ◆Concomitant administration of other sympathomimetic agents may potentiate the undesirable effects of Onbrez Breezhaler. Onbrez Breezhaler should not be used
in conjunction with other long-acting beta 2 -adrenergic agonists or medicinal products containing long-acting beta 2 -adrenergic agonists. ◆Concomitant hypokalaemic treatment with methylxanthine derivatives, steroids, or
non-potassium-sparing diuretics may potentiate the possible hypokalaemic effect of beta 2 -adrenergic agonists, therefore use with caution. ◆Indacaterol should not be given together with beta-adrenergic blockers (including eye
drops) as these may weaken or antagonise the effect of beta 2 -adrenergic agonists. Where required, cardioselective beta-adrenergic blockers should be preferred, although they should be administered with caution. ◆Inhibition of
the key contributors of indacaterol clearance, CYP3A4 and P-gp, does not raise any safety concerns given the safety experience of treatment with Onbrez Breezhaler. ◆Indacaterol has not been shown to cause interactions with
co-medications. Adverse reactions: ◆The most common adverse reactions with Onbrez Breezhaler are: nasopharyngitis, upper respiratory tract infection, sinusitis, diabetes mellitus and hyperglycaemia, headache, ischaemic heart
disease, cough, pharyngolaryngeal pain, rhinnorrhoea, respiratory tract congestion, muscle spasm, peripheral oedema. ◆Uncommon: paraesthenia, atrial fibrillation and non-cardiac chest pain. ◆Please refer to SmPC for a full list
of adverse events for Onbrez Breezhaler. Legal Category: POM Pack sizes: Carton containing 30 capsules (3x10 capsule blister strips) and one Onbrez Breezhaler inhaler. Marketing Authorisation Holder: Novartis Europharm
Limited, Wimblehurst Road, Horsham, West Sussex, RH12 5AB, United Kingdom. Marketing Authorisation Numbers: EU/1/09/593/002 & 007. Full prescribing information is available on request from Novartis Ireland Ltd, Beech
Hill Office Campus, Clonskeagh, Dublin 4. Tel: 01 2601255 or at www.medicines.ie Date of Creation of API Text: Jan 2010 Date of Preparation: March 2011 NO0311145 References: 1. Onbrez Breezhaler SmPC. Available at
www.medicines.ie 2. Donohue JF et al. Once daily Bronchodilators for Chronic Obstructive Lung Disease: Indacaterol versus Tiotropium. Am J Crit Care Med. Vol 182. Pp 155-162, 2010. 3. Balint et al. Onset of action of indacaterol
in patients with COPD: Comparison with salbutamol and salmeterol-fluticasone. International Journal of COPD.2010:5 311-318. * INHANCE Study comparitor was open label tiotropium.
clinical review
Asthma in adults
Asthma is a common, chronic, inflammatory condition which affects all age groups.
This article focuses on asthma in adults and examines the recently updated Global
Initiative for Asthma guidelines from 2011 (GINA, 2011).
Ruth Morrow, ANP (Primary Care),
Primary Care Centre, Carrigallen, Co Leitrim
A
sthma affects an estimated 300 million individuals
worldwide. 7.1% of Irish adults have asthma
(www.asthmasociety.ie accessed 18 April 2012).
Unfortunately, even in 2012, there is still an average
of one death from asthma in Ireland every week
despite advances in the knowledge of the mechanisms of
asthma and pharmacology. Asthma is a condition that can be
treated effectively and most patients can obtain good control
through optimal use of their medication and appropriate
management plans. Optimally controlled asthma includes:
• Little or no use of reliever inhaler
• Have no nighttime or daytime symptoms
• Have productive physically active lives
• Have near normal lung function
• Avoidance of serious attacks
(GINA, 2011)
Symptoms
The symptoms of asthma include wheezing, coughing,
shortness of breath and chest tightness. These symptoms are
variable and usually troublesome at night or early morning.
Patients may present with one, two, three or all four symptoms.
Diagnosis
The diagnosis of asthma is made by the patient’s symptoms
and medical history with the measurement of lung function
using spirometry. (GINA, 2011).
If the patient has a history of any of the following then
asthma should be suspected:
• Cough which is worse at night
• Recurrent wheeze
• Recurrent difficulty breathing
• Recurrent chest tightness
21
clinical review
Inhaled medications
are the preferred
method as the drugs are
delivered directly to the
lungs where they are
needed. This results in
an optimum therapeutic
effect with reduced risk
of systemic side effects.
Symptoms are variable and may occur or worsen in a
seasonable pattern. The patient may also have eczema and
hayfever. A positive family history of asthma or other atopic
conditions may also be present. The patient may describe their
symptoms becoming worse when exposed to certain trigger
factors. These may include animal dander, aerosol chemicals,
changes in temperature, dust mite, exercise, pollen, respiratory
infections (viral), smoke and emotion. The list of possible
trigger factors can be lengthy and it may take the patient some
time before they can identify their trigger factors.
Spirometry is the preferred method for measuring airflow
obstruction with reversibility to establish a diagnosis of asthma.
An increase in FEV1 of 12% or 200mls fifteen minutes after
inhaling a bronchodilator demonstrated airflow limitation
consistent with asthma (GINA, 2011). However, not all patients
with asthma will have reversibility and repeated tests are
advised.
Peak flow measurements can be used if the patient is unable
to perform spirometry and are very useful as a monitoring and
educational tool for patients. An improvement of 60l/min or
greater than 20% post bronchodilator or a greater than 20%
in diurnal variation (with twice daily readings, more than 10%)
suggests a diagnosis of asthma (GINA, 2011).
Methacholine and histamine challenges may be carried out
in patients who have a normal lung function. Indirect challenges such as inhaled mannitol or an exercise challenge may also
assist with the diagnosis of asthma. Allergy testing such as the
skin prick test or measurement of IgE may help identify trigger
factors and assist the patient in controlling their symptoms.
Challenges to the diagnosis of asthma include:
• Cough variant asthma – some patients have chronic cough
which occurs at night. Evidence of lung function variability
and airway hyperresponsiveness are important to determine
the presence or absence of asthma
• Exercise induced bronchoconstriction – for some patients,
physical activity may be the only trigger for asthma. An 8
minute running challenge can confirm an asthma diagnosis
• Asthma in the elderly can be difficult to determine as there
are several complicating factors such as poor perception of
symptoms, reduced expectations of mobility and activity
and the possibility of other conditions such as COPD, heart
failure, lung cancer, and TB to mention but a few.
• Occupational asthma requires a defined history of
occupational exposure to sensitizing agents, an absence of
asthma symptoms prior to employment and a documented
relationship between symptoms and the workplace. The
patient should be asked to maintain a peak flow diary
while at work and while away from work to help determine
the diagnosis. The opinion of an occupational respiratory
physician should be sought.
Classification of asthma by level of control
Table 1 illustrates levels of asthma control. All patients
should be assessed and their level of control established. In
general, good clinical control of asthma leads to reduced risk
of exacerbations (GINA, 2011). There are a number of well
validated tools available which can assist the practice nurse
in assessing asthma control such as the asthma Control Test
(www.asthmacontrol.com)
Table 1: Levels of asthma control
Levels of asthma control
A. Assessment of current clinical control (preferably over 4 weeks)
Characteristics
Controlled
(All of the following)
Partly Controlled
(Any measure presented)
Daytime symptoms
None (twice or less/week
More than twice/week
Limitation of activities
None
Any
Nocturnal symptoms/wakening
None
Any
Need for reliever/rescuer
None (twice or less/week)
More than twice/week
Lung function (PEF/FEV1)
Normal
<80% predicted or personal best (if
known)
B. Assessment of future risk (risk of exacerbation, instability, rapid decline in lung function, side effects)
Features that are associated with increased risk of adverse events in the future include: poor clinical control, frequent
exacerbations in the past year, ever admission to critical care for asthma, low FEV1, exposure to cigarette smoke, high dose
medication
22
(mometasone furoate)
For the regular treatment to control mild to moderate
persistent asthma in patients aged > 12 years1
Proven Asthma Control with Once-Daily Dosing2*
Easy to Use Inhaler3
Once-daily dosing may improve patient adherence4
* Some patients may be more adequately controlled on 400 micrograms daily, given in two divided doses (200 micrograms twice daily)
ASMANEX TWISTHALER 200 AND 400 MICROGRAMS INHALATION POWDER
ABRIDGED PRODUCT INFORMATION Refer to Summary of Product Characteristics before prescribing. Presentation: Inhalation powder for oral inhalation containing 200 or 400 micrograms mometasone furoate per inhalation.
USES: Regular treatment to control persistent asthma. DOSAGE: For use in adult and adolescent patients 12 years of age and older with persistent mild to moderate asthma: the recommended starting dose for most patients is 400 micrograms once daily in the evening.
Some patients may be more adequately controlled on 400 micrograms daily given in two divided doses. Dose reduction to 200 micrograms once daily in the evening may be an effective maintenance dose for some patients. Patients with severe asthma: the recommended
starting dose is 400 micrograms twice daily, which is the maximum recommended dose. In patients receiving oral corticosteroids, Asmanex Twisthaler treatment will be initiated concurrently with systemic corticosteroid, which will be gradually withdrawn. Children <12
years of age: not recommended. Elderly patients >65 years: no dosage adjustment necessary. CONTRAINDICATIONS: Hypersensitivity to any of the ingredients. PRECAUTIONS AND WARNINGS: Oral candidiasis may occur, requiring appropriate treatment or discontinuation
of Asmanex Twisthaler therapy. Recommended doses of Asmanex Twisthaler must not be exceeded, and must be titrated to the lowest effective dose for each individual patient at which effective control of asthma is maintained in order to reduce system effects. Patients
who are transferred from systemically active corticosteroids to Asmanex Twisthaler require careful attention due to the possibility of adrenal insufficiency. During dose reduction, withdrawal symptoms such as joint and/or muscle pain, lassitude and depression may occur.
