NIGP January - February 2021 by GreenX Publishing

For patients with severe persistent allergic asthma1

Think Allergy, Think IgE, Think XOLAIR®

XOLAIR 75 mg and 150 mg solution for injection in pre-filled syringe

ABBREVIATED PRESCRIBING INFORMATION for Severe Allergic Asthma.

Xolair is also indicated for chronic spontaneous urticaria so for full details please refer to Summary of Product Characteristics (SmPC) before prescribing. Presentation: XOLAIR (omalizumab) solution for injection. XOLAIR 75mg solution for injection - each pre-filled syringe of 0.5ml solution contains 75mg of omalizumab. XOLAIR 150mg solution for injection - each pre-filled syringe of 1ml solution contains 150mg of omalizumab. Indications: Adults and adolescents (12 years of age and older) Add-on therapy to improve asthma control in patients with severe persistent allergic asthma who have a positive skin test/in vitro reactivity to a perennial aeroallergen and have an FEV1 <80%, frequent daytime symptoms or nighttime awakenings, multiple documented severe asthma exacerbations despite daily high-dose inhaled corticosteroids, plus a long-acting inhaled beta2-agonist. Children (6 to <12 years of age) Add-on therapy to improve asthma control in patients with severe persistent allergic asthma who have a positive skin test/ in vitro reactivity to a perennial aeroallergen and frequent daytime symptoms or night-time awakenings, multiple documented severe asthma exacerbations despite daily high-dose inhaled corticosteroids, plus a long-acting inhaled beta2-agonist. Xolair treatment should only be considered for patients with convincing IgE mediated asthma. Dosage and Administration: Treatment should be initiated by physicians experienced in the diagnosis and treatment of severe persistent asthma. Doses of more than 150mg should be divided across two or more injection sites. Patients with no known history of anaphylaxis may self-inject Xolair or be injected by a caregiver from the 4th dose onwards if a physician determines that this is appropriate. The patient or the caregiver must have been trained in the correct injection technique and the recognition of the early signs and symptoms of serious allergic reactions. Patients or caregivers should be instructed to inject the full amount of Xolair according to the instructions provided in the package leaflet. The appropriate dose and frequency of Xolair is determined by baseline IgE (IU/ml), and body weight (kg). 75-600 mg of Xolair in 1 to 4 injections may be needed for each administration. The maximum recommended dose is 600mg omalizumab every 2 weeks. See full prescribing information for conversion charts, dose determination charts and dosing instructions. Contraindications: Hypersensitivity to omalizumab or to any of the excipients. Precautions/Warnings: ♦ Not indicated for the treatment of acute asthma exacerbations, acute bronchospasm or status asthmaticus ♦ Xolair has not been studied in patients with hyperimmunoglobulin E syndrome or allergic bronchopulmonary aspergillosis or for the prevention of anaphylactic reactions, including those provoked by food allergy, atopic dermatitis or allergic rhinitis. ♦ Caution is warranted in patients with autoimmune diseases, immune complex-mediated conditions or pre-existing renal or hepatic impairment. ♦ Abrupt discontinuation of systemic or inhaled corticosteroids after initiation of Xolair therapy is not recommended, however gradual discontinuation of omalizumab should be considered in all severe cases of any of the listed immune system disorders. ♦ Type I local or systemic allergic reactions, including anaphylaxis and anaphylactic shock may occur when taking omalizumab, also with onset after long duration of treatment (most occurred within 2 hours after the first and subsequent injections). Medications for treating anaphylactic reactions should always be available for immediate use following administration of Xolair. Prompt medical attention should be sought if allergic reactions occur. A history of anaphylaxis unrelated to omalizumab may be a risk factor for anaphylaxis following Xolair administration. The first 3 doses for all patients and all injections for patients with a history of anaphylaxis must be administered by a healthcare professional. ♦ Serum sickness and serum sickness-like reactions, which are delayed

ABBREVIATED PRESCRIBING INFORMATION for Severe Allergic Asthma. Xolair is also indicated for chronic spontaneous urticaria so for full details please refer to Summary of Product Characteristics (SmPC) before prescribing. Presentation: XOLAIR (omalizumab) solution for injection. XOLAIR 75mg solution for injection - each pre-filled syringe of 0.5ml solution contains 75mg of omalizumab. XOLAIR 150mg solution for injection - each pre-filled syringe of 1ml solution contains 150mg of omalizumab. Indications: Adults and adolescents (12 years of age and older) Add-on therapy to improve asthma control in patients with severe persistent allergic asthma who have a positive skin test/in vitro reactivity to a perennial aeroallergen and have an FEV1 <80%, frequent daytime symptoms or nighttime awakenings, multiple documented severe asthma exacerbations despite daily high-dose inhaled corticosteroids, plus a long-acting inhaled beta2-agonist. Children (6 to <12 years of age) Add-on therapy to improve asthma control in patients with severe persistent allergic asthma who have a positive skin test/ in vitro reactivity to a perennial aeroallergen and frequent daytime symptoms or night-time awakenings, multiple documented severe asthma exacerbations despite daily high-dose inhaled corticosteroids, plus a long-acting inhaled beta2-agonist. Xolair treatment should only be considered for patients with convincing IgE mediated asthma. Dosage and Administration: Treatment should be initiated by physicians experienced in the diagnosis and treatment of severe persistent asthma. Doses of more than 150mg should be divided across two or more injection sites. Patients with no known history of anaphylaxis may self-inject Xolair or be injected by a caregiver from the 4th dose onwards if a physician determines that this is appropriate. The patient or the caregiver must have been trained in the correct injection technique and the recognition of the early signs and symptoms of serious allergic reactions. Patients or caregivers should be instructed to inject the full amount of Xolair according to the instructions provided in the package leaflet. The appropriate dose and frequency of Xolair is determined by baseline IgE (IU/ml), and body weight (kg). 75-600 mg of Xolair in 1 to 4 injections may be needed for each administration. The maximum recommended dose is 600mg omalizumab every 2 weeks. See full prescribing information for conversion charts, dose determination charts and dosing instructions. Contraindications: Hypersensitivity to omalizumab or to any of the excipients. Precautions/Warnings: ♦ Not indicated for the treatment of acute asthma exacerbations, acute bronchospasm or status asthmaticus ♦ Xolair has not been studied in patients with hyperimmunoglobulin E syndrome or allergic bronchopulmonary aspergillosis or for the prevention of anaphylactic reactions, including those provoked by food allergy, atopic dermatitis or allergic rhinitis. ♦ Caution is warranted in patients with autoimmune diseases, immune complex-mediated conditions or pre-existing renal or hepatic impairment. ♦ Abrupt discontinuation of systemic or inhaled corticosteroids after initiation of Xolair therapy is not recommended, however gradual discontinuation of omalizumab should be considered in all severe cases of any of the listed immune system disorders. ♦ Type I local or systemic allergic reactions, including anaphylaxis and anaphylactic shock may occur when taking omalizumab, also with onset after long duration of treatment (most occurred within 2 hours after the first and subsequent injections). Medications for treating anaphylactic reactions should always be available for immediate use following administration of Xolair. Prompt medical attention should be sought if allergic reactions occur. A history of anaphylaxis unrelated to omalizumab may be a risk factor for anaphylaxis following Xolair administration. The first 3 doses for all patients and all injections for patients with a history of anaphylaxis must be administered by a healthcare professional. ♦ Serum sickness and serum sickness-like reactions, which are delayed

allergic type III reactions, may occur when taking omalizumab, with onset typically 1-5 days after the first or subsequent injections, also after long duration of treatment. Symptoms suggestive of serum sickness include arthritis/arthralgias, rash (urticaria or other forms), fever and lymphadenopathy. ♦ Patients with severe asthma may present with or develop systemic hypereosinopihilic syndrome or Churg-Strauss syndrome, both of which are usually treated with systemic corticosteroids. ♦ Patients on therapy with anti-asthma agents, including omalizumab, may present or develop systemic eosinophilia and vasculitis, particularly upon reduction of oral corticosteroid therapy. In these patients, physicians should be alert to the development of marked eosinophilia, vasculitic rash, worsening pulmonary symptoms, paranasal sinus abnormalities, cardiac complications, and/or neuropathy. ♦ Caution is warranted in patients at high risk of helminth infection, in particular when travelling to areas where helminthic infections are endemic. ♦ There is a potential risk for hypersensitivity reactions for latex-sensitive individuals as the removable needle cap of the pre-filled syringe contains a derivative of natural rubber latex. ♦ If clinically needed, the use of Xolair may be considered during pregnancy and breast-feeding. Interactions: Xolair may indirectly reduce the efficacy of medicinal products for the treatment of helminthic or other parasitic infections. There is little potential for drug-drug interactions. In clinical trials, Xolair was commonly used in conjunction with commonly used anti-asthma medicinal products and there was no indication that the safety of Xolair was altered. Adverse reactions: ♦ Most commonly reported undesirable effects during clinical trials in adult and adolescent patients 12 years of age and older are: injection site pain, swelling, erythema, pruritus and headaches. Most commonly reported undesirable effects during clinical trials in children 6 to <12 years of age are: headache, pyrexia and upper abdominal pain. ♦ Uncommon: Pharyngitis, syncope, paraesthesia, somnolence, dizziness, postural hypotension, flushing, allergic bronchospasm, coughing, dyspeptic signs and symptoms, diarrhoea, nausea, photosensitivity, urticaria, rash, pruritus, influenza-like illness, swelling arms, weight increase, fatigue. For a full list of adverse events please refer to the SmPC. Legal Category: Prescription-only. Pack Size: Xolair is supplied in packs of one pre-filled syringe and multipacks containing 4(4x1);6(6x1) or 10(10x1) pre-filled syringes containing 0.5ml solution for injection (75mg) or 1ml solution for injection (150mg). Not all pack sizes may be marketed. Marketing Authorisation Number: EU/1/05/319/005-011. Marketing Authorisation Holder: Novartis Europharm Limited, Vista Building, Elm Park, Merrion Road, Dublin 4, Ireland. Full prescribing information is available upon request from: Novartis Ireland Limited, Vista Building, Elm Park Business Park, Merrion Road, Dublin 4, D04 A9N6, Tel: +353 1 2601255 or at www.medicines.ie. Date of Revision of API Text: August 2019.

ADVERSE EVENT REPORTING

Reporting suspected adverse reactions of the medicinal product is important to Novartis and the HPRA. It allows continued monitoring of the benefit/risk profile of the medicinal product. All suspected adverse reactions should be reported via www.hpra.ie or email to medsafety@hpra.ie. Adverse events could also be reported to Novartis preferably via www.report.novartis.com or by email: drugsafety.dublin@novartis.com or by calling 01 2080 612.

*Xolair provides clinically meaningful improvements in quality of life for patients with severe allergic asthma and chronic spontaneous urticaria.

*Xolair provides clinically meaningful improvements in quality of life for patients with severe allergic asthma and chronic spontaneous urticaria.2,3

2017; 31(10): 1715-1721. Date of Preparation: January 2020 IE02/XSA19-CNF002(1)

Think Allergy, Think IgE, Think XOLAIR®

For patients with severe persistent allergic asthma1

omalizumab

References: 1. XOLAIR® SmPC for Ireland Available at http://www.medicines.ie/

accessed: January 2020. 2. Braunstahl GJ et al. Resp Med 2013; 107: 1141-51. 3. Finlay AY et al. J Eur Acad Dermatol

Date

Venereol

omalizumab

GJ et al. Resp Med

3. Finlay AY et al. J Eur Acad

References: 1. XOLAIR® SmPC for Ireland Available at http://www.medicines.ie/ Date accessed: January 2020.

Braunstahl

2013; 107: 1141-51.

Dermatol Venereol 2017; 31(10): 1715-1721. Date of Preparation: January 2020 IE02/XSA19-CNF002(1)

2,3

A UNIQUE OPPORTUNITY TO CHANGE OUR APPROACH TO THE PREVENTION AND MANAGEMENT OF CHRONIC DISEASE

Dear Readers,

The population in Ireland is living longer and with more complex chronic disease and multiple co-morbidities than ever. People living with chronic disease and who utilise the current healthcare service experience episodic, reactive care, culminating in repeated hospital admissions and inappropriate outpatient attendances. This is neither person-centred nor sustainable. Our health services need to evolve to meet our changing needs: A shift from hospital-centred focus to a person-centred focus is now required. The National Framework, in partnership with the companion guide National Framework for the Integrated Prevention and Management of Chronic Disease: A 10-step guide to support local implementation, addresses these unmet needs and is intended to support the implementation of integrated care at both the national and local levels.

‘Integrated care’ for chronic disease is defined as healthcare provided at the lowest appropriate level of complexity, with responsive services built around patient need to support and empower individuals to optimise their health, actively address and minimise their risk factors for chronic disease and to live well with chronic disease. The National Framework for the Integrated Prevention and Management of Chronic Disease (published in 2020) builds on existing policies while also addressing health promotion, disease prevention, diagnosis, treatment, disease management and rehabilitation services that are coordinated across different healthcare providers (nurses, GPs, consultants, physiotherapists, dietitians, podiatrists, rehab co-ordinators, psychologists) and healthcare settings. It involves a new way of working together across the health continuum. The Model of Care for the Integrated Prevention and Management of Chronic Disease describes five levels of care, with level 0 being

living well with chronic disease, level 1 involving general practice which has already been introduced through the Chronic Disease Model (CDM), level 2 being specialist community ambulatory hubs, level 3 covering acute specialist ambulatory care, and level 4 hospital specialist care.

Plans are in place for the new specialist community ambulatory care hubs for chronic disease due to be implemented at 11 sites across the country soon. Each ambulatory care hub will be linked with a secondary care hospital. The hospital sites are: University Hospital Galway, University Hospital Limerick, Cork University Hospital, University Hospital Waterford, St Luke’s in Kilkenny, St Vincent’s University Hospital, Tallaght Hospital, St James’s Hospital, Connolly Hospital, Beaumont Hospital, and the Mater Hospital, Dublin. Such services available in a hub will include pulmonary rehabilitation, cardiac rehabilitation, diabetes structured patient education, diabetes prevention, and weight management programmes. This means that patients will have access to these services in their community and should avoid hospital attendances. It should also make referral pathways more accessible for general practice nurses and GPs, particularly for rehabilitation programmes. Prior to this, patients had to be attending a hospital consultant to avail of these programmes which meant these programmes were delivered to patients who already had an event and were reactive rather than being proactive in preventing hospital admission.

The chronic disease specialist team for each Community Health Network (CHN), based in the hub will work with the GPs and practice nurses in their respective networks. The team will comprise of diabetes, respiratory and cardiovascular teams and will be supported

by a GP lead with a special interest. It is envisaged that staff recruitment for each site will be carried out by each individual site based on the needs of the site.

The key functions that are carried out in the specialist ambulatory care hub are:

 Integration between preventive, primary care, community and acute ambulatory care services;

 Access to a multidisciplinary specialist team based in the community;

 Access to community diagnostics such as phlebotomy, x-ray, echocardiography, BNP and spirometry;

 Access to self-management support services including cardiac rehabilitation, pulmonary rehabilitation, foot protection services, diabetes structured education, diabetes prevention and weight management programmes;

 A case management function;

 Promotion and support of population health initiatives within primary care. Unfortunately, it has taken a pandemic to bring the need to re-think how we deliver health services and how to make services more accessible to people who need them. While this has been on the Sláintecare agenda prior to the pandemic, Covid-19 has accelerated the implementation of the ambulatory care hubs.

We now have a unique opportunity to change our approach to the prevention and management of chronic disease, working together to provide a proactive and seamless service that emphasises patient empowerment, promotes selfmanagement and meets patient needs in a way that is timely and accessible.

The National Framework for the Integrated Prevention and Management of Chronic Disease in Ireland 2020-2025 can be accessed here: www.hse.ie/eng/about/ who/cspd/icp/chronic-disease/documents/ national-framework-integrated-care.pdf

Welcome JANUARY-FEBRUARY 2021 1

A message from Ruth Morrow, Consulting Editor

EDITOR

Priscilla Lynch

CONSULTING EDITOR

Ruth Morrow

SUB-EDITOR

Emer Keogh emer@greenx.ie

GENERAL PRACTICE NURSES AND

COVID-19 VACCINATION

While the start of 2021 has seen an unprecedented spike in Covid-19 cases and hospitalisations in Ireland, with resultant huge pressure on our health services, it has also seen the extremely welcome commencement of the national Covid-19 vaccination programme.

As general practice nurses (GPNs) are among the most experienced vaccinators in the country, they will play a key role in the administration of Covid-19 vaccines in the coming months. Firstly, as priority 1 frontline healthcare workers access to vaccination for GPNs themselves in line with their GP colleagues is absolutely essential. While some GPs and GPNs have been, and continue to be, vaccinated through their local hospitals and nursing homes, the HSE finally launched a dedicated Covid-19

vaccination booking portal for general practice staff on 12 January.

The HSE has launched the necessary training updates for vaccinators to administer Covid-19 vaccines, and a new Chapter of the Immunisation Guidelines on coronavirus was published by the National Immunisation Advisory Committee in January, following the licensing of the Pfizer/BioNTech and Moderna Covid-19 vaccines and their distribution in Ireland. These will continue to be updated as more vaccines are authorised by the European Medicines Agency and new evidence emerges.

