The Journal of the Irish Practice Nurses AssociationIssue 6 Volume 3 November / December 2010

MANAgINg MAloDour IN PAllIATIve cAre wouNDs IN PrIMAry cAreGeorgina Gethin

soNAs, sPrAoI Agus sláINTeIPNA ANNuAl coNfereNce 2010

BAllyBofey, co DoNegAl

TAsTINg urINe IN BuruNDI

Marjorie Haire

cANcer eDucATIoN for PrAcTIce NursesRita Lawlor, Hilary Murphy, Marie Courtney and Rhonda Forsythe

INfANT feeDINg forMulAs– The gooD AND The BADSally-Ann McLaughlin

Because Travel advice only goes so far...Sanofi Pasteur MSD brings you

www.healthytravel.ieA resource which contains information and advice on healthy

travel practices as well as a list of useful checklists and contacts when travelling.

For you and your patients

08/10 IE00011

Let them know before they go

1

editorial

How times have changed. Imagine, the nursing services director now has a facebook and twitter account, all in the name of improving communications between the

HSE, Nursing and Midwifery groups. (Nursing Times Sept. 2010) At the same time nurses and midwives all over the world are celebrating 2010 as the International Year of the Nurse...Florence is dead 100 years.

Would Florence be proud of us I ask myself? The National cervical cancer screening round is on its last lap of the first three year screening round. The efficiency of the service has further improved by allowing direct programme entry since 1st September 2010 and is certainly welcomed.

The direct programme entry will make it easier and more user friendly, particularly for the new eligible women, minority populations, and the ‘harder to reach women’. Every avenue is now open for all women to get screened. We as practice nurses can continue our opportunistic screening without any barriers where CervicalCheck is concerned. Since the introduction of the National Screening Programme the smear test uptake has increased. This is thought to be due to a number of reasons such as the heightened awareness of the disease, (Jade Googy) easier access and reminder invitations.

Let us not forget about BreastCheck. This has also proved to be a successful screening strategy. Breast cancer has increased in Ireland in the past decade and it is expected that there will be 3000 new cases of breast carcinoma diagnosed per year by 2015.

Most recently it has been identified by The Irish Heart Foundation that women are often more concerned about breast cancer even though seven times as many women die from heart disease and stroke each year in Ireland.

The practice nurse has many roles and is pivotal to all three of the above initiatives

of cervical, breast and heart health. We celebrated Red Dress day in September to remind women that heart disease is not only a man’s disease. (Red Alert Campaign Sept., 2010). Heart disease actually kills more Irish women than any other disease in Ireland (IHD. 2010)

For the first time ever stroke has been included in the cardiovascular policy review. The FAST Campaign was launched in May 2010. This acronym was developed to inform the public about the key symptoms of stroke.

• Face: Has the face fallen to one side• Arms: Can they raise both arms and keep

the up• Speech: Is the speech slurred• Time: Time to call 999 if you see any of

the above.According to Dr Angie Brown, medical

director of the Irish Heart Foundation up to 10,000 people die each year of CVD.

The prediction is that by 2020 CD illnesses will have increased by a further 40%.

”Cardiovascular health is about maintaining health as well as providing care to those with problems. In this regard, the policy’s new 10 year targets for behaviour changes in the overall population are very welcome, particularly targets to reduce smoking by 1% per annum over 10 years. “ (A. Browne 2010)

As practice nurses we are ahead of ourselves promoting good health and reducing smoking, amongst many other elements mentioned in the new cardiovascular policy.

In essence it is to continue what we are already doing and improving our methods according to best practice....keeping up to date with the research and evidence based practice available at all times.

I am sure our sister Florence would approve. Of course there is always the matter of resources...but that’s for another day!

Darina Lane

Programmes and campaigns are having definite impact

Protecting today.Growing tomorrow.

Pfizer Healthcare Ireland, 9 Riverwalk, National Digital Park, Citywest Business Campus, Dublin 24, Ireland.

Pfizer Vaccines – helping to protect children right from the start.

PRE/2010/002

Pfizer Vaccines MI Advert.indd 1 20/09/2010 14:42:08

3

Issue 5 Volume 2 september / october2009

ContentsThe Journal of the Irish Practice Nurses Association

Nursing in General Practice is published by GreenCross Publishing, 7 Adelaide Court, Adelaide Road, Dublin 2. Tel: 4189799 Fax: 4789449Email: maura@greencrosspublishing.ie

© Copyright GreenCross Publishing 2010The contents of Nursing in General Practice are protected by copyright. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form by any means – electronic, mechanical or photocopy recording or otherwise – whole or in part, in any form whatsoever for advertising or promotional purposes without the prior written permission of the editor or publishers

EDITORMaura Henderson

CONSuLTING EDITORSDarina Lane and Ruth Morrow

SuB EDITORTim Ilsley

DESIGNERBarbara Vasic

PuBLISHERSGraham CookeMaura Henderson

*GreenCross Publishing is a recently established publishing house which is jointly owned by Graham Cooke and Maura Henderson. Between them Graham and Maura have over 25 years experience

working in healthcare publishing. Their stated aim is to publish titles which are incisive, vibrant and pertinent to their readership.

Graham can be contacted at graham@greencrosspublishing.ieMaura at maura@greencrosspublishing.ie

DisclaimerThe views expressed in Nursing in General Practice are not necessarily those of the publishers, editor or editorial advisory board. While the publishers, editor and editorial advisory board have taken every care with regard to accuracy of editorial and advertisement contributions, they cannot be held responsible for any errors or omissions contained.

Issue 6 Volume 3 November / December 2010

4 News

11 BrANch News

14 IPNA ANNuAl coNfereNce AND AgM

PIcTure gAllery

revIew

21 cANcer eDucATIoN for PrAcTIce Nurses rita lawlor, hilary Murphy, Marie courtney and

rhonda forsythe

25 MANAgINg MAloDour IN PAllIATIve cAre wouNDs IN PrIMAry cAre

georgina gethin

35 INfANT NuTrITIoN serIes

INfANT feeDINg forMulAs – The gooD AND The BAD sally-Ann Mclaughlin

32 ouT of hours

TAsTINg urINe IN BuruNDI Marjorie haire

38 PosTer serIes

exPerIeNce of woMeN IN A PosT NATAl suPPorT grouP IN wesT DuBlIN

christine Kelly

39 BooK revIew

ABsTrAcTs

41 eNDocrINology

42 gAsTroeNTerology

40,44 ProDucTs

45 crossworD

4

newslIsA NolAN, IPNA ADMINIsTrATorTel: 042 9692403email: admin@irishpracticenurses.ie

IPNA coNfereNce/AgM 2010Congratulations to the IPNA Donegal Branch and to Gráinne Lynch, IPNA Conference Coordinator, for a wonderful conference that was thoroughly enjoyed by all who attended. The speakers were well-received and the AGM was very productive with lots of discussion and debate from enthusiastic delegates. There were good suggestions on how to address the issue of non-renewals (166 in 2010) and various branches shared their own successful solutions for keeping membership numbers steady.

elecTIoN of Nec offIcers AT AgMSean Carey stood down from his role as National Vice-Chairperson. The NEC would like to thank Sean and wish him all the very best. Orla Loftus-Moran was re-elected National Chairperson, Róisín Doogue was elected National Vice-Chairperson, Mary O’Connor was re-elected National Treasurer and Lynn Cartwright was re-elected National PRO.

AwArDsCongratulations to the following members who won awards at the conference – Maureen Delaney, IPNA Galway Branch (Practice Nurse of the Year Award 2010), Jane Campion, IPNA Wicklow Branch (IPNA Educational Bursary 2010) and una Quill, IPNA Cork Branch (Valerie Mangan IPNA Loyalty Award 2010).

reMINDer re MeMBershIP reNewAlsPlease remember to send your renewal forms back to Tracey as soon as possible if you have not already done so. Any member who is not included in the Membership Database on 1st January 2011 will not:• Receive automatic invitations to their monthly branch

educational meetings.• Receive e-mail and text alerts with educational news.• Have access to the Members Area of the website which includes

educational speakers’ presentations from previous conferences.• Receive relevant mail shots.• Be entitled to enter the various IPNA Educational Awards, Grants

and Bursaries.• Receive invitation to the 2011 Annual Educational Conference.

(IPNA conferences include educational speakers on current topics relevant to Practice Nursing, research presentations, practical clinical workshops, exhibition area with plenty of opportunity to speak to relevant companies and groups, poster displays).

• Be entitled to receive a free IPNA Professional Development Portfolio and Resource Pack or any of the updates for this.

• Have access to discounts offered to IPNA members by other companies/groups.**Remember** The Nurses Act (being passed into law at present)

makes provision for the new Nursing and Midwifery Board to “develop, establish and operate one or more than one scheme for the purposes of monitoring the maintenance of professional competence by registered nurses and registered midwives.”, and confers a duty on registered nurses and registered midwives to “maintain professional competence on an ongoing basis.”

Nec MeeTINgs 2011 Ashling Hotel, Parkgate Street, Dublin 8.

Wednesday 2nd February 2011Wednesday 4th May 2011Wednesday 7th September 2011Friday of Conference weekend – October 2011.

NEC NEWS

Type 2 Diabetes – new treatments versus oldSince publication of the above named article (Sept/Oct issue ) the European Medicines Agency has suspended marketing authorisation of the drug Rosiglitazone (Avandia) and drugs containing Rosiglitazone (Avandament). As such these products are being withdrawn by the Irish Medicines Board. Further information may be obtained on the following websites: www.icgp.ie; www.imb.ie; www.emea.europa.eu

low back pain – is exercise the answer?On the cover and contents of our last issue, the name of the author was spelt incorrectly, the name Clarke should have been spelt Clark.

CORRECTIONS AND CLARIFICATIONS

As many of you will be aware, our very dear friend and colleague, Kathy O’Brien passed away peacefully at home on the 26th October 2009.

Kathy fought a brave and dignified battle during her 16 month illness with the future of her family her primary concern - so typi-cal of Kathy.

Kathy trained at the Mercy Hospital, Cork followed by Midwifery at the Erinville also in Cork.

she then worked for many years in Orthopaedics at Water-ford Regional Hospital. During this busy time she met and married her beloved Vincent and raised their two beautiful daughters Fiona and Claire.

In the millennium year Kathy changed direction and joined Western House Medical Centre as a Practice Nurse. Water-ford’s loss was definitely our gain. She was an exceptional Practice Nurse, much loved by patients and colleagues alike, a truly valued member of the team, a whirlwind and a real organiser: while we were just thinking about it Kathy had it already sorted!

She was a long term, proactive and enthusiastic member of the IPNA, holding office for many years at both local and national level. Kathy loved nothing better than catching up with friends at the annual Conference and hatching plans for the season ahead. Among other things she was to the fore in promoting pension rights for Practice Nurses.

Kathy was a truly unique person. She is so sadly missed by her family, friends and all her colleagues. She leaves a per-sonal and professional legacy that will not be forgotten.

The South Tipperary Branch of the IPNA extend our most sincere condolences to her husband, children and family.

Ar dheis Dé go raibh a hanam dílis.

oBITuAry

Kathy O’Brien

5

conference report

Friday 15th October this year saw many stylish women arriving in the town of Ballybofey, Co Donegal. Was there an international sporting event on? Was there a VIP in town? Was Mr McElhinney giving clothes away? No. This was the location for the 2010 Irish Practice Nurses Association Educational Conference. Exhibitors, guests and speakers joined the IPNA members at Jackson’s Hotel and were given the warmest of welcomes by the host branch, Donegal.

sláinteIn this time of financial and social difficulties, the Donegal ladies stayed true to their traditional bright outlook and chose the theme of ‘Sonas, Spraoi agus Sláinte’ (happiness, laughter and health). The Conference programme was the perfect mix of clinical/theory and practical presentations – all of which took care of the Sláinte part of the theme.

The conference opened on Friday with clinical sessions. Kathleen Crerand spoke on diabetes and its practical management in the community, whilst Maeve Cusack updated us on changes to Breast-Check. Nicola Fullam, PR Manager for Merck Crystal Clear Literacy Awards, demonstrated that the awards are achievable for all, and the importance of adult literacy in healthcare. Michael Power gained admiration for his frank presentation of his own experience with regard to adult literacy in the area of family health.

Elsie Stewart, chairperson of Donegal Branch, gave us a warm ‘poetic’ opening address, followed by Dr Gerry Lane (Consultant in Emergency Medicine at Letterkenny General Hospital who ex-plained to us all ‘What not to do at a road traffic accident!’ followed by a surprise visit by Ambulance and Emergency Response unit personnel, who were waiting to show attendees the inside of the emergency vehicles. We all left the presentation knowing the dif-ference between a yellow and a white hard hat and were putting high visibility jackets at the top of the next shopping list. What most would not have been aware of, however, was that as Dr Lane started speaking three road traffic accidents were happening out on the roads of Donegal...

Jane Campion, winner of the IPNA Educational Bursary 2010, presented the results of her research into ‘Chronic disease manage-ment and multimorbidty in the Irish primary care setting’.

Saturday morning started with Brona Cloonan sharing her knowledge of motivating weight management. As an ex-practice nurse herself, she was able to focus on problems facing the practice nurse today. The nutrition theme was continued by Louise Sullivan, Corporate Communications Manager from Kelloggs (who kindly sponsored this presentation). Kelloggs then invited us to join them for the ‘big breakfast’. With a hearty feed – not a rasher in sight – there was still plenty of time to view the exhibition stands and chat with the exhibitors.

Our next two speakers were sponsored by Promed. Dr Janice Richmond informed us of what can be expected of us with the care of oncology patients moving into primary care. We returned to nu-trition with local GP Dr Aidan McMenamin helping us understand vitamin B12 deficiency. His slide of a tape worm just before lunch was perhaps badly timed!

The Winner of the Valerie Mangan IPNA Loyalty Award 2010 was una Quill from Cork. This prize is open to any IPNA member who has loyally attended all their branch meetings during the year. Valerie was devoted to IPNA loyalty and felt very strongly about branch attendance. This year the Award was sponsored by GSK and was presented by Val’s sister Dorothy.

‘Ballyvegas’The evening programme opened with all being invited to show off their gambling skills at the roulette wheel and blackjack table – Las Vegas in the Hills of Donegal. No money exchanged hands but a lot of laughing took place. A delicious Gala Dinner was followed by the presentation of Practice Nurse of the Year Award 2010 (sponsored by Allen & Hanbury) to Maureen Delaney (see separate attach-ment). The evening concluded with lively entertainment from the Beefsteak Dancers ably abetted by Pauline Kilkoyne’s beautiful voice.

The 2011 IPNA Educational Conference will take place on 14th and 15th October, in the Tullamore Court Hotel. With this central lo-cation, we look forward to seeing many more members attending.

Congratulations to the 2010 Practice Nurse of the Year Maureen Delaney”

At the recent annual conference of the Irish Practice Nurse Association, held in Balleybofey, Donegal. Maureen Delaney received the award for Practice Nurse of the Year 2010.

Maureen trained in both general and midwifery nursing in University College Hospital Galway

She has worked in her Practice Nurse post with Dr Eugene O’Brien in the Dunloe Medical Centre, Ballinasloe for the past 8years.

Independent judges commented that Maureen employs all the attributes of advocacy in her role as practice nurse , and this ,on behalf of her Diabetes patients also singles her out She has developed both her knowledge and skills in order to care for her patients with evidence base health care. She has shown that she fulfills the role of clinical specialist in her support and encouragement to colleagues. She is an active member of her local branch of the IPNA.

One of her colleagues commented that “ she is an excellent role model and demonstrates that Practice nurses can indeed make significant differences in Primary Care

New members always welcome and practice nurses can obtain further details of local meetings and of membership at www.irishpracticenurses.ie

Sonas, spraoi agus sláinteLynn Cartwright

orla loftus-Moran, National chairperson, IPNA, Maureen Delaney winner Practice Nurse of the year Award 2010, Ann Mcgill previous winner of the award in 2009 and Irene walsh representing sponsors Allen & hanburys.

Practice Nurse of the year 2010 – Maureen DelaneyAt the recent annual conference of the Irish Practice Nurse Association, held in Balleybofey, Donegal. Maureen Delaney received the award for Practice Nurse of the Year 2010.

Maureen trained in both General and Midwifery Nursing in university College Hospital Galway.

She has worked in her Practice Nurse post with Dr Eugene O’Brien in the Dunloe Medical Centre, Ballinasloe for the past 8years.

Independent judges commented that Maureen employs all the attributes of advocacy in her role as practice nurse on behalf of her diabetes patients and this was just one of the factors that singled her out. She has developed both her knowledge and skills in order to care for her patients with evidence based healthcare. Maureen has shown that she fulfills the role of clinical specialist in her support and encouragement to colleagues. She is an active member of her local branch of the IPNA.

One of her colleagues commented that “she is an excellent role model and demonstrates that Practice Nurses can indeed make significant differences in primary care”.

6

news

ATHENS A Trial of HPV Education and Support

The much anticipated human papillomavirus (HPV) vaccine programme has now been rolled out in Irish schools. Meanwhile, the national cervical cancer screening service, CervicalCheck, is entering its third year. And there is considerable debate in the media, and elsewhere, about the future role of HPV testing in clinical practice and cervical screening. How do GPs and practice nurses keep up to speed with this rapidly developing area, so that they can provide the best advice and care to their patients?

The Irish Cervical Screening Research Consortium, also known as CERVIVA, is embarking on a trial of resources to support GPs and practice nurses in the area of cervical screening, HPV infection, HPV vaccination and HPV testing. The aim is to develop resources to help health professionals translate the vast amount of information available into their clinical practice. As part of this research, over the next few months, practice nurses (and GPs) across the country will be invited to take part in telephone interviews and/or a postal survey.

If you would like to find out more about the study, or to take part, please contact the study co-ordinator, Lisa McSherry, at the National Cancer Registry, on 1800 283097 or email athens@ncri.ie

Eligard launches gold service training and information Astellas Pharma the makers of the prostate cancer hormone drug EligardTM has launched the new Eligard Gold Standard Service ensuring that the medical practitioner and their patient will have the best knowledge, understanding and support feasible for treating prostate cancer.

Launched in November and working with TCP Homecare, Astellas Pharma will be offering training on the administration of EligardTM to medical practitioners including nurse specialists and GPs.

Patricia healy, TcP homecare Nurse, sampling the eligard Product at the launch.

New research reveals that two thirds of Irish people (67%) are concerned about the health of their heart. The data came out to mark the start of an awareness drive around atrial fibrillation (AF), and the Irish Heart Foundation’s publication of a new information booklet, AF and you, for people with the condition.

Dr Angela Brown, medical director at the Irish Heart Foundation, says:

“Every year, we receive many calls from people about AF. Now there is a booklet, AF and you, and we want people with AF to contact us and get their free copy. The causes of AF are not always clear, but your chances of developing AF can be increased by several medical conditions such as high blood pressure, diabetes and heart disease. Fortunately, there are treatments available and AF can be corrected or controlled. People with AF should work closely with their doctor to minimise the risk of stroke, or other related heart problems.

“The first step when someone develops AF is to look for any underlying cause. The history may reveal a background of heart valve disease, coronary artery disease or thyroid disease. Alcohol plays an important role in precipitating AF in some patients. People with AF should talk to their doctors particularly if they have symptoms such as breathlessness, dizziness or palpitations, as new treatments for AF are available.”

People with AF, and their carers, are invited to call 01 668 5001 or email info@irishheart.ie to get their free copy of AF and you. Or send a letter of request to AF Awareness, Irish Heart Foundation, 4 Clyde Road, Ballsbridge, Dublin 4. You can also ring the Irish Heart Foundation helpline on 1890 432 787. The AF and you booklet is produced in association with sanofi-aventis.

Marie upton, Nurse, Irish heart foundation, Aidan stacy, head of fundraising, Irish heart foundation and sinead Duffy, communications Director, sanofi-aventis at the launch of the booklet.