During periods of stress, including trauma, surgery, or infection, or a severe asthma attack, patients transferred from systemic corticosteroids will require supplementary treatment with a short course of systemic corticosteroids. Periodic testing of adrenocortical function
is recommended. Pre-existing allergic conditions may be unmasked in patients who are transferred from systemic corticosteroid therapy to Asmanex Twisthaler. Asmanex Twisthaler is not a bronchodilator and is not indicated for rapid relief of bronchospasm or asthma
attacks. Patients should be instructed to contact their physician immediately when asthmatic episodes are not responsive to bronchodilators during treatment with Asmanex Twisthaler. If bronchospasm occurs immediately following dosing, immediate treatment with a
bronchodilator is recommended. Asmanex should be discontinued in these patients. Use with caution, if at all, in patients with untreated active or quiescent tuberculous infections of the respiratory tract, or in untreated fungal, bacterial, systemic viral infections or ocular
herpes simplex. Patients who are potentially immunosuppressed should be warned of the risk of exposure to certain infections. A reduction of growth velocity in children or adolescents may occur as a result of inadequate control of chronic diseases such as asthma
or from use of corticosteroids for treatment. It is recommended that the height of children or adolescents receiving prolonged treatment with inhaled corticosteroids is regularly monitored. If growth is slowed, review therapy with the aim of reducing the dose of inhaled
corticosteroids if possible, to the lowest dose at which effective control of symptoms is achieved. When using inhaled corticosteroids, significant adrenal suppression may occur, especially after treatment with higher than recommended doses; however, during clinical trials
there was no evidence of HPA axis suppression after prolonged treatment with Asmanex Twisthaler at doses ≤ 800 micrograms per day. Lack of response or severe exacerbation of asthma should be treated by increasing the maintenance dose and if necessary administering
a systemic corticosteroid and/or antibiotic and beta-agonist therapy. Patients should be advised against abrupt discontinuation of Asmanex therapy. Asmanex Twisthaler should not be used in pregnancy or lactation unless the potential benefit justifies the potential risk to
the mother, foetus or infant. INTERACTIONS: Co-administration of Asmanex Twisthaler with the potent CYP3A4 inhibitor ketoconazole causes small but marginally significant (p= 0.09) decreases in serum cortisol AUC(0-24) and there may be potential for increased systemic
exposure. There may be a potential for increased systemic exposure to mometasone furoate when strong CYP3A4 inhibitors (e.g. ketoconazole, itraconazole, nelfinavir, ritonavir) are co-administered. SIDE EFFECTS: The most common treatment-related undesirable effects
reported in placebo-controlled clinical studies were oral candidiasis, pharyngitis, headache and dysphonia. Uncommonly reported were dry mouth, dyspepsia, weight increase and palpitations. Systemic effects of inhaled corticosteroids may occur, particularly when
prescribed at high doses for prolonged periods. Rare cases of glaucoma, increased intraocular pressure or cataracts have been reported with the use of inhaled corticosteroids. Package Quantities: Asmanex Twisthaler 200 micrograms: 1 unit of 30 or 60 metered doses.
Asmanex Twisthaler 400 micrograms: 1 unit of 30 or 60 metered doses. Legal Category: Prescription only medicine Marketing Authorisation Holder: Merck Sharp & Dohme Ireland (Human Health) Limited, Pelham House, South County Business Park, Leopardstown, Dublin
18, Ireland Marketing Authorisation Numbers: Asmanex Twisthaler 200 micrograms: PA 1286/39/2 Asmanex Twisthaler 400 micrograms: PA 1286/39/3 Date of Review: September 2011 Additional perscribing information is available on www.medicines.ie or on request from
MSD Pelham House, South County Business Park, Leopardstown, Dublin 18, Ireland. Date of Preparation: October 2011 Copyright © 2011 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. Whitehouse Station, NJ USA. All rights reserved.
References: 1. ASMANEX Summary of Product Characteristics September 2011 2. D’Urzo A, Karpel JP, Busse WW et al. Efficacy and safety of mometasone furoate administered once-daily in the evening in patients with persistent asthma dependent on inhaled corticosteroids. Curr Med Res
Opin. 2005;21(8):1281-9 3. Wardlaw A, Larivee P, Eller J et al. Efficacy and safety of mometasone furoate dry powder inhaler vs fluticasone propionate metered-dose inhaler in asthma subjects previously using fluticasone propionate. Ann Allergy Asthma Immunol. 2004;93(1):49-55. 4. Friedman
H, et al: Adherence and asthma control with mometasone furoate versus fluticasone propionate in adolescents and young adults with asthma. J Asthma;2010: Early online:1-7.
Pelham House, South County Business Park, Leopardstown, Dublin 18, Ireland
10-12-ASM-2011-IRL-4983-J
Asmanex is not intended to be used ”on demand” as a reliever medication to treat acute symptoms.
*
come as standard
When it comes to the treatment of prostate cancer,
look no further than Prostap DCS
*IMPORTANT CHANGE: Prostap Dual Chamber Syringe (DCS) is replacing Prostap,
so it’s necessary for prescriptions to reflect this change of name. A video demonstrating
the five steps of administration can be viewed at www.ProstateCancerUpdate.ie
Prescribing Information
PROSTAP *SR DCS, 3.75mg / PROSTAP *3 DCS, 11.25mg powder and solvent
for prolonged-release suspension for injection in pre-filled syringe; Leuprorelin
Acetate 1 month / 3 month Depot Injection Before prescribing PROSTAP SR
DCS/PROSTAP 3 DCS, please refer to the full Summary of Product Characteristics
(SmPC). PRESENTATION: Powder and solvent for prolonged- release suspension for
injection in pre-filled syringe (Dual Chamber Syringe); PROSTAP SR DCS Powder:
Contains 3.75mg of leuprorelin acetate. PROSTAP 3 DCS Powder: Contains 11.25mg
of leuprorelin acetate. INDICATIONS: PROSTAP SR DCS and PROSTAP 3 DCS:
Management of prostatic carcinoma for which suppression of testosterone is indicated.
Management of oestrogen dependent gynaecological disorders including the
management of pain and lesions associated with endometriosis. Preoperative
management of uterine fibroids to reduce their size and associated bleeding.
PROSTAP SR DCS is also indicated for: Endometrial preparation prior to intrauterine
surgical procedures including endometrial ablation or resection. DOSAGE AND
ADMINISTRATION: Male adults: PROSTAP SR DCS: 3.75mg administered as a single
subcutaneous or intramuscular injection every month. PROSTAP 3 DCS: 11.25mg
administered as a single subcutaneous or intramuscular injection every 3 months. Do
not discontinue when remission or improvement occurs. Response to therapy should
be monitored clinically. Female adults: Treatment should be initiated during the first
5 days of the menstrual cycle. PROSTAP SR DCS: 3.75mg administered as a single
subcutaneous or intramuscular injection every month for a period of 6 months
(endometriosis), for a maximum of 6 months (uterine fibrosis). Vary the injection site
periodically. PROSTAP 3 DCS: 11.25mg administered as a single subcutaneous or
intramuscular injection every 3 months: For a period of 6 months (endometriosis), for
a maximum of 6 months (uterine fibroids). Vary the injection site periodically. Elderly:
As for adults. Children: Use in children not established. CONTRAINDICATIONS:
Hypersensitivity to any of the ingredients or to synthetic GnRH or GnRH derivatives.
Men: Use in patients insensitive to endocrine therapy or post-orchidectomy. Women:
Use in women who are or may become pregnant, in women who are breastfeeding
or who have undiagnosed abnormal vaginal bleeding. PRECAUTIONS AND
WARNINGS: Development or aggravation of diabetes may occur, therefore diabetic
patients may require more frequent monitoring of blood glucose. Hepatic dysfunction
and jaundice with elevated liver enzyme levels have been reported. Therefore, close
observation should be made and appropriate measures taken if necessary. Spinal
fracture, paralysis, hypotension and worsening of depression have been reported.
Men: Should only be used under the direction of a clinician having appropriate
facilities for monitoring response to treatment. Testosterone should fall to castrate
levels within 6 weeks; failure to do so requires reassessment. Initial transient rise in
levels of testosterone may be associated with tumour “flare” manifesting as systemic
or neurological symptoms. Patients at risk of ureteric obstruction or spinal compression
should be carefully considered and monitored during initial weeks of treatment. An
anti-androgen may be administered to reduce the risk of “flare” (see section 4.4 of
the SmPC). Any urological or neurological complications which occur should be
treated by appropriate specific measures. Women: Menstruation should stop during
treatment; therefore the patient should notify her physician if regular menstruation
persists.Spotting/breakthrough bleeding may occur with PROSTAP SR DCS and
PROSTAP 3 DCS treatment. An increase in clinical signs and symptoms may be
observed during the initial days of therapy as sex steroids temporarily rise above
baseline. In the case of uterine fibroids, it is mandatory to confirm the diagnosis of
fibroids and exclude ovarian mass, before therapy is instituted. May cause an increase
in uterine cervical resistance. The induced hypo-oestrogenic state results in a clinically
significant loss in bone density over the course of treatment, some of which may not
be reversible. The generally accepted level of bone loss with LHRH analogues such
as PROSTAP is 5%. During one 6 month treatment period, this bone loss should not
be important. In patients with major risk factors for decreased bone mineral content
such as chronic alcohol and/or tobacco use, strong family history of osteoporosis, or
chronic use of drugs that can reduce bone mass, therapy may pose an additional risk.