An updated version of Chapter 3 Immunisation of Immunocompromised Persons is also available to download, and both chapters are available online at: www.hse.ie/eng/health/immunisation/ hcpinfo/guidelines

Here is what the IPNA NEC and various branch members have to say about the roll-out of Covid-19 vaccination in Ireland:

“The roll-out of the Covid-19 vaccine in general practice we know will be challenging especially on top of an already busy workload for GPNs, but we know GPNs are knowledgeable and already competent at managing and delivering vaccinations. We’re at the heart of every community and it's what we do every day, we know our patients and we have their trust so we're well placed to help accelerate the roll-out nationally.” Jane Campion, IPNA National Chairperson

“GPNs all over Ireland are eagerly awaiting the roll-out of the Covid-19 vaccine for our general practice populations. While some GPNs and practice staff have received their first dose of vaccine, there was a number

Cover Feature Covid-19 Vaccination 4 JANUARY-FEBRUARY 2021

Author: Priscilla Lynch GPN Elaine Scanlan, IPNA ex Vice Chair and long standing member of the Dublin Branch of the IPNA, receiving the Covid-19 vaccine live on the Late Late Show on Friday, January 8 2021

of issues and delays with the HSE se ing up the GP practice team registration section of the Covid-19 registration portal, with many members eagerly waiting to register and be vaccinated. It is imperative that all practice staﬀ get vaccinated as quickly as possible, in order to maintain continuity of vital health services for our general practice patients. The educational programme for registered nurses and midwives under the medicine protocol to administer the Covid-19 vaccine is now live on HSELand, and GPNs nationwide are actively completing this training and ensuring we are updated with the necessary skills, knowledge and understanding to competently administer this new vaccine to our patients. GPNs are highly-skilled experts in their ﬁeld and among the largest and most experienced group of vaccinators in the country. We are ready and looking forward to playing a major role in vaccinating the general population against Covid-19.”

Theresa Lowry-Lehnen, IPNA PRO

“As the largest group of vaccinators in Ireland, I think a lot of us were disappointed not to be consulted or included in the initial roll-out of the vaccine. I was delighted to receive the vaccine and look forward to giving it when it is rolled out to general practice.” Clair

Wallace, IPNA Wicklow Branch

“Nurses make up 37 per cent of clinicians working in general practice; the delivery of all national immunisation programmes within

general practice is nurse led. As highly skilled clinicians in this area we have been following Covid-19 vaccine technology development with great interest. We are informed and eager to oﬀer this vaccine to our patients who have been contacting surgeries in unprecedented numbers to enquire as to when it will be available. It is also vital that the general practice workforce is immunised against Covid-19 urgently. Within general practice 90 per cent of an estimated 25 million episodes of patient care are completed and managed annually without requiring onward referral. Importantly our service supports and shields secondary care, particularly so during the current pandemic. General practice teams have demonstrated ﬂexibility, dedication, and innovation in maintaining our day-to-day activities during the pandemic. This includes continuing immunisations, cervical screening, chronic disease, and acute and minor illness management, whilst also providing care to over 80 per cent of Covid-19 presentations. Do I need to make a stronger argument as to why it is imperative to immunise ‘Team GP’ against Covid-19 and protect our essential service?.”

Cover Feature Covid-19 Vaccination JANUARY-FEBRUARY 2021 5

As the largest group of vaccinators in Ireland, I think a lot of us were disappointed not to be consulted or included in the initial roll-out of the vaccine

Orla Lo us Moran, Advanced Nurse Practitioner (General Practice), Knock, Co Mayo Cork GPN Ruth Ring, who received her Covid-19 vaccine at SIVUH Cork GPN Sheila Kingston with her Covid-19 vaccine card a ter receiving the vaccine GPN Caitriona Keye, receiving her Covid-19 vaccine before completing the HSE training programme to administer the vaccine

Annual renewals for nurses and midwives through the Nursing and Midwifery Board of Ireland (NMBI) are well underway and the usual end of January deadline has been extended to 28 February in recognition of the challenges posed by the Covid-19 pandemic. As of 11 January, 45,587 registrants had successfully completed their annual renewal on the new online system on the NMBI website, www.nmbi.ie.

“Our new way of renewing is gathering extra information on our professions for the first time so that NMBI and our stakeholders can plan better for the future. This takes a bit longer than previous years.

“However, we recognise that some registrants are having difficulty in completing the process and we apologise sincerely for this. Our helpline centre has also been extremely busy and we would like to apologise for this also,” said the NMBI.In response to feedback the NMBI has developed a range of aids which it is asking registrants to access before renewing online. These include a video, a step-by-step PDF guide and a list of answers to the most Frequently Asked Questions (FAQs) received from users.

AWARD

PRACTICE NURSE OF THE YEAR 2020

IPNA PRO Theresa Lowry-Lehnen, Clinical Nurse Specialist at IT Carlow Medical Centre and member of the Carlow branch of the IPNA, won the 'Practice Nurse of the Year’ award 2020, at the Irish Healthcare Awards, which took place on 1 December. The Irish Healthcare Awards are Ireland's leading and most prestigious medical awards and recognise innovation and excellence across the Irish healthcare sector.

Announcing the winner of the ‘Practice Nurse of the Year’ award 2020, the MC said: “The winning nurse blew the judges away. Her practice clearly demonstrates how innovative and progressive she is within her position. They praised her ongoing achievements, which go over and above the usual duties of practice. They are thrilled to give the award of Practice Nurse of the Year 2020 to Theresa Lowry-Lehnen.”

Theresa is a graduate of Mater Misericordiae University Hospital, The Open University, NUIM, The University of Surrey, St Mary's Teacher Training University College London, and RCSI University of Medicine and Health Sciences. She is a registered teacher with the Teaching Council of Ireland, an IUHPE Registered Health Promotion Practitioner and a Registered Nurse Prescriber (RNP).

Theresa has a vast background and experience in both secondary and primary care, and specialised in General Practice Nursing at Surrey University. She has 38 years' experience in clinical nursing practice, combining her practice with 17 years in educational, teaching, and lecturing roles. She has a PhD and has published a number of books and medical journal articles. She is a regular contributor to the Medical Independent, Update Journal and Nursing in General Practice Journal and has had over 40 academic articles published on a wide range of medical and nursing topics in recent years.

Some of her academic work has been used to create CPD modules for general practice nurses’ continuous education and professional development.

Theresa was awarded the Irish Practice Nurses Association (IPNA) Educational Research Award in 2019, and won the 'Nursing Project of the Year Award' at the Irish Healthcare Centre Awards in 2019. She was shortlisted for the Practice Nurse of the Year Award at the GP Buddy Awards in 2018 and 2019 and commended for the Practice Nurse of the Year at the Irish Healthcare Awards 2019. A member of the IPNA expert educational panel involved in producing a new, soon to be released online educational CPD series for general practice nurses, Theresa was also elected as National PRO for the IPNA at the AGM in November 2020.

On receiving the award, Theresa said: "2020 was the Year of the Nurse, a time to celebrate the many wonderful achievements of the nursing profession and all those working in it. Having spent almost four decades working at the heart of our great profession, I am truly honoured and very proud as a general practice nurse and member of the IPNA to win the Practice Nurse of the Year award 2020".

The full list of Irish Healthcare Awards 2020 winners can be viewed online at: https:// irishhealthcareawards.ie/ IHCAs2020/en/page/awards-page

6 JANUARY-FEBRUARY 2021 News

Theresa Lowry-Lehnen

ANNUAL NMBI RENEWALS DEADLINE EXTENDED TO END OF FEBRUARY

STRESS SELFASSESSMENT TOOL LAUNCHED FOR NURSES AND NURSING STUDENTS

A personal stress self-assessment tool for both student nurses and qualified nurses has been launched by The Student Stress e-Mobile Management (SSTeMM) research project led by a team at Waterford Institute of Technology (WIT).

In 2019 WIT secured funding of almost €300,000 to lead the two-year pan-European SSTeMM research project. Research over the last five years and recent news reports have highlighted that there is a rise in problems of mental wellbeing amongst people attending college, which has risen drastically since the Covid-19 pandemic, particularly in healthcare students.

The project has developed a mobile application to support student nurses to manage their work related stress.

Project co-ordinator, Prof John Wells, Head of the School of Health Sciences at WIT explains how the tool can help stressed frontline workers: “One of the consequences of the Covid-19 pandemic is the impact of work-related stress on healthcare workers. In particular, student nurses and other healthcare students who were called upon

PREGNANCY

to support health services address the crisis. Students and qualified nurses can complete this tool online at https://sstemm.eu/survey/ to obtain their very own personal stress score and identify areas of their work that can cause them stress. If the user chooses, they can share this score, anonymously, with the

OBSTETRICIANS AND NIAC ISSUE INFORMATION ON THE COVID-19 VACCINE FOR WOMEN WHO ARE PREGNANT OR BREASTFEEDING

The Institute of Obstetricians and Gynaecologists together with the National Immunisation Advisory Committee (NIAC) at the Royal College of Physicians of Ireland (RCPI) have compiled information for women who are pregnant or breastfeeding and their doctors about the Covid-19 vaccine. This information has also been endorsed by the HSE National Women and Infants Health Programme.

Dr Cliona Murphy, Chair of the Institute of Obstetricians and Gynaecologists, said: “We are issuing

information to help to inform women who are pregnant or breastfeeding about the Covid-19 vaccine and also for their doctors which can help to inform discussions at this critical time.” She continued: “It is important that women seek trusted information about the vaccines and can assess their risks with regards to Covid-19 and the vaccine in consultation with their healthcare providers.”

The information, titled 'Questions and Answers for pregnant or breastfeeding women and their doctors about Covid-19

SSTeMM project which will help us expand our research in this area.”

The data gathered will help the SSTeMM project in its work to develop further online tools to support students, and their clinical qualified colleagues, to better manage stress in their clinical work.

vaccination', is available on the RCPI website and can be viewed at www.rcpi.ie.

The NIAC recommends that pregnant women who are at high risk of severe Covid-19 and pregnant healthcare workers should talk to their obstetrics care provider about having the Covid-19 vaccine. They should discuss their risk of getting Covid-19 in light of their particular circumstances. Based on this they can consider getting the vaccine balancing the small unknown risks related to the vaccine against the serious risks associated with Covid-19.

News JANUARY-FEBRUARY 2021 7

NUI GALWAY LEAD THREE COVID-19 RAPID RESPONSE RESEARCH AND INNOVATION PROJECTS

NUI Galway will lead three research projects as part of a coordinated Covid-19 Rapid Response Research, Development and Innovation programme. Announced by Government Ministers recently, the new investment of €10.5 million will support 39 Covid-19 research and innovation projects.

The three NUI Galway projects awarded almost €700,000 in total will investigate: How do the antibodies our bodies make affect the course of disease in Covid-19; Respecting People with disabilities’ Needs and rights in Crisis and Emergency; and Crisis coping for marginalised youth: Living and learning through Covid-19.

Dr Michelle Kilcoyne a researcher and lecturer in Glycosciences at NUI Galway, will lead a project that looks at one of the ways that our bodies can fight the Covid-19 virus, by making antibodies against it. Science Foundation Ireland is funding the project to clarify the links between blood antibodies, virus-killing activity and symptoms in patients.

At present, it is not known exactly how our immune system’s antibody response to the Covid-19 virus is linked to how mild or severe the symptoms are. The research project will examine blood samples from patients with Covid-19 and look at how the type and amount of antibodies link with recruitment of immune cells and the patient’s experience of the disease. By understanding more about how the body reacts to the Covid-19 virus, and how that links to disease, the findings will help inform how to vaccinate against and treat Covid-19.

Dr Kilcoyne explained: “Developing vaccines and antibody therapies depends on using a particular viral antigen to recruit the correct immune response, or effector function, in the patient. However, antibody effector functions for particular viral antigens are not well studied in Covid-19 patients and different effector functions may be linked to disease severity and outcome. Combining a strong team of clinicians and research scientists, we are applying a multiplexed and high throughput approach to understand the link between the viral antigen, the individual

patient effector function, and disease severity.”

Prof Eilionóir Flynn, Established Professor, School of Law and Director of the Centre for Disability Law and Policy, NUI Galway, will lead a new project supported by the Health Research Board (HRB) and the Irish Research Council that will look at decisions made during the pandemic in several European countries and their impact on people with disabilities. The research will provide guidance for decision-making bodies to help them maintain their obligations under the United Nations Convention on the Rights of People with Disabilities.

Strategic decisions made by countries and healthcare systems in the pandemic may not always support the rights of people with disabilities. Using a framework developed by the United Nations Convention on the Rights of People with Disabilities, this project will analyse laws, policies and guidelines that emerged in response to the Covid-19 pandemic in Ireland, Spain, UK, Italy, Sweden, and Germany. The project will provide guidance to governments, medical councils and healthcare professionals in order to maintain obligations under the United Nations Convention on the Rights of People with Disabilities.

Prof Flynn said: “Emerging research findings, including from the International Disability Alliance and other disability

groups, demonstrate that disabled people globally are disproportionately impacted by the current pandemic. Not only are disabled people at greater risk of contracting the virus and experiencing adverse effects (especially those living in institutional settings), but they are also disproportionately affected by restrictions in access to community services and supports. This research will help us to understand in more depth how countries can respond to the challenge in ways that protect the human rights of disabled people.”

Profs Pat Dolan and Gerry MacRuairc will lead a project focusing on young people aged between 12 and 18 years who are marginalised or are at high-risk during the Covid-19 pandemic restrictions, and there is evidence that the most marginalised are becoming increasingly disconnected from school.

Funded by the HRB and the Irish Research Council, the project will work with marginalised young people and their families to come up with ways of coping with and improving wellbeing. The results will be tailor-made approaches and supports for marginalised young people, as well as evidence to inform policymakers and provide tools for important stakeholders, such as teachers and parents.

Young people who are marginalised are at risk of disengaging from school, and from society more generally, during the Covid-19 pandemic. The research will work with marginalised young people and their families to come up with new ways to support those at risk. By developing solutions with marginalised young people, the project can inform strategies that can help them engage with school and reduce the risk of disengagement.

Prof MacRuairc, School of Education, NUI Galway, said: “This project is a unique opportunity not just to research the problem but, working directly with youth and their schools, to come up with realworld, practical solutions.”

News 8 JANUARY-FEBRUARY 2021

HIQA

PUBLISHES ITS RECOMMENDATIONS TO THE MINISTER FOR HEALTH ON THE IMPLEMENTATION OF A NATIONAL ELECTRONIC PATIENT SUMMARY

The Health Information and Quality Authority (HIQA) has published its Recommendations to the Minister for Health on the Implementation of a National Electronic Patient Summary.

A national electronic patient summary (also known as a summary care record) was listed by the Sláintecare Implementation Plan (2018) as a crucial element of Ireland’s national eHealth policy and a key area for the modernising of the health and social care system in Ireland. A commitment to introduce summary care records was also featured in the Terms of Agreement between the Department of Health, the HSE and the Irish Medical Organisation regarding GP Contractual Reform and Service Development (2019).

An electronic patient summary, which is used internationally by healthcare providers, is a snapshot of a patient’s essential clinical

information. It brings together information from various IT systems into a single place to support medical treatment during an episode of unscheduled care. The patient summary is expected to contain the following clinical information: subject of care (the patient’s demographic information); health conditions; medication prescribed; allergies; procedures; and vaccinations.

HIQA found that the introduction of a patient summary provided huge benefits for citizens across all age groups and walks of life, resulting in better information, better decisions, and a better experience for all involved. No longer did citizens need to remember details of their health condition or medications repeatedly. Nor did they have to explain recent procedures or diagnosed allergies.

Rachel Flynn, HIQA’s Director of Health

Please email your recruitment ads to Louis, Recruitment Manager: Louis@mindo.ie

GENERAL PRACTICE NURSE REQUIRED FERNDALE

A single-handed GP in West Limerick, Abbeyfeale is looking for a general practice nurse. 22 hours a week/negotiable. Fully computerised practice - Health 1. Range of duties including phlebotomy, ECGs, 24-hour blood pressure monitors, chronic disease management, venesections, smears, and vaccinations. CV to ferndalefamilypractice@gmail.com

PRACTICE NURSE REQUIRED

BLACKROCK, CO DUBLIN

Two days per week (Tue/Thu).

Fully computerised practice. General PN duties to include child vaccinations/ECGs.

Please call PM Anne Martin on 01 288 7328 or email carysfortclinicgp@gmail.com

FULL-TIME PRACTICE NURSE REQUIRED

KILKENNY CITY

Single-handed practice in Kilkenny city requires full-time practice nurse with drive and motivation. Experience desired but not essential. CV to kilkennydoc2020@gmail.com

Information and Standards, said: “Electronic patient summaries have the potential to make healthcare delivery safer and more effective by ensuring healthcare professionals have access to a patient’s information, such as medical history and prescribed medications, at the point of care. This is essential in an emergency or unscheduled health visit and very useful during other episodes of care.”

Ms Flynn continued: “A summary care record supports information sharing, the development of digital services and creates greater patient empowerment. Throughout our consultation process, we found that the introduction of a summary care record in Ireland was widely supported.”

This supporting evidence has been published alongside the recommendations and is available on the HIQA website: www.hiqa.ie

Recruitment

PRACTICE NURSE REQUIRED DUBLIN 7

Practice nurse/RGN required to provide maternity cover at a friendly, appointment-based practice in Dublin 7. The role includes phlebotomy, vaccinations, antenatal care, cervical smears, chronic disease management, and all aspects of nursing in general practice. Previous general practice experience is an advantage. Candidates should have a passion for nursing and work well both as a team member and on their own initiative. Ideal is 20+ hours per week; flexible hours available for the right candidate. Modern surgery, central location with parking and excellent transport links. See www.sironamedical.ie for location. Please apply with CV to practice.manager@sironamedical.ie or contact Sinéad at 01 868 0242 for more information and a detailed job description.

News JANUARY-FEBRUARY 2021 9

ICGP URGES PUBLIC TO HELP PROTECT GENERAL PRACTICE FROM COVID-19 INFECTIONS

The ICGP has advised its members to reduce face-to-face contact with the public to protect GPs, staff and those patients who require consultations in person, while the current Covid-19 surge continues.

GP practices all over the country have experienced an unprecedented level of calls and consultations from the public from early January due to the huge surge in Covid-19 cases in the community following the Christmas period.

Some out-of-hours services were fielding over 150 calls per hour at the peak of the surge in early January with extra doctor and administrative staff on duty to help deal with the demand from people with Covid-19 symptoms.

Many GP surgeries have reduced staffing levels due to Covid-19 infections or staff being close contacts, at the same time as the level of demand grows.

