Medical Independent - Full Preview by Chris Fildes

Rehab reform

Clinical skills

A life in medicine

p10-14

p25-28

p35

June Shannon examines why rehabilitation services in Ireland are the worst in Europe

A photo roundup of the recent Festschrift to celebrate Prof Colm O’Morain's career

This issue’s clinical module explores the use of novel therapeutic approaches in oncology

Medical Medical

Forall allthat thatmatters matters in in medicine medicine For

www.medicalindependent.ie

InDEPEnDEnt InDEPEnDEnt Into the lion’s den

14 July 2011 Issue 14 Volume 2 | €3.95

temple Street ‘near miss’ on oxygen levels JAMES FOgARty

xygen at one of Dublin’s three children’s hospitals was at risk of dropping below optimum levels during last December’s Big Freeze, the Medical Independent has learned. The Children’s University Hospital Temple Street learned that there could be a risk to the oxygen levels if a bulk storage delivery truck was unable to gain access to the off-load point due to poor weather conditions. According to documents released to this publication under the Freedom of Information Act, the hospital’s Executive Management Committee became aware of the incident in December 2010, calling it “a near miss”. A contingency

hSE CEO Cathal Magee makes his way into leinster house to answer questions on the operation of hospital emergency departments at the first meeting of the Public Accounts Committee on July 7th. During his address, Mr Magee confirmed that 172 nChD posts remained vacant less than a week ahead of the hospital rotation on July 11th. he said hospital managers and senior doctors around the country were working together to come up with contingency plans to ensure there would be minimum impact on patient services.

plan has since developed to deal with a recurrence. The Management Committee also heard that a member of staff experienced acute respiratory symptoms and became ill after using a shower at the hospital, possibly due to the high level of chlorine in the water. The shower at the centre of the incident was closed. The hospital undertook a complete review of the water system and identified excess chlorine which was confined to that particular area of the hospital. The hospital has since introduced independent checks of the chlorine dioxide system to ensure appropriate levels are maintained. A new monitoring device has been installed which will shut the system down in the event of excess chlorine recurring.

Photo: Bríd Ní Luasaigh

hSE spends nearly €200m on taxis and private ambulances

he hSE spent a whopping €190.3 million on taxis and private ambulance services between 2005 and 2010, the Medical Independent can reveal. The HSE spent a total of €164.36 million on patient taxis from 2005 to the end of 2010, while it spent €24.1 million on private ambulanc-

es in the same period. Between 2008 and the end of 2010, a total of €1.86 million was spent on taxis for HSE staff. The HSE could not provide the cost of staff taxis from 2005 to 2007. The cost of private ambulances was €1.8 million in 2005, but trebled to €5.53 million in 2007, though the figure reduced to €2.89 million last year. The HSE explained that the staff taxi costs can include staff members accom-

panying patients and clients to appointments. Responding to the revelation about the HSE’s expensive taxi bill at a time when health services are being cut, Deputy Caoimhghín Ó Caoláin, Sinn Fein Spokesperson on Health, called for an audit to be carried out on the Executive’s spending in this area. “There should be a full audit of all transport provision by the HSE, including ambulance services with-

in the HSE, with a focus always on ensuring patients’ needs are met,” he said. Last year, when he was a member of the opposition party, Health Minister James Reilly criticised the HSE’s high spend on taxis and said savings needed to be made on transport instead of painful cutbacks to patient services. He added that while there was a need to provide transport for patients, the high figContinued on page 3 »

Indicated for the treatment of allergic rhinitis and urticaria in children (from age 1) and adults Legal Category: POM 03-12-NCR-2011-IRL-4340-J

PRISCIllA lynCh

Marketing Authorisation Holder: Schering-Plough Europe, Rue de Stalle 73, B-1180 Bruxelles, Belgium. Further information is available from www.medicines.ie or on request from: MSD, Pelham House, South County Business Park, Leopardstown, Dublin 18. © Merck Sharp & Dohme Limited 2011. All rights reserved.

08/07/2011 19:12

This way to the future

Leading the change in HIV PRESCRIBING INFORMATION PREZISTA® 75 mg, 150 mg, 400 mg & 600 mg film-coated tablets Active ingredient: 75 mg, 150 mg, 400 mg or 600 mg of darunavir (as ethanolate). See Summary of Product Characteristics (SmPC) before prescribing. INDICATIONS: PREZISTA, co administered with low dose ritonavir is indicated in combination with other antiretroviral medicinal products for the treatment of patients with human immunodeficiency virus (HIV 1) infection. PREZISTA 75 mg, 150 mg and 600 mg tablets may be used to provide suitable dose regimens: • For the treatment of HIV 1 infection in antiretroviral treatment (ART) experienced adult patients (including highly pre treated). • For the treatment of HIV 1 infection in ART experienced children and adolescents from the age of 6 years and at least 20 kg body weight. Genotypic or phenotypic testing (when available) and treatment history should guide the use of PREZISTA. PREZISTA 400 mg tablets may be used to provide suitable dose regimens: • For the treatment of HIV 1 infection in antiretroviral therapy (ART) naïve adults. For the treatment of HIV 1 infection in ART experienced adults with no darunavir resistance associated mutations (DRV RAMs) and who have plasma HIV 1 RNA < 100,000 copies/ml and CD4+ cell count ≥ 100 cells x 106/l. In deciding to initiate treatment with PREZISTA in such ART experienced adults, genotypic testing should guide use. DOSAGE AND ADMINISTRATION: Therapy should be initiated by physician experienced in management of HIV. ART-naïve adults: PREZISTA 800 mg once daily with ritonavir 100 mg once daily, taken with food. ART-naïve children: Not recommended for use in this group. ART-experienced adults with no DRV-RAMs: PREZISTA 800 mg once daily with ritonavir 100 mg once daily, taken with food. All other ART experienced adults; 600 mg PREZISTA /100 mg ritonavir twice daily with food. ART-experienced children ≥ 20 kg and < 30 kg: 375 mg PREZISTA/50 mg ritonavir twice daily with food. ART-experienced children ≥ 30 kg and < 40 kg: 450 mg PREZISTA/60 mg ritonavir twice daily with food. ART-experienced children > 40 kg: 600 mg PREZISTA /100 mg ritonavir twice daily with food. Use 75 mg/150 mg PREZISTA tablets to achieve recommended 600 mg dose in this group if possibility of e.g., swallowing difficulty or specific colouring agent hypersensitivity. Children < 6 years of age or < 20 kg body weight: Not recommended Elderly: Limited information available. Caution should be exercised. Hepatic impairment: Use with caution in patients with mild or moderate hepatic impairment and contraindicated in patients with severe hepatic impairment. Renal impairment: No dose adjustment required. CONTRAINDICATIONS: Hypersensitivity to active substance or any excipients. Severe hepatic impairment. Combination of rifampicin/ritonavir or lopinavir/ritonavir with PREZISTA. Preparations containing St John’s wort. Active substances that are highly dependent on CYP3A for clearance e.g. amiodarone, bepridil, quinidine, systemic lidocaine, alfuzosin, astemizole, terfenadine, dihydroergotamine, ergonovine, ergotamine, methylergonovine, cisapride, pimozide, sertindole, triazolam, orally administered midazolam, sildenafil (in treatment of pulmonary arterial hypertension), simvastatin and lovastatin. SPECIAL WARNINGS AND PRECAUTIONS: Regular assessment of virological response is advised. Perform resistance testing if lack of/loss of virological response. Do not use PREZISTA/rtv 800/100 mg once daily dose regimen in ART-experienced patients with one or more DRV-RAMs. Advise patients that current antiretroviral therapy does not cure HIV and precautions should be taken to avoid transmission. Do not use in children < 6 years of age or weighing < 20 kg. Severe skin reactions: Discontinue PREZISTA/rtv immediately if signs or symptoms of severe skin reactions develop. Stevens-Johnson Syndrome and toxic epidermal necrolysis reported rarely. Rash: In clinical studies, mild to moderate rash more common in treatment-experienced patients receiving both PREZISTA + raltegravir compared to patients on either PREZISTA or raltegravir alone. Patients with known sulphonamide allergy: Contains a sulphonamide moiety; caution advised. Hepatotoxicity: Drug-induced hepatitis has been reported. Patients with pre existing liver dysfunction including chronic active hepatitis B or C have increased risk of liver function abnormalities (including severe/potentially fatal hepatic adverse events) and should be monitored. Prompt interruption/discontinuation of treatment if liver disease worsens. Haemophiliac patients: Possibility of increased bleeding. Immune reactivation syndrome: An inflammatory reaction to asymptomatic or residual opportunistic pathogens may arise in immune reactive patients with severe immune deficiency at start of combination antiretroviral therapy (CART). Other: Onset/exacerbation of diabetes mellitus or hyperglycaemia reported. Lipodystrophy and metabolic abnormalities. Consider measurement of fasting serum lipids and blood glucose and manage as appropriate. Patients with advanced HIV disease and/or long term exposure to CART may develop osteonecrosis. Life-threatening/fatal drug interactions reported in patients treated with colchicine and powerful CYP3A and Pgp inhibitors. Patients with renal or hepatic impairment should not be given colchicine with DRV/r. PREZISTA 400 mg & 600 mg tablets contain sunset yellow FCF (E110) which may cause allergic reaction. INTERACTIONS: Refer to the SmPC for full details before initiating therapy. Interaction studies have only been performed in adults.

