Nursing In General Practice January February 2022 by GreenX Publishing

A detailed overview of oesophageal cancer CPD MODULE AT R I A L F I B R I L L AT I O N The latest treatment approaches ACUTE PAIN O N C O L O G Y Risk factors, diagnosis, and management O LANRUOJLAICIFF • LANRUOJLAICIFFO • O FFICIALJOURNAL • OFFICIALJOURNAL • ISSUE 1 VOLUME 15 JANUARY-FEBRUARY 2022 INFECTIOUS MONONUCLEOSIS Presentation and treatment

recommended from Halloween to St. Patrick’s Day*2

Toddler Milk

Just 2 beakers a day (300ml) of Aptamil Toddler

milk provides toddlers with 100% of the RDA3 for Vitamin D and 53% of the RDA3 for Iron

*Along with fortified foods and drinks where possible. Available in 800g powder, 200ml & 1 litre liquid.

Scan for more information. Alternatively, call our dedicated freephone on 1800 22 12 34 or visit nutricia.ie

This information is for healthcare professional use only. Aptamil Toddler Milk should be used as part of a varied and balanced diet from 1 year. Recommended serving per day is 300ml.

1. Irish Universities Alliance (IUNA), National Pre-school Nutritional Survey. Further analysis for Danone Nutricia (data available on request). Main survey available at:

(300ml) of Aptamil Toddler milk provides toddlers with 100% of the RDA3 for Vitamin D and 53% of the RDA3 for Iron

https://www.iuna.net/surveyreports 2. Food Safety Authority of Ireland (FSAI), Scientific Recommendations for Food-Based Dietary Guidelines for 1 to 5 Year-Olds in Ireland. Available at: https://www.fsai.ie/Dietary_Recommendations_1-5_Year_Olds/ 3. Food Safety Authority of Ireland (FSAI), Recommended Dietary Allowances for Ireland 1999.

*Along with fortified foods and drinks where possible. Available in 800g powder, 200ml & 1 litre liquid.

Available at: https://www.lenus.ie/handle/10147/44808

Toddler Milk

APTAMIL This information Aptamil Toddler 1. Irish Universities https://www.iuna.net/surveyreports Available at: https://www.fsai.ie/Dietary_Recommendations_1-5_Year_Olds/ Available at: https://www.lenus.ie/handle/10147/44808 Scan freephone * al. Pediatrics 2003;111:e355-9. management of frequent reflux options available including breastfeeding. premature infants. Suitable for use PHARMACY OUTLETS symptoms of regurgitation www.eln.nutricia.co.uk Clinically proven reduce infant regurgitation episodes 78% APTAMIL TODDLER MILK This information is for healthcare professional use only. Aptamil Toddler Milk should be used as part of a varied and balanced diet from 1 year. Recommended serving per day is 300ml. 1. Irish Universities Alliance (IUNA), National Pre-school Nutritional Survey. Further analysis for Danone Nutricia (data available on request). Main survey available at: https://www.iuna.net/surveyreports 2. Food Safety Authority of Ireland (FSAI), Scientific Recommendations for Food-Based Dietary Guidelines for 1 to 5 Year-Olds in Ireland. Available at: https://www.fsai.ie/Dietary_Recommendations_1-5_Year_Olds/ 3. Food Safety Authority of Ireland (FSAI), Recommended Dietary Allowances for Ireland 1999. Available at: https://www.lenus.ie/handle/10147/44808 Scan for more information. Alternatively, call our dedicated freephone on 1800 22 12 34 or visit nutricia.ie MORE THAN 90% OF 1-3 YEAR OLDS IN IRELAND DO NOT GET ENOUGH VITAMIN D1 FSAI Dietary Guidelines for Toddlers 2020 • Fortified foods and drinks may contribute to the intakes of Vitamin D, Iron & Omega 3 in toddlers2 • Daily Vitamin D supplementation of 5μg is recommended from Halloween to St. Patrick’s Day*2 Just 2 beakers a day

January 2022

January

2022

Advancing care despite ongoing challenges

Welcome to the first edition of NiGP for 2022. I hope you all managed to get some rest and relaxation over the holidays. 2022 will, no doubt, bring its own challenges as well as facing the current ones. General practice continues to evolve to meet the current public health challenges, whilst trying to maintain some level of normal service and care to our patients.

In this issue of NiGP, we cover a wide range of issues which reflects the diverse role of nursing in general practice.

In the first of two articles by Eamonn Brady, he provides an overview of arial fibrillation, a condition which GPNs frequently meet and often goes undetected. The article focuses on the different types of arrhythmias, diagnostic methods, and the drugs and procedures that can be used to treat the condition. In his second article, Eamonn explores common presentations of acute pain in general practice and the treatment modalities, pharmacological and nonpharmacological, used.

In two separate articles, Theresa Lowry-Lehnen provides a review of oesophageal cancer and infectious mononucleosis.

Oesophageal cancer is the eighth most common cancer and sixth most common cause of cancer mortality worldwide. Ireland has one of the highest rates of oesophageal cancer in Europe with rates of 7.9 per 100,000. Like a lot of cancers, the incidence is

projected to rise in the coming years as a result of the pandemic. This article provides information which will alert the GPN when faced with a patient who has symptoms and therefore, prompt further action.

Theresa’s second article on infectious

mononucleosis, or glandular fever, provides an overview of a condition commonly seen in 15-to-24 year olds.

Also in this issue, former General Secretary of the INMO Liam Doran provides an overview of Sláintecare, a 10-year strategy to reform the health service. Sláintecare aims to provide personalised healthcare, which is tailored healthcare, quality assured, individualised, flexible, and is delivered where the person wants it on a 24/7 basis. It aims to keep people at home, as far as is possible, recognising their autonomy and independence. The development of hubs to provide care for people living with diabetes, coronary heart disease, heart failure, asthma, and COPD has begun. This will see a shift of managing chronic disease from a secondary care model to a primary care model, with nurses and physiotherapists working in an integrated care role.

And finally, Mary Jordan, National Chair of the IGPNEA, outlines her hopes for the Association as we move forward. I wish Mary and the NEC all the best with their endeavours in the year ahead.

Ruth Morrow, Consulting Editor

If you are interested in writing an article for NiGP, please email priscilla@mindo.ie

A message from Ruth Morrow, Consulting Editor

IRELAND HAS ONE OF THE HIGHEST RATES OF OESOPHAGEAL CANCER IN EUROPE WITH RATES OF 7.9 PER 100,000

EDITOR

Priscilla Lynch

CONSULTING EDITOR

Ruth Morrow

SUB-EDITOR

Emer Keogh emer@greenx.ie

CREATIVE DIRECTOR

Laura Kenny laura@greenx.ie

Days left for registrants to complete 2022 annual NMBI renewal

NMBI registrants who have yet to renew their registration for 2022 have just days left to do so. The renewal window will close at midnight on Monday, 31 January.

team in the time ahead.”

Ms McClelland has held a number of senior positions in Northern Ireland, including Chief Executive of Carrickfergus Borough Council. She has also served as a member of the Board of Cooperation Ireland since June 2017, sits on the Board of the Community Relations Council for Northern Ireland and is Chair of the Consumer Council for Northern Ireland.

Ms McClelland said: “I have thoroughly enjoyed leading the NMBI team as interim CEO and I am delighted I have been given the opportunity to continue to lead an excellent team of highly-motivated and dedicated staff members over the next five years.

“I look forward to expanding our engagement with our registrants and stakeholders in the time ahead to ensure the advancement of the nursing and midwifery professions.”

The term of Ms McClelland’s permanent appointment runs for five years until 2027.

Registrants must renew online through the MyNMBI portal, https://my.nmbi.ie/, and the NMBI said it would like to advise all registrants that it no longer accepts renewal payments by phone. You can pay online using your own debit/credit card or if you are using a card issued to another person, please ensure that you have authorisation to do so. Under new EU requirements, the card provider/bank will request authentication to complete the payment.

To renew your registration, you can log into MyNMBI using the email address that the notice was sent to and your password.

To complete the process, you will need:

 The renewal notification sent to you by email.

 Your password.

 Employment details (if employed).

 A valid debit or credit card.

For those who require assistance to complete the renewal process, call 0818 200 116 (Monday-Friday 9:00am - 5:30pm) or email the NMBI Registration Department at regservices@nmbi.ie.

If you no longer wish to have your name on the Nurses and Midwives Register (for example if you are taking a career break or you are retiring), you can voluntarily remove your name from the register on the MyNMBI portal. This service is free of charge and the deadline for voluntary removal is 16 March 2022. If you are planning to return to the Register in the future you can do so at any time using the NMBI Restoration service (the fee for doing so is the same as the annual renewal fee).

S heila M c C lelland appointed permanent CEO of the Nursing and Midwifery Board of Ireland

BREATHE DEEP FOR WINTER WELLNESS IN THE NEW YEAR –

Asthma Society Winter Wellness campaign

The Asthma Society of Ireland recently launched their Winter Wellness campaign to provide tips and advice to people with asthma on how to best manage their symptoms. The campaign will see a Winter Wellness Support Pack distributed to every member of the Asthma Society and an accompanying digital and PR campaign. It is supported by GSK.

As Ireland experiences colder weather over the coming weeks, the 380,000 people living with asthma in Ireland may experience more severe and more frequent respiratory symptoms.

The Asthma Society is aware that this winter is proving particularly challenging for patients and carers as they struggle to manage respiratory infections, weather triggers and air pollution. Many patients and carers are reporting to Asthma Society nurses that they are feeling sicker than in previous years and are also feeling less equipped to manage their asthma or respiratory symptoms.

Furthermore, these challenges are compounded by uncertainties surrounding new Covid-19 variants, and high case numbers in Ireland. Patients are also indicating that they are missing the support and advice that they normally receive from healthcare professionals, as a result of diminished access to in-person GP or practice nurse appointments. Taking all these factors into account, it is imperative that people living with asthma get help and support to prioritise their own health and wellbeing this Winter.

With this in mind, the Asthma Society has created a Winter Wellness Support Pack – distributed for free by post to all

members of the Asthma Society and free to download on www.asthma.ie.

Ten tips for managing asthma include:

1. Know the 5 Step Rule for dealing with an asthma attack.

2. Take your medications as prescribed, even when you’re feeling well and carry your reliever inhaler at all times.

3. Use a written Asthma Action Plan to manage your asthma.

4. Schedule an asthma review with your GP and have your inhaler and spacer technique checked during winter months.

5. Get your flu vaccine from your GP or pharmacist.

6. Cold air can trigger asthma symptoms - wear a snood and wrap up when outside.

7. Eat a healthy balanced diet and exercise regularly.

8. Do not smoke and ask people to not smoke around you.

9. Know the signs when your asthma is worsening and when to seek help from your GP or nurse.

10. Call the Asthma Society’s Free Adviceline on 1800 44 54 64 for a nurse appointment or message our nurse on WhatsApp on 086 059 0132.

It is also very important for patients

to follow the HSE’s advice on preventing the spread of Covid-19.

Ruth Morrow, Respiratory Nurse Specialist with the Asthma Society, said: “This year, in particular, we are seeing adults and children with asthma hard-hit by respiratory infections and this is having a knock-on impact on their asthma management. Our services have been busy with appointments and queries about weather triggers, respiratory infections (including RSV and viral wheeze in children where they may never have had such severe symptoms before) and indoor air triggers. They can call the Asthma Society’s Free Adviceline on 1800 44 54 64 for a nurse appointment or message our Beating Breathlessness nurse on WhatsApp on 086 059 0132 to get ongoing support.”

The Winter Wellness Support Pack includes:

 A Top Ten Winter Wellness tips leaflet;

 A 5 Step Rule wallet card with QR code linking to the 5 Step Rule videos in eight languages;

 A six-week symptom tracker;

 A Children’s Asthma Activity Booklet, designed to spark positive asthma conversations between children and adults;

 A message from Ruth with her Winter Wellness advice;

 A letter from Patient Advocate Colet Murphy, telling her story of transforming her experience of the winter period by controlling her asthma;

 And, an Asthma Action Plan. To donate to the Asthma Society, visit: www.asthma.ie/donate.

Study reveals potential to reduce number of medications prescribed for older people

Astudy by researchers at RCSI University of Medicine and Health Sciences on GPdelivered medication for older people led to an overall reduction in the number of medicines prescribed.

The research, published in PLOS Medicine, was led by Prof Susan Smith and Dr Caroline McCarthy of the Department of General Practice at the RCSI.

There is an increasing number of older people living with multiple medical conditions (multimorbidity) who are prescribed several medicines. This creates significant challenges for the healthcare system at large in terms of costs, as well as for the individual (and their carers) in coping with taking so many medicines, and for the clinicians who decide what should be taken. The SPPiRE (Supporting prescribing in older people with multimorbidity and significant polypharmacy in primary care) research project aimed to address these challenges.

This study consisted of a randomised controlled trial involving 51 GP practices and 404 patients throughout the Republic of Ireland. Older patients

One-in-seven

with multimorbidity taking at least 15 regular medicines were invited to attend a medication review with their GP. The review included screening their prescription for potentially inappropriate combinations of medicines, considering opportunities for stopping medicines and assessing the patient’s priorities for treatment. It then assessed whether this once-off GPdelivered medication review reduced the number of medicines and improved the quality of prescribing.

There was a significant reduction in the number of medicines in the intervention group compared to the control group, with over 800 medicines being stopped in 208 intervention patients. Of the 800+ medicines ceased, 15 possible adverse events were reported, almost all of which were mild reactions that stopped once the medicine was re-introduced, indicating that stopping certain medicines in older people is generally safe.

The quality of prescribing was also assessed, using a checklist of potentially inappropriate combinations of medicines. While there were no

significant improvements in the quality of prescribing in the intervention group compared to the control group, overall there were improvements in both groups during the study period.

Dr Caroline McCarthy, GP and Clinical Lecturer and Research Fellow in the Department of General Practice at RCSI, said: “It’s possible that the identification of this at-risk group who are prescribed at least 15 medicines may in itself have led to improvements in prescribing.

“It can be daunting for GPs with limited time and resources to actively manage these prescriptions and patients can also be wary about change, particularly if they have been on a medicine a long time,” Dr McCarthy added.

Prof Susan Smith, Associate Director of the HRB Primary Care Clinical Trials Network, commented: “The intervention approach to managing this challenging problem is promising and demonstrates that, even in this very complex group, stopping medicines that may no longer be needed or appropriate is both possible and generally safe.”

This research was funded by the HRB Primary Care Clinical Trials Network.

people still putting off seeking medical advice – Irish Cancer Society

People who notice worrying changes in their lung health are being urged to seek help amid new evidence that some people are putting off going to their GP of hospital when needed.

In the last three months, around onein-seven people have put off seeking medical advice even though they have felt unwell, according to new research.

Reasons for delaying going to a doctor include not thinking the issue was serious enough or not wanting to bother their GP. Issues around getting in-person appointments, as well as concerns over personal safety amid the pandemic were also factors.

A survey of 1,000 people carried out by Core Research for the Irish Cancer Society also found half of those who

put off seeking medical advice are still experiencing symptoms and have yet to make an appointment to see their GP.

January marks the Irish Cancer Society’s Lung Cancer Awareness Month and early detection is key to survival for lung cancer. Patients who present later in their illness face a much more difficult treatment pathway with less chance of success. According to the

latest available data from the National Cancer Registry Ireland, six-in-10 lung cancers are diagnosed at stage 3 or 4.

Dr Jarushka Naidoo, Thoracic Oncologist at Beaumont Hospital, Dublin, said: “People who develop symptoms of lung cancer tend to be reluctant to come forward. This can be due to concern about poor outcome if a lung cancer is found. However, more than 20 new treatments have been developed for lung cancer in the last 5-to-10 years, and these treatments have resulted in major improvements for our patients.

“Treatment for early-stage lung cancer is given with the goal of cure.

Early detection and diagnosis by being symptom aware will increase our ability to cure. If you are experiencing any symptoms of lung cancer (cough, shortness of breath, weight loss), it is vital to contact your GP.”

Commenting on the research, Irish Cancer Society Director of Advocacy Rachel Morrogh said: “It should never be the case that someone avoids going to the doctor because they think a cancer concern isn’t serious enough.

“The increased focus on respiratory issues due to Covid-19 offers an opportunity to talk about lung health, and inform people of what to look out for and increase awareness of the vital

difference that catching cancer early can make. Some tell-tale signs to look out for include difficulty breathing, a persistent cough or chest infections, coughing blood or sudden weight loss.

“We don’t yet know what the impact of the pandemic will be on the stage of diagnosis of cancer, but we do not want to go backwards. The stated objective of the Cancer Strategy is to increase the number of cancers diagnosed at stage 1 and stage 2 – we can’t lose sight of this.

“Anyone who wants to talk about a cancer concern can get helpful advice and information from our Freephone Support Line on 1800 200 700,” she concluded.

RECRUITMENT

PRACTICE NURSE REQUIRED

Experienced practice nurse required for 2.5 days in group practice in Irishtown/Sandymount, Dublin 4.

Role to include childhood immunisations, cervical smears, phlebotomy, ear syringe, travel vaccines and other practice nurse duties.

Informal enquiries to Dr Miriam Daly by email to arrange a call back: mdalyomeara@yahoo.co.uk

To apply, please email CV plus short cover letter to megan@sandymountroadgp.ie

PRACTICE NURSE REQUIRED

Practice nurse required urgently in Dunboyne for a busy GP practice. Ideally for 26 hours a week approximately, but flexible. Experience in phlebotomy and childhood immunisations, cervical smear taking desirable. Experience in antenatal care and BP monitoring an advantage. Pleasant working conditions in a modern building and very supportive staff.

Apply with CV to dunboynegpsurgery@gmail.com

If you would like to place a recruitment advert in the next edition, please contact Louis@mindo.ie

To mark Cervical Cancer Prevention Week (17 – 23 January), Ireland’s population screening programme, CervicalCheck, highlighted the barriers faced by women aged over 50 years in accessing this vital health screen.

A new HSE public attitudes survey carried out by Core Research in 2021 has reported on the barriers women of menopausal age face when considering taking up their screening invitation. These barriers included a fear of the process; finding screening more uncomfortable at this age; and finding screening embarrassing. In addition, half of all women surveyed said a fear of finding something was wrong would deter them from attending screening, whilst onein-five women said they were concerned about attending their screening appointment due to Covid-19.

Women and people with a cervix aged 25 to 65 years are invited to attend free cervical screening every three-to-five years, depending on their age and previous screening history. However, new screening data shows that attendance declines as women age –meaning women over 50 are at a slightly higher risk of developing changes that could develop into cancer.

The National Screening Service programme has now begun a targeted campaign to raise awareness amongst women over 50 that screening is still for them – and that screening at regular intervals is one of the best ways to reduce their risk of developing cervical cancer.

A recent study in Australia that looked at screening in older age groups found that women aged 50-59 years

who have had an abnormal smear test, and who later had no test aged between 60-64, had a higher risk of developing cervical cancer (10in-1,000). For women who have had no cervical screening test in their 50s, one test between age 60-64 was found to halve the subsequent risk of developing cervical cancer from 8.4 to 3.5 per 1,000 people.

Dr Sarah Fitzgibbon, Primary Care Clinical Advisor with CervicalCheck, said that women over 50 can benefit from regular cervical screening tests: “Once women have finished having periods they often feel, ‘Screening is not for me, I don’t have a period, why would I need a screening test?’ In fact, we do encourage women to continue attending screening up to the age of 65.”

She added “if women aged in their 50s haven’t ever had a cervical screen done through CervicalCheck, the programme is ‘actively’ encouraging them to take part. We are letting women know that just because you haven’t had a test done before, and you’re 55 say, you absolutely can come in and have a test done. Once you’re in the eligible age category, you can come any time and to any registered screener.”

CervicalCheck Clinical Director Dr Nóirín Russell urged women to talk to their GP or general practice nurse about screening, if they were unsure if they were eligible, or had fears about the test. “Cervical cancer is typically slow growing – it typically develops over 10-to-15 years – so it is important for women to continue to come for screening at regular intervals pre- and post-menopause. We know that for some women the screening test can

be more uncomfortable after menopause, and this might put them off coming. However, there are things we can do to alleviate this. We’d ask these women to consult their GP on ways to make the test more comfortable for them.”

Dr Caroline Mason Mohan, Director of Public Health at the National Screening Service said: “It’s important for me that we do all we can in screening to give women, who are at the age of menopause, enough information to make a decision on whether screening is for them.

Accessibility is very important to our programmes. Last year we produced an Equity Report to show all the work we have done so far to help people access our services. This year we are further developing an Equity Strategy, which includes the creation of more information for women of menopause age who are eligible for screening, to show our commitment to making sure everyone has a chance to use our services.”

Meanwhile, Minister for Health, Stephen Donnelly has asked Dr Gabriel Scally to conduct a final progress review of implementation of the recommendations of his Scoping Inquiry into the CervicalCheck screening programme.