Atrial fibrillation awareness drive

• Superior Bronchodilation

versus tiotropium1,2,*

• 5 minute rapid onset of action3

A new first line once daily maintenance treatment for COPD

1

Onbrez® Breezhaler®

Please refer to Summary of Product Characteristics (SmPC) before prescribing. Presentation: Onbrez Breezhaler 150mcg and 300mcg inhalation powder hard capsules containing indacaterol maleate, and separate Onbrez Breezhaler inhaler. Indications: For maintenance bronchodilator treatment of airflow obstruction in adult patients with chronic obstructive pulmonary disease (COPD). Dosage and administration: Recommended dose is the inhalation of the content of one 150mcg capsule once a day, administered at the same time of the day each day, using the Onbrez Breezhaler inhaler. Capsules must not be swallowed. Dose should only be increased on medical advice. The inhalation of the content of one 300mcg capsule once a day has been shown to provide additional clinical benefit with regard to breathlessness, particularly for patients with severe COPD. Maximum dose is 300mcg once daily. No dose adjustment required in elderly patients, for patients with mild and moderate hepatic impairment or for patients with renal impairment. No data available for use in patients with severe hepatic impairment. No relevant use in the paediatric population. Contraindications: Hypersensitivity to the active substance, to lactose or to any of the other excipients. Warnings/Precautions: Asthma: ◆ONBREZ BREEZHALER SHOULD NOT BE USED IN ASTHMA. Paradoxical bronchospasm: ◆If paradoxical bronchospasm occurs Onbrez Breezhaler should be discontinued immediately and alternative therapy substituted. Deterioration of disease: ◆Not indicated for treatment of acute episodes of bronchospasm, i.e. as rescue therapy. Systemic effects: ◆Indacaterol should be used with caution in patients with cardiovascular disorders (coronary artery disease, acute myocardial infarction, cardiac arrhythmias, hypertension), in patients with convulsive disorders or thyrotoxicosis, and in patients who are unusually responsive to beta2-adrenergic agonists. Cardiovascular effects: ◆Indacaterol may produce a clinically significant cardiovascular effect in some patients as measured by increases in pulse rate, blood pressure, and/or symptoms, ECG changes. In case such effects occur, treatment may need to be discontinued. Hypokalaemia: ◆ Beta2-adrenergic agonists may produce significant hypokalaemia in some patients, which has the potential to produce cardiovascular effects. In patients with severe COPD, hypokalaemia may be potentiated by hypoxia and concomitant treatment which may increase the susceptibility to cardiac arrhythmias. Hyperglycaemia: ◆Inhalation of high doses of beta2-adrenergic agonists may produce increases in plasma glucose. Upon initiation of treatment with Onbrez Breezhaler plasma glucose should be monitored more closely in diabetic patients. ◆During clinical studies, clinically notable changes in blood glucose were generally more frequent by 1-2% on Onbrez Breezhaler at the recommended doses than on placebo. Onbrez Breezhaler has not been investigated in patients with not well controlled diabetes mellitus. Pregnancy and Lactation: ◆No data available from the use of indacaterol in pregnant women. Onbrez Breezhaler should only be used during pregnancy if the expected benefits outweigh the potential risks. ◆Not known whether indacaterol / metabolites are excreted in human milk. A decision must be made whether to discontinue breast-feeding or discontinue Onbrez Breezhaler therapy, taking into account the benefit of breast-feeding for the child and the benefit of therapy for the woman. Interactions: ◆Concomitant administration of other sympathomimetic agents may potentiate the undesirable effects of Onbrez Breezhaler. Onbrez Breezhaler should not be used in conjunction with other long-acting beta2-adrenergic agonists or medicinal products containing long-acting beta2-adrenergic agonists. ◆Concomitant hypokalaemic treatment with methylxanthine derivatives, steroids, or non-potassium-sparing diuretics may potentiate the possible hypokalaemic effect of beta2-adrenergic agonists, therefore use with caution. ◆Indacaterol should not be given together with beta-adrenergic blockers (including eye drops) as these may weaken or antagonise the effect of beta2-adrenergic agonists. Where required, cardioselective beta-adrenergic blockers should be preferred, although they should be administered with caution. ◆Inhibition of the key contributors of indacaterol clearance, CYP3A4 and P-gp, does not raise any safety concerns given the safety experience of treatment with Onbrez Breezhaler. ◆Indacaterol has not been shown to cause interactions with co-medications. Adverse reactions: ◆The most common adverse reactions with Onbrez Breezhaler are: nasopharyngitis, upper respiratory tract infection, sinusitis, diabetes mellitus and hyperglycaemia, headache, ischaemic heart disease, cough, pharyngolaryngeal pain, rhinnorrhoea, respiratory tract congestion, muscle spasm, peripheral oedema. ◆Uncommon: paraesthenia, atrial fibrillation and non-cardiac chest pain. ◆Please refer to SmPC for a full list of adverse events for Onbrez Breezhaler. Legal Category: POM Pack sizes: Carton containing 30 capsules (3x10 capsule blister strips) and one Onbrez Breezhaler inhaler. Marketing Authorisation Holder: Novartis Europharm Limited, Wimblehurst Road, Horsham, West Sussex, RH12 5AB, United Kingdom. Marketing Authorisation Numbers: EU/1/09/593/002 & 007. Full prescribing information is available on request from Novartis Ireland Ltd, Beech Hill Office Campus, Clonskeagh, Dublin 4. Tel: 01 2601255 or at www.medicines.ie Date of Creation of API Text: Jan 2010 Date of Preparation: July 2010 NO0610286 References: 1. Onbrez Breezhaler SmPC. 2. Donohue JF, Fogarty C, Lotvall J, Mahler DA, Worth H, Yorgancioglu A, Iqbal A, Swales J, Owen R, Higgins M, Kramer B. Once daily Bronchodilators for Chronic Obstructive Lung Disease: Indacaterol versus Tiotropium. Am J Crit Care Med. June 2010 3. Balint et al. Fast onset of bronchodilation with indacaterol in patients with COPD (ERS Poster) 2009. * INHANCE Study comparitor was open label Tiotropium

ABBREVIATED PRESCRIBING INFORMATION

Project3 16/11/2010 17:17 Page 1

8

newsSIMPONI launch meeting

At the sIMPoNI launch were Ms Ann Mc Dermott (MsD) and rheumatology Nurse specialists; Ms Patricia Minnock, Ms Trish Bewley, and Ms geraldine Mannion.

At the sIMPoNI launch were rheumatology Nurse specialists; Ms Madeline o’Neill, Ms Angela camon and Ms louise Moore.

Practice Nurse RequiredPractice nurse required for 11 months maternity leave cover in inner city practice. Full time position. Duties include: primary childhood vaccination programme, cervical screening, phlebotomy and chronic disease management. Starting 3rd January 2011. Experience desirable but not essential.

Contact Deirdre Langton, Practice Manager, Coombe Healthcare Centre, Dublin 8. 4730893 / 0863275461deirdre.langton@gmail.com

Clinical Nurse Manager

Clinical Nurse Manager required for full time position in large General Practice in North Tipperary. Management experience essential.

Interested applicants please send cv to mccaugheyg@hotmail.com

The 25th November was the united Nations designated International Day for the Elimination of Violence against Women. This day acts as a prompt to ensure that relevant and appropriate information on domestic violence and sexual violence is available in all GP practices, both for the GP and Practice Nurse but also for reception staff and for patients to access every day. The SAFE Ireland and Rape Crisis Network Ireland (RCNI) leaflets enclosed in this edition of Nursing in General Practice provide concise, national referral information on free and confidential domestic violence services and sexual violence services available to women across Ireland.

Practice nurses have a critical role in identifying and supporting patients who have experienced or are experiencing domestic and/or sexual violence. Recognising the indicators and signs of abuse and sexual violence, providing an empathetic and confidential practice environment, being aware of services and supports available (both local and national) and giving appropriate support service information are key to what a Practice Nurse can offer to patients. Supporting a patient in the context of domestic and/or sexual violence includes providing pertinent information on services and resources available and encouraging the patient to seek support and help when she wishes to.

The Rape Crisis Network Ireland (RCNI) is the national representative body for Rape Crisis Centres (RCCs) in Ireland. SAFE Ireland is the national representative body for women’s frontline domestic violence services in Ireland. Additional free copies of the leaflets and further information are available respectively from SAFE Ireland on 0906 479078 or info@safeireland.ie or from the Rape Crisis Network Ireland on 091 563676 or info@rcni.ie

Domestic violence – the role of the practice nurse

More Taste, Less Waste.New Ensure Plus –It’s the taste we love!

REFORMULATED

ENSURE PLUS

NEW

* Study to improve Understanding of Sensory factors and Taste And their Impact on compliance with Nutritional drinks.

References available on request.Abbott Laboratories Ltd., 4051 Kingswood Drive, Citywest Business Campus, Dublin 24Tel: (01) 4691500. Fax: (01) 4691501. Email: abbott_nutrition_irl@abbott.comDate of Preparation: April 2010 ANI/SIP/2010/015

SUSTAINstudy*n >1,700

SUSTAINSUSTAIN

Ensure Plus -The preferred supplement1

10

news

Osteoporosis guidelines for healthcare professionalsA new booklet has been launched by the Irish Osteoporosis Society to mark World Osteoporosis Day 2010 which took place on October 20th. Osteoporosis Guidelines is aimed at healthcare professionals to aid diagnosis and recognise symptoms of an otherwise silent disease.

Currently, 300,000 people in Ireland over the age of 50 are estimated to have osteoporosis and one in two Irish women and 1 in five men over the age of 50 will have an osteoporosis-related fracture in their lifetime. This is predicted to become a major healthcare burden over the next 25 years as the population ages.

President of the Irish Osteoporosis Society, Professor Moira O’Brien warned that osteoporosis is set to become a ‘new epidemic’.

“Osteoporosis suffers from severe under recognition and often goes unnoticed until a fracture occurs. unfortunately, only 15% of people who have osteoporosis are actually diagnosed. Even after a fracture, the majority of these women will not receive treatment for their osteoporosis.

“We have drafted these guidelines to help healthcare professionals look out for signs of osteoporosis. While there have been many advances in the management of the disease, there are still important care gaps and we must do all we can to promote the detection of osteoporosis before the first fracture occurs.”

It is estimated that 90% of all hip fractures in Ireland are due to osteoporosis. The fractures associated with osteoporosis can cause significant pain and disability. A hip fracture has a major impact on quality of life and in some cases, can be fatal as one in five patients suffering hip fracture die within four months

and 30% within a year. Furthermore, 50% of people aged 60 and over who fracture their hip will be unable to dress, bathe or walk across a room unaided and only 30% will regain their independence. The cost of osteoporotic hip fractures to the Irish Government is estimated to be €402 million demonstrating the urgent need for better treatments to prevent fractures associated with osteoporosis.

To order copies of the Osteoporosis Guidelines contact the Irish Osteoporosis Society on 1890 252 751.

The increasing popularity of social media is affecting young people’s attitudes to drinking and, in some cases, glorifying drunken behaviour, according to Fionnuala Sheehan, Chief Executive of drinkaware.ie, speaking recently at the launch of the 2010/2011 DARE2BDRINKAWARE.ie competition.

Now in its fourth year, DARE2BDRINKAWARE.ie is a film and multimedia competition open to third-level students throughout Ireland. It is sponsored by drinkaware.ie and organised by the Digital Hub Development Agency (DHDA).

“In recent years, we have noticed how the use of social media outlets are impacting on young people’s attitudes to drinking,” said Fionnuala Sheehan. “The growing popularity of social networking, video sharing and publishing photos online means young people consider it normal to document their nights out and use social media to let their friends know what they’re up to.

“unfortunately, in some cases, this has led to a normalisation of drunken behaviour. Some students find it amusing to post videos or photographs online of their own or others’ binge drinking, for example. Others use social media outlets to brag about the amounts they are drinking on nights out. There is almost a sense of competition around who can have the most shocking stories or photographs, or the most amusing videos.

“We are concerned about trends such as these because, the more people are exposed to images of excessive drinking, the more they normalise such behaviour. If you are in your late teens or early 20s, and your perception is that all your peers drink to excess and engage in anti-social behaviour, you may view this as

acceptable, if not essential to fitting in. What we are hoping to do with the DARE2BDRINKAWARE.ie competition is to counteract this perception, and show young people it is possible to enjoy alcohol in a more responsible manner.”

This year, DARE2BDRINKAWARE.ie has a new multimedia category, which means students can submit not only short films as entries but also multimedia projects such as websites, interactive CD-Roms, gaming projects or mobile phone apps. All entries must challenge the relationship between Irish culture and drinking; must be produced entirely by third-level students over the age of 18; and must be made specifically for DARE2BDRINKAWARE.ie.

Winning entries will be chosen for their creativity; artistic and technical quality; and for the insight they offer into students’ attitudes to alcohol. A total prize fund of €5,000 is up for grabs, and the competition will culminate in a screening and awards ceremony in spring 2011.

Students now have four weeks to come up with film and multimedia ideas for DARE2BDRINKAWARE.ie: the deadline for receipt of proposals is Thursday, 11th November 2010. Teams that have submitted successful proposals will then have until 18th March 2011 to produce and submit their short films or multimedia projects.

DARE2BDRINKAWARE.ie will culminate in a screening and awards ceremony in April 2011. Further information and full guidelines for the competition are available at www.DARE2BDRINKAWARE.ie

Social media affecting attitudes to drinking

11

NEWS FOR IPNA BR ANCHES COuNTRY WIDE regional news

cArlow/KIlDAreKATE ATTRIDE

The October meeting of the Carlow/Kildare branch of the IPNA took place in the Clonard Court Hotel in Athy. In attendance were secretary Anita Ryan and chairperson Margaret Clancy. Thank you to all members who attended the meeting. It was kindly sponsored by Glaxo Smith Kline and Amgen whose medical representatives, Jacqueline Jennings and Michelle Murphy, were present. Phillipa Quigley from Amgen and the David Asken CNS from Tallaght Hospital’s Rheumatology Team gave a very interesting talk on osterporosis.

Congratulations to Donegal on hosting excellent educational and thought provoking conference. Congratulations to Roisin Doogue who was elected National Vice-Chairperson. All members should have received their renewal membership forms and should return them as soon as possible to Tracey Rooney IPNA membership secretary. New members are very welcome. Meetings are held on the third Tuesday of every month in the Clonard Court Hotel.

corKTRISH O’CONNOR

The Cork Branch would like to take this opportunity to congratulate the Donegal Branch for their National Conference and AGM, a week-end which was thoroughly enjoyed by all who attended! Also a big congratulations to all Award winners with a special mention to una Quill, Cork IPNA Chairperson for who was awarded the Valerie Mangan IPNA Loyalty Award - a great reward for una’s hard work and com-mitment to the branch over the past year.

Back to business, our October IPNA Meeting was held in The Mallow Primary Care Centre. Very kindly sponsored by Cathy O Sullivan and Alan Copps from Astra Zeneca. Guest Speaker: Fiona Barton, CNS in CVD. Fiona gave a very educational and practical talk on ECGs - record-ing, reading etc, relevant to practice nursing. A very educational evening in a wonderful new clinical setting.

November’s meeting which also doubles as the Cork IPNA Branch’s AGM was held on the 10th November and was very kindly sponsored by Rose Howard from Milupa. Guest speaker on the night is Lorraine O’Hagan who is a clinical nurse specialist in lactation at the National Maternity Hospital, Dublin. Lorraine’s excellent presentation was on how best to encourage & support new mothers in breastfeeding.

We would also like to take this opportunity to thank the Cork Branch members for their continued support and large attendances at our monthly meetings - long may it continue.

DoNegAlELSIE STEWART

The venue for the September meeting was the Radisson Hotel, Letterkenny. Bernie McNulty, Assistant Director of Public HealthNursing specific to Immunisation, gave a presentation on the HPV Vaccine Programme at both national and local levels, followed by an update on the HPV Virus by Ann McGill, PDC.

As the remainder of the evening took the form of an AGM it had beendecided not to have a sponsor. Top of the agenda was the election of a new branch secretary. Anna McLaughlin has had to step down as she was leaving her position in general practice. Sincere thanks, Anna, for all your hard work and commitment during the past two years and on behalf of all the members may I wish you every success and happiness as you continue your career in Public Health Nursing. Many thanks to Lorraine Porter who agreed to fill the position for the remaining term of the present committee.

Most of the subsequent discussion was related to the upcoming conference and a further meeting of the organising committee was scheduled for 7th October to finalise arrangements.

Sincere thanks from the members of the Donegal branch to all involved in making the 2010 IPNA Annual Educational Conference such a great success. Thanks to the guest speakers, many of whom work in providing local services in both primary and secondary care. Special thanks to the keynote speaker, Dr Gerry Lane, Consultant in Emergency Medicine based at Letterkenny General Hospital. Thanks to Grainne Lynch, the Conference Co-ordinator, to Pfizer, Kelloggs, Promed and the other pharmaceutical companies present for their sponsorship.

Sincere thanks to Anna Mclaughlin, Helen McLaughlin, Lorraine Porter and all members who helped in any way. Most of all thank you to the members of the IPNA who attended, especially those of you who travelled long distances. We appreciate that the overall success of the conference depended greatly on the support of our colleagues nationwide.

Congratulations to Maureen Delaney, Galway branch, on becoming Practice Nurse of the Year 2010. Best wishes go to the South Tipper-ary branch as they prepare to host the 2011 Conference.

KIlKeNNy LEONIE FINNEGAN

Despite the ‘seasonal fatigue’ associated with the flu vaccination season we had a good attendance at the recent branch meeting, which was both AGM and an educational session. Thanks to all for coming.

Firstly, at the AGM, Leonie Finnegan was elected as Chairperson, replacing Patricia McQuillan. Other officers remain unchanged for this year. Úna Stapleton continues performing a sterling role as secretary with the strong support of Mary Fogarty Treasurer, and Kath-leen Renehan as IPNA NEC rep. We wish to thank Patricia for all her input and work as chairperson over the past two years.

Secondly, on the educational front, McNeal Healthcare facilitated by our local rep Lisa Dunworth, sponsored the meeting. With

12

NEWS FOR IPNA BR ANCHES COuNTRY WIDEregional news

presentations on smoking cessation from both Lisa and Bernie O’Brien, Health Promotion Officer in Kilkenny, we enjoyed a great and informative update and lively discussion around this challenging patient management area. Health Promotion Dietician from Kilkenny Carlow area, Aisling, also gave a very pertinent update on supplementation of infants with vitamin D following on from the national HSE directive that all babies from 0-12 months have vitamin D supplementation.

The Kilkenny branch would like also to thank and congratulate the Donegal branch on the recent IPNA conference. While the geo-graphical location did prove a barrier to some Kilkenny members, Kathleen Renehan had attended and gave us all an in-depth account of her experience at the conference and updated us on the topics and discussions from there. Well done to you all.

We also wish to extend congratulations from all, to both Sandra Hughes and Mary Walsh, each on the birth of baby daughters recently.Our next branch meeting is scheduled for the 8th December at 7pm in Hotel Kilkenny and we look forward to presentation with Dr

Susan Foley, Respiratory Physician, Waterford Regional Hospital. We always welcome new regional members at any time so please feel free to contact our secretary Úna by email; umstapleton@gmail.com or pop into our next meeting if you are interested.

gAlwAy MOIRA NOONE

Congratulations to Maureen Delaney who won Practice Nurse of The Year. On behalf of the Galway Branch Committee and members I would like to congratulate the Donegal branch for a very enjoyable AGM. Well done.

At our recent AGM in Galway, held in the Clayton Hotel, our chairperson Maureen Delaney, Vice-Chairperson, Catherine Kirrane and Secretary Sally Whelan, stepped down. Thank you for the wonderful job you have done. You have all worked tirelessly and gave up some valuable time to support and develop our branch. The new Chairperson is Margie Nestor; Vice-Chairperson, Moira Noone; and Treasurer, Doreen Eaton. Our evening was sponsored by Eoin Barton of Novartis. Speaker on the night was Caitriona d’Courcey who talked about the Management of Osteoporosis in Primary Care.

On Thursday 7th October our meeting was held in The Ardilaun Hotel and sponsored by Michelle Heneghan of Cow and Gate. We had a very interesting talk on cranio sacral therapy in infants and children by Cranio Sacral Therapist Bernadette Molloy, Galway.

Our next meeting will be held on 11th November at 7.30 sharp in the Clayton Hotel, kindly sponsored by John Downes, Novartis. Each member will receive a text message with details of our meetings each month. We would like to thank our PDC Kathy McSharry who

through emails, keeps us well informed of all educational meetings and relevent information, on a regular basis enabling us to work confidently and competently within our scope of practice. The annual Cardiac Vascular Nurse Symposium, takes place on 12th and 13th of November, Radis-son Hotel, Galway. Informal enquiries to alma@croi.ie or tel 091 480816, Croi, West of Ireland Cardiac Foundation university Galway. The pro-gramme to be delivered offers an excellent opportunity to keep abreast of all latest developments in CVD.

LAST BuT NOT LEAST WELL DONE TO MAuREEN, Congratulations! We are all so proud of you,what an achievement, Practice Nurse of the Year the first time it has come to West and to Galway. There’s no doubt you deserve it. Maureen is courteous, professional, friendly and is a very popular person in our branch. She keeps abreast of all advances in practice nursing, and is always up to date with all aspects of her profession and she attends educational events/talks. Maureen was our chairperson for 4 years and vice chairperson for 1 year, she has marvellous organisational skills. We all thought you were our outstanding choice for Practice Nurse of the Year and now we know you are as the IPNA has endorsed it.