MI14.2011July14th.indd 2

Medicinal products that affect darunavir/ritonavir exposure: Darunavir/ritonavir must not be co-administered with medicinal products that are highly dependent on CYP3A4 for clearance and for which increased systemic exposure is associated with serious and/or life threatening events. Refer to “Contraindications” for more details. Medicinal products that are affected by the concomitant use of darunavir/ritonavir: PIs –Lopinavir/ritonavir contraindicated. Saquinavir: not recommended. Indinavir: dose adjustment may be required. Atazanavir: can be used with darunavir/ritonavir. The efficacy and safety of the use of darunavir/ritonavir and any other PI not established (e.g. fos (amprenavir), nelfinavir and tipranavir). Generally, dual therapy with PIs not recommended. NNRTIs : Efavirenz: if in combination with PREZISTA/rtv, the PREZISTA/ rtv 600/100 mg twice daily regimen should be used. .Clinical monitoring for CNS toxicity may be required. Etravirine, nevirapine: no dose adjustment required. NRTIs: Tenofovir: monitoring of renal function may be required. No interactions expected with zidovudine, zalcitabine, emtricitabine, stavudine, lamivudine, didanosine and abacavir. Non-antiretroviral products – Do not use: phenobarbital, phenytoin, voriconazole, salmeterol, sildenafil/tadalafil (treatment of pulmonary arterial hypertension). Monitoring required/possible dose adjustments: carbamazepine, clarithromycin, ketoconazole, itraconazole and clotrimazole, warfarin (monitor INR), calcium channel blockers, oestrogen hormone replacement therapy, cyclosporine, tacrolimus and sirolimus, methadone coadministration, parenteral midazolam, atorvastatin, pravastatin PDE-5 inhibitors, rifabutin, colchicine, bosentan. Maraviroc: dose should be 150mg twice daily. Careful titration required: digoxin, SSRI’s. No dose adjustment: H2-receptor antagonists, proton pump inhibitors. Alternative or additional contraceptive measures required: oestrogen based contraceptives. Caution: dexamethasone. Not recommended: fluticasone, budesonide (unless potential benefit outweighs risk of systemic corticosteroid effects). PREGNANCY AND LACTATION: Use during pregnancy only if potential benefit justifies potential risk. HIV infected women must not breast feed their infants under any circumstances. SIDE EFFECTS: Refer to SmPC for full details of side effects. Safety profile in children and adolescents is similar to that in adult population. Very common: diarrhoea. Common: lipodystrophy, hypertriglyceridaemia, hypercholesterolaemia, hyperlipidaemia, insomnia, headache, peripheral neuropathy,dizziness, vomiting, nausea, abdominal pain, increased blood amylase, dyspepsia, abdominal distension, flatulence, increased alanine aminotransferase, increased aspartate aminotransferase, rash, pruritus, asthenia, fatigue. Uncommon: thrombocytopenia, neutropenia, anaemia, immune reconstitution syndrome, drug hypersensitivity, diabetes mellitus, gout, anorexia, decreased appetite, weight changes, hyperglycaemia, insulin resistance, depression, confusional state, disorientation, anxiety, altered mood, sleep disorder, abnormal dreams, lethargy, paraesthesia, hypoaesthesia, somnolence, conjunctival hyperaemia, vertigo, myocardial infarction, angina pectoris, prolonged electrocardiogram QT, hypertension, dyspnoea, cough, pancreatitis, gastritis, gastrooesophageal reflux disease, aphthous stomatitis, retching, dry mouth, abdominal distension, flatulence, constipation, hepatitis, cytolytic hepatitis, hepatic steatosis, increased enzyme levels, allergic dermatitis, urticaria, hyperhidrosis, night sweats, alopecia, osteoporosis, myalgia, arthralgia, pain in extremity, renal failure, nephrolithiasis, increased blood creatinine, decreased creatinine renal clearance, proteinuria, bilirubinuria, erectile dysfunction, gynaecomastia, pyrexia, chest pain, peripheral oedema, malaise. Patients co infected with hepatitis B and/or hepatitis C virus: more likely to have baseline and treatment emergent hepatic transaminase elevations than those without chronic viral hepatitis. LEGAL CATEGORY: POM. PRESENTATIONS, PACK SIZES & PRODUCT LICENCE NUMBERS: 75 mg tablets: 1 bottle containing 480 tablets. EU/1/06/380/005. 150 mg tablets: 1 bottle containing 240 tablets. EU/1/06/380/004. 400 mg tablets: 1 bottle containing 60 tablets. EU/1/06/380/003. 600 mg tablets: 1 bottle containing 60 tablets. EU/1/06/380/002. MARKETING AUTHORISATION HOLDER: JANSSEN-CILAG INTERNATIONAL NV, Turnhoutseweg 30, B-2340 Beerse, Belgium. FURTHER INFORMATION AVAILABLE FROM: Janssen-Cilag Ltd, 50-100 Holmers Farm Way, High Wycombe, Buckinghamshire, HP12 4EG UK. © 2009 Janssen-Cilag Ltd Prescribing information last revised: March 2011 PIVER: MAR 2011 IRE/PRE/2011/0004 Date of Preparation: April 2011

08/07/2011 19:12

Alcohol-related illness costs Irish hospitals €800 million in 5 years PRISCIllA lynCh

lcohol associated illness cost Irish hospitals more than €800 million in a five-year period and accounted for almost 9 per cent of all hospital bed days, far greater than previously thought, new research has found. The Irish study found that alcohol consumption accounted for almost 2.9 million bed days between 2000 and 2004. The net in-patient costs due to the negative effects of alcohol amounted to €805,158,217, equivalent to 15 per cent of the total health budget for the fiveyear study period. Ninety-six per cent of the bed days related to chronic conditions associated with alcohol, while the remaining 4 per cent related to acute conditions. Conditions partially caused by alcohol accounted

used these to the best of our sed the media, saying “the ability,” Prof Kelly said. He truth doesn’t make much added that the RSCI’s reimpact on media stateThe CEO of the RCSI has sponse has been dictated by ments”. condemned recent media what will have the biggest “I don’t believe that the radio programmes or articomments on the College’s impact in Bahrain, rather handling of the Bahraini sit- than “what will have the bigcle/letters in the Irish Times uation. In an email seen by gest impact in Ireland”. will have any impact on acthe Medical Independent, The RCSI has been crittions in Bahrain, but they do Professor Cathal Kelly told icised in recent weeks behave an impact on our repstudents and staff at the cause of its perceived inacutation in Ireland and the RCSI that the College has tion the detention of three self-confidence of the RCSI “done more than any other Irish-trained doctors in community. I am truly sorry organisation to influence Bahrain. for the distress that this has the circumstances of the However, according to Prof caused to all of you,” he said. detained healthcare profes- Kelly, “real progress” has been He added that the RCSI sionals in Bahrain”. made on the ground. Thirwill continue to “ensure the “Our response has been ty-four of the 48 doctors and safety and security of our guided by the tools availnurses detained have now 900 students and staff; and IE_FF_0004_11_Avamys_Ad_Garden_Apr_256x166:AVM336 Garden Butterfly ad B aw 27.04.2011 14:40 Page 1 able to us to optimally in- been released, he said. to advocate for the detained Prof Cathal Kelly fluence events and we have healthcare professionals”. Prof Kelly’s email criticiJAMES FOgARty

fluticasone furoate

Allergic rhinitis relief

the Medical Independent announces ProDev winner

Whatever the reason whatever the season

Congratulations to Dr Eímhín Ansbro, winner of the Medical Independent’s ProDev draw on June 30th. Dr Ansbro won a pre-reg bag worth €1,000 courtesy of Medstore and is pictured accepting her prize from the Medical Independent’s Editor, Dawn O’Shea

ss, te

Continued from page 1 »

e, gy, n, n, ia, n,

ures, especially for staff taxis, triggered alarm bells. Defending its overall use of taxis, the HSE said HSE vehicles and staff are prioritised for frontline emergency work “and therefore a much more effective service is provided for patients or clients who are not acutely ill through the use of taxis”. “The use of taxis for patient transport represents a more cost-effective solution when compared to investment in a fleet of HSEowned vehicles for this purpose. Additional costs re-

for just over two-thirds of these hospital bed-days. Alcohol-related cardiovascular and cerebrovascular diseases accounted for 48 per cent of bed-days due to alcohol, with neuropsychiatric disease accounting for 36 per cent. The impact of alcohol on hospital bed-days was greater in men and greater in young to middle-aged people. A total of 37 per cent of male bed-days due to alcohol use were due to conditions wholly attributed to alcohol, whereas in women the proportion was 25 per cent. The protective effect of low alcohol consumption levels prevented some hospitalisations. The study estimated that 1.6 per cent of bed days were prevented, mainly through preventing cardiovascular disease. However, this was only seen in the older age groups and was less than the figures in other Western countries.

RCSI defends position on Bahrain

lating to this would include the provision of 24/7 staffing, maintenance, fuel, insurance and tax. The use of taxis also allows the HSE flexibility in the face of variable demand,” a HSE spokesperson told the Medical Independent. After coming under fire last year for not putting its taxi services out to tender, the HSE confirmed that it has recently advertised a National Framework Agreement for Transport Services (Taxi, Hackney & Minibus) covering 22 counties.

medical independent | 14 July 2011 MI14.2011July14th.indd 3

IE/FF/0004/11

n ls. e .g. A/ s: vir. g s, 5 or ot

news

Abridged Prescribing Information (see SPC for full prescribing information). Trade name: AVAMYS 27.5 micrograms/spray nasal spray suspension Quantity of active ingredient per unit dose: Each spray actuation delivers 27.5 mcg of fluticasone furoate. Therapeutic indications: Adults, adolescents (12 years and over) and children (6 – 11 years) Treatment of the symptoms of allergic rhinitis Posology and method of administration: By the intranasal route only. Regular usage is recommended. Onset of action has been observed as early as 8 hours after initial administration. However, it may take several days of treatment to achieve maximum benefit. The duration of treatment should be restricted to the period that corresponds to allergenic exposure. Adults and Adolescents (12 years and over) The recommended starting dose is two sprays in each nostril once daily (total daily dose, 110 mcg fluticasone furoate). Once adequate control is achieved, dose reduction to one spray in each nostril may be effective for maintenance. The dose should be titrated to the lowest effective dose required to maintain control of symptoms. Children (6 to 11 years of age) The recommended starting dose is one spray in each nostril once daily (total daily dose, 55mcg fluticasone furoate). Patients not responding to one spray in each nostril once daily may use two sprays in each nostril once daily (total daily dose, 110 mcg). Once control of symptoms is achieved, dose reduction to one spray in each nostril once daily is recommended. Children under 6 years

of age: Safety and efficacy in this group has not been well established (see SPC for further information). Elderly Patients and Renal Impaired Patients: No dose adjustment required. Hepatic Impaired Patients: No dose adjustment required in mild to moderate hepatic impairment. There are no data in patients with severe hepatic impairment. Administration: Shake the device before use. Prime the device by pressing the button for six sprays actuations. Re-prime if the cap is left off for 5 days or the device has not been used for 30 days. Clean after use and replace the cap. Contraindications: Hypersensitivity to any of the ingredients. Special warnings and precautions: Systemic effects may occur, particularly at high doses prescribed for prolonged periods. Treatment with higher than recommended doses may result in clinically significant adrenal suppression. The total systemic burden of corticosteroids should be considered whenever other forms of corticosteroid treatment are prescribed concurrently. Growth retardation has been reported in children receiving some nasal corticosteroids at licensed doses. The height of children receiving prolonged treatment should be monitored. If growth is slowed, therapy should be reviewed. If adrenal function is impaired, care must be taken when transferring patients from systemic steroid treatment to fluticasone furoate. Caution is advised when treating patients with severe liver disease. Concomitant administration with ritonavir is not recommended. Close monitoring is warranted