Minister Donnelly said: “Significant progress has been made in implementing Dr Scally’s recommendations since his last progress review report in April 2020. Just six of the 170 actions arising now remain to be completed, and these are all in progress. I believe it is now timely and feasible to proceed with a final progress review, and Dr Scally has confirmed his availability to commence this work in January 2022.”

Women of menopausal age less likely to take up cervical screening invitations, putting them at increased risk of developing cervical cancer

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IE_Omega7_Ad_NursinginGP_214x275_0122

NEC NEWS

NEC Meeting

The next meeting of the NEC and the branch Reps will take place on Tuesday, 1 February at 8pm. The meeting will be held virtually, via Zoom. The agenda and meeting link details will be circulated to each branch representative in the next fortnight. If at your branch AGM your NEC representative has changed, please advise same to IGPNEA administrator, Mary Osakwe, with updated contact details where necessary.

Conference

We are very excited to be hosting our next IGPNEA conference on the 13 and 14 May at the Tower Hotel in Waterford. We will soon be sending out details on how to book early bird tickets to all members.

We have some fantastic speakers lined up and we will be sharing more information on this over the next few months.

Membership renewals

It is membership renewal time. It is very simple to renew your membership, just click on our website, log in and pay https:// irishpracticenurses.ie/ fees-payment/. If you need any help with your renewal, please email Jacqui

MEET THE TEAM

Mary Jordan, IGPNEA Waterford Contact via: chair@irishpracticenurses.ie

NATIONAL

Siobhan Leacy, IGPNEA Kildare Contact via: vice-Chair@irishpracticenurses.ie

Sarah O’Donnell, IGPNEA Waterford Contact via: treasurer@irishpracticenurses.ie

Tobin our Membership Officer at membership@ irishpracticenurses.ie.

We are working away on some exciting educational opportunities and in 2022 members will have access

to all IGPNEA Webinars, CPDme webinars and ICGP webinars. Each IGPNEA and CPDme webinar attendance will provide you with a CPD Certificate in your IGPNEA ePortfolio.

ICGP webinars

The ICGP webinars will take place on the first and third Wednesday of each month. You will find the dates for all webinars listed on the events calendar on

NATIONAL CHAIRPERSON NATIONAL VICE CHAIRPERSON HONORARY TREASURER

Contact via: pro@irishpractice nurses.ie

MEMBERSHIP OFFICER

Jacqui Tobin

(Monday and Tuesday 09.00 – 12.00, Friday 09.00 – 10.30)

Email: membership@ irishpracticenurses.ie

Phone or text: 086 263 4917

Contact via: pro@ irishpracticenurses.ie

the IGPNEA website. You will need to register for each ICGP webinar. To do this, log into the IGPNEA website, go to Education, Webinars, ICGP Webinar Registration and complete the online form.

ADMINISTRATOR

Mary Osakwe (Monday – Friday

09.30 – 13.30 and 14.30 – 16.30)

Email: admin@ irishpracticenurses.ie

Phone: 087 130 4115

If you have any issues please email Jacqui at membership @irishpracticenurses.ie

Vaccine hesitancy survey

IGPNEA members were

delighted to be asked recently by the HSE National Immunisation Office to take part in a project which focused on vaccine hesitancy among parents. A survey was shared with GPNs to understand their experiences of vaccine hesitancy with parents in their practices, specifically about the primary childhood immunisation programme. There was a near 40 per cent response rate and considering how busy GPNs are at the moment with Covid-19 vaccines/boosters this reflects the continued importance that GPNs place on the primary childhood immunisation programme. We await the publication of the findings of the research project. All those GPNs who completed the survey were entered into a draw for a €50 One-4-All voucher and the lucky winner was Aine O'Driscoll, who works in Broadale medical centre, Douglas, Cork.

Become a new member

Becoming a new member of the IGPNEA is very easy; you can join anytime through our website: https://irishpractice nurses.ie/registration/.

Please encourage your fellow GPN colleagues to become members and share

with them the benefits of our Association: https://irishpracticenurses. ie/about-us-2/#benefits.

IGPNEA CONTACT DETAILS

ADMINISTRATOR

Mary Osakwe admin @irishpractice nurses.ie 087 130 4115

MEMBERSHIP OFFICER

Jacqui Tobin membership @irishpractice nurses.ie 086 263 4917

NATIONAL PRO Sonja Corrigan, IGPNEA South Dublin NATIONAL PRO Rachel Dyer, IGPNEA North Dublin

Irish Thoracic Society, Annual Scientific Meeting, virtual, 19 November 2021

Author: Priscilla Lynch

Lung cancer screening should be rolled out as a priority, ITS hears

Lung cancer screening with low-dose CT (LDCT) in highrisk populations has been proven to save lives, is cost effective and should be rolled out in Europe without further delay, the 2021 ITS Scientific Meeting heard from a renowned international expert in the area.

Prof Harry de Koning, Professor of Public Health and Screening Evaluation, Erasmus University Medical Centre, Rotterdam, gave a detailed presentation on the role and value of lung cancer screening, citing data from a number of trials and real world experiences.

Lung cancer currently kills more people worldwide than any other type of cancer, being responsible for 18.4 per cent of all cancer-related mortality. This is partly because 70 per cent of diagnoses are made at an advanced stage, with five-year survival of only 15 per cent.

In Ireland, lung cancer is the fourth most commonly diagnosed cancer, with approximately 2,750 cases diagnosed annually. Average life expectancy for lung cancer patients upon diagnosis is 200 days, but with appropriate LDCT screening this could be increased to 12.5 years, he said.

Prof de Koning designed and is principal investigator of the DutchBelgian NELSON trial, Europe’s largest randomised lung cancer screening trial, which confirmed that regular screening for lung cancer would significantly reduce overall lung cancer mortality in current

and former smokers (24 per cent in men and 33 per cent in women [up to 48 per cent in women in the earlier years]).

He said the roll-out of LDCT screening in Europe could save at least 22,000 lives annually, and has now been shown to be cost-effective, with the benefits outweighing the potential harms (overdiagnosis/-treatment). Quoting data from

Prof Harry de Koning

cancer screening trial, which showed similar results in improved mortality rates, but had a much higher referral and false-positive rate. “Whereas the NSLT trial referred about 20 per cent or more, we referred about 2 per cent for suspicious lesions. That has to do with the volumetrics that we use, with having a completely different health system [in Europe]….”

the NELSON trial, Prof de Koning said that in the control arm, 46 per cent of lung cancers were diagnosed at stage 4 while in the screening arm, particularly in the first five/six years, 60 per cent were detected at stage 1, while 10 per cent were detected at stage 4.

“So it works,” he said.

Prof de Koning also compared the NELSON results to the US NSLT lung

He pointed out that the Covid-19 pandemic has significantly impacted lung cancer diagnosis and screening in countries where it exists, such as the US, which is already having a negative impact on outcomes.

Optimal screening intervals for lung cancer are also an important consideration with yearly, two years, and 2.5 years among those studied, with current trial results and modelling supporting annual screening, Prof de Koning reported. He noted that the US

IT IS ACTUALLY UNETHICAL TO WITHHOLD POTENTIALLY BENEFICIAL TREATMENT FROM PEOPLE WHO ARE LIKELY TO BENEFIT, EVEN IF ALL THE EXACT BEST APPROACHES ARE NOT KNOWN

For patients not adequately controlled on dual therapy with moderate to severe COPD

UNLEASH THE PROTECTION OF TRIXEO1,2

Significant protection against exacerbations*

TRIXEO Aerosphere is indicated as a maintenance treatment in adult patients with moderate to severe chronic obstructive pulmonary disease (COPD) who are not adequately treated by a combination of an inhaled corticosteroid and a long-acting beta2-agonist or combination of a long-acting beta2-agonist and a long-acting muscarinic antagonist.1

*Significant reductions in the rate of moderate or severe exacerbations vs LAMA/LABA (24%, n=2137 vs n=2120, annual rates 1.08 vs 1.42, 95% CI 0.69–0.83; p<0.001) and ICS/LABA (13%, n=2137 vs n=2131, annual rates 1.08 vs 1.24, 95% CI 0.79–0.95; p=0.003).1,2 COPD, chronic obstructive pulmonary disease; ICS, inhaled corticosteroid; LABA, long-acting beta2-agonist; LAMA, long-acting muscarinic antagonist. In the clinical trial programme for TRIXEO, LAMA/LABA refers to glycopyrronium/formoterol fumarate and ICS/LABA refers to budesonide/formoterol fumarate. ©AstraZeneca 2021. All rights reserved.

ABRIDGED PRESCRIBING INFORMATION

TRIXEO AEROSPHERE® 5 micrograms/7.2 micrograms/160 micrograms pressurised inhalation, suspension (formoterol fumarate dihydrate/ glycopyrronium/ budesonide)

Consult Summary of Product Characteristics (SmPC) before prescribing.

Indication: Trixeo Aerosphere is indicated as a maintenance treatment in adult patients with moderate to severe chronic obstructive pulmonary disease (COPD) who are not adequately treated by a combination of an inhaled corticosteroid and a long acting beta2 agonist or combination of a long-acting beta2 agonist and a long acting muscarinic antagonist. Presentation: Pressurised inhalation, suspension. Each single actuation (delivered dose, ex-actuator) contains 5 micrograms of formoterol fumarate dihydrate, glycopyrronium bromide 9 micrograms, equivalent to 7.2 micrograms of glycopyrronium and budesonide 160 micrograms. This corresponds to a metered dose of 5.8 micrograms of formoterol fumarate dihydrate, glycopyrronium bromide 10.4 micrograms, equivalent to 8.2 micrograms of glycopyrronium and budesonide 182 micrograms. Dosage and Administration: The recommended and maximum dose is two inhalations twice daily (two inhalations morning and evening). If a dose is missed, take as soon as possible and take the next dose at the usual time. A double dose should not be taken to make up for a forgotten dose. Special populations: Elderly: No dose adjustments required in elderly patients. Renal impairment: Use at recommended dose in patients with mild to moderate renal impairment. Can also be used at the recommended dose in patients with severe renal impairment or end-stage renal disease requiring dialysis, only if expected benefit outweighs the potential risk. Hepatic impairment: Use at recommended dose in patients with mild to moderate hepatic impairment. Can also be used at the recommended dose in patients with severe hepatic impairment, only if expected benefit outweighs the potential risk. Paediatric

Population: No relevant use in children and adolescents (<18 years of age).

Method of administration: For inhalation use. To ensure proper administration of the medicinal product, the patient should be shown how to use the inhaler correctly by a physician or other healthcare professional, who should also regularly check the adequacy of the patient’s inhalation technique. Patients who find it difficult to coordinate actuation with inhalation may use Trixeo Aerosphere with a spacer to ensure proper administration of the medicinal product. Contraindications: Hypersensitivity to the active substances or to any of the excipients. Warnings and Precautions: Not for acute use: Not indicated for treatment of acute episodes of bronchospasm, i.e. as a rescue therapy.

Paradoxical bronchospasm: Administration of formoterol/glycopyrronium/ budesonide may produce paradoxical bronchospasm with an immediate wheezing and shortness of breath after dosing and may be life threatening. Treatment should be discontinued immediately if paradoxical bronchospasm occurs. Assess patient and institute alternative therapy if necessary.

Deterioration of disease: Recommended that treatment should not be stopped abruptly. If patients find the treatment ineffective, continue treatment but seek medical attention. Increasing use of reliever bronchodilators indicates worsening of the underlying condition and warrants reassessment of the therapy. Sudden and progressive deterioration in the symptoms of COPD is potentially life threatening, patient should undergo urgent medical assessment.

Cardiovascular effects: Cardiovascular effects, such as cardiac arrhythmias, e.g. atrial fibrillation and tachycardia, may be seen after the administration of muscarinic receptor antagonists and sympathomimetics, including glycopyrronium and formoterol. Use with caution in patients with clinically significant uncontrolled and severe cardiovascular disease such as unstable ischemic heart disease, acute myocardial infarction, cardiomyopathy, cardiac arrhythmias and severe heart failure. Caution should also be exercised when treating patients with known or suspected prolongation of the QTc interval (QTc > 450 milliseconds for males or > 470 milliseconds for females), either congenital or induced by medicinal products. Systemic corticosteroid effects: May occur with any inhaled corticosteroid, particularly at high doses prescribed

for long periods. These effects are much less likely to occur with inhalation treatment than with oral corticosteroids. Systemic effects include Cushing’s syndrome, Cushingoid features, adrenal suppression, decrease in bone mineral density, cataract and glaucoma. Potential effects on bone density should be considered particularly in patients on high doses for prolonged periods that have co existing risk factors for osteoporosis. Visual disturbances: May be reported with systemic and topical corticosteroid use. If patient presents symptoms such as blurred vision or other visual disturbances, consider ophthalmologist referral for evaluation of possible causes which may include cataract, glaucoma or rare diseases such as central serous chorioretinopathy (CSCR). Transfer from oral therapy: Care is needed in patients transferring from oral steroids, since they may remain at risk of impaired adrenal function for a considerable time. Patients who have required high dose corticosteroid therapy or prolonged treatment at the highest recommended dose of inhaled corticosteroids, may also be at risk. These patients may exhibit signs and symptoms of adrenal insufficiency when exposed to severe stress. Additional systemic corticosteroid cover should be considered during periods of stress or elective surgery. Pneumonia in patients with COPD: An increase in the incidence of pneumonia, including pneumonia requiring hospitalisation, has been observed in patients with COPD receiving inhaled corticosteroids. Remain vigilant for the possible development of pneumonia in patients with COPD as the clinical features of such infections overlap with the symptoms of COPD exacerbations. Risk factors for pneumonia include current smoking, older age, low body mass index (BMI) and severe COPD. Hypokalaemia: Potentially serious hypokalaemia may result from β2-agonist therapy. This has potential to produce adverse cardiovascular effects. Caution is advised in severe COPD as this effect may be potentiated by hypoxia. Hypokalaemia may also be potentiated by concomitant treatment with other medicinal products which can induce hypokalaemia, such as xanthine derivatives, steroids and diuretics.

Hyperglycaemia: Inhalation of high doses ofβ2-adrenergic agonists may produce increases in plasma glucose. Blood glucose should be monitored during treatment following established guidelines in patients with diabetes. Co-existing conditions: Use with caution in patients with thyrotoxicosis. Anticholinergic activity: Due to anticholinergic activity, use with caution in patients with symptomatic prostatic hyperplasia, urinary retention or with narrow-angle glaucoma. Patients should be informed about the signs and symptoms of acute narrow-angle glaucoma and should be informed to stop using this medicinal product and to contact their doctor immediately should any of these signs or symptoms develop. Co-administration of this medicinal product with other anticholinergic containing medicinal products is not recommended. Renal impairment: Patients with severe renal impairment (creatinine clearance of <30 mL/min), including those with end-stage renal disease requiring dialysis, should only be treated with this medicinal product if the expected benefit outweighs the potential risk. Hepatic impairment: In patients with severe hepatic impairment, use only if the expected benefit outweighs the potential risk. These patients should be monitored for potential adverse reactions. Drug Interactions: Co-treatment with strong CYP3A inhibitors, e.g. itraconazole, ketoconazole, HIV protease inhibitors and cobicistat-containing products are expected to increase the risk of systemic side effects. Should be avoided unless the benefit outweighs the increased risk, in which case patients should be monitored for systemic corticosteroid adverse reactions. This is of limited clinical importance for short-term (1-2 weeks) treatment. Since glycopyrronium is eliminated mainly by the renal route, drug interaction could potentially occur with medicinal products affecting renal excretion mechanisms. Other antimuscarinics and sympathomimetics: Co-administration with other anticholinergic and/or long-acting β2-adrenergic agonist containing medicinal products is not recommended as it may potentiate known inhaled muscarinic antagonist or β2-adrenergic agonist adverse reactions. Concomitant use of other beta-adrenergic medicinal products can have potentially additive effects. Caution required when prescribed concomitantly with formoterol. Medicinal product-induced

hypokalaemia: Possible initial hypokalaemia may be potentiated by xanthine derivatives, steroids and non potassium sparing diuretics. Hypokalaemia may increase the disposition towards arrhythmias in patients who are treated with digitalis glycosides. β-adrenergic blockers: β-adrenergic blockers (including eye drops) can weaken or inhibit the effect of formoterol. Concurrent use of β-adrenergic blockers should be avoided unless the expected benefit outweighs the potential risk. If required, cardio-selective β-adrenergic blockers are preferred. Other pharmacodynamic interactions: Concomitant treatment with quinidine, disopyramide, procainamide, antihistamines, monoamine oxidase inhibitors, tricyclic antidepressants and phenothiazines can prolong QT interval and increase the risk of ventricular arrhythmias. L-dopa, L-thyroxine, oxytocin and alcohol can impair cardiac tolerance towards beta2sympathomimetics. Concomitant treatment with monoamine oxidase inhibitors, including medicinal products with similar properties such as furazolidone and procarbazine, may precipitate hypertensive reactions. Elevated risk of arrhythmias in patients receiving concomitant anaesthesia with halogenated hydrocarbons.Pregnancy and Lactation: Administration to pregnant women/women who are breast-feeding should only be considered if the expected benefit to the mother justifies the potential risk to the foetus/ child. Ability to Drive and Use Machines: Dizziness is an uncommon side effect which should be taken into account. Undesirable Events: Consult SmPC for a full list of side effects. Common (≥ 1/100 to < 1/10): Oral candidiasis, pneumonia, hyperglycaemia, anxiety, insomnia, headache, palpitations, dysphonia, cough, nausea, muscle spasms, urinary tract infection. Uncommon (≥ 1/1,000 to < 1/100): Hypersensitivity, depression, agitation, restlessness, nervousness, dizziness, tremor, angina pectoris, tachycardia, cardiac arrhythmias (atrial fibrillation, supraventricular tachycardia and extrasystoles), throat irritation, bronchospasm, dry mouth, bruising, urinary retention, chest pain. Very Rare (< 1/10,000): Signs or symptoms of systemic glucocorticosteroid effects, e.g. hypofunction of the adrenal gland, abnormal behaviour. Not known: Angioedema, vision blurred, cataract, glaucoma.

Legal Category: Product subject to prescription which may be renewed (B)

Marketing Authorisation Number: EU/1/20/1498/002 120 actuations

Marketing Authorisation Holder: AstraZeneca AB, SE-151 85, Södertälje, Sweden.

Further product information available on request from: AstraZeneca Pharmaceuticals (Ireland) DAC, Block B, Liffey Valley Office Campus, Dublin 22.

Tel: +353 1 609 7100.

TRIXEO and AEROSPHERE are trademarks of the AstraZeneca group of companies.

Date of API preparation: 07/2021 Veeva ID: IE-2842

Adverse events should be reported directly to; HPRA Pharmacovigilance, Website: www.hpra.ie Adverse events should also be reported to AstraZeneca Patient Safety on Freephone 1800 800 899

1. TRIXEO AEROSPHERE 5 micrograms/7.2 micrograms/160 micrograms pressurised inhalation, suspension. Summary of Product Characteristics. Available at www.medicines.ie

2. Rabe KF et al. Triple inhaled therapy at two glucocorticoid doses in modeate-to-very-severe COPD. N Engl J Med. 2020;383:35–48. doi: 10.1056/ NEJMoa1916046 COPD. N Engl J Med. 2020;383:35–48. doi: 10.1056/NEJMoa1916046

Veeva ID: IE-2925 Preparation Date: July 2021

has recently changed its lung cancer screening recommendations – the US Preventive Services Task Force (USPSTF) now recommends annual screening for lung cancer with LDCT in adults aged 50-to-80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years, though Australia is preparing to roll-out a twoyear screening interval programme for high-risk individuals.

However, annual lung cancer screening in high-risk individuals across Europe

would probably mean some 142 million CT scans in the next 10 years, he noted, so it is being examined if the interval can be successfully lengthened without significantly impacting early detection rates. He added that coronary artery calcium scoring is a useful additional potential marker, which is also being studied in lung cancer screening.

Concluding, Prof de Koning said LDCT lung cancer screening has been shown to be at least as effective (and more in some scenarios) as longer established

cancer screening programmes, and called for it to be rolled out across Europe as a priority, adding that “collaboration in the next few years would help come up with the best strategies”.

“It is not necessary to delay initiating screening until all answers are in. You can always find an argument to postpone; that is not the issue. It is actually unethical to withhold potentially beneficial treatment from people who are likely to benefit, even if all the exact best approaches are not known.”

Pulmonary rehabilitation should be more widely available

Pulmonary rehabilitation should be made more widely available for respiratory patients, the 2021 ITS Scientific Meeting heard. Noted expert in the area, Prof Thierry Troosters, Professor in Rehabilitation Sciences, KU Leuven, Belgium, provided an update on pulmonary rehabilitation and its beneficial role in many respiratory conditions.