Kerry MARY BRICK (outgoing chairperson)

Kerry branch resumed our meetings on 15th Sept at the Ballygarry House Hotel, Tralee. Our meeting and gorgeous buffet were kindly sponsored by Sarah Hyde of McNeill Healthcare. Guest speaker was Mary Kelly, SRN, spoke on the topic of smoking cessation.

Looking forward to the dance of the seven veils and wishing the Donegal branch all the best for the AGM. I would like to take this opportunity to thank the wonderful Kerry branch committee for their energy, enthusiasm and support to me during the past two years. Sheila Ryle has done Trojan work as educational co-ordinator locally. Amina Parks has been running a marathon as NEC REP and is due a well deserved rest. A big thank you to Mary Cullen who has kept our moneys very safe, and to to Marie Courtney for her hard work as educational co-ordinator. I am very grateful to Marie Rolls for her great support and help at all times. Best of luck to the incoming committee.

TIPPerAryAINE LALLY

The Clare branch reconvened on 21st September. Rheumatologist, Dr El-Rafi, gave a very informative talk on bone health and the benefits of vita-min D. Increasing people’s awareness is paramount in preventing osteoporosis which is of think of as solely a woman’s disease, however, men are just as at risk. Dr El-Rafi also reminded us that Arthritis Ireland is more than happy to provide information leaflets for GP surgeries. This talk was very kindly sponsored by Joe McCormack of MSD.

Our October talk, kindly sponsored by Jez Blackburn and Sheila Gleeson, was given by Dr Beatrice M Neufeldt who runs the specialist female and male medical clinic in Limerick. As usual her talk was most informative. We learned a lot about male health issues specifically related to sexual problems. We do need to be more aware and able to ask the right questions of our male patients. She also talked to us about polycystic ovary syndrome. We look forward to her next talk on the management of menopausal symptoms and STDS.

We are as always trying to encourage our branch members to attend our monthly meetings. In an effort to encourage attendance Anne Akamnonu will circulate a letter/questionnaire to all practices. It is hoped that practice nurses will give feedback as to why non-attendance at the meetings is such an issue.

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14

IPNA Conference 2010 sonas, spraoi, agus sláinte

elsie stewart cP Donegal Branch introducing the speakers on thesaturday morning.

Katleen crerand, clinical session on

diabetes.

Dr gerry lane, consultant in emergency Medicine, letterkenny.

Dr Janice richmond.

Ambulance personel explain the functions of an emergency vehicle.

15

sonas, spraoi, agus sláinte IPNA Conference 2010

Practice nurse of the year awards.

elsie stuart, thanking gráinne on behalf of the Donegal branch.

lynn cartwright, siobhan Jordan and Brid Buckley, who won prizes sponsored by Jackson’s hotel.

Presentation of the valerie Mangan loyalty Award.

lisa Nolan, Administrator IPNA; lynn cartwright, Pro; Mary o’connor, Treasurer; orla loftus Moran, chairperson.

16

IPNA Conference 2010 sonas, spraoi, agus sláinte

Dublin branch members.

rita lawlor, PDc Dublin with Kathy Mcsharry, PDc Mayo.

emer oByrne, galway and róisín Doogue, carlow/Kildare.

Judy hayes, rita o’carroll and Mary hunter, North Tipperary.

ruth Taylor and emer o’Byrne. Joan Pentony, louth/Meath, roisin Doogue, carlow/Kildare.

Members of the Donegal branch.

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IPNA Conference 2010 sonas, spraoi, agus sláinte

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sonas, spraoi, agus sláinte IPNA Conference 2010

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IPNA Conference 2010 sonas, spraoi, agus sláinte

Pauline Kilcoyne, Donegal and cathy Ball and sheila gleeson, Bayer healthcare.

lynn cartwright with chris Kenny of McNeil healthcare.

Nina Morrisson, Bayer healthcare and ruth Taylor, cavan Monaghan.

Damien Mccormick and Damien conefrey, Paralink.

21

clinical review

– looking beyond cancers

The National Cancer Control Programme (NCCP), in partnership with the Professional Development Coor-dinators for Practice Nurses (PDCs), has announced the introduction of a cancer education programme to meet the needs of practice nurses who work in primary care.

The programme will focus on cancer prevention, clinical presenta-tion and multi-disciplinary treatment of common cancers, referral pathways and the psychological implications of cancer.

Primary care providers make a significant difference, not just in treating illness, but also in supporting people tin caring for themselves and their families, improving wellness, preventing ill-ness and supporting those with long-term problems from a health and social well-being perspective. (Primary Care Strategy, 2001). It is well recognised that general practice cares for a broad clinical area for all ages on a daily basis. However, there are times when changes in evidence based practice and clinical skills require us to update our knowledge.

Practice nurses play a key role, not only in caring for patients who have been diagnosed with cancer, but also in helping to pre-vent cancer amongst their practice population. (Robinson 2009).

why is cancer an important illness?Cancer has a major impact on the health of Irish people. It is our leading cause of premature death. By the age of 75 one in three men and one in four women will have developed cancer.

The National Cancer Registry (NCRI) records, analyses and publishes information in relation to cancer diagnoses in Ireland. Between 2005 and 2007, it registered an average of 27,023 new cases per year. The number of cases diagnosed each year has been steadily increasing since 1994, by approximately 3% per year and by more than 25% overall since recording began (see Figure 1). As our population continues to grow and age, the number of new cancers diagnosed each year is expected to keep rising. Within the next 10 years the number of new cases diagnosed is predicted to double from today’s figure of 27,000.

Apart from non-melanoma skin cancer (NMSC) the commonest invasive cancers diagnosed per year (annual average between 2005 and 2007) were:

• prostate (2462 cases)• breast (2335 cases; 2315 were female)• colorectal (2156 cases)• lung (1810 cases).

These four cancers account for over 60% of all cancers diagnosed. In women, the most common cancer diagnoses were breast (30%), colorectal (12%) and lung (10%). In men, the most common diagnoses were prostate (29%), colorectal (15%) and lung (13%). The next most common cancer in women was melanoma (4.8%) and in men it was lymphoma (4.3%).

Lung cancer is the most common cause of cancer death in Ireland in 2005 with over 1600 deaths per year. It is the most common cause of death from cancer in men (934 deaths) and the second commonest cause in women (653 deaths). Breast cancer remains the most common cause of cancer death in women (696 deaths). Colorectal cancer was the second commonest cause of death overall (930 deaths of all cancer deaths).

cancer education programme for practice nurses

rITA lAwlor, PROFESSIONAL DEVELOPMENT COORDINATOR FOR PRACTICE NuRSEShIlAry MurPhy, SPECIALIST NuRSE, NATIONAL CANCER CONTROL PROGRAMMEMArIe courTNey, PROFESSIONAL DEVELOPMENT COORDINATOR FOR PRACTICE NuRSESrhoNDA forsyThe, PROFESSIONAL DEVELOPMENT COORDINATOR FOR PRACTICE NuRSES

recognising suspicious symptoms enables primary care health professionals to make appropriate referrals to cancer specialist services.

22

clinical review

Though there are almost 8000 deaths in Ireland from cancer, survival rates are improving. Figure 2 shows five-year relative survival rates for common cancers in Ireland. It compares survival for those diagnosed between 1994-1999 with those diagnosed between 2000-2004. Survival is steadily improving for all cancers except for lung cancer where the improvement is very marginal. Five-year survival rates for breast and prostate cancer have now reached 80%. Survival rates for some common cancers have increased by more than 20 per cent in the past two decades.

Development of the education programmeAs a result of focus group research facilitated by Professional Development Coordinators (PDCs) and conducted by the National Cancer Control Programme (NCCP), practice nurses identified a need for additional education in cancer in the primary care setting. The nurses acknowledged that, while they meet many patients with cancer regularly, they feel that there is a gap in their clinical knowledge. The following issues emerged from the focus group research:

• Information sharing and communication: The importance of clear and comprehensive patient information between primary and secondary care in relation to diagnosis, treatment and the patient pathway was highlighted. Poor communication and imprecise clinical information are barriers to effective care.

• New developments in cancer care and referral guidelines: All health professionals need to be aware of new developments in treatment that can be provided for their patient. ” It is very difficult to follow guidelines if you don’t have a copy of them and you want to do the best you can for your patients”

• Psychological care of the patient and the family: A diagnosis of cancer can cause distress for the patient and the family and it has to be identified early and well managed.

“I really don’t know what to do when the family come crying to the door and are extremely distressed. Where do I go for help?”

• guidance on health promotion and prevention: The practice nurse is in a pivotal position to promote healthy lifestyles to prevent cancer at all ages. ” I would love to have the skills for brief intervention”

• early discharge of patients from hospital back to primary care: Early discharge and the integration of care between hospital and primary care are of increasing importance. “ When patients, following discharge from hospital, arrive to the clinic with no correspondence, I really cannot do anything and this lowers confidence”

figure 2

figure 1 Trends in Incidence 1994-2007

Source: National Cancer Registry. * 2006 and 2007 data are provisional.

Numbers of New Cancer Cases by Gender, Ireland, 1994-2007*

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

Year

Number

Male 6,260 6,181 6,328 6,542 6,632 6,761 7,118 7,411 7,827 7,817 8,503 8,308 8,514 8,577

Female 5,832 5,729 5,963 6,139 6,163 6,290 6,629 6,710 7,186 7,273 7,418 7,425 7,644 7,582

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Numbers of new cancer cases by gender, Ireland, 1994-2007*

* Danone Actimel is a probiotic food containing the exclusive probiotic culture Lactobacillus casei DN 114 001. Danone Actimel helps strengthen the natural defences when consumed daily as part of a healthy diet & lifestyle.

1 Riezzo G, Chiloiro M & Russo F (2005) Functional foods: salient features and clinical applications. Curr Drug Targets Immune Endocr Metabol Disord 5, 331–337.2 Turchet P, et al. Effect of fermented milk containing the probiotic Lactobacillus casei DN-114 001 on winter infections in free living elderly subjects: a randomised, controlled pilot study. J Nutr Health Aging 2003;7(2):75-77.3 Guillemard E. et al. Consumption of a fermented dairy product containing the probiotic Lactobacillus casei DN-114 001 reduces the duration of respiratory

infections in the elderly in a randomised controlled trial; Br J Nutr. 2010;103, 58–68.

A support in Winter*A support in Winter

Winter Infections and the ElderlyWinter can be challenging, particularly for the elderly who experience more frequent and severe community-acquired respiratory and gastrointestinal infections.1

The effect of Actimel® on common infectious diseases (CIDs both gastrointestinal and respiratory) has been investigated fi rstly in an exploratory pilot study followed by a large confi rmatory study involving free-living elderly people.

Multicentre, randomized, double-blind controlled study involving 1,072

free-living adults aged over 70 years of age consuming Actimel (2x100g) daily

for 3 months.

Reduction in the average duration per episode of common infectious diseases

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Reduction in duration of Common Infectious Diseases3

Reduction in duration of Winter infections2

Controlled pilot study involving 360 people over 60 consuming Actimel (2x100g)

for 3 weeks.

Reduction in duration of winter infections by 20% v’s control (p=0.024).

For example seasonal infl uenza syndrome and upper respiratory tract infections.

Guillemard et al 2010Turchet et al 2003 Actimel n=64Control Group n=68 Actimel n=537Control Group n=535

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These results add to the body of evidence to support the effect of Actimel® in helping to strengthen the natural defences of the elderly which has an important impact on the overall health of the elderly population.

These results add to the body of evidence to support the effect of evidence to support the effect of Actimelnatural defences of the elderly which has an important impact on the overall health of the elderly population.

in helping to strengthen the natural defences of the elderly which has an important impact on the overall

Control Group n=535Control Group n=535

10

2

345678910

7.0

Control Actimel10

2

345678910

6.5

Actimel

Tim

e (in

day

s) 8.0

Control

-19%

10

2

345678910

7.0

Control Actimel10

2

345678910

8.77.0

Control Actimel

Tim

e (in

day

s) -20%

2464_Actimel_HCP_A4.indd 1 22/09/2010 16:47

24

clinical review

Following the focus group research a working group was set up by the PDCs and the NCCP. As a result the education programme was developed.

Aim and content of the education programmeThe education programme aims to provide practice nurses with relevant knowledge and skills to fulfil their role in promoting health, reducing cancer incidence, integrating their work with the acute sector and helping to promote wellness in people living with cancer. It intends to empower practice nurses to advocate on behalf of their practice population and to promote patient confidence which is essential for this cohort.

As several cancers can now be regarded as chronic diseases, many people with a history of cancer can expect to live long and healthy lives. Though some patients may experience a relapse in symptoms, they can continue to live for long periods with their disease well controlled. unfortunately, for other patients the outcome is not good and the role of the practice nurse with the palliative care team becomes important. All patients, irrespective of their prognosis require multidisciplinary care at all stages of their disease. The role of the general practitioner and the practice nurse is paramount at all times.

As up to 50% of cancers can be prevented, improved awareness of modifiable lifestyle cancer risk factors and adopting simple actions to reduce these risk factors will play a major role in reducing the burden of cancer in Ireland. The practice nurse is central in this regard e.g. advising on smoking cessation, physical activity, obesity avoidance and care in the sun. The role of the practice nurse in screening programmes is crucial. Creative learning methods will be used in the programme e.g. role play to show the impact of brief interventions.

Recognising suspicious symptoms enables primary care health professionals to make appropriate referrals to cancer specialist services. upon completion of the programme, the practice nurse will have a greater understanding of suspicious

symptoms, referral process, the use of referral guidelines and electronic referral systems and multidisciplinary treatment.

Psychological factorsThe psychological implications of many conditions are frequently overlooked in a busy general practice setting due to time constraints or other competing demands. The role of the practice nurse in providing patient support e.g. coping with serious illness, altered body image, family distress, and impending mortality may be an area that practice nurses have not considered previously as general practice is a generalist rather than a specialist service.

When a diagnosis of breast cancer is made, many women are more concerned with survival than body image but deterioration in body image may occur when survival becomes more assured. Informing family, friends and children may be difficult for some people without psychological support. There is evidence that patients often feel ‘lost’ or ‘unsupported’ when they are discharged from the specialist service. The practice nurse is a key health provider at this stage of the patient’s journey.

This education programme will focus on the following four common cancers:

• Breast• Lung• Prostate • SkinEach of these four cancers will be discussed under the

following headings:• Epidemiology and prevention• Clinical presentation and referral • Treatment options and multidisciplinary care• Post-acute care and psycho-oncology.Although nurses are not expected to diagnose various

diseases, they must be able to recognise suspicious symptoms and to answer questions about benign and malignant disease, as they may be the first point of contact for their practice population.

outline of the programme The education programme will be delivered by cancer specialists who work in the designated NCCP cancer centres and by NCCP personnel. The programme is endorsed by the NCCP, the NCCP Strategic Cancer Nursing Group and the School of Nursing at uCD. Category 1 approval will be sought from An Bord Altranais.

The programme will be delivered on one afternoon per week over four weeks of a calendar month. Each session will run from 13:30 to 17:30. Participants will be required to attend each of the four sessions.

locationsInitially the programme will be provided in three locations nationally – Cork, Galway and Dublin . Depending on demand, it may be extended to Limerick and Waterford. Further details about the programme can be obtained from your Professional Development Coordinator for Practice Nurses. The programme is free to participants.

references Department of Health & Children 2001. Primary Care A New Direction, Dublin, Stationary Office.

As up to 50% of cancers can be prevented, improved awareness of modifiable lifestyle cancer risk factors and adopting simple actions to reduce these risk factors will play a major role in reducing the burden of cancer.

25

clinical review

Malodorous wounds are very distressing for patients and carers. Odour may be a sign of infection in some wounds but it is also one of the most distressing symptoms of malignant fungating wounds. It can cause social isolation,

depression, nausea, anorexia and in some cases is so distressing as to cause a gagging or vomiting reflex. This paper will explore the causes of malodour with particular reference to palliative care wounds. It will also highlight its effect on individuals and present some strategies to manage or control it.

PrevAleNce The World Health Organisation estimates that 10.9 million new cases of cancer are diagnosed annually (WHO, 2009). In Ireland, the national cancer forum reports almost 20,000 new cases each year (NCF, 2006). Cancer is a major cause of morbidity and worldwide accounted for 7.4 million deaths in 2004 (WHO, 2009). This is expected to increase to 12 million by 2030 (WHO, 2009).

Cancer is a generic term for a large group of diseases that can affect any part of the body (WHO, 2009). One defining feature of cancer is the rapid creation of abnormal cells that grow beyond their usual boundaries, and which can then invade adjoining parts of the body and spread to other organs. This process is referred to as metastases, which are the major cause of death from cancer (WHO, 2009). While there are no precise figures for fungating wounds it is estimated that of those persons with metastatic disease, approximately 5-10%

experience skin involvement which usually occurs during the last 6-12 months of life (Lo et al, 2006). Of those with skin involvement and specifically, malignant fungating wounds (MFW), approximately 62% originate from breast cancer, followed by head and neck 24%, genitals and back 3% and other sites 8% (Naylor, 2002).

Fungating refers to a malignant process of both ulcerating and proliferative growth. Lesions that have a predominantly proliferative growth pattern may develop into a nodular ‘fungus’ or ‘cauliflower’ shaped lesion, whereas a lesion that is ulcerating will produce a wound with a crater-like appearance (Grocott, 1995). Some lesions present with a mixed appearance of both proliferating and ulcerating areas.

QuAlITy of lIfePalliative care focuses on relieving suffering and achieving the best possible quality of life for patients and their care providers. Optimal palliative care services integrate the expertise of a team of providers from different disciplines to address the complex needs of seriously ill patients and their families. According to Grocott (2010) palliative wound care is essentially concerned with improving quality of life and one of the key goals is to prevent wounds inhibiting patients’ and families’ day-to-day functioning.

unfortunately, persons with malignant fungating lesions often present late seeking help (Boon et al, 2000). It is speculated that this may be due to embarrassment about appearance such as exudate leakage or due to a fear of being

Managing malodour in palliative care wounds in primary care

georgINA geThIN, PhD, rgN, he DIP wouND cArE, FFNMRCSIRESEARCH CO-ORDINATOR/LECTuRER, CENTRE FOR NuRSING AND MIDWIFERY RESEARCH, RCSI

26

clinical review

diagnosed with cancer (Probst, 2010). Such wounds have enormous psychological impact on the quality of life of the individual causing embarrassment, social isolation, withdrawal from daily activities, poor self esteem, and all at a time when support is much needed (Lund-Nielsen et al, 2005; Lo et al, 2008; Probst et al, 2009). Malodour which is cited as being one of the most distressing features of such wounds has also been the cause of involuntary gagging and vomiting (Draper, 2005).

A study by Lo et al (2008) reported that in the absence of specialist knowledge about the management of fungating wounds, some patients report engaging in a variety of strategies to manage the wound, including; restricting water intake, using toilet paper to cover the wound, brushing using a baby toothbrush and herbal remedies

cAuses of oDourWound malodour is caused by bacterial infection in devitalized tissue within the wound. More specifically it is due to a cocktail of volatile agents that includes short chain organic acids, produced by anaerobic bacteria (Moss et al, 1974), together with a mixture of amines and diamines such as cadaverine and putrescine that are produced by the metabolic processes of other proteolytic bacteria (Thomas et al, 1998).

Organisms frequently isolated from malodorous wounds include anaerobes such as bacteroides and Clostridium species and aerobic bacteria including Proteus, Klebsiella and Pseudomonas spp. (Thomas et al, 1998). More recently, a study to determine the chemical identity of the cancer derived-wound odour among women with breast cancer identified dimethyl trisulfide (DMTS), as the source of odour (Shirasu et al, 2009). DMTS is a compound that is known to be emitted from some vegetables and micro-organisms and is also produced by aerobes such as Pseudomonas aeruginosa (Shirasu et al, 2009).

Dead and devitalized tissue also causes wound malodour and provides an ideal environment for bacterial proliferation which in turn contributes to odour. Together with exudate production, all serve to increase odour. Furthermore, fungating lesions are thought to interfere with tissue oxygenation, lymphatic drainage and haemostasis and reduced tissue perfusion, due to abnormalities in the vascularisation of solid tumors, lead to local cell anoxia and sometimes cell death and tissue necrosis (Hirst, 1992: Cited in Adderley and Smith, 2010).