in patients with a change in vision or a history of increased intraocular pressure, glaucoma and/or cataracts. Avamys contains benzalkonium chloride which may cause irritation of the nasal mucosa. Drug interactions: Concomitant administration with ritonavir is not recommended. Caution is recommended when co-administering fluticasone furoate with potent CYP3A4 inhibitors. Pregnancy and lactation: Fluticasone furoate should be used only if the benefits to the mother outweigh the potential risks to the foetus or child. Side effects: Respiratory, thoracic and mediastinal disorders: Epistaxis (very common), Nasal ulceration (common). Immune system disorders: Hypersensitivity reactions including anaphylaxis, angioedema, rash, and urticaria (rare). PA number: EU/1/07/434/003 Name and address of PA holder: Glaxo Group Ltd, Greenford, Middlesex, UB6 0NN, United Kingdom Legal category: POM For further information please contact: GlaxoSmithKline (Ireland) Ltd, Stonemasons Way, Rathfarnham, Dublin 16. API job number: 032010Avamys2522 Date of API preparation: March 2010

www.medicalindependent.ie

3 08/07/2011 19:12

news

analysis Ailbhe Jordan

A summer of discontent The summer rotation has left Emergency Departments around the country with less junior medical staff than ever before. Can they cope under the strain of a service stretched bare? Ailbhe Jordan investigates

anicked nChD recruitment drives that precede the rotation of hospital training posts in January and July have, in recent years, become as much of a tradition as the changeover itself. The situation appears to deteriorate further every year and last January culminated in the HSE joining forces with the IMO, the IHCA and a number of other stakeholders to come up with a contingency plan aimed at preventing unnecessary full or partial closures of emergency departments (EDs). The weeks leading up to the most recent changeover on July 11th saw anxiety levels reaching fever pitch as falling staff numbers and dwindling resources, along with a perceived mass abandonment of the Irish health system by newly trained NCHDs, combining to create a perfect storm that threatened to overcome several of the country’s 33 EDs. The Irish Association of Emergency Medicine (IAEM) warned that the situation on changeover day would be “substantially worse than anything that has been seen before”, and urged the HSE to “urgently reconsider its approach to the matter”. Without a doubt, the logistics of the July changeover were more alarming than usual. In January, emergency department closures were avoided in spite of concerns over Letterkenny General Hospital, the Mid Western Regional Hospital Limerick and Beaumont Hospital. This July saw the announcement that the ED in St Columcille’s Hospital Loughlinstown was to close, with its annual patient traffic of 21,000 being absorbed by St Vincent’s Hospital. In addition, Taoiseach Enda Kenny himself confirmed ED services in Roscommon County Hospital would no longer operate on a 24/7 basis from July 11th. At the time of going to print, major concerns also existed over the future of emergen-

cy services in hospitals in Portlaoise, Limerick, Portinucula and Letterkenny. On January 13th, just ahead of the January changeover, the HSE confirmed it still had 150 posts to fill, while as late June 30th, Health Minister James Reilly told the Dáil that just 221 of 475 vacant NCHD posts had been filled. There have also been glimpses of a far deeper crisis brewing below the surface.

Investigations

The decision by HIQA last month to investigate emergency services in Tallaght hospital, followed a harrowing inquest into the death of 65-year-old Thomas Walsh, who died while waiting in a corridor that was referred to by the hospital as a “virtual ward”.

‘They talked about virtual wards in Tallaght, well it looks like we will have virtual doctors to staff these virtual wards’ Dr James Gray, an emergency consultant in the hospital told the inquest he and his colleagues had complained about the conditions at Tallaght ED to HIQA and a number of other bodies,

per cent fall in mental health in-patient re-admission in 2010 4

www.medicalindependent.ie

MI14.2011July14th.indd 4

while Dublin County Coroner Dr Kieran Geraghty said Tallaght Hospital sounded like a “very dangerous place”. A survey last month by the IAEM predicted that just five hospital emergency departments would have a full team of medics following the July changeover. The survey also showed, even more worryingly, that the biggest shortage was in experienced middle grade doctors with the authority to take part in senior decision making, where a 30 per cent deficit was predicted. In addition, the Medical Independent has learned more about the extent to which the HSE has under-reported the crisis, not only to the public but to the medical profession itself. Not only that, but a number of medical professionals have spoken to this publication about their fears that the sticking plaster measures currently in place will not prevent but merely prolong the ED crisis. A previous issue of the Medical Independent revealed that, just three weeks shy of the changeover on June 24th, the Medical Council had received just 63 applications forregistrationfrom doctors who were offered posts as part of the HSE’s recruitment drive in India and Pakistan. Staff had to follow up on 75 per cent of those applications seeking clarification or requesting additio nal documentation. Speaking to the Medical

1.1m:

people attended emergency departments in 2010

Independent less than a week before July 11th, a despondent IAEM secretary Dr John McInerney revealed how feedback from his colleagues around the country indicated that, in reality, less than 10 SHOs had completed their paperwork, registered and were ready to start work on the day of the changeover.

Recruitment

“I know in St Columcille’s they were trying to recruit five SHOs from India and Pakistan and they have been trying to get in touch with them. They have still not heard back. They have no idea when these guys will get their registration from the Medical Council or when they will touch down on Irish soil,” Mr McInerney told the Medical Independent. “In the Dublin Mid Leinster Region there were three separate interview boards as part of this centralised recruitment process. They had 23 vacancies to fill across hospitals like Naas, Portlaoise and Tullamore. They interviewed 16 candidates and after three interview processes only one SHO to date has their paperwork in order... My outlook would be pessimistic at this point. I don’t know how these hospitals are going to manage or where the staff are going to come from. These departments will all have to get locums or close,” he said. Mr McInerney said the 30 per cent shortage of senior registrars identified by the

3.5m:

IAEM’s June survey has not changed. “I have received updates from my colleagues in recent days relating to the survey we carried out,” Mr McInerney said. “While some hospitals have managed to recruit a few SHOs, there is still a 30 per cent deficit in senior registrars. Even more worryingly, the overall number of SHOs has remained about level, because some people who had signed up to training schemes have now resigned. This might well be because of the working conditions, the overcrowding etc, it’s a vicious cycle really.” Anecdotally he was aware of SHOs who had resigned from the paediatric scheme in Tallaght and that Sligo General Hospital had withdrawn an SHO post on the basic training course in Emergency Medicine as the NCHD who signed up had been offered a job elsewhere and decided not to take up the post. “This is very worrying. It suggests these NCHDS are leaving the country because the only way to train is to get on these schemes,” Mr McInerney said. “Emergency medicine is in a state of complete confusion as to how many have

registered and are ready to work,” he added. “There could be less than 10 around the whole country and that is clearly not enough to manage rosters. It’s like a bad dream. They talked about virtual wards in Tallaght, well it looks like we will have virtual doctors to staff these virtual wards.” “The HSE are not communicating this with the public. It’s as if they are afraid to tell the public the extent of it,” he said. “My fear is that they will turn to locums who will be able to name their price. In financially straightened times, this is no way to save money.” Overcrowding in emergency departments has long been a bugbear of the Irish health system and a reliable political stick opposition parties have used to beat successive health ministers. Lack of beds, waiting lists and junior doctor shortages are among the contentious issues which have taken up thousands of column inches in the Irish media and, embarrassingly, have even been noted by American Embassy officials. Official US embassy cables leaked to the Irish Independent earlier this year

Mr John McInerney

Attendances in out-patients departments last year, an increase of 6 per cent over 2009

13.5m:

extra life years Irish people could gain by eliminating socioeconomic mortality differentials in Ireland 14 July 2011 | medical independent 08/07/2011 19:12

news

analysis by the website wikileaks.org revealed how embassy officials here have highlighted hospital overcrowding and ED waiting times on several occasions in dispatches to the US State Department in Washington and have even warned visiting diplomats to be patient in the event of a medical emergency. “Emergency room services tend to be oversubscribed; patients can expect waits up to 12 hours before being seen. It’s not uncommon for persons to be treated in an emergency room or surrounding hallway,” one cable sent in January 2010 warned. However, there seems to be consensus across the medical profession that it has reached a point where emergency departments have quite literally never had to do so much with so little. The budget for hospitals fell by almost €220 million in 2011 under the HSE Service Plan for 2011. Against this backdrop of reduced funding and pressure to reduce agency medical staff numbers, the most recent HSE Performance Monitoring Report showed that ED attendances were more than 7,000 higher in March 2011 than in the same period last year. A report from the Comptroller and Auditor General last year showed that 23 of the 33 emergency departments had delays in accessing senior decision makers. Waiting times are also falling pitifully short of the sixhour target introduced by the HSE in January 2009 from the registration of the patient in the emergency department to admission or discharge, with two out of every five people still waiting longer than six hours in EDs, according to the HSE Annual Report for 2010. The most recent HealthStat report found that only one ED in the entire country – St James’s Hospital – received a ‘green light’ for good performance in terms of waiting times. In Tallaght Hospital, meanwhile, more than half of patients awaiting ED admission on a trolley have to wait over 12 hours for a bed. Just over 10 per cent have to wait over 24 hours to be seen. The HSE’s Emergency Medicine Programme is the latest in a long history of initiatives aimed at improving efficiency and patient outcomes across EDs. It forms part of the HSE’s Transformation Programme under the Clinical and Quality

331:

Care Directorate led by Dr Barry White, to reconfigure its acute services and concentrate emergency, urgent and complex acute care into regional centres supported by a network of minor injury units in smaller local centres. The multifaceted programme promises to deliver reduced numbers of patients on trolleys in EDs in conjunction with the implementation of the related Acute Medicine and Chronic Disease programmes, which the HSE says will save one life a week. The Medical Independent submitted a number of enquiries in relation to the progress of the programme and asked to interview its Clinical Lead Dr Una Geary but the HSE declined both requests. Mr McInerney, who is a regional lead of the programme believes “it will improve patient care”, but that the current manpower challenges will make progress difficult. “Our aim is to provide a consultant-led services,” he said. “We were promised 14 consultant posts but it will be hard to track these people when they have no staff to work with.”