Over 80 per cent of all Covid-19 cases are dealt with by GPs in the community.

The ICGP’s Covid-19 Clinical Lead Dr Nuala O’Connor said: “GPs are working in unprecedented conditions with this new surge in cases. Face-to-face consultations will continue, but we are using telephone and

video consultations where it is possible to deliver safe care.

“We are advising GPs to limit foot-fall to the practice while maintaining essential services such as childhood vaccinations and assessing medically unwell patients who need a face-toface assessment.”

“In the first lockdown we know a lot of people with non-Covid-19 medical conditions felt they should not contact their GP. We wish to reiterate that our surgeries are open, but working behind closed doors. People must phone their GPs first for an assessment and if a doctor feels they need to see you, we recommend you do come in. We do not want to miss possible strokes, heart conditions or possible cancers or other non-Covid-19 medical conditions. GPs are here to help with mental health conditions also.”

New Irish research on patients with severe Covid-19 has found that elevated levels of a marker in the blood, von Willebrand factor propeptide, is linked to more severe disease and poorer outcomes for hospitalised patients with Covid-19.

The findings may help clinicians to stratify patients at high risk of developing severe thrombotic and respiratory complications. The study, led by researchers from the RCSI University of Medicine and Health Sciences, is published in the current edition of the British Journal of Haematology.

The research helps clinicians to understand why patients with Covid-19 develop the blood clotting abnormalities that can trigger micro-clot development in the lungs. Previous research has found that the development of these micro-clots can lead to a poorer prognosis for patients and increased risk of intensive care admission.

This study links the formation of these micro-clots to elevated blood levels of the marker, von Willebrand factor propeptide, an established blood marker for damage to the endothelial cells lining the blood vessels in the body. Acute damage of these cells results in the rapid release of von Willebrand factor propeptide, but also initiates clot formation and inflammation. The study observed the highest levels of the blood marker in patients with most severe Covid-19 disease or those who succumbed to Covid-19, indicating that levels of the marker may be predictive for poor prognosis and outcome in patients with Covid-19.

Prof James O’Donnell, Director of the Irish Centre for Vascular Biology, RCSI and Consultant Haematologist in the National Coagulation Centre in St James’s Hospital, said: “We have

previously established that abnormal blood clotting and the development of micro-clots within the lungs contributes to a greater risk of a poorer prognosis and intensive care admission for Irish patients with Covid-19. The mechanisms through which Covid-19 triggers the formation of these micro-clots, however, has been puzzling doctors throughout the world. This research now critically helps us to more clearly understand these mechanisms.”

10 JANUARY-FEBRUARY 2021 News

RCSI RESEARCH

RESEARCH

MAY HELP CLINICIANS IDENTIFY COVID PATIENTS AT HIGHEST RISK OF DEVELOPING COMPLICATIONS

HEALTH INFORMATION

CALL FOR MEMBERS OF THE PUBLIC TO APPLY FOR CITIZENS’ JURY ON ACCESS TO HEALTH INFORMATION

A nationwide campaign has been launched to identify 25 members of the public, broadly representative of the Irish population, willing to step up as members of a Citizens’ Jury to deliberate on the matter of access to health information.

The campaign is the brainchild of IPPOSI, the Irish Platform for Patients’ Organisations, Science and Industry. Following careful deliberation by the jury, the aim is to arrive at a consensus on the issues raised, with recommendations delivered to Government in the context of the development of new health information legislation and the creation of a national Electronic Health Record.

For Dr Derick Mitchell, CEO of IPPOSI, the Citizens’ Jury is an opportunity to “crossexamine” the experts: “I think it’s fair to say that people generally acknowledge that health professionals need to be able to access our health information when it comes to delivery of our individual treatment and

care. Nurses and doctors need to able to look up our charts to review our medical history before deciding on what investigations or treatments to undertake.

“However, when it comes to use of that information for a wider purpose, such as informing developments in broader health service delivery or research, people want to know more about who will be looking at their information and why. There can be stronglyheld views both for and against and it’s fair to say that, in this regard, the jury is still out.

“With this Citizens’ Jury, we want to assemble a group of people reflective of the Irish population, who would hear a wide range of perspectives from experts and who would then have the opportunity to ‘crossexamine’ them.

“We want to know the jury’s views on whether a balance can be struck between individual information needs and using that information more broadly when in the public interest. If so, how do we ensure

transparency and trust in the system to safeguard its use?”

For Dr Jane Suiter, Associate Professor at Dublin City University, and member of the Citizens’ Jury oversight board, jury members will perform an important public service: “We have already seen with the Citizens’ Assembly put in place by Government how useful and worthwhile such gatherings can be in teasing through sometimes complex issues and reflecting the view of the wider public.

“Similarly, with this Citizens’ Jury, we want a really broad section of members of the public to be able to tease out the pros and cons of accessing health information.

“I would encourage everyone who would like to perform this important public service to make an application today.”

The Citizens’ Jury will sit virtually during the month of April for a series of twohour sessions and, in recognition of their commitment, members will receive a €400 gratuity for their participation.

PERSISTENT ILL-HEALTH POST-COVID OCCURS IRRESPECTIVE OF SEVERITY OF INITIAL INFECTION: NEW IRISH RESEARCH

Researchers from Trinity College Dublin have presented the first study globally to assess lung function and respiratory symptoms in patients across the full range of initial Covid-19 severity. To date, little has been known about lung health following infection with SARS-CoV-2, the virus that causes Covid-19, and whether later respiratory problems, fatigue and ill-health are associated with the disease’s initial severity.

The team found that fatigue, ill-health and breathlessness were all common following Covid-19. However, these symptoms appeared to be unrelated to the severity of initial infection or any single measurement at the time of an outpatient appointment. The paper was published in the Annals of the American Thoracic Society

The research, led by Dr Liam Townsend, Research Fellow, Department of Clinical Medicine, Trinity College and St James’s Hospital, Dublin, is the largest study of post-Covid lung assessment and imaging, with 153 patients included.

Researchers looked at a number of measures of recovery for 153 patients who were followed in an outpatient clinic a median of 75 days after their Covid-19 diagnoses. The findings suggest that

Covid-19 does not cause significant fibrosis, with lung scarring seen on CT scans of only 4 per cent of study participants, following x-ray detection of earlier abnormalities in a larger group.

Almost two-thirds – 62 per cent – of patients felt they had not returned to full health, while 47 per cent were classified as having fatigue. Patients who felt they had to exert themselves during moderate exercise also reported they felt fatigued and in poor health. Patients’ length of inpatient hospital stay and frailty were associated with covering less distance in the ‘walk test’ element of the research.

The findings show significant symptom burden, but a relatively low rate of abnormal objective findings. These results add to previously published work, including in the area of postCovid fatigue, that suggest that there is no simple diagnostic test for so-called long-haul symptoms, and that the diagnosis is based on patients' own reported symptoms.

No disease-related features have been associated with the development of fatigue. So far, the highestrisk group identified has been females under the age of 60 years. One of the difficulties in assessing symptom duration in acute illness in these patients

is that it is hard to identify when the acute illness ends and the 'post Covid' symptoms begin.

Dr Liam Townsend, Research Fellow, Trinity College said: “We were surprised by our findings. We expected a greater number of abnormal chest x-rays. We also expected the measures of ongoing ill-health and abnormal findings to be related to severity of initial infection, which was not the case."

This study demonstrates the contrast between the high levels of symptoms reported post-Covid and low levels of abnormal test results. The clinical impact of this is that patients will need to be assessed (either in person or virtually) to evaluate their post-Covid symptoms, rather than relying on diagnostics.

The findings have implications for clinical care, in that they demonstrate the importance of following up all patients who were diagnosed with Covid-19, irrespective of severity of initial infection as it is not possible to predict who will have ongoing symptoms. “We also suggest a multidisciplinary team approach, involving doctors, nurses, physiotherapists and occupational therapists, in order to develop an individual treatment plan for each patient.”

News 12 JANUARY-FEBRUARY 2021

Regional News

NEWS FROM IPNA BRANCHES COUNTRYWIDE

Please email your branch news to Priscilla Lynch priscilla@mindo.ie

NEC News

THANK YOU

The NEC o cers: Jane, Úna, Theresa, and Mary would like to take this opportunity to thank you all for your ongoing support of the association and wishing you and all your families and friends the very best for 2021.

BRANCH AGMS

Just a reminder to all branches that each branch shall hold its annual AGM between Jan and March. Following this the annual accounts for 2020 including branch ﬁnancial statements, all bank statements, and all receipts are to be forwarded to the administrator by the last day in March please.

Please also email admin@irishpracticenurses.ie with the updated 2021 branch committee contact details.

Thank you

NEW NAME FOR IPNA

DUBLIN SOUTH BRANCH KAREN CANNING

Happy New Year to all IPNA members. We hope you are all keeping safe and well and looking forward to being vaccinated against Covid-19 very soon.

We opened 2021 on 12 January with our ﬁrst branch webinar, which was kindly sponsored by Hazel Travers, Primary Care Specialist, Consilient Health. Hazel brought us through her company’s female contraception types, particularly their contraceptive pills, which are a cheaper option to other brands. She also recommended their website – www.knowyourcontraceptives.ie

Dr Deidre Lundy followed with a presentation on contraception types, CHC, progesterone-only products and LARCs as well as products due to come on stream soon.

A total of 35 branch members logged in for Dr Lundy’s slides, which was way above the average number to usually a end our meetings.

Our branch AGM followed.

I had decided to step down as branch Chair and Mary Ma hews as Secretary. Ciara Deegan agreed to remain on as branch treasurer.

We were delighted that Jessica Sheridan was nominated and seconded as Chairperson and Joanne Lambe as Secretary.

Back in early 2012, I was lucky to have the support of so many fantastic GPNs, which enabled me in se ing up the IPNA South Dublin branch. Both Mary Ma hews and I have been Chairs since.

Mary, as Secretary, has done trojan work over many years and made my role very easy.

Ciara has maintained our branch accounts, paid our meeting venue monthly (up to March 2020) and our guest speakers. She also has had our accounts ready for the IPNA accountant at the end of each ﬁnancial year.

I would like to say a HUGE THANK YOU to both Mary and Ciara for their amazing support and help. We have worked very well together over the past number of years.

Wishing the best of luck to Ciara, Jessica, and Joanne for the coming year.

A motion to change the name IPNA was passed at the 2020 AGM by 98 per cent. It was agreed that the name title should include 'general practice nurses', the educational objective of the organisation and the term 'Ireland/ Irish'. Meetings were then held with IPNA National Executive Committee Representatives and IPNA Branch O cers. Following this a survey was circulated to all our members for their opinion on the term to be used that reflects the educational purpose of the organisation. This survey closed on 18 December with the majority of respondents requesting that educational association/association of education be reflected in the new name. The majority of respondents also identified that they did NOT want the logo of the IPNA changed at this time. The NEC will continue to engage with all its members in progressing this development.

NEW ADMINISTRATOR

A warm welcome to Mary Osakwe who joins the IPNA as National Executive Administrator with a varied range of administrative skills having worked with an out-of-hours GP hub in the UK, Medway Practice Alliance and previously held positions as Finance and Corporate Services Administrator.

Mary is looking forward to working with the IPNA and is delighted to be joining the administrative team, working closely with Barbara Shanahan, IPNA Membership and Social Media O cer, to support the NEC and IPNA members nationally.

NEC MEETINGS FOR 2021

 Wednesday 3 February

 Wednesday 5 May

 Wednesday 1 September

 NEC meeting TBC pre IPNA annual conference Oct/Nov

GET IN TOUCH

You can contact us at admin@irishpracticenurses.ie

Mary Osakwe 087 130 4115 and membership@irishpracticenurses.ie

Barbara Shanahan 086 263 4917

14 JANUARY-FEBRUARY 2021

Authors:

Dr Marie Talty,1 Helen Mulryan,1 Prof Anthony O’Regan,1 and

Ms Mona Thornton.2

UNDERSTANDING ASTHMA AND SINUS DISEASE

For many years there has been a clearly described association between chronic rhinosinusitis (CRS) and asthma, with a prevalence of around 25 per cent of asthma in those with CRS, compared to a prevalence of up to 10 per cent in the general population. In patients with asthma, up to 90 per cent of those with allergic asthma describe rhinitis and up to 80 per cent of those with non-allergic asthma. In the adult population, chronic rhinosinusitis has been defined as the presence of two or more symptoms, one of which should be either nasal blockage, obstruction or congestion; or nasal discharge (ie, anterior or posterior nasal drip) with or without facial pain/pressure; or reduction or loss of smell; for at least 12 weeks. Previously, CRS has been divided into two groups based on clinical history and nasoendoscopic exam, either with or without nasal polyps.

In recent years there has been an increase in interest and popularity of the concept of a united airways disease, also sometimes termed global airways disease. It is suggested that if the role of the upper airway to act as a humidifier, filter and heat regulator for air entry onwards into the lower airways is disrupted, it leads to more generalised inflammation progressing to the lower airways. Allergic rhinitis has

long been considered a risk factor for the development of asthma, but there is some speculation that this is truly the early presentation of a reactive airways disease, which may then progress to asthma. There is a commonality in the factors which can trigger upper and lower airways disease. These include allergens, aspirin, infections both viral and bacterial, or irritants such as pollutants. Also at a cellular level, the infiltrates that characterise inflammation in both asthma and CRS include eosinophils, mast cells, macrophages and T-cells. Cytokines promoting

inflammation are also similar, such as histamine, interleukin 4, 5, and 13, and leukotrienes. This correlates with CRS being associated with the asthma clinical subgroup of TH2 dominant asthma, which includes allergic and eosinophilic asthma.

The relationship between allergy and allergic rhinitis and the development of CRS remains unclear and incompletely understood, as CRS has not been considered as related to atopy, unlike allergic rhinitis. Recent studies suggest in the setting of sinusitis, grouping patients on their inflammatory patterns into either type 1 or type 2 inflammation is more

Feature JANUARY-FEBRUARY 2021 15 Asthma

1Department of Respiratory Medicine, University Hospital Galway; 2Department of Otorhinolaryngology, University Hospital Galway NASAL CAVITY FRONTAL SINUS LEFT LUNG RIGHT LUNG SPHENOID SINUS

In patients with asthma, up to 90 per cent of those with allergic asthma describe rhinitis and up to 80 per cent of those with non-allergic asthma

useful than general atopic status. Also, in patients with upper airway sinus disease and lower respiratory symptoms it is important to consider other causes/ associations outside of asthma, including vasculitis such as granulomatosis with polyangiitis (GPA) and eosinophilic granulomatosis with polyangiitis (EGPA).

In asthmatic patients, symptoms of CRS contribute significantly to quality-of-life, however this is largely in relation to poorer asthma control due to upper airway disease. The outcomes of poorer asthma control apart from quality-of-life including work days missed, exposure to more frequent courses of antibiotics and steroids as well as increased State spending on hospitalisations and maintenance therapy have a clear population impact. Data from the Asthma Society of Ireland published last year revealed overall State spending of €473 million per annum on asthma.

Treatment

Treatment aims in CRS are to reduce inflammation and associated oedema, allow for adequate sinus drainage, eliminate any colonising or infecting organisms and to reduce the number of acute exacerbations. Asthma is usually associated with diffuse bilateral sinus disease, the mainstay of treatment of which is intranasal corticosteroids and saline. Adequate delivery and technique, as well as compliance with this quite cumbersome therapy is of vital importance for treatments to have beneficial effect. Local delivery can be enhanced by saline irrigation prior to use of other topical agents, angling of the head slightly downwards, and aiming the tip of the spray away from the nasal septum.

Antimicrobial therapy in CRS has limited evidence, outside of acute exacerbations. A single course of antibiotics may often be used, especially if increasing purulent nasal discharge. In some post-operative patients there may be sinus cultures available, but generally an empiric regimen is chosen. This would need to cover anaerobic organisms, staph aureus and streptococci Broad-spectrum agents such as co-amoxiclav and doxycycline are routinely prescribed. Doxycycline offers a synergistic anti-

inflammatory effect in theory and has been shown to reduce nasal polyp size. Longer-term suppressive antibiotics including macrolides are sometimes used in secondary care, however, there is currently a low quality of evidence to support same and side effects of such should certainly be considered.

Oral steroids are often used in the shortterm for those with refractory symptoms, and can be particularly beneficial in those with nasal polyps.

Leukotriene receptor antagonists such as montelukast, are used as an adjunct therapy to nasal corticosteroids and seem to show additional benefit in CRS patients with asthma or aspirin-exacerbated airways disease.

Dupilumab was the first monoclonal antibody approved as an add-on therapy for chronic rhinosinusitis with nasal polyps by the European Commission in 2019. It is an interleukin 4 receptor antagonist, and modulates signalling of interleukin 4 and 13. For asthma, omalizumab is approved for those with severe persistent asthma, with clear IgE mediation. Phase 3 trials published in 2019 showed significantly reduced nasal congestion and polyps in those with CRS, while a previous study has shown a similar benefit in alleviation of sinus symptoms with omalizumab in a cohort with coexisting severe allergic asthma and CRS with polyps. There have been no efficacy studies examining CRS without polyps.

Mepolizumab, an anti-IL-5 monoclonal antibody, is approved for those with severe refractory eosinophilic asthma. A phase 3 trial preliminary data published in 2020 for mepolizumab also suggested positive results in relation to size of nasal polyps and relief of obstruction, again in CRS without polyps. However, given the costly nature of these drugs, significant study is still needed into cost benefit analysis as well as very careful patient selection and optimisation of other therapies.

If symptoms are not responsive to usual treatment, CT of the sinuses as well as otorhinolaryngology review is recommended by the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 , which can identify any more localised disease, as well as suitability for surgical intervention.

Endoscopic sinus surgery in asthma has been reported to improve multiple clinical asthma parameters with improved overall asthma control, reduced frequency of asthma attacks and number of hospitalisations, as well as decreased use of oral and inhaled corticosteroids.