Treatment options for vasomotor symptoms and bone mineral density loss should be
considered. In the treatment of endometriosis, the addition of HRT (an oestrogen and
progestogen) has been shown to reduce bone mineral density loss and vasomotor
symptoms. SIDE EFFECTS: Refer to section 4.8 of the SmPC in relation to other side
effects Serious: Pituitary apoplexy, anaphylactic reactions, alteration of glucose
tolerance which may affect diabetic control. Common: Weight gain, anorexia,
depression (occasionally severe), headache, hot flushes, nausea, vomiting, muscle
weakness, arthralgia, impotence, decreased libido, orchiatrophy, gynaecomastia,
irritation at the injection site, sweating, fatigue, peripheral oedema, insomnia,
parasthesia, increases in liver function test values (usually transient). Men: If tumour
flare occurs, symptoms and signs due to disease may exacerbate e.g. bone pain and
urinary obstruction, which should subside on continuation of therapy. Women:
Adverse events occurring most frequently with PROSTAP SR DCS and PROSTAP 3
DCS are associated with hypo-oestrogenism. The induced hypo-oestrogenic state
results in a loss in bone density over the course of treatment, some of which may not
be reversible (see Precautions and Warnings). In women who have submucous fibroids
there have been reports of severe bleeding following the administration of PROSTAP
SR DCS and PROSTAP 3 DCS as a consequence of the acute degeneration of the
fibroids. Patients should be warned of the possibility of abnormal bleeding or pain in
case earlier surgical intervention is required. LEGAL CATEGORY: POM. PACKAGE
Needle shown is not actual size
QUANTITIES: PROSTAP SR DCS: One dual chamber pre-filled syringe containing
3.75mg leuprorelin acetate powder in the front chamber and 1ml of Sterile Solvent in
the rear chamber. One 25 gauge needle, one syringe plunger and one injection site
swab are included in a single injection pack. PROSTAP 3 DCS: One dual chamber prefilled syringe containing 11.25mg leuprorelin acetate powder in the front chamber
and 1ml of Sterile Solvent in the rear chamber. One 23 gauge needle, one syringe
plunger and one injection site swab are included in a single injection pack. PRODUCT
AUTHORISATION NUMBER: PROSTAP SR DCS PA 1547/3/3; PROSTAP 3 DCS PA
1547/3/4. PRODUCT AUTHORISATION HOLDER: Takeda UK Limited, Takeda House,
Mercury Park, Wooburn Green, High Wycombe, Bucks. HP10 0HH, UK. DATE OF
PREPARATION: May 2011. Full prescribing information is available on request from:
Takeda UK Limited, Takeda House, Mercury Park, Wooburn Green, High Wycombe,
Bucks. HP10 0HH, UK. Tel: +44 1628 537900 * Trade mark of Takeda PS110525.
Adverse events should be reported to the
Pharmacovigilance Unit at the Irish Medicines Board
(IMB) ([email protected]).
Information about adverse event reporting
can be found on the IMB website (www.imb.ie).
Adverse events should also be reported to
Takeda UK Ltd. on +44 1628 537900.
Date of preparation: August 2011 PT110703
clinical review
Table 2: Treatment steps (GINA, 2011)
Step 1
Step 2
Step 3
Step 4
Step 5
Asthma education Environmental control
(If step up treatment is being considered for poor control, first check inhaler technique, check adherence, and confirm
symptoms are due to asthma
As needed rapid-acting
B2 agonist
Select one
Select one
Step 3 and select one
Step 4 treatment, add
either
Low dose inhaler ICS
Low dose ICS plus long
acting B2 agaonist
Medium or high dose
ICS plus long acting B2
agaonist
Oral
glucocorticosteroids
(lowest dose)
Leukotriene modifier
Medium or high dose
ICS
Low dose ICS plus
leukotriene modifier
Leukotriene modifier
Sustained release
theophylline
Add IgE treatment
Low dose ICS plus
sustained release
theophylline
Four components of asthma care
GINA (2011) identifies four interrelated components of asthma
care:
Component 1: Develop doctor/patient relationship
Component 2: Identify and reduce exposure to risk factors
Component 3: Assess, treat and monitor asthma
Component 4: Manage asthma exacerbations
This article will focus on component 3 with regard to
the management of asthma but it is important that all four
components are addressed so that health professionals provide
a holistic approach to patient care. All patients should be
assessed to establish their treatment regimen and that they
are on the appropriate for their level of control. This may mean
either increasing or decreasing their treatment. However,
before any changes are made to the patient’s regimen, inhaler
technique and concordance with medication should be
established (GINA, 2011). Each patient is assigned to one of five
treatment steps and patients may move up or down the steps
depending on symptoms and the amount of reliever therapy
being used (see table 2). Inhaled glucocorticosteroids are the
cornerstone of asthma treatment and are the most effective
controller medications available. However, there are additional
medications such as leukotriene receptor antagonists which
can be added on and are very useful in patients who have an
allergy component to their asthma. These medications are
also licensed for use in allergic rhinitis, a condition which a
significant number of people with asthma also have. Newly
diagnosed patients who are not yet on medication should
be commenced on Step 2 or Step 3 depending on severity
of symptoms (GINA, 2011). Patients who do not reach an
acceptable level of control at Step 4 can be considered to have
difficult to treat asthma and should be referred to a respiratory
specialist for management.
Inhaled medications are the preferred method as the drugs
are delivered directly to the lungs where they are needed. This
results in an optimum therapeutic effect with reduced risk
of systemic side effects. It is imperative that all patients are
trained in the use and maintenance of their device and that
inhaler technique is checked at every opportunity.
Ongoing monitoring is essential to maintain control and
establish the lowest dose of medication for optimal control. If
asthma is not controlled, treatment should be stepped up. If
partly controlled, consider stepping up. If asthma is controlled
for at least 3 months, consider stepping down treatment. The
goal of treatment is to be on the least amount of medication to
maintain optimal control.
Table 3: Severity of asthma exacerbations (GINA, 2011)
Parameter
Mild
Moderate
Severe
Respiratory arrest
imminent
Breathless
Walking
Can lie down
Talking
Prefer sitting
At rest
Hunched forward
Talks in
Sentences
Phrases
Words
Alertness
May be agitated
Usually agitated
Usually agitated
Respiratory rate
Increased
Increased
Often >30/min
Accessory muscles
Usually not
Usually
Usually
Paradoxical thoracoabdominal movement
Wheeze
Moderate
Loud
Usually loud
Absence of wheeze
Pulse/min
<100
100-200
>120
Bradycardia
PEFR
Over 80%
Approx 60-80%
<60% or response lasts
<2 hours
SaO2
>95%
91-95%
<90%
Drowsy or confused
25
clinical review
Patients should be offered self-management plans with
instructions on how to adjust their medications in response to
worsening symptoms and/or worsening PEFR. An example of a
self-management plan is available on www.asthmasociety.ie
Acute exacerbations
It is important not to underestimate the severity of an asthma
attack. A progressive increase in shortness of breath, cough,
wheezing, chest tightness or a combination is indicative of an
acute exacerbation. Red flags for acute asthma include:
• A history of near fatal asthma requiring intubation and
mechanical
• Hospitalisation or ED visit within the last year
• Currently using or have recently stopped using oral
glucocorticosteroids
• Over dependence on rapid-acting bronchodilators
• History of psychiatric or psychosocial problems
• History on non-compliance with an asthma medication plan
(GINA, 2011)
Table 3 illustrates severity of asthma exacerbations. Mild
attacks are defined by a reduction in peak flow of 20%,
nocturnal wakening and increased use of rapid-acting
bronchodilator. Mild attacks can be treated at home if the
patient has a personal asthma management plan. Moderate
attacks and severe attacks usually require hospital care. It is
important that the severity of the asthma is assessed so that
the appropriate treatment is administered (see GINA, 2011).
Prompt treatment includes:
• Inhaled rapid-acting beta2 agonists in adequate doses are
essential – 2 to 4 puffs every 20 minutes for the first hour,
then 2 to 4 puffs every 3 to 4 hours (mild exacerbations), 6 –
10 puffs every 1 – 2 hours (moderate exacerbations)
• Oral glucocorticosteroids 0.5 to 1mg of prednisolone/kg
during a 24 hour period
• Oxygen if hypoxic – aim to achieve o2 saturation of 95%.
(GINA, 2011)
It is imperative that response to treatment is monitored and
that the patient is offered follow-up. The purpose of follow-up
is to identify the factors that precipitated the exacerbation
so that these can be avoided in the future. It also provides an
opportunity to review the patient’s medication plan and to
ensure that the patient is on the appropriate medication.
Conclusion
This article has reviewed the updated GINA (2011) guidelines.
The diagnosis, management of stable asthma and the
management of acute exacerbation of asthma in adults has
been discussed from a primary care perspective.
Further reading
Global Initiative for Asthma, 2011, Pocket Guide for Asthma
Management and Prevention (For Adults and Children over 5
Years).