MANAgINg oDourWound malodour is not an isolated phenomenon and thus, treatment strategies should attempt to address the cause

of the odour and management of it. There is a paucity of clinical research studies which have evaluated strategies for the management of wound malodour. This may be due in part to the difficulties surrounding quantifying something which cannot be seen or touched or measured. One study demonstrated that of all wound assessment parameters the inter-rater reliability of wound odour was very poor (Gethin and Cowman, 2007). Strategies to manage malodour can be divided into two categories: wound management agents and environmenal agents.

wouND MANAgeMeNT AgeNTsFlagylMetronidazole (Flagyl) is an antibiotic agent used topically or systemically for reduction of malodour and is particularly effective for anaerobic bacteria and protozoa. While used extensively there are variations in the concentrations used and the methods of application. Metronidazole tablets have been crushed and mixed with sterile water to create either a 0.5% solution (5mg/cc) or 1% solution (Seaman, 2006). This is then used as a wound irrigant or alternatively gauze is soaked in the solution and applied to the wounds. There is much anecdotal evidence to support this practice although little scientific evidence exists. It is also used as a gel at a concentration of 0.75% (Kalinski et al 2005). Research has shown a statistically significant (p<0.05) decrease in wound odour after 24 hours, as determined by both patient and investigator (Kalinski et al 2005). This statistical difference was maintained through days 7 and 14. Importantly, this method of application has not been associated with any pain or discomfort for the patient.

In a study of eleven patients with fungating wounds Bowler et al (1992) evaluated the efficacy of metronidazole gel on wound odour. Patients received either 0.8% gel or placebo applied daily for six days. Odour was measured using a ten point visual analogue scale In the placebo group (n=5), the average odour assessment remained above six. In the treatment group the mean odour scores showed a statistically significant reduction over the six days (p> 0.01).

HoneyHoney has been reported to effectively reduce and even eradicate odour as a result of the preferential metabolism by bacteria of honey’s glucose, which produces lactic acid, instead of amino acids that produce malodorous ammonia, amines and sulfur compounds (White and Molan, 2005). Honey and in particular Manuka honey has been reported to eliminate wound odour in fungating and non-fungating lesions (Gethin and Cowman, 2009; Simon et al, 2009; Moore, 2010; Segovia, 2010). As honey also has

Malodour which is cited as being one of the most distressing features of such wounds has also been the cause of involuntary gagging and vomiting.

27

clinical review

antimicrobial and debriding properties it is particularly useful, as it assists in eliminating those elements which cause the odour initially, namely, slough and bacteria (Gethin and Cowman, 2009). As an antibacterial agent it has demonstrated efficacy against a wide range of wound colonising pathogens (Cooper and Molan, 1999; Gethin and Cowman, 2008). It has anti-inflammatory properties which can assist in reducing exudate production (Molan, 2002).

A systematic review of the use of honey in cancer care concluded that honey may be used for radiation-induced mucositis, radiotherapy-induced skin reactions, hand and foot skin reactions in chemotherapy patients and for oral cavity and external surgical wounds (Bardy et al, 2008). The authors suggest that there is further scope for the use of honey within the cancer setting and particularly in the care of head and neck cancer patients.

Many formulations of honey exist but for the malignant fungating wound it can be applied either directly as a gel or in alginate dressings impregnated with honey. Frequency of application should be based on levels of exudate and efficacy of treatment. In order to maximize its potential, honey should be in close contact with the wound surface for at least 12 hours, although if levels of exudate are small it can be left in place for up to seven days (Gethin and Cowman, 2009). It is worth nothing that not all honeys are suitable for use in open wounds and clinicians should restrict their use to licensed medical grade honey.

CharcoalA systematic review reported that activated charcoal dressings applied to fungating wounds significantly controlled odour if the dressings fit as a sealed unit and if the wound was maintained dry (Draper, 2005). If not sealed the odour can escape. This is a problem in management of fungating wounds in which the peri-wound skin is often very sensitive and is not amenable to the use of adhesives. Activated charcoal dressings absorb toxins, as well as pro-inflammatory endogenous and exogenous proteases (Wound Care Handbook, 2010). The use of a charcoal cloth for management of odour has been incorporated into pads containing surgical gauze and a layer of a water repellent fabric. When these pads were used in the treatment of fungating breast cancer, gangrene and immediate post operative colostomies, the associated odours were said to be totally suppressed (Thomas et al, 1998). According to Thomas et al (1998) charcoal dressings which combine a physical absorbent with a charcoal component performs best.

One study of the management of malignant lesions reported a reduction in malodour

by both patients and investigators when wounds were cleansed and either charcoal applied directly to the wound surface or as a secondary dressing when hydrogel was used to deslough the wound bed (Lund-Nielsen et al, 2005). The use of charcoal

dressing in combination with a foam dressing with an adhesive border made the patients in that study feel protected against malodour and encouraged them to resume social activities (Lund-Nielsen et al, 2005). Given the variations in composition

of dressings containing charcoal the manufacturer’s instructions should be consulted prior to use

for optimal performance.

AroMATherAPy AgeNTsAn interesting report by Mercier and Knevitt (2005) shares their experience of using aromatherapy in patients with fungating lesions. The choice of essential oil is decided by the patient in consultation with the staff member. If odour is only present during dressing changes the oil may be vaporized in the room before and during the procedure. When the odour is detectable outside of dressing changes a few drops are applied to the outer dressing. Some oils are then used in the cleaning of the wound such as tea tree oil. Oils are also blended into a cream and applied directly to the wound. It is recommended that such practices should be discussed with a pharmacist who is assess the safety of particular oils for use in patient care.

The use of green tea bags has also been explored (Yian, 2005). The author of this paper reports on the application of green tea bags as a secondary dressing. The bags help to absorb exudate and the antioxidants in the green tea act as a deodorizer. Further research is required to explore this option further but it may offer an interesting option for some patients.

eNvIroNMeNTAl AgeNTsWound odours have traditionally been masked by burning incense and in more recent times, by the use of aerosols or air fresheners. While there is a abundance of ‘retail’ products aimed at eliminating odour these are often perfumed and are poorly tolerated by persons with cancer.

Much anecdotal evidence exists for various environmental strategies including burning of oils which can create a pleasant aroma, in particular dried sage may be helpful. Other oils such as eucalyptus or clove oil can be beneficial. However, caution should be exercised in over-use as the strong odour may in itself be distressing.

Placing charcoal or cat litter in an open tray under a bed can assist in absorbing odours. Additionally an open dish of coffee beans or shaving cream in a room is said to be very effective. General environmental control strategies such as removal of soiled linen or open bins can also make an atmosphere more pleasant and enhance the patient’s surroundings.

conclusionOdour caused by wounds can be distressing for both the patient and the caregiver and may be a reminder of their underlying disease process. Odour can cause the patient to feel embarrassed or ashamed, and may lead them to become isolated and withdraw from their daily activities. Effective management should be based on reduction in slough, control of bacteria and can include a number of topical or environmental agents including charcoal, iodine, honey or Flagyl.

honey and in particular Manuka honey has been reported to eliminate wound odour in fungating and non-fungating lesions.

28

clinical review

referencesAdderley, u. and Smith, R. (2010) Topical agents and dressing for fungating wounds (Review), Cochrane Database of Systematic Reviews, issue 2, Art. No: CD003948. DOI: 10.1002/14651858.CD 003948, pub2.Bardy, J., Slevin, N., Mais, KL. and Molassiotis A. (2008) A systematic review of honey uses and its potential value within oncology care, Journal of Clinical Nursing, 17 (19), 2604-2623.Boon, H., Brophy, J. and Lee, J. (2000) The community care of a patient with a fungating wound, British Journal of Nursing, 9(6), 35-38.Bowler, M., Stein, R., Evans, T., Hedley, A., Pert, P. and Coombes, R. (1992) A double-blind study of the efficacy of metronidazole gel in the treatment of malodorous fungating tumors, European Journal of Cancer, 28(4), 888-889.Cooper, R. and Molan, P. (1999) The use of honey as an antiseptic in managing Pseudomonas infection, Journal of Wound Care, 8, 161-164.Draper, C. (2005) The management of malodour and exudate in fungating wounds. British Journal of Nursing, 14911), S4-12.Gethin, G. and Cowman, S. (2007) Inter-rater reliability and content validity of a wound assessment inventory (WAI) Proceedings of conference of European Wound Management Association, May, No: 086.Gethin, G. and Cowman, S. (2008) Bacteriological chances in sloughy leg ulcers treated with Manuka honey or hydrogel: an RCT, Journal of Wound Care, 17(6), 241-247.Gethin, G. and Cowman, S. (2009) Manuka honey vs. Hydrogel – a prospective, open label, multicentre, randomised controlled trial to compare desloughing efficacy and healing outcomes in venous ulcers. Journal of Clinical Nursing, 18(3), 466-474.Grocott, P. (1995) The palliative management of fungating malignant wounds. Journal of Wound Care, 4(5), 240-242.Grocott, P. (2007) Care of patients with fungating malignant wounds, Nursing Standard, 21(24), 57-62.Kalinski, C., Schnepf, M., Laboy, D., Hernandez, L., Nusbaum, J., McGrinder, B., Comfort, C. and Alvarez, O. (2005) Effectiveness of Topical Formulation Containing Metronidazole for Wound

Odour and exudate Control, Wounds: a Compendium of Clinical Research and Practice, 17(4), 84-90.Lo, S., Hsu, M. and Chang, S. (2006) Clinic follow-up of patients with malignant fungating wounds in adults in Taiwan, Proceedings of the 16th Biennial Congress of the World Council of Enterostomal Therapists, abstract A180, Hong Kong Enterostomal Therapist Association, Hong Kong.Lo, S., Hu, W., Hayter, M., Chang, S., Hsu, M. and Wu, L. (2008) Experience of living with a malignant fungating wound: a qualitative study, Journal of Clinical Nursing, 17, 2699-2708.Lund-Nielsen, B., Muller, K. and Adamsen, L. (2005) Qualitative and quantitative evaluation of a new regime for malignant wounds in women with advanced breast cancer, Journal of Wound Care, 14(2), 69-73.Mercier, D. & Knevitt, A. (2005) using topical aromatherapy for the management of fungating wounds in a palliative care unit. Journal of Wound Care, 14(10), 497-501.Molan, P. (2002) Re-introducing honey in the management of wounds and ulcers – theory and practice, Ostomy Wound Management, 48(11), 28-40.Moore, S. (2010) Squamous cell carcinoma of the head and neck: using active Leptospermum honey for wound management and odour control, Poster CS-064 presented at SWAC conference, Florida, uSA, April.Moss, C., Dees, S. and Guerrant, G. (1974) Gas chromatography of bacterial fatty acids with a fused silica capillary column, Journal of Clinical Microbiology, 28, 80-85.Naylor, W. (2002) Malignant wounds: aetiology and principles of management, Nursing Standard, 16, 45-46.NCF (2006) National Cancer Forum: A strategy for Cancer Control in Ireland, Government of Ireland, Stationary Office, Dublin.Probst, S., Arber, A. and Faithfull, S. (2009) Malignant fungating wounds: A survey of nurses’ clinical practice in Switzerland, European Journal of Oncology Nursing, 13(4), 295-298.Seaman, S. (2006) Management of malignant fungating wounds in advanced cancer, Seminars in Oncology Nursing, 22(3), 185-193.Segovia, D. (2010) The clinical benefits of active Leptospermum honey: oncology Wounds, Poster CS-104 presented at SAWC Conference, Florida, April uSA.Shirasu, M., Nagai, S., Hayashi, R., Ochiai, A. and Touhara, K. (2009) Dimethyl Trisulfide as a characteristic odor associated with fungating cancer wounds, Bioscience Biotechnology Biochemistry, 73(9), 2117 – 2120.Simon, A., Blaser, G. and Santos, K. (2009) Honey in paediatric care and oncology. In: White, R., Cooper, R. and Molan, P. eds. Honey: a modern wound management product, 2nd edition, Wounds uK Publishing, Aberdeen, 153-167.Thomas, S., Fisher, B., Fram, P. and Waring, M. (1998) Odour absorbing dressings: a comparative laboratory study, World Wide Wounds, April, www.worldwidewounds.com/1998 .White, R. and Molan, P. (2005) A summary of published and clinical research on honey in wound management. In: White, R., Cooper, R. and Molan, P. eds. Honey: a modern wound management product, Wounds uK Publishing, Aberdeen, 130-142.WHO (2009) Cancer, Fact sheet 297, http://www.who.int/mediacentre/factsheets/fs297/enWound Care Handbook (2010) The comprehensive guide to product selection, MA Healthcare Limited.Yian, LG. (2005) Case study on the effectiveness of green tea bags as a secondary dressing to control malodour on fungating breast cancer wounds. Singapore Nursing Journal, 32(2), 42-48.

unfortunately, persons with malignant fungating lesions often present late seeking help...this may be due to embarrassment about appearance ...or fear of being diagnosed with cancer.

Abbreviated Prescribing Information Victoza® 6 mg/ml solution for injection in pre-filled pen (liraglutide). Please refer to theSummary of Product Characteristics for full information. Victoza® 2 x 3 ml pre-filledpens. Victoza® 3 x 3 ml pre-filled pens. 1 ml of solution contains 6 mg of liraglutide.Indication: Treatment of adults with type 2 diabetes mellitus in combination withmetformin or a sulphonylurea, in patients with insufficient glycaemic control despitemaximal tolerated dose of metformin or sulphonylurea monotherapy; or in combinationwith metformin and a sulphonylurea, or metformin and a thiazolidinedione in patientswith insufficient glycaemic control despite dual therapy. Dosage: Victoza® isadministered once daily by subcutaneous injection and can be administered at any timeindependent of meals however, it is preferable that Victoza® is injected around thesame time of the day. Victoza® should not be administered intravenously orintramuscularly. Recommended starting dose is 0.6 mg daily. After at least one week,the dose should be increased to a maintenance dose of 1.2 mg. Based on clinicalresponse, after at least one week the dose can be increased to 1.8 mg to furtherimprove glycaemic control in some patients. Daily doses higher than 1.8 mg are notrecommended. When used with existing metformin therapy or in combination withmetformin and thiazolidinedione therapy, the current dose of metformin andthiazolidinedione can continue unchanged. When added to existing sulphonylureatherapy or in combination with metformin and sulphonylureas, a reduction in the doseof sulphonylurea may be necessary to reduce the risk of hypoglycaemia. Victoza® canbe used in the elderly (>65 years old) without dose adjustment but therapeuticexperience in patients ≥75 years of age is limited. No dose adjustment is required forpatients with mild renal impairment (creatinine clearance ≤60-90 ml/min). Due to lackof therapeutic experience Victoza® is not to be recommended for use in patients withmoderate (creatinine clearance of 30-59 ml/min) and severe renal impairment(creatinine clearance below 30 ml/min), patients with end stage renal disease, patientswith hepatic impairment and children below 18 years of age. Contraindications:

Hypersensitivity to the active substance or any of the excipients. Warnings andPrecautions for use: Victoza® should not be used in patients with type 1 diabetesmellitus or for the treatment of diabetic ketoacidosis. Limited experience in patientswith congestive heart failure New York Heart Association (NYHA) class I-II and noexperience in patients with NYHA class III-IV. Due to limited experience Victoza® is notrecommended for patients with inflammatory bowel disease and diabetic gastroparesis.Victoza® is associated with transient gastrointestinal adverse reactions, includingnausea, vomiting and diarrhoea. Other GLP-1 analogues have been associated withpancreatitis; patients should be informed of symptoms of acute pancreatitis: persistent,severe abdominal pain. If pancreatitis suspected, Victoza® and other suspect medicinalproducts should be discontinued. Thyroid adverse events, including increased bloodcalcitonin, goitre and thyroid neoplasm reported in clinical trials particularly in patientswith pre-existing thyroid disease. Risk of hypoglycaemia in combination withsulphonylureas; lowered by dose reduction of sulphonylurea. No studies on the effectson the ability to drive and use machines performed. Patients should be advised to takeprecautions to avoid hypoglycaemia while driving and using machines, in particularwhen Victoza® is used in combination with a sulphonylurea. Substances added toVictoza® may cause degradation; in the absence of compatibility studies Victoza® mustnot be mixed with other medicinal products. Pregnancy and lactation: Victoza®

should not be used during pregnancy or during breast-feeding. If a patient wishes tobecome pregnant, or pregnancy occurs, treatment with Victoza® should bediscontinued; use of insulin is recommended instead. Undesirable effects: Duringclinical trials with Victoza® the most frequently observed adverse reactions which variedaccording to the combination used (sulphonylurea, metformin or a thiazolidinedione)were: Very common: nausea, diarrhoea, hypoglycaemia when used in combination withmetformin and a sulphonylurea and headache when used in combination withmetformin; Common: hypoglycaemia when used in combination with athiazolidinedione, vomiting, constipation, abdominal pain, discomfort and distension,

dyspepsia, gastritis, flatulence, gastroesophageal reflux disease, gastroenteritis viral,toothache, headache, dizziness, nasopharyngitis, bronchitis, anorexia, appetitedecreased, fatigue and pyrexia. Gastrointestinal adverse reactions are more frequent atstart of therapy but are usually transient. Very few hypoglycaemic episodes observedother than with sulphonylureas. Patients >70 years or with mild renal impairment(creatinine clearance ≤ 60-90 ml/min) may experience more gastrointestinal effects.Consistent with medicinal products containing proteins/peptides, patients may developanti-liraglutide antibodies following treatment but this has not been associated withreduced efficacy of Victoza®. Few cases reported of angioedema (0.05%), acutepancreatitis (<0.2%) and injection site reactions (approx. 2%). Injection site reactionsusually mild. Causal relationship between Victoza® and pancreatitis can neither beestablished nor excluded. Thyroid neoplasms, increased blood calcitonin and goitres arethe most frequent thyroid adverse events and were reported in 0.5%, 1% and 0.8% ofpatients respectively. The Summary of Product Characteristics should be consulted for afull list of side effects. Overdose: In the event of overdose, appropriate supportivetreatment should be initiated according to the patient’s clinical signs and symptoms.MA numbers: Victoza® 2 x 3ml pre-filled pens EU/1/09/529/002. Victoza® 3 x 3ml pre-filled pens EU/1/09/529/003. Legal Category: POM. For complete prescribinginformation please refer to The Summary of Product Characteristics which is availableon www.medicines.ie or by email from info@novonordisk.ie or from Medicaldepartment, Novo Nordisk Limited, 3-4 Upper Pembroke Street, Dublin 2, Ireland;www.novonordisk.ie. Date created: July 2009.

Information about adverse event reporting is available at www.imb.ie. Adverse events should be reported to the Novo Nordisk Medical department:

Tel: 1850 665 665.

Further Information is available from: Novo Nordisk Limited

3/4 Upper Pembroke StreetDublin 2, IrelandTel: 01 678 5989 Fax: 01 676 3259

Lo Call: 1850 665 665www.novonordisk.ie

Victoza® is a trademark owned by Novo Nordisk A/S.

Date of preparation: August 2010. IR/LR/0810/0159

References: 1. Victoza® Summary of Product Characteristics. 2. Nauck M et al; for the LEAD-2 Study Group. Efficacy and safety comparison of liraglutide, glimepiride, and placebo, all in combination with metformin, in type 2 diabetes: the LEAD (liraglutide effect and action in diabetes)-2 study. Diabetes Care 2009;32(1):84-90.

Once-daily Victoza® (liraglutide), in combination with metformin,impacts on multiple factors associated with type 2 diabetesproviding, from baseline:1,2

Reductions in HbA1c: up to 1.30%1,2

Reductions in weight: up to 2.8kg1,2

Reductions in systolic blood pressure1,2

Improvements in beta-cell function1,2

Victoza IMT Sep 24 10(1):Levemir sep 24 13/09/2010 08:29 Page 1

12.30pm – 1.30pm Official Opening and Registration

SATURDAY 29th January 2011

SYSTemS of cARe foR DiAbeTeS

Multi-target care for better outcomes – how to translate into practice Dr Peter Gaede, DenmarkReal-world integration of care: practical experience Dr Roy Harper, N.IrelandSelf-care: taking care of your own diabetes Prof Steven Edelman, USA

10.30am – 11.00am Coffee break

for further information on the conference contact Brian Deegan of M+C Events on +353 1 665 0300 or email bdeegan@mandcgroup.ie

DiAbeTeS complicATionS

Diabetes neuropathy - a crystal ball towards cardiovascular complications Prof Andrew Boulton, UKNovel surgical approaches to foot complications Dr Karin Schara, Slovenia

innovATionS in TYpe 2 DiAbeTeS

Gene therapy for the Type 1 diabetes model in dogs Prof Fatima Bosch, SpainThe closed-loop system, towards an artificial pancreas Dr Roman Hovorka, UKNew approaches to the care of children with diabetes Prof Thomas Danne, Germany

innovATionS in TYpe 1 DiAbeTeS

Metabolomics – a new perspective on obesity, insulin resistance and diabetes Prof Chris Newgard, USAIron metabolism – a new approach to the prevention of diabetes Prof Don McClain, USAThe importance of Food Prof Jeya Henry, UKLong-term cure of diabetes by obesity surgery Dr Carel le Roux, UK

DIAMAP: A 10-year vision for research and care in Europe Prof John Nolan, IrelandDiabetes in China Prof Zhangrong XU, ChinaAccelerated Type 2 diabetes in India Dr Shailaja Kale, IndiaEnvironment and lifestyle: how Finland has succeeded Prof Jaakko Tuomilehto, Finland

3.30pm – 4.00pm Coffee break4.00pm – 6.00pm Workshops 1-3

DiffeRenT fAceS of The epiDemic: eURope AnD ASiA

fRiDAY 28th January 2011

Module 11.30pm – 3.30pm

Module 29.00am – 10.30am

Module 311.00am – 12.00pm

Module 42.00pm – 3.30pm

Module 54.00pm – 6.00pm

Workshops Friday

innovATionjAn 28/29 2011

in DiAbeTeS

www.innovATioninDiAbeTeS.com

A GLobAL vIEWFEATuRING SoME oF ThE WoRLD’S LEADING RESEARChERS AND CLINICIANS IN DIAbETES

IrIsh EndocrInE socIEty

Supported by:y College Dublin

CME accreditation pending

3.30pm – 4.00pm Coffee break

when you register onlinewww.innovationindiabetes.com

15% DISCouNT

Gala Dinner – Trinity College 8.30pm. Early booking is advised.