However, of note, endoscopic sinus surgery’s role is to optimise local treatment and as CRS is a chronic condition, ongoing medical management is still required. Naturally, this is also the case with ongoing treatment of asthma as a chronic condition.

A developing area of interest in CRS, as it is in asthma treatment, is biologic therapy.

Role of joint care

If we look at the overlapping problems of asthma and CRS as a united airways disease, it certainly does seem strange to have it managed very separately by respiratory and otorhinolaryngology, often across different centres. Close collaboration between respiratory and otorhinolaryngology specialists leads to improved access to care and therefore intervention for asthmatic patients with difficult to control disease. In our centre, this has led to the establishment of a joint respiratory and rhinology clinic. Certainly patients anecdotally self-report improved satisfaction with access to both services with one appointment, rather than remaining on waiting lists with ongoing symptoms or exacerbations. The management and outcomes of these patients is being evaluated in ongoing research.

References on request

Feature 16 JANUARY-FEBRUARY 2021

Asthma

Oral steroids are often used in the short-term for those with refractory symptoms, and can be particularly beneficial in those with nasal polyps

Latest module

Crohn’s disease — presentation, diagnosis and management was devised by Theresa Lowry-Lehnen, Clinical Nurse Practitioner and Associate Lecturer at Institute of Technology Carlow, Assistant PRO Irish Student Health Association.

Crohn’s disease is an inflammatory bowel disease (IBD) that may affect any part of the gastrointestinal tract. True or False?

Check your answer against the latest module on nursecpd.ie.Successful completion of this module will earn you 2 CPD credits

Free CPD – accessible on android, iPhone and tablet

Free independent CPD

A B C

for Irish nurses

UPDATED NATIONAL BREAST CANCER GP REFERRAL GUIDELINE

The

NCCP is rolling out an updated Breast Cancer GP Referral Guideline and accompanying e-referral form

The National Breast Cancer GP Referral

Guideline and accompanying e-referral form have been updated and will be available to GPs across Ireland from early this year. The aim of the updated guideline is to ensure that patients with symptoms most suspicious for breast cancer can continue to be seen and treated in a symptomatic breast disease (SBD) clinic as a matter of priority.

Breast cancer is the most common invasive cancer affecting women in Ireland, with 3,667 cases annually. Survival is increasing, with a fiveyear survival of 84 per cent and 10-year survival of 77 per cent.

There are eight SBD clinics across Ireland (with one satellite clinic in Letterkenny), where approximately 40,000 new patients are referred by their GP each year.

The original referral guideline was developed by the National Cancer Control Programme (NCCP) in 2010. It is now timely for a new guideline to be developed to reflect the most up-to-date evidence available.

Breast symptom algorithms

The updated guideline was developed by a stakeholder group which included GPs,patients and nursing, medical and administrative representation from SBD clinics. The stakeholder group made a series of recommendations based on the best available international evidence, combined with clinical expertise and patient values. These recommendations were then incorporated into a number of clearly defined, evidence-based algorithms which form the basis of the guideline. When a patient presents to the GP with a concern, the GP can refer to the updated referral guideline when considering next steps for their patient. These will facilitate GPs in determining which patients with breast symptoms require referral to secondary care, where they will then

be triaged by the SBD clinic.

There are three evidence-based algorithms:

1. A patient with a breast lump.

2. A patient who presents with another breast complaint.

3. A patient who presents with mastalgia (breast pain) alone.

Electronic referral

GPs are strongly encouraged to refer patients to the SBD clinics using the new e-referral form, which has been updated to reflect the new referral guideline and algorithms. The new e-referral form allows GPs to provide more details of the patient’s signs and symptoms so that the SBD clinic can more effectively triage patients. The following methods of sending referrals are not acceptable: Fax, old versions of the referral form, email (including via Healthmail) or hand-delivered letters/forms.

How will this impact me/my GP colleagues?

It is not anticipated that the new, updated guideline will lead to major changes in how GPs go about their everyday work. However, the new e-referral form will look different to the previous form and will be completed in a different way.

How will this impact my patients? These new developments will have a positive impact on patients. They will enable a more effective triage of patients by the SBD clinics and improve the prioritisation of patients most suspicious of cancer.

How soon will my patient be seen? Streamlining the referral process will allow prioritisation of patients with symptoms suspicious of breast cancer. Two week appointments for urgent patients will continue.

Will we have to change our practice software?

GPs will not be required to make any changes to their software. The e-referral form will be updated automatically, and free of charge to GPs, on Socrates, Helix Practice Manager, Health One, and GP Clinical. Non-computerised practices can access the e-referral form using Healthlink, the secure national health messaging system.

Where can I find out more?

The guidelines will be available on the NCCP website (www.hse.ie/cancer). Further information updates will be disseminated to all stakeholders as part of the project roll-out.

When will the new guideline be put into use?

It is anticipated that the new guideline and accompanying e-referral form will be rolled out in early 2021. Cognisant of the workload faced by GPs, every effort has been made to ensure that the switch over to the updated breast cancer guideline and e-referral form will be as seamless as possible.

The introduction of the new National Breast Cancer GP Referral Guideline and accompanying e-referral form will provide many benefits to all stakeholders. Prof Risteárd Ó Laoide, National Director NCCP, outlined: “We are happy that work is progressing on the Breast Cancer GP Referral Guideline and are anticipating a launch in early 2021. It is a priority for the NCCP that all national cancer guidelines are developed using an evidence-based approach, which aims to improve the outcome for patients diagnosed with cancer. It is always our main goal to ensure patients are treated at the right time, in the right place and by the right people.”

References on request

Feature 18 JANUARY-FEBRUARY 2021 Breast Cancer

Dr Una Kennedy, GP Advisor to National Cancer Control Programme (NCCP), Ms Aine McKenna, Ms Maeve Cusack, Dr Eve O’Toole, and Ms Niamh Kilgallon, NCCP

COLDS AND FLU Managing in the community

Eamonn Brady, MPSI, provides a clinical overview of treating coughs, colds, and ﬂu in the pharmacy

There is no cure for a cold or influenza (flu), as they are caused by viruses, but the symptoms can be relieved so that they are not noticeable. These symptoms include runny/blocked nose, sneezing/ coughing, aches and pains, high temperature and sore throat. The flu comes on suddenly, whereas a cold develops over several hours.

Flu is a much more ‘hard-hi ing’ illness than a cold and will usually leave the sufferer confined to bed for a few days (more about flu symptoms later in this article).

The symptoms of a cold, while unpleasant, usually allow the sufferer to continue his or her normal daily activities, although with Covid-19 in our community, movements must be restricted until Covid-19 is ruled out. Symptoms of a cold are generally confined to the head, while a patient with the flu will feel sick all over. The treatment is the same for each condition, regardless. Colds and flu generally last for about seven days at most and need no specific treatment other than painkillers for aches, pains and temperature and simple measures, such as decongestant rubs or vaporisers. Antibiotics are of no benefit.

Covid-19 must always be assumed

Covid-19 has complicated things, as when people now get cold- or flu-like symptoms, it first must be considered whether it is Covid-19. People should phone their GP who will advise if they should get a Covid-19 test. If ge ing a test, the person should self-isolate until they get a negative result. Even if the Covid-19 result is negative, the person should still restrict movements until 48 hours a er the cold/flu-like symptoms ease.

Covid-19 is a coronavirus, like the common cold, but the symptoms can be a lot more severe. While the symptoms of inﬂuenza can be like

Covid-19, influenza is a completely unrelated virus to Covid-19. For this article, I will concentrate on colds and flus (rather than Covid-19), but for those who contract Covid-19 and are lucky enough to have mild symptoms, the treatment of the symptoms like high temperature and cough are the same as to treat colds and flus. Anyone who develops breathing difficulties with Covid-19, especially those in more vulnerable categories, must get medical advice from their GP promptly.

Dry cough

a cold — paracetamol is very useful to bring down a high temperature. A sore throat is usually the ﬁrst sign of a cold, and one of the common over the counter (OTC) sore throat lozenges will help.

Precautions

versions

Cold and ﬂu treatment

The age of the patient will influence the choice of products. Runny nose and congestion are both treated by decongestants. Sneezing is treated by an antihistamine. A cough may be due to irritation or to post-nasal drip. An expectorant mixture can help. Headaches are due to inflammation of the sinuses and nasal passages and muscular or joint pain is common — this will need a painkiller. Sinus pain worsens on leaning forward or lying down and may develop into an infection. High temperature is more common in the flu than with

Many cold and ﬂu remedies contain several drugs, so anyone on prescription medication should speak to their pharmacist. Anyone who is pregnant, has heart disease or lung disease or the very young or old should also be seen by the pharmacist.

So, for example, if someone suﬀers from high blood pressure, it is best to avoid many cold and ﬂu remedies which contain decongestants, as these products tend to raise blood pressure.

People with asthma and people with stomach complaints such as stomach ulcers should avoid products which contain aspirin and non-steroidal anti-inﬂammatories (NSAIDs) like ibuprofen. This is because aspirin and NSAIDs can trigger asthma a acks in some people with asthma and irritate stomach ulcers. There is a vast number of preparations available for the treatment of cold and ﬂu symptoms, some of which are combination preparations and may be capable of treating many symptoms at once.

Feature Coughs, Cold, and Flu 20 JANUARY-FEBRUARY 2021

mixtures contain ingredients such as pholcodeine, codeine and dextromethorphan. Dry cough mixtures come in drowsy or non-drowsy

Coughs, Cold, and Flu

Dry cough mixtures contain ingredients such as pholcodeine, codeine and dextromethorphan. Dry cough mixtures come in drowsy or non-drowsy versions

Cough

Essentially, there are two types of cough — a DRY or a CHESTY cough. During a cold, a cough is o en caused by a nasal drip irritating the back of the throat. Chesty coughs occur when mucus (aka phlegm or catarrh) builds up in the airways, and the cough occurs so that the body can clear the mucus. Chesty cough mixtures with an expectorant, like guaifenesin or carbocisteine, liquefy the catarrh so that it can be coughed-up easier. There are other cough mixtures that cause drowsiness which can be used at night to help sleep. Sugar-free versions of cough mixtures are available for people with diabetes.

Dry cough mixtures contain ingredients such as pholcodeine, codeine and dextromethorphan. Dry cough mixtures come in drowsy or non-drowsy versions. There are also cough mixtures available that contain decongestants, which can be eﬀective with a congested head as well as a cough.

Self-help for coughs

Stop smoking

If patients are determined to continue smoking, they should at least stop for the duration of the cough. This gives the lungs an opportunity to try to clear the infection. When someone stops smoking, they will ﬁnd they cough more for a few weeks as their lungs clear the tar that coated their lungs while they smoked.

Steam inhalations

Steam inhalations can be useful, particularly in productive (chesty) coughs. Simply pu ing hot steaming water (not boiling) in a basin, pu ing a towel over one’s head and inhaling the steam can accelerate the clearing of catarrh. The steam helps to liquefy lung secretions and the warm, moist air is comforting. Adding a li le eucalyptus to the steaming water is a favourite of some people.

Increase ﬂuid intake

A high ﬂuid intake helps to hydrate the lungs and hot drinks can have a soothing eﬀect.

Could the cough be due to blood pressure medication?

A type of blood pressure medication can cause a persistent dry cough in some people. The class of drug that cause this cough is ACE inhibitors. Examples include ramipril, perindopril, and lisinopril. About 10-to-15 per cent of people who use this class of blood pressure medication experience a dry cough. The incidence of cough appears to be higher in women. It is a persistent dry cough which is worse when lying down and generally does not start for 24 hours a er starting an ACE inhibitor.

If the dry cough occurs, the doctor will need to change to another drug, ie, an angiotensin 2 inhibitor. The cough will subside once the ACE inhibitor is stopped.

Coughs in children

Coughs are more common during school term and are caused by common viruses which are commonly passed from child-to-child in school. While rarely serious, coughs and colds are an inconvenience and lead to many missed school days.

Some tips to help prevent coughs and colds: Examples, which have become more common due to Covid-19, include ensuring children wash their hands regularly and properly, especially a er touching their nose or mouth

WHEN TO SEE THE DOCTOR

Patients should see their GP if they experience any of the following symptoms with cough, as it can be a sign of more serious conditions, ie, COPD, cancer:

 Phlegm, which is green, yellow, or rusty in colour.*

 Coughing-up blood.

 Cough lasting longer than two weeks.

 Shortness of breath.

 Chest pain on breathing or coughing.

 Unexpected loss of weight.

 Regular night-time cough.

 Harsh barking cough in children (croup).

 Whooping sound when breathing in after a t of coughing (whooping cough).

*The meaning of di erent colours of phlegm: Green phlegm means a bacterial infection; yellow phlegm means a viral infection; brown or reddish phlegm can mean the presence of blood (serious sign); and clear phlegm means no infection.

and before handling food.

Teach them to always sneeze and cough into tissues to prevent spreading infection. Sharing unwashed cups and utensils is another common way to pick up colds and ﬂu. Chesty coughs are especially common as kids return to school, but an antibiotic is rarely needed. Only 20 per cent of chest infections are bacterial, so antibiotics are ineﬀective in most cases.

Guidelines for cough and cold remedies for children

Guidelines came out in 2011 restricting the sale of cough and cold remedies to children aged under six years. The Health Products Regulatory Authority (HPRA) brought these guidelines out not because of any safety concern in children under six, but because they recognised that coughs and colds in children are frequent and normally self-limiting, and there is no real evidence to support the use of these products in children under six.

So, due to these guidelines, pharmacies can no longer sell products containing cough suppressants, decongestants or antihistamines for under-sixes. Common OTC remedies can no longer be given to children under six. For a child under six, the best advice is rest and plenty of ﬂuids. Most coughs and colds in children under six will pass quickly but if it is not improving or there are signs of a bacterial chest/nasal infection (green mucus is a sign), an antibiotic may be needed, however over 80 per cent of coughs and colds are viral, so generally no antibiotic is needed.

Saline drops or spray are a good and safe option to clear sinuses in children over six. Decongestant rubs or drops that can be put on the child’s chest or hankie beside the bed can be comforting for the child. Paracetamol liquid is still recommended for high temperature in under-sixes. For children over six, there are many OTC products and there is no one that stands out as best. Caregivers should always double-check the dose before giving, as there are diﬀerent doses for diﬀerent ages.

Prevention

As so many diﬀerent viruses can cause the common cold, no vaccination against it has yet been developed. Some prevention tips are:

 Wash your hands regularly and properly, especially a er touching your nose or mouth and

Feature

JANUARY-FEBRUARY 2021 21

before handling food.

 Always sneeze and cough into tissues to prevent spreading infection.

 Do not share cups or kitchen utensils with others. Use your own cup, plates, and cutlery.

Inﬂuenza

Influenza (flu) is a highly infectious acute respiratory illness caused by the influenza virus. It can affect people of any age. The seasonal flu vaccine (flu jab) protects against four strains of flu virus. These are the strains most likely to be circulating this flu season based on World Health Organisation (WHO) evidence and based on virus circulation in the Southern Hemisphere. Symptoms of flu include sudden fever, chills, headache, muscle pain, sore throat, nonproductive dry cough, exhaustion, and weakness. The annual flu vaccination can be go en at GP surgeries or local pharmacies in Ireland. Free eligibility was extended this winter and a free

THOSE CONSIDERED MORE ‘AT-RISK’ FROM FLU

Some people are more at risk of getting complications if they catch u. A person can get the HSE u vaccine for free if they:

 Are 65 years of age and over.

 Are pregnant.

 Are a child aged two-to-12 years (new for 2020/2021).

 Are an adult or child aged six months or older with a longterm health condition like:

● Chronic heart disease, including acute coronary syndrome.

● Chronic liver disease.

● Chronic renal failure.

● Chronic respiratory disease, including chronic obstructive pulmonary disease (COPD), cystic brosis, moderate or severe asthma or bronchopulmonary dysplasia.

● Chronic neurological disease, including multiple sclerosis, hereditary and degenerative disorders of the central nervous system.

● Diabetes mellitus.

● Haemoglobinopathies.

● Morbid obesity, ie, body mass index (BMI) over 40.

● Immunosuppression due to disease or treatment (including treatment for cancer).

 Are a child with a moderate-to-severe neurodevelopmental disorder, such as cerebral palsy.

 Were born with Down syndrome.

 Live in a nursing home or other long-term care facility.

nasal version was also introduced for children aged under 12 years initially and then up to 17 years. There were well-documented shortages of the adult ﬂu vaccine this winter but despite this, the HSE is conﬁdent that most people in vulnerable categories got vaccinated through their GP or pharmacy, as a record 1.3 million doses were administered up until early December.

Symptoms of ﬂu

Symptoms of ﬂu include sudden fever, chills, headache, muscle pain, sore throat, nonproductive dry cough, exhaustion, and weakness. Flu characteristically causes a temperature of 38-to-40°C that lasts for three-to-four days.

Di erence between cold and ﬂu

A cold will develop slowly over a few days, with symptoms like a sore throat and a blocked or runny nose. The symptoms of flu hit suddenly and severely, with symptoms like fever and muscle aches. O en, people suffering from a bad cold wrongly believe they have flu. Flu causes extreme exhaustion, muscle aches, severe sweats and leaves a person so weak, they will not be able to get out of bed. Work and other normal routines are not possible with flu.

Complications of ﬂu

Most people recover from flu in two-to-seven days, but in some, it can last for up to two or three weeks. Flu can be severe and can cause serious illness and death, especially in the very young and in the elderly. Serious respiratory complications can develop, including pneumonia and bronchitis. Older people and those with certain chronic medical conditions are at particular risk of these complications. Pregnant women and women up to six weeks a er giving birth have also been found to be at increased risk of the complications of flu. Eighty-to-90 per cent of reported deaths from influenza occur in the elderly, mainly from bacterial pneumonia (average 200 deaths per year in Ireland), but also from the underlying disease. The good news is that with social distancing, mask-wearing and increased uptake in flu vaccines, incidence of influenza is a lot lower this flu season, with no cases reported as of mid January, as the flu virus has had less chance to spread. The incidence of flu in Australia was also a lot lower in 2020/21 due to the measures brought in to combat Covid-19.