References
Global Initiative for Asthma, 2011, Pocket Guide for Asthma
Management and Prevention (For Adults and Children over 5
Years).
www.asthmasociety.ie accessed 18 April 2012
MCQs
Having read the article now test your knowledge of asthma.
Q1. What percentage of adults in Ireland are affected by
asthma?
a) 10%
b) 5.4%
c) 7.1%
d) 7.8%
Q2. The symptoms of asthma are:
a) Wheeze
b) Cough and chest tightness
c) Shortness of breath
d) All of the above
Q4 The cornerstone of asthma treatment is:
a) Inhaled corticosteroids
b) Leukotriene receptor antagonists
c) Short-acting bronchodilators
d) Theophyllines
Q5. Patients who experience mild exacerbations of
asthma should be:
a) Referred to hospital for treatment
b) Managed in primary care
c) Referred to respiratory consultant
d) Managed in primary care, patient given an action
plan and followed up after the exacerbation
Q3. Diagnosis of asthma includes
Q1. c
Q2. d
Q3. b
Q4. a
Q5. d
a) Spirometry
b) Symptoms, detailed history taking with spirometry
assessment with reversibility
c) Serial peak flow measurement
d) Response to a trial of treatment
Answers:
26
clinical review
Tuberculosis – role of the
practice nurse
Ireland has a very low incidence of TB but that is no reason for complacency, as even
one infected person can in turn infect 10 to 15 people per annum.
Maria Kane, TB CNM3, St James’s Hospital, Dublin
T
uberculosis (TB) remains a significant cause of
morbidity and mortality globally. It is estimated that
a third of the world’s population is infected with TB
and that 10% may go on to develop active disease at
some stage in their life ime.1 In 2008, 9 million new
cases of TB, and 1.7 million deaths, were reported globally.
Ireland has one of the lowest TB incidence rates in Western
Europe with an incidence of ~11/100,000 pop/year. With
less than 500 new cases in Ireland per annum, TB is not seen
every day in general practice.2,3 However we should not be
complacent about this infection; if left untreated a patient with
active TB can infect 10 to 15 people in a year. Recent reports
from India highlight the risk of total drug resistance developing
from inadequate treatment received by patients.4 Effective
treatment is essential both for the survival of individual
patients, to control the spread of TB, and to minimise the
impact of multi-drug resistant TB.
Transmission
Tuberculosis (TB) is a disease caused by infection with bacteria
(bacilli) of the Mycobacterium tuberculosis complex group. It
is spread via airborne particles called droplet nuclei, expelled
when a person with infectious TB coughs, sneezes, shouts, or
sings. Transmission occurs when droplet nuclei inhaled, reach
the alveoli of the lungs, via nasal passages, respiratory tract,
and bronchi. A small number of tubercle bacilli can enter the
bloodstream and spread throughout the body. The tubercle
bacilli may reach any part of the body, including areas where
TB disease is more likely to develop (such as the brain, larynx,
lymph node, lung, spine, bone, or kidney). Within 2 to 8 weeks,
macrophages ingest and surround the tubercle bacilli. The cells
form a barrier shell, called a granuloma, that keeps the bacilli
contained and under control (LTBI). If the immune system
cannot keep the tubercle bacilli under control, the bacilli begin
to multiply rapidly (TB disease).5 The majority of cases involve
the respiratory system.
Consider TB in your differential
Consider TB as a differential in general practice, if your patient
has a cough for longer than 3 weeks, haemoptysis, night sweats
or weight loss. TB is not prejudiced and can affect anyone, but
there are people who are more vulnerable due to a higher risk
of exposure and/or co-morbidities (see Table 1). Additionally
the proximity, frequency, and duration of exposure, the air
concentration and the Infectiousness of person with TB (i.e.,
number of bacilli TB patient expels into the air), all play a part.
27
clinical review
Table 1.
Persons at higher risk for exposure to, or infection with, TB
• Close contacts of person known or suspected to have
active TB
• Foreign-born persons from areas where TB is common
• Personsl who visit TB-prevalent countries
• Residents and employees of high-risk congregate settings
• Healthcare workers who serve high-risk clients
• Populations defined locally as high risk for infection or
disease, such as medically underserved, low-income
persons who abuse drugs or alcohol
• Children and adolescents exposed to adults at increased
risk for infection or disease
• Those on prolonged high-dose corticosteroid or
immunosuppressants
• Certain medical conditions including diabetes mellitus,
chronic renal failure, malignancies
3 investigations; chest x-ray, sputum, Mantoux
TB tests should ideally be started in general practice. Speed of
diagnosis reduces the risk of infection spread and out ruling
TB prevents unnecessary referral to hospital services. A chest
x-ray (posterior-anterior) is the initial step in assessing a patient
with TB symptoms. If the chest x-ray is abnormal sputum
samples should be collected. TB culture must be specifically
requested as TB is not tested for routinely when (C&S) culture
and sensitivity is requested. The results are only as good as
the quality of the sample provided. When sending sputum
samples to the lab ensure there is an adequate sample amount
of 5mls and send the sample within 24hours of collection. The
best results are achieved when the patient produces 3 early
morning samples on 3 consecutive days. The sputum smear
result is usually available within 24 hours but the culture and
sensitivities can take many weeks.
Having test results before or during that first consultation
is of immense benefit. If TB is out ruled it may be more
appropriate to refer to general respiratory clinic. Even if a TB
specialist referral is necessary, the information is invaluable
when prioritizing patient appointments. For example a
patient with possible TB on chest x-ray will be given an urgent
appointment. In cases with normal chest x-rays, culture and
smear negative sputum but a positive Mantoux the patient may
be given an appointment for the latent TB clinic.
If sputum samples are smear negative (the patient is less
infectious). Knowing the smear result at the first clinic will
guide the staff as to the need for the patient to wear a mask
while in clinic. This is an important infection control measure.
TB medications are not commenced until a sputum sample is
sent because the sample will be tested for drug sensitivities,
therefore sending samples from general practice gets the
patient started on treatment sooner. It can take up to 8 weeks
to have the final sputum culture results so the earlier sputum is
sent to the lab the better.
Mantoux skin test is an aid to the diagnosis of TB. It is an
intradermal injection of purified protein derivative (PPD),
derived from tuberculin. An infected person’s immune cells
recognize TB proteins in PPD and respond by causing a wheal
to rise at the injection site. Reading and interpretation of TST
reaction must be done within 48-72 hours. Interpreting the
Mantoux skin test is based on the size of the reaction, and
the patient’s history.6 If not involved in Mantoux skin testing
regularly, measurement and interpretation can be difficult.
Support
The role of the practice nurse in TB does not end when a
patient is referred to a specialist clinic. The majority of patients
28
have their TB management as outpatients and may require
additional support from the community healthcare providers
and general practice may be a centre to facilitate this care.
Ongoing support can help the patients deal with the stigma
associated with TB. The stigma of TB remains an issue for some
who prefer not to disclose their diagnosis to others. Patients at
our TB clinic have refused to have a nurse call to their homes
where neighbours may question why they are visiting. Others
refused to use interpreters as they feared members of their
own ethnic community hearing of their diagnosis.
Combination therapy is used to treat TB for a minimum
of 6 to 9 months and contains Isoniazid and Rifampicin plus
Pyrazinamide (for the first 2 months) plus Ethambutol until
sensitivities are confirmed. General practice is often the first
port of call for patients experiencing side effects. They may
be unaware that symptoms they are experiencing are as
result of TB medications. Familiarity with TB drug side effects
can assist in providing advice to patients. If side affects occur
advise the patients to hold their TB medication and contact
the TB clinic immediately. The patient should avoid alcohol
and paracetamol at all times when on TB medication to reduce
hepatic complications. LFT’s are frequently taken when patients
experience side effects. Common side effects are outlined in
Table 2.
Table 2. Common side effects of TB drugs
Rifampicin
Isoniazid
Pyrazinamide
Ethambutol
Allergic
reactions
Allergic
reactions
Allergic
reactions
Allergic
reactions
GI
disturbance
GI
disturbance
GI disturbance
GI
disturbance
Hepatitis
Hepatitis
Hepatitis
Bleeding
problems
Peripheral
neuropathy
Increased uric
acid
Retrobulbar
neuritis
Discoloration
of body fluids
Sun
sensitivity
OCP Efficacy
Whilst providing support and monitoring side effects,
another role that the practice nurse can offer is smoking
cessation advice. Smoking is associated with a prolonged
period of infectivity and requirement for longer course of
treatment.7
One of the most challenging elements of TB management
in Ireland is insuring adherence to the course of antibiotics.
Most TB patients have their disease managed as an outpatient
and complete their course of antibiotics, albeit a long
course, without any difficulties. A small number of patients
adhere poorly to the regimes and this group is more likely to
experience prolonged illness, disability, future relapse and even
possible death or develop Multi-drug resistant (MDR-TB).
The World Health Organization recommends that every
patient receive Directly Observed Therapy (DOT). This means
that a health care worker watches the patient swallow every
dose of their prescribed TB drugs. However, there are not
enough public health resources in Ireland to achieve this
goal, so we have to think outside the box when it comes to
providing this service. Traditionally DOT’s has been provided
in the patient’s home by the Public Health Nurse. DOT’s can be
carried out in any venue: in a clinic, the home or at the roadside
and by a variety of health care professionals: practice nurses,
clinical review
pharmacists or other responsible person. Studies have shown
improved cure rates and less drug resistance when DOT’s
programmes are in place.8
The stigma of TB
remains an issue for
some who prefer
not to disclose their
diagnosis to others.