Junior doctors

However admirable its aims, the programme does not address what is vastly being acknowledged as the true crisis in emergency medicine and a major problem in other specialties – the fact that our highly skilled, expensively trained NCHDs are choosing to take their skills abroad rather than work in the Irish health system. And who can blame them? The lack of opportunity to reach consultant level is a serious problem, with NCHDs standing a mere 25 per cent chance of going on to become consultants in Ireland. The ratio of NCHDs to consultant posts has improved slightly from 2.02:1 in 2008 to 1.93:1 currently, but still falls well below international standards. There is also the issue of the pay cuts which few in the public sector have escaped and which have seen the basic salary of a junior doctor fall by some 30 per cent over the past two years. But these problems are dwarfed by the difficult working conditions and extreme overtime which are caus-

New cases of HIV in Ireland in 2010

30:

‘We told the HSE HR several times not to go down the centralised recruitment route that it would make things worse. Doctors would end up getting sent to places they didn’t want to go and would pull out altogether’ “I feel I must speak out because over those 20 years I truly believe that myself and my colleagues have done everything we can to improve the service we offer in our Emergency Department and to improve the training and prospects for trainees.” “To that end I have helped to commission education centres, education services, grand rounds, intern training programmes, skills cours-

per cent of individuals infected with HIV who are unaware of their infection

medical independent | 14 July 2011 MI14.2011July14th.indd 5

ing so many junior doctors to flee. It is costing the HSE dearly to hire locums to fill the gap. The Medical Independent last month reported on how the NCHD shortage has cost the HSE an extra €1 million a month in hiring agency doctors. According to the HSE’s most recent Performance Monitoring Report, it spent an average of €4.8 million a month on agency doctors in the first quarter of 2011, compared to an average monthly spend of €3.8 million in 2010. This has given rise to heated debate over whether the carrot or stick approach is most appropriate in convincing NCHDs to stay. Dr Chris Luke, a consultant in emergency medicine at Cork University Hospital, has faced criticism from the NCHD community over his support of the “stick” approach of indenturing junior doctors to carry out a mandatory period of service upon graduating. “I’ve been a consultant for almost two decades and I’ve been a medical educationalist for 10 years, so I believe I have earned the right to speak out,” he told the Medical Independent.

es and brand new emergency departments. I’ve also supported moves over 25 to 30 years to improve salaries and all the rest of it and I’m happy to report that, as far as I’m aware, EWTD working hours are complied with in every ED in this country. But I gave up in 2007 because despite all my efforts, I found that instead of these doctors then going on to serve our patients in the frontline, they were all going straight Down Under in their droves. And I suddenly realised that all my efforts were in vain. I was heartbroken and basically gave up in absolute despair.” Dr Luke believes a way of retaining junior doctors must be prioritised as a matter of urgency. “It has now become a logistical, financial and economic training nightmare trying to staff the EDs,” he said. “I don’t know if a locum is going to turn up. I don’t know if that locum will have worked in Ireland or in this hospital before. I don’t know if he’s suitably trained or qualified. I don’t know whether he’ll understand the new systems or whether he’ll spend hours getting to know the new x-ray computer systems and so on and so forth. It’s next to impossible to reliably educate or train people who are coming for a day here and a day there. In my view, that kind of chaotic, erratic and utterly unreliable staffing arrangement, is absolutely heartbreaking for me and it’s absolutely devastating for the service. You have to start completely afresh every day. It’s like the myth of Sisyphus and the quality suffers.” He dislikes the term “indenture”, preferring to incentivise the commitment to carry out a period of mandatory service from medical student level.

Incentives

“One solution could be for medical schools to offer an incentive to would-be medical students and say to them ‘look, we will give, let’s say 20 leaving cert equivalent points if you sign up in advance to one or two years in the service of the citizens of this country’,” he suggested. “Instead of this ludicrous, fatuous HPAT system we would instead say, well if you’re actually going to commit to stay and serve the citizens of our country, then arguably there should be some incentive for people to work at the frontline be-

€117m:

Mark Murphy cause it is difficult working in emergency medicine and one would have thought that simple economic logic would have said those doing the hardest job should get some kind of reward. This country has no more money to offer doctors at any level as a sort of super duper incentive. It would cost the health service less to run the frontline if our graduates stayed for a couple of years because locum services cost so much more, it would allow us to export far better trained and experienced doctors in their third or fourth year of postgraduate training and it would transform the quality of care that patients experience in our health service because if you have local graduates who have been in your hospital two or three years before they start as SHOs, it is, I think, unarguable that they are going to provide a better service in terms of orientation and their awareness and their abilities to navigate the system in a hospital.” Mr McInerney, however, believes indenture will not solve the shortage of senior registrars and that a more nuanced way of running the recruitment process is necessary. “The idea of indenture, I think our survey shows that it would completely defeat the purpose of addressing the shortages we have identified,” he said. “SHO numbers were just over 10 per cent short of fill rates but in the actual registrar grade, nearly a third are

budget overrun for the four HSE regions at the end of April

missing. That is the figure that was quite scary when we got the results back. We’ve heard about doctors that are senior, who make decisions who give us 24-hour rosters, who make patient care much safer, they’ve actually left and you can’t indenture people three or four years after they’ve qualified.” Centralised recruitment must be abolished and replaced with a fairer system, he said. “We told the HSE HR several times not to go down the centralised recruitment route, that it would make things worse. Doctors would end up getting sent to places they didn’t want to go and would pull out altogether,” according to Mr McInerney. “If you applied for a post in the HSE you could be sent anywhere, you didn’t have a choice. People from abroad perhaps wouldn’t feel comfortable that they’d applied for a job in Ireland and could not go to where they wanted to. And obviously people in posts didn’t want to apply either through that route because they might be happy staying in Roscommon or Portlaoise but end up getting sent to Sligo. So the central recruitment needs to be reversed and I think local hospitals need to be able to do their own recruitment and obviously bring forward their own attributes and things that make them popular.” The IAEM has called on the HSE to incentivise junior doctors to work in the country’s EDs “in recogni-

€400m:

projected HSE deficit by year end if cuts are not implemented www.medicalindependent.ie

5 08/07/2011 19:12

news tion of the greater intensity of ED clinical work and the demands of working night and evening shifts on 24/7 rosters”. “Australia went through the same problem five or 10 years ago when I was out there,” Mr McInerney said. “In places like Queensland and some of the hinterland, it was very difficult to recruit. What they did was ask, well how can we make ourselves attractive and they improved the rosters, they made sure that overcrowding didn’t become an issue. They introduced full capacity protocols and in some places they had to incentivise doctors to go and work there. When I trained in the UK, they couldn’t get

analysis doctors to the Isle of White, so they offered free accommodation, improved training, training grants to go back to the mainland. There are lots of ways you can incentivise which involve only a little bit of investment.” Dr Mark Murphy, IMO NCHD Chair opposes the idea of indenture and has been openly critical of Dr Luke’s views on NCHDs in particular. He believes that root and branch reform of the recruitment and retention system is needed. “I think if there is a commitment from the Minister that there will be radical restructuring of postgraduate training over the next five years, if we increase con-

sultant numbers, if there is a clear channelling of postgraduate training and qualification through a structured training programme that is more family friendly, leading to a definite specialist position, NCHDs will stay here. And if there is a commitment in the short term to do that over the next five to 10 years, I think you will find that NCHDs will stay here,” he said. In the short term however, the crisis is more difficult to solve. “I can’t see how we’re going to be able to run more than maybe a dozen departments in the country in July if the figures turn out to be reliable,” said Dr Luke, who is also an IAEM member.

“What often happens is that at the last minute for political reasons they throw huge amounts of money at the problem and then they go back to normal and the problem continues to slowly worsen and worsen. This problem has been developing for years. I’m looking for our medical students to sign up in advance to work for a year or two in return for being trained here and in return for the prospect of a really wonderful career. As a quid pro quo, I don’t think it’s a lot to ask and I don’t see how the services will survive otherwise. I think we’ve tried everything else and there isn’t the money anymore to do it any other way than to get our doctors

ark. m d o o g a t To d a y I go And made a d. new frien

and our graduates to voluntarily stay and serve the people of the country for six or 12 or 24 months.” Mr McInerney believes that, while the changeover has occured, the magnitude of the junior doctor shortage is likely to be felt as the summer goes on. “We’re pretty depressed about this,” he said. “What is going to happen a week or two into the new rotation when people need to take time off? Roscommon has only one ambulance. If it closes that’s not sufficient to get patients to Galway. It’s like they [the HSE] are afraid to tell the public how bad it is. They are reluctant to release this information but they real-

ly need to as it will help prepare GPs and patients to plan ahead. There comes a point where you just have to be straight with people.” In the longer term, he believes the Executive must communicate the principles of reconfiguration more effectively to the public. “There needs to be a public debate if you like,” he said. “It always goes back to this thing of, ‘oh if they close my local hospital we’ll die’. But often it’s the converse. If you go to your local hospital and there is no one trained to treat you there, you might be worse off than if you had travelled another half hour up the road to a different hospital. It’s that sort of logic that needs to be teased out.”

Emergency Department Crisis – a timeline ● June 15th: HSE announces that the 24-hour ED unit in St Columcille’s hospital in Loughlinstown is to be reduced to a day-time minor injury service. The hospital will also stop accepting acute surgical cases before the end of 2011. ● June 17th: Public anger greets the news that the opening of the new ED at Letterkenny has been delayed by a year due to problems with the building contract. Several out-patient clinics are cancelled due to overcrowding and delays at the hospital.

a t y! a d a b h a f W

For children with ADHD getting through the day can be difficult.1, 2

Equasym XL’s unique 30:70 dose ratio is designed to make the most of the school day.3 It provides immediate release methylphenidate in the morning when it’s needed with extended release for continued coverage through the school day.4

● June 17th: Internal documentation, seen by the Medical Independent suggests that the Emergency Department at the Midlands Regional Hospital in Portlaoise could be reduced to a day-time minor injuries service in an effort to deal with ongoing NCHD shortages. ● June 22nd: Dr Orla Smithwick, a consultant at the Portiuncula Emergency Department, tells the Westmeath Independent that “at this moment in time we do not have enough staff for July”. ● June 22nd: Director of Operations in HSE West area says there is no possibility of the Mid Western Regional Hospital’s ED being closed down at night due to a shortage of junior doctors. ● June 24th: IAEM says Mayo General Hospital is facing a staff shortage crisis in its ED with 12 junior doctor posts out of 80 unfilled in the areas of emergency and medicine. ● June 25th: HIQA launches an investigation into services and supporting arrangements provided to patients requiring acute admission and receiving care in Tallaght Hospital ED.

www.fullattention.ie Equasym XL is indicated for ADHD in children (aged 6 years and over) and adolescents as part of a comprehensive treatment programme when remedial measures alone prove insufficient.4

Methylphenidate (MPH) is indicated as part of a comprehensive treatment programme for ADHD in children aged six years and over when remedial measures alone prove insufficient. Treatment must be under the supervision of a specialist in childhood behavioural disorders. Pre-treatment screening and on-going monitoring are required. The summary of product characteristics (SPC) should be consulted before prescribing.