He pointed out that pulmonary rehabilitation has been shown beyond any doubt to be effective: Research has demonstrated that it improves exercise capacity (6MWD), quality-of-life and symptoms, brings an improvement in mood status, a reduction of utilisation of healthcare resources, and a reduction of postural balance and risk of falling.

“In terms of programme components, we all agree that endurance and resistance exercise training are absolutely crucial, but also other components are important [eg, smoking cessation].”

Prof Troosters outlined the main scenarios for pulmonary rehabilitation, which include stable patients with

conditions such as chronic obstructive pulmonary disease (COPD), interstitial lung disease and pulmonary arterial hypertension, where it can help improve muscle function, exercise tolerance, symptoms and quality-of-life; rehabilitation post severe exacerbation, where it has been shown to reduce readmission risk and increase survival (it may be easier to start four weeks postdischarge rather than immediately, but uptake and referral remain a problem); and rehabilitation during an exacerbation (resistance training; lifting weights), with a focus on blocking deleterious effects on skeletal muscle function.

“If you catch patients with COPD in a stable phase then one of the best things you can offer these patients is a pulmonary rehabilitation programme. It will improve exercise tolerance and quality-of-life in these patients, way beyond what we call a minimal difference in these patients.... The evidence is there, we know it works, for now it is time to implement this in our clinical routine across the different lines of healthcare.”

A properly designed multidisciplinary pulmonary rehabilitation programme will also improve anxiety and depression in patients with these issues, which is about a third of patients with chronic lung diseases, he added.

It is important to note, however, that exercise training programmes need to be adapted to the exercise limitation of patients to maximise effects and comfort, Prof Troosters stressed.

Enhancing physical activity is not a given after pulmonary rehabilitation and requires a behavioural intervention, and methodology to assess physical activity is now standardised and a framework for interventions is available, he said.

New exercise platforms (eg, telemedicine, step counters, smart phone applications) for pulmonary rehabilitation are now being explored, which should help address access and referral issues, Prof Troosters said. “We can’t just offer rehabilitation in tertiary centres very far from where our patients live so they have to travel half a day to get there. We need to get these programmes closer to the patient.”

Irish Endocrine Society, Annual Meeting, virtual, 19-20 November 2021

Author: Valerie Ryan

Increases in vitamin D levels during pandemic highlighted by researchers

Researchers highlighted increases in vitamin D levels during the pandemic in a number of presentations at the latest Irish Endocrine Society (IES) annual meeting.

Vitamin D levels increased and deficiency decreased between 2015-20 and 2020-21 in a study population in the west of Ireland, the meeting heard in an oral presentation by Ms Caoimhe Moran, School of Biological and Health Sciences, Technological University Dublin, and colleagues.

Vitamin D may reduce the risk and severity of infection with the SARSCoV-2 virus, but the effects of lockdown on population vitamin D status in Ireland were unknown.

Following their cross-sectional study ‘Changes in vitamin D concentration and deficiency in the West of Ireland during the Covid-19 lockdown’, she added that it remained unknown whether this trend related to lockdown or to changes in diet and supplementation practices. This study compared wintertime serum 25-hydroxy vitamin D (25OHD) in 16,725 samples analysed between October and February 2015-20 (13,449 samples) and between October 2020 and February 2021 (3,276 samples) at University Hospital Galway (UHG).

Vitamin D deficiency was defined at the Institute of Medicine (IoM) ((<30nmol/L) and Endocrine Society (<50nmol/L) thresholds. Mean total

serum vitamin D and mean serum vitamin D3 concentrations were higher in 2020-21 (65.7nmol/l and 61.7nmol/l respectively) than in 20152020 (59.9nmol/l and 55.6nmol/l respectively) (p<0.001).

Prevalence of deficiency decreased at the <30nmol/L threshold from 18.2-to-14.6 per cent, and at 50nmol/L threshold from 43.6-to-34.6 per cent, between 2015-20 and 2020-21. Deficiency at both thresholds was more common in females (p<0.001).

Deficiency was higher in inpatients and nursing home residents than in

outpatients and GP patients, with a trend towards greater deficiency in younger adults.

During the Q&A following her presentation, Ms Moran agreed the importance of good public health advice directing the public to appropriate levels of supplementation.

Another cross-sectional study: ‘Sex, sunshine, and sample-origin –predictors of emerging spring and summertime vitamin D deficiency trends amongst Irish adults during the Covid-19 lockdown’ by Ms Maria

O’Sullivan, School of Biological and Health Sciences, Technological University Dublin, and colleagues found, overall, vitamin D deficiency was more prevalent in males, hospital inpatients, and nursing home residents.

The divergent trends in vitamin D status between males and females between 2015-19 and 2020 suggested possible sex-specific differences in the effects of lockdown, and of diet and supplementation changes, on vitamin D status.

A further study by Mark Kilbane and colleagues at St Vincent’s University Hospital in Dublin, detailed how they had conducted a laboratorybased trend analysis of serum 25OHD comparing yearly average

concentration in the 12 months prior to the pandemic with the first 12 months of the pandemic.

In a large sample, they noted the average yearly 25OHD increased by 2.8nmol/L in combination with a lower per cent of low vitamin D status and a higher per cent of high vitamin D status. The yearly increase was almost three-fold higher than the yearly increase in average 25OHD based on two similar trend analyses that they conducted between 1993 and 2016.

This indicated “that caution should be exercised about blanket recommendations for vitamin D supplementation in favour of maximising low dose daily supplementation in at-risk groups and

clinically vulnerable patients”.

They advised strongly in favour of targeted supplementation policies.

Following an audit of serum 25OHD measures in the Irish population during the 2019-21 Covid-19 pandemic, Ms Katrina Hutchinson, Eurofins Biomnis, and colleagues found vitamin D mean concentrations had increased annually since 2019, particularly in 2020. They suggested this was probably due to lifestyle changes in Ireland because of lockdowns, which might have allowed more outdoor activity.

They added in their poster that further audits in 2022 would enable them to fully examine changes in vitamin D status in Ireland when lockdown had finished.

Early identification of pre-frailty may improve self-perception and prevent early retirement

Early identification of prefrailty in employees with and without diabetes, and implementation of tailored workplace interventions, may improve the self-perception of ability to work and prevent early retirement, according to Dr Duygu Sezgin, School of Nursing and Midwifery, National University of Ireland Galway (NUIG) and colleagues at NUIG and University College Cork.

In a European overview of ‘Prefrailty in working middle-aged and older adults with and without diabetes and its association with fear of health limiting their ability to work and early retirement plans’, the researchers noted diabetes mellitus was associated with increased frailty risk, resulting in

loss of working days.

A significant proportion of middleaged and older adults sought early retirement, potentially due to pre-frailty caused by health issues limiting their ability to work. Dr Sezgin underlined that this could be detected before frailty had an impact on people’s lives.

As a concept, pre-frailty was a multidimensional state. Identification of frailty at early (pre-frailty) stage could prevent this negative outcome. She told the IES meeting that factors leading to frailty status could be managed and tailored interventions based on people’s needs were needed.

The study investigated the prevalence of pre-frailty in working adults and reported the association between

diabetes, pre-frailty, fear of health limiting ability to work, and plans for early retirement.

They combined data from 29 European countries using waves 1-8 of the Survey of Health, Ageing, and Retirement in Europe (SHARE, 2004-2020).

Participants aged 50 years or over, with data on employment (including selfemployment), frailty and diabetes status, were included in the descriptive and logistic regression analyses. A total of 38,220 participants (mean age 55.7±3.8) were analysed. Of these, 13,909 were pre-frail (36 per cent), 2,264 (6 per cent) had diabetes, 17,614 (46 per cent) sought early retirement, and 11,406 (30 per cent) were afraid that their health limited their ability to work.

Prescribing Information:

For the treatment of diabetes mellitus in adults, adolescents and children from the age of 6 years1 ®

Toujeo (insulin glargine 300 units/ml)

Please refer to Summary of Product Characteristics (SmPC) before prescribing.

Presentation: Toujeo SoloStar and DoubleStar pre-filled pens. Each ml contains 300 units of insulin glargine. SoloStar pen contains 1.5ml (450 units) of solution for injection. DoubleStar pen contains 3ml (900 units) of solution for injection.

Indication: Treatment of diabetes mellitus in adults, adolescents and children from the age of 6 years. Dosage and

Administration: Toujeo is administered subcutaneously, by injection into the abdominal wall, the deltoid or the thigh, once daily, at any time of the day, preferably at the same time every day. Injection sites must be rotated within a given injection area from one injection to the next in order to reduce the risk of lipodystrophy and cutaneous amyloidosis. The dose regimen (dose and timing) should be adjusted according to individual response. Do not administer intravenously. In type 1 diabetes mellitus, Toujeo must be combined with short-/rapid-acting insulin to cover mealtime insulin requirements. In patients with type 2 diabetes mellitus, recommended daily starting dose is 0.2 units/kg followed by individual dose adjustments. Toujeo can also be given together with other anti-hyperglycaemic medicinal products. Switch between insulin glargine 100 units/ ml and Toujeo: Insulin glargine 100 units/ml and Toujeo are not bioequivalent and are not directly interchangeable. When switching from insulin glargine 100 units/ml to Toujeo, this can be done on a unit to unit basis, but a higher Toujeo dose (approximately 10-18%) may be needed to achieve target ranges for plasma glucose levels. When switching from Toujeo to insulin glargine 100 units/ml, the dose should be reduced (approximately by 20%). Switching from other basal insulins to Toujeo: A change of dose and/or timing of the basal insulin and concomitant anti hyperglycaemic treatment may be required. Dose adjustments may also be required if the patient’s weight or lifestyle changes, the timing of insulin dose is changed or other circumstances arise that increase susceptibility to hypo- or hyperglycaemia. Toujeo must not be mixed or diluted with any other insulin or other medicinal products. Close metabolic monitoring is recommended during a switch and in the initial weeks thereafter. SoloStar 1-80 units per single injection in steps of 1 unit and DoubleStar 2-160 units in steps of 2 units. When changing from Toujeo SoloStar to Toujeo DoubleStar, if the patient’s previous dose was an odd number then the dose must be increased or decreased by 1 unit. Toujeo DoubleStar prefilled pen is recommended for patients requiring at least 20 units per day. Special Populations: Insulin requirements may be diminished in the elderly or patients with renal or hepatic impairment. Paediatric: When switching basal insulin to Toujeo, dose reduction of basal and bolus insulin needs to be considered on an individual basis, in order to minimise the risk of hypoglycaemia. The safety and efficacy of Toujeo in children and adolescents below 6 years of age have not been established. Contraindications: Hypersensitivity to insulin glargine or any excipients. Precautions and Warnings: Traceability: In order to improve the traceability of biological medicinal products, the name and the batch number of the administered product should be clearly recorded. Toujeo is not the insulin of choice for treatment of diabetic ketoacidosis. Patients must be instructed to perform continuous rotation of the injection site to reduce the risk of developing lipodystrophy and cutaneous amyloidosis. There is a potential risk of delayed insulin absorption and worsened glycaemic control following insulin injections at sites with these reactions. A sudden change in the injection site to an

References: 1. Toujeo® Summary of Product Characteristics

Date of preparation: September 2020 | MAT-IE-2001062 (v1.0)

unaffected area has been reported to result in hypoglycaemia. Blood glucose monitoring is recommended after the change in the injection site, and dose adjustment of antidiabetic medications may be considered. Hypoglycaemia: In case of insufficient glucose control or a tendency to hyper/hypoglycaemic episodes, the patient’s adherence to the prescribed treatment regimen, injection sites and proper injection technique and all other relevant factors must be reviewed before dose adjustment is considered. Particular caution should be exercised, and intensified blood glucose monitoring is advisable for patients in whom hypoglycaemic episodes might be of clinical relevance and in those where dose adjustments may be required. Warning signs of hypoglycaemia may be changed, less pronounced or absent in certain risk groups, potentially resulting in severe hypoglycaemia and loss of consciousness. Risk groups include patients in whom glycaemic control is markedly improved, hypoglycaemia develops gradually, an autonomic neuropathy is present, or who are elderly. The prolonged effect of subcutaneous insulin glargine may delay recovery from hypoglycaemia. Intercurrent illness: Requires intensified metabolic monitoring and often it is necessary to adjust the insulin dose. Insulin antibodies: administration may cause insulin antibodies to form. Use with pioglitazone: Cases of cardiac failure have been reported when pioglitazone was used in combination with insulin, especially in patients with risk factors for development of cardiac heart failure. If the combination is used, patients should be observed for signs and symptoms of heart failure, weight gain and oedema. Pioglitazone should be discontinued if any deterioration in cardiac symptoms occurs. Medication errors: Insulin labels must always be checked before each injection to avoid errors between Toujeo and other insulins. Patients must be instructed to never use a syringe to remove Toujeo from the SoloStar or DoubleStar pre-filled pen, A new sterile needle must be attached before each injection. Needles must not be re-used. Pregnancy and lactation: There is no data from exposed pregnancies in controlled clinical trials. However, there is a large amount of data on use of insulin glargine 100 units/ml in pregnant women indicating no specific adverse effects on pregnancy and no specific malformative nor feto/neonatal toxicity. The use of Toujeo may be considered during pregnancy, if clinically needed. Careful monitoring of glucose control is essential. It is unknown if insulin glargine is excreted in breast milk. Interactions: Substances that affect glucose metabolism may require adjustment of insulin glargine. Adverse Reactions: Very common: Hypoglycaemia. Prolonged or severe hypoglycaemia may be life-threatening. Common: Lipohypertrophy, injection site reactions, including redness, pain, itching, hives, swelling, or inflammation. Legal Category: POM. Marketing Authorisation Number: SoloStar 3 Pen pack: EU/1/00/133/034, DoubleStar EU/1/00/133/038. Marketing Authorisation Holder: Sanofi Aventis Deutschland GmbH, D-65926 Frankfurt am Main, Germany. Further information is available from: Medical Information, Sanofi 18 Riverwalk, Citywest Business Campus, Dublin 24 or contact IEmedinfo@sanofi.com. Date of preparation: July 2020.

Adverse events should be reported. Reporting forms and information can be found at www.hpra.ie; email: medsafety@hpra.ie Adverse events should also be reported to Sanofi Ireland Ltd. Tel: 01 403 5600. Alternatively, send via email to IEPharmacovigilance@sanofi.com

How SLÁINTECARE is the appropriate framework for achieving personalised healthcare in Ireland

LIAM DORAN, FORMER GENERAL SECRETARY, IRISH NURSES AND MIDWIVES ORGANISATION (INMO), AND FORMER MEMBER OF THE ADVISORY COUNCIL FOR SLÁINTECARE

As he announced the then biggest health budget in history in October 2020, the Minister for Public Expenditure Michael McGrath, said: “We must grasp the nettle, implement Sláintecare, and re-double our commitment to a publicly funded, universally accessible health service.”

Our health service has been the beneficiary of similarly grand pronouncements on many occasions, but Sláintecare, for the first time, clearly articulates an ambitious, but sustainable blueprint for a truly modern health service, one that has cross-party support and is nonpolitical. This redesign and reimagination of how we deliver healthcare in Ireland has been further galvanised by the bruising experience of the Covid-19 pandemic.

But while many have heard the term Sláintecare, they may not be entirely sure what it means or the potential it holds for how we or our friends and families utilise and experience the healthcare system in Ireland.

The scope of health reform as outlined in Sláintecare, representing the greatest shift in social policy in this country in decades, is as vast and as complex as one would expect, but ultimately it aims to improve patient and service user experience, as well as the clinician experience. Yes, it aims to deliver cost savings so that our health service is more efficient, but this is with a view to improving patient outcomes, not in spite of patient outcomes.

Central to this ambitious vision will be the delivery of truly personalised healthcare, with a focus on the patient and maximising the benefit they derive from their care. The

paternalistic one-size-fits-all model of healthcare is outdated and now we must look to the needs of the individual to shape service delivery. Personalised healthcare is essentially tailored healthcare; it is quality assured, is individualised, is flexible, and is delivered where the person wants it delivered on a 24/7 basis. It keeps people at home, as far as is possible, recognising their autonomy and independence.

Historically, we have explained many of the failings of our healthcare system because ‘that’s the way it was always done’. This argument is no longer valid. The person is what is important – not the system. Bureaucracy should come a distant second.

The good news is that the building blocks of this revolutionary approach to healthcare are already being laid, even with the disruption to services that the Covid-19 pandemic has wrought. Critical to this transformation will be data and the use of patient data to improve the wider health service, informing planning, and addressing deficiencies. Ireland’s health service has a chequered past when it comes to the prudent and judicial use of people’s data, so transparency and trust will be key tenets of this approach. Considerable political and public buy-in will be necessary if we are to utilise this priceless information to deliver enhanced healthcare in a more precise and expedient fashion.

The recent findings of the FutureProofing Healthcare Personalised Health Index, supported by Roche, showed Ireland lagging significantly behind our European counterparts in this regard, with poor collection of, and access to, health data. As a result, Irish patients are missing out.

Building blocks require scaffolding –in this instance it is our IT infrastructure that must be carefully built first. Ireland has considerable problems with legacy IT infrastructure. Our failure to introduce a fully integrated electronic health record and individual patient identifier as part of a cohesive and coordinated eHealth strategy must be rectified and the necessary investment made if we are to truly future proof Irish healthcare and protect the privacy of our citizens as we roll-out personalised healthcare and deliver Sláintecare.

The health system is a dynamic entity. Service users should be able to traverse seamlessly between the acute sector and the community, between the GP and elder care, with their records effortlessly accompanying them. The multidisciplinary team approach to providing care should be the default one and obstacles to accessing the right healthcare at the right time in the right place must be removed.

Essentially upgrading our entire healthcare system is not an overnight task, but over the course of the 10-year strategy, Sláintecare should ultimately deliver us a health service that is fit for purpose and fit for patients. Its implementation has already begun, but the urgency of its adoption is greater than ever. The Covid-19 pandemic has provided us with an opportunity to rethink the status quo and consider personalised healthcare as our fundamental approach within a patientcentric healthcare system. Sláintecare is a carefully considered, ambitious, yet achievable roadmap for where we want to go. Bringing the public along on this journey will be critical. ●

Patients with type 2 diabetes should expect more after metformin

Once-weekly type 2 diabetes treatment with CV benefits† and superior efﬁcacy1-9*

SUPERIOR GLYCAEMIC CONTROL1-9*

• Ozempic® -1.8% vs dulaglutide‡ -1.4%1,2,§

• Up to 79% achieved ADA target of HbA1c <7% (53 mmol/mol) vs other diabetes treatments1-10

SUPERIOR AND SUSTAINED WEIGHT LOSS1-9*

• More than double the weight loss vs dulaglutide (-6.5 kg vs -3.0 kg)1,2,§

• Weight loss sustained over 2 years1,3

PROVEN CV BENEFITS1,3†‡

• 26% CV risk reduction in patients with type 2 diabetes and high CV risk, compared to placebo in addition to standard treatment1,3,4,†

Ozempic® is indicated for the treatment of adults with insufficiently controlled type 2 diabetes mellitus as an adjunct to diet and exercise • as monotherapy when metformin is considered inappropriate due to intolerance or contraindications • in addition to other medicinal products for the treatment of diabetes. For study results with respect to combinations, effects on glycaemic control and cardiovascular events and the populations studied, see sections 4.4, 4.5 and 5.1. of the summary of product characteristics.1 CV=cardiovascular. SUSTAIN = Semaglutide Unabated Sustainability in treatment of Type 2 Diabetes. *Results apply to Ozempic® across SUSTAIN trials, which included placebo, sitagliptin, dulaglutide, canagliflozin, exenatide PR and glargine U100.1-9 †In SUSTAIN 6, Ozempic® reduced CV risk (CV death, nonfatal myocardial infarction [MI] or nonfatal stroke) versus placebo in patients with type 2 diabetes at high CV risk treated with standard of care.1,3 ‡When added to standard of care, which included oral antidiabetic treatments, insulin, antihypertensives, diuretics and lipid-lowering therapies. §SUSTAIN 7, Ozempic® 1.0 mg vs. dulaglutide 1.5 mg.