A multidisciplinary approach to the treatment of diabetesInnovation in Diabetes focuses on new approaches and research in clinical science and clinical care, towards a cure for diabetes. The central focus is on innovations for the benefit of people with diabetes. The meeting combines presentations from a panel of the world’s leading researchers and clinicians, with interactive workshops on new approaches to care.

In association with the School of Medicine, Trinity College Dublin

12.00pm – 1.00pm Workshop 41.00pm – 2.00pm Lunch

4.00pm – 6.00pm Workshops 5-8

4. Practical approach to foot complications (with patients)

6. Diabetes and pregnancy 7. Diabetes in children 8. Diabetes for the practice nurse

Workshops Saturday

5. Diabetic eye disease

1. New technologies in diabetes care and self care 2. Diet and diabetes 3. Exercise and physical activity

Scientific agenda

12.30pm – 1.30pm Official Opening and Registration

SATURDAY 29th January 2011

SYSTemS of cARe foR DiAbeTeS

Multi-target care for better outcomes – how to translate into practice Dr Peter Gaede, DenmarkReal-world integration of care: practical experience Dr Roy Harper, N.IrelandSelf-care: taking care of your own diabetes Prof Steven Edelman, USA

10.30am – 11.00am Coffee break

for further information on the conference contact Brian Deegan of M+C Events on +353 1 665 0300 or email bdeegan@mandcgroup.ie

DiAbeTeS complicATionS

Diabetes neuropathy - a crystal ball towards cardiovascular complications Prof Andrew Boulton, UKNovel surgical approaches to foot complications Dr Karin Schara, Slovenia

innovATionS in TYpe 2 DiAbeTeS

Gene therapy for the Type 1 diabetes model in dogs Prof Fatima Bosch, SpainThe closed-loop system, towards an artificial pancreas Dr Roman Hovorka, UKNew approaches to the care of children with diabetes Prof Thomas Danne, Germany

innovATionS in TYpe 1 DiAbeTeS

Metabolomics – a new perspective on obesity, insulin resistance and diabetes Prof Chris Newgard, USAIron metabolism – a new approach to the prevention of diabetes Prof Don McClain, USAThe importance of Food Prof Jeya Henry, UKLong-term cure of diabetes by obesity surgery Dr Carel le Roux, UK

DIAMAP: A 10-year vision for research and care in Europe Prof John Nolan, IrelandDiabetes in China Prof Zhangrong XU, ChinaAccelerated Type 2 diabetes in India Dr Shailaja Kale, IndiaEnvironment and lifestyle: how Finland has succeeded Prof Jaakko Tuomilehto, Finland

3.30pm – 4.00pm Coffee break4.00pm – 6.00pm Workshops 1-3

DiffeRenT fAceS of The epiDemic: eURope AnD ASiA

fRiDAY 28th January 2011

Module 11.30pm – 3.30pm

Module 29.00am – 10.30am

Module 311.00am – 12.00pm

Module 42.00pm – 3.30pm

Module 54.00pm – 6.00pm

Workshops Friday

innovATionjAn 28/29 2011

in DiAbeTeS

www.innovATioninDiAbeTeS.com

A GLobAL vIEWFEATuRING SoME oF ThE WoRLD’S LEADING RESEARChERS AND CLINICIANS IN DIAbETES

IrIsh EndocrInE socIEty

Supported by:y College Dublin

CME accreditation pending

3.30pm – 4.00pm Coffee break

when you register onlinewww.innovationindiabetes.com

15% DISCouNT

Gala Dinner – Trinity College 8.30pm. Early booking is advised.

A multidisciplinary approach to the treatment of diabetesInnovation in Diabetes focuses on new approaches and research in clinical science and clinical care, towards a cure for diabetes. The central focus is on innovations for the benefit of people with diabetes. The meeting combines presentations from a panel of the world’s leading researchers and clinicians, with interactive workshops on new approaches to care.

In association with the School of Medicine, Trinity College Dublin

12.00pm – 1.00pm Workshop 41.00pm – 2.00pm Lunch

4.00pm – 6.00pm Workshops 5-8

4. Practical approach to foot complications (with patients)

6. Diabetes and pregnancy 7. Diabetes in children 8. Diabetes for the practice nurse

Workshops Saturday

5. Diabetic eye disease

1. New technologies in diabetes care and self care 2. Diet and diabetes 3. Exercise and physical activity

Scientific agenda

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BabyVitD3Vitamin D food Supplement

“It is recommended that all infants, from birth to 12 months, whether breastfed or formula fed, begiven a daily supplement of 5 ug (200 IU)2 vitamin D.This should be provided by a supplement containingvitamin D exclusively.”*

*HSE Vitamin D Recommendation 2010

80% Reliefin 2 Days

• For the care of dry and sensitive nipples• Protects the nipple before and during breastfeeding• Does not need to be removed prior to breastfeeding

• For Cracked sore or swollen nipples• Gives immediate comfort and relief•Prevents against infection• Gel is natural and harmless when swallowed

33

nutrition

Breastfeeding is the preferred first food for babies. However, in order to inform parents who are no longer breastfeeding, are partially breastfeeding, or have made an informed choice not to breastfeed, it is important to be familiar with the various types

of infant formulae that are suitable to use as an alternative to breast feeding. Although nutritionally complete, formula milks cannot provide the wide range of non-nutritional components in breast milk. Infant formulas are adopted from cows milk and are intended as a sole source of nutrition for infants during the first four to six months of life and should be continued until the infant is one year of age.

To try and approximate the nutritional content of breast milk infant formula manufacturers have added the following to their feeds.1. Long chain fatty acids (LCFAs), which are essential for

healthy development of brain, eye and nervous system.12. Nucleotides aimed at enhancing the immune system,

decreasing the risk of diarrhoea and improving growth.1 They are low-molecular-weight precursors of nucleic acids, deoxyribonucleic acid (DNA), and ribonucleic acid (RNA).

• Prebiotics which are the selective substrates for friendly bacteria.1 A high level of friendly bacteria provides increased protection by reducing the risk of allergy, promoting digestion and produce softer stools.The bio-availability of these artificial additives is much less

than in human milk where they are naturally occurring.Formulas are produced either in dried powdered or ready

to use form. Ineither case the manufactures instructions for use should be followed precisely. It is not recommended that formula brands and products are ‘chopped and changed’. They should be used appropriately and as clinically indicated.2 There are different types of infant formulas but they can be largely divided into four groups.

1. whey DoMINANT forMulAe (BIrTh - 1 yeAr)1,2

Key points: • The 60: 40 ratio of whey: casein is similar to breast milk• It is recommended by the department of health and children

that infants stay on whey based formula throughout the first year of life unless clinically indicated. 2, 3

2. cAseIN DoMINANT forMulAe (BIrTh - 1 yeAr) 1,2

Key points• The 20:80 ratio of whey:casein is similar to cows’ milk • The protein in these formulas takes longer to digest, thus

making them more satisfying. Parents may change to casein dominant formula to make the baby go longer between feeds; however, there is no firm evidence that these milks are more suitable than the whey based milks.

3. follow oN MIlKs/ToDDler MIlKs 1,2,3

Key points• They are higher in protein (casein), iron and calcium.• In general they are not needed when a child is having a wide

variety of weaning/complementary foods• They may have a role to play among at risk groups,

preventing iron deficiency anemia and vitamin D deficiency• The World Health Assembly (1986) stated that follow-on

milks were “unnecessary”. However the Eu has published regulations permitting their use after 4 months. In Ireland companies who market follow on milks have agreed voluntarily to market them for infants of 6 months +.3

4. sPecIAlIseD forMulA2

4.1 Partially hydrolysed formula2

• Can be used from birth• The whole proteins in the feed are broken down rendering

the feed more digestible

sAlly-ANN MclAughlIN, SENIOR COMMuNITY DIETITIAN, COMMuNITY NuTRITION & DIETETIC SERVICE OF THE HEALTH PROMOTION DEPARTMENT, HSE DuBLIN NORTH EAST.

There is a plethora of infant feeding

formulas so it is important to

familiarise oneself with the ones that

are both suitable and unsuitable.

Infant formula feeding(Part 3 of a three part series on infant nutrition)

34

nutrition

• May help with symptoms of colic, constipation and digestive discomfort.

4.2 Extensively hydrolysed formula2 - to be used under medical supervisionKey points• For use in cows milk protein allergy or multiple severe food

allergies• Formula are made from pre-digested nutrients and contain

essential vitamins and minerals.

4.3 lactose-free/low lactose formula1, 2 Key points• use in lactose intolerance and lactase deficiency and where

cows’ milk protein cannot be tolerated• Lactose-free feeds are not indicated for use in infants with

eczema.

4.4 Anti reflux/regurgitation formulae2

Key points• Can be used from birth• Formulae thickens on contact with the acid pH of the

stomach• For use with infants who vomit/regurgitate feed and fail to

improve on standard infant thickeners.

4.5 soya based formulae 1,2,4

Key points• Soya based formula provide a nutritionally complete

alternative to modified cows milk formula. • Soya based infant formulae should not be used unless

medically indicated as they may be (1) more carinogenic due to use of glucose polymers1 (2) may pose difficulties for future fertility and sexual development due to the unknown effect of phytoestrogen;1

(3) the mineral absorption from soya formulae is less predictable e.g. unknown effects of high aluminium.3

• Soya formula are often used inappropriately, and more widely than necessary, for the treatment of colic, cows milk protein allergy (CMPI) and lactose intolerance. Infants with a CMPI should not use soya formula as they may also develop sensitivity to soya protein.1,5,7

• In infants under 6 months the use of soya formula is only indicated in the following circumstances 1,7

• Infants with galactosaemia• Cows milk protein intolerance CMPI, only where a

hydrolysed formula is not tolerated• Infants of non-breastfeeding vegan mothers.

4.6 sheep/rice/goats milks2,6

Key points• The Food Safety Authority of Ireland has stated that goats

milk formula is not an infant formula; it cannot be presented or displayed as such when on the shelves in shops/pharmacies/supermarkets 2,6

• Goats or sheeps milk are not suitable drinks for infants under 12 months. They are nutritionally inadequate in terms of iron, sodium, vitamin D and folic acid when compared to human milk.4

• Infant formulas based on goats or sheeps milk proteins are not suitable alternatives for babies who are intolerant or allergic to cows milk formula. Some of the proteins in goats and sheeps milk are similar to those found in cows milk and most babies that react to cows milk protein are also likely to react to goats and sheep milk protein.1

Date of preparation: May 2010 05-11-NUV-2010-IRL-J

Minimal Oestrogen MonthlyJust 0.015mg ethinylestradiol daily 1

References 1. NuvaRing - Summary of Product Characteristics 2. van den Heuval MW et al. Contraception 2005 Sep;72(3):168-74. 3. Milsom I et al. Hum Reprod 2006;21(9):2304-2311 4. Novak A et al. Contraception 2003;67:187-194. 5. Organon data on file.

5.5 million women years exposure to NuvaRing® worldwide 5

Pelham House, South County Business Park, Leopardstown, Dublin 18, Ireland

NuvaRing® provides a low and steady delivery of hormones compared to a COC 2

Neutral effect on weight – no difference vs. drospirenone 3

96% user satisfaction rate 4

Nuvaring 0.120 mg/0.015mg per 24 hours vaginal delivery system® (See SPC before Prescribing) Etonogestrel and ethinylestradiol. Presentation: Vaginal ring. Uses: Contraception. Dosage and Administration: A ring should be inserted into the vagina and left in for 3 weeks. Strictly follow insertion instructions. Contraindications: Presence/history of venous thrombosis, with/without the involvement of pulmonary embolism. Presence/history of arterial thrombosis or prodromi of a thrombosis. Known predisposition for venous/arterial thrombosis, with/without hereditary involvement or the presence of severe/multiple risk factors. History of migraine with focal neurological symptoms. Diabetes mellitus with vascular involvement. Pancreatitis or history thereof if associated with severe hypertriglyceridemia. Presence/history of severe hepatic disease if liver function values abnormal. Presence/history of liver tumors. Known/suspected sex-hormone dependent tumors. Undiagnosed vaginal bleeding. Hypersensitivity to any ingredients. Precautions and Warnings: No epidemiology data available on vaginal administration but the warnings for combined OCs (COCs) are considered applicable. Risk of breast cancer possibly similar to that associated with COCs. This may be due to earlier diagnosis in COC users, the biological effects of the COC, or a combination of both. Use of hormonal contraceptives has been associated with increased risk of venous thromboembolism (VTE, DVT, PE) and arterial thrombosis. It is unclear whether NuvaRing carries the same risk. Remove ring in event of a thrombosis and before long-term immobilisation. Council patients on symptoms of thrombosis. Increased risk of cervical cancer in long term COC users has been reported, but this may be confounded by other factors. Abnormal liver function or liver tumors. Increased risk of pancreatitis in women with hypertriglyceridemia taking hormonal contraceptives. Hypertension. Diabetes. Crohn’s disease/ulcerative colitis. Chloasma. History during pregnancy/previous use of sex steroids: jaundice and/or pruritis related to cholestasis, gallstone formation, porphyria, SLE, HUS, Sydenham’s chorea, herpes gestationis, otosclerosis. Remove ring if there is increased frequency/

severity of migraine. Increased risk of thromboembolism in the puerperium. May not be suitable for women with a prolapse or severe constipation. Consider incorrect positioning in case of cystitis. Occasional vaginitis. If ring accidentally expelled follow SPC instructions. Interactions: Possible interactions with phenytoin, phenobarbital, primidone, carbamazepine, rifampicin, oxcarbazepine, topiramate, felbamate, ritonavir, griseofulvin, penicillins, tetracyclines, ciclosporin, lamotrigine and St John’s Wort. Use of antimycotic ovules may increase the chance of ring disconnection. Pregnancy and Lactation: Not recommended. Common Undesirable effects: Vaginal infection, depression, decreased libido, headache, migraine, abdominal pain, nausea, acne, pelvic pain, breast tenderness, genital pruritis, female dysmenorrhoea, vaginal discharge, weight increased, discomfort, device expulsion. See SPC for full details of other uncommon side effects. Overdose: No reports of serious effects from overdose. Legal Category: Prescription Medicine Product Authorisation Number: PA 61/29/1. Price: NuvaRing x 1 €9.41, NuvaRing x 3 €28.23 Product Authorisation holder: Organon Ireland Limited, a part of Schering-Plough Corporation, P.O. Box 2857, Drynam Road, Swords, Co. Dublin, Ireland. Further information is available from: Schering-Plough Ltd, Shire Park, Welwyn Garden City, Hertfordshire, AL7 1TW, UK. Telephone +44 (0)1707 363636.

Please refer to the full SPC text before prescribing this product. Adverse events should be reported. Reporting forms and information can be found at www.yellowcard.gov.uk (UK) and www.imb.ie (Ireland). Adverse events with this product should also be reported to Schering-Plough Drug Safety Department on +44 (0)1707 363773.

Date of revision of prescribing information: December 2008 Nuvaring/IRL/API/12-08/1

H54641 NUV Ire 375x126 v6.indd 1 18/5/10 12:25:22

35

nutrition

Introducing new oestrogen-free1 Cerazette for a star performance

Reference 1. Cerazette Summary of Product Characteristics. Cerazette® 75 microgram fi lm-coated tablets Desogestrel Abbreviated Prescribing Information (Refer to Summary of Product Characteristics before prescribing) Presentation: One sachet containing 1 strip of 28 tablets, each tablet containing 75mcg desogestrel. Uses: Contraception. Dosage: One tablet daily at about the same time. There is no pill-free week between strips. Contraindications: Known or suspected pregnancy, active venous thromboembolic disorder, presence or history of severe hepatic disease with current abnormal liver function tests, known or suspected sex-steroid sensitive malignancies, undiagnosed vaginal bleeding, hypersensitivity to any ingredients. Precautions and warnings: Women currently using combined oral contraceptives (COCs) have a slightly increased risk of having breast cancer diagnosed. The risk in users of progestogen only pills is possibly of similar magnitude to COCs. This risk is low compared to the risk of getting breast cancer ever in life. The increased risk in COC users may be due to an earlier diagnosis, biological effects of the pill, or a combination of both. Refer to a specialist if acute or chronic disturbances of liver function occur. Epidemiological studies have associated the use of COCs with an increased incidence of venous thromboembolism (VTE, deep venous thrombosis and pulmonary embolism). It is unclear whether desogestrel used alone carries the same risk. Discontinue in the event of a thrombosis. Consider stopping prior to long term immobilisation due to surgery or illness. Caution patients with a history of thromboembolic disorders. Consider discontinuation if hypertension develops. Benefi t/risk assessment should be made in women with liver cancer. Monitor patients with diabetes during the fi rst months of use. Effects on bone density are unknown. Despite the fact that Cerazette consistently inhibits ovulation, ectopic pregnancy should be taken into account in the differential diagnosis if the woman gets amenorrhoea or abdominal pain. Chloasma may occasionally occur. Cerazette contains less than 65mg lactose, and therefore should not be administered to patients with rare hereditary problems of galactose intolerance, the Lapp lactase defi ciency, or glucose-galactose malabsorption. Use in pregnancy and lactation: Not

recommended during pregnancy. Cerazette does not infl uence the production or quality of breast milk. Small amounts of the metabolite etonogestrel are excreted with the milk. Limited long term follow-up data (up to 2.5 yrs) on children who were breast-fed do not indicate any differences compared to those whose mother used a copper IUD. However development and growth of the nursing infant should be carefully observed. Interactions: Interactions may lead to breakthrough bleeding and contraceptive failure. This may be seen with enzyme inducers such as hydantoins, barbiturates, primidone, carbamazepine, rifampicin, oxcarbazepine, topiramate, rifabutin, felbamate, ritonavir, nelfi navir, griseofulvin and products containing St John’s Wort. Reduced absorption of etonogestrel may be seen with medical charcoal. Hormonal contraceptives may interfere with metabolism of other drugs, and therefore increase or decrease their plasma or tissue concentrations. Adverse reactions: Refer to SmPC for full details. Common: irregular bleeding, amenorrhoea, headache, weight gain, breast pain, nausea, acne, mood changes, decreased libido. Breast discharge may also occur. Other less common and rarely reported side effects are listed on the SmPC. Overdose: No serious effects have been reported. Symptoms may include nausea, vomiting and in young girls, slight vaginal bleeding. Treatment should be symptomatic. Legal category: Prescription Only Medicine. Product licence number: PA 61/27/1 Price: 1 carton Cerazette containing 28 tablets - €5.90 Product licence holder: Organon (Ireland) Limited, P.O. Box 2857, Drynam Road, Swords, Co. Dublin, Ireland Further information is available from: Schering-Plough Ltd, Shire Park, Welwyn Garden City, Hertfordshire, AL7 1TW, UK. Telephone +44 (0) 1707 363636 Date of revision of Prescribing Information: July 2009

Please refer to the full SmPC text before prescribing this product. Adverse events should be reported. Reporting forms and information can be found at www.imb.ie Adverse events with this product should also be reported to Schering-Plough Drug Safety Department on +44 (0) 1707 363773.

Date of preparation: May 2010 05-11-CER-2010-IRL-3270-J

Pelham House, South County Business Park, Leopardstown, Dublin 18, Ireland

...when Oestrogen isn’t right 1

New

75µg desogestrel

Primarily Inhibits

Ovulation 1

Oestrogen-FREE 1Pregnancy Protection

Comparable to a COC 1

H54641 CZT Ire 375x126 v6.indd 1 18/5/10 10:41:19

• The Food Safety Authority of Ireland recommends8 “toddlers and young children between 1 and 4.5 yrs old should not have rice drinks as a replacement of cows’ milk, breast milk or infant formula. This is because thy may drink a relatively large amount of it, and their intake of arsenicwill be greater than that of older children and adults relative to their body weight”.

forMulA feeDINg AND vITAMIN DThe Department of Health and Children and the Health Service Executive (HSE) has now endorsed the the Food Safety Authority of Ireland’s (FSAI) recommendation.9

‘All infants, from birth to 12 months, whether breastfed or formula fed, be given a daily supplement of 5 µg (200 IU) vitamin D. This should be provided by a supplement containing vitamin D exclusively’.