ABBREVIATED PRESCRIBING INFORMATION (Before prescribing, please consult the Summary of Product Characteristics (SPC) for pre-treatment screening and potential side effect profile). Equasym® XL 10mg, 20mg and 30mg modified release capsules, hard. Active Ingredient: Methylphenidate Hydrochloride 10mg, 20mg or 30mg. Also contains 45mg, 90mg and 135 mg sucrose. Uses: Attention-deficit hyperactivity disorder (ADHD) in children aged 6 and over as part of a comprehensive treatment programme under supervision of a specialist in childhood behavioural disorders where remedial measures alone prove insufficient. Dosage and Administration: Children (aged 6 years and over) and adolescents: Conduct pre-treatment screening. Maximum daily dose is 60mg. New patients: Starting dose is 10mg taken before breakfast. Careful dose titration is necessary at the start of treatment. Patients currently using methylphenidate: 20mg Equasym XL is intended to replace 10mg of immediate release methylphenidate taken at breakfast and lunchtime. Administration: The capsules may be swallowed whole with liquid, or capsule contents sprinkled onto soft food such as applesauce, taken immediately and followed by a drink. The capsule contents must not be crushed or chewed. Adults: Not applicable. Long-term Use: The safety and efficacy of long term use of methylphenidate has not been systematically evaluated in controlled trials. Methylphenidate treatment should not and need not, be indefinite. Methylphenidate treatment is usually discontinued during or after puberty. The physician who elects to use methylphenidate for extended periods (over 12 months) in children and adolescents with ADHD should periodically re-evaluate the long term usefulness of the drug for the individual patient with trial periods off medication to assess the patient’s functioning without pharmacotherapy. It is recommended that methylphenidate is de-challenged at least once yearly to assess the child’s condition (preferable during times of school holidays). Improvement may be sustained when the drug is either temporarily or permanently discontinued. Contraindications: Known hypersensitivity to methylphenidate or excipients, Glaucoma, Phaeochromocytoma, Hyperthyroidism, Thyrotoxicosis, During treatment with non-selective, irreversible monoamine oxidase inhibitors (MAOIs) (or within a minimum of 14 days of discontinuation of non-selective irreversible MAOIs), Diagnosis or history of severe depression, anorexia nervosa/

Equasym Ad 166x254 D2.indd 1

anorexic disorders suicidal tendencies, psychotic symptoms, severe mood disorders, mania, schizophrenia, psychopathic/borderline personality disorder, Diagnosis or history of severe and episodic (Type I) Bipolar (affective) disorder (that is not well-controlled), Pre-existing cardiovascular disorders including severe hypertension, heart failure, arterial occlusive disease, haemodynamically significant congenital heart disease, cardiomyopathies, myocardial infarction, potentially lifethreatening arrhythmias and channelopathies (disorders caused by the dysfunction of ion channels), Pre-existing cerebrovascular disorders cerebral aneurysm, vascular abnormalities including vasculitis or stroke. Warnings: Monitor cardiovascular status carefully as sudden cardiac or unexplained death has been reported, Monitor psychiatric status as may exacerbate symptoms in psychotic children, may precipitate mixed/manic episodes. Equasym XL is associated with worsening or emergence of aggressive behaviour, emergent suicidal ideation or behaviour, onset or exacerbation of tics, worsening of Tourette’s syndrome, worsening of pre-existing anxiety, agitation or tension. Use with caution in epileptics as may increase frequency of seizures. Monitor abuse potential as chronic abuse may lead to tolerance, dependency with abnormal behaviour and addiction in later life. Precautions: Equasym XL is not indicated in all cases of ADHD, detailed history and clinical evaluation necessary. Monitor weight, growth, blood pressure, blood counts and platelet counts during long term use. Patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucrase-isomaltase insufficiency should not take Equasym XL. Supervise drug withdrawal. Should not be used for abnormal fatigue states. Interactions: drugs that elevate blood pressure, anticonvulsants (e.g. phenobarbital, phenytoin, primidone), tricyclics and SSRIs, coumarin anticoagulants, clonidine and other alpha-2 agonists, anti-hypertensives, halogenated anaesthetics, alcohol, dopamine agonists or antagonists including amtipsychotics. Pregnancy and Lactation: Methylphenidate is not recommended in pregnancy and should not be used by breast feeding mothers when the risk to the child outweighs the benefit of therapy to the mother. Driving: Caution is advised when driving, operating machines or engaging in other potentially hazardous activities. Adverse Effects: Very common: Nervousness, insomnia, headache. Common: Arrhythmias, palpitations, tachycardia, hypertension, abdominal pain, nausea, diarrhea, stomach

www.medicalindependent.ie

MI14.2011July14th.indd 6

discomfort and vomiting, dry mouth, changes in blood pressure and heart rate, decreased appetite and moderately reduced weight gain and height gain during prolonged use, pyrexia, athralgia, dizziness, drowsiness, dyskinesia, hyperactivity, abnormal behaviour, aggression, agitation, anorexia, anxiety, depression, irritability, alopecia, rash, pruritus, urticaria, nasopharyngitis, affect lability, abnormal behaviour, psychomotor hyperactivity, somnolence, cough, pharyngolaryngeal pain. Consult SPC in relation to uncommon, rare and very rare side effects. Pharmaceutical Precautions: Store below 30°C. Legal Category: POM. Product Authorisation Numbers: PA 1575/1/1 (10mg); PA 1575/1/2 (20mg); PA 1575/1/3 (30mg). Date of Revision: June 2010 Name and Address of Authorisation Holder: Shire Pharmaceuticals Ireland Limited, 5 Riverwalk, Citywest Business Campus, Dublin 24. Tel: 01 429 7700. Further information is available on request. Equasym XL is a registered trade name.

Adverse events should be reported to the Pharmacovigilance Unit at the Irish Medicines Board (IMB) (imbpharmacovigilance@imb.ie). Information about adverse event reporting can be found on the IMB website (www.imb.ie). Adverse events should also be reported to Shire Pharmaceuticals Ltd. on +44 1256 894000. References: 1. Green C & Chee K. 1995. Understanding ADHD – A Parent’s Guide to Attention Deficit Hyperactivity Disorder in Children. London, Vermilion. 2. American Psychiatric Association - DSM-IV-TR. 2004. 3. Wigal SB et al. J Applied Research 2003. 4. Equasym XL Summary of Product Characteristics.

● June 27th: Taoiseach Enda Kenny tells a crowd of local protesters that the Emergency Department in Roscommon County Hospital will no longer operate on a 24-hour basis. ● June 27th: IAEM urges HIQA to extend its investigation into Tallaght Hospital to include all hospitals with chronic Emergency Department overcrowding ● June 28th: Health Minister James Reilly says extra patients may have to be accommodated on hospital wards to alleviate overcrowding in EDs. ● Friday July 1st: HSE says Portlaoise Hospital “will be able to maintain 24-hour emergency services from July 11th pending the anticipated filling of a number of remaining vacant junior doctor posts in this approved hospital setting. The provision of a safe, quality service is paramount to all involved”.

P ( C

R S a f a f w D S d ( w 1 w c u H R o o c a P u o c n p I p c e a C i m P S r o 3 o l e p b m t c t i Q t A R s c f i c d i n i r t p a w e R s i a d e d b a f m f d b P 1 R a t A M N o i 5 I

R 1

● July 3rd: More than 2,000 people march in opposition to changes to ED services in Portlaoise Hospital. ● July 5th: Dr David O’Keefe, Hospital Manager of the HSE West says emergency services will cease altogether in Roscommon County Hospital from next week if junior doctors are not secured by July 11th. Currently only five out of the nine needed are in place. For latest updates on the ED crisis check out www. medicalindependent.ie

Item Code: IRE/EQU/11/0001 Date of preparation: January 2011.

28/01/2011 09:34:34

14 July 2011 | medical independent 08/07/2011 19:12

H55974

No w

Prescribing Information (Please refer to the full Summary of Product Characteristics before prescribing).

Reference: 1. Resolor. Summary of Product Characteristics. December 2010.

W able a il av

RESOLOR® 1 mg and 2 mg film-coated tablets. Selective serotonin (5-HT4) receptor agonist, enterokinetic agent, available as 1 mg and 2 mg film-coated tablets for oral administration, once daily, with or without food, at any time of the day. Indication: Resolor is indicated for symptomatic treatment of chronic constipation in women in whom laxatives fail to provide adequate relief. Dose: Women: 2 mg once daily, elderly (>65 years): Start with 1 mg once daily and increase to 2 mg once daily if necessary. Patients with severe renal impairment (GFR <30 ml/min/1.73m2): 1 mg once daily. Patients with severe hepatic impairment (Child-Pugh class C): 1 mg once daily. No dose adjustment required in patients with mild to moderate renal or hepatic impairment. Men, children and adolescents <18 years: not recommended until further data become available. Contraindications: Hypersensitivity to prucalopride or any of the excipients. Renal impairment requiring dialysis. Intestinal perforation or obstruction due to structural or functional disorder of the gut wall, obstructive ileus, severe inflammatory conditions of the intestinal tract, such as Crohn’s disease, and ulcerative colitis and toxic megacolon/megarectum. Precautions: Patients with severe and clinically unstable concomitant disease (e.g. liver, cardiovascular or lung disease, neurological or psychiatric disorders, cancer or AIDS and other endocrine disorders) have not been studied. Caution should be exercised when prescribing Resolor to patients with these conditions. In particular Resolor should be used with caution in patients with a history of arrhythmias or ischaemic cardiovascular disease. In case of severe diarrhoea the efficacy of oral contraceptives may be reduced and an additional contraceptive method is recommended. Contains lactose monohydrate. Patients with galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption must not take Resolor. Interactions: Prucalopride has a low potential for drug interactions. Studies in healthy subjects did not show a clinically relevant effect of prucalopride on the pharmacokinetics of warfarin, digoxin, alcohol or paroxetine. There was a 30% increase in plasma concentrations of erythromycin on coadministration with prucalopride. This was more likely to be related to a high intrinsic variability in erythromycin kinetics rather than due to an effect of prucalopride. Ketoconazole increased prucalopride bioavailability by 40% possibly via inhibition of P-gpmediated renal transport. This effect is thought too small to be clinically relevant. Therapeutic doses of probenecid, cimetidine, erythromycin and paroxetine did not affect the pharmacokinetics of prucalopride. Use with caution in patients receiving concomitant drugs known to cause QTc prolongation. Atropine-like substances may reduce the 5-HT4-mediated effects of prucalopride. Pregnancy: Animal studies did not indicate harm. Experience of Resolor during human pregnancy is limited. Cases of spontaneous abortion have been observed in human clinical studies although, in the presence of other risk factors, the relationship to Resolor is unknown. Resolor is not recommended during pregnancy. Women of childbearing potential should use effective contraception during treatment with Resolor. Lactation: Prucalopride is excreted in breast milk, however at therapeutic doses no effects are anticipated on the breastfed newborn/ infant. In the absence of human data Resolor is not recommended during breastfeeding. Effects on ability to drive and use machines: No studies have been performed. Resolor has been associated with dizziness and fatigue, particularly on the first day of treatment, which may affect driving or using machines. Side effects: The most commonly reported side effects in Resolor clinical trials were headache and gastrointestinal symptoms (abdominal pain, nausea, diarrhoea) occurring in about 20% of patients each. These events occur mostly at the start of therapy and usually disappear within a few days whilst continuing Resolor. Other common adverse events in controlled trials included dizziness, vomiting, dyspepsia, rectal haemorrhage, flatulence, abnormal bowel sounds, pollakiuria and fatigue. Uncommon adverse events included anorexia, tremors, palpitations, fever and malaise. After the first day of treatment the most common adverse events were reported with similar frequency for Resolor and placebo except nausea and diarrhoea: these remained higher but the difference between Resolor and placebo was smaller (1 to 3%). Palpitations were reported in 0.7% of placebo patients, 1.0% of 1 mg Resolor patients and 0.7% of 2 mg Resolor patients. As with any new symptom, patients are advised to discuss new onset palpitations with their physician. Legal category: POM. Marketing Authorisation number: EU/1/09/581/001-008. Marketing Authorisation Holder: Shire-Movetis N.V., Veedijk 58 (1004), 2300 Turnhout, Belgium. Date of preparation: March 2011. Further information is available from: Shire Pharmaceuticals Ireland Ltd, 5 Riverwalk, Citywest Business Campus, Dublin 24, Ireland. Tel: 01 4297700.