Infection control
If a patient is attending a busy general practice and is
suspected of having TB it is advisable that they are not left
waiting in the waiting area with others. They could be seen
first or asked to attend at the end of the day. Good respiratory
hygiene is important. The patient can be asked to wear a
surgical mask or cover the mouth and nose with a tissue when
coughing. The risk of infection greatly diminishes when the
patient is two weeks on treatment. The TB clinic will give the
patient specific advice about people and places to avoid until
non infectious.
Summary
The role of the practice nurse should not be under estimated
in the care of a TB patient. He/she can recognise possible TB
cases, in particular high risk individuals, act quickly to get
chest x-ray and sputum tests, support patients during ongoing
treatment by monitoring side effects, providing DOT’s and
being an alternative point of contact in the health care system.
5.
References
1. World Health Organisation. Tuberculosis facts, 2008.
Geneva, World Health Organisation.
2. World Health Organisation. Global tuberculosis control:
surveillance, planning, financing. WHO report 2008. WHO/
HTM/TB/2008.393. Geneva, World Health Organisation.
3. Health Protection Surveillance Centre. Report on the
epidemiology of tuberculosis in Ireland 2006. Dublin, Health
Protection Surveillance Centre 2008.
4. Udwadia, Z. Amale, R. Ajbani, K. Rodrigues, C .
7.
6.
8.
Correspondence: Totally Drug-Resistant Tuberculosis in
India. Clinical Infectious Disease, 2011:0 (15th October)
Core Curriculum on Tuberculosis: What the Clinician Should
Know. http://www.cdc.gov/tb/publications/slidesets/
corecurr/default.htm
Guidelines on the Prevention and Control of Tuberculosis in
Ireland 2010. National TB Advisory Committee, April 2010.
ISBN: 978-0-9551236-5-8. Available online: http://www.
hpsc.ie/hpsc/AZ/VaccinePreventable/TuberculosisTB/
Guidance
UA Siddiqui,M O’Toole,Z Kabir,S Qureshi,N Gibbons,M
Kane,J Keane. Smoking Prolongs the Infectivity of Patients
with Tuberculosis (2010) Irish Medical Journal. October
Volume 103 : 9
Leimane, V. Leimans, J. Tuberculosis control in Latvia:
integrated DOTS and DOTS-plus programmes. (2006) Euro
Surveillance 11 (3): 29-33
Recommended Reading
Francis J Curry TB Guidelines. http://www.nationaltbcenter.edu/
TB School / TB Study Day
Friday 19th October 2012, 9.00 to 16.00 hrs
Centre for Learning & Development, St. James’s Hospital, Dublin 8
This is the opportunity to participate in an intensive full day education and training programme related to the clinical aspects
of TB. The programme will be facilitated through a combination of lectures & workshops.
The programme is open to all health care professionals involved in the care of patients with TB. It will be of particular interest
to Respiratory Physicians, Doctors and Nurses working in public health, infectious diseases, general practice, specialist centres
and institutions where TB incidence rates are high.
Cost: Doctors & other HCP’s €100, nursing staff €75, free to SJH staff
Includes refreshments and lunch / See registration form for payment details.
Programme Credits: 6 CME’s RCPI & ABA category 1 Approval / 5 CEU’s
Conference updates: http://www.stjames.ie/GPsHealthcareProfessionals/ConferencesCourses/TB.pdf
Programme Organisers: Dr Anne-Marie McLaughlin and Ms Maria Kane, St James’s Hospital, Dublin 8
Enquiries to: Bookings through: Ms Maria Kane, Ph: 01 4284716, Email: [email protected]
The Centre for Learning & Development – [email protected] or call 4162200/1/2
29
clinical review
Childhood nutrition from an
nursing perspective
Nutrition: the process of providing or obtaining the food necessary for health and
growth; the branch of science that deals with nutrients and nutrition, particularly in
humans. (OED)
Elizabeth Wallace, RGN, Practice Nurse, Cork
T
he requirement for adequate nutrition, essential
for the healthy growth and development of a child,
begins at the pre natal/pregnancy – planning stage.
The Practice Nurse, well known to her patients – a
familiar and trusted professional and confidante
– is ideally placed to play a key role in advising and guiding
the woman to reduce the risks to her developing baby
and maximize her chances of a successful outcome to her
pregnancy. The nurse will continue to be available to counsel
and encourage throughout the journey ahead for mother,
father and baby.
Pre-natal/pregnancy planning
The woman’s general state of health will be assessed and
recorded: weight, height, BMI, urinalysis, full blood profile.
Her smoking and alcohol status will be ascertained. The nurse
will promote lifestyle changes if issues arise around obesity,
smoking or alcohol consumption. Using brief intervention skills,
she can explain that smoking in pregnancy contributes to low
birth weight1 and encourage cessation; advise that the woman
should ideally abstain from alcohol consumption or at least
cut down to a minimum – one or two units per week – since
30
alcohol is a toxin that crosses the placental barrier. Heavy, binge
drinking can cause damage to the developing nervous system
and lead to foetal alcohol spectrum disorder.2 There are many
leaflets that can be given to underscore the advice regarding
these issues in pregnancy.
The nurse should examine current eating habits, outlining
the benefits of losing weight by modifying food choices and
reducing sodium intake. An important point to emphasize
is that folic acid (folate) 400 mcg supplement taken for two
months prior to conception and during the first trimester,
reduces the risk of neural tube defects by up to 70%. Although
this supplement is now added on a voluntary basis to a wide
range of foodstuffs, e.g. some dairy spreads, fruit juices, milk,
yogurts, soups and cereal bars, the National Committee on
Folic Acid Fortification (NCFAFF) recommends that all women
of childbearing age who may become pregnant should take
folic acid supplements at the dosage stated.3
Antenatal
Throughout this period, the Practice Nurse will continue to
monitor and record progress in relation to weight gain, blood
pressure, urinalysis, haemoglobin and ferritin levels. If relevant,
clinical review
she will check, in a nonjudgmental manner, how the motherto-be is managing her lifestyle and give advice and affirmation.
Plans for infant feeding will be discussed and literature
given or books on the subject recommended. The nurse will
promote breast feeding as the ideal food for baby, having
all the essential nutrients in correct proportion as well as
providing some antibodies that help keep baby healthy in
the first months of life. In the event that she does not wish to
breastfeed, the nurse must accept the woman’s decision and
not impose her own opinion.
She should advise the woman to attend antenatal classes
and to bring her partner along as well.
Postnatal
The Practice Nurse will first meet the new mother and baby,
very often accompanied by the father, on their attendance for
baby’s two-week check up.
This provides an opportunity to weigh the baby, review
feeding and talk about any associated issues that have arisen.
New mothers are often exhausted by their babies’ frequent
demands for feeds at this stage. They may feel too tired
to prepare meals for themselves and may not be drinking
sufficient fluids. The nurse should stress the importance
of taking care of their own nutritional needs by having a
good balanced diet and plenty of fluids. Partners should be
encouraged to be aware of their partner’s levels of tiredness
and to cook some nice, nourishing meals.
Both breast and bottle fed babies may suffer from colic. The
GP will examine the baby – and provided no abnormality is
detected – the nurse will advise on strategies for dealing with
colic, such as commencing the feed before baby becomes so
hungry that they gorge the milk; allowing them to break wind
half way through and at the end of the feed, and in the case
of the bottle fed baby, ensuring that the teat nipple is not too
large (the nipple should drip at a rate of one drip per second
when the bottle is inverted). Rarely, sensitivity to lactose is
diagnosed, in which case the doctor may prescribe a lactosefree formula. The nurse can also advise the mother to visit the
local Public Health Nurse, who has a vast store of knowledge
and experience of infant feeding.
Parents should be
advised not to make
a fuss when the child
makes the inevitable
mess but to let the
child enjoy the tactile
experience as much as
the taste.
The Practice Nurse will have an opportunity to discuss
baby’s feeding progress during subsequent routine primary
vaccination visits. She can point out that breast milk or milk
formula provides all baby’s nutritional needs until he is 6
months old and it is recommended that this is the ideal time at
which to commence weaning.
Weaning – 6 months
At this stage, baby’s digestive system is sufficiently mature
to metabolize wheat based cereals and foods such as puréed
vegetables and meat such as lamb and chicken. The store of
iron in the baby’s liver will become depleted now and iron rich
foods need to be introduced. The Practice Nurse will provide
information on sources of iron such as spinach, red meat and
liver and perhaps recommend literature on weaning.
If weaning is introduced earlier than 6 months of age, but
certainly never earlier than 17 weeks, a rice based cereal and
some puréed vegetables and fruit may be gradually introduced.
Wheat based cereal should not be introduced before 6 months.
Advice can be given on the benefits of introducing savoury
flavours initially to avoid the development of a ‘sweet tooth’
and on introducing the growing baby to a wide variety of
textures, natural flavours and colours. An interval of several
days should be allowed between the introductions of each new
food so that any food which might cause digestive problems or
adverse reactions can be easily identified. Salt, sugar or honey
should be not be added to food; eggs should be well cooked
and no unpasteurized food should be given. She should also
advise the mother of the recommended limits for fruit juices.
The American Academy of Paediatrics, in their report on
the ‘Use and Misuse of Juice in Paediatrics’, recommends
limits on how much fruit juice should be given to children,
while recommending that juice is totally avoided because of
its association with obesity, dental caries and digestive tract
problems.