A daily vitamin D supplement for infants of 5µg can prevent vitamin D deficiency without risk of toxicity. The FSAI recommends the supplement is vitamin D alone in the form of vitamin D

3 (cholecalciferol). A list of the current available

vitamin D supplements suitable for infants can be found on www.hse.ie

These commercial preparations are available without a prescription and can be purchased over the counter in pharmacies and some other outlets.

The choice of preparation is at the discretion of the parent/care giver. It is important to read the information leaflet accompanying the supplement.

Further information leaflets for both health professionals and carers can be downloaded from www.hse.ie. Copies of the parent/carer information leaflet can be ordered on www.healthpromotion.ie or by contacting the local Health Promotion Offices in each HSE area.10

references1. HSE (2006) Training programme for public health nurses

and doctors in child health screening, surveillance and health promotion: unit 7 – food and nutrition

2. Community Nutrition and Dietetic Department, Bray HSE (2008), Nutrition reference pack for infants (0-12months), for health care professionals in the community setting.

3. Food Safety Authority of Ireland (1999) Recommendations for a national feeding policy

4. Merritt RJ, Jenks BH (2004): Safety of soya based infant formulas contains isoflavones: the clinical evidence. J Nut 134

5. American Academy of Pediatrics Committee (1998), Soya infant formula, the health concerns, a food commission briefing paper. Soy protein based formulas: recommendations foe use in infant feeding. Pediatrics 101 (1)14853

6. Food Safety Authority of Ireland (1999b). Marketing of infant formulas www.fsai.ie

7. British Dietetic Association Paediatric Group Position Statement (2003). use of infant formula based on soy protein for infants

8. FSAI (2009). Advice against the consumption of rice milk for infants and young children. www.fsai.ie

9. Food Safety Authority of Ireland (FSAI). Recommendations for a National Policy on vitamin D supplementation for Infants and Young Children. Food Safety Authority of Ireland, Abbey Court, Lower Abbey street, Dublin 1(2007).

10. Health Service Executive (HSE) National Steering Group on Vitamin D. Policy on vitamin D supplementation for infants in Ireland. Health Service Executive, 2010.

36

out of hours

In order to see if a person has diabetes, taste the urine, and compare it with other urine you have tasted.” says Denise. She is reading David Werner’s Where there is no doctor. “Fair enough” I

say, “ Go ahead”. We are driving up to the hills in the centre of Burundi. With each kilometre we travel we are leaving the swel-tering heat of the African capital, Bujumbura further behind. I like this countryside; it’s fresher and greener than the city, full of life – people crowded around tiny stalls selling fruit, nuts and hens. Goats rushing here and there, usually followed by dirty, half dressed children.

Our driver blows his horn at every opportunity, scattering women and children off the road. Women with enormous piles on their heads jump nimbly out of the way, accepting the supremacy of the car. Men, side saddle on the bar of their bicy-cles, hitch a ride up the hill, holding on to the back of the truck in front of us. I’m terrified a bump in the road will send a bike flying and hurl one of them under the wheels of our car.

I’m delighted when we reach our destination, a new hos-pital, not yet opened, in the hills of central Burundi. The air is warm and pleasant and feels cool after the stifling heat of the lowlands. But it is not the hospital that interests me, but the re-

cently opened nutrition centre. This is where Denise and I have been asked to help the local staff. There are three Burundi staff employed to set up the hospital and run the nutrition centre, two nurses, Imelda and Claud, and a social worker, Constance.

foreIgNer souPNext day, at the centre, I don’t feel as awkward as I thought I would. At first look around I don’t see many problems, I see a noisy group of chattering woman and kids. They seem to be very well organised, sitting in rows on benches. A hush falls over the crowd as we appear. They are greeting us, I don’t un-derstand the words, but I figure it’s friendly. Hopefully it’s not foreigner soup today.

There are two fires burning in the kitchen with an enormous pot on each. I taste the porridge, it’s not great, but I figure it’s not me that’s eating it. The kids love it. They devour every last teaspoon of it. In fact there are kids on the sidelines, that are not part of the programme, waiting to clean the pots of any-thing that is left.

I sit on a bench, trying to blend in with the crowd (like that’s likely). Now I look at the kids more closely. I’m drawn to an older woman, probably a granny, with a baby on her knee. The baby moves and her legs and arms are exposed and I see that this is not a baby, she is a much older child. The limbs are so thin and the skin hangs wrinkled around the bone. The face looks old on the small body. This is Geesling, she is five years old, she weighs the same as a baby, and is not much longer. She is too weak to hold her head up. I cannot find out how she got into that condition, what started her on the road to such severe malnutrition. It seems obvious to me that this child cannot survive, or, if she does, she will be severely brain damaged.

Now I see other children, thin arms and legs hidden be-hind big, adult tee-shirts. Some have the puffy face and feet

Tasting urine and other matters

MArJorIe hAIre, PRACTICE NuRSE, IONAD SLAINTE, AN CHEATHRu RuA, CO. NA GAILLIMHE

On a working trip to Burundi to help ‘educate’ the locals about western medicine, Marjorie learnt much herself...including how to ‘chill’

“

37

out of hours

of kwashiorkor, but most have marasmus, with or without, kwashiorkor. Some look well nourished and I wonder what the discharge criteria is. Maybe this warrants discussion in our classes.

The only man in the group has come to help his wife carry their triplets. They are a little underweight but healthy enough, running around and trying to climb the red dirt bank that sur-rounds the centre.

roDger rATIn the evening we return to our guesthouse. There is a rat in my room. Denise kindly names him Rodger. I would rather not share my room with Rodger and shout at him to go but he dives under the bed. I cannot find any staff to help me, so sleep with the light on. I’m not sure what the light is supposed to do but it makes me feel braver. I have the mosquito net tucked in around the bed and wonder would he bite through the net-ting. Next day I tell the staff. This is met with laughter. Nothing is done. I go to the top and insist the owner puts traps in my room. Rodger is not caught but I see him chatting to his cousins outside the room later.

Next day we have arranged to meet with the staff for a teach-ing session.

Denise and I have divided up between us the subjects we want covered . On the first day she takes recognising malnutri-tion and I take food groups.

Denise is finding it hard going explaining the weight chart we hope to introduce into the centre. “This is very difficult “ says Imelda. Imelda is head nurse in charge of the hospital. It strikes me again how different our education, and even our academic environment, is in Western countries. Charts don’t seem to be used in common situations like we would use them.

We saw a torn piece of paper taped to a bed in the hospital in Bujumbura stating “Temp. 37”. There was no chart.

Denise is blu-tacking two posters on the wall which she has drawn. One titled Dry Malnutrition – skin and bones (Maras-mus) and the other Wet Malnutrition – skin and bones and water (Kwashiorkor). For someone who never did this before she is making a pretty good fist of it. She tells me she was up to two o’clock in the morning preparing.

I use a simplified version of the food pyramid, found in Where there is no doctor. This book is really a gem. I talk of Main foods (cereals and starches), Go foods (energy helpers), Grow foods (protein) and Glow foods (vitamins and minerals). I’m grateful for the talk I had with Dr Aline, head of the African Revival Mis-sion, who told me about a local, affordable, source of protein. This little, sardine-like fish is sold in the market. Meat is much too expensive for most of the population. She also filled me in on locally available fruit and vegetables.

chIll AT wIll In the evening, we are back in the guesthouse dinning room waiting for dinner. Although we ordered it in the morning we are still waiting one and a half hours. This is Africa and I have to learn to chill out. We fill the time in by making arm bands. A well nourished child, aged 1 to 5 years will have a upper arm circumference of, at least,13 ½ cm. We make the arm bands of paper, strengthened with sellotape, with different colours at the 12½ cm (severe malnutrition) mark and the 13 1/2 cm (mild malnutrition) mark. Next day the staff are delighted with this equipment and there are smiles all round.

I look at my feet, these once well manicured, painted toes are filthy. The red dust that covers everything in Burundi has found it’s way into every pore and crease. It will take a week by the sea to restore them to their former glory.

Back home, weeks later. my flip-flops still have Burundi dust in them. A little bit of Burundi in Galway. I like that.

I would rather not share my room with rodger and shout at him to go, but he dives under the bed.

geesling was five years old. she weighed the same as a baby.

38

poster series

THE BENEFITS OF A POSTNATAL SUPPORT GROUPTHE BENEFITS OF A POSTNATAL SUPPORT GROUPAim of Study

• This is a qualatative study which desribes the experiences of women who attended a postnatal

support group in West Dublin over a 20 week periodfaciliated by a qualified Councellor

The Study• To Explore the benefits and disadvantages of the

support group and the difference it made to the livesof the women who attended

Author• Christine Kelly,RGN, CNS General Practice, MSc Women’s Health

•AcknowledgementRita Lawlor RGNm RM, BNSCM (Hons)Professional Development Co-ordinator for Practice Nurses

Mothers Experiences

Methodology• Data was gathered by in depth

semi structured one to one interviews with mothers who attended the group.

•Each interview was audiotaped and transcribed by the researcher

Findings• Postnatal Support Groups works

• Greater understanding of the needs of new mothers is required• Creche facilities required to enable mothers

to participate in the group• Postnatal support groups should be establishedin all areas

• Meeting other mothers and sharing experiencesis effective and can make a difference to future

experiences of motherhood.

Why the Group was Established

• The post natal period can be potentially stressful one when women need to face both the the new task of her

maternal role and changes to her body

�� ���

Even though you are a mother

you are entitled to your own

identity and you need time

for yourself

I made new friends and

during the course it was great to

get out once a week and have the

children minded

in the creche.

I learned to relax about parenting and do the

best I can.

�We had a wonderful pampering day and relaxation in the Shanti, I had never experienced this before.

Nothing prepares you for the

loneliness of motherhood and

it was great to meet other women

who had the same feelings

Its okay to look for helpwhen I need it and my partnercan help and share theresponsibilities.

Abstract of research submitted as part of M.Sc in Women’s Health, Christine Kelly, Practice Nurse, Springfield Medical Centre.This was an entry for the branch poster award 2006

Experiences of women in a post natal support group in West Dublin

AbstractA qualitative study of the experiences of women who attended a post natal support group in an area of West Dublin. The group was facilitated by a trained counsellor and run over a period of 20 weeks. Child care facilities were provided for the children of the mothers attending.

The need for the group was identified within the GP practice and by the Public Health Nurses in the area who realised support is not always available to new mothers in the community and many mothers live in isolation.

MethodThe data for the study was collected by means of semi structured questions in face to face interview with the attenders of the group. Two Public Health Nurses who were in two neighbouring health centres within the area were also interviewed. Each interview was taped and transcribed.

resultsThe research endeavoured to describe the outcomes of the women’s experiences, whether they were positive or not, who had attended the post natal support group.

Throughout the interviews the women described their experiences of attending the group weekly for the 20 weeks. These women described struggling as new mothers and leant to share ‘what it was like’. They described feelings of loneliness as new mothers and valued the feelings of talking with others who identified with them.

They described the group process as helping them to support and encourage one another.

The two Public Health Nurses who were interviewed, described how they had identified the need for the group, the encouragement they gave to the women to attend and the changes they saw women had made due to attending the group.

39

book reviewreADers offer

Nurse: Past, Present and future: The Making of Modern Nursing

edited by: Kate Trant and susan usheruK Price: £19.95

Covering all aspects of the culture of nursing from education to practice, and the increasing value and impact of the profession in one fully illustrated volume, Nurse explores the development of nursing in the uK and internationally, offering a multi-cultural approach to nursing worldwide.

Commencing with an exploration of the importance of nursing to healthcare systems and economics across the world, the book includes essays by international nursing experts, including Carol Etherington, winner of the FNIF International Achievement Award and Mireille Kingma, consultant for nursing and health policy with the International Council of Nurses. The book also includes first hand accounts from nurses on the ground worldwide, conveying the aspirations, opportunities, frustrations and achievements of this fascinating vocation.

Nurse is an exceptional source for healthcare professionals, and an illuminating text for those interested in care. Beautifully illustrated, with iconic images from historical sources and contemporary photographs, this is the first book dedicated to the past, present and future of the culture of nursing.

‘The text and photographs in this book will interest and give pleasure to all nurses and everyone who knows and cares about nursing.’ – Nursing Standard

To order at the discounted price, IPNA members simply need to email –

Jessica Atkins at jess@blackdogonline.com with the delivery addressPlease do let me know if you have any queries – I’d be happy to help.

architecture art designfashion history photographytheory and things

Nurse: past, present and futureThe Making of Modern Nursing

Edited by Kate Trant and Susan Usher

May 2010 Paperback192 pages126 colour and b/w ills24.5 x 17 cm / 6.5 x 9.5 inISBN: 978 1 906155 99 5

UK: £19.95US: $29.95

Nurse: past, present and future is a compelling look at the evolution of nursing. Covering all aspects of the culture of nursing from education to practice, and the increasing value and impact of the profession in one fully illustrated volume, Nurse explores the development of nursing in the UK and internationally, offering a multi-cultural approach to nursing worldwide.

Commencing with an exploration of the importance of nursing to healthcare systems and economics across the world, Nurse: past, present and future includes essays by international nursing experts, including Carol Etherington, winner of the FNIF International Achievement Award, Dr Helen Sweet, Oxford University, and Mireille Kingma, PhD, consultant for nursing and health policy with the International Council of Nurses, in addition to first hand accounts from nurses on the ground worldwide, conveying the aspirations, opportunities, frustrations and achievements of this fascinating vocation.

From patient homes around the world to war-zone triage and from high-tech hospitals to call centres, Nurse inspects the vast range of settings in which nurses currently practice, and how developments taking place in these settings are redefining how they will work in the future.

Nurse: past, present and future is an exceptional source for healthcare professionals, and an illuminating text for those interested in care. Beautifully illustrated, with iconic images from historical sources and contemporary photographs, this is the first book dedicated to the past, present and future of the cultureof nursing.

Kate Trant is a design historian and the author of several books on contemporary design. She has recently focused on aspects of hospital design and healthcare environments.Susan Usher is Director of the Health Policy Division, Parkhurst Publishing Ltd, Montreal, Canada. She is the editor and author of numerous papers and books on a wide range of healthcare topics.

PRESS RELEASE

Black Dog Publishing Ltd London UK10a acton streetlondon wc1x 9ngunited kingdom

t: + 44 (0) 207 713 5097f: + 44 (0) 207 713 8682 www.blackdogonline.com

For review copies or further information please contact Charlotte Jansen press@blackdogonline.com

living with a problem drinker – your survival guide

Publisher: sheldon PressPrice: €9.50

Dr rolande Anderson.

Any practice nurse who attended the 2009 conference hosted by Mayo Branch in Westport will remember Dr Rolande Anderson and his dynamic presentation ‘The Celtic Tiger Hangover’.

Rolande has now written a book on the impact of drinking. The book’s straightforward form makes it suitable for both the medical professional and lay person. With its anecdotal case studies highlighting certain issues, it will touch a nerve not only in the person with a drink problem but also with family members (including children) who are affected by living with a problem drinker.

Chapter 1 puts the various issues around alcohol in context. Chapter 2 has a very helpful A-Z.

Although primarily dealing with drink, many of the book’s insights are applicable to other addictive behaviours. While the entire book is thought provoking, it also allows the reader an insight into some controversial concepts. Personally, I had never heard of a ‘dry drunk’ or what ‘co-dependency’ meant.

I was also naïve to the fact that some family members may want him or her to remain dependant on alcohol. Rolande cleverly alternates the various sections with ‘he’ and ‘she’. He gives psychological advice and addresses practical realities for both the drinker and the family member. In a chapter outlining the type of help available, he gives some very practical advice about what to look for in a counsellor.

“I believe there is a river running right through the middle of Ireland,” he comments, “and that river is called denial. I think people are more open now than they were 20 years ago but there is still horrendous shame and suffering, and much secrecy in families where alcohol problems occur.”

It only took me a couple of days to read the book, but it is one I will be keeping handy as a reference. If I had to make one criticism it would be that, being designed for both the Irish and the uK markets, there is a lack of useful Irish addresses. But, as Frances Black said at the book’s lively launch in Trinity College back in August 2010, “I shall be recommending this to all my clients”.

Lynn Cartwright, IPNA PRO

House to LetSt. James’s & The CoombeArchitect’s house to rent. Recently renovated and newly furnished 2 bed. GFCH. Free parking. Would suit 2/3 professionals. Non smokers only. Viewing recommended.

Contact: 087 4176134.

40

product news

www.yourmedicines.ie

Novartis gains FDA approval for Gilenya, an oral first-line MS treatment shown to significantly reduce relapses and delay disability progression

The uS Food and Drug Administration (FDA) has approved the oral multiple sclerosis (MS) treatment Gilenya (fingolimod) 0.5 mg daily, Novartis has announced. A first-line treatment for relapsing forms of multiple sclerosis – the most common forms of the disease – Gilenya the first FDA approved oral treatment indicated for relapsing forms of MS available in the uS.

Gilenya reduces the frequency of MS relapses (flare-ups) and helps slow the build-up of some of the physical problems caused by MS. Gilenya 0.5 mg reduced relapses by 52% (P<0.001) at one year compared with interferon beta-1a IM (Avonex), one of the most commonly prescribed treatments for MS. In clinical trials, Gilenya had a well-studied safety and tolerability profile, which has been characterized in over 2,600 clinical trial patients, some of whom are in their seventh year of treatment, with more than 4,500 patient years of experience.

The Gilenya approval was based on the largest clinical trial program ever submitted to date to the FDA for a new MS drug. It combined data from clinical studies showing significant efficacy in reducing relapses, the risk of disability progression, and the number of brain lesions detected by magnetic resonance imaging (MRI), a measure of disease activity, in people with relapsing forms of MS.

“We are proud to have worked successfully with the MS community toward a shared goal of bringing a novel efficacious treatment to people with relapsing forms of MS,” said Dr Greg Hays, Medical Director, Novartis Ireland. “The European Medicines Agency (EMEA) regulatory review is ongoing at present.”

Dr Hays added that Novartis was delighted that Ireland was able to contribute to this significant development in the treatment of MS through the participation of St Vincent’s Hospital in the Freedoms Trial, which was published in the New England Journal of Medicine in February of this year.

Commenting on the FDA approval, Professor Michael Hutchinson, Principal Investigator of the Freedoms Trail at St Vincent’s Hospital, added: “The future for treatment of multiple sclerosis with this new powerful oral therapy looks good’.

Multiple Sclerosis Ireland said it was delighted to learn that the FDA had given approval for the first oral therapy for MS in the uS. Communications Manager Taragh Donohoe added: “While it may be a while before it comes to Irish shores it signals a new therapy option for those living with relapsing-remitting MS. A significant number of people with MS rely on disease modifying therapies to reduce their relapse rate and disability progression. We hope that Gilenya will soon be added to this treatment option for those with MS in Ireland.”

Multaq – first-line option in new 2010 ESC Guidelines for the Management of Atrial Fibrillation

Sanofi aventis announced recently that the European Society of Cardiology (ESC) 2010 new Guidelines for the Management of Atrial Fibrillation (AF) have been released and recommend that Multaq (dronedarone) should be used for maintenance of sinus rhythm as a first-line treatment option in all patients with paroxysmal and persistent AF (class of recommendation I, level of evidence A) other than those with CHF NYHA class III/IV or unstable CHF NYHA class II (class of recommendation III, level of evidence B).

Multaq was granted a Class I recommendation, a designation assigned in the guidelines when “there is evidence and/or general agreement that a given procedure/therapy is beneficial, useful, and effective.” The Task Force for the Management of Atrial Fibrillation of the ESC recognised the extensive clinical development of Multaq, giving it their highest ranking A for level of evidence. Moreover, the guidelines recommend that Multaq may also be used to achieve rate control in non-permanent AF except for patients with NYHA class III – IV or unstable heart failure (class of recommendation IIa, level of evidence B).

Importantly the new guidelines include, for the first time, a statement on the importance of reducing hospitalisation as a key therapeutic goal in the management of AF. They also state that Multaq should be considered in order to reduce cardiovascular hospitalisation in patients with non-permanent AF and cardiovascular risk factors (Class of recommendation IIa, level of evidence B) as well as in patients with AF and stable heart failure (NYHA Class I, II) (Class of recommendation IIa, level of evidence C). 1

The guidelines do not recommend use of Multaq in patients with NYHA class III and IV or with recently unstable (decompensation within the prior month) NYHA class II heart failure.