Abbreviated Prescribing Information

Ozempic®t semaglutide

Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Ozempic® 0.25 mg solution for injection in pre-filled pen. Ozempic® 0.5 mg solution for injection in pre-filled pen. Ozempic® 1 mg solution for injection in pre-filled pen. One ml of solution contains 1.34 mg of semaglutide (human glucagonlike peptide-1 (GLP-1) analogue). Indication: Ozempic® is indicated for the treatment of adults with insufficiently controlled type 2 diabetes mellitus as an adjunct to diet and exercise • as monotherapy when metformin is considered inappropriate due to intolerance or contraindications • in addition to other medicinal products for the treatment of diabetes. For study results with respect to combinations, effects on glycaemic control and cardiovascular events, and the populations studied, see sections 4.4, 4.5 and 5.1 of the Ozempic® SmPC. Posology and administration: Administered once weekly at any time of the day, with or without meals. Injected subcutaneously in the abdomen, thigh or upper arm. Starting dose: 0.25 mg once weekly. After 4 weeks the dose should be increased to 0.5 mg once weekly. After at least 4 weeks with a dose of 0.5 mg once weekly, the dose can be increased to 1 mg once weekly to further improve glycaemic control. When Ozempic® is added to a sulfonylurea or insulin, a reduction in dose of sulfonylurea or insulin should be considered to reduce the risk of hypoglycaemia. Blood glucose self-monitoring is necessary to adjust the dose of sulfonylurea and insulin, particularly when Ozempic® is started and insulin is reduced. A stepwise approach to insulin reduction is recommended. Children: No data available. Elderly: No dose adjustment required, therapeutic experience in patients age ≥75 is limited. Renal impairment: No dose adjustment is required for patients with mild, moderate or severe renal impairment. Experience in patients with severe renal impairment is limited. Not recommended for use in patients with end-stage renal disease. Hepatic impairment: No dose adjustment is required for patients with hepatic impairment. Experience with severe hepatic impairment is limited. Caution should be exercised when treating these patients with semaglutide. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Special warnings and precautions for use: Should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis. Not a substitute for insulin. Diabetic ketoacidosis has been reported in insulin-dependent patients whom had rapid discontinuation or dose reduction of insulin. There is no experience in patients with congestive heart failure NYHA class IV and is therefore not recommended in these patients. Use of GLP-1 receptor agonists may be associated with gastrointestinal adverse reactions. This should be considered when treating patients with impaired renal function as nausea, vomiting, and diarrhoea may cause dehydration which could cause a deterioration of renal function. Acute pancreatitis has been observed with the use of GLP-1 receptor agonists. Patients should be informed of the characteristic symptoms

of acute pancreatitis. If pancreatitis is suspected, semaglutide should be discontinued; if confirmed, semaglutide should not be restarted. Caution should be exercised in patients with a history of pancreatitis. Use of semaglutide in combination with a sulfonylurea or insulin may have an increased risk of hypoglycaemia, therefore consider reducing the dose of sulfonylurea or insulin when initiating treatment with Ozempic®. In patients with diabetic retinopathy treated with insulin and semaglutide, an increased risk of developing diabetic retinopathy complications has been observed. Caution should be exercised when using semaglutide in patients with diabetic retinopathy treated with insulin. These patients should be monitored closely and treated according to clinical guidelines. Rapid improvement in glucose control has been associated with a temporary worsening of diabetic retinopathy, but other mechanisms cannot be excluded. When semaglutide is used in combination with a sulfonylurea or insulin, patients should be advised to take precautions to avoid hypoglycaemia while driving and using machines. Fertility, pregnancy and lactation: Women of childbearing potential are recommended to use contraception when treated with semaglutide. Should not be used during pregnancy or breast-feeding. Discontinue at least 2 months before a planned pregnancy. Effect on fertility unknown. Undesirable effects: Very common (≥1/10); Hypoglycaemia when used with insulin or sulfonylurea, nausea, diarrhoea. Common:(≥1/100 to <1/10); Hypoglycaemia when used with other oral antidiabetic medications, decreased appetite, dizziness, diabetic retinopathy complications, vomiting, abdominal pain, abdominal distension, constipation, dyspepsia, gastritis, gastro-oesophageal reflux disease, eructation, flatulence, cholelithiasis, fatigue, increased lipase, increased amylase, weight decreased. Uncommon: (≥1/1,000 to <1/100); Dysgeusia, increased heart rate, acute pancreatitis, injection site reactions. Rare:(≥1/10,000 to <1/1,000)Anaphylactic reaction. The Summary of Product Characteristics should be consulted for a full list of side effects. MA Numbers: Ozempic® 0.25 mg pre-filled pen EU/1/17/1251/002. Ozempic® 0.5 mg pre-filled pen EU/1/17/1251/003. Ozempic® 1 mg prefilled pen EU/1/17/1251/005. Each pre-filled pen delivers 4 doses and includes 4 disposable NovoFine® Plus needles. Legal Category: POM. For complete prescribing information, please refer to the Summary of Product Characteristics which is available on www.medicines.ie or by email from infoireland@novonordisk.com or from the Clinical, Medical and Regulatory Department, Novo Nordisk Limited, 1st Floor, Block A, The Crescent Building, Northwood Business Park, Santry, Dublin 9 Ireland. Date last revised: March 2020

tThis medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Healthcare Professionals are asked to report any suspected adverse reactions to the Health Products Regulatory Authority. Information about adverse event reporting is available at www.hpra.ie. Adverse events should also be reported to Novo Nordisk Medical Department Tel; 1850 665 665.

References: 1. Ozempic® Summary of Product Characteristics www.medicines.ie 2. Pratley RE et al. Semaglutide versus dulaglutide once-weekly in patients with type 2 diabetes (SUSTAIN 7): a randomised, open-label, phase 3b trial. Lancet Diabetes Endocrinol. 2018; 6: 275 - 286. 3. Marso SP, Bain SC, Consoli A, et al. Semaglutide and cardiovascular outcomes in patients with type 2 diabetes. N Engl J Med. 2016;375:1834-1844. 4. Marso SP, Bain SC, Consoli A, et al. Semaglutide and cardiovascular outcomes in patients with type 2 diabetes. N Engl J Med. 2016;375(suppl1):S1-S108. 5. Lingvay I, et al. Once weekly Semaglutide vs Canagliflozin in type 2 diabetes: results of the SUSTAIN 8 trial. https://doi.org/10.1016/S2213-8587(19)30311-0. 6. Ahmann AJ et al. Efficacy and safety of once-weekly semaglutide versus exenatide ER in subjects with type 2 diabetes (SUSTAIN 3): A 56-Week, Open-Label, Randomized Clinical Trial. Diabetes Care 2018;41:258-266. 7. Aroda VR et al. Efficacy and safety of once-weekly semaglutide versus once-daily insulin glargine as add-on to metformin (with or without sulfonylureas) in insulin-naive patients with type 2 diabetes (SUSTAIN 4): a randomised, open-label, parallel-group, multicentre, multinational, phase 3a trial. Lancet Diabetes Endocrinol. 2017;5: 355–66. 8. Sorli C et al. Efficacy and safety of once-weekly semaglutide monotherapy versus placebo in patients with type 2 diabetes (SUSTAIN 1): a double-blind, randomised, placebo-controlled, parallel-group, multinational, multicentre phase 3a trial. Lancet Diabetes Endocrinol 2017; 5: 251–60. 9. Ahrén B et al. Efficacy and safety of once-weekly semaglutide versus once-daily sitagliptin as an add-on to metformin, thiazolidinediones, or both, in patients with type 2 diabetes (SUSTAIN 2): a 56-week, double-blind, phase 3a, randomised trial. Lancet Diabetes Endocrinol. 2017; 5: 341–54. 10. American Diabetes Association. Standards of medical care in diabetes—2018. Diabetes Care. 2018;41(suppl1):S1-S159.

Novo Nordisk Limited, First Floor, Block A, The Crescent Building, Northwood Business Park Santry, Dublin 9, D09 X8W3, Ireland. Tel: 01 8629 700, Fax: 01 8629 725, Lo call: 1 850 665665

infoireland@novonordisk.com www.novonordisk.ie

Ozempic®, NovoFine® and the Apis bull logo are registered trademarks owned by Novo Nordisk A/S

Date of preparation: September 2020. IE20OZM00029

AUTHOR: Mary Jordan, GPN, Waterford and National Chairperson, IGPNEA

Forging a for GPNs

STRONG, SUPPORTIVE FUTURE

AN UPDATE FROM THE IGPNEA NATIONAL CHAIRPERSON

Welcome to 2022. I hope you managed to find some time over the festive season to rest, recuperate, and recharge the batteries. We have survived 2021. My hope/aim is that we thrive in 2022, both professionally and personally. The past 12 months have, again, been dominated by the Covid-19 pandemic, but finally there is light at the end of the tunnel. Widespread antigen testing, vaccine boosters, and the arrival of new, effective medications for the virus means we will be able to live with Covid-19.

The IGPNEA shall continue to build on the advancements and innovations that my predecessors have achieved. It is right and fitting to thank those of you who have and continue to volunteer your time and energy to

the cause of bringing recognition and educational advancement to your general practice nursing colleagues.

Our role as GPNs has evolved organically over the past decades.

Historically, general practice nursing was perceived as being for nurses at the end of their nursing career. The role has moved away from being a task-orientated position to now being a key player within a multidisciplinary team. Our near neighbours in the UK, through their General Practice Nursing Ten Point Plan, are aiming to enhance recognition of the GPN role by recruiting more nurses into the profession, attracting younger newlyqualified nurses to general practice as a first-destination career, and providing support and development for GPNs. Ireland will surely follow. Having knowledge and access to up-to-date education is crucial if we are to have fulfilling careers in general practice and patients are to receive quality care. This is why we are members of IGPNEA.

The restrictions resulting from the pandemic have had an enormous impact on how we as members of this Association have been able to interact with each other. I have held ‘meet and greet’ zoom meetings with 12/18 of our branches since taking on the role of National Chair. I hope to be afforded the opportunity to reach the remaining branches early in the New Year. Zoom meetings are not an adequate substitute for the interaction that occurs when face to face. The feedback from members has been of isolation, feeling unsupported by the Association, too many changes in a short space of time (though recognition that some changes were necessary), and feeling overwhelmed by the move to a mostly virtual learning environment.

The NEC team, administrator, membership officer and media/website officer are working very hard on your behalf to bring educational opportunities to you in this new environment.

Ms Mary Jordan

1. Our monthly webinars via Medcafe are just one of many examples of this. If you cannot attend the live event on the night, you have access to the recording, a certificate of attendance and thus accumulate CPD points.

2. You also continue to have access to ICGP webinars by registering your interest via the IGPNEA website. The email from the ICGP confirming your attendance can then be uploaded to your ePortfolio on our website. This along with a reflective entry in your ePortfolio diary will generate a certificate of attendance and earn you CPD points.

night to put in your diary and I hope as many as possible will attend.

New developments

My hope for the coming year is for members to feel more involved and supported; that there is a greater level of transparency; that each of us feels part of this Association; that we know we are in this together and that we recognise that we are stronger together.

We are introducing a membership card for the Association this year. It will be a proud statement that we are part of the IGPNEA and not just working in isolation. It will be used for entry to the

looking into blended branch meetings going forward so that those who cannot attend a face-to-face meeting on the night (when conditions are more favourable to do so) can join a branch meeting virtually. This should ensure greater attendances at branch meetings and facilitate greater interaction and peer support among members.

Work has begun on a handbook (both printed and an electronic version) for the Association which, as I have discussed at the Zoom meet and greets, promises to be a valuable resource for both new and established GPNs. Each branch will be involved in putting forward contact information details for their own locale. I hope everyone will be generous in sharing their policies, procedures, protocols and guidelines (PPPGs).

3. In the coming days you will also have access to CPDme webinars via our website and yet more opportunities to accumulate evidence of continued education as warranted by the NMBI to maintain registration and work within our scope of practice.

We have arranged a series of information webinars on how to use the ePortfolio, step by step, to accompany the ‘how to’ videos on our website. The first of these webinars will be held on Thursday, 28 January. There will be ample opportunity to ask questions on the night. Andrew Ormerod will also show you how to navigate the CPDme website to get the most out of their offering of educational webinars. It is definitely a

National Conference in May, cutting down on paperwork and reducing time delays during the registration processes. We also intend to use the membership card as a means of accessing exclusive discounts/rewards with retailers etc. More about that as the weeks go by. But for now, please remember to renew your subscription as soon as possible to avail of the many benefits of membership.

Many/most branches continue to hold their monthly branch meetings virtually due to Covid-19 restrictions. Did you know you can avail of the national Zoom account for your meetings? Just let IGPNEA Administrator Mary Osakwe know when you are planning the meeting and she will fully assist you to set it up. Also, we are

There are plans coming to fruition to enhance the visibility of GPNs in the healthcare community and the wider public. We should be very proud of the work that we do, not just in Covid-19 times, but every day. We are a valuable resource within the healthcare team. Securing HSE funding for GPNs to undertake the upcoming Post Graduate Diploma in Community Nursing is a major step in the right direction. We are forging strong working relationships with our GP colleagues, evident by our inclusion in their educational webinars through the ICGP.

It is an exciting time to be part of the IGPNEA. We are moving in the right direction. Let’s work together to keep the momentum going. I look forward to interacting with you all over the coming months and I promise to work hard on your behalf. ●

MY HOPE FOR THE COMING YEAR IS FOR MEMBERS TO FEEL MORE INVOLVED AND SUPPORTED; THAT THERE IS A GREATER LEVEL OF TRANSPARENCY; THAT EACH OF US FEELS PART OF THIS ASSOCIATION; THAT WE KNOW WE ARE IN THIS TOGETHER, AND THAT WE RECOGNISE THAT WE ARE STRONGER TOGETHER

AUTHOR: Eamonn Brady, MPSI

ATRIAL FIBRILLATION

Atrial fibrillation is the most common form of arrhythmia, of which there are several. An arrhythmia is a heart rhythm problem and can manifest itself as the heart rate being too quick, too slow or irregular. On completion of this module, the reader should have an enhanced understanding of atrial fibrillation, including different types of arrhythmia, diagnostic methods, and the drugs and procedures that can be used to treat the condition.

Types of arrythmia include:

 Tachycardia: Fast heart rate of more than 100 beats per minute.

 Bradycardia: Slow heart rhythm below 60 beats per minute.

 Supraventricular arrhythmias: Arrhythmias manifesting from the atria (heart’s upper chambers).

 Ventricular arrhythmias: Arrhythmias manifesting from the ventricles (heart’s lower chambers).

 Bradyarrhythmias: Slow heart rhythms due to disease in the heart’s conduction system affecting the sinoatrial (SA) node, atrioventricular (AV) node or the His-Purkinje network.

Atrial fibrillation (AF) is classed as a supraventricular arrhythmia, ie, it manifests from the atria. Atrial flutter is another atrial arrhythmia caused by one or more rapid circuits in the atrium where heartbeats are faster than normal. Atrial flutter is usually more organised, meaning more regular than beats in AF. Atrial flutter

can be a symptom of AF or can occur without having AF.

Normal functioning of the heart

The heart has four chambers – two upper and two lower chambers. The upper chambers are the right and left atria, and their function is to receive blood. The lower chambers are called the right and left ventricles and their function is to pump blood out of the heart, so are more muscular than the atria. There are four heart valves that allow blood to flow in the right direction. The four heart valves are the mitral, tricuspid, pulmonary and aortic valves; they act as 'gates' at the chamber openings.

Heartbeats are controlled by small

electrical signals that start at the sinus node (acts like a 'timer') in the right atrium. These electrical signals pass through a 'junction' called the atrioventricular node and move down to the ventricles, causing heart muscles to contract.

During a single cardiac cycle, the atria and ventricles beat alternately to each other. The atria contract prior to ventricular contraction. A timing delay allows all four chambers of the heart to fill. The left and right side of the heart pump in parallel, meaning seamless filling and emptying of blood to and from the heart to the rest of the body’s circulatory system.

At rest, a normal healthy heartbeat range is 50-to-100 beats per minute; the variance depends on factors like the patient’s age and fitness. For example, people who are

FIGURE 1: Diagram of heart Reference: NHS

very fit generally have a lower resting heart rate. Exertion like exercise, excitement and fever means the body requires more oxygen-filled blood, so the heart rate rises to over 100 beats per minute before going back to its normal resting rate. With AF, that heart rate can go over 100 beats per minute on a more permanent basis without any exertion.

Background to AF

AF is caused by irregular heart rhythm and (but not always) tachycardia (fast heart rate). While AF can cause physical symptoms like tiredness, breathlessness and chest tightness or chest pain, most patients with AF experience no symptoms. Often, the only reason a patient knows they have AF is when it shows up during a regular checkup or is discovered due to another heart problem brought on by AF, ie, stroke. Like hypertension or hypercholesterolaemia, AF could be described as a 'silent killer'; like these conditions, it is often symptomless yet significantly increases the risk of potentially fatal heart problems like stroke and heart failure. AF increases the risk of stroke by up to five-fold. AF is managed with medication or procedures like an electrical cardioversion and once managed with appropriate treatment, will rarely cause serious or life-threatening problems.

Aetiology of AF

Instead of steady and regular electrical impulses from the sinus node in the right atrium that occur when a person has normal heart function, with AF, electrical impulses from the sinus nodes fire irregularly and randomly. These disorganised impulses cause the atria to quiver or twitch (fibrillate) instead of a steady, smooth beat. This means the atria cannot efficiently pump blood into the ventricles.

The loss of normal efficient pumping mechanism can reduce blood flow from the heart to the rest of the circulatory system, especially if tachycardia occurs; not all patients with AF experience

tachycardia (over 100 beats per minute). For many, AF is symptomless, but some patients can feel the physical sensation of the palpitations. The patient may experience paroxysmal AF where AF comes and goes but for others, AF occurs indefinitely, so the patient will have persistent or permanent AF unless treated. While AF in itself is not life-threatening, it is a major risk factor for blood clots that can lead to stroke.

Atrial flutter is a characteristic of AF where the atria beat regularly, but faster than usual, meaning atria beat more often than the ventricles. In a patient with normal heart rhythm, there is a normal one-to-one ratio of atrial beats to ventricular beats. In patients with atrial

AF INCREASES

THE RISK OF STROKE BY UP TO FIVE-FOLD

flutter, there can be three or four atrial beats for every one ventricular beat. Patients can experience atrial flutter without AF. Atrial flutter treatment is similar to AF, ie, medication to slow and regulate heart rate, cardioversion, and cardiac ablation.

Prevalence

AF has a prevalence of approximately 1 per cent in the overall population, but this increases to up to 10 per cent in people over 80 years. The risk of stroke varies significantly, ranging from 1-to-15 per cent per year, depending on coexisting coronary risk factors, such as age and presence of hypertension, hypercholesteraemia, diabetes, and smoking.

Causes of AF

 Hypertension.

 Myocardial infarction.

 Damaged heart muscle.

 Heart valve disease.

 Congenital heart disease.

 Pericarditis (inflammation of the pericardium, the protective sac surrounding the heart).

 Cardiomyopathy.

 Heart or other major surgery.

 Sick sinus syndrome (damage to the sinus node in right atrium).

Certain activities or lifestyle factors can trigger an episode of AF, including binge-drinking of alcohol, physical or mental stress, obesity, excessive caffeine, smoking, and illegal drugs (especially amphetamines and cocaine).

AF can sometimes be associated with other health conditions like asthma, diabetes, lung problems (lung cancer or pulmonary embolus), and severe infections, ie, pneumonia. There may be no obvious cause. Where there is no other heart or other risk factors, AF is known as 'lone AF'. These patients are at lower risk of stroke.

Types of AF

The four subtypes of AF include paroxysmal, persistent, long-term persistent, and permanent AF. These four subtypes are classified by the frequency with which AF occurs and how well it responds to treatment.

Paroxysmal AF

This is characterised with a brief e pisode of AF known as a 'paroxysm' of AF. This brief episode of AF may be symptomless and go unknown by the patient, or the patient can experience anything from mild to severe symptoms. It usually subsides within 24 hours, but can last up to a week. Paroxysmal AF can repeatedly occur. Symptoms may go away without treatment, but often, treatment is needed. Sometimes this type of AF alternates with a slower than normal heartbeat, creating a phenomenon called tachybrady syndrome.

Persistent AF

Persistent AF is where the arrhythmia lasts for more than a week. While it may stop on its own without intervention, most often, treatment is needed to stop arrhythmias.

Long-term persistent AF

With this type of AF, arrhythmias are for longer than a year.

Permanent AF

Despite treatment with medication and other options, there are occasions where AF is resistant to treatment. This is known as permanent AF.

Symptoms

The patient may be symptomless but if symptoms occur, they range from mildto-severe and can include:

 Breathlessness.

 Tiredness.

 Palpitations: The patient may feel the sensation the heart beating fast or irregularly.

 Light-headedness or dizziness.

 Chest pain or tightness. The Euro Heart Survey on Atrial Fibrillation

surveyed 5,333 AF patients in 182 hospitals in 35 countries over 2003 and 2004 and found that 69 per cent of AF patients experienced symptoms related to AF at some stage since their diagnosis. Over half – 54 per cent – were asymptomatic at the time of the survey, and the lowest symptom burden was reported in patients with permanent AF. Patients with AF and no symptoms are often detected to have AF during a physical examination or electrocardiogram.

Diagnosis Echocardiogram

An electrocardiogram (ECG) checks the heart’s rhythm and electrical activity and confirms AF by recording the heart’s electrical signals. If the ECG is normal, but the clinician still suspects bouts of AF (paroxysmal atrial fibrillation), then a record of the heart rhythm over 24

hours will be needed to confirm. A holter monitor can be used for this purpose. A holter monitor is a type of portable electrocardiogram (ECG) that the patient can wear at home and records electrical activity of the heart continuously over 24 hours or even longer.