At last! A new way out of chronic constipation in women

Resolor® is indicated for symptomatic treatment of chronic constipation in women in whom laxatives fail to provide adequate relief. Resolor works by targeting impaired colonic motility. In placebo-controlled studies, Resolor 2 mg was effective in helping to restore normal bowel movements* and alleviating a broad range of constipation symptoms in women.1 * Defined as an average of ≥3 spontaneous, complete bowel movements (SCBM) per week over the 12-week treatment period.

IRE/RES/11/0016 March 2011

H55974 RES(Ire) Med Ind7(395x273) v3.indd 1 MI14.2011July14th.indd

23/3/11 12:54:22 08/07/2011 19:12

news

Irish fare better in MPS rate hikes AIlBhE JORDAn

onsultants in high-risk specialties in Ireland saw the cost of medical indemnity increase by significantly less than their UK counterparts this year, figures obtained by the Medical independent reveal. Medical Protection Society subscriptions for the highest risk specialties – namely private obstetricians, neurosurgeons and spinal surgeons – rose by less than 6 per cent in Ireland in 2011. In its annual report for 2010, MPS Chief Ex-

ecutive Tony Mason said the society had been forced to increase rates “substantially for the highest risk specialties”. “This was a move we took with great reluctance but has been forced upon us by the extraordinary awards currently being made by the Courts for claims involving catastrophic injury,” Mr Mason wrote. An MPS spokesperson confirmed to the Medical Independent that Irish specialists in these fields “fared far better than their counterparts in the UK” in terms of the cost of indemnifying themselves against medico-legal claims.

“This is because, although claims costs arising from catastrophic injury claims are undoubtedly rising in Ireland, the far-sighted introduction by the Government of limits on the amount that consultants have to indemnify themselves for, means that they are protected from sudden leaps in the value of the largest catastrophic injury claims,” the spokesman said. The MPS would not provide specific information about the extent of the rate increase following a decision by the Society earlier this year not to publish UK subscription rates.

tony Mason

“We instead ask doctors to contact our membership department to obtain a personal quote,” an MPS spokesperson said. According to figures obtained by this publication last year, the highest number of claims submitted through the Clinical Indemnity Scheme was in surgery, with 119 claims up to December 2009. Medicine recorded the second highest number with 110, followed by obstetrics with 102. A total of 62 claims related to emergency medicine and 24 claims related to gynaecology.

vox box “These are very challenging times in our healthcare service. Demand for services continues to grow year on year and is exceeding our capacity to meet this demand. At the same time we are implementing almost €1 billion in budget reductions in 2011.”

Minimal Oestrogen Monthly Just 0.015mg ethinylestradiol daily 1

Cathal Magee, addressing the Public Accounts Committee about emergency services in Ireland.

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

“This is a leviathan structure that did not deliver what it was supposed to deliver and it has got to change direction and change its structure and change the way it does its business, and that is not an easy task Minister Reilly has taken on. But that is what the Government is going to do in the interests of the care of our patients and the quality of services provided.”

Neutral effect on weight – no difference vs. drospirenone 3

96% user satisfaction rate 4

taoiseach Enda Kenny, defending the Government’s plans to reform smaller hospitals around the country.

Since launch, there are 8 million NuvaRing® users worldwide 5

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 Date of preparation: August 2010

www.medicalindependent.ie

MI14.2011July14th.indd 8

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. Very rarely it has been reported that the ring adhered to vaginal tissue, necessitating removal by a healthcare provider.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. Product Authorisation 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. 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: Aug 2010 Nuvaring/IRL/API/08-10/1

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

10-11-NUV-2010-IRL-3742-J

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. Data on file, MSD.

“This crisis will not be solved, or alleviated, by the further curtailment of small and medium 24/7 ED units, thus directing sick people into already overcrowded and overworked larger units.” InMO general Secretary Mr liam Doran, reacting to the news that emergency services in Roscommon County Hospital are to be reduced.

14 July 2011 | medical independent 08/07/2011 19:13

news temple Street predicts €12 million deficit JAMES FOgARty

hildren’sUniversityHospital Temple Street expects to face a deficient of almost €12 million in 2011, the Medical Independent has learned. According to minutes of the Executive Management Committee meeting released to this publication under the Freedom of Information Act, the hospital is preparing to cope with a €4 million reduction in funding, as well as an €8 million increase in pay and non-pay costs.

During the November meeting last year, the Committee heard that the hospital’s financial plan assumed that its budget would be reduced by 5 per cent in 2011. However, in an earlier meeting, Temple St’s Financial Director hoped that the hospital would be able to find an additional €4 million through negotiation with the HSE. According to the minutes, the remaining €8 million will have to come from a 75 per cent decrease in the wage bill, particularly from NCHD overtime, maternity leave cover, and agency

Children’s University hospital temple Street

news at a glance

nursing locums. The hospital’s Cost Containment Plan identified €250,000 that could be saved on NCHD overtime, and a further €200,000 could be saved from non-payment of rest days, while a saving of €1 million has be earmarked in nursing agency costs. Savings from non-pay will make up the remaining 25 per cent, although the Committee warned that it would be “difficult and require a change in culture within the organisation”. Staff have also been encouraged to take holidays

during designated hospital down times. Management also suggested that the canteen close at 2.00pm Monday to Friday, with an early morning opening only at weekends. Members of the Medical Board, however, objected to the idea. The hospital was also instructed to reduce its staff from 984 WTEs to 950 in 2011, a “major challenge” according to the hospital. In December 2010, 15 members of staff had opted to avail of the voluntary redundancy and voluntary early retirement schemes.

For o Long Lasting Bones

Applications invited for palliative care fellowship Applications are now being invited for the a Doctoral Fellowship in Hospice and Palliative Care being run by the Health & Social Care Research & Development Division of the Public Health Agency (HSC R&D Division), in conjunction with the All Ireland Institute of Hospice and Palliative Care (AIIHPC). The three-year Doctoral Fellowship in Hospice and Palliative Care is intended to enable the individual to undertake research training as a means of developing a research career in palliative care, and to follow a training programme leading to a PhD. The Doctoral Fellowship represents a significant investment for the AIIHPC, HSC R&D Division and for the individual Fellow. It is essential that applicants intend to pursue a long-term career in the area of palliative or endof-life care and must be prepared to demonstrate their commitment to research in that field. Application forms are available from the HSC R&D Division in either a paper or electronic format. Electronic format application forms can be supplied as an e-mail attachment. Alternatively, information can be obtained from the HSC R&D Division website at www. publichealthagency.org/directorate-public-health/ hsc-research-and-development. For more on the All Ireland Institute of Hospice and Palliative Care see www.aiihpc.org.

Irish College of Psychiatry supports new hSE report Despite the fact that 50 per cent of people with severe to profound intellectual disabilities and 20-25 per cent of those with mild to moderate difficulties, will have a mental health problem at some stage in their lives, many are unable to access treatment, the College of Psychiatry of Ireland has said. Welcoming a new report commissioned by the HSE entitled Time to move on from congregated settings – A strategy for community inclusion, the College said it supports the report’s recommendations that adults with intellectual disabilities should be living in the community and emphasised that inspections for health and quality care in these community settings needed to be implemented. Dr Anita Ambikapathy, Vice-Chair of the College’s Faculty of Learning Disability Psychiatry said: “If people with intellectual disability develop mental health problems or difficulties these individuals must and should be afforded the same rights to a person-centered mental health service as every other citizen.”

Calcium (as carbonate) / Cholecalciferol

ALLOW TABLET W S e k ta 2 to t n der a le t e s Convenie rk a m e m than th % more calciu

s 20

ABBREVIATED PRESCRIBING INFORMATION (Please refer to Summary of Product Characteristics before prescribing)

calcium & vitamin D3

CALTRATE* 600 mg/400 IU, film-coated tablet

Presentation: Each tablet contains 600 mg of calcium (as calcium carbonate) & 10 micrograms of cholecalciferol (equal to 400 IU vitamin D3). Contains sucrose & partially hydrogenated soya bean oil. Indications: Correction of combined vitamin D & calcium deficiencies in the elderly. As an adjunct to specific treatments for osteoporosis, in patients where combined vitamin D & calcium deficiencies have been diagnosed or those at high risk of deficiency. Dosage & Administration: Adults & Elderly: One tablet twice a day (morning/evening). Pregnant women One tablet a day. Oral (Swallow with 200mls water). The elderly or patients with known difficulties in swallowing, may break the tablet into two parts before taking with water. Do not suck or chew. Contraindications: Hypersensitivity to any ingredients including peanut or soya. Patients who now have, or have had renal failure, kidney stones, hypervitaminosis D, hypercalciuria & hypercalcaemia & diseases &/or conditions that lead to hypercalcaemia &/or hypercalciuria. Precautions: In prolonged treatment, check calcaemia & renal function, particularly in the elderly (see interactions). If renal function deteriorates, the dose must be reduced or treatment interrupted. Caution is advised in immobile patients. This product contains vitamin D; further administration of vitamin D or calcium must be medically supervised with regular monitoring of calcaemia & calciuria. Patients with sarcoidosis calcaemia & calciuria must be monitored. Risk of soft tissue calcification must be considered. In severe renal insufficiency, vitamin D3 as cholecalciferol is not metabolised normally & other forms of vitamin D3 must be used. Cases of asphyxiation due to tablet choking have been reported. This product contains sucrose; patients with sugar intolerance should not take this medicine. Not intended for use in children & adolescents. Interactions: Thiazide diuretics & systemic corticosteroids (calcium monitoring required). Orlistat, combined ion-exchange resins (cholestyramine) or laxatives (paraffin oil) can reduce the GI absorption of vitamin D3. Take tetracycline 2 hours before or 4 to 6 hours after taking calcium. Cardiac glycosides (monitor patients regularly with ECG check & calcaemia). Phenytoin or barbiturates (may reduce the activity of vitamin D3). Iron, zinc or strontium preparations, estramustin or thyroid hormones should be spaced at least 2 hours from calcium medicines. Bisphosphonate, sodium fluoride or fluoroquinolone administration, Caltrate should be spaced by at least 3 hours from these medicines. Oxalic acid (found in spinach & rhubarb) & phytic acid (found in wholegrain cereals) can inhibit calcium absorption by forming insoluble compounds with calcium ions. Patients must not take calcium containing-products in the two hours after consumption of foods rich in oxalic acid & phytic acid. Pregnancy & lactation: Caltrate may be used during pregnancy & breastfeeding. Daily intake in pregnancy should not exceed 1500mg calcium & 600IU cholecalciferol. Avoid prolonged use as hypercalcaemia can affect the developing foetus. Calcium & vitamin D3 pass into breast milk, this should be considered when vitamin D3 is given concomitantly to infants. Side-effects: Hypercalcaemia, hypercalciuria, constipation, flatulence, nausea, abdominal pain, diarrhoea, pruritis, rash & urticaria. Legal Category: P. Pack Size: 90 tablets. PAH: Pfizer Consumer Healthcare Ltd., Sandwich, Kent, CT13 9NJ, United Kingdom. PA number: PA172/38/1. Further information is available upon request from Pfizer Consumer Healthcare Ltd., Citywest, Dublin 24. or look up, www.medicines.ie Date of preparation: June 2010. Reference: 1 Based on sales (data on file). 2 MIMS Ireland Jan 2011, Pg 299. Artwork version Mar 11 Ref: 11 101 Med. * Trade Mark.