“Sanofi-aventis is pleased with this first-line recommendation for Multaq in the AF guidelines which recognises the extensive clinical development for the product as well as the innovative outcome of reducing cardiovascular hospitalisation as demonstrated in the ATHENA trial,” said Marc Cluzel, Executive Vice President, Research and Development, sanofi-aventis. “Multaq provides symptom control and for the first time for an anti-arrhythmic drug, a long term benefit by reducing the risk of distressing and repeat cardiovascular hospitalisations. AF hospitalisations represent a significant human and economic burden for patients, healthcare practitioners and payers as recently reported.”

Commenting on the new guidelines, Dr Niall Mahon, Consultant Cardiologist at the Mater Hospital said. ‘Dronedarone is a welcome new option for rhythm control in atrial fibrillation. In comparison with other approved agents, it lacks amiodarone’s potential for long term toxicity and (unlike agents such as flecainide that may be pro-arrhythmic) appears safe for most cardiac patients, with the important exception of those with advanced or recently decompensated heart failure. Other specified contra-indications are concomitant treatment with QT-prolonging drugs or powerful CYP 3A4 inhibitors, and severe chronic renal failure’.

41

abstractsfocus on: gastroenterology

How does co-morbidity affect cost of healthcare in patients with irritable bowel syndrome? a cohort study in general practice

Johansson PA, farup Pg, Bracco A,

vandvik PoBMC

Gastroenterol 2010 Mar 17;

10: 31

Irritable bowel syndrome (IBS) is associated with other disorders (co-morbidity), reduced quality of life and increased use of health resources. The authors from this Norwegian study from the Department of Medicine, Innlandet Hospital Trust, Gjøvik, aimed to explore the impact of co-morbidity on the cost of healthcare in patients with IBS in general practice.

In this cohort study, 208 consecutive patients with IBS (Rome II) were recruited. Sociodemographic data, IBS symptoms and co-morbidity (somatic symptoms, organic diseases and psychiatric disorders) were assessed at baseline. Based on a follow-up interview after six to nine months and use of medical records, IBS – and non-IBS-related health resource use were measured as consultations, hospitalisations, use of medications and alternative healthcare products and sick leave days.

Costs were calculated by national tariffs and reported in Norwegian Kroner (NOK; €1 = 8 NOK). Multivariate analyses were performed to identify predictors of costs.

A total of 164 patients (mean age 52 years, 69 per cent female, median duration of IBS 17 years) were available at follow up, 143 patients (88 per cent) had consulted their GP of whom 31 (19 per cent) had consulted for IBS.

Mean number of sick-leave days for IBS and co-morbidity were 1.7 and 16.3 respectively (P < 0.01), costs related to IBS and co-morbidity were 954 NOK (€119.25) and 14,854 NOK (€1,856.75) respectively (P < 0.001). Age, organic diseases and somatic symptoms, but not IBS severity, were significant predictors for total costs.

Costs for health resource use among patients with IBS in general practice were largely explained by co-morbidity, which generated 10 times the costs for IBS.

Different characteristics of patients with gastro-oesophageal reflux disease on their path through healthcare: a population follow-up study

flameling rD, Numans Me,

ter linde J, de wit NJ,

siersema PDEur J

Gastroenterol Hepatol 2010

May; 22 (5): 578-82

Only a minority of patients with gastro-oesophageal reflux symptoms (GORS) seek medical advice. Little is known about patient characteristics associated with consultation in primary care and referral to secondary care.

The authors of this study from the Julius Center for Health Sciences and Primary Care, university Medical Center utrecht, The Netherlands, compared the characteristics of patients with GORS in the general population, those who consulted their GP and those referred to secondary care for upper endoscopy.

Flameling and colleagues aimed to identify differences between patients with short-term (<90 days) and chronic symptoms, and differences between patients with symptoms in primary and secondary care. The study was performed in a primary care-based prospective dynamic population.

In total, 16 per cent of 7,237 adult patients were identified with GORS. Twenty-five per cent of these patients consulted the GP, of whom 40 per cent were referred for endoscopy. Patients with chronic GORS were older, had a higher body mass index, were more often referred for upper endoscopy (all P < 0.001) and more frequently had relevant findings during endoscopy (oesophagitis: 50 per cent and Barrett’s oesophagus: 10 per cent). Patients referred for upper endoscopy were older than non-referred patients (P < 0.001).

It was found that only a minority of people with GORS visit their GP. After consulting, referral for endoscopy oc-curs relatively often. underlying endoscopic abnormalities are frequently found in patients with chronic GORS.

nasoenteral feeding tube placement by nurses using an electromagnetic guidance system

Mathus-vliegen eM,

Duflou A, spanier MB,

fockens PGastrointest Endosc 2010

Apr; 71 (4): 728-36

The early institution of feeding in patients who need postpyloric feeding tubes is often hampered by a limited availabil-ity of endoscopists experienced in safe tube positioning.

The aim of the study from the Department of Gastroenterology and Hepatology, university of Amsterdam, was to test the feasibility of having nurses place postpyloric feeding tubes by using a universal path-finding system device.

The success rate and learning curve of a senior nurse placing postpyloric feeding tubes in 50 patients was studied, fol-lowed by a study in 160 patients on the success rates and learning curves of four inexperienced nurses instructed by the senior nurse. Finally, the success rate of postpyloric feeding tube placement by the senior nurse in 50 critically ill patients was investigated.

The postpyloric feeding tube positioning by the nurses used an electromagnetic universal path-finding system device which enabled them to follow the path of the tip of the feeding tube on a monitor screen.

Success was defined by postpyloric positioning of the feeding tube. The ultimate aim was to reach at least the duode-nojejunal flexure.

In the first part, the senior nurse was successful in 72 per cent of cases. There was a clear learning curve. In the second part, the four newly instructed nurses had a success rate of 89.4 per cent without an evident learning curve.

In the third part, successful feeding tube positioning was achieved in 78 per cent of critically ill patients. Of the 217 successfully positioned tubes, 74 per cent reached at least the duodenojejunal flexure. In half of the unsuccessful cases, an explanation for the failure was found at endoscopy. No complications were seen.

The authors suggested that the generalisation to less-specialised hospitals should be investigated.Postpyloric positioning of feeding tubes by nurses at the bedside without endoscopy is feasible and safe. Nurses may

take over some of the tasks of doctors in a time of high endoscopic needs.

42

abstractsfocus on: enDocrinology

intentional and unintentional non-adherence in community dwelling people with type 2 diabetes: the effect of varying numbers of medicines

stack rJ, Bundy ce, elliott rA

et al. British Journal of

Diabetes & Vascular Disease 2010; 10(3):

148-152.

A recent study on type 2 diabetes medicine adherences has explored the effect that varying numbers of medicines can have on these adherence behaviours and that intentional non-adherence did not vary between OADs, anti-hypertensives and statins.

People with type 2 diabetes are often prescribed multi-medicines which can be difficult to manage. Non-adherence to medicines can be intentional (e.g. active decision) or unintentional (e.g. forgetting).

The objective of this study was to measure intentional and unintentional non-adherence to differing numbers of medicines prescribed in type 2 diabetes. A cross-sectional survey using the Morisky medication adherence scale (with intentional and unintentional non-adherence subscales) was completed by 480 people prescribed oral antidiabetic drugs (OADs), antihypertensive agents and statins. A within-subject analysis of variance (ANOVA) showed that intentional non-adherence did not vary between OADs, anti-hypertensives and statins. Intentional non-adherence to statins significantly increased when the number of medicines prescribed was included as a between-subjects variable (p<0.05). Another within-subject ANOVA on unintentional non-adherence found a significant difference between OADs, anti-hypertensives and statins; unintentional non-adherence to OADs was significantly higher (p<0.05). When the number of medicines was added as a between-subject variable unintentional non-adherence was associated with higher numbers of medicines.

This study shows the difference between intentional and unintentional non-adherence behaviours, and the effect that varying numbers of medicines can have on these behaviours. The authors stressed the importance of type 2 diabetes patients working with multi-disciplinary medical team from nursing to specialists to combat diabetes drug non-adherence.

treatment of type B insulin resistance: a novel approach to reduce insulin receptor autoantibodies

Malek r, chong Ay,

lupsa Bc et al.

The Journal of Clinical

Endocrinology & Metabolism 2010; 95(8): 3641-3647.

A new standardised type B insulin resistance treatment with rituximab, cyclophosphamide, and pulse steroids has resulted in remission in patients with the Type B insulin resistance.

Type B insulin resistance belongs to a class of diseases caused by an autoantibody to a cell surface receptor. Blockade of insulin action results in hyperglycemia, hypercatabolism, severe acanthosis nigricans, and hyperandrogenism in women. In the past this rare autoimmune disorder has been treated with various forms of immunosuppression with mixed success.

Fourteen patients with type B insulin resistance referred to the National Institutes of Health, adding to an existing cohort of 24 patients. The report focused on seven patients who were treated with an intensive combination protocol of rituximab, cyclophosphamide, and pulse corticosteroids aimed at control of pathogenic autoantibody production. Haematological, metabolic, and endocrine parameters, including fasting glucose, glycated hemoglobin, insulin dose, lipids, and testosterone, were monitored before and after treatment.

Results found that all seven treated patients achieved remission, defined as amelioration of hyperglycemia, discontinuation of insulin therapy, and resolution of hyperandrogenism. Glycated haemoglobin has normalised in all seven treated patients. Remission was achieved on average in 8 months from initiation of treatment. The medication regimen was well tolerated, with no serious adverse events.

The authors concluded that in seven patients with type B insulin resistance, standardised treatment with rituximab, cyclophosphamide, and pulse steroids did result in remission of the disease. They added that future studies are necessary to determine whether this treatment protocol can be applied to other autoantibody/cell surface receptor disease states.

For patients not at goal on metformin aloneIn clinical studies of patients with type 2 diabetes,

Powerful and sustained HbA1c reductions over 1 year1,2

Weight loss and less hypoglycemia vs an SU* + metformin (with sitagliptin 100 mg + metformin)3

3-D Control: comprehensive mechanism of action targets 3 key defects of type 2 diabetes1

JANUMET® for powerful glucose reductions1

(sitagliptin/metformin)

Changing the course to glucose control.

Janumet 50mg/850mg and Janumet 50mg/1000mg film-coated tablets (50 mg of sitagliptin as phosphate monohydrate and 850 mg or 1000mg of metformin hydrochloride).ABRIDGED PRODUCT INFORMATION Refer to Summary of Product Characteristics before prescribing.PRESENTATION Janumet 50mg/850mg film-coated tablets: Capsule-shaped, pink film-coated tablet with “515” debossed on one side con-taining 50 mg of sitagliptin as phosphate monohydrate and 850 mg of metformin hydrochloride. Janumet 50mg/1000mg film-coated tablets: Capsule-shaped, red film-coated tablet with “577” debossed on one side containing 50 mg of sitagliptin as phosphate monohydrate and 1000 mg of metformin hydrochloride. USES For patients with type 2 diabetes mellitus: Janumet is indicated as an adjunct to diet and exercise to improve glycaemic control in patients inadequately controlled on their maximal tolerated dose of metformin alone or those already being treated with the combination of sitagliptin and metformin. Janumet is indicated in combination with a sulphonylurea (i.e., triple combination therapy) as an adjunct to diet and exercise in patients inadequately controlled on their maximal tolerated dose of metformin and a sulphony-lurea. Janumet is also indicated as triple combination therapy with a PPARγ agonist (i.e., a thiazolidinedione) as an adjunct to diet and exer-cise in patients inadequately controlled on their maximal tolerated dose of metformin and a PPARγ agonist. Janumet is also indicated as add-on to insulin (i.e., triple combination therapy) as an adjunct to diet and exercise to improve glycaemic control in patients when stable dosage of insulin and metformin alone do not provide adequate glycaemic control. DOSAGE AND ADMINISTRATION The dose of antihyper-glycaemic therapy with Janumet should be individualised on the basis of the patient’s current regimen, effectiveness, and tolerability while not exceeding the maximum recommended daily dose of 100 mg sitagliptin. For patients not adequately controlled on metformin alone, the usual starting dose of Janumet should provide sitagliptin dosed as 50 mg twice daily (100 mg total daily dose) plus the dose of metformin already being taken. For patients switching from co-administration of sitagliptin and metformin, Janumet should be initiated at the dose of sitagliptin and metformin already being taken. For patients inadequately controlled on dual combination therapy with the maximal tolerated dose of metformin and a sulphonylurea, the dose of Janumet should provide sitagliptin dosed as 50 mg twice daily (100 mg total daily dose) and a dose of metformin similar to the dose already being taken. When Janumet is used in combination with a sulphonylurea, a lower dose of the sulphonylurea may be required to reduce the risk of hypoglycaemia. For patients inadequately controlled on dual combination thera-py with the maximal tolerated dose of metformin and a PPARγ agonist, the dose of Janumet should provide sitagliptin dosed as 50 mg twice daily (100 mg total daily dose) and a dose of metformin similar to the dose already being taken. For patients inadequately controlled on dual combination therapy with insulin and the maximal tolerated dose of metformin, the dose of Janumet should provide sitagliptin dosed as 50 mg twice daily (100 mg total daily dose) and a dose of metformin similar to the dose already being taken. When Janumet is used in combina-tion with insulin, a lower dose of insulin may be required to reduce the risk of hypoglycaemia. All patients should continue their diet with an adequate distribution of carbohydrate intake during the day. Overweight patients should continue their energy-restricted diet. Janumet should be given twice daily with meals to reduce the gastrointestinal undesirable effects associated with metformin. Use in renal insuffi-ciency: Janumet should not be used in patients with moderate or severe renal impairment (creatinine clearance < 60 ml/min). Use in hepatic insufficiency: Janumet should not be used in patients with hepatic impairment. Use in elderly: Janumet should be used with caution as age increases. Monitoring of renal function is necessary to aid in prevention of metformin-associated lactic acidosis. Limited safety data on sitagliptin is available in patients > 75 years of age and care should be exercised. Use in children: Not recommended for use in children below 18 years of age. CONTRAINDICATIONS • hypersensitivity to the active substances or to any of the excipients • diabetic ketoacidosis, dia-betic pre-coma • moderate and severe renal impairment (creatinine clearance < 60 ml/min) • acute conditions with the potential to alter renal function such as: dehydration, severe infection, shock, intravascular administration of iodinated contrast agents • acute or chronic disease which may cause tissue hypoxia such as: cardiac or respiratory failure recent myocardial infarction, shock • hepatic impairment • acute al-cohol intoxication, alcoholism • lactation. PRECAUTIONS Janumet should not be used in patients with type 1 diabetes and must not be used for the treatment of diabetic ketoacidosis. Lactic acidosis: It is a very rare serious metabolic complication that can occur due to metformin accumulation. Reported cases of lactic acidosis in patients on metformin have occurred primarily in diabetic patients with significant renal failure. The incidence of lactic acidosis can and should be reduced by also assessing other associated risk factors. If metabolic acidosis is suspected, treatment with the medicinal product should be discontinued and the patient hospitalised immediately. Renal function: As met-formin-related lactic acidosis increases with the degree of impairment of renal function, serum creatinine concentrations should be deter-mined at least once a year in patients with normal renal function and at least two to four times a year in patients with serum creatinine levels at or above the upper limit of normal and in elderly patients. Decreased renal function in elderly patients is frequent and asymptomatic. Special caution should be exercised in situations where renal function may become impaired, for example when initiating antihypertensive or diuretic therapy or when starting treatment with a nonsteroidal anti-inflammatory drug (NSAID). Hypoglycaemia: Patients receiving Janu-met in combination with a sulphonylurea or with insulin may be at risk for hypoglycaemia. Therefore, a reduction in the dose of the sulpho-nylurea or insulin may be necessary. The use of Janumet in combination with insulin has not been adequately studied. Hypersensitivity reac-tions: Postmarketing reports of serious hypersensitivity reactions in patients treated with sitagliptin have been reported. These reactions include anaphylaxis, angioedema, and exfoliative skin conditions including Stevens-Johnson syndrome. Onset of these reactions occurred within the first 3 months after initiation of treatment with sitagliptin, with some reports occurring after the first dose. If a hypersensitivity reaction is suspected, discontinue Janumet, assess for other potential causes of the event, and institute alternative treatment for diabetes. Surgery: As Janumet contains metformin hydrochloride, the treatment should be discontinued 48 hours before elective surgery with general, spinal or epidural anaesthesia. Janumet should not usually be resumed earlier than 48 hours afterwards and only after renal function has been re-evaluated and found to be normal. Administration of iodinated contrast agent: The intravascular administration of iodinated contrast agents in radiological studies can lead to renal failure which has been associated with lactic acidosis in patients receiving metformin. Therefore, Janumet should be discontinued prior to, or at the time of the test and not reinstituted until 48 hours afterwards, and only after renal function has been re-evaluated and found to be normal. Change in clinical status of patients with previously controlled type 2 diabetes: A patient with type 2 diabetes previously well controlled on Janumet who develops laboratory abnormalities or clinical illness (especially vague and poorly defined illness) should be evaluated promptly for evidence of ketoacidosis or lactic acidosis. Evaluation should include serum electrolytes and ketones, blood glucose and, if indicated, blood pH, lactate, pyruvate, and metformin levels. If acidosis of either form occurs, Janumet must be stopped immediately and other appropriate corrective measures initiated. Drug interactions: Co-administration of multiple doses of sitagliptin (50 mg twice daily) and metformin (1,000 mg twice daily) did not meaningfully alter the pharmacokinetics of either sitagliptin or metformin in patients with type 2 diabetes. There is increased risk of lactic acidosis in acute alcohol intoxication (particularly in the case of fasting, malnutrition or hepatic insufficiency) due to the metformin active substance of Janumet. Consumption of alcohol and medicinal products containing alcohol should be avoided. Cationic agents that are eliminated by renal tubular secretion (e.g., cimetidine) may interact with metformin by competing for common renal tubular transport systems. Therefore, close monitoring of glycaemic control, dose adjustment within the recommended posology and changes in diabetic treatment should be considered when cationic agents that are eliminated by renal tubular secretion are co-administered. The intravascular administration of iodinated contrast agents in radiological studies may lead to renal failure, resulting in metformin accumulation and a risk of lactic acidosis. Therefore, Janumet should be discontin-ued prior to, or at the time of the test and not reinstituted until 48 hours afterwards, and only after renal function has been re-evaluated and found to be normal. Combination requiring precautions for use: Glucocorticoids (given by systemic and local routes) beta-2-agonists, and diuretics have intrinsic hyperglycaemic activity. The patient should be informed and more frequent blood glucose monitoring performed, especially at the beginning of treatment with such medicinal products. If necessary, the dose of the anti-hyperglycaemic medicinal product should be adjusted during therapy with the other medicinal product and on its discontinuation. ACE-inhibitors may decrease the blood glu-cose levels. If necessary, the dose of the anti-hyperglycaemic medicinal product should be adjusted during therapy with the other medicinal product and on its discontinuation. Effects of other medicinal products on sitagliptin: Clinical data described below suggest that the risk for clinically meaningful interactions following co-administration of other medicinal products is low. Cyclosporin: A study was conducted to assess the effect of cyclosporin, a potent inhibitor of p-glycoprotein, on the pharmacokinetics of sitagliptin. Co-administration of a single 100 mg oral dose of sitagliptin and a single 600 mg oral dose of cyclosporin increased the AUC and Cmax of sitagliptin by approximately 29 % and 68 %, respectively. These changes in sitagliptin pharmacokinetics were not considered to be clinically meaningful. The renal clearance of sitagliptin was not meaningfully altered. Therefore, meaningful interactions would not be expected with other p-glycoprotein inhibitors. In vitro studies indicated that the primary enzyme responsible for the limited metabolism of sitagliptin is CYP3A4, with contribution from CYP2C8.