An ECG is a heart ultrasound scan that gives visibility of the heart’s structure and functioning. An echocardiogram is considered the best diagnostic tool to diagnose AF. Echocardiographic predictors of AF are enlargement of left atrium, reduced function of the left ventricle, and increased thickness of left ventricular walls.

Blood tests

Blood tests cannot help in diagnosing AF, but once a patient is diagnosed with AF, they may be done to determine and rule out possible causes of AF, ie, diabetes, pulmonary embolus, infection.

Complications due to AF

AF is not in itself life-threatening, but it can cause serious complications, such as stroke and heart failure. The reason AF increases stroke risk is due to blood clots forming in the atria brought on by sluggish blood flow.

Sluggish blood flow due to AF increases risk of these blood clots breaking off and travelling to the brain and blocking blood supply to parts of the brain, ie, stroke.

Congestive heart failure (CHF) is when the heart is not working adequately. It cannot meet the body’s need for blood because it is not pumping properly and this usually occurs because the heart muscle has become too weak or stiff to work properly. CHF is the leading cause of hospital admissions in the over-65 age group, accounting for 20 per cent of hospital admissions in this age group. In the case of AF, CHF is brought on by the heart not pumping properly. AF causes inefficiencies in the heart’s pumping mechanism, meaning the heart in unable to pump enough blood around the body, leading to peripheral oedema (especially in the lower legs) and lung congestion.

Figure 2: Normal heart function versus atrial fibrillation Reference: New Zealand Guidelines Group (NZGG), 2006

Reference: Journal of Biomechanics 41 (2008) 2515–2523

Risk of stroke

According to the Irish Heart Foundation, approximately 7,500 people have a stroke annually in Ireland, of whom approximately 2,000 die from stroke annually.

Rates of stroke in patients with AF averages 5 per cent a year; this is between two-and-seven times the stroke rate in those without AF. This increased risk of stroke is not solely due to AF; the risk increases significantly

undertreatment with warfarin and other anticoagulants, though not all studies concur with this theory, with one study of patients over 65 years of age with recently-diagnosed AF finding that under-use of anticoagulants in women compared to men had no influence on increased stroke risk in women.

Stroke risk increases with the following:

 Previous stroke or mini-stroke.

 Damaged heart valve.

Relieving symptoms

A decision the clinician must make is whether to try get 'rhythm control' (ie, return heartbeat to a normal rhythm) or whether to accept 'rate control' (ie, put up with an abnormal rhythm, but slow the heart rate). This clinical decision depends on factors such as:

 Age.

 The type of AF.

 How often symptoms occur.

 How severe the symptoms are.

 Risk of side-effects and contraindications from medication.

 Presence of other conditions.

Reasons to favour rate control:

 Brief symptoms.

 Infrequent symptoms.

 No symptoms or mild symptoms.

Reasons to favour rhythm control:

 Constant symptoms.

 Frequent symptoms.

 Severe symptoms.

Rate control is the treatment of choice in most patients.

Weight loss added to guidelines

with the presence of coexisting cardiovascular risk, such as increasing age, hypertension, diabetes, obesity, etc. Prevalence of stroke in the general population in patients under 60 years is less than 0.5 per cent and from 70 years onwards, the prevalence doubles with each decade. The attributable stroke risk due to AF is approximately 1.5 per cent for patients aged 50-to-59 and it increases to 30 per cent for patients aged 80-to-89. Attributable stroke risk is higher in women due to AF than in men. Some studies suggest this increased attributable risk in women is due to

 Hypertension.

 CHF.

 Diabetes.

 Over 65 and especially over 75 years of age.

Treatment

Aims of AF management are to:

 Relieve symptoms, such as palpitations, tiredness, dizziness, and breathlessness.

 Prevent serious complications, such as stroke and CHF.

 Regulate heart rate.

 Treat the cause of AF where identifiable.

The new guidelines now include recommending weight loss for overweight or obese AF patients. Studies find that losing weight can reduce the health risks associated with or even reverse AF. It can also help to lower blood pressure. High blood pressure is often associated with AF.

Medication

Medications used to slow the heart rate include:

 Beta-blockers (atenolol, metoprolol).

 Digoxin.

 Dihydropyridine calcium channel blockers (CCBs), ie, verapamil, diltiazem.

 Amiodarone (less often used due to risk of side-effects.

Rate control versus rhythm control

Trials over the last 50 years show that

Figure 3: ECG showing normal heart rhythm (top) and atrial fibrillation (bottom)

RATES OF STROKE IN PATIENTS WITH AF AVERAGES 5 PER CENT A YEAR; THIS IS BETWEEN TWO-AND-SEVEN TIMES THE STROKE RATE IN THOSE WITHOUT AF

rate control has better patient outcomes when compared to rhythm control in AF patients, however, there is no difference in terms of mortality in achieving rate control versus rhythm control. Rate control is easier to achieve than rhythm control, all of which means the preferred initial aim of drug treatment for AF is rate control over rhythm control. The few exceptions to this are:

 New-onset AF: Within 48 hours.

 Patients with atrial flutter: Cardiac ablation is preferred to drug treatment.

 AF has a reversible cause, ie, it is due to other conditions like myocardial infarction and damaged heart muscle; the first treatment option is to control these conditions, which in turn may reverse AF.

 If there is another specific reason that rhythm control is required to control rate, ie, constant and severe symptoms.

Beta blockers

Beta blockers such as atenolol and metoprolol are used to control ventricular rate in AF. Sotalol is not recommended due to poor patient outcomes, especially in patients with CHF and post-MI.

Dihydropyridine calcium channel blockers (CCBs)

Dihydropyridine CCBs such as diltiazem or verapamil as monotherapy are an option for ventricular rate control in AF.

Dihydropyridine CCBs have the effect of relaxing and widening blood vessels, as well as the additional effects of being rate-limiting, meaning they decrease myocardial contractility and heart rate. Non-dihydropyridine CCBs such as amlodipine and felodipine are not rate-limiting, so are not effective for AF. Verapamil is licensed for AF, while diltiazem is not; however, diltiazem is used as an unlicensed indication by cardiac specialists for ventricular rate control in AF.

The choice of use of beta blockers versus dihydropyridine CCBs is based on type of symptoms, heart rate, and the presence of other conditions.

Digoxin

Studies indicate that digoxin is less effective than CCBs and amiodarone at controlling heart rate acutely, ie, need for fast rate control. Digoxin is more effective at controlling ventricular rate when the patients are at rest, so is reserved as monotherapy for AF patients with a sedentary lifestyle and for nonparoxysmal AF, especially those with left ventricular systolic dysfunction. Digoxin is used when beta-blockers do not give sufficient rate control and where beta blockers are poorly tolerated and/or contraindicated.

nausea and vomiting, anorexia, and neurological symptoms. Digoxin has a narrow therapeutic index, which makes dosing more challenging. Digoxin interacts with many drugs, with its effect being increased by nephrotoxic drugs, including angiotensin-convertingenzyme (ACE) inhibitors, angiotensin 2 receptor antagonists, non-steroidal anti-inflammatory drugs (NSAIDs), and ciclosporin. Digoxin is indicated for patients with CHF and reduced left ventricular function, so is an option where a patient has CHF and AF.

Combination drugs

A single drug may not be sufficient to control ventricular rate, so a combination of two drugs such as a beta-blocker, digoxin, or diltiazem is the next option. When ventricular function is reduced, the combination of a beta-blocker and digoxin is a preferred option. A beta blocker licensed for CHF should be used when ventricular function is reduced, ie, bisoprolol, carvedilol, nebivolol. If two drugs do not control rate, then rhythm control is the next option.

Drugs used to maintain sinus rhythm prepost-cardioversionand

Digoxin should be used in caution with older patients and patients with renal failure. Potassium levels must be monitored regularly to avoid digoxin toxicity due to hypokalaemia. Hypokalaemia is more of an issue for patients also prescribed diuretics, as diuretics, especially loop diuretics, reduce potassium levels. Hypokalemia can be a cause of digoxin toxicity because digoxin binds to the ATPase pump at the same site as potassium.

With low potassium levels, digoxin more easily binds to the ATPase pump, thus increasing inhibitory effects of digoxin on heart muscle (increases force of contraction). This can lead to digoxin toxicity, which manifests as

For pharmacological maintenance of sinus rhythm after an electrical cardioversion, a standard beta-blocker (ie, bisoprolol) is preferred. If a standard beta blocker is not effective, other options to maintain sinus rhythm post-cardioversion include sotalol, flecainide, propafenone, amiodarone or dronedarone. The data to support the use of newer drugs like dronedarone is limited currently.

Amiodarone should be considered post-cardioversion where left ventricular impairment or heart failure are present. Amiodarone should be commenced four weeks before and up to 12 months after cardioversion to maximise the cardioversion success rate.

Amiodarone is considered the most effective atrial arrhythmic drug, however amiodarone has potentially irreversible

| | NURSING IN GENERAL PRACTICE | 26 | JANUARY – FEBRUARY 2022

CARDIOLOGY

VERAPAMIL IS LICENSED FOR AF, WHILE DILTIAZEM IS NOT; HOWEVER, DILTIAZEM IS USED AS AN UNLICENSED INDICATION BY CARDIAC SPECIALISTS FOR VENTRICULAR RATE CONTROL IN AF

side-effects (ie, ocular deposits, liver impairment, pulmonary toxicity). Therefore, amiodarone is mainly avoided as a long-term maintenance option. It is normally reserved for shorter courses (two-to-six months), particularly for patients who have been successfully treated for a secondary cause of AF or short-term post-cardioversion.

Flecainide, sotalol, and propafenone should be avoided in the presence of ischaemic or structural heart disease.

Paroxysmal AF

Treatment of paroxysmal AF is quite similar to longer-term AF. For paroxysmal AF, a standard beta blocker (ie, bisoprolol) is the first option to control ventricular rhythm. If a standard beta blocker is not effective, other options to maintain sinus rhythm post-cardioversion are sotalol, flecainide, propafenone, amiodarone or dronedarone.

Occasionally, in specially selected patients with infrequent bouts of symptomatic paroxysmal AF, normal rhythm can be restored using what is referred to as the 'pill in the pocket’ method; the patient is trained to take oral flecainide acetate or propafenone to selftreat an episode of AF when it occurs, ie, they recognise symptoms like palpitations.

Cardioversion

If AF is recent or causing severe symptoms, cardioversion is a good option to reinstate normal heart rhythm and therefore control symptoms. Cardioversion involves using a small electric shock through electrodes (patches or paddles) placed on the chest while the patient in under a general anaesthetic. The electrodes are connected to a defibrillator, which delivers shocks in a controlled manner to the chest. The defibrillator monitors heart rhythm during the procedure and the clinician knows immediately once the procedure is done if the cardioversion is successful, ie, if normal heart rhythm has been restored. The procedure itself only takes five minutes, while the whole procedure, from being put under a general anaesthetic to recovery,

takes about 45 minutes. Cardioversion is done in hospital. Cardioversion is done as a day procedure, so the patient does not need to stay overnight in hospital.

Risks from cardioversion

As blood clots may develop within the atria due to slow or less consistent blood flow due to AF, a risk from cardioversion is that a thrombus (blood clot) breaks away from the atria, as normal heart rhythm is restored during the cardioversion. This can lead to a blood clot travelling through the circulatory system, ie, thromboembolism.

A transoesophageal echocardiogram (TEE) may be undertaken prior to the cardioversion to check for clots in the atria; a TEE involves insertion of an ultrasound probe under sedation via the throat and oesophagus and the probe gives ultrasound images of the heart to show up any clots.

For this reason, anticoagulants such as warfarin or a direct oral anticoagulant (DOAC) are prescribed for most patients for at least four weeks before and after the cardioversion. The risk of thromboembolism is higher for patients who have had AF for more than 24-to-48 hours. Very early diagnosis of AF (within 48 hours) is very unlikely and even if it was, organising a cardioversion within this time period is less likely, meaning anticoagulants are nearly always prescribed before and at least four weeks after a cardioversion. Many patients are prescribed anticoagulants long-term after a cardioversion.

There is no consistent agreement as to whether warfarin or DOACs are better to prevent thromboembolism before and after a cardioversion; neither appear superior in terms of anticoagulant effect. DOACs offer the advantage of not having to monitor INR and consistent (less complicated) dosing, however, patient compliance is more difficult to monitor with DOACs compared to warfarin (the INR identifies patient compliance with warfarin), meaning many clinicians still

choose warfarin as the anticoagulant of choice for cardioversion due to the considerable importance of proper coagulation during cardioversion.

Despite DOACs such as apixaban being increasingly used, European data shows that warfarin is still used as the anticoagulant of choice in over 65 per cent of patients in Europe, though this figure varies from country-to-country.

Other risks from cardioversion include a small risk of heart tissue damage from the electrical shocks, but this risk is extremely low due to the strict monitoring of the current level used. There may be a small degree of burning of the skin on the site where the patches are applied, but this is also rare.

Pharmacological cardioversion

Pharmacological cardioversion is done with oral or intravenous anti-arrhythmic drugs, including flecainide or amiodaron. Electrical cardioversion is preferred if AF has been present for over 48 hours.

Success rates of cardioversion

Cardioversion success rates for restoring normal heart rhythm from AF are over 90 per cent. The success rate is lower if AF is present for more a few months. For this reason, cardioversion is recommended as soon as possible after AF presents. Success from cardioversion is lower if there is enlargement of the left atrium. A cardioversion may only maintain sinus rhythm for a few minutes, days, or weeks after the procedure. Recurrence rates of AF after cardioversion range from 70-to-85 per cent one-year post-cardioversion, meaning antiarrhythmic drugs are often used long-term after the cardioversion.

Other options to maintain sinus rhythm

Other options may be considered if cardioversion or anti-arrhythmic drugs are not successful or if side-effects from medication are a problem.

Cardiac ablation

Cardiac ablation involves using small burns or freezes to create some scarring on the inside of the heart to prevent conduction of abnormal electrical signals travelling from the atria to the ventricles. An ablation involves inserting and threading a small catheter via blood vessels in the groin to the heart, either to administer small burns to heart tissue using radiofrequency energy, or freezing to specific areas of heart tissue (micro-ablation). Risks from cardiac ablation include blood vessel damage, heart valve damage and blood clot risk. Major complications from ablation are reported in 6 per cent of ablation procedures worldwide, which is a reason it is reserved for more persistent cases. Cardiac ablation is more successful in the management of paroxysmal AF, with more recent European and American guidelines pointing to the benefits of cardiac ablation in managing paroxysmal AF. About 40 per cent of AF patients have co-existing CHF, and cardiac ablation appears to give good

treatment outcomes when compared to other treatment options when AF coexists with CHF. The efficacy of ablation techniques continues to improve, meaning the threshold for when ablation is used continues to fall, which means it is likely to be used more to treat AF in the future as success rates and complications fall.

Pacemaker

Clinical evidence rarely supports the use of a pacemaker for AF, however, when bradycardia is an issue as part of AF, it may be considered if other treatments fail.

Stroke prevention

Traditionally, the two main anticoagulants for stroke and general clot prevention from AF were warfarin and aspirin. Warfarin has a better anticoagulant effect than aspirin and is used for patients with a high or moderate stroke risk. Warfarin reduces the stroke risk, no matter how high the risk is, by approximately two-thirds. Aspirin reduces stroke risk from AF by about 20 per cent and is reserved for lower-risk patients or where warfarin or DOACs are contraindicated.

DOACs are now the anti–coagulant of choice for stroke prevention in AF

DOACs are also known as non-vitamin K antagonist oral anticoagulants and are the newest class of anticoagulant drug. DOACs are now the first choice of anticoagulant for stroke prevention in AF in worldwide guidelines, unless a patient has a mechanical heart valve or moderate-to-severe mitral stenosis (narrowing of the heart’s mitral valve).

DOACs include rivaroxaban, apixaban, dabigatran and edoxaban. DOACs are now first choice, as evidence shows DOACs are safer than warfarin due to less risk of bleeding and are more effective than warfarin in preventing blood clots. DOACs also have less drug and food interactions than warfarin. DOACs are contraindicated with impaired renal and hepatic function and function should be checked prior to DOAC initiation and annually thereafter.

DOACs are at least as good as warfarin for the prevention of ischaemic stroke and thromboembolism elsewhere in the body. DOACs offer the additional benefit of reducing haemorrhagic

Indications for reduction If 2 of 3 factors present:

*Age ≥80 years

*SCr ≥1.5mg/dL Weight ≤60kg2

1CrCl 15-30mL/min OR, CrCl 30-50mL/ min with concomitant dronedarone or ketoconazole

15-50mL/min

| | NURSING IN GENERAL PRACTICE | 28 | JANUARY – FEBRUARY 2022

Usual

5mg BD 150mg BD 60mg daily (Contraindicated if CrCl ≥95mL/min) 20mg daily with food Reduced dose 2.5mg BD 75mg BD 30mg daily 15mg daily with food

CARDIOLOGY

APIXABAN DABIGATRAN EDOXABAN RIVAROXABAN

dose

CrCl

*Co-administered with combined P-gp and strong CYP3A4 inhibitors (eg, ketoconazole, itraconazole, ritonavir) CrCl

≤50mL/mi

Table 1: DOAC dosing for AF

Reference: American College of Cardiology

stroke risk by 50 per cent. An ischaemic stroke is a blood clot in an artery (and less frequently a vein) in the brain and account for approximately 87 per cent of all strokes. Haemorrhagic stroke is bleeding on the brain and accounts for approximately 13 per cent of strokes. More evidence is emerging that DOACs should be used for patients even at very low risk of stroke from AF, but more studies are needed before this recommendation becomes universal. DOACs are also considered an appropriate alternative to warfarin to prevent thromboembolism during and after cardioversion.

There has been more evaluation and evidence that DOACs are more effective versus warfarin for the prevention of stroke with nonvalvular AF (ie, AF that is not caused by a heart valve problem), but less studies and evidence of their efficacy over warfarin for prevention of stroke with valvular AF (AF caused by a heart valve problem). However, evidence emerged in 2021 which indicates that DOACs have a better efficacy of stroke risk benefit over warfarin for valvular AF. Warfarin is more effective than DOACs and is still the anticoagulant of choice to prevent clot risk for patients

with mechanical heart valves (with and without AF).

DOACs versus warfarin during the Covid-19 pandemic

DOACs have significant practical advantages over warfarin during the Covid-19 pandemic, which include no need for regular clinic visits to monitor INR, which reduces risk of catching Covid-19 and reduces workload for overstretched healthcare systems. ●

References on request

TRUE/FALSE QUESTIONS True or false?

Q1 Atrial fibrillation is the most common type of arrhythmia. True or false?

Q2 During a single cardiac cycle, the atria and ventricles beat alternately to each other. The ventricles contract prior to AF. True or false?

Q3 AF doubles the risk of stroke. True or false?

Q4 AF has a prevalence of approximately 1 per cent in the overall population, but this increases to up to 10 per cent in people over 80 years of age.

Q5 Amiodarone should be used long-term for AF.

True or false?

Q6 A transoesophageal echocardiogram (TEE) may be undertaken prior to the cardioversion to check for clots in the atria.

True or false?

Q7 DOACs have a stronger anticoagulant effect than warfarin to prevent stroke after a cardioversion.

True or false?

Q8 Recurrence rates of AF after cardioversion range from 70-to-85 per cent one-year post cardioversion, meaning antiarrhythmic drugs are often used long-term after the cardioversion.

True or false?

Q9 Clinical evidence supports the use of a pacemaker for AF.

True or false?

Q10 DOACs are now the first choice for anticoagulant for stroke prevention in AF in worldwide guidelines, unless a patient has a mechanical heart valve or moderate-to-severe mitral stenosis (narrowing of the heart’s mitral valve).

True or false?

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AUTHOR: Eamonn Brady, MPSI

ACUTE PAIN IN FOCUS

AN OVERVIEW OF THE TYPES OF ACUTE PAIN OFTEN SEEN IN COMMUNITY AND GP SETTINGS AND CURRENT MANAGEMENT STRATEGIES

Pain is defined by the International Association for the Study of Pain as “an unpleasant sensory and emotional experience, associated with actual or potential tissue damage, or described in terms of such damage”. Pain may also occur in the absence of tissue damage or any identifiable pathophysiological cause. Pain can be considered more than just a symptom of disease and is sometimes classed as a disease state in itself. Pain is universal, however, pain perception varies and is affected by the likes of cultural backgrounds and genetic differences.

The 2006 National Disability Survey Ireland (CSO, 2008) stated that pain was one of the most common disability types reported. Almost 50 per cent of individuals reporting pain as the main cause of their disability and of those, with 34 per cent indicating arthritis as being the most common cause of injury or illness. Almost 20 per cent stated the pain disability was caused by an accident or injury.