‘When you give your child juice, it should be 100%
pasteurized fruit juice and not fruit drinks. Infants under 6
months of age should not be given juice, although many
pediatricians do recommend small amounts of juice for
children that are constipated. Infants between 6 and 12 months
can drink up to 4 to 6 ounces of juice a day, but should do it
only in a cup, not a bottle.
31
clinical review
Younger children aged 1 to 6 years should have only 4 to 6
ounces of juice a day. Older children should be limited to 8 to
12 ounces of juice a day. Instead of juice; children should be
encouraged to eat whole fruits.’4
The Public Health Nurse will see the baby in the community
at 9 months for a developmental check and any problems
presenting there will be referred to the GP where again the
Practice Nurse may have a contribution to make on nutrition
and feeding.
1 year and up
At one year old, baby has reached toddler stage and will
be attending the surgery for primary vaccination boosters.
Toddlers often go through a ‘fussy eater’ phase. The Practice
Nurse will again have an opportunity to assess the child’s
weight and height and to talk with the parents and reassure
them that this is a normal behavior pattern for their child’s
stage of development. The toddler is beginning to develop
an independent mind and strong opinions about what they
will and will not eat. Their rate of growth has slowed and their
appetite decreases accordingly. The parents should be advised
not to force the baby to eat but rather to offer healthy choices
of very small meals and snacks and plenty of fluids during the
day. If baby gets fixated on one specific meal such as pasta,
alternative choices should be offered rather than giving in
and serving pasta at every meal. The baby will not go hungry;
and will eat eventually. If a particular new food or vegetable is
rejected, remove it without comment and keep offering it at
each meal time.
By 18 months, the toddler may still have phases of fussiness
and refusal to eat what is offered. The toddler should now be
joining the rest of the family at table in their high chair and
attempting to feed themselves using a spoon and a cup or
beaker. Parents should be advised not to make a fuss when
the child makes the inevitable mess but to let the child enjoy
the tactile experience as much as the taste. The child should
not, however, be allowed to throw food; should this occur, it
signifies that they are no longer hungry and the plate should be
removed. As long as the child has a wide variety of nutritious
sugar-free whole meal cereals, meat, vegetables and fresh fruit
and has not more than 720 ml whole milk and plenty of water,
they will continue to be well nourished.
As children get older and spend time watching television
or playing computer games, they are continuously being
bombarded by targeted advertising of foods that are high in
sugars, salt and calories and have little or no nutritional value.
Recent studies estimate that there are approximately 300,000
children in Ireland who are either overweight or obese. The
number of teenage boys who are overweight has increased
from 6 per cent in 1990 to 19 per cent in 2008. Obese children
are predisposed to grow into obese adults. Organizations
including the Irish Health Foundation have campaigned for
tighter restrictions on the advertising of junk food. 5
The Broadcasting Authority of Ireland is currently considering
the introduction of a ban on advertising of non healthy foods
on TV programmes watched by children.
The outcomes of poor nutrition and low levels of exercise
are evident in the statistics quoted above. The eventual costs
to the individual in terms of obesity, diabetes, hypertension,
cardiovascular disease and cancer are immense. There is also an
enormous financial cost both to the individual, in terms of lost
income and opportunities, and to the wider economy in terms
of work days lost through illness and increased pressure on an
already strained health service.
32
Good nutrition – key points
• Have regular family meals where everyone sits at the
table together.
• Serve a variety of healthy foods and snacks including
fresh fruit and vegetables.
• Be a role model by eating healthily yourself.
• Avoid rows over food; they are counter-productive.
• Don’t bribe children to eat.
• Encourage children to get involved in meal preparation.
• Don’t give high calorie/low nutrient snack bars; give a
piece of fresh or dried fruit instead.
• Keep juice to a minimum; give water or milk instead.
• Do not add high sugar/high salty snacks to your shopping
basket.
• Give plenty of water to drink. Bottled water is not suitable
for under 1 year olds.
• Do not use a deep-fat fryer and limit the use of the frying
pan; grill or bake food instead.
• For occasional treats, use low-fat or homemade chips or
wedges, roasted in the oven.
• Make sweets, chocolates and ice-cream a rare treat.
The Practice Nurse has an important role to play in the
education of parents by promoting, at every opportunity, the
benefits of good nutrition and regular exercise for themselves
and their children.
References
1. Bull World Health Organ. 1987; 65(5): 663–737.
2. Department of Health and Children, www.dohc.ie
3. National Committee on Folic Acid Fortification (NCFAFF)
4. American Academy of Paediatrics “Use and misuse of Juice
in paediatrics”. 2001.
5. Oireachtas Library & Research Service. 2011. Obesity – a
growing problem. http://www.oireachtas.ie/parliament/
media/housesoftheoireachtas/libraryresearch/spotlights/
spotObesity071111_150658.pdf
The American
Academy of Paediatrics
recommends that
juice is totally
avoided because of
its association with
obesity, dental caries
and digestive tract
problems.
advertorial
SMA tackles
tummy troubles
A
recent Irish study1 confirms that the most commonly reported gastrointestinal-related conditions
in infants during the first 6 weeks postpartum
include colic, constipation, reflux and lactose
intolerance. The study lead by Dr Roslyn Tarrant, a
clinical paediatric and research dietitian at Our Lady’s Children’s
Hospital, Crumlin was the first of its kind and followed up a
sample of 450 mothers and their babies, recruited from the
Coombe Women and Infants Hospital. The study was published
in the March issue of Irish Medical Journal1 and Dr Roslyn Tarrant
reported that ‘20% of infants who experienced an illness during the first 6 weeks were potentially feeding-related including
constipation, colic, lactose intolerance and gastro-oesophageal
reflux disease’. Dr Tarrant recently spoke at Pfizer Nutrition’s
Study Day and addressed the topic of infant feeding difficulties.
The first few months of life can be stressful for a newborn’s
body as they adapt to digesting a range of nutrients. 2,3 Mild
digestive issues are common in young babies whether bottle
or breastfed and often means that babies cry from discomfort
which can be worrying for mums. Tummy troubles in the
first few months of life can include: wind, crying and colicky
symptoms, constipation, spitting up and fussing. SMA Comfort
is designed to be easy to digest and gentle on babies tummies4
and has three modifications that contribute to easier digestion
including:
• Partially hydrolysed whey protein to improve gastric transit
and emptying times.5
• Reduced lactose to minimise fussing and wind2,3
• SN-2 enriched fat blend for softer stools4
A recent study has shown that infants fed formula with an
SN-2 enriched fat blend spent significantly less time crying
when compared to those fed a non SN-2 enriched formula.6
Pfizer Nutrition support a range of study days chaired
and presented by leading healthcare professionals on infant
nutrition and related issues and are tailored to meet the
learning needs of the specialist multi-disciplinary team who
care for and support infants and their families.
IMPORTANT NOTICE: Breastfeeding is best for babies. You
should always seek the advice of a doctor, midwife, health
visitor, public health nurse,dietitian or pharmacist on the need
for and proper method of use of infant milks and on all matters
of infant feeding.
References:
1. Tarrant RC, Sheridan-Pereira M, Younger KM, Kearney JM. Ir Med J. 2012 Mar;
105(3):75-8.
2. Infante Pina D et al. J Gastroenterol 2008; 14:248-254.
3. Infante D et al. World J Gastroenterol 2011; 17: 2104-2108.
4. Bettler J et al. Presented at: EIP: Gastroenterology, Nutrition and Metabolism.
2011 Istanbul,Turkey.
5. WA et al. Acta Paediatra 2001; 90:196-198.
6. Limanovitz I et al. ESPGHAN 2011.
33
product news
SMA Comfort – easy to digest
Kelkin Baby Vitamin D
New SMA Comfort milk has been specially formulated to be
easy to digest and gentle on babies’ tummies. It has three
modifications designed to aid digestion:
Partially Hydrolysed - 100% whey protein
* Large protein molecules are broken down into smaller, more
easily digested peptides
* This improves gastric transit and emptying times, making
them similar to breastfed babies
Reduced lactose - to minimise fussing and winding
* Lactose can be hard for babies to efficiently digest in the
first few weeks of life causing discomfort due to wind.
* In babies fed formula with less lactose, wind and crying are
both reduced.
SN-2 enriched fat blend - to help make stools softer
* SN-2 enriched fat is structurally similar to the fat found in
breast milk
* This means it is well absorbed and can reduce hard stools
Kelkin ihas announced the launch of it’s new Kelkin Baby
Vitamin D3, which has been developed based on the
recommendation from the HSE and the FSAI stating that all
babies from birth up to 12 months, both breastfed or formula
fed, should be given a daily supplement of 5 micrograms (5µg)
of Vitamin D.
Each 3 drop dose of Kelkin Baby Vitamin D3 provides 100%
of the RDA of 5µg of D3 in cholecalciferol form – the preferred
and most recommended form of vitamin D
supplement for infants. Kelkin Baby Vitamin
D3 product is presented as a 20ml
dropper bottle which contains
6 months supply of Vitamin D3.
Kelkin Baby Vitamin D3:
• has no preservatives, artificial
colours, flavours or sweeteners
• is gluten, soya, dairy and nut
free
• is odourless and tasteless
• is suitable for vegetarians.