Feature Coughs, Cold, and Flu 22 JANUARY-FEBRUARY 2021

IRISH OSTEOPOROSIS SOCIETY 2020 CONFERENCE COVERAGE

General practice nurses urged to be alert about osteoporosis risk, reports Priscilla Lynch

The Irish Osteoporosis Society 2020 Annual Medical Conference for Health Professionals took place online on 17 October and featured a stellar line up of expert speakers, research presenters and powerful patient advocates discussing the latest prevention, diagnosis and treatment strategies for this common disease.

Osteoporosis is commonly known as ‘the silent disease’ because there are frequently no signs or symptoms before a person starts to experience fractures. However, this disease is not silent, and the effects of undiagnosed/untreated osteoporosis are devastating, the conference was reminded.

At present it is estimated that 300,000 people in Ireland have osteoporosis. One-in-four men and one-in-two women over 50 will develop a fracture due to osteoporosis in their lifetime, and the disease can also affect children.

Women going through the menopause with risk factors for bone loss, such as low body weight, prior fracture, or having a condition or medication that causes bone loss are at particular risk. Some women lose up to 30 per cent of their overall bone whilst going through the menopause.

Only approximately 19 per cent of patients with bone loss are diagnosed, “and the effects of untreated osteoporosis are horrific on the patients, and a significant financial burden on the health system,” pointed out the IOS.

The impact on quality-of-life can be profound as a result of loss of independence, decreased selfesteem, distorted body image, and depression.

Vertebral fractures also significantly impact on activities of daily living, such as washing, dressing and walking.

However, fractures and osteoporosis are

preventable in most people and treatable in the majority, so general practice nurses (GPNs)were urged to be alert to the risk factors in their patients.

The key message of this IOS conference was continuation of care for osteoporosis patients during the Covid-19 pandemic and the importance of fracture prevention efforts.

Many patients and healthcare professionals themselves are not fully cognisant of the risks of ‘drug holidays’ for osteoporosis therapies, which anecdotally seem to have increased during the pandemic, the conference heard.

A number of speakers warned against taking drug holidays for the stronger osteoporosis therapies in particular, such as the human monoclonal antibody denosumab, a RANK ligand inhibitor, which is used for the treatment of osteoporosis and treatment-induced bone loss. The six-monthly subcutaneous injection

inhibits osteoclast bone resportion, thereby decreasing the release of calcium from bone into the blood stream, and is a very potent treatment, but its effects can wear off very quickly if stopped suddenly, rapidly increasing fracture risks.

The conference heard powerful testimonies from a number of Irish female osteoporosis patients about their negative experiences of drug holidays (fractures, falls, pain, and disability) and the impact of late diagnosis and inadequate osteoporosis treatment.

Speaking to NIGP, IOS President Prof Moira O’Brien said she would never put one of her patients on a drug holiday, and voiced concern about osteoporosis patients “slipping through the cracks” during the Covid-19 pandemic. She called on all healthcare professionals to ensure that their patients continue to receive appropriate care and treatments for osteoporosis, and that suspected cases continue to be referred for DXA scans and full assessments.

“Don’t assume it is the menopause. Please do blood tests and the vitamin D absolutely must be done as that is the commonest causes of bone loss. If the vitamin D is low the parathyroid goes up and they lose bone,” she said, stressing the need to prevent fractures wherever possible, and not wait until a patient experiences a fracture to commence treatment.

High stress levels raise cortisol levels and cause bone loss. “This is very important to remember and very few people realise it,” Prof O’Brien said, noting that the pandemic has increased stress levels among the population.

The IOS helpline has received an increased number of calls in recent months from osteoporosis patients who report not attending their medical professionals for follow-ups or to receive treatment and scans as they are frightened of getting Covid-19, and are thus increasing their fracture risks.

Prof O’Brien advised that the IOS website (www.irishosteoporosis.ie) contains a number of useful tools and educational resources for both healthcare professionals and patients, and the IOS is asking GPNs to please refer all their relevant patients to the IOS website, to take the ‘Risk check for bone loss’. This test is a quick (three minutes) and easy way for someone to see if they are at risk of osteoporosis.

“Patients themselves can take the bone risk assessment on the website, and it is only then

Feature Osteoporosis JANUARY-FEBRUARY 2021 23

Prof Moira O’Brien

they realise how many risk factors there are and if they need to be followed up,” Prof O’Brien said, acknowledging how busy GPNs are, but that the IOS tools and resources can help them.

Need to maintain bone health treatment during the Covid-19 pandemic

Prof Bernard Walsh, Director of the Bone Health and Osteoporosis Unit at the Mercer’s Institute. St James's Hospital, Dublin, and Trinity College Dublin, addressed the issue of bone health treatment during the coronavirus pandemic in a comprehensive presentation.

He noted that by 17 June last year, Ireland had 25,341 cases of Covid-19 and 1,710 associated deaths, “which is very similar to the number of osteoporotic fractures which occur each year in Ireland (30,000-40,000), and the number of people who die following that fracture”.

Prof Walsh then outlined the details of the Joint Guidance on Osteoporosis Management in the Era of Covid-19 from the American Society for Bone and Mineral Research (ASBMR), American Association of Clinical Endocrinologists (AACE), Endocrine Society, European Calcified Tissue Society (ECTS) and National Osteoporosis Foundation (NOF), which has been created to assist clinicians in the management of patients with osteoporosis in the era of Covid-19.

The current pandemic has necessitated the implementation of social distancing strategies that have the potential to disrupt the medical care of patients with osteoporosis. The guidance creators acknowledge that there is a paucity of data to provide clear guidance, thus their recommendations are based primarily on expert opinion.

General recommendations

The guidelines say that initiation of oral bisphosphonate therapy can be done via telephone or video visit and should not be delayed in patients at high-risk for fracture (eg, in patients who have recently sustained an osteoporotic fragility fracture).

Bone mineral density (BMD) examinations may need to be postponed when public health guidance recommends the halting of elective procedures.

When possible to do safely, patients who are already taking osteoporosis medications should continue to receive ongoing medications including

oral and intravenous (IV) bisphosphonates, denosumab, oestrogen, raloxifene, teriparatide, abaloparatide, and romosozumab (approved in 2019 in Europe, but not yet reimbursed in Ireland).

There is no evidence that any osteoporosis therapy increases the risk or severity of Covid-19 infection or alters the disease course (in either a positive or negative way), the document notes. However, there are early signals that Covid-19 may be accompanied by an increased risk for hypercoagulable complications, in which case caution should be used for oestrogen and raloxifene, both of which may modestly increase thrombotic risk.

To facilitate social distancing guidelines and to minimise patient exposure at phlebotomy centres, the guidelines state standard pre-treatment labs (such as calcium, 25-hydroxyvitamin D, and/ or creatinine) prior to IV bisphosphonate and/or

rebound fractures and people who have just missed one dose in three months. That message must get out there. There is no reason for stopping denosumab if people are tolerating it and they are still osteoporotic and have had fractures,” Prof Walsh said, adding that if people have to be taken off denosumab they have to take an alternative therapy (eg, bisphosphonate) to suppress the rebound issue and to be monitored.

Echoing Prof Walsh, Mr Kevin Carroll, Consultant, Medicine for the Elderly, St James Hospital, Dublin, also strongly advised against drug holidays of denosumab, noting that missing an injection is a particular risk during Covid-19.

He emphasised the need to replace denosumab with a bisphosphonate and to continue checking bone markers if it was stopped. However, BMD loss can continue despite taking zoledronic acid after denosumab; so if it is being tolerated well in older patients to continue it, Mr Carroll stated.

He also outlined the risks of medicationinduced bone loss, citing steroids (>5mg for >three months), aromatase inhibitors, and androgen deprivation therapies as particular offenders, stressing the need for adequate BMD monitoring and appropriate antiresorptive prescriptions where indicated in those at moderate-/high-risk of fractures.

‘Under-diagnosis of vertebral fractures must be addressed’

denosumab administration can be avoided if labs within the preceding year were normal and it is the clinical judgement of the medical provider that a patient’s health has been stable.

However, laboratory evaluation is recommended for patients with fluctuating renal function and those who are at higher risk of developing hypocalcaemia, such as those with malabsorptive disorders, hypoparathyroidism, advanced renal dysfunction (chronic kidney disease stage 4 or 5), or taking loop diuretics.

As per the guidance, Prof Walsh strongly emphasised the need for patients to continue taking denosumab, “at all costs. I think it is absolutely crucial for patients to get their denosumab” to avoid rebound and increased fracture risk.

“It is our most potent drug for bone suppression, but rebound is the big worry. It can come on very quickly and we have all seen

Vertebral fractures are highly predictive of future fracture risk and account for significant morbidity and mortality among older patients, the 2020 IOS conference heard.

Dr Rosie Lannon, Consultant Physician in Geriatric Medicine, St James’s Hospital, Dublin, outlined a number of interesting case studies and discussed the impact of vertebral fractures on patients and the health service.

While vertebral fractures are the most common type of osteoporotic fractures, 70 per cent remain undiagnosed, she said, stressing the need to address this to try to prevent a cascade of further fractures and morbidity through early diagnosis and commencement of bone protection medication.

A woman with one vertebral fracture has a 4.4 times increased risk of another and a 2.3 times increased risk of hip fracture, with further fractures far more likely to be more severe and to

Feature Osteoporosis 24 JANUARY-FEBRUARY 2021

BMD loss can continue despite taking zoledronic acid after denosumab; so if it is being tolerated well in older patients to continue it

occur in multiples.

“As well as increasing your risk of further fractures, there is the worsening physical health and quality-of-life – they cause pain, kyphosis, reduced mobility and independence, height loss, and swallow and respiratory problems.”

Treatment can reduce the risk of fracture within 12 months by 50-80 per cent, while fracture liaison has been shown to reduce morbidity and mortality, Dr Lannon noted.

Warning signs of a first vertebral facture include the patient being older, having had a previous non-vertebral fracture, having a low BMD and or low BMI, being physically inactive, being a current smoker, and having a fall. Height loss of 2cm is also a key warning sign, along with postural changes such as their head becoming forward from their body, rounded shoulders or a Dowager’s hump developing.

Some of the reasons for under-diagnosis of vertebral fractures include that only a minority result from a fall, and the symptoms are often attributed to other causes by both patients and healthcare professionals. In addition when imaging is undertaken for indications other than back pain the spine may not be scrutinised or the referring physician may regard a vertebral fracture as incidental to the reason for referral, she said.

Diagnosis wise, DXA scans with an LVA ( lateral vertebral assessment) have a very important role in detecting vertebral fractures and compared to radiography are more convenient, have less radiation and combined with a BMD score have better risk prediction accuracy, said Dr Lannon.

Following diagnosis, appropriate treatment and follow-up is key to avoid further fractures, she concluded.

Addressing the topic of physiotherapy for osteoporosis patients during the Covid-19 pandemic, Ms Aoife Ni Eochaidh, Chartered Physiotherapist, Clinical Specialist Physiotherapist, Women’s and Men’s Health and Continence, Bon Secour Consultants Clinic, Galway, advised of the importance of informing patients on the significant advancements in incontinence in bowel and bladder care. This is not only important to prevent slips, falls and fractures but also for their mental health, as the fear of embarrassment of an accident is very high.

Ms Aoife Ni Mhuiri, Chartered Physiotherapist,

Chartered Physiotherapist, Founder and CEO, Salaso Health Solutions Ltd. and Lecturer at Institute of Technology Tralee, relayed that for those cocooning, at least 30 minutes of moderate activity five days a week is advisable, pointing to the evidence on how appropriate exercise, including weight-bearing and resistance activities, helps reduce the incidence of frailty, pain, and falls as well as a myriad of other positive health benefits.

“We really need to encourage older people to maintain activity for bone health,” she stressed, saying that gentle encouragement and support is very helpful, adding that while walking is very beneficial it is not enough on its own. Ideally activity advice should be tailored to the individual patient and a ‘one size fits all’ approach avoided.

FRAX screening should be considered in older women

Systematic, community-based screening programmes of fracture risk in older women should be considered in an effort to reduce hip fractures, Prof Cyrus Cooper, OBE, President of the International Osteoporosis Foundation (IOF); and Professor of Epidemiology, University of Oxford, told the IOS conference.

He quoted the results of the UK SCOOP study, which investigated whether communitybased screening intervention could reduce fractures in older women, through a two-arm randomised controlled trial in women aged 70–85 years comparing the use of the Fracture Risk Assessment Tool (FRAX) with usual management. Treatment was recommended in 898 (14 per cent) of 6233 women. Use of osteoporosis medication was higher at the end of year one in the screening group compared with controls (15 per cent vs 4 per cent), with uptake particularly high (78 per cent at six months) in the screening high-risk subgroup. While screening did not reduce the primary outcome of incidence of all osteoporosis-related fractures (hazard ratio [HR] 0.94, 95 per cent CI 0.85–1.03, p=0.178), nor the overall incidence of all clinical fractures (0.94, 0.86–1.03, p=0.183), it reduced the incidence of hip fractures (0.72, 0.59–0.89, p=0.002). He said the findings show FRAX screening is potentially feasible and effective in reducing hip fractures.

Prof Cooper discussed the IOF European guidelines for the diagnosis and management of

osteoporosis, stressing the importance of checking bone turnover markers to verify compliance to bone resorption inhibitors after three-to-six months in patients prescribed these therapies.

As per the guidelines, Prof Cooper said regular review and follow up is key in these patients and clinicians should consider continuing or changing treatment after three years for IV or five years for oral bisphosphonates; and if the patient has an incident fracture. In low-risk patients, the guidelines say to consider possible discontinuation for two years (reconsider yearly), but in high-risk patients continue treatment.

Prof Cooper echoed previous speakers on the dangers of stopping denosumab (vertebral fracture risk) without an exit strategy involving replacement with bisphosphonates.

He also discussed the risk of osteonecrosis of the jaw (ONJ) and the crucial need for very careful planning for dental work in osteoporosis patients on bisphosphonates to minimise ONJ risk.

Both primary and secondary prevention of osteoporotic fractures should be a key goal for any clinician treating patients at risk of this disease, he said.

“In Europe all osteoporotic fractures combined number 3.5 million each year and cost around €40 billion. It is important to remember about 40 per cent are non-hip, non-spine, non-wrist sites,” Prof Cooper said, highlighting the importance of collating and comparing international data and creating patient registries, such as the Irish national hip fracture database which shows that there is an average of 3,750 hip fractures annually.

Calcium and vitamin D

Meanwhile, discussing nutrition and bone health, Ms Marie Roddy, Senior Paediatric Dietician, Letterkenny General Hospital, Donegal, stressed the combined role of calcium and vitamin D in maintaining BMD; “without vitamin D only 10-15 per cent of calcium is absorbed in the body."

She pointed out how vitamin D insufficiency remains common in Ireland and highlighted the importance of supplementation, as well as promotion of dairy products from a young age. Ms Roddy noted how vegetarians and vegans, coeliacs, diabetics and those with dairy allergies are at increased risk of having low BMD and the importance of highlighting this.

Feature Osteoporosis 26 JANUARY-FEBRUARY 2021

Theresa Lowry IPNA PRO, CNS at Institute of Technology

in my new role as a

SAFE AND EFFECTIVE PRACTICE REGISTERED NURSE PRESCRIBER

Theresa Lowry Lehnen discusses how systematic clinical decision-making and rigorous risk management processes within relevant clinical governance frameworks inform prescribing decisions and help maximise safe and effective practice in her new role as a Registered Nurse Prescriber (RNP)

Prescribing medication is a significant addition to a registered nurse’s scope of practice. As a professional skill it builds on the qualifications and competencies traditionally recognised at the point of general nurse registration. A nurse prescribing candidate attains the competencies of prescriptive authority by completing an accredited nurse prescribing educational programme. When considered competent to prescribe as per the HEI’s standards for the theoretical and clinical components of the programme, the prescribing candidate gains formal recognition by entry to the Registered Nurse Prescriber division of the register

maintained by the NMBI. Minimising risk and maximising effectiveness are two key underlying principles of nurse prescribing practice. Safe and effective practice is founded on a thorough understanding of the theory, concepts, legislation, frameworks, policies, procedures and guidelines pertaining to nurse prescribing. Patient safety is paramount. Therefore, professional and ethical nurse prescribing practice must be based on systematic clinical decision-making and rigorous risk management processes within relevant clinical governance frameworks. This paper discusses how such processes will inform prescribing decisions and help maximise safe and effective practice in my new role as an RNP.

Background

Prescribing medication is a complex and multifaceted process, which can be associated with adverse risks and inadvertent consequences. Prescriptive authority is therefore governed by a dual framework of professional regulation and legislation pertaining to medication and its associated regulations. Practice standards, decision-making frameworks, clinical governance structures and NMBI guidelines outline the criteria for safe and effective nurse prescribing practice. They provide a regulatory framework and professional guidance for prescriptive authority, which should be subject to continuous quality assurance and regular audits. The laws and regulations, the

Feature Nurse Prescribing 28 JANUARY-FEBRUARY 2021

Lehnen, Carlow and member of the Irish Student Health Association

standards, frameworks and criteria are designed to assure the public of the RNP’s accountability and professional competence. They ensure that appropriate measures of clinical and selfgovernance are in place.

While the Office of Nursing and Midwifery Services Director (ONMSD) has responsibility for leading the national implementation of nurse and midwife medicinal product prescribing in Ireland, the NMBI has overall responsibility to act in the interest and protection of the public. It provides for the registration, regulation and education of nurses and midwives and deals with matters pertaining to their professional practice.

Following successful registration with the NMBI, RNPs must work within their scope of practice and adhere to the most up-to-date decision-making framework for prescriptive practice. At all times, they must be aware of, and act in accordance with, the latest legislation and professional regulation as well as national and local health services best practice policies, procedures, protocols and guidelines (PPPGs).