For the purpose of this article, I will discuss the types of acute pain often seen in community and GP settings. The management of acute pain from severe trauma (eg, RTAs) that requires management with likes of opioids and sedation in hospital settings is outside the scope of this article.

Causes of pain

The cause of pain is sometimes difficult to determine and there are often many aspects to consider. Chronic pain can be more difficult to determine the cause;

acute pain more often has a more clearly identifiable cause, eg, muscle injury. It is the indeterminate nature that can present the biggest obstacle to health professionals to establishing proper diagnosis of the condition.

The infographic below on reported causes of pain from the PRIME study, National University of Ireland Galway (NUIG) 2011, illustrates the problem further.

Acute pain

Acute pain starts quickly and lasts a short period of time. The definition of acute pain is pain that improves within one-to-three months of onset. Pain that lasts longer than six months is considered chronic pain and will require more specialist treatment from a pain expert. The period between three and six months is classified as the time of transition from acute pain to chronic pain. Patients require more specialist evaluation and treatment at this stage rather than just taking painkillers to avoid transitioning into chronic pain.

Common examples of acute pain:

 Headaches;

 Sprains and strains;

 Dental work;

 Surgery;

 Broken bones;

 Burns or cuts;

 Childbirth.

Acute pain can be difficult to diagnose and treat, especially when caused by injuries that are not visually evident like a fractured rib, a herniated disc, or a pinched nerve. Pain can develop to be more than a physical sensation. For example, it can develop to become an emotional problem, such as fear, or anxiety related to a traumatic event that triggered the pain. For example, a person may avoid driving after suffering severe injuries in a car accident.

Reasons for acute pain

The majority of acute pain episodes arise from causes that can be categorised as musculoskeletal conditions.

FIGURE 1: ‘Reported cause of pain’ from the PRIME study

Pain is a sensation experienced through the nervous system (nerves, spinal cord, and brain). Reflexes are the nervous system’s immediate response to acute pain. This is demonstrated by when a hot plate is touched, it takes milliseconds for the nervous system and muscles to coordinate and make the hand move away immediately; ie, a reflex reaction.

In addition to reflexes, the nervous system has more sophisticated mechanisms for processing pain. The brain releases neurotransmitters that influence pain levels and have an influence on mood, which is one of the reasons why depression can occur in response to pain. Pain and depression can create a vicious cycle in which pain worsens the symptoms of depression and then the resulting depression worsens feelings of pain.

Symptoms of acute pain

Acute pain can be felt in a specific body area, such as the neck or back, or the patient may have widespread pain with conditions, such as a viral illness.

Acute pain may be described as:

 Sharp;

 Dull;

 Stabbing;

 Throbbing (sign of inflammation);

 Shooting or shock-like (sign of nerve involvement).

Diagnosis for acute pain

The reason for the pain may not be visually obvious. Diagnostic tests are helpful and include:

 Blood tests;

 Imaging studies (x-ray, CT, MRI, nuclear scans);

 Local anaesthetic injections;

 Dye-injection studies, such as a diskogram to identify painful disks in the spine or myelogram to identify areas of spinal nerve compression;

 Electromyography and nerve conduction studies to identify nerve abnormalities.

Chronic pain versus acute pain

Chronic pain can be defined as pain which lasts longer than what is considered a ‘normal’ healing time, perhaps as part of recovery from illness or injury — generally more than three months.

Chronic pain may be attributable to an event, such as an accident, developing from acute pain. Opinion differs as to whether previous acute pain is always the root cause of chronic pain or simply appears, sometimes without an initial cause. In some cases, especially in relation to sports injury in contact sports, the underlying chronic pain may appear sometime after an event. Pain may also be related to another condition.

Surveys show that in Ireland, 35 per cent of reported chronic pain was arthritis related. It may site-specific, ie, back, knee, and wrist, however, 80 per cent of sufferers in Ireland report that their pain relates to more than one site.

Types of chronic pain

Pain can be classified either by type of pain, or by body region. Pain types include:

 Nociceptive pain: Aching, boring, worse on movement, anatomically defined, fluctuates in severity.

 Neuropathic pain: Burning sensation, sharp stabbing type, tingling, transient limb pain (shooting), associated with allodynia (experience of pain from a non-painful stimulation of the skin, such as light touch), hypersensitivity, or other sensory changes.

 Mixed nociceptive and neuropathic pain: Combination of symptoms.

 Visceral pain: Dull, non-specific, difficult to pinpoint.

 Autonomic symptoms: Physiological changes (colour, temperature), sweating.

Treatment

Aims of treatment are to:

 Reduce intensity of the pain;

 Enhance physical functioning;

 Improve mood;

Osteoarthritis

Rheumatoid arthritis

Osteomyelitis

Osteoporosis

Ankylosing spondylitis

Myofascial diseases

Polymyalgia rheumatica

Polymyositis

Fractures

Chronic or repetitive overuse

Carpel tunnel syndrome

Muscular strains

Faulty posture

Mechanical low-back pain

Cluster headaches

Migraine

Trigeminal neuralgia

Giant cell (temporal) arteritis

Glaucoma

Smoking Alcohol

Temporo-mandibular joint dysfunction

Drug or substance overuse or misuse

Diabetic sensorimotor polyneuropathy (up to 25 per cent of diabetics)

Spinal stenosis

Brachial plexus

traction injury

Thoracic outlet syndrome

Post-herpetic neuralgia

Multiple sclerosis

Alcoholism

Thyroid disease

Pernicious anaemia

Infections (ie, HIV), polyneuropathies

Polyradiculopathies

Depression

Anxiety

Personality disorders

Sleep disturbances

TABLE 1: General pain classification

MUSCULOSKELETAL HEADACHE AND/ OR MIGRAINE NEUROLOGICAL PSYCHOLOGICAL CAUSES

MEDICATION CAN BE USED FOR BENEFITS SIDE-EFFECTS

Paracetamol To treat pain anywhere in the body. Can be used alone or with other drugs, such as NSAIDs or a codeinelike opioid, such as co-codamol and codydramol

Oral non-steroid anti-inflammatories (NSAIDs), for example: Ibuprofen, diclofenac, etoricoxib, ketorolac, piroxicam, naproxen and celecoxib, in the form of a tablet

Low back pain

Hip or knee osteoarthritis pain (pain that affects the joints)

Musculoskeletal pain (pain that affects the muscles, ligaments, and tendons and joints)

Relieves pain quickly. Has few side-effects and is considered generally safe if used within the recommended dose

Relieves pain quickly, reduces inflammation, for example in joints

Side-effects from paracetamol are rare, if taken within safe limits

However, taking more than the amount recommended (more than 4g daily) is extremely dangerous

Rare side-effects can include:

 Skin rash

 Liver (and less commonly kidney) problems if higher than the recommended dose is taken

Side-effects can include:

 Stomach pain

 Diarrhoea

 Heartburn

 High blood pressure

 Rash

 Dizziness and headaches

In a small number of people, NSAIDs can cause heart problems. Over-use can be associated with serious bleeding. For this reason, NSAIDs should not be used with aspirin. If the patient has asthma, there is a risk of it becoming worse when taking NSAIDs

COX-2 inhibitors are a type of NSAID that directly targets

cyclooxygenase-2, COX2. Examples include celecoxib and etoricoxib. They demonstrate a significantly reduced risk for upper and lower gastrointestinal complications compared with conventional NSAIDs. However, evidence suggests that some of these agents, at some doses, may be associated with an increased risk for cardiovascular adverse events compared with no therapy. COX-2 inhibitors are best avoided in patients with cardiovascular issues

Topical non-steroid anti-inflammatory drugs (NSAIDs), for example: Ibuprofen, diclofenac, etoricoxib, ketorolac, piroxicam, naproxen, and celecoxib, in the form of gel, cream or patches

Other topical medicines (medication applied to the skin in the form of creams, gels, or patches), for example: Capsaicin; lidocaine patch; and rubefacients (substance that produces redness of the skin)

Should be considered when treating localised musculoskeletal pain, particularly if unable take NSAID tablets

Should be used for a short time

Works directly on the affected area of the body

Less risk of sideeffects as the medication does not go through the whole body

Side-effects are rare, but some people can get mild skin reactions, for example a rash

Should be considered for nerve pain or musculoskeletal pain which hasn’t improved with other medication, or if unable to take other medication

Works directly on the affected area of the body

Less risk of side-effects as medication does not go through the whole body

Sometimes topical painkillers can cause:

 Redness

 Itching

 Stinging

 Burning

 Other skin reactions

MEDICATION CAN BE USED FOR BENEFITS SIDE-EFFECTS

Opioids, for example: Codeine, dihydrocodeine, tramadol, oxycodone, hydrocodone, tapentadol, morphine, diamorphine, transdermal fentanyl, buprenorphine and methadone

Should be considered for chronic low-back pain or osteoarthritis

Should only be continued if there is ongoing pain relief

Some opioids are weak (for example, codeine), and some are strong (for example, morphine)

Because opioids can have serious sideeffects, their long-term use should only be considered after a detailed discussion with a GP

These are strong painkillers which reduce the intensity of pain and improve physical symptoms and day-to-day living

Common sideeffects include:

 Nausea

 Vomiting

 Dizziness

 Constipation

 Drowsiness

 Confusion

 Breathing problems

 Itch

Side-effects associated with longer-term use of opioids include:

 Feeling lethargic

 Headaches

 Stomach problems (including constipation)

 Urinary problems

 Reduced immunity to infections

 Hormone problems

 Dry mouth

 Over-sensitivity to pain, or pain getting worse

 Addiction

 Mood changes

 Sleep disturbances

Anticonvulsants, for example: Gabapentin, pregabalin and carbamazepine

This medication is commonly used to treat epilepsy, but can also help nerve pain

Can stop nerve impulses causing some types of pain

Recent studies indicate they may not be as effective as first thought for pain and increasing evidence of abuse

Side-effects may be worse in the first few days, when the body is getting used to new medication. The most common side-effects include:

 Dizziness

 Drowsiness

 Weight gain

 Rash

 Dry mouth

 Nausea

 Vomiting

Less common sideeffects include:

 Swollen legs

 Blurred vision

 Headaches

 Diarrhoea and tremors (movement disorders)

Antidepressants, for example: Amitriptyline, duloxetine, and fluoxetine

As well as helping people who have depression, this medication can help others with chronic pain

Amitriptyline (or nortriptyline) should be considered for treatment of fibromyalgia (chronic widespread pain) and nerve pain

Duloxetine should be considered for treatment of nerve pain

Fluoxetine should be considered for treatment of fibromyalgia

Work by interfering with the way nerve impulses are transmitted and ease some types of pain

Different antidepressants have different side-effects, and side-effects are rare with some of them. When patients first start to take amitriptyline or duloxetine, they may experience:

 Dry mouth

 Nausea

 Dizziness

 Urinary retention

 Constipation

 Drowsiness

 Problems sleeping

 Anxiety

 Agitation

 Problems with the central nervous system

TABLE 2: Types of medications, their benefits, and potential side-effects

 Promote the return to work or school and/or role within family and society;

 Improve quality-of-life;

 Support pain-management planning decisions;

 Reduce need for healthcare services.

First-line treatment options include:

 Resting the affected area;

 Applying ice or heat;

 Paracetamol or non-steroidal antiinflammatory drugs (NSAIDs) such as aspirin, ibuprofen, or naproxen;

 Exercise;

 Physiotherapy;

 Stress reduction;

 Bioelectric therapy (ie, local electrical stimulation like a TENs

machine for moderate pain);

 Opioid medication, such as codeine or morphine;

 Muscle relaxant medications. Second-line treatment options include:

 Antidepressants: some tricyclics such as amitriptyline have a role in nerve pain and some antidepressants may be needed for mood and insomnia issues exacerbated by pain;

 Anticonvulsants: more often used for nerve pain;

 Nerve blocks: local anaesthetics to block nerve activity;

 Trigger point injections: to treat muscle spasms;

 Steroid injections: to reduce tissue inflammation.

PAIN TYPE EVIDENCE-BASED RECOMMENDED ANALGESIC

Lower back pain

Overview of pain medications

A successful outcome from general practice visits should be a pain management plan. It is highly likely that as part of this, some form of pain-relieving medication will be prescribed. Ideally, advise on promotion of self-help, selfmanagement, and other treatments to help improve their condition and add value to the benefit offered by medication.

Given the wide and varied nature of acute and chronic pain, there is a myriad of medication options. The effectiveness of medication depends on the nature and severity of the pain.

Tension-type headache

Migraine (must be medically diagnosed before OTC medication can be recommended)

NSAIDs, (eg, ibuprofen 400mg three times per day) at the lowest possible dose for the shortest possible time. Do not offer paracetamol alone

Aspirin (300mg three times per day), paracetamol or NSAID, taking account of patient preference and comorbidities

Combination of triptan (eg, sumatriptan no more than two 50mg tablets in 24 hours), NSAID or triptan, and paracetamol. If the patient prefers one drug only, consider monotherapy with oral triptan, or NSAID (eg, ibuprofen) or paracetamol alone, considering comorbidities. Opioids should not be used for the acute treatment of migraine

Types of medications, their benefits and potential side-effects are shown in Table 2 Regarding treatment of acute pain caused by headache (ie, migraine), in addition to standard paracetamol and NSAIDs, triptans are considered the most effective to combat acute attacks if ordinary analgesics do not work. These include:

● Almotriptan ● Frovatriptan

● Sumatriptan ● Zolmitriptan

● Eletriptan ● Naratriptan All are prescription-only medicines (POM), apart from sumatriptan, which has an over the counter (OTC) version available in Ireland.

Efficacy of OTC painkillers

Sprains and strains

Paracetamol (500mg to 1g four times per day, with a maximum 4g in 24 hours) or topical NSAID (eg, ibuprofen or diclofenac gels) are recommended first-line. Consider oral NSAID (eg, ibuprofen 400mg three times per day) 48 hours after the initial injury if needed

Period pain

NSAID (eg, ibuprofen or naproxen) unless contraindicated. Paracetamol can be used if a NSAID is contraindicated or provides insufficient pain relief

Common acute pain conditions and the recommended, OTC, evidence-based analgesia

Reference: National Institute of Health and Care Excellence (UK)

Cochrane reviews (39 in total) of randomised controlled trials on effectiveness of OTC analgesics in acute pain found reliable evidence to indicate that simple, inexpensive, and common analgesics give good pain relief to many patients with acute pain, such as headache, toothache, sprains, and strains. Data demonstrated the most efficacious OTC drugs used were ibuprofen/paracetamol combinations in respective 400mg/ 1,000mg and 200mg/500mg doses. These formulations gave effective relief in seven-out-of-10 patients. Fast-acting ibuprofen 200mg and 400mg was effective in at least five-out-of-10 patients. Paracetamol alone was effective in four-out-of-10 patients.

World Health Organisation (WHO) analgesic ladder

The WHO analgesic ladder (introduced in 1986) was developed to help clinicians decide cancer pain treatment. It was developed for chronic pain, but the principles apply to the management of acute pain. OTC painkillers can be used for mild pain according to this tool, starting with a non-opioid (eg, paracetamol or aspirin) for mild pain then trialling an opioid plus a non-opioid (eg, co-codamol) for mild-to-moderate pain. Despite its origin to manage cancer-related pain, the WHO analgesic ladder now acts as a useful guide for pain control in both acute and chronic pain from malignant and nonmalignant causes. As pain is a subjective experience, the stepwise approach of the WHO analgesic ladder is not always appropriate for managing intense pain.

Guidance on musculoskeletal injures

The American Academy of Family Physicians (AAFP) and American College of Physicians (ACP) guidelines published in 2020 (after a review of 13 million patients) recommend topical NSAIDs as first-line therapy for patients experiencing pain from musculoskeletal injuries (excluding lower back pain). The guidelines recommend that clinicians not prescribe opioids except in cases of severe injury or if patients cannot tolerate first-line therapeutic options.

The recommendations state that topical NSAIDs were the only intervention that improved all outcomes in patients with acute pain from non-lower back musculoskeletal pain. They found that topical NSAIDs also were among the most effective options for treatment satisfaction, pain reduction, physical function, and symptom relief, and were not associated with a statistically significant increased risk of adverse effects.

Oral NSAIDs were shown to be effective in reducing pain within two hours and one-to-seven days after treatment and were associated with greater likelihood of symptom relief. However, oral NSAIDs also

were associated with an increased risk of gastrointestinal adverse events.

Self-help Pain management programme

The Pain Management Programme (PMP) is a psychologically based rehabilitative treatment for people with persistent pain. It is delivered in a group setting by a multidisciplinary team of experienced healthcare professionals working closely with patients. The main aim is to teach a group of patients with similar problems about pain, how best to cope with it, and how to live a more active life. Referral to a PMP is usually through the general practitioner to your local pain clinic.

There are public PMP in * :

 St Vincent’s University Hospital, Dublin.

 Tallaght University Hospital, Dublin.

 Mater Misericordiae University Hospital, Dublin.

 Mercy University Hospital, Cork.

* This list not exhaustive Private hospitals also have pain clinics. For example, the Beacon Hospital in Dublin operates an acute pain service and a chronic pain service.

Physical therapy

Physical therapy covers a number of different treatment types, which can be beneficial for chronic pain, especially pain due to musculoskeletal disorders.

 Hot or cold (ice) pack treatment;

 Ultrasound;

 Peripheral nerve stimulation/ transdermal electronic nerve stimulation (TENS).

A chartered physiotherapist can help with manual therapy, which helps to increase tissue extensibility and range of movement, thereby decreasing pain. Manual therapy can also help with alignment and joint mechanics issues, which in itself can also help alleviate pain. Therapeutic exercise — such as hydrotherapy, can restore joint movement and flexibility and strengthen and condition muscles to help movement, thereby reducing pain.

Patient education — Can support physical therapy in a self-help or homebased manner. Reading and learning about their condition can assist in management of their own pain.

Exercise — Staying active can be the key to improving chronic pain symptoms. Any activity that increases mobility can have not only a positive physical benefit, but also an affirming mental health benefit also.

Cognitive behavioural therapy (CBT)

CBT is a proven ‘talk therapy’, the primary aim of which is to how to recognise and manage negative thinking or unhelpful beliefs that lead to increased distress. Generally delivered on a one-to-one basis, the participant is taught techniques and strategies to enable them to challenge their thoughts and change their attitude, leading to a change in future behaviour. Through regular attendance, confidence builds, leading to positive goal setting. These goals should relate to achieving resumption of activities previously restricted by pain. Learning problem-solving strategies and stress reduction techniques will help achieve a successful outcome.

General practice

The patient’s needs will affect treatment choice so GPs, GPNs and primary care teams should have available (and understand) a range of guidance and literature to best advise patients about the most effective treatment for them.

Regular review of the continued suitability of all medications used by those with both acute and chronic pain is vital. For many, beyond the pharmacy, the GP surgery is the first port of call when a pain-related problem arises. Using some of the ideas regarding questions, pain diary, etc, will really help in enabling people to make betterinformed decisions about their own next step. Becoming familiar with local resources like physios, support groups, conditionspecific charities, etc, and signposting these will only add value to a positive perception. ●

References on request

AUTHOR: Mary Jordan, GPN and National Chairperson, IGPNEA

IGPNEA position on sponsorship and advertising revenue from SUBSTITUTE COMPANIES BREAST MILK

AN EXPLANATION OF THE IGPNEA’S STANCE ON SPONSORSHIP AND ADVERTISING REVENUE FROM BREAST MILK SUBSTITUTE COMPANIES

The Irish General Practice Nurses Education Association (IGPNEA) is a professional membership body with Charitable Tax Exemption (CHY 17932). The main objective for which it was established is the advancement of education in general practice in Ireland by promoting and assisting general practice nurses (GPNs) in further education

programmes, and to provide a forum for the dissemination of information on developments in the general practice nursing field, which will promote the highest standards of care to benefit the community. All activities aim to encourage and foster the highest standards within general practice nursing for the benefit of patients and their families.

Article 4.1a of the IGPNEA Articles

of Association states that it will work positively with other groups and organisations that it deems to be suitably equipped to provide the necessary educational programmes or skills required for the enhancement of nursing in general practice. Article 4.1b states that the IGPNEA shall not associate itself with any group whose work is not in keeping with the ethos, aims and objectives of the Association.

The last statement that the IGPNEA produced in regard to sponsorship was in 2011. It states that the IGPNEA will not:

a) Participate in any project, research, study, steering group, etc, that is set up by, or receives funding in any way (either directly or indirectly), from the groups listed below; or

b) Seek or accept sponsorship from the groups listed below:

 Companies from the drinks industry.

 Companies from the tobacco industry.

 Companies from the fast-food industry.

 Companies from the snacks/ sweets industry.

 Any other company whose work is deemed by the National Executive Council (NEC) not to be in keeping with the aims and objectives of the Association. Thus, it was felt necessary by the NEC to discuss with the Association’s members whether or not breast milk substitute companies should be added to this list.