For further information
please contact Kelkin Ltd. at 014600400 or email info@kelkin.
ie. Alternatively check out our
website: www.babyvitamind3.ie
IMPORTANT NOTICE: Breastfeeding is best for babies. You
should always seek the advice of a doctor, midwife, health
visitor, public health nurse,
dietitian or pharmacist on the need for
and proper method of use of infant milks
and on all matters of infant feeding.
If you would like your local paediatric
product specialist to visit you and update
you on our current product innovations
and solutions to common feeding
problems, please contact Cillian Lynch 014676588 or [email protected]
Actavis launches Citalopram
Actavis Ireland would like to notify the market of the following
product name change; Cipralam 10mg & 20mg Film-coated
Tablets will change to the new name of Citalopram Actavis 10
mg & 20 mg x 28 Film-coated Tablets.
The product with the new name will be introduced to the
market as existing stock depletes. All other relevant product
information remains unchanged. All pharmacy information
systems have been updated accordingly. GMS codes remain
unchanged. Citalopram Actavis is subject to medical
prescription and available from all wholesalers now.
Product
Citalopram Actavis 10 mg x 28 Tablets
Citalopram Actavis 20 mg x 28 Tablets
For further information on the Actavis portfolio please contact us
in Cork today on 1890 33 32 31 or email on [email protected]
34
Actavis launches Pioglitazone
Actavis Ireland is delighted to be the first to launch the generic
version of Pioglitazone 15 mg, 30 mg and 45 mg x 28 Tablets on
the Irish market.
Pioglitazone Actavis is indicated as second or third line
treatment for type 2 diabetes mellitus.
Pioglitazone will compliment Actavis’ growing diabetes
range. This brings the total number of Day One launches from
Actavis this year to seven, further adding to Actavis’ proud
position as the fastest growing generic company on the Irish
market.
Pioglitazone is GMS reimbursable and subject to medical
prescription.
Product
Pioglitazone Actavis 15 mg x 28 Tablets
Pioglitazone Actavis 30 mg x 28 Tablets
Pioglitazone Actavis 45 mg x 28 Tablets
For further information on the Actavis portfolio please contact us
in Cork today on 1890 33 32 31 or email on [email protected]
product news
Data reinforce clinical efficacy
of Xiapex in the treatment of
Dupuytren’s contracture
Lyxumia in combination with
insulin demonstrates significant
reductions in HbA1C
Real-world data from clinical practice, presented recently at
the annual congress of the Federation of European Societies
for Surgery of the Hand (FESSH), show that Xiapex (collagenase
clostridium histolyticum) improved the degree of Dupuytren’s
contracture by 36.6 ± 20.3 degrees (n=546 joints) with an
84% improvement in range of motion.1 These results are in
line with those seen in the pivotal CORD I study1, and further
support the role of collagenase clostridium histolyticum (CCH)
as a minimally invasive option in the treatment of Dupuytren’s
contracture in adult patients with a palpable cord.2
The retrospective chart review of 501 US patient charts,
representing 629 unique joints, examined the effectiveness
of CCH for Dupuytren’s contracture in a real-world setting,
compared to efficacy findings from the clinical registration
trial (CORD-I). The number of CCH injections per joint was 1.08
± 0.32 (n=629 joints) and the average number of office visits/
treatment was 2.92 ± 1.0 (n=620). Both of these figures are
lower than those seen in the phase III study, where the mean
number of CCH injections per joint was 1.5 (CI 1.39-1.61).
Dr Gary Pess, Orthopaedic Surgeon at the Drexel University
School of Medicine, Philadelphia, PA and Central Jersey Hand
Surgery, USA, explained, “This data supports collagenase
clostridium histolyticum as a viable alternative, in some
patients, to invasive surgical options currently available. It is
good to hear that treatment outcomes can be achieved with
fewer injections and visits than seen in clinical trials, and this
could potentially lead to a positive impact on healthcare costs
associated with Dupuytren’s contracture treatment in some
countries.”
Sanofi recently announced that once-daily Lyxumia (lixisenatide)
achieved the primary efficacy endpoint of significantly reducing HbA1c in combination with Lantus (insulin glargine), with an
associated significant reduction in post-prandial glucose (PPG), in
patients with uncontrolled type 2 diabetes (T2DM) on oral antidiabetics (OADs).
Positive results from the GetGoal Duo study, presented at the
American Diabetes Association (ADA) meeting, showed that HbA1c
decreased on average from 8.60% to 7.60% during the run-in
period with insulin glargine. The addition of lixisenatide led to a further significant HbA1c decrease to 6.96% after 24 weeks, compared
to 7.3% in patients receiving placebo (p<0.0001). A significantly
higher percentage of patients achieved target HbA1c of <7.0% with
lixisenatide, compared to placebo (56.3% vs. 38.5%, respectively,
p=0.0001). Results also showed a beneficial effect on body weight.
In order to achieve complete glycaemic control in T2DM, both
fasting plasma glucose (FPG) and PPG components need to
be addressed.5 PPG is the term used to define plasma glucose
concentrations after eating. A patient’s PPG profile is determined
by carbohydrate absorption, insulin and glucagon secretion, and
their co-ordinated effects on glucose metabolism in the liver and
peripheral tissues.
With traditional treatment regimens focusing on FPG control, approximately 40% of patients currently treated with basal
insulin+OADs are not achieving target HbA1c, despite optimised
FPG control. This can be due to inadequately controlled PPG. The
role of PPG in overall HbA1c control is therefore increasingly recognised. A wider choice of therapies to target PPG would support
patients in achieving better control of their condition.
Viropharma’s Buccolam licensed for emergency treatment of
seizures in children and adolescents
ViroPharma recently announced that Buccolam (midazolam,
oromucosal solution) is approved for reimbursement by the
HSE and is available through the national health system for
children and adolescents, from three months to less than 18
years of age, who suffer from prolonged, acute, convulsive
seizures. In Ireland, there are up to 42,000 patients with
epilepsy and it is estimated that one in every 200 children has
the condition. For children aged between 5 and 18 years old,
the national prevalence is between 3 and 5 people in every
1,000, or a total of up to 5,000 children.
For infants between three to six months of age, treatment
of Buccolam must be administered in a hospital setting where
monitoring is possible and resuscitation equipment is available.
Buccolam must only be used by parents/carers where the
patient has been diagnosed to have epilepsy.
“Buccolam, as a licensed preparation of buccal midazolam
for emergency treatment of prolonged seizures, is a welcome
additional option for care of children with epilepsy,”
commented Dr Bryan Lynch, Consultant Paediatric Neurologist
at the Children’s University Hospital in Dublin.
Buccolam is oromucosal midazolam provided in a pre-filled,
age-specific dose formulation for convenient buccal cavity
(i.e. via the cavity between the cheek and gum) delivery.
Oromucosal midazolam has been shown in four clinical studies
to be either comparable or superior in both its effectiveness
and speed of onset of action to the current standard licensed
treatment, rectally-administered diazepam, for terminating
paediatric convulsive seizures.
“The availability of a further emergency medication within
Ireland is good news for parents and carers of children with
epilepsy,” commented Mr Mike Glynn, CEO of Brainwave, The
Irish Epilepsy Association. “It provides a practical means of
treating young people at risk of prolonged, acute seizures in
the community. We support parents and carers in their wish for
an emergency treatment for young people that is simple to use
and may reduce the number of hospitalisations.”
35
product news
Baxter’s treatment regimen
Pinewood Healthcare launches
may reduce cardiovascular risk Torvan
Healthcare, the company which is bringing a new
factors in diabetic renal patients Pinewood
version of the acclaimed lipid-lowering agent atorvastatin to
Baxter International recently announced results from two
large, international multicenter trials demonstrating that a low
glucose peritoneal dialysis (PD) regimen favorably impacted
metabolic measures important for end-stage renal disease
(ESRD) patients with diabetes, including blood glucose (sugar)
control and selected lipids (fats and cholesterol). The combined
results were presented as a late-breaking presentation at the
49th Annual European Renal Association – European Dialysis
and Transplant Association (ERA-EDTA) congress in Paris.
Results from the combined IMPENDIA/EDEN trials showed
that a low-glucose PD regimen led to clinically and statistically
significant reductions in serum levels of HbA1c (the standard
marker for assessing blood glucose control) in adult PD
patients with diabetes. In the studies, significant reductions
also were seen with certain lipid parameters including serum
triglycerides (type of lipid or fat found in the blood), VLDLcholesterol and apolipoprotein B (a protein that helps form
LDL, or bad cholesterol, in blood) following a low-glucose PD
regimen.
“A low-glucose prescription should be considered when
managing diabetic patients on peritoneal dialysis,” said Joanne
Bargman, MD, University Health Network and professor of
Medicine at the University of Toronto and presenting study
investigator. “The data demonstrate low glucose PD regimens
may be beneficial in aiding the management of glucose and
lipid levels in diabetic PD patients.”
Prichard, MD, vice president and therapeutic area lead for
Baxter’s Renal franchise.
MSD launches Elonva
MSD, recenlty announced the availability of Elonva
(corifollitropin alfa injection), a new treatment for fertility, in
Ireland. Elonva is approved for controlled ovarian stimulation
(COS) in combination with a gonadotropin-releasing hormone
(GnRH) antagonist for the development of multiple follicles in
women participating in an assisted reproductive technology
(ART) program
Packaged in Swords, North County Dublin, Elonva is a novel
sustained follicle stimulant. A single subcutaneous injection
of the recommended dose of ELONVA may replace the first
seven injections of any conventional daily recombinant follicle
stimulating hormone (rFSH) preparation in a COS treatment
cycle. It has the ability to initiate and sustain multiple follicular
growth for an entire week, and offers similar efficacy to rFSH.1
Approval was granted based upon extensive data from
clinical trials, including Engage, the largest randomized,
double-blind fertility agent trial in in-vitro fertilization (IVF)
performed to date. In the Engage trial, the ongoing pregnancy
rate (the primary endpoint) achieved in the Elonva treatment
arm (38.9% per started cycle) was similar to that achieved in
patients receiving a daily dose of rFSH (38.1% per started cycle).