medical independent | 14 July 2011 MI14.2011July14th.indd 9

www.medicalindependent.ie

9 08/07/2011 19:13

news

feature June Shannon

Fulfilling a duty of rehabilitative care

It is said that a society can be judged by how it treats its most vulnerable members. The Medical Independent reports that when it comes to providing appropriate rehabilitation services, Ireland is neglecting its duty of care

lmost 20 per cent of the Irish population have some form of disability and it is estimated that thousands are suffering in silence with a neuro-disability. Despite this, Ireland has the lowest number of consultants in rehabilitation medicine in Europe and just one specialist rehabilitation centre, which is 50 years old. The National Rehabilitation Hospital (NRH) in Dunlaoghaire has 150 patients on its waiting list, some of whom have been waiting for up to a year. Because of a lack of specialists and in-patient beds, those with the most complex needs are often forced to wait the longest. Perhaps even more telling is that despite the granting of planning permission three years ago for a new 235-bed purpose-designed rehabilitation hospital on the NRH site, the Department of Health and the HSE have yet to sanction the build. Ireland currently has the lowest number of physical and rehabilitation specialists in Europe. While the European average is approximately 3.3 consultants per 100,000 population, Ireland has languished at the bottom of the table for quite some time with just 0.17 per 100,000 citizens. Croatia has the highest number of specialists in the field in Europe, followed by Latvia and the Czech Republic. Our nearest neighbours the UK, against which Ireland’s heath service is regularly pitted, has the second worst ratio of rehab consultants to population in Europe. Dr Áine Carroll was recently appointed National Clinical Lead for the HSE’s rehabilitation medicine programme and is also a former Chair of the Medical Board at the NRH in Dunlaoghaire. A consultant in rehabilitation medicine at the NRH and St Vincent’s University Hospital in Dublin, Dr Carroll is one of just six consultants working in rehabilitation medicine in Ireland today, one of whom is in a temporary position. According to Dr Carroll,

Dr Áine Carroll when discussing the need for more consultants and beds in rehabilitation medicine, Ireland regularly quotes from the British Society of Rehabilitation Medicine guidelines. However given that our consultant staffing levels are second only to the UK, this means that Ireland is aspiring to be the second worst in Europe.

targets

“Even when we make recommendations about staffing levels and numbers of in-patient beds we are told that we are reaching for the stars and we are not; we are actually reaching for the bottom,” Dr Carroll remarked. She advised that we should be reaching for the stars. However that would mean increasing the number of consultants from 0.17 to approximately seven per 100,000 and Dr Carroll feels that the costof such a rapid expansion would be prohibitive. In fact, with just six consultants – five of whom are based in Dublin – Ireland does not even have the recommended minimum 27 posts which would be required to provide an effective rehabilitation service. The chronic lack of services throughout the coun-

www.medicalindependent.ie

MI14.2011July14th.indd 10

try means that all six of the consultants in rehabilitation medicine here are forced to split their time between acute hospital attachments, community-based sessions and their own specialist areas. “Each of us has an acute hospital attachment and some of us have community-based sessions. Two of my colleagues do sessions with Enable Ireland, for example, but all of us are split three ways. Another consultant is involved with disabled drivers; each of us has got an area of special interest. I would be one of four brain injury consultants. I have one spinal injuries colleagues and one prosthetic, orthotic and limb absence colleague,” Dr Carroll explained. As five of the six consultants are based in Dublin, Dr Carroll and her colleagues also try to provide as many outreach clinics as possible around the country. However limited manpower makes this extremely difficult. “There is only so much that one can do. I think we have to be very realistic about that. Six specialist consultants for an entire country is not just inadequate, it is ridiculous,” she said. Dr Carroll said there is a need to develop acute neu-

rological rehabilitation services on site at the two neuroscience centres in Beaumont Hospital in Dublin and at Cork University Hospital. She predicted that Beaumont would see two-thirds of all neurosurgical cases and a third of cases would be seen at the Cork unit. “In the States they talk about Trauma 1. You can’t be a Trauma 1 centre without on-site acute rehabilitation so in this country we don’t have any Trauma 1 centres. For that matter we don’t have any major trauma networks in this country. What happens if you have a head injury and a spinal cord injury? Who is going to make the call? Do you go to Beaumont or the Mater? You could end up going to a district general hospital with no inhouse expertise.” This is not rocket science. We know that the outcomes are much better when you have centres with appropriate expertise, she added. Dr Carroll’s view is sup-

ported by the findings of a recent UK study published in the Journal of Neurosurgical Anesthesiology. The study on the effect of specialist neurosciences care on outcome in adult severe head injury has

‘Six specialist consultants for an entire country is not just inadequate, it is ridiculous’ shown that following severe head injury, mortality rates are higher when the patient is not treated in a specialist neuroscience unit. According to the researchers, the “data support current national [UK] guidelines and suggest that increasing transfer rates to NSUs [Neuroscience Units] represents an important strategy in improving outcomes in patients with severe head injury”.

In Ireland today if someone suffers an Acquired Brain Injury (ABI) in Donegal or Sligo, they are transferred to Dublin for treatment. Dr Carroll said the time taken to transfer the patient results in “a significant delay” before they can be assessed by a rehabilitation medicine consultant. Dr Carroll said there is also a requirement to develop regional centres and a huband-spoke model for rehabilitation services in Ireland, which is something that both she and her colleagues at the NRH have been advocating for some time. Like so many medical emergencies, time is of the essence following an ABI and any delay can have a detrimental effect on the long-term outcome for the patient. According to Dr Carroll, one of the most important roles consultants in rehabilitation medicine have in an acute setting is in assessing the patient as soon as possible post injury. This is particularly vital to avoid further

number of physical and rehabilitation medicine specialists per 100,000 population 2010

14 July 2011 | medical independent 08/07/2011 19:13

MI14.2011July14th.indd 11

08/07/2011 19:13

news complications. Consultants like Dr Carroll can advise on issues such as fracture, spasticity and pressure sore avoidance as well as the management of neuro-behavioural complications. “Patients, mainly with traumatic brain injuries, are agitated and in a state of, what we call, post-traumatic amnesia. We can give advice about how to manage these cases.” There can also be continence and quality-of-life issues. The patient may also be subject to the inappropriate prescribing of sedating medication. Apart from the very obvious human costs for individual patients and their families, a delay in accessing specialist treatment can also have financial consequences, which manifest in an increased length of stay. It is estimated that up to 18 per cent of people in Ireland have a disability of some kind, with the main ones being cardiovascular or musculoskeletal. While neurological disabilities are less prevalent, they tend to be more severe and affect a larger proportion of young people. However a dearth of any real Irish data means that the prevalence of neurological disabilities in Ireland is almost impossible to quantify. “Acquired brain injury really is a silent epidemic in this country. Most of those individuals with ABI will never have access to rehabilitation medicine expertise because they simply never get referred. A lot of ABIs would go to casualty and never be admitted in the first place,” Dr Carroll stated.

Epidemic

The lack of any real Irish data also makes it impossible to quantify how many people with ABI have not received adequate care. However Dr Carroll said it was likely to be in the 1,000’s. “If you think that there are approximately 11,000 strokes in the country every year, you can multiply that by two to include all causes of ABI. It is probably going to be higher

feature than that but we don’t know because our data collection is so poor.” Dr Carroll explained that while the most complex cases are appropriately referred to specialists like herself and her colleagues, the lack of manpower means that they simply cannot access the 1,000s who may be suffering in silence. “If there was a critical mass of us to screen, ideally we would like to be hearing about the people who haven’t been admitted from ED, to have a follow-up clinic just to make sure that none of these people are having any difficulties.”

‘Most individuals with ABI will never have access to rehabilitation medicine expertise because they simply never get referred’ Dr Carroll said that the hidden disabilities following mild traumatic brain injuries can lead to ongoing difficulties for many years. These can include cognitive deficits, problems with attention, concentration, memory and personality changes. A sufferer can also have difficulty in planning, organising and sustaining relationships. Issues such as fatigue and depression are also common. Mr Kieran Loughran has been CEO of Headway for the last five years. The charity provides support and services to people affected by ABI. According to Mr Loughran, in that time, services for those affected and their families have “stood still” and the lack of any real da ta on the exact number of pe ople affected in Ireland serves to further hampers developments.