Benefits of breastfeeding

Breastfeeding is important for the health of both mother and infant. For mothers, this includes a lower risk of postpartum depression, a reduced risk of cardiovascular disease, breast cancer and ovarian cancer, and a faster return to pre-pregnancy weight. It is associated with a reduced risk of type 2 diabetes later in life for the mother, even if she has had gestational diabetes. For infants, breastfeeding provides better protection

from acute infections, otitis media, neonatal enterocolitis and respiratory illness. Links have also suggested that breastfeeding reduces the risk of obesity in the child.

WHO International Code of BreastmilkMarketingSubstitutes

The World Health Organisation (WHO) recognises the importance of breastfeeding "for healthy growth and development of infants; it forms a unique biological and emotional basis for the health of both mother and child; the antiinfective properties of breast milk help to protect infants against disease". The WHO International Code of Marketing Breastmilk Substitutes was adopted in 1981 by the World Health Assembly (WHA) to promote safe and adequate nutrition for infants, by the protection and promotion of breastfeeding and by ensuring the proper use of breast milk substitutes, when these are necessary.

For the purpose of the WHO Code a ‘healthcare worker’ is defined as any person working in the healthcare system, whether professional or nonprofessional, including voluntary and unpaid workers, in public or private practice, is a health worker. Under this definition, ward assistants, healthcare assistants, housekeeping, nurses, midwives, social workers, dietitians, physiotherapists, hospital pharmacists, doctors, administrators, clerks, etc, are all health workers.

Healthcare workers involved in maternal and infant nutrition should make themselves familiar with their responsibilities under the Code. (Available at www.hse.ie/file-library/thewho-code-of-marketing-of-breast-milksubstitutes.pdf). This clearly includes GPNs.

Irish perspective

Healthy Ireland, the Framework for Improved Health and Wellbeing 2013 –2025, aims to improve the health and wellbeing of the population of Ireland over the coming generation, by outlining clear

pathways and strategies for all people to follow. It is the policy of the health sector in Ireland that “all health service providers will protect breastfeeding in line with the WHO International Code of Marketing of Substitutes and subsequent relevant WHA resolution”. Despite the evidence of the importance of breastfeeding, rates in Ireland remain amongst the lowest in the OECD. While the rate has improved from 38 per cent in 2000, only 56 per cent of babies in Ireland were breastfed on discharge from maternity hospitals/ units in 2013. This compares with rates of babies being breastfed at any time of 96 per cent in Australia, and 81 per cent in the UK. In March 2015, the HSE Performance Assurance Report included

unnecessary or improper use of formula. If a mother makes an informed decision not to breastfeed, healthcare professionals should not promote a specific brand of formula, or be involved in the promotion of products used for infant feeding. Mothers who decide to use infant formula should be given one-to-one or small group instruction on the safe preparation on formula feeds in the postnatal period.

Following discussion amongst our members the following points were noted:

 GPNs' first encounter with infants is usually at the two-month immunisation visit, at which time the infant is usually established on a feeding regime, be that breast or breast milk substitute, as chosen by the infant’s parents/guardians.

 GPNs are therefore not influencing the choice of infant feeding.

 This visit is often used to discuss feeding issues.

 The provision of safe and adequate nutrition of infants is our goal.

 Protection and promotion of breastfeeding is a given.

 Breast milk substitute companies only deliver scientific and factual material.

 In our experience the breast milk substitute company always reiterates that breast is best.

breastfeeding rates for the first time and this additional reporting is welcomed.

September 2015 data shows that at the first PHN visit, which normally takes place within 72 hours of discharge, 53.2 per cent of babies were breastfed. At the three-month PHN visit, the rate fell to 34.2 per cent.

Articles 6 and 7 of the WHO Code states that information provided by companies to health professionals must be restricted to scientific and factual matters and not imply or create a belief that formula feeding is equivalent or superior to breastfeeding. All information and educational materials for pregnant women and mothers should explain the superiority of breastfeeding, the social and financial implications of formula, and the health hazards of the

 Mothers have an expectation that healthcare professionals have the knowledge and skill to assist them with common feeding problems.

 Some mothers choose not to breast feed because of their smoking or drug use.

 In order to best advise mothers on formula feeding GPNs require adequate information.

 Supporting material is made available to evidence-based information by the companies. The majority consensus was that the IGPNEA would not adopt a policy to cease engagement with breast milk substitute companies. The IGPNEA acknowledges the role that these companies play in providing GPNs with balanced information on infant nutrition. ●

References available on request

DESPITE THE EVIDENCE OF THE IMPORTANCE OF BREASTFEEDING, RATES IN IRELAND REMAIN AMONGST THE LOWEST IN THE OECD

AUTHOR:

INFECTIOUS MONONUCLEOSIS: An overview

INFECTIOUS MONONUCLEOSIS SHOULD BE SUSPECTED IN PATIENTS WHO PRESENT CLINICALLY WITH THE CLASSIC TRIAD OF FEVER, PHARYNGITIS, AND CERVICAL LYMPHADENOPATHY

Infectious mononucleosis, commonly known as glandular fever, characterised by fatigue, fever, pharyngitis, and lymphadenopathy, is an infection usually caused by the Epstein–Barr virus (EBV), (human herpesvirus 4) a member of the herpes virus family. It can affect people of any age, but is most common in young adults and teenagers aged 15-to-24 years. The infection is primarily spread through saliva, by kissing or exposure to coughs and sneezes and objects, such as eating and drinking utensils and toothbrushes. Following exposure, EBV infects epithelial cells of the oropharynx and salivary glands. B lymphocytes may become infected through exposure to these cells or may be directly infected in the tonsillar crypts. B-cell infection allows viral entry into the bloodstream, which systemically spreads the infection. The host immune response involves cytotoxic T-cells reacting against the infected B lymphocytes, resulting in enlarged, atypical lymphocytes.8 Infectious mononucleosis can also rarely be spread through other bodily fluids such as blood or semen. EBV can remain in saliva for up to 18 months post infection, and a few individuals may continue to have the virus present in their saliva intermittently for years. There is no vaccine for EBV,

however, most individuals develop immunity after the initial infection.1,4,6

Infectious mononucleosis accounts for approximately 1 per cent of all patients who present with a sore throat. In those aged 16-to-20 years, however, it is the cause of about 8 per cent of throat infections. EBV causes approximately 90 per cent of cases of infectious mononucleosis, with the remainder due largely to cytomegalovirus, human herpesvirus 6, toxoplasmosis, HIV, and adenovirus. Because their management is much the same, it is not always necessary to distinguish between EBV mononucleosis and cytomegalovirus infection. However, in pregnant women, differentiation of mononucleosis from toxoplasmosis is important, since it is associated with significant consequences for the foetus.

After an incubation period of four-to-

eight weeks, EBV infection of adolescents or adults results in infectious mononucleosis in up to 70 per cent of cases. Most symptoms tend to resolve in two-to-four weeks, although approximately 20 per cent of patients continue to complain of a sore throat after one month.3,4,8

Before puberty, the illness typically produces symptoms similar to those of common throat infections. In adolescence and young adulthood, the disease presents with a characteristic triad of fever, sore throat and lymphadenopathy. Other symptom include fatigue, headaches, nausea, vomiting, and abdominal pains. The most prominent sign is pharyngitis accompanied by enlarged tonsils with exudate similar to strep throat. In approximately 50 per cent of cases petechiae can be seen on the roof of the

Theresa Lowry-Lehnen, CNS, GPN, RNP, PhD, and Associate Lecturer at Institute of Technology Carlow

EBV CAUSES APPROXIMATELY 90 PER CENT OF CASES OF INFECTIOUS MONONUCLEOSIS, WITH THE REMAINDER DUE LARGELY TO CYTOMEGALOVIRUS, HUMAN HERPESVIRUS 6, TOXOPLASMOSIS, HIV, AND ADENOVIRUS

mouth. Spleen enlargement is common in the second and third weeks, although this may not be apparent on physical examination. Rarely, in approximately 1 per cent of cases, the spleen may rupture. There may also be some enlargement of the liver.2,3 When adults over the age of 40 develop the illness, they display less characteristic symptoms and are more likely to develop prolonged fever, fatigue, malaise, and body pains with liver enlargement and jaundice.3,4

Diagnosis

Infectious mononucleosis should be suspected in patients who present clinically with the classic triad of fever, pharyngitis, and cervical lymphadenopathy. Lymphadenopathy may be prominent in both the anterior and posterior triangles of the neck, which distinguishes infectious mononucleosis from bacterial tonsillitis where the lymphadenopathy is usually limited to the upper anterior cervical chain. Other common physical signs include palatal petechiae, splenomegaly, hepatomegaly, and jaundice.

Diagnosis of infectious mononucleosis is primarily based on symptoms, but should be confirmed by the heterophile antibody monospot test. Sensitivity is 85 per cent and specificity is 100 per cent. The heterophile antibody monospot test results may be negative early in the course of EBV infectious mononucleosis. Positivity increases during the first six weeks of the illness. Patients who remain heterophile-negative after six weeks with a mononucleosis illness are considered to have heterophile-negative infectious mononucleosis and should be tested for EBV-specific antibodies. Patients who are heterophile-positive, but specific antibody-negative, should be considered for testing for possible causes of false positive heterophile antibodies. A realtime polymerase chain reaction (PCR) test identifying infectious mononucleosis DNA may be useful in cases of diagnostic doubt or where rapid diagnosis is helpful, such as in patients with a high risk of splenic rupture.9 White blood cell count and differential can be useful in establishing a diagnosis. A typical finding is increased

blood lymphocytes. Liver function tests (LFTs) are also abnormal in more than 90 per cent of patients with infectious mononucleosis. Serum transaminase and alkaline phosphatase levels are usually moderately elevated. The serum bilirubin may be increased in approximately 40 per cent of patients, but jaundice typically only occurs in approximately 5 per cent of infectious mononucleosis cases.7,8 ESR is elevated in most patients with infectious mononucleosis, but is not elevated with group A streptococcal pharyngitis. Abdominal ultrasound may be required to assess for splenomegaly and other investigations may be required to differentiate from other possible diagnoses, for example, lumbar puncture for meningism. 9

CAEBV

Chronic active Epstein–Barr virus (CAEBV) infection is a rare condition characterised by severe, chronic, or recurrent infectious mononucleosis-like symptoms after a well-documented primary infection with EBV in a previously healthy person. The

Figure 1: Algorithm for diagnosing infectious mononucleosis Source: Lennon P, Crotty M, Fenton J. (2015) 3

disease is progressive with markedly elevated levels of EBV DNA in the blood and infiltration of organs by EBV-positive lymphocytes. Patients often present with fever, lymphadenopathy, splenomegaly, EBV hepatitis, or pancytopaenia. Over time, these patients develop progressive immunodeficiency and, if untreated, develop infections, haemophagocytosis, multi-organ failure, and EBV-positive lymphomas. The only proven effective treatment for chronic active EBV is haematopoietic stem cell transplantation.2,3

Complications

Infectious mononucleosis usually resolves over a period of weeks, but occasionally can be exacerbated by complications. While uncommon, complications can be serious when they occur. Complications include secondary infection of the brain or nervous system, breathing difficulties as a result of inflamed tonsils and ruptured spleen. Airway obstruction may develop in patients with severe inflammation and swelling of the tonsils and adenoids. This complication may occur in one of every 100-to-1,000 cases and most often occurs in younger patients with infectious mononucleosis.4,8

Neurological disorders may occur in 1-to-5 per cent of patients. These include encephalitis, meningoencephalitis, seizures, optic neuritis, sudden sensorineural hearing loss, idiopathic facial palsy, and Guillain-Barré syndrome.2,3

Haematological complications are more common, particularly haemolytic anaemia and thrombocytopaenia and rarely, aplastic anaemia, pancytopaenia, and agranulocytosis. Other rare acute complications include myocarditis, pericarditis, pancreatitis, interstitial pneumonia, rhabdomyolysis, and psychological complications.3 There is evidence that a history of infectious mononucleosis significantly increases (doubles) the risk of multiple sclerosis.3

Severe abdominal pain is uncommon in patients with infectious mononucleosis, and should prompt immediate reaction to the possibility of splenic rupture.8

Treatment

Infectious mononucleosis can be treated in most cases with rest, hydration, analgesia, and antipyretics. Paracetamol and NSAIDs, such as ibuprofen, may be used to reduce fever and pain. Antibiotics are not effective in treating infectious mononucleosis, because they have no effect on viral infection. Antibiotics may be prescribed if a secondary bacterial infection of the throat occurs, however, ampicillin and amoxicillin are not recommended during acute EBV infection, as a diffuse itchy maculopapular rash may develop.3,4,5

Although antivirals are not usually recommended for people with simple infectious mononucleosis, they may be useful in the management of severe EBV manifestations, such as EBV meningitis, peripheral neuritis, hepatitis, or haematologic complications. Antiviral treatment with acyclovir has been shown to significantly decrease the rate of oropharyngeal EBV shedding. There is insufficient evidence to recommend steroid treatment for symptom control in infectious mononucleosis, however, short courses of corticosteroids are beneficial for haemolytic anaemia, central nervous

REFERENCES

1. MSD (2019). Infectious Mononucleosis. MSD Manual Professional Version. US. Available at www.msdmanuals.com/ professional/infectious-diseases/herpesviruses/infectious-mononucleosis

2. Balfour H, Dunmire S, Hogquist K. (2015). Infectious mononucleosis. Clinical Translation Immunology. 4(2), Feb. doi: 10.1038/cti.2015

3. Lennon P, Crotty M, Fenton J. Infectious Mononucleosis. BMJ 2015. Education Clinical Review. doi: 10.1136/ bmj.h1825. Available at: www.bmj. com/bmj/section-pdf/895012?path=/ bmj/350/8005/Clinical_Review.full.pdf

4. HSE (2018). Glandular Fever. Health Service Executive. Available at: www. hse.ie/eng/health/az/g/glandular-fever/treating-glandular-fever.html

5. Bennett J, Dolin R, Blaser M. (2014). Principles and Practice of In-

system involvement or extreme tonsillar enlargement.9 The need for rest and return to usual activities after the acute phase of the infection should be based on the person's general energy levels. However, to decrease the risk of splenic rupture, avoidance of contact sports and heavy physical activity is advised for the first three-to-four weeks or until enlargement of the spleen has resolved. Alcohol should be avoided for the duration of the illness.3,4,5 Resolution of the acute illness is usually followed by a lifelong latent infection. Once the acute symptoms of an initial infection resolve, they usually do not reoccur, however, the virus remains dormant in B lymphocytes in the body and the person is a carrier for the rest of their life. Independent infections of mononucleosis may be contracted, regardless of whether the person is already carrying the dormant virus. Occasionally, the virus can reactivate, during which time the person is again infectious, but usually without any symptoms of illness. However, in susceptible hosts the virus can reactivate causing vague physical symptoms, and during this phase the virus can spread to others.7 ●

fectious Diseases. Elsevier Health Sciences. p.1760. ISBN 9781455748013

6. Rezk SA, Zhao X, Weiss L. (2018). Epstein-Barr virus (EBV)-associated lymphoid proliferations, a 2018 update. Human Pathology. 79: 18–41. doi:10.1016/j. humpath.2018.05.020. PMID 29885408

7. BMJ (2018). Infectious Mononucleosis. BMJ Best Practice. Available at: https://bestpractice.bmj.com/topics/en-gb/123?gclid=Cj0KCQjwy97 qBRDoARIsAITONTK-4evuG9PmZxU8NL5pHlILFWFGk_Oieeo4wg6wLUY7A7weEA0Eup4aAvtyEALw_wcB

8. Medscape (2019). Infectious Mononucleosis (IM) in Emergency Medicine. Available at: https://emedicine.medscape.com/article/784513-overview

9. Knott L. (2016). Infectious Mononucleosis. Patient Information. Available at: https://patient.info/ doctor/infectious-mononucleosis

AUTHOR: Theresa Lowry-Lehnen, CNS, GPN, RNP, PhD, and Associate Lecturer at Institute of Technology Carlow

OESOPHAGEAL CANCER: An overview

IRELAND HAS ONE OF THE HIGHEST RATES OF OESOPHAGEAL CANCER IN EUROPE WITH RATES OF 7.9 PER 100,000 AND INCIDENCE IS PROJECTED TO RISE IN THE COMING YEARS

Oesophageal cancer is the eighth most common cancer and sixth most common cause of cancer mortality worldwide.7

Approximately 450-to-500 people in Ireland are diagnosed with the condition annually.1 Ireland has one of the highest rates of oesophageal cancer in Europe with rates of 7.9 per 100,000 and incidence is projected to rise in the coming years.9

Oesophageal cancer is an aggressive neoplasm that manifests in the gastrointestinal (GI) tract and is the result of numerous factors that can contribute to the development of the disease.4 Oesophageal cancer occurs when cells in the oesophagus develop mutations in their DNA and the cells grow and divide out of control. The accumulating abnormal cells form a tumour in the oesophagus that can grow to invade nearby structures and spread to other parts of the body. 4 The tumour does not cause symptoms at first, but as it grows causes difficulty with swallowing. As oesophageal cancer expands, the lumen of the oesophagus narrows, and dysphagia occurs due to mechanical obstruction. Due to the muscular and expansive nature of the oesophagus, symptoms from an obstructing or stricturing lesion may only become apparent when the tumour

has reached a relatively locally advanced or even metastatic stage.12

Symptoms of oesophageal cancer include dysphagia, acid reflux, pain in the sternum, back or throat, weight loss, anorexia, cough, hoarseness, frequent hiccoughs, vomiting or regurgitation of food. 2

Risk factors for developing oesophageal cancer include increasing age, gender (it is two-to-three times more common in males than females), gastroesophageal reflux disease (GORD), Barrett's oesophagus, achalasia, obesity, smoking, alcohol, drinking very hot liquids, poor diet, and undergoing radiation treatment

to the chest or upper abdomen.4,5 Oesophageal cancer is classified according to the type of cells that are involved. Two histologic types account for the majority of malignant oesophageal neoplasms; adenocarcinoma and squamous cell carcinoma. Adenocarcinomas typically start in the lower oesophagus and squamous cell carcinoma can develop throughout the oesophagus. The epidemiology and histology of these types varies markedly.17 Other rare types of oesophageal cancer include small cell carcinoma, sarcoma, lymphoma, melanoma, and choriocarcinoma. Globally, squamous cell carcinoma remains the most common histological type, as 80 per cent of oesophageal cancers occur in developing countries where squamous cell cancer is more common. In Western countries, however, the epidemiology of oesophageal cancer has significantly changed and adenocarcinoma has become the leading histological subtype, corresponding to a rise in the incidence of obesity, GORD and Barrett’s oesophagus.7 The incidence of adenocarcinoma has increased most notably among Caucasian males. The risk of oesophageal adenocarcinoma conferred by Barrett’s oesophagus depends on factors such as genomic instability, race and gender of the

THE MAIN RISK FACTORS ASSOCIATED WITH DEVELOPMENT OF OESOPHAGEAL ADENOCARCINOMA ARE GASTRO-OESOPHAGEAL REFLUX, OBESITY, HIGH INTAKE OF RED MEAT, AND LOW INTAKE OF FRUITS AND VEGETABLES

patient. Oesophageal adenocarcinoma predominately arises from Barrett's oesophagus, with histological progression from metaplasia through to invasive carcinoma, and is typically localised to the distal oesophagus. Barrett’s oesophagus contains glandular epithelium cephalad to the oesophagogastric junction. Three different types of glandular epithelium can be seen; metaplastic columnar epithelium, metaplastic parietal cell glandular epithelium within the oesophageal wall, and metaplastic intestinal epithelium with typical goblet cells. Dysplasia is particularly likely to

develop in the intestinal type mucosa.17

The main risk factors associated with development of oesophageal adenocarcinoma are GORD, obesity, high intake of red meat, and low intake of fruits and vegetables. Oesophageal squamous cell carcinoma develops from squamous epithelial cells and is typically localised to the upper two-thirds of the oesophagus. Tobacco consumption and alcohol intake are the most notable risk factors, although their relative risk varies by region.3

The increase in the incidence of oesophageal adenocarcinoma has paralleled with the rise of obesity in the Western world. A variety of

TUMOUR, NODE AND METASTASIS (TNM) STAGING IS THE MOST COMMON WAY TO STAGE OESOPHAGEAL CANCER

TUMOUR (T)

 T1: The cancer has grown no further than the submucosa. T1 is divided into T1a and T1b.

 T1a: The cancer is in the inner layer (mucosa) or thin muscle layer of the oesophagus wall. T1b: the cancer has grown into the supportive tissue (submucosa).

 T2: The cancer has grown into the muscle layer of the wall of the oesophagus.

 T3: The tumour has grown into the adventitia, the membrane covering the outside of the oesophagus.

 T4: Tumour has grown into other organs or body structures. T4 is divided into T4a and T4b.

 T4a: The cancer has grown into the pleura, pericardium, diaphragm, or peritoneum.