“MSD is delighted to announce the availability of the first
ovarian stimulant in over a decade. Elonva reduces the number
of daily injections, and therefore its availability in Ireland is a
positive step towards helping reduce the burden of fertility
treatment for women experiencing difficulty conceiving,” said
Dr Colm Galligan, Medical Director, MSD.
36
the Irish market has suggested that Irish GPs and their patients
will benefit significantly from the new product’s availability.
Pinewood Healthcare, which is launching Torvan in Ireland,
is announcing details of the potential savings that could be
delivered now that clinicians have a choice of efficacious
treatment options. Based on Torvan’s list price, there is the
potential for a saving of €24.5 million over five years.
The largest selling drug in history (Lipitor) lost its patent
protection in Ireland on 6th May. Atorvastatin is the number
one selling drug in Irelandand the second most commonly
prescribed drug, after Aspirin. Estimates vary, but there could
be as many as 160,000 patients in Ireland with coronary
heart disease. It is estimated that 44% of people with higher
than target cholesterol are prescribed a statin. In addition,
increasing this percentage to 75% was proven to be achievable
and this would prevent 95% of cardio-vascular events among
the sample over a five-year periodv.
Fergal Murphy, Company Director, Pinewood Healthcare, said
that GP and hospital-based prescribers who were considering
switching to the new generic alternative for atorvastatin,
TORVAN, should bear in mind that they could significantly
reduce costs, not just for their private patients but on a wider
dramatic scale for the economy as a whole.
“Initially, what may look like relatively small savings begin to
mount up when you take into account the numbers of people
who are prescribed atorvastatin and who are likely to be placed
on this tried and trusted agent as the age profile of the Irish
population increases.”Pinewood Healthcare is also announcing
the findings of new research into statin prescribing habits and
patterns to coincide with the launch of TORVAN. The research
established that:
• GPs treat an average of 123 dyslipidaemia patients per
month
• 90% are diagnosed by the GP through routine screening
with remainder identified in hospital
• A statin is prescribed to 94% of these patients
• The typical patient is male, over 50 with at least one other
risk factor such as hypertension, diabetes, obesity, smoker or
family history
To coincide with the launch, Pinewood Healthcare has
developed a leaflet to assist GPs in switching their patients
to TORVAN and to encourage compliance with this new
atorvastatin. The leaflet is available to GPs through Pinewood
Healthcare’s team of medical representatives.
crossword
1
2
3
4
5
6
1
4
7
8
9
10
12
15
17
19
20
21
7
9
8
10
12
11
13
16
17
19
20
21
Caltrate is a trademark. PA 172/38/1.
Full prescribing information available from
Pfizer Consumer Healthcare Ltd., 9 Riverwalk,
National Digital Park, Citywest Business Campus, Dublin 24
or from www.medicines.ie
Name:
Address:
Email:
Absorbs food in condensed books? (7)
Respiratory problem found in micro upsurge (5)
...or flame of the femur (7)
Wild-west show in Bustrode, Oregan (5)
A neat hospital attendant? (7)
Confused in Siam, like apes (6)
French farewells! (6)
Try nuke to reform warder (7)
I dove into a TV recorder (5)
A handy fortune teller? (7)
This spasm is a pain in the neck! (5)
Skipper – Bird’s-eye, perhaps (7)
Down
14
15
Across
18
1 Put off or freed in confusion (5)
2 Orca Sam could show a tumour (7)
3 Confused models rarely encountered (6)
4Love-god that takes a bow! (5)
5 Watch out for verbose shenanigans (7)
6 It’s so near the larynx it rhymes with it! (7)
10 Rushdie’s devilish verses (7)
11 Cocktail I mixed in Antrim (7)
13 Grow into a more mature state - photographically
perhaps! (7)
14 It would be short-sighted of one to be like this! (6)
16 Rap for site of Horan International Airport (5)
18 Frequently the opposite of 3 down (5)
Answers to last month’s crossword
Across: 1 Sizable, 4 Molar, 7 Archaic, 8 Prowl, 9 Pulsate, 10 Offset,
12 Ignore, 15 Entitle, 17 Ether, 19 Elation, 20 Yield, 21 Leeches.
Down: 1 Scalp, 2 Braille, 3 Escape, 4 Medal, 5 Lumbago, 6 Relieve,
10 Obesity, 11 Fatigue, 13 Grenade, 14 Reveal, 16 Tepid, 18 Rings.
Congratulations to the winner of last month’s crossword,
Sandra Cloughley, 69 Vanessa Lawns, Celbridge,
Co Kildare
Please send your answers to the Editor,
Nursing in General Practice,
GreenCross Publishing,
7 Adelaide Court, Adelaide Road, Dublin 2.
Closing date for entries: 1st September 2012.
Winner will receive v50.
Please note: the winners’ cheques will be sent out
within 45 days.
37
For Long Lasting Bones
Calcium ((as carbonate)) / Cholecalciferol
WALLOWTABLET
S
e
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ta
2
to
t
n
ie
ader
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t
e
sConven
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a
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th
m than
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ABBREVIATED PRESCRIBING INFORMATION
(Please refer to Summary of Product Characteristics before prescribing)
CALTRATE* 600 mg/400 IU, film-coated tablet
calcium & vitamin D3
Presentation: Each tablet contains 600 mg of calcium (as calcium carbonate) & 10 micrograms of cholecalciferol (equal to 400 IU vitamin D3). Contains sucrose & partially hydrogenated soya bean oil. Indications: Correction of combined vitamin D & calcium deficiencies in the elderly. As an adjunct to specific
treatments for osteoporosis, in patients where combined vitamin D & calcium deficiencies have been diagnosed or those at high risk of deficiency. Dosage & Administration: Adults & Elderly: One tablet twice a day (morning/evening). Pregnant women One tablet a day. Oral (Swallow with 200mls water).
The elderly or patients with known difficulties in swallowing, may break the tablet into two parts before taking with water. Do not suck or chew. Contraindications: Hypersensitivity to any ingredients including peanut or soya. Patients who now have, or have had renal failure, kidney stones, hypervitaminosis D,
hypercalciuria & hypercalcaemia & diseases &/or conditions that lead to hypercalcaemia &/or hypercalciuria. Precautions: In prolonged treatment, check calcaemia & renal function, particularly in the elderly (see interactions). If renal function deteriorates, the dose must be reduced or treatment interrupted.
Caution is advised in immobile patients. This product contains vitamin D; further administration of vitamin D or calcium must be medically supervised with regular monitoring of calcaemia & calciuria. Patients with sarcoidosis calcaemia & calciuria must be monitored. Risk of soft tissue calcification must
be considered. In severe renal insufficiency, vitamin D3 as cholecalciferol is not metabolised normally & other forms of vitamin D3 must be used. Cases of asphyxiation due to tablet choking have been reported. This product contains sucrose; patients with sugar intolerance should not take this medicine.
Not intended for use in children & adolescents. Interactions: Thiazide diuretics & systemic corticosteroids (calcium monitoring required). Orlistat, combined ion-exchange resins (cholestyramine) or laxatives (paraffin oil) can reduce the GI absorption of vitamin D3. Take tetracycline 2 hours before or 4 to
6 hours after taking calcium. Cardiac glycosides (monitor patients regularly with ECG check & calcaemia). Phenytoin or barbiturates (may reduce the activity of vitamin D3). Iron, zinc or strontium preparations, estramustin or thyroid hormones should be spaced at least 2 hours from calcium medicines.
Bisphosphonate, sodium fluoride or fluoroquinolone administration, Caltrate should be spaced by at least 3 hours from these medicines. Oxalic acid (found in spinach & rhubarb) & phytic acid (found in wholegrain cereals) can inhibit calcium absorption by forming insoluble compounds with calcium ions.
Patients must not take calcium containing-products in the two hours after consumption of foods rich in oxalic acid & phytic acid. Pregnancy & lactation: Caltrate may be used during pregnancy & breastfeeding. Daily intake in pregnancy should not exceed 1500mg calcium & 600IU cholecalciferol. Avoid
prolonged use as hypercalcaemia can affect the developing foetus. Calcium & vitamin D3 pass into breast milk, this should be considered when vitamin D3 is given concomitantly to infants. Side-effects: Hypercalcaemia, hypercalciuria, constipation, flatulence, nausea, abdominal pain, diarrhoea, pruritis,
rash & urticaria. Legal Category: P. Pack Size: 90 tablets. PAH: Pfizer Consumer Healthcare Ltd., Sandwich, Kent, CT13 9NJ, United Kingdom. PA number: PA172/38/1. Further information is available upon request from Pfizer Consumer Healthcare Ltd., Citywest, Dublin 24. or look up, www.medicines.ie
Date of preparation: June 2010.
Reference: 1 Based on sales (data on file). 2 MIMS Ireland Jan 2011, Pg 299.
Artwork version Mar 11 Ref: 11 101 Med. * Trade Mark.