The NMBI (2019) Practice Standards and Requirements for Education Programmes for Nurses and Midwives with Prescriptive Authority sets out the current educational standards and requirements for nurse and midwife prescriptive authority. The domains of competence represent the levels of knowledge, skills and competence the prescribing candidate must achieve in order to prescribe safely and effectively. The competency framework provides assurance of best practice and demonstrates that nurse prescribers have acquired the theoretical knowledge and utilise decision-making, problem-solving, analytical and reflective skills within their expanded role.

Context

Good prescribing practice should support patient care and encourage treatment concordance and adherence while taking into account clinical response, tolerability and lifestyle factors. Patients should be included in clinical decisionmaking processes which affect them, providing them with choices, while ensuring that prescriptive practice is also safe and appropriate. Unsafe practices are a leading cause of medication errors worldwide. The World Health Organisation’s (WHO’s) Global Patient Safety Challenge: Medication Without Harm outlines key local, national and global actions required

to reduce the level of medication-related harm, among them patient engagement, education and training, communication and teamwork, professional competence, and incident reporting and learning.

An Irish research study by Naughton et al. (2013) found that most prescribing decisions by nurses and midwives were clinically safe and appropriate. However, not all decisions were safe, indicating a level of inappropriate prescribing and the potential for drug errors. Nurse and midwife prescribers from eight different hospitals across 17 different areas of practice were included in this study. The sample included 142 patient records and 208 medications prescribed by 25 RNPs. Two expert reviewers applied the modified Medication

ensure safe and appropriate prescribing.

Continuous professional development, education, audit and evaluation of nurse prescribing practice maximise safe and effective prescribing. Audit, monitoring and evaluation of prescribing practice is a continuous process. It promotes best practice and measures the clinical outcomes and effectiveness of care.

Personal practice

Prescribing medication is a complex process often associated with side effects, risks and unintended consequences. It is paramount and in the patient’s best interest to minimise risk and maximise the effectiveness of prescribed medications. While most medication errors are avoidable, risk cannot always be eliminated. However, as an RNP every step must be taken to ensure that safety is maximised and risk is minimised within my professional practice.

Appropriate Index tool (eight criteria) to each medication, and concordance was calculated using the Cohen's kappa statistic for inter‐rater reliability. The study found that 95-96 per cent of medications prescribed for the diagnosed condition were both indicated and effective. Dosage, directions, drug-drug or disease-condition interaction, and duplication of therapy was appropriate in 87-92 per cent of reviewed prescriptions while duration of therapy received the lowest score (76 per cent). Overall, 69 per cent (reviewer two) – 80 per cent (reviewer one) of nurse prescribing decisions assessed by the reviewers met all eight criteria in the study. The researchers pointed out the value of good collaborative working and effective communication within multidisciplinary teams to reduce medication errors. They concluded that continuous education and evaluation of practice are essential for nurses and midwives to

In-depth knowledge of the theory, concepts, legislation, ethics and guidelines relating to nurse prescribing must be combined with best practice risk management procedures, including clinical governance and audit processes within the practice setting. My professional practice will adhere to clinical governance guidelines for prescribing medicinal products. While no longer compulsory, the continued use of a Collaborative Practice Agreement (CPA), designed in conjunction with my mentor, practice site coordinator (PSC) and GP employers, will promote safe and effective practice and provide guidance for the development, audit and evaluation of prescribing practice within my clinical setting.

A systematic clinical decision-making process will underpin my prescribing decisions, and all treatment decisions will involve discussion and agreement with the patient. Effective communication is important at all stages of the therapeutic consultation, from carrying out an accurate history with the patient to establishing a diagnosis, concordance and treatment adherence. It is important that patients are fully informed, consenting and compliant, and that any concerns raised by them are acknowledged and addressed.

Nurse prescribers must have a thorough understanding of the medication they prescribe, including side effects and possible interactions.

Feature Nurse Prescribing JANUARY-FEBRUARY 2021 29

Following successful registration with the NMBI, RNPs must work within their scope of practice and adhere to the most up-to-date decision-making framework for prescriptive practice

They must be proficient in practice and demonstrate the understanding, skills and knowledge required to carry out a competent history, assessment and examination specific to the patient’s presenting condition. This includes understanding the relevance of any diagnostic tests and results in relation to specific conditions and medications. In practice, I must be satisfied that the patient’s presenting condition is within my scope of clinical and prescriptive practice. An understanding of pharmacology, the patient’s needs and the condition being treated will help determine the most appropriate medication including dose, form, frequency and route of administration based on the individual patient’s characteristics.

Prescribed medication must be safe, evidencebased and in the patient’s best interest. Underlying principles of good prescribing practice involve selecting appropriate, safe and cost-eﬀective medicines, individualised for the patient’s needs. While the BNF and Irish Medicines Formulary will inform prescribing decisions and guide safe practice, each individual consultation must also closely examine the patient’s past medical history, current medications (including OTC, herbal remedies, vitamins and food supplements, homeopathic medications and any possible interactions), known allergies, sensitivities, and previous drug reactions. Other relevant factors that may need to be addressed include pregnancy, breastfeeding, co-morbidities, polypharmacy, cognitive impairment, or diﬃculties adhering to medication regimen. In addition, social, occupational and family history must be taken into consideration, and lifestyle factors such as smoking, alcohol and illicit drug use explored to assess potential risks or interaction with the medication prescribed.

Good prescribing practice involves patient education and a management plan for follow-up, monitoring and evaluation of care. Reviewing medications and monitoring the eﬀectiveness of treatment at each visit enhances patient safety. This is particularly important when polypharmacy exists and in patients with co-morbidities. Patients should be provided with clear explanations and a rationale for the medication prescribed, including name,

description, purpose, dose, frequency, duration, route, and any additional instructions required. Any potential side eﬀects or interactions with other medicines or food products should be discussed, and patients advised what to do if they have any concerns.

Prescriptions issued in my practice will comply with the relevant legislation and NMBI practice standards. In my clinical se ing, prescriptions will be issued electronically and will state the precise medication, generic name, regimen, dose, strength, route and frequency. Prescriptions will clearly state the patient’s name, address, date of birth, date of initiation of the medication and maximum duration. Abbreviations will be avoided, and only internationally and nationally recognised units will be used. All prescriptions issued will be dated and signed, and will include my nurse prescriber’s NMBI personal identiﬁcation number (PIN). Should a wri en error occur the script will be re-issued rather than altered or amended.

In my personal practice, I will not be prescribing MDA and oﬀ-label medication. However, it is important to be aware that particular requirements are necessary for Schedule 4 and 5 MDA drugs and a named schedule 2 or 3 MDA drug to be prescribed and issued by an RNP. Nurse prescribers have no legal authority to prescribe for any condition or change the route of administration for any Schedule 2 or 3 MDA medication not listed in Schedule 8. Issuing prescriptions for oﬀ-label use and EMPs must be within the RNP’s scope of practice. Nurse prescribers must be aware of

PPPGs and governance regarding oﬀ-label prescribing and the use of medical products outside of the terms of marketing authorisation in Ireland by the HPRA or EMA. Issuing a prescription verbally, by telephone, email or fax, is not permi ed under normal circumstances. However, provision under Regulation 8 of the Medicinal Products Prescription and Control of Supply Regulations (2003, amended 2007) allows certain prescription-only medicines to be supplied in emergency situations where a wri en prescription cannot be issued immediately. Legislation changes have recently been implemented to facilitate the safe supply of medicines during the Covid-19 pandemic. Under the new Covid-19 Emergency Provisions, the national electronic prescription transfer system allows for the transfer of a prescription between the prescriber and dispensing pharmacy by electronic means. However, any prescription sent outside of the national electronic prescription transfer system by fax or personal or commercial email accounts is not recognised in the legislation as a legally valid prescription.

A number of other important considerations apply within my prescriptive practice. In the case of repeat prescriptions, an established therapeutic relationship must exist with the patient, and an assessment of the need for continued treatment carried out and documented. The actions of prescribing and administering medication will be separated as part of an episode of care, except in the agreed circumstances outlined in my CPA. In keeping with professional practice, prescribing for myself, family or friends will not be undertaken. All nurse prescribing decisions and actions undertaken will be documented. Documentation provides information and continuity of care and also promotes quality and evidence-based practice. Comprehensive documentation is a legal requirement and an integral part of the prescribing consultation to ensure accountability and patient safety, thus minimising risk in practice.

To comply with standards and ensure safe and eﬀective nurse prescribing in my own practice, risk assessment tools and guidelines have been put in place. They include PPPGs for

Feature Nurse Prescribing 30 JANUARY-FEBRUARY 2021

medication safety, managing adverse events and incident reporting.

Medication errors

If a medication error or adverse incident occurs, nursing and medical interventions must be implemented immediately, focusing first on the patient’s physical needs to ensure safety and limit potential adverse effects. Medication adverse risk management guidelines and protocols must be strictly followed and adhered to. Line management and relevant staff must be informed of the incident as soon as possible and the National Medicines Information Centre (NMIC) and/ or the National Poisons Information Centre (NPIC) contacted where appropriate. The patient, their family or carer must be made aware and informed of the incident as per the HSE's National Open Disclosure Policy. The incident and all actions taken must be documented and incident management forms completed and returned. Medication errors resulting in adverse reactions must be reported to the HPRA in accordance with their criteria. The National Incident Report Form (NIRF) should be completed and returned as soon as possible after the incident occurs, usually within one working day.

The main objective of incident reporting and management is to learn from the incident in order to reduce the risk of its reoccurrence and ensure the safety of future patients. Incident reviews determine what took place as well as how and why an incident occurred. By establishing what was learned from a given incident such reviews allow steps to be taken to reduce the risk of reoccurrence, promote patient safety and establish lessons from the incident.

The WHO’s Patient Safety Workshop: Learning from Error focuses on five ways by which error can be reduced. These include the use of guidelines and standard operating procedures (SOPs) in practice, up-to-date training, medication safety, patient engagement and effective communication. The Patient Safety Tool Box Talks (HSE) provide an overview and easy to follow guidelines for effectively preventing and managing incidents in the work setting. The Patient Safety Strategy 2019-2024 (HSE) sets out six strategic commitments to identify risks and promote systems which help to improve performance and reduce adverse events. The HIQA National Standards for Safer

Better Healthcare and Guide to Medication Safety Monitoring Programme provide guidance for improving the safety, quality, and reliability of healthcare for patients, including medication safety. These workshops, guidelines, standards and strategies have informed and will guide my future practice.

Nurses and midwives with prescriptive authority are now prescribing a much wider range of medications across populations that are more diverse. While this has the positive impact of improved user outcomes, it is also more important than ever to carry out safe and effective prescribing practice to reduce the possibility of prescribing errors and adverse reactions. Prescribing has become more complex.

This in turn will enhance my knowledge and understanding of prescribed medications, ensure best practice is maintained and reduce the risk of drug interactions and errors occurring.

Conclusion

An RNP’s decisions are based on pharmaceutical knowledge, professional judgement and practical skills, and underpinned by an in-depth understanding of the relevant professional, legal and ethical frameworks and guidelines. Through an accredited nurse prescribing educational programme, I have gained the theoretical knowledge necessary for safe and effective nurse prescribing practice. I have collaborated and worked with the PSC and have the firm commitment and backing of my employers to oversee the introduction of nurse prescribing in my practice setting and ensure that all national guidelines, PPPGs and risk assessment procedures are in place. Throughout the programme I have worked consistently with my mentor, whose practice I observed and learned from and who has supervised and assessed my practice, ensuring that I am competent and proficient in the skills and knowledge required to practice safely, effectively and autonomously.

Polypharmacy is common, especially in older people, those who have co-morbidities, and in patients with long-term and chronic illnesses. Prescription errors can and do occur and it is important to minimise the risk. If uncertainty exists, it is important to consult with a pharmacist or another prescribing practitioner before prescribing medication. A system is in place within my organisation for reporting errors and near misses, and a no-blame culture for reporting errors exists. Continued use of a CPA provides guidance for the development, audit, monitoring and evaluation of my prescribing practice and will promote safety and effectiveness within my clinical setting. Drug and therapeutic committees have an oversight function in their role of assurance for appropriate patient drug therapy and outcomes, which supports and promotes safe patient care. Regular meetings with the Drugs and Therapeutics Committee Review Group will provide opportunities for continuous education and further audit and evaluation of my practice.

Safe and effective practice in the best interest of patients is of the highest importance and must take precedence in nurse prescribing practice. A commitment to continuous education and professional development, including regular audit, monitoring and evaluation of care will help ensure safe and effective prescribing practice within the clinical setting. While risk cannot always be fully eliminated, it can be minimised, and effectiveness maximised, through collaborative working, clear communication, systematic clinical decision-making and rigorous risk management processes within relevant clinical governance frameworks.

See www.nmbi.ie for more information on standards and guidance for RNPs.

References on request

Theresa would like to thank the Irish Practice Nurse Association for awarding her the IPNA Educational Bursary 2019 for her research. The €1,000 educational bursary awarded was used to help fund the cost of the nurse prescribing course, which she recently completed at the RCSI.

Feature Nurse Prescribing JANUARY-FEBRUARY 2021 31

Nurses and midwives with prescriptive authority are now prescribing a much wider range of medications across populations that are more diverse

The latest insights on MULTIPLE MYELOMA

It may have taken place via the medium of Zoom, but the 2020 Multiple Myeloma Ireland Patient and Carer Information Day was no less valuable in terms of helpful advice and education for patients with the blood cancer. The close-knit community of patients, supporters and healthcare professionals made the most of the virtual gathering, with an array of topical presentations on offer throughout the day.

Dr Niamh Keane, a Consultant Haematologist at Galway University Hospital, opened the meeting by giving an overview of the condition, explaining its biology, the clinical features of multiple myeloma, and the range of management options available.

Multiple myeloma is a neoplastic disease characterised by clonal proliferation of malignant plasma cells in the bone marrow. This leads to a wide range of manifestations, and CRAB is the acronym for the most common symptoms of multiple myeloma – elevated calcium, renal failure,anaemia, or bone problems.

Understandably, an extensive whole body assessment is needed in order to definitively diagnose the disease – this includes blood and urine tests to check for abnormal antibodies or paraproteins, as well as kidney damage, plus bone marrow biopsies and imaging such as MRI and/or PET scanning to assess bone damage. “For many patients, up to one-fifth, the presenting symptoms can be simply tiredness, which is very non-specific,” noted Dr Keane.

She outlined the spectrum of bone marrow disease that can precede multiple myeloma, such as monoclonal gammopathy of undetermined significance (MGUS) and smouldering myeloma; neither of these conditions display symptoms and so do not require treatment, but patients will need to be monitored as there is potential to progress to symptomatic multiple myeloma.

The principles of therapy in multiple myeloma are to stop the production of abnormal plasma cells, strengthen the bone and prevent fractures, treat anaemia and reduce fatigue, as well as

ensuring optimum quality-of-life by tailoring the treatment to the patient. Dr Keane explained that as a disease that affects multiple organ types, it often requires the input of several different specialists, such as haematologists, oncologists, orthopaedic surgeons, etc. “Every patient is different and support needs to be tailored to the individual patients.” Supportive and preventive care are essential to derive maximum benefit from the latest advances in treatment but the good news is that the whole suite of multiple myeloma care options is continually improving. Dr Keane concluded on a positive note: “Patients are living longer than ever with multiple myeloma in 2020.”

Psychological stress

Sorcha Connellan, a senior clinical psychologist at University Hospital Limerick then delivered a presentation on coping skills for those with multiple myeloma. Outlining the psychological and emotional responses to multiple myeloma, Ms Connellan noted that stress is a natural response to feeling threatened. Once the diagnosis of multiple myeloma is made, the most common responses are fear, sadness and anger, she explained. Patients can get stuck in an unhelpful pattern of thinking, expecting the worst, or just noticing the things they can’t do. She suggested using tools like meditation, yoga, and mindfulness at times when people feel overwhelmed with fear and anger. Low mood can be lifted via an upregulating activity such as exercise. She urged patients to keep a sense of perspective; “accept the things you cannot change and change the things you can, take control.” Multiple Myeloma Ireland support groups are invaluable for patients, as well as the Irish Cancer Society and local cancer support centres.

The process of stem cell transplant for myeloma was outlined by Karen Mulhall, a clinical nurse specialist in haematology at Galway University Hospital. She outlined the basis of the procedure, as well as the many practical issues involved for patients. Prior to the procedure, significant workup is required, including pulmonary function tests, an echocardiogram, a dental assessment, and a skeletal survey, among other tests. The procedure itself takes roughly five-to-six hours and side effects usually begin few days later; this includes significant mouth soreness, as well as gut irritation, which can cause nausea and diarrhoea. Fatigue is also common, and this can persist

Feature Multiple Myeloma 32 JANUARY-FEBRUARY 2021

Danielle Barron reports on the Multiple Myeloma Ireland Patient and Carer Day 2020, which took place virtually

Multiple Myeloma

throughout the recovery period.

Exercise

Miriam Flatley, a senior physiotherapist at Galway University Hospital with a special interest in haematological disorders, presented on the importance of exercise and movement for multiple myeloma. Ms Flatley outlined the myriad health benefits of exercise on general wellbeing, but also noted that in recent years there is a growing body of evidence to suggest that it is of significant benefit for patients with cancer. “As well as being effective, exercise is also very safe for you to take, before, during, and after your cancer treatment.” She acknowledged, however, that fitness levels can be affected by the disease as well as the treatments the patient is undergoing, emphasising the importance of including physical activity in the management plan.

Exercise can help prevent functional decline, and will also help to strengthen bones, hugely important in the context of multiple myeloma, explained Ms Flatley. It also improves fatigue, a common symptom of the disease and can help to alleviate the side effects of some treatments. Patients should not exercise when they are feeling nauseous, if their blood count is low, or if they have an infection and/or fever, she noted.