 T4b: The cancer has spread into nearby structures such as the trachea, vertebra or the aorta.

observational studies, systemic reviews and meta-analyses have shown and confirmed association between obesity and oesophageal adenocarcinoma. The risk of oesophageal adenocarcinoma in patients with a BMI of 30 or above is approximately 16 times greater compared to those with a normal BMI. Studies have also shown that increasing waist circumference is strongly associated with an increased risk of oesophageal adenocarcinoma, independent of BMI.7,8

Patients with Barrett’s oesophagus have been shown to have a 30-to60-fold increase in the incidence of oesophageal adenocarcinoma, although the annual absolute risk is 0.12 per cent. The incidence of Barrett’s oesophagus is

NODE (N)12 Node (N) describes whether the cancer has spread to the lymph nodes. There are four possible stages – N0 to N3.

 N0: No lymph nodes containing cancer cells.

 N1: There are cancer cells in one or two nearby lymph nodes.

 N2: There are cancer cells in three-to-six nearby lymph nodes.

 N3: There are cancer cells in seven or more nearby lymph nodes.

METASTASIS (M)12

Metastasis (M) describes whether the cancer has spread to a different part of the body. There are two stages of metastasis.

 M0 where the cancer has not spread to other organs.

 M1 where the cancer has spread to other parts of the body.

T4: The cancer has grown into another body structure

two-to-three times higher in men than women, and male sex is an independent risk factor for malignant transformation. The conservative estimate of the 10year cumulative risk of oesophageal adenocarcinoma is 3-to-6 per cent in the absence of dysplasia and 7-to-13 per cent in the presence of low-grade dysplasia. High-grade dysplasia can be synonymous with microscopic adenocarcinoma in up to 40 per cent of cases, especially if the Barrett’s segment is nodular.7

The role of HPV infection in the development of oesophageal cancer has long been suspected. Although HPV has been widely studied, the overall rate of HPV infection in oesophageal squamous cell carcinoma (OSCC) remains controversial and there is a lack of robust evidence for a definitive aetiological role. The association between HPV and oropharyngeal SCC, and the histologic similarities between the squamous epithelium of the oral mucosa and upper oesophagus could suggest a similar association. HPV16 and HPV18 are the most frequently detected types in HPVassociated cancers. Studies have shown a significant association between HPV16 and OSCC, but not HPV18. According to meta-analyses and reviews, worldwide HPV-OSCC infection rates range from 11.7 per cent to 38.9 per cent. HPV prevalence correlates strongly with highOSCC-incidence regions, but in Western countries, HPV-OSCC infection rates are low, in the order of 5-to-15 per cent.7

Non-steroidal anti-inflammatory drugs (NSAIDs) can exert an anti-tumor effect through the inhibition of cyclooxygenase 2, as well as actions independent of cyclooxygenase inhibition. A number of cohort and case control studies have shown a significantly lower risk of oesophageal adenocarcinoma among patients who routinely consume aspirin or NSAIDs, compared to non-users. NSAIDs can have adverse effects however, and the use of NSAIDs solely for chemoprevention in Barret’s oesophagus is discouraged.7

There is no national screening programme for oesophageal cancer. One

impediment for introducing screening is the diagnostic modality – endoscopy is the gold standard for diagnosis of oesophageal cancer, but it is invasive and expensive and would only detect a small number of oesophageal cancers.2

Diagnosis, staging, and treatment

In 2019, new national clinical guidelines, Diagnosis, staging, and treatment of patients with oesophageal or oesophagogastric junction cancer, National Clinical Guideline No 19, supported by the HSE’s National Cancer Control Programme (NCCP) and the National Clinical Effectiveness Committee (NCEC), were launched to help with the diagnosis, staging and treatment of patients with oesophageal or oesophagogastric junction (OGJ) cancer. The document details advances in staging, diagnosis, and treatment that define and underpin a modern standard of care across all designated centres in Ireland.10

Patients with oesophageal cancer usually present with dysphagia, prompting endoscopy and biopsy. Diagnosis incudes clinical history, examination, barium swallow, endoscopy, endoscopic ultrasound (EUS), liver ultrasound scan, biopsy. 2 Endoscopy is the traditional gold standard for detecting oesophageal cancer, but less invasive screening methods are being developed such as Cytosponge, a cell collection device that is swallowed and retrieved with a string, followed by analysis of cells for trefoil factor 3 protein. This method aims to identify patients who warrant an endoscopy for suspected Barrett's oesophagus. 3

Tumour characteristics documented at endoscopy should include the exact site relative to the gastro-oesophageal junction, extension into the stomach and distance from the teeth, length of the lesion, circumferential involvement, and presence of obstruction. Any adjacent pre-malignant lesions, ie, squamous dysplasia or Barrett’s oesophagus should be documented and measured.11 Tumours

of the oesophagus are conventionally described in terms of distance of the upper border of the tumour to the incisors. When measured from the incisors via endoscopy, the oesophagus extends approximately 30-to-40cm. The oesophagus is divided into four main segments: Cervical oesophagus (15-to20cm from the incisors); upper thoracic oesophagus (20-to-25cm from the incisors); middle thoracic oesophagus (25-to-30cm from the incisors); and lower thoracic oesophagus and gastroesophageal junction (30-to-40cm from the incisors).17

Once the diagnosis is confirmed, clinical staging is the next step for which CT and PET scans are the two most useful imaging tools.7

Treatment for oesophageal cancer includes surgery, radiotherapy, and chemotherapy. Management is dependent on the patient’s characteristics and the tumour stage. Tumour, node, and metastasis (TNM) staging is the most common way to stage oesophageal cancer although the number staging system can also be used. Early tumours may be suitable for endoscopic removal, whereas more locally advanced cancers are treated with chemotherapy, chemo-radiotherapy, surgical resection or combinations of these.11

Treatment

Treatment depends on the type and stage of oesophageal cancer, where in the oesophagus the cancer is located, and the patient’s general health. Treatment requires a multidisciplinary team approach and optimal therapy is still debated. Endoscopic therapies, including radiofrequency ablation, endoscopic mucosal resection and endoscopic sub mucosal dissection, have become the standard treatment modality for Barrett’s oesophagus and early carcinoma. Advances in the understanding of the role of genomic instability in Barrett’s oesophagus will facilitate identifying patients at risk for malignant transformation who would benefit from early intervention.7

Multimodal treatment, which includes chemotherapy, radiation therapy followed by surgical resection or without surgical resection, in varying orders remains the main mode of treatment for most patients.

Chemotherapy can be given before surgery to shrink the tumour and make it easier to remove or after surgery, to lower the risk of the cancer coming back. Chemotherapy may also be required both before and after surgery. This is common with adenocarcinoma. Many oesophageal cancer patients receive a combination of two or three chemotherapy drugs.15

External radiotherapy can be given before surgery to shrink the tumour or after surgery to kill any cancer cells left behind to prevent the cancer coming back.15

Survival and quality-of-life

St James’s Hospital, Dublin, is the National Centre for Oesophageal and Gastric Cancer and the National Centre for Management of Early Upper Gastrointestinal Mucosal Neoplasia. The hospital manages approximately 65 per cent of oesophageal surgical resections nationally. Cure rates are improving, with overall survival at 35 per cent, 65 per cent for node negative disease, and 75 per cent for stage I/II disease. Outcomes are consistent with best international benchmarks.5

Weight loss, malnutrition, and sarcopaenia are prevailing side-effects of oesophageal cancer and its treatments, resulting in significant deficits in quality-

per cent. Survival rates depend on several factors, including type and stage of cancer, level of fitness of the patient and previous treatment. Surgical treatment of resectable oesophageal cancers results in five-year survival rates of 5-to-30 per cent. Patients with early-stage disease have a better chance of survival and have a five-year relative survival rate of 46.4 per cent. The five-year survival rate for those with disease that has spread to surrounding tissues or organs and/or the regional lymph nodes is 25 per cent, however, once spread to distant parts of the body, the five-year survival rate is 5 per cent.16,17

Emerging treatments

Internal radiotherapy (brachytherapy) is an option for some patients.15 In some patients with partial oesophageal obstruction, dysphagia may be relieved by placement of an expandable metallic stent or by radiation therapy if the patient has disseminated disease or is not a candidate for surgery.17

Surgery is the most common treatment for cancer that has not spread outside the oesophagus.15 Minimally invasive surgical approaches have become the standard for oesophagectomy and current literature has demonstrated similar oncological outcomes with reduced morbidity.7

As oesophageal cancer surgery is associated with considerable morbidity and changes in postoperative quality-oflife, careful attention to patient selection for resection is essential in order to minimise the risk of futile surgery in patients with incurable disease.11

of-life and physical functioning from diagnosis into survivorship.13 Oesophageal cancer patients’ quality-of-life is first negatively affected by the obstructing tumour and later by complex treatment. Before a diagnosis of oesophageal cancer is established a majority of patients have experienced dysphagia and appetite loss, resulting in considerable weight loss and fatigue, which influence the patient's daily living and quality-of-life. Patients with advanced tumour stage may experience additional problems, eg, odynophagia, hoarseness, and coughing due to tumour overgrowth or metastatic disease.7 Given the often poor prognosis of oesophageal cancer and impact of surgery, it is important to address patients’ support needs.14

In most cases, oesophageal cancer is a treatable disease, but it is rarely curable. The five-year relative survival rate is 19.9

As a new approach, targeted therapies, immunotherapies and novel drugs play an important role in the current and future treatment of this cancer. Examples include cetuximab and bevacizumab, which target epidermal growth factor receptor (EGFR) and vascular endothelial growth factor (VEGF), respectively. Research studies continue to find out more about specific molecular targets and new treatments directed at them. Drugs targeting surface antigens and signalling pathways or acting on immune checkpoints are being continuously developed, such as trastuzumab, a monoclonal antibody targeting human epidermal growth factor receptor 2 (HER-2).18

New data presented at the European Society for Medical Oncology Congress (ESMO 2020) showed that immunotherapy is beneficial for patients with oesophageal cancers who currently have poor survival. The results of the CheckMate 649 trial, for example, show that nivolumab and chemotherapy improved overall survival and progression-free survival in patients with PD-L1 combined positive score (CPS) >5 tumours. Improvements were also observed in patients with PDL1 CPS >1 tumours and in the overall patient population.

The KEYNOTE 590 trial, meanwhile, demonstrated that pembrolizumab plus chemotherapy improved overall survival in patients with squamous cell carcinoma

THE MAIN RISK FACTORS ASSOCIATED WITH DEVELOPMENT OF OESOPHAGEAL ADENOCARCINOMA ARE GORD, OBESITY, HIGH INTAKE OF RED MEAT, AND LOW INTAKE OF FRUITS AND VEGETABLES

of the oesophagus with PD-L1 CPS >10 tumours, all squamous cell carcinomas, all patients with CPS >10, and the study population as a whole.

Targeted therapies and novel drugs continue to advance and improve the treatment efficacy and prognosis of cancer patients; however, adverse events, optimal dosages and effective combinations require further investigation.19

Furthermore, while Irish oesophageal cancer rates remain among the highest in Europe, with approximately 450 new

REFERENCES

1. Irish Cancer Society (2021) Oesophageal Cancer. Irish Cancer Society. Available at: www.cancer. ie/cancer-information-and-support/ cancer-types/oesophageal-cancer

2. Irish Cancer Society (2021). Symptoms and diagnosis of oesophageal cancer. Irish Cancer Society. Available at: www.cancer. ie/cancer-information-and-support/ cancer-types/oesophageal-cancer/ symptoms-and-diagnosis-ofoesophageal-cancer

3. Ho A, Smith E. (2020). A global perspective on oesophageal cancer: two diseases in one. The Lancet

Gastroenterology and Hepatology Volume 5, Issue 6, pp 521-522 June 2020

4. Hull R, Mbele M, Makhafola T, et al. (2020). A multinational review: Oesophageal cancer in low to middleincome countries (Review). Oncology Letters, 20, 42

5. St James’s Hospital. (2021). Oesophageal Cancer. Available at: www.stjames.ie/cancer/typesofcancer/ oesophagealcancer/

6. Andrew S, Parker C, Conklin L. (2020). Clinical and Basic Neurogastroenterology and Motility: Chapter 5 - Esophageal Anatomy and Physiology: Pages 79-88

7. Abbas G, Krasna M. (2017). Overview of oesophageal cancer. Ann Cardiothorac Surg 2017 Mar; 6(2): 131136. doi: 10.21037/acs.2017.03.03

8. Corley D, Kubo A, Zhao

W. Abdominal obesity and the risk of esophageal and gastric cardia carcinomas. Cancer Epidemiol

diagnoses each year, a recent study shows that the impact of ongoing and vital initiatives like the Barrett’s Registry and Biobank (established in 2007), along with other factors, is moving the survivorship-dial in the right direction. A study published in The Lancet Oncology21 in 2019 revealed that oesophageal cancer survival rates had shown the greatest improvement in Ireland compared to six other high-income countries. The research looked at the survival rate for 3.9 million cases of cancer in Australia,

Biomarkers Prev 2008;17:352-8. 10.1158/1055-9965.EPI-07-0748

9. Lynch P. (2019). New national clinical guidelines on ovarian and oesophageal cancer. Medical Independent, November 14, 2019. Available at: www. medicalindependent.ie/new-nationalclinical-guidelines-on-ovarian-andoesophageal-cancer/

10. Department of Health (2019). Diagnosis, staging and treatment of patients with oesophageal or oesophagogastric junction cancer

National Clinical Guideline No 19. Available at: www.hse.ie/eng/services/ list/5/cancer/profinfo/guidelines/ diagnosis-staging-and-treatment-ofpatients-with-oesophageal-cancer.pdf

11. Smyth E, Lagergren J, Fitzgerald R, et al. (2017). Oesophageal cancer. Nat Rev Dis Primers 3, 17048 (2017)

12. Cancer Research UK (2021). TNM staging for oesophageal cancer. Available at: www.cancerresearchuk. org/about-cancer/oesophageal-cancer/ stages-types-and-grades/tnm-staging

13. O’Neill L, Gannon G, Guinan E, Reynolds J, Hussey J. (2017).

Multidisciplinary rehabilitation across the esophageal cancer journey, Journal of Thoracic Disease. Volume 9, Issue 12

14. Larsen M, Schultz H, Mortensen M. (2020). Patients’ experiences with illness, treatment, and decision-making for esophageal cancer: A qualitative study in a Danish hospital setting. Global Qualitative Nursing Research. Sage

15. Irish Cancer Society (2021). Surgery for oesophageal cancer. Available at: www.cancer.ie/ cancer-information-and-support/

Canada, Norway, New Zealand, Denmark, Ireland, and the UK from 1995-2014, and Ireland had the largest improvement across the seven nations, with an almost doubling in survival between 1999 and 2014, while the 2020 annual report from the National Cancer Registry Ireland revealed that Ireland ranks fourth internationally in terms of survivorship from oesophageal cancer.

So there is a now a progressively more positive future for people who develop this aggressive cancer. ●

cancer-types/oesophageal-cancer/ how-is-oesophageal-cancer-treated/ surgery-for-oesophageal-cancer

16. ASCO Cancer.net (2021). Oesophageal cancer statistics. Available at: www.cancer.net/cancertypes/esophageal-cancer/statistics

17. NIH National Cancer Institute (2021). Esophageal Cancer Treatment (Adult) (PDQ®)–Health Professional Version. National Cancer Institute at National Institutes of Health. Available at: www.cancer.gov/types/esophageal/ hp/esophageal-treatment-pdq

18. Yang Y, Hong P, Xu W, et al. Advances in targeted therapy for esophageal cancer. Sig Transduct Target Ther 5, 229 (2020)

19. ASCO Cancer.net (2020). Oespohageal Cancer types and treatment. Available at: www.cancer. net/cancer-types/esophageal-cancer/ types-treatment

20. ESMO 2020. Immunotherapy is beneficial in gastric and oesophageal cancers, studies show. Available at: www.esmo.org/newsroom/press-office/ esmo2020-gastric-oesophagealcancer-immunotherapy-checkmate649attraction4-keynote590

21. Arnold M, Rutherford MJ, Bardot A, et al. Progress in cancer survival, mortality, and incidence in seven high-income countries 1995-2014 (ICBP SURVMARK-2): A populationbased study. Lancet Oncol. 2019 Nov;20(11):1493-1505. doi: 10.1016/ S1470-2045(19)30456-5

22. NCRI. Annual Report 2020. Available at: www.ncri.ie/publications

AN ENGROSSING ACCOUNT OF A CAREER IN EMERGENCY MEDICINE

MEDICINE CAN BE DISPIRITING AT TIMES, AS OUTCOMES APPEAR TO BE SHAPED BY FORCES BEYOND THE CLINICIAN’S CONTROL: POVERTY, TRAUMA, SERVICE DEFICIENCIES, RANDOM BAD LUCK, AND A HOST OF OTHER THINGS

TITLE: A Life in Trauma: Memoirs of an Emergency Physician

AUTHOR: Dr Chris Luke

PUBLISHER: Gill Books

REVIEWER: Prof Brendan Kelly

Trauma is everywhere. More precisely, the term “trauma” is now used to describe everything from truly traumatic experiences that would disturb most people, to the routine ups and downs of everyday life that leave some of us slightly upset. Everything is traumatic, it seems.

It is not entirely clear when this trend started, or why there was a collective, unconscious decision to expand the idea of trauma to this point. What is clear is that the word “trauma” has lost much of its meaning, with the result that the suffering of people who experience deep trauma is being systematically devalued.

The subjective impact of life events varies between individuals. Not everyone is traumatised, even

when terrible things happen. Some people are fine.

The fact that someone does not describe trauma in their past does not mean that they are repressing something dreadful. It probably means that they did not experience traumatic events. They are not traumatised, repressed, or governed by unacknowledged psychological wounds. They are fine.

Against this background, I approached Dr Chris Luke’s memoir, A Life in Trauma, with some trepidation. My

medicine in the broadest sense, moving beyond the clinic and into service development. Most readers will be familiar with Luke’s advocacy on the airwaves and elsewhere, arguing for better, smarter services that truly meet the population’s needs. All of that is in here.

I will not rehearse every twist and turn in Luke’s story because he does this far better in the book than I can in a review. In a nutshell, Luke qualified at UCD in 1982 and has worked as an emergency physician

Luke tells a complicated, compelling story. As with any life, no single event, no matter how dramatic, can be seen in isolation. Everything has a context. Most lives contain infinitely more good judgements than poor ones, more steps than missteps. Luke’s story is no different: It is the totality that matters, vastly more than any single event.

For me, two points emerge clearly. The first is the potential for a committed clinician to make a difference. Medicine can be dispiriting at times, as outcomes appear to be shaped by forces beyond the clinician’s control: Poverty, trauma, service deficiencies, random bad luck, and a host of other things. Luke’s account gives plenty of reason for hope: The individual clinician can make a genuine impact, even in the face of these overarching factors.

anxiety was quickly dispelled, however, not least by the book’s subtitle: Memoirs of an Emergency Physician . If anyone is routinely exposed to high levels of trauma, both physical and psychological, it is an emergency physician.

The other reason why this book raised slight anxiety in me is because it awakened my memories of working in emergency medicine many years ago. As a surgical intern, I was first oncall to an emergency department one night in every four (I think) and every fourth weekend. It is in everyone’s interest that I do not linger on that period of my life. Let’s just say that the contrast with Dr Chris Luke’s work in this field could not be starker.

From the outset of Luke’s memoir, it is apparent that he has a genuine gift and deep passion for emergency medicine. (I had neither). Luke’s commitment is inspiring and this account of his professional career invigorates me to engage more deeply in my chosen field (which, thankfully, is not emergency medicine).

But this is a book about good

for over 35 years. He worked in Ireland, the UK, and Australia, and has been a consultant in emergency medicine in Cork for more than 20 years.

With this trajectory, exposure to trauma is inevitable. Much of this is discussed in the book in a way that is engaging, direct, honest, and utterly human.

The second point is that delivering healthcare is ultimately about people helping people. Luke’s acknowledgements list is vast, recognising colleagues, friends, and family who have contributed to his story. I was especially moved by Luke’s account of his visits to psychiatrist Prof Anthony Clare in 2007, just months before Clare’s untimely death. Clare was “profoundly sympathetic” to Luke’s difficulties. When Clare died suddenly later that year, Luke felt “grief-stricken, as if I’d lost a recently discovered, highly charismatic uncle”.

Like Clare, Luke has a keen appreciation of the challenges of medicine, the value of collegiality, and the essential humanity that lies at the heart of both. How Luke developed this understanding makes for an engrossing, invigorating read. ●

Prof Brendan Kelly is Professor of Psychiatry at Trinity College Dublin and author of The Science of Happiness: The Six Principles of a Happy Life and the Seven Strategies For Achieving It (Gill Books).

F ROM THE OUTSET OF LUKE’S MEMOIR, IT IS APPARENT THAT HE HAS A GENUINE GIFT AND DEEP PASSION FOR EMERGENCY MEDICINE

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