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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 disease age 65+ diabetes weakened immune system smoker other at-risk groups** infant* Pneumococcal Disease Vaccinate your at-risk patients and those 65 years and over against serious pneumococcal disease. s it on .i e vi Marketing authorisation holder: Sanofi Pasteur MSD Limited, Block A, Second Floor, Cookstown Court, Old Belgard Road, Tallaght, Dublin 24. Marketing authorisation number: PA 544/21/3 Legal category: POM einseven Information about adverse event reporting can be found at www.imb.ie. Adverse events and inadvertent vaccination during pregnancy should also be reported to Sanofi Pasteur MSD by calling 00 44 1628 785291. * 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 visit www.danacol.ie Make small daily changes to lower LDL cholesterol e n o s ’ e Her Drinking 1 Danacol a Day Drives Down Cholesterol* Contains plant sterols, scientifically proven to reduce LDL cholesterol by 7-10% in 21 days Danone Danacol® is a low fat fermented milk drink with added plant sterols. A daily intake of 1.5-2.4g of plant sterols has been shown to reduce blood cholesterol by up to 10% in 2 to 3 weeks. High cholesterol is a risk factor for coronary heart disease, which has multiple risk factors. Changing one of these risk factors may or may not be beneficial. Danone Danacol® is intended exclusively for people who want to lower their cholesterol levels. Patients on cholesterol lowering medication should only consume Danone Danacol® under medical supervision. Consumption of more than 3g/day of plant sterols should be avoided. This product may not be nutritionally appropriate for pregnant and breastfeeding women, and children under the age of five years. *Danone Danacol® should be consumed as part of a healthy and balanced diet and lifestyle. 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 for you and your baby 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 k ta 2 to t n ie ader le t e sConven rk a m e th m than % more calciu s20 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.