Covid-19

Covid-19 and multiple myeloma was the topic of the talk delivered by Geraldine Walpole, an advanced nurse practitioner at Sligo University Hospital. She explained how treatment had been adapted or adjusted for different cohorts of multiple myeloma patients. Although treatment is being postponed in some situations due to Covid risk, Ms Walpole explained that for the young transplant-eligible patients, treatment should not be postponed and therapeutic decisions should be made on a case by case basis. Granulocyte-colony stimulating factor (G-CSF) support would also be considered in order to avoid neutropaenia.

For some patients on continuous first-line treatment, however, consideration should be given to delaying the autologous stem cell transplant (ASCT) and instead prolong the induction regimen for up to six-to-eight cycles. “This will be at the discretion of your consultant as we know transplant is a very immunocompromising event and we have to tread very carefully,” she explained, adding that patients who are scheduled to undergo

transplant should be tested for Covid-19 as a precaution beforehand.

Phone and virtual visits are being used to great effect to monitor the patients on maintenance treatment, in order to decrease clinic attendance and thus reduce risk even further, Ms Walpole said. Patients who are stable should also be minimising their visits to the hospital, and community services have been invaluable during this time, she added. Some supportive treatments may be delayed, but again this is on an individual basis.

“The usual precautions that everyone is using for Covid-19 also apply to you and I would suggest that you should be wearing face coverings every time you leave your house,” she concluded.

cells, this may indicate more about the biological signature of the disease in each patient. “This could be the most important tool in multiple myeloma to predict outcomes,” she advised.

Nowadays, treatment is tailored to the patient in order to maximise the benefit of the treatment while minimising toxicity or side effects; “there is no one size fits all.” Shared decision-making between healthcare professionals and patients is key, she added.

The natural course of multiple myeloma typically involves an asymptomatic phase before patients develop symptoms and require treatment. Dr Glavey explained that induction treatment is required once this happens and the aim of this phase is to get the patient into a complete remission using first-line available therapies and possibly a stem cell transplant based on their age and performance status. “Unfortunately, we know that the vast majority of these patients will eventually relapse and in that case will require additional therapy, fortunately we have a wide range of therapies now available to patients, both in the frontline and relapsed refractory settings,” she said.

Treatment strategies

‘Current Developments in Managing Multiple Myeloma’ was the title of the concluding presentation, delivered by Dr Siobhan Glavey, a Consultant Haematologist at Beaumont Hospital, Dublin. She used the time to outline the various options involved in the treatment of multiple myeloma, the push towards individualised therapy, as well as some of the novel therapies that have recently become available. Latest data indicates that the incidence of myeloma has increased by 126 per cent from 1990 to 2016, noted Dr Glavey; “this is likely due to increased incidence of cancers worldwide, but also due to better diagnostics.” She pointed out that Ireland is among the countries with the top incidence rates of multiple myeloma, with an incidence here of somewhere between five and six per 100,000.

The importance of cytogenetics was highlighted, with Dr Glavey explaining that by understanding the genetics of the myeloma

Thalidomide was approved in 2008, followed by bortezomib and lenalidomide in their various doublet and triplet combinations and then came the next generation drugs like pomalidomide and carfilzomib. Several new classes of drugs are also now available, including the monoclonal antibodies daratumumab and elotuzumab and also some novel histone deacetylase (HDAC) inhibitors. “New mechanisms of action have markedly expanded the treatment options for multiple myeloma,” said Dr Glavey.

Despite these advances, however, stem cell transplant remains the most effective therapy in eligible patients, providing the “best chance of deep and durable remission”, said Dr Glavey, noting however, that there are significant associated side effects, including the risk of infection, as well as the associated psychological distress.

The next exciting novel therapy in myeloma is cellular therapy, Dr Glavey concluded. “To date this has been in the form of CAR-T-cells, but other cell types are also showing remarkable results,” she told the online audience. Irish patients will be partaking in European Myeloma Network trials in the near future, she added.

See www.multiplemyelomaireland.org for more information on the work of MMI Ireland.

Feature

JANUARY-FEBRUARY 2021 33

Thalidomide was approved in 2008, followed by bortezomib and lenalidomide in their various doublet and triplet combinations and then came the next generation drugs like pomalidomide and carfilzomib

OTITIS MEDIA

Otitis media is the term for a group of infective and inflammatory conditions affecting the middle ear, with a variety of subtypes differing in presentation, associated complications, and treatment.12

Acute otitis media (AOM) is an acute, suppurative infection marked by the presence of infected middle ear fluid and inflammation of the mucosa lining the middle ear. AOM can be caused by bacteria and viruses. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the main bacterial causes of the infection. Viruses that cause AOM include respiratory syncytial virus (RSV), rhinoviruses, influenza, and adenoviruses.3

AOM affects about 11 per cent of the global population annually. It occurs more often in children than in adults and is one of the most common paediatric infections for which antibiotics are prescribed. Half of cases involve children under five years of age and more than 75 per cent of episodes occur in children under 10 years of age. Most cases occur in young children aged six-to-24 months.1,2

The main symptoms of AOM include severe earache, a high temperature of 38°C or above and slight deafness. Other symptoms include tenderness of the skin above the ear, purulent discharge from the ear, loss of balance, irritability, vomiting, lethargy, and diarrhoea in infants. Since an episode of otitis media is usually precipitated by an upper respiratory tract infection (URTI), there are often accompanying symptoms like a cough and rhinorrhoea. A feeling of fullness in the ear may also occur.2 Other symptoms in young children include pulling, tugging or rubbing their ear, poor feeding, restlessness at night, unresponsiveness to quiet sounds or other signs of hearing difficulty or being inattentive.2

Complications of AOM include perforation of the ear drum, mastoiditis, and more rarely

intracranial complications such as bacterial meningitis, brain abscess or dural sinus thrombosis.9

It is important to make an accurate diagnosis of AOM to avoid overtreatment with inappropriate antibiotic therapy. Ear infections will often resolve on their own without antibiotic treatment. Taking antibiotics when they are not needed can be harmful, and may lead to unwanted side effects like diarrhoea, rashes, nausea, and stomach pain. Symptoms alone are not sufficient to diagnose AOM. Evaluation of the patient's clinical presentation and careful otoscopic examination are important in making the correct diagnosis.1

To confirm a diagnosis of AOM, middle-ear effusion and inflammation of the eardrum

must be identified. Signs include fullness, bulging, cloudiness and redness of the eardrum. It is important to differentiate between AOM and otitis media with effusion (OME), as antibiotics are not recommended for OME. Bulging of the tympanic membrane suggests AOM rather than OME.4

OME, often referred to as 'glue ear’, is the presence of non-infectious fluid in the middle ear for more than three months. It is not typically associated with symptoms, but occasionally a feeling of fullness is described. OME frequently occurs following AOM and may be related to viral upper respiratory infection irritants such as smoke, or allergies. Sometimes the fluid becomes infected, leading to AOM. After an episode of AOM has been treated or has resolved on its own, fluid may remain in the middle ear and take longer than a month to resolve.3 OME rarely develops in adults. When it does it is more likely to signify underlying Eustachian tube dysfunction rather than preceding AOM. It usually follows a significant URTI such as sinusitis. Other possible underlying factors include severe nasal septal deviation, large tonsils and adenoids, nasopharyngeal tumour, head and neck

34 JANUARY-FEBRUARY 2021 Otitis Media Feature

Theresa Lowry-Lehnen RGN, Clinical Nurse Specialist and Nurse Prescriber outlines the diagnosis and management of otitis media

To confirm a diagnosis of AOM, middle-ear effusion and inflammation of the eardrum must be identified

radiotherapy and radical head and neck surgery. Middle ear fluid in adults should be treated as suspicious, particularly if it is unilateral.11

Chronic suppurative otitis media (CSOM), is a chronic inflammation of the middle ear and mastoid cavity, characterised by a discharge from the middle ear through a perforated tympanic membrane for at least six weeks. It may be a complication of AOM. Pain is rarely present. Inflammation produces mucosal ulceration and breakdown of the epithelial lining. Granuloma formation can develop into polyps in the middle ear. Chronic suppuration can occur with or without cholesteatoma, and the clinical history of both conditions can be very similar. Cholesteatoma is an abnormal accumulation of squamous epithelium usually found in the middle ear cavity and mastoid process of the temporal bone. Granulation tissue and ear discharge are often associated with secondary infection of the desquamating epithelium.13,14

All three types of otitis media may be associated with hearing loss.3 Children with recurrent episodes of AOM and those with OME or CSOM have higher risks of developing conductive and sensorineural hearing loss. This is more common in males than females. Conductive hearing loss from otitis media can have a serious effect on speech and language development in children.7

The aetiology of otitis media is multifactorial and relates to anatomical variations, pathophysiology including the interaction between microbial agents and host immune response, and cell biology of the middle ear cleft and nasopharynx. URTIs such as a common cold can lead to mucosal congestion in the Eustachian tube and nasopharynx. The resultant congestion prevents normal Eustachian tube function and pressure regulation is altered within the middle ear.12 The mucus cannot drain properly, making it easier for an infection to spread to the middle ear. Younger children are particularly vulnerable to middle ear infections as they have a smaller Eustachian tube and larger adenoids than adults. Children who are born prematurely also have a higher risk of developing complications. Certain conditions such as a cleft palate and Down’s syndrome increase the risk of developing middle ear infections.6

Prevention

While it is not possible to prevent middle ear infections, there are a number of ways to reduce the risk in children. AOM is less common in breastfed than in formulafed infants, and the greatest protection is associated with exclusive breastfeeding for the first six months of life.4 Ensuring children are up to date with vaccines, especially PCV and DTaP/IPV/Hib vaccines, in early infancy decreases the risk of AOM in healthy infants. PCV, however, has not been shown to decrease the risk for high-risk infants or older children, who have previously experienced otitis media. Influenza vaccination in children has also been shown to reduce rates of AOM by up to 4 per cent. Environmental exposure to tobacco smoke, feeding children while lying on their back, and the use of pacifiers are all associated with increased risk of developing otitis media in children and should be avoided. Minimising contact with other children who are unwell may also help reduce a child's chances of catching an infection that could lead to a middle ear infection.6

Treatment and management

Most cases of otitis media resolve within a few days, however, it is important to seek medical attention if symptoms show no sign of improvement after two or three days, if there is a lot of pain, discharge, pus or fluid coming from the ear, of if there is an underlying health condition, such as cystic fibrosis. People with congenital heart disease, lung, liver, neuromuscular conditions, and those who are and immunosuppressed are also at higher risk of developing serious complications.6

NSAIDs, for example, ibuprofen or paracetamol, are used for symptomatic relief. Aspirin, however, should not be considered or given to children under 16 years of age. Decongestants or antihistamines may reduce swelling of the mucous membranes in the nose and back of the throat, keep the Eustachian tubes clear and allow mucus to drain from the middle ear, however, research has shown that antihistamines and decongestants do not help prevent ear infections.2 A warm compress over the affected ear may help reduce the pain.

JANUARY-FEBRUARY 2021 35 Otitis Media Feature AGE NORMAL DOSEMAXIMUM DOSE MAXIMUM DOSE CHECK (AVERAGE WEIGHT FOR AGE) 1-11 months 125mg TDS 30mg/kg per dose to be given three times daily 1 month (4.3kg): 125mg three times daily 11 months (8kg): 250mg three times daily 1-4 years 250mg TDS 30mg/kg per dose to be given three times daily 1 yr (9kg): 250 mg three times daily 4 yrs (16kg): 500mg three times daily 5-11 years 500mg TDS 30mg/kg per dose to be given three times daily 5 yrs (18kg): 500mg three times daily 11 yrs (35kg): 1g three times daily 12-17 years 500mg TDS 1g three times daily 1g three times daily

Table 1: Amoxicillin preferred antibiotic. Recommended duration five days

APPROXIMATE AGE WEIGHT DOSE (BASED ON 7.5MG/KG PER DOSE TWICE DAILY) 1-2 years 8-11kg 62.5mg per dose to be given twice daily 3-6 years 12-19kg 125mg per dose to be given twice daily 7-9 years 20-29kg 187.5mg per dose to be given twice daily 10-12 years 30-40kg 250mg per dose to be given twice daily

Table 2: Clarithromycin if allergic to penicillin. Recommended duration five days

Most children over the age of six months who develop AOM do not benefit from antibiotic therapy. Antimicrobials are not routinely used to treat middle ear infections, although they may occasionally be prescribed if symptoms persist or are particularly severe.5 Many cases of otitis media are viral in nature and the illness resolves over four days in 80 per cent of cases without antibiotics.8 A Cochrane review in 2015 concluded that ‘watchful waiting’ is the preferred approach for children over six months with non-severe AOM.10 A no or delayed antibiotic strategy should always be considered, however, if a bacterial infection is likely and antibiotics are clinically indicated amoxicillin is the preferred choice, with a recommended duration of five days (Table 1). If the child is allergic to penicillin clarithromycin is recommended for a duration of five days (Table 2). Children with otorrhoea, or who are aged less than two years of age with bilateral AOM, achieve greater benefit, but are still eligible for delayed prescribing.8

For children with recurrent, severe otitis media, tympanostomy tubes (grommets) may be inserted to help drain the fluid. Removal of the adenoids and tonsils may help if they are blocking the entrance to the Eustachian tube. Antibiotics, steroids, antihistamines and decongestants are not recommended to treat OME and if present for 12 weeks or more, OME requires referral to ENT.2

Otitis media in adults

The signs and symptoms of AOM in adults are very similar to those in childhood, with hearing loss, otalgia and fever. In adolescents and adults, otalgia is a more common presenting symptom than in children under the age of two. In adults, otalgia may occur without fever or hearing loss and may be the only presenting feature. Analgesics such as ibuprofen, or paracetamol are used for symptomatic relief. Nasal and oral steroids are sometimes indicated for adults with persistent AOM and a history of allergies. For most adults, a no antibiotic or a delayed antibiotic prescribing strategy should be considered. Antibiotic therapy when indicated is the same as for children; a five-day course of amoxicillin, or for those allergic to penicillin a five-day course of clarithromycin or erythromycin following adult

dosage guidelines. An immediate antibiotic prescription should be issued to patients who are systemically unwell, those at high risk of complications because of significant heart, lung, kidney, liver or neuromuscular disease, patients who are immunocompromised and to those whose symptoms have lasted for four days or more and are not improving.11

Differential diagnosis for AOM in adults is essentially the same as in children. However, in adults temporomandibular joint dysfunction and associated differential diagnoses should be considered. These can include angina and acute coronary syndromes, giant cell arthritis, dental problems, trigeminal neuralgia, migraine, trauma, herpes zoster and ENT disorders.11

Cultures may be carried out if chronic perforation is suspected and CT or MRI scanning may be required to exclude complications. Tympanocentesis may be indicated where local or systemic complications have developed, and in patients who are immunocompromised. Patients with acute complications of AOM, such as meningitis, mastoiditis, facial nerve paralysis or who are systemically very unwell, should be admitted for assessment. Routine referral to an ENT specialist is required if the patient has a craniofacial abnormality or has recurrent

References

1. Limb C, Lustig L, Durand M (2020). Acute otitis media in adults. Available at: www.uptodate.com/contents/acute-otitis-media-in-adults

2. HSE (2018) Ear infection inner. HSE. Available at: www.hse.ie/ eng/health/az/e/ear-infection,-inner/symptoms-of-otitis-media. html#:~:text=The per cent20main per cent20symptoms per cent20of per cent20acute,lethargy per cent20(a per cent20lack per cent20of per cent20energy)

3. CDC (2013) Ear Infections. Centres for Disease Control and Prevention. Available at: https://web.archive.org/web/20150219034155/http://www. cdc.gov/getsmart/antibiotic-use/uri/ear-infection.html

4. Lieberthal A, Carroll A, Chonmaitree T, Ganiats T, Hoberman A, Jackson M, et al (2013). The diagnosis and management of acute otitis media. Paediatrics. 131 (3): e964-99. doi:10.1542/peds.2012-3488

5. Coon E, Quinonez R , Morgan D, Dhruva S, Ho T, Money N, Schroeder R (2019). 2018 Update on Pediatric Medical Overuse: A Review. JAMA Paediatrics. 173 (4): 379–384. doi:10.1001/jamapediatrics.2018.5550

6. NHS (2020) Middle ear infection (otitis media). National Health Sevice. Available at: www.nhsinform.scot/illnesses-and-conditions/earsnose-and-throat/middle-ear-infection-otitis-media

7. Rosito L, da Costa S, Dornelles C (2009). Sensorineural hearing loss in patients with chronic otitis media. European Archives of Oto-RhinoLaryngology. 266 (2): 221–4. doi:10.1007/s00405-008-0739-0

8. HSE Antibiotic Prescribing (2020) Otitis Media Child Doses. HSE.

episodes, which are distressing or associated with complications. Urgent referral to an ENT specialist is required if nasopharyngeal cancer is suspected in adults, especially in the presence of persistent symptoms not responding to treatment, persistent cervical lymphadenopathy and unilateral epistaxis.11

As with children, complications in adults include tympanic membrane perforation, OME and CSOM. Severe infratemporal complications in adults include mastoiditis, acute labyrinthitis, petrositis, facial palsy, and acute necrotic otitis. Intracranial complications include meningitis, encephalitis, otitic hydrocephalus, sigmoid sinus thrombosis, and brain abscesses.11

In summary

Patients with uncomplicated AOM are usually treated in primary care and the prognosis for most people is very good. While seen frequently in children, AOM is less common in adults and the incidence is approximately 0.25 per cent per annum. Early diagnosis and prompt treatment decreases the risk of complications occurring, resulting in better patient outcomes. With the exception of those with risk factors and complications most middle ear infections in adults completely resolve in a couple of days.11

Available: www.hse.ie/eng/services/list/2/gp/antibiotic-prescribing/ conditions-and-treatments/upper-respiratory/otitis-media/

9. Jung, T, Alper, C, Hellstrom, S, Hunter, L, Casselbrant, M, Groth, A, et al (2013). Panel 8: Complications and sequelae. Otolaryngology – Head and Neck Surgery. 148 (4 Suppl): E122-43. doi:10.1177/0194599812467425

10. Venekamp R, Sanders S, Glasziou P, Del Mar C, Rovers M. (2015). Antibiotics for acute otitis media in children. The Cochrane Database of Systematic Reviews. 6 (6): CD000219. doi:10.1002/14651858.CD000219. pub4

11. Patient info (2016): Acute Otitis Media in Adults. Patient info for Medical Professionals. Available on line at: https://patient.info/doctor/acuteotitis-media-in-adults

12. Qureishi A, Lee Y, Belfiel J, Birchall P, Daniel M (2014). Update on otitis media – prevention and treatment. Infect Drug Resist. 7: 15-24. doi: 10.2147/IDR.S39637

13. AFP (2013) Chronic Suppurative Otitis Media. AFP. Clinical Evidence Handbook: A Publication of BMJ Publishing Group. Available at: www.aafp. org/afp/2013/1115/p694.html

14. Patient info (2018). Chronic Suppurative Otitis Media. Patient info for Medical Professionals. Available on line at: https://patient.info/doctor/ chronic-suppurative-otitis-media

Feature 36 JANUARY-FEBRUARY 2021 Otitis Media

Researchers from Trinity College Dublin, the Mercer’s Institute for Successful Ageing (MISA), Department of Biochemistry at St James’s Hospital and the University of Surrey have shown that rates of vitamin D deficiency are widespread within the Irish Asian community. The study was published recently in the journal Nutrients.