In patients with normal renal function, metabolism, including via CYP3A4, plays only a small role in the clearance of sitagliptin. Metabolism may play a more significant role in the elimination of sitagliptin in the setting of severe renal insufficiency or ESRD. For this reason, it is pos-sible that potent CYP3A4 inhibitors (i.e., ketoconazole, itraconazole, ritonavir, clarithromycin) could alter the phamacokinetics of sitagliptin in patients with severe renal insufficiency or ESRD. The effects of potent CYP3A4 inhibitors in the setting of renal insufficiency has not been assessed in a clinical study. In vitro transport studies showed that sitagliptin is a substrate for p-glycoprotein and OAT3. OAT3 mediated transport of sitagliptin was inhibited in vitro by probenecid, although the risk of clinically meaningful interactions is considered to be low. Concomitant administration of OAT3 inhibitors has not been evaluated in vivo. Effects of sitagliptin on other medicinal products: In vitro data suggest that sitagliptin does not inhibit nor induce CYP450 isoenzymes. In clinical studies, sitagliptin did not meaningfully alter the pharma-cokinetics of metformin, glyburide, simvastatin, rosiglitazone, warfarin, or oral contraceptives, providing in vivo evidence of a low propen-sity for causing interactions with substrates of CYP3A4, CYP2C8, CYP2C9, and organic cationic transporter (OCT). Sitagliptin had a small ef-fect on plasma digoxin concentrations, and may be a mild inhibitor of p-glycoprotein in vivo. Digoxin: Sitagliptin had a small effect on plasma digoxin concentrations. Following administration of 0.25 mg digoxin concomitantly with 100 mg of sitagliptin daily for 10 days, the plasma AUC of digoxin was increased on average by 11 %, and the plasma Cmax on average by 18 %. No dose adjustment of digoxin is recommended. However, patients at risk of digoxin toxicity should be monitored for this when sitagliptin and digoxin are administered concomitantly. Use in pregnancy and lactation: Janumet should not be used during pregnancy or breast-feeding. Effects on ability to drive and use machines: No studies on the effects on the ability to drive and use machines have been performed. However, when driving or operating machines, it should be taken into account that dizziness and somnolence have been reported. Patients should be alerted to the risk of hypoglycaemia when Janumet is used in combination with other sulfonylurea agents or with insulin. SIDE EFFECTS There have been no therapeutic clinical trials conducted with Janumet tablets however bioequivalence of Janumet with co-administered sitagliptin and metformin has been demon-strated. Sitagliptin and Metformin Adverse reactions considered as drug related reported in excess (> 0.2 % and difference > 1 patient) of placebo and in patients receiving sitagliptin in combination with metformin in double-blind studies are listed below. Frequencies are defined as: very common (≥ 1/10); common (≥ 1/100 to < 1/10); uncommon (≥ 1/1,000 to < 1/100); rare (≥ 1/10,000 to < 1/1,000); very rare (< 1/10,000). Sitagliptin with Metformin In a placebo-controlled 24-week study of sitagliptin 100 mg once daily added to ongoing metformin, the incidence of adverse reactions considered as drug-related in patients treated with sitagliptin added to ongoing metformin compared to treatment with placebo added to ongoing metformin was 9.3 % and 10.1 %, respectively. Investigations Uncommon: blood glucose decreased Nervous system disorders Uncommon: somnolence Gastrointestinal disorders Common: nausea Uncommon: upper abdominal pain, diarrhoea. In a 1-year study of sitagliptin 100 mg once daily added to ongoing metformin, the incidence of adverse reactions considered as drug-related in patients treated with sitagliptin added to ongoing metformin compared to sulphonylurea added to ongoing metformin was 14.5 % and 30.3 %, respectively. In pooled studies of up to 1 year in duration comparing sitagliptin added to ongoing metformin to a sulphonylurea agent added to ongoing metformin, adverse reactions considered as drug-related reported in patients treated with sitagliptin 100 mg occurring in excess (> 0.2 % and difference > 1 patient) of that in patients receiving the sulphonylurea agent are as follows: Metabolism and nutrition disorders Uncommon: anorexia Investigations Uncommon: weight decreased Sitagliptin with Metformin and a Sulphonlylurea In this 24-week place-bo-controlled study of sitagliptin 100 mg once daily added to ongoing combination treatment with glimepiride and metformin, the overall in-cidence of adverse reactions considered as drug-related in patients treated with the addition of sitagliptin to the ongoing treatment with glimepiride and metformin was 18.1 % compared to treatment with the addition of placebo to the ongoing treatment with glimepiride and metformin which was 7.1 %. Gastrointestinal disorders Common: constipation Metabolism and nutrition disorders Very common: hypogly-caemia COMBINATION WITH A PPARγ AGENT (rosiglitazone) and METFORMIN In this study of sitagliptin 100 mg once daily in combination with rosiglitazone and metformin, which continued through 54 weeks, the incidence of adverse reactions considered as drug-related in pa-tients treated with sitagliptin combination compared to treatment with the placebo combination was 15.3 % and 10.9 %, respectively. Other drug-related adverse reactions reported in the 54-week analysis (frequency common) in patients treated with sitagliptin combination occur-ring in excess (> 0.2 % and difference > 1 patient) of that in patients treated with the placebo combination were: headache, cough, vomiting, hypoglycaemia, fungal skin infection, and upper respiratory tract infection. Nervous system disorders Common: headache Metabolism and nutrition disorders Common: hypoglycaemia Gastrointestinal disorders Common: diarrhoea, vomiting General disorders Common: peripheral oedema Sitagliptin with Metformin and Insulin In this 24-week placebo-controlled study of sitagliptin 100 mg once daily as add-on to insulin and metformin, the incidence of adverse reactions considered as drug-related in patients treated with sitagliptin in combination with insulin/metformin compared to treatment with placebo in combination with insulin/metformin was 16.2 % and 9.0 %, respectively. Nervous system disorders Uncommon: headache Gastrointestinal disorders Uncommon: dry mouth Metabolism and nutrition disorders Very common: hypo-glycaemia. In a 24-week study of initial combination therapy with sitagliptin and metformin administered twice daily (sitagliptin/metformin 50 mg/500 mg or 50 mg/1,000 mg), the overall incidence of adverse reactions considered as drug-related in patients treated with the combina-tion of sitagliptin and metformin compared to patients treated with placebo was 14.0 % and 9.7 %, respectively. The overall incidence of adverse reactions considered as drug-related in patients treated with the combination of sitagliptin and metformin was comparable to metformin alone (14.0 % each) and greater than sitagliptin alone (6.7 %), with the differences relative to sitagliptin alone primarily due to gastrointestinal adverse reactions. Additional information on the individual active substances of the fixed dose combination Sitagliptin In addition, in monotherapy studies of up to 24 weeks in duration of sitagliptin 100 mg once daily alone compared to placebo, adverse reactions considered as drug-related reported in patients treated with sitagliptin in excess (> 0.2 % and difference > 1 patient) of that in patients receiv-ing placebo are headache, hypoglycaemia, constipation, and dizziness. In addition to the drug related adverse reactions described above, adverse events (reported regardless of causal relationship to medicinal product) occurring in at least 5 % and more commonly in patients treated with sitagliptin included upper respiratory tract infection and nasopharyngitis. Additional adverse events that occurred more fre-quently in patients treated with sitagliptin (not reaching the 5 % level, but occurring with an incidence of > 0.5 % higher with sitagliptin than that in the control group) included osteoarthritis and pain in extremity. Across clinical studies, a small increase in white blood cell (WBC) count was observed due to an increase in neutrophils. This observation was seen in most but not all studies. This change in laboratory pa-rameters is not considered to be clinically relevant. No clinically meaningful changes in vital signs or in ECG (including in QTc interval) were observed with sitagliptin treatment. Post-marketing data Sitagliptin During post-marketing experience of Janumet or sitagliptin, one of the active substances of Janumet, the following additional adverse reactions have been reported (frequency not known): hypersensitivity reac-tions including anaphylaxis, angioedema, rash, urticaria, cutaneous vasculitis, and exfoliative skin conditions including Stevens-Johnson syndrome; pancreatitis. Metformin Nervous system disorders Common: metallic taste Gastrointestinal disorders Very common: gastrointes-tinal symptoms Skin and subcutaneous disorders Very rare: urticaria, erythema, pruritis Metabolism and nutrition disorders Very rare: lactic acidosis, vitamin B12 deficiency Hepatobiliary disorders Very rare: liver function disorders, hepatitis PACKAGE QUANTITIES Janumet 50mg/850mg and 50mg/1000mg film-coated tablets, 56 tablets. POM Date of preparation: Nov 2009 Marketing Authorisation numbers: Janu-met 50mg/850mg film-coated tablets, EU/1/08/455/003. Janumet 50mg/1000mg film-coated tablets, EU/1/08/455/010. Marketing Authorisation Holder: Merck Sharp & Dohme Limited, Hertford Road, Hoddesdon, Hertfordshire EN11 9BU, UK. © Merck Sharp & Dohme Limited 2009. All rights reserved. API.JANUMET.Nov09.IRL. References: 1. Data on file, MSD. 2. Goldstein BJ, Feinglos MN, Lunceford JK, et al; for the Sitaglip-tin 036 Study Group. Effect of initial combination with sitagliptin, a dipeptidyl peptidase-4 inhibitor, and metformin on glycemic control in pa-tients with type 2 diabetes. Diabetes Care. 2007;30:1979–1987. 3. Nauck MA, Meininger G, Sheng D, et al; for the Sitagliptin Study Group 024. Efficacy and safety of the dipeptidyl peptidase-4 inhibitor, sitagliptin, compared with the sulfonylurea, glipizide, in patients with type 2 diabe-tes inadequately controlled on metformin alone: a randomized, double-blind, non-inferiority trial. Diabetes Obes Metab. 2007;9:194–205. * SU = sulfonylurea; specifically glipizide. Additional prescribing information available on request or from www.medicines.ie

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product news

DuoPlavin: dual antiplatelet fixed dose combination – Plavix and aspirin – launched

Sanofi-aventis has launched its dual antiplatelet fixed dose com-bination tablet, DuoPlavin, in Ireland. DuoPlavin provides a new treatment option and a more convenient alternative for patients with acute coronary syndrome (ACS). The new dual antiplatelet formu-lation contains Plavix (clopidogrel hydrogen sulphate) 75mg and aspirin (acetylsalicylic acid) 75mg in a single tablet.

Dr Robert Kelly, Consultant Cardiologist, Beacon Hospital, said: “DuoPlavin is an exciting new treatment option which may help pa-tient compliance with important medicines. Combining established antiplatelet formulations into one tablet makes it easier for patients. It is vitally important that ACS patients take their antiplatelet therapy as prescribed. There is also a further gain in terms of lower cost com-pared with aspirin and Plavix taken separately.”

DuoPlavin is indicated for the prevention of atherothrombotic events in patients with ACS already taking both clopidogrel and aspi-rin (acetylsalicylic acid – ASA). DuoPlavin is a fixed-dose combination medicinal product for continuation of therapy in: 1. Non-ST seg-ment elevation myocardial infarction and unstable angina including patients undergoing a stent placement following percutaneous coro-nary intervention. 2 ST segment elevation acute myocardial infarc-tion in medically treated patients eligible for thrombolytic therapy.

www.yourmedicines.ie

Xamiol 60g Gel discontinued

LEO Pharma has announced that Xamiol Gel 60g will be dis-continued from November 2010. Please note that Dovobet Gel 60g will continue to be available. Dovobet Gel 60g contains the identical product form, active ingredients and strength as Xa-miol (calcipotriol/bethamethasone dipropionate). Dovobet Gel is indicated for both scalp and mild to moderate body plaque psoriasis. The price is also identical.

This discontinuation is not due to any safety or quality issues with Xamiol Gel, therefore pharmacists and patients may con-tinue to dispense or use Xamiol Gel that they currently have.

If you require any further information, please contact the Marketing Department at 01 4908924 or email paul.kirwan@LEO-Pharma.com

‘Change one thing’ information pack launched for patients with high blood pressure

Sanofi-aventis has launched a new patient advice tool for doctors and nurses treating patients with high blood pressure under the Triapin brand. The Change One Thing pack provides physicians with ready-made patient advice literature for those patients who may need to adapt their lifestyle to help lower their blood pressure.

Change One Thing provides advice across five lifestyle areas in the management of blood pressure – salt intake; smoking; stress reduc-tion, being more active, and; complying with medications. Patients are often presented with a range of lifestyles habits to adapt in one go. It can be hard to maintain these changes. Change One Thing pack helps to achieve this. The doctor or nurse enters an agreement with the patient on changing one lifestyle habit over an agreed period of time by giving only one item from the pack. When this becomes a new habit a new item can be added and so on.

Dr Garrett Hayes lent his support to the launch of the news tool and he said: “The EuROASPIRE study has demonstrated a high prevalence of modifiable risk factors in coronary heart disease patients. We have seen the positive impact made on the treatment of coronary heart disease through statins and other medications, but there has not been a corresponding improvement in patient lifestyle management.”

Dr Velichka Valcheva, Medical Director of sanofi-aventis said: “Our goal is to assist doctors in delivering meaningful, lasting lifestyle advice to their patients”

If you would like a Change One Thing pack sent to you, please con-tact Celine Reilly at 01 403 5600 or email celine.reilly@sanofi-aventis.com.

Dr garrett hayes, with

elaine ryan, sanofi-aventis

and Dr elen shiryayeva

also of sanofi-aventis.

Prolia (denosumab): unique new treatment for post-menopausal osteoporosis now reimbursed in Ireland

Amgen Ireland and GlaxoSmithKline (Ireland) Ltd (GSK) recently announced that denosumab has become available in Ireland to treat osteoporosis in post-menopausal women at increased risk of fracture and will be reimbursed under the General Medical Services and Drugs Payment Schemes.

In Ireland, more than 300,000 people have osteoporosis. Despite the availability of treatment options, many of these women experience fractures due to poor compliance with therapy. With proven efficacy and a six-monthly injection, denosumab offers women with osteoporosis a new alternative to current treatments.

Denosumab works in a different way from other osteoporosis treatments. It is the first and only approved therapy that specifically targets RANK ligand, an essential regulator of osteoclasts (the cells that break down bone). Denosumab helps stop the process that causes bone loss throughout the skeleton, resulting in greater bone density, stronger bones, and reduced risk for fractures at the spine, hip and other non-vertebral sites.

The reimbursement for denosumab follows a review of the therapy’s cost-effectiveness by the National Centre for Pharmacoeconomics (NCPE) for the prevention of osteoporotic fractures in postmenopausal women and will be available on both the GMS and DPS schemes as of October 1st.

Discussing denosumab, specialist in bone health at St James’s Hospital, Professor Bernard Walsh said: “It is good to have another proven therapeutic arm available to us in the treatment of osteoporosis. The clinical study results are impressive and confirm the efficacy of the use of a monoclonal antibody treatment in this disease.”

Dr Gillian Darling, GP Specialist in Women’s Health in Leopardstown and the Dublin Well Woman Centres commented: “As most osteoporosis patients are treated in primary care it is an advantage to have a treatment that can be administered in the GP surgery as well as the hospital clinic setting.

“Recent studies would seem to point to a strong efficacy and good tolerability profile of denosumab in the treatment of osteoporosis in post-menopausal women.”

Denosumab, which is being co-marketed in Ireland by Amgen and GSK, marks an innovative approach to the treatment of post menopausal osteoporosis. Statistics show that 90% of hip fractures in senior citizens are due to osteoporosis and that one in five patients suffering hip fracture die within four months and 30% within a year.

For more information on denosumab’s reimbursement, please visit www.ncpe.ie

45

crossword

Name:

Address:

Email:

Congratulations to the winner of last month’s crossword, Colette Gibbons, Killadoon, Louisburgh, Co Mayo

Please send your answers to the Editor, Nursing in General Practice, GreenCross Publishing, 7 Adelaide Court, Adeliade Road, Dublin 2. Closing date for entries: 4th January 2011.Winner will receive v50. Please note: the winners’ cheques will be sent out within 45 days.

Caltrate is a trademark. PA 172/38/1. Full prescribing information available from Wyeth Consumer Healthcare, Plaza 254, Ballycoolin, Dublin 15 or from www.medicines.ie

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ANswers To lAsT MoNTh’s crossworDACROSS: 6 fibroid 7 sabre 9 zinc 10 appendix 11 nuncio 13 idle 15 erie 16 spades 18 escallop 21 trim 22 deuce 23 ecstasyDOWN: 1 tibia 2 fracture 3 lima 4 earn 5 braille 8 apnoea 12 castle 13 identity 14 crosier 17 rinse 19 arch 20 pack

Across6. Pat takes Ella on his knee! (7)7. Saw these like a surgeon in slang (5)9. An opera seen in bonsai dahlias (4)10. Deviates deviating — with a calming effect (8)11. Mitt to modify for a little bird (6)13. Overwhelming defeat in war outfit (4)15. It is woe, we hear, to tell a horse to stop (4)16. What Bill Clinton did not do with the joint! (6)18. Move iron awkwardly for animal that eats

everything (8)21. A noble look? (4)22. A northern briton for a racecourse in southern

Britain? (5)23. Scent is scattered for fleas or flies (7)

DowN1. Am I an abnormal case of euphoria? (5)2. A mole-man suffers with skin cancer (8)3. It's a positive sign! (4)4. Wine — left at sea? (4)5. Worried about this system of the body? (7)8. As thick as... (1,5)12. He makes suits between tinker and soldier, in

rhyme! (6)13. Sad leper contorted and got sick again (8)14. He needs a regular supply of drugs to keep

going (7)17. Give them a twist for the Irish royal county (5)19. Fe, in periodic table, for golf club (4)20. Mount this — it's a volcano! (4)

Calcium and/or vitamin D deficiency in the elderly can lead to lossof muscle tone and an increase in falls and osteoporotic fractures.1-5

Calcichew-D3 Forte is indicated for the treatment and prevention of calcium and vitamin D deficiency.6

CALCICHEW-D3 FORTE CHEWABLE TABLETS PRESCRIBINGINFORMATION(Please refer to full Summary of Product Characteristics whenprescribing)Presentation: Chewable tablet containing 1250mg calcium carbonate(equivalent to 500mg of elemental calcium) plus 400IU colecalciferol(equivalent to 10 micrograms vitamin D3). Uses: Treatment andprevention of vitamin D/calcium deficiency. Supplementation ofvitamin D and calcium as an adjunct to specific therapy forosteoporosis, in pregnancy, in established vitamin D dependentosteomalacia and in other situations requiring therapeuticsupplementation of malnutrition. Dosage and administration: Oral(suck or chew). Adults and elderly: Two tablets daily. Children: Notintended for use in children. Hepatic impairment: No dose adjustmentrequired. Renal impairment: Should not be used in patients withsevere renal impairment. Contraindications: Diseases and/orconditions resulting in hypercalcaemia and/or hypercalciuria, renalstones, hypervitaminosis D, hypersensitivity to ingredient(s) especiallysoybean oil and peanut. Precautions: Monitor serum calcium andcreatinine levels, particularly in elderly patients on cardiac glycosidesor diuretics and in patients with high tendency to calculus formation.Use with caution in patients with impaired renal function. Take intoaccount risk of soft tissue calcification. Avoid in patients with

phenylketonuria or sugar intolerance. Prescribe with caution inpatients with sarcoidosis. Use with caution in immobilised patients.Additional doses of calcium or vitamin D should only be taken underclose medical supervision. Interactions: Tetracyclines (take 2 hoursbefore, or 4 to 6 hours after Calcichew-D3 Forte), bisphosphonates orsodium fluoride (take 3 hours before Calcichew-D3 Forte), thiazidediuretics, corticosteroids, cardiac glycosides, ion exchange resins(cholestyramine), laxatives (paraffin oil). Calcichew-D3 Forte shouldnot be taken within 2 hours of eating foods high in oxalic acid (e.g.spinach and rhubarb) or phytic acid (e.g. whole cereals). Side effects:Hypercalcaemia, hypercalciuria, constipation, flatulence, nausea,abdominal pain, diarrhoea, pruritus, rash, urticaria. Use in pregnancyand lactation: Can be used in case of calcium and vitamin Ddeficiency. Daily intake in pregnancy should not exceed 1500mgcalcium and 600IU colecalciferol (15 micrograms vitamin D3). Avoidoverdose as permanent hypercalcaemia affects developing foetus.Calcium and vitamin D3 pass into breast milk so consider this whengiving additional vitamin D to the child. Pharmaceuticalprecautions: Do not store above 30°C. Keep container tightly closed.Legal category: Pharmacy product. Product Authorisation No:535/1/3. Product Authorisation holder: Shire Pharmaceuticals Ltd.,Hampshire International Business Park, Chineham, Basingstoke,Hampshire RG24 8EP UK. Distributed in Republic of Ireland by: Cahill

May Roberts, P.O. Box 1090, Chapelizod, Dublin 20, Republic ofIreland. Further information is available on request. Date of revision:July 2007. CALCICHEW is a registered trademark of Shire Pharmaceuticals Ltd inthe Republic of Ireland.

Adverse events should be reported to the PharmacovigilanceUnit at the Irish Medicines Board (IMB)(imbpharmacovigilance@imb.ie). Information about adverseevent reporting can be found on the IMB website(www.imb.ie). Adverse events may also be reported to ShirePharmaceuticals Ltd on +44 1256 894000.

References: 1. Perez-Lopez FR. Maturitas 2007;58: 117-137. 2. Dawson-Hughes B & Bischoff-Ferrari HA. J Bone Miner Res 2007; 22: S2; v59-v63.3. Lin JT & Lane JM. Phys Med Rehabil Clin N Am 2005; 16: 109-128.4. Heaney RP. Endocrinology and Metabolism Clinics 1998; 27(2): 255-265. 5. Hunter DJ & Sambrook PN. Arthritis Res 2000; 2(6): 441-445.6. Calcichew-D3 Forte. Summary of Product Characteristics. July 2007. 7. MIMS May 2010.

Date of preparation: April 2010. Item Code: IRE/CDF/10/0008

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