The team examined blood levels of vitamin D from 186 patients tested in the St James’s Hospital Laboratory (2013-2016) and found that 66 per cent were deficient, which is three-to-four times the deficiency rate of Irish Caucasians. Another 27 per cent were insufficient, leaving less than 7 per cent who were vitamin D-replete. These high rates of deficiency and insufficiency were observed regardless of season, gender, or age. However, as shown in other populations by this research team, males and younger adults had higher deficiency rates in comparison to females and older adults (>50 years). This is the first study

in Ireland to investigate vitamin D in an ethnic minority community. The team’s findings are similar to reports from the UK and Europe, where immigrant population groups have also been shown to have high levels of vitamin D deficiency.

Dr Eamon Laird, Senior Research Fellow at the School of Medicine, Trinity College, and first author, said: “This study highlights that vitamin D deficiency is common within ethnic minority groups within the Irish population. Of concern, there are no specific vitamin D food intake or supplement guidelines for immigrant populations in Ireland. Currently, adults in Ireland are recommended to take 10µg (400IU) daily through foods (oily fish, fortified foods) or a supplement. Older adults (>65 years) are now recommended to take a supplement of 15µg (600IU) daily.”

Prof James Bernard Walsh, from the Mercer’s Institute and Clinical Professor in Trinity College and co-author, said: “This study reflects our

experience in our Bone Health Unit in the Mercer’s Institute, where members of the Black, Asian, and Minority Ethnic (BAME) communities are presenting with very low vitamin D levels. Many need substantial amounts of vitamin D supplements to bring them up to normal levels. We also know from other recent research we have undertaken that Irish-born Caucasian people have a high level of vitamin D deficiency and insufficiency. Therefore, it is crucial that the Department of Health and HSE strongly advocate that Irish Caucasian people and BAME members of the community take regular intakes of vitamin D fortified foods, including dairy as appropriate, in addition to vitamin D supplements, especially in winter time. The association of low vitamin D levels and adverse Covid-19 outcomes in some studies also gives cause for concern.”

The paper is freely available at: www.mdpi.com/2072-6643/12/12/3674

DIABETES NEW UL CLINICAL RESEARCH FINDS PROMISING DRUG TREATMENT TO PROTECT KIDNEY FUNCTION IN DIABETES

A clinical trial involving researchers at the University of Limerick (UL) has demonstrated the potential benefits of new drugs in protecting kidney function in diabetes.

The new study has found that combining two treatments that lower uric acid concentrations in the blood reduces the leakage of albumin in the urine, one of the earliest signs of kidney damage in diabetes.The discovery could help to prevent kidney failure in diabetes patients, the UL researchers believe.

Researchers from the University of Limerick School of Medicine and University Hospital

Limerick, working with investigators from the University of California, San Diego, US, and AstraZeneca, found that the combination of Verinurad and Febuxostat reduced albuminuria in the urine by 39.4 per cent in patients with type 2 diabetes after 12 weeks of treatment, compared to placebo.

The results of this phase 2a clinical trial were recently published in the American Journal of Kidney Disease

Verinurad is a novel inhibitor of the uric acid transporter (URAT1) and is currently under investigation for the treatment of hyperuricaemia

and kidney disease. Febuxostat is a potent, selective xanthine oxidase inhibitor used to lower urate levels in patients with gout and hyperuricaemia.

The CITRINE clinical trial results show that the combination of drugs reduces the leaking of protein through the kidney.

“This is exciting news, as leaking of protein is the earliest clinical sign of kidney damage,” said Prof Austin Stack, Foundation Chair of Medicine at UL’s School of Medicine and Consultant Nephrologist at University Hospital Limerick, who was lead author of the study.

“The results are very promising, as they demonstrate an important reduction in albuminuria and hyperuricaemia in patients with type 2 diabetes when treated with a combination of Verinurad and Febuxostat.

“If we can intervene early on, then we are more likely to prevent patients from going into kidney failure. The findings raise hope for the 350 million people with type 2 diabetes globally who are at increased risk of kidney failure,” added Prof Stack.

In the multi-centre, randomised clinical trial, 60 patients with type 2 diabetes with albuminuria

and elevated uric acid levels were randomised to receive either Verinurad 9mg, and Febuxostat 80mg or placebo. The patients were followed up for 24 weeks.

The primary endpoint of the study was met and showed a 39 per cent reduction in albuminuria after 12 weeks with combined treatment of Verinurad and Febuxostat versus placebo. This effect persisted at 24 weeks, with an overall 49 per cent reduction in albuminuria. Treated patients also experienced a 57 per cent reduction in uric acid levels at 12 weeks. Both Verinurad and Febuxostat were well tolerated by patients, according to the study.

“One of the earliest signals of kidney disease is development of albuminuria... and recent studies have shown that this can be associated with high levels of uric acid,” said Prof Stack. “A key goal in protecting kidney function is the lowering of albuminuria in the urine, as patients with high levels are at risk of progressing to kidney failure.

“Although these are early clinical findings, our results show that combined treatment with Verinurad and Febuxostat in patients with diabetes results in a rapid reduction in albuminuria that was sustained through week 24.”

JANUARY-FEBRUARY 2021 37 Irish Research

NUTRITION RESEARCH SHOWS THAT VITAMIN D DEFICIENCY IS HIGHLY PREVALENT IN THE IRISH ASIAN COMMUNITY

THE DEMONISATION OF FAT

Tom Doorley recalls his mother's facination with food and its preparation

Iinherited my love of cooking and gardening very definitely from my mother. My obsession with secondhand bookshops came from my father, along with another unconscious bequest: A small appetite, especially for a male somewhat over six feet tall in old money.

My mother’s approach to food was always generous. Her philosophy in the kitchen could be summed up thus: How much food I give you reflects how much I love you. This had interesting consequences for my father and myself; we rarely managed to clear our plates.

My mother’s appetite was, as they used to say, healthy. She was not only fascinated by food and its preparation, she greatly enjoyed eating, and there was a time when she worried about weight; hers and mine.

By the time I was 12 I had the qualities of a straight line as defined by Euclid: Length and no breadth. There was concern that I was fading away. Around this time, she decided the time had come for her to diet. Many regimens were tried, but none seemed to do the trick.

I do recall, at first, that she decided to avoid what she called starchy food. Out went bread and potatoes; rice and pasta. While not unknown in Dublin at the dawn of the 1970s, they were not much of a sacrifice. Cakes and puddings, especially for a baker of her calibre, were.

In 1825, the French gastronome Jean-Anthelme Brillat-Savarin demonstrated that he had given some thought to obesity. History doesn’t relate very clearly how well-upholstered he was, but I wonder if he was speaking from personal experience when he wrote that the ‘cure’ for being overweight was abstinence from all things floury and starchy.”

Sugar

I’m grateful to Alan Watson, the American nutrition researcher, for reminding me of this, and for pointing out that around this time the annual per capita consumption of sugar in the US was 15lbs. Brillat-Savarin probably didn’t consider it to be even nearly as significant as the floury and starchy stuff. It is now 150lbs, by the way.

I make that just over 68kg per annum. The figure in Ireland seems to be - and I’m open to

correction - about 38kg per annum. But I digress.

In 1863, William Banting, the corpulent London undertaker, lost over six stone on a low carbohydrate and high fat diet, writing of his experience in his Letter on Corpulence. The leading medical journals of the day warned that Banting’s diet could be dangerous but their main gripe, it would appear, was that a layman was “meddling” in medical affairs.

Watson leaps forward to 1910 and recalls that American per capita butter consumption was 18lbs per annum while mortality from heart disease was under 10 per cent, as against 40 to 45 per cent today. At this point, lard was the leading cooking fat, butter being too precious a commodity for putting in the pan. The latest figure I can get for butter consumption in the US is for 2018: 5.8lbs per capita.

In 1910, the lifetime risk of developing type 2 diabetes was one-in-30; today, it is one-in-three.

A year later, according to Watson, “Proctor and Gamble introduce Crisco, [the] first shortening made from hydrogenated vegetable fat. P & G bought the patent for hydrogenation from an English company that was attempting to make candles out of the artificially hardened fat. When rural electrification wiped out the candle market, P & G hydrogenated vegetable oil and introduced Crisco, a cheap alternative to lard. Crisco featured a much longer shelf life and, over decades, gave unsuspecting Americans hundreds of millions of pounds of trans fatty acids.”

Cholesterol

In 1934, the blood test for cholesterol (which had

been isolated by de la Salle in the 18th century) was introduced and in 1937, two Columbia University biochemists, David Rittenberg and Rudolph Schoenheimer, noted that dietary cholesterol had very little effect on blood cholesterol.

Fast forward to 1953 and the publication of Ancel Keys’ Seven Countries Study, which concluded that high fat intake causes heart disease. If it had been called the Twenty-Two Countries Study, the conclusion would have been different. Keys had data from that many countries, but cherry-picked to support his own unfounded hypothesis. France, for example, where the diet was high in fat and the incidence of cardiovascular disease was low, was highly inconvenient. He left it, and similar countries, out.

Fast forward to 1997 and Keys, retired and unrepentant, stated, baldly, “dietary cholesterol and serum cholesterol are not related.” Despite this, and while the 2015 USDA guidelines say that cholesterol “is not a nutrient of concern” they recommend people to eat as little of it “as possible”.

In 1955, John Goffman, Professor of Molecular and Cell Biology at University of California Berkeley, demonstrated that carbohydrates elevate VLDL. The following year, he stated that the majority of people with cardiovascular disease had elevated triglycerides and depressed HDL, “not high cholesterol”. His paper, ‘Carbohydrate-Induced Lipemia’ was ignored by the American Heart Association and by the powers-that-be.

No doubt Goffman had read The Practice of Endocrinology, a British textbook by Greene et al, published in 1951. The dietary advice was identical to Banting’s, but went a little further, advising the avoidance of everything made with flour, cereals, including breakfast cereals and milk puddings, potatoes and all other root vegetables, foods containing sugar and all sweets. The medical journals of the time didn’t complain.

The ‘low fat equals good health’ mantra continues and while sales of butter have rallied a little, I still hear people speaking of full fat dairy products and red meat as “guilty” pleasures.

There’s a lot of money riding on the demonisation of fat. And money talks, often nonsensically.

38 JANUARY-FEBRUARY 2021 Life Food

NEW COVID-19 VACCINATION CENTRE ESTABLISHED AT THE BEACON HOSPITAL IN DUBLIN TO SUPPORT HSE ROLL-OUT

Covid-19 vaccinations have commenced for healthcare workers from across Dublin South, Kildare and West Wicklow (CHO7) and the Beacon Hospital at a newly set up mass vaccination centre, managed and facilitated by the Beacon Hospital.

Mary Paula Linehan, Public Health Nurse, was the first person from CHO 7 to be vaccinated with the Pfizer BioNTech Covid-19 vaccine as part of the rollout. She was vaccinated by her Beacon Hospital Vaccinator, Martina Jensen, ICU Clinical Instructor.

Sandra Spain was the first healthcare worker in the Beacon Hospital ICU to be vaccinated with the Pfizer BioNTech Covid-19 vaccine. She was vaccinated by Martina Jensen, ICU Clinical Instructor and vaccinator.

The newly set up vaccination centre, once home to The Beacon Hotel and recently purchased by the Beacon Hospital, has been totally transformed providing vaccination stations, and appropriate social distancing in line with infection prevention and control guidance. The mass centre can provide a minimum 100 vaccines per hour and has the flexibility to rapidly expand by adding additional vaccination stations. A peer vaccination team of up to 90 Beacon Hospital doctors and nurses will vaccinate staff Monday to Saturday, ensuring

that all personnel are protected in a planned and timely way. The vaccination centre at the Beacon Hospital is one of the first in the country, which will provide additional capacity to the Dublin Midlands Hospital Group and its Community partner, Dublin South, Kildare, and West Wicklow (CHO7). More than 900 doses of the vaccine were available to the facility initially, with further deliveries expected to support the scheduling plans for the ongoing programme across community and hospital services.

Ann O’Shea, Chief Officer, Dublin South, Kildare and West Wicklow (CHO7) said: “We are delighted to extend the commencement of our vaccination programme by partnering with the Beacon Hospital through our ongoing integration and partnership with the Dublin

Midlands Hospital Group. With circa 7,000 staff to be vaccinated across our area, we have a mammoth task on our hands, but one that we believe with patience and cooperation, we can deliver. The mass centre at the Beacon Hospital will ensure we can immediately protect the first 550 staff who are patient-facing, frontline carers, such as our home support staff, social inclusion staff, Covid testing staff, Covid vaccinators, GPs, mental health, and disability personnel. We would hope to be in a position to progress the vaccination programme in a timely manner, however, this is dependent on the vaccine availability. The increasing number of cases in the community is very concerning. We would ask our staff and community to work with us to flatten the current surge in Covid cases. It is really within our hands. Please stay at home and protect yourself and others."

Ms Eileen Whelan, Chief Director of Nursing at Dublin Midlands Hospital Group said: “Vaccinations work, and vaccination is key to ensuring patient and staff safety during the Covid-19 pandemic. We prioritise patient and staff safety equally during the pandemic and we continue to advocate to ensure vaccine allocations for all of our healthcare workforce.”

RESPIRATORY MEDICINE EDUCATIONAL MATERIALS NOW AVAILABLE IN NEW WEBSITE

Teva Ireland has announced the launch of www.LetsTalkRespiratory.ie, a free to access online hub of educational materials and resources, providing the latest news and updates supporting medical education in asthma, cystic fibrosis and COPD for healthcare professionals. The aim of www.LetsTalkRespiratory.ie is to support healthcare professionals to make a real difference to the lives of those living with asthma, cystic fibrosis, and COPD, which effect over 881,300 people in Ireland. All content is available at www.LetsTalkRespiratory.ie

Healthcare professionals will be able to access resources that they can use with patients to help manage their conditions, such as asthma and COPD patient booklets and consultation guides, self-management plans and peak flow diaries.

www.LetsTalkRespiratory.ie will also contain articles written by experts in the field, with titles such as ‘Managing COPD in Dementia’, ‘Impact of Obesity on Respiratory Diseases’ and ‘Biologic Use in Pregnancy’, providing great insight into managing patients with comorbidities or complications.

Commenting on the launch of the new hub, Dr Brian Kent, Consultant Respiratory and Sleep physician at St James’s Hospital, Dublin, said: “www.LetsTalkRespiratory.ie is an incredibly valuable resource for healthcare professionals working in respiratory. With easily digestible content, healthcare professional led videos and one minute to read white papers, this should be a go-to resource for anyone working in this field.”

Ms Clodagh Kevans, Specialty Medicines, Teva Ireland, said: “In addition to our significant respiratory manufacturing and R&D hub in Waterford, Teva is committed to providing bestin-class education and support to the healthcare community that we serve.

"The www.LetsTalkRespiratory.ie hub has been developed to deliver against this objective and we hope that all healthcare professionals working in the area of respiratory health will find this a helpful and knowledgeable resource that they can use to keep up-to-date on a range of topics that will in turn support the care that they provide to people living with asthma, COPD and cystic fibrosis in Ireland."

Visit www.LetsTalkRespiratory.ie to find out more.

Product News JANUARY-FEBRUARY 2021 39

ACROSS

Across

7 - Relating to growth (13)

7 Relating to growth (13)

8 Higher in rank (8)

8 - Higher in rank (8)

9 E xtent of a surface (4)

10 Subdivision (7)

12 Pilfer (5)

Down

SCRIBBLE BOX DOWN

1 List of food items available (4)

2 Turn down (6)

9 - Extent of a surface (4)

14 Journal (5)

10 - Subdivision (7)

16 Confer with others (7)

19 Sued (anag) (4)

12 - Pilfer (5)

20 Come nearer to (8)

On the ___ : About to happen (7)

4 Hurt; clever (5)

5 Whole (6)

6 Sport popular in America (8)

11 T he production and discharge of something (8)

13 Contrast (7)

1 - List of food items available (4)

2 - Turn down (6)

3 - On the ___ : about to happen (7)

4 - Hurt; clever (5)

5 - Whole (6)

14 - Journal (5)

22 Close mental application (13)

15 Lower (6)

17 Trousers that end above the knee (6)

18 Pale or dim (5)

16 - Confer with others (7)

21 Plant yield (4)

19 - Sued (anag) (4)

20 - Come nearer to (8)

22 - Close mental application (13)

6 - Sport popular in America (8)

11 - The production and discharge of something

13 - Contrast (7)

15 - Lower (6)

- Trousers that end above the knee (6)

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