Artist’s impression of the new nRh

www.medicalindependent.ie

MI14.2011July14th.indd 12

He said it has been recognised that services for brain injured people in this country are “inadequate” and he pointed to a dearth of community-based services as another example of how the needs of these most vulnerable people are being ignored. Mr Loughran explained that, in general, there is a four- to five-year gap between the onset of injury and the time those affected approach organisations like Headway seeking support. He explained that the reason for this time lapse is multifactorial and includes the fact that, for seriously ill patients and their families, surviving and recovering from the initial brain injury obviously take priority. “Very often they have to recover from the first trauma of the accident. At one stage we had a hospital-based service and when we heard of head trauma cases, we would go to the family and they wouldn’t want to know, understandably… they didn’t want to talk about brain injury and ongoing life with brain injury, [they] just wanted to make sure that the person survived,” Mr Loughran said. Headway provides a range of community-based services for all those affected by ABI, from counselling for the client and their loved ones, to rehabilitation and therapeutic supports to help the sufferer return to work. The charity also provides day rehabilitation services for those more profoundly affected by brain injury. We provide counselling and support for both the family and the person. The consequences of that person not knowing or recognising their family has a profound impact on the family, children, wife or husband of the person affected, Mr Loughran explained. According to Mr Loughran, for some ABI sufferers, it is a matter of “learning the whole process of living all over again”. Mr Loughran said “the lucky ones” are admitted to

the NRH in Dunlaoghaire, while the “unlucky ones” are those treated in an acute hospital and discharged back into the community once their visible wounds have healed. Like Dr Carroll, Mr Loughran said that ABI has been dubbed the “silent epidemic” as, for some, the consequences of an injury may not manifest for weeks or months. According to the Headway CEO, those sufferers who are discharged from an acute setting once the immediate acute stage of their illness has passed, are in real danger of being simply “forgotten” or “lost to the system”. “If you are in hospital, you are in the system. When you leave hospital you are out of the system. The injury can manifest itself in many ways – by violence, drug addiction, inappropriate behaviour, the whole brain has been scrambled.” “I could bang my head doing some DIY at home and just continue on as if nothing has happened. Then a month later something might happen and I start behaving strangely or odd. People brought into A&E are not always scanned for brain injury, it may manifest itself later,” he added. Again the lack of epidemiological studies in this area makes it impossible to know just how many ABI sufferers are lost to the system in this way, and Mr Loughran said that this information gap desperately needs to be addressed. Like most voluntary agencies fighting for survival in the current economic climate, Headway’s budget has reduced by approximately 10 per cent over the last three years. Funding for disability services was somewhat spared in Budget 2011, being cut by just 1.8 per cent, a relatively lower reduction compared to other areas in the health budget. However the overall budget was cut from €1,582 million in 2010 to €1,554 million

Kieran loughran, headway in 2011 and the amount spent by the HSE in the voluntary sector was cut from €411 million in 2010 to €391 million in 2011. The exact figure spent on rehabilitation services for individuals with ABI is not specified in the HSE’s 2011 Service Plan. However Mr Loughran said that even if the figure has quadrupled, it would still not be enough to provide the level of services that people need. He said that in the current economic environment where funds are limited, it was important to encourage those within the sector to find a smarter way of working i.e. make the most of what little resources they do have. “Or as the Government are saying, do more with less,” he stated. Mr Loughran added that as brain injury affects “every part” of a person’s life, inter-departmental working at Government level is also important

nRh

The NRH in Dunlaoghaire, which this year celebrates its 50th anniversary, is the only specialist rehabilitation hospital in the country. The Sisters of Mercy originally purchased the current building in 1916 and opened it on February 11th 1918 as a TB sanatorium. In the 1950’s, with the demand for TB services on the wane, the Order, together with a number of visionary doctors including Dr Thomas Gregg, established a hospital for the provision of rehabilitation services. The hospital was, and still is, a unique self-contained rehabilitation unit, the only hospital of its kind in Ireland. Before the advent of the NRH, Irish patients suffering from spinal cord injury were sent to Stoke Mandeville in the UK for treatment. The first paraplegic patient, a victim of a road accident, was

admitted to the NRH in 1961. In 2008 the NRH received full planning permission for a new 235-bed purpose-designed rehabilitation hospital but three years later, funding has still not been made available. “The hospital continues to advocate for the new hospital which is in line with its recommendation for the development of a hub-and-spoke model for rehabilitation services in Ireland, as outlined in the hospital’s submission to the Working Group for a National Strategy for Rehabilitation,” the NRH stated. The pre-tender estimate in 2008 for the new project was €124 million, which in today’s economic climate could arguably be less, and the completion time was three to four years. The NRH has said that planning approval has been granted for the new hospital to be built on a greenfield site within the existing hospital campus. This allows the NRH to remain fully operational and continue service provision to patients with minimal disruption while the new hospital is being constructed. So why, three years after full planning permission has been granted and the need for more in-patient rehabilitation beds is so painfully clear, has the HSE or the Department of Health not sanctioned the build? The Medical Independent put this question to HSE Dublin Mid-Leinster and was told that “such developments were put on hold pending the completion of a review entitled the National Policy and Strategy for the Provision of Neuro Rehabilitation Services in Ireland 2011-2015. The report was commissioned jointly by the Department of Health and the HSE.” The Medical Independent then asked the HSE Dublin Mid Leinster for more detail

14 July 2011 | medical independent 08/07/2011 19:13

Nebido

Convenient Gel

Long-acting injection

Two solutions. One Result.

Significantly reduced symptoms of testosterone deficiency syndrome1,2,3 NebidoÂŽ 1000 mg/4ml, solution for injection. See full Summary of Product Characteristics (SmPC) before prescribing. Presentation: testosterone undecanoate 250 mg per ml (corresponding to 157.9 mg testosterone). Each 4 ml ampoule contains 1000 mg testosterone undecanoate. Indication: Testosterone replacement therapy for male hypogonadism when testosterone deficiency has been confirmed by clinical features and biochemical tests. Dosage and administration: For intramuscular use only. Inject very slowly, deep into the gluteal muscle, immediately after opening ampoule. Take special care to avoid intravasal injection. Adult and elderly men: One ampoule every 10 to 14 weeks to maintain sufficient testosterone levels without leading to accumulation. The first injection interval may be reduced to a minimum of 6 weeks, depending on serum testosterone levels and symptoms. Serum testosterone levels should be measured before and regularly during treatment, especially during initiation (see SmPC). Paediatric population: Not indicated. Not evaluated clinically in males under 18 years. Contraindications: Androgen-dependent carcinoma of the prostate or male mammary gland; past or present liver tumours; hypersensitivity to the active substance or any of the excipients; use in women. Warnings and Precautions: Should be used only if hypogonadism has been demonstrated and other aetiology excluded. Testosterone insufficiency should be clearly demonstrated by clinical features and confirmed by two separate blood testosterone measurements. Limited experience in patients over 65 years. Physiological testosterone levels are lower with increasing age. Exclude risk of pre-existing prostatic cancer before treatment. Regular monitoring of the prostate and breast recommended, at least once yearly (twice yearly in elderly and in at risk patients). Testosterone concentrations, haemoglobin, haematocrit and liver function should be checked periodically. All testosterone measurements should be carried out in the same laboratory. Androgens may accelerate progression of sub-clinical prostatic cancer and benign prostatic hyperplasia. Use with caution and with regular monitoring of serum calcium in cancer patients at risk of hypercalcaemia due to bone metastases. Benign and malignant liver tumours have been reported in users of hormonal substances such as androgen compounds. Testosterone treatment may cause severe complications (oedema with or without congestive cardiac failure) in patients suffering from severe cardiac, hepatic or renal insufficiency or ischaemic heart disease. Stop treatment immediately in such cases. No efficacy/safety studies in patients with renal/hepatic impairment: use with caution. As treatment with androgens may result in increased sodium retention, use with caution in patients predisposed to oedema. Observe limitations of using intramuscular injection in patients with acquired or inherited blood clotting irregularities. Epilepsy and migraine may be aggravated: use with caution. Insulin sensitivity may change. Irritability, nervousness, weight gain, prolonged or frequent erections may indicate excessive exposure requiring dosage adjustment. Pre-existing sleep apnoea may be potentiated. Nebido might result in a positive finding in anti-doping tests. Not suitable for enhancing muscular development in healthy individuals or increasing physical ability. Discontinue permanently if symptoms of excessive exposure persist or reappear during treatment. Must be injected intramuscularly. Inject extremely slowly to avoid pulmonary microembolism, which can rarely lead to reactions during/ immediately after injection, with symptoms such as cough, dypnea, malaise, hyperhidrosis, chest pain, dizziness, paresthesia or syncope. Interactions: Changes in activity of oral anticoagulants: increased monitoring, including prothrombin time and INR, recommended, especially at beginning and end of treatment. Concurrent use with ACTH or corticosteroids may enhance oedema formation: use with caution, especially in patients with cardiac/hepatic disease or who are predisposed to oedema. May interfere with laboratory tests for thyroid activity. Fertility, pregnancy and lactation: May reversibly reduce spermatogenesis. Nebido is not indicated for use in women and must not be used in pregnant or breastfeeding women. Undesirable Effects: Most frequently reported reactions are acne and injection site pain (10%). Common adverse reactions (ADRs): Polycythaemia, weight increased, hot flush, prostate specific antigen increased, prostate examination abnormal, benign prostate hyperplasia, various kinds of injection site reactions. Uncommon ADRs: Haematocrit increased, red blood cell count increased, haemoglobin increased, hypersensitivity, increased appetite, glycosylated haemoglobin increased, hypercholesterolaemia, blood triglycerides increased, blood cholesterol increased, depression, emotional disorder, insomnia, restlessness, aggression, irritability, headache, migraine, tremor, cardiovascular disorder, hypertension, dizziness, bronchitis, sinusitis, cough, dyspnoea, snoring, dysphonia, diarrhoea, nausea, liver function test abnormal, aspartate aminotransferase increased, alopecia, erythema, rash, pruritus, dry skin, arthralgia, pain in extremity, muscle disorders, musculoskeletal stiffness, blood creatinine phosphokinase increased, urine flow decreased, urinary retention, urinary tract disorder, nocturia, dysuria, prostatic intraepithelial neoplasia, prostate induration, prostatitis, prostatic disorder, libido changes, testicular pain, breast induration, breast pain, gynaecomastia, oestradiol increased, testosterone increased, fatigue, asthenia, hyperhidrosis. Further information available on request from MA Holder: Bayer Limited, The Atrium, Blackthorn Rd, Dublin 18. Tel. 01-2999313. PA No: 1410/20/1. Classification for sale or supply: Prescription only. Date of preparation: 22.02.11 Testogel 50mg, gel in sachet (Testosterone). Refer to full SmPC before prescribing. Presentation: Each sachet contains 50mg testosterone in 5g gel. Indication: Testosterone replacement therapy for male hypogonadism when testosterone deficiency has been confirmed by clinical features and biochemical tests. Dosage and administration: 5g of gel (50mg testosterone) applied once daily, preferably in the morning. Dose can be adjusted in steps of 2.5g gel, depending on clinical or laboratory response, to a maximum of 10g gel daily. Apply to clean, dry, healthy skin over both shoulders, both arms or abdomen. Do not apply to genital areas. Not indicated for use in children. Contraindications: Known or suspected prostatic cancer or breast carcinoma; known hypersensitivity to testosterone or to any other constituent of the gel. Precautions and Warnings: Testosterone insufficiency should be clearly demonstrated by clinical features and confirmed by two separate blood testosterone measurements (both measurements should be carried out in the same laboratory). Other aetiology responsible for the symptoms should be excluded. Before therapy, exclude prostate cancer. Androgens may accelerate progression of subclinical prostatic cancer and benign prostatic hyperplasia. Examine prostate and breast at least annually, or twice yearly in elderly or at risk patients. Testogel is not a treatment for male sterility or impotence. Use with caution in cancer patients at risk of hypercalcaemia due to bone metastases; regular monitoring of serum calcium recommended. In patients suffering from severe cardiac, hepatic or renal insufficiency, Testogel may cause severe complications characterised by oedema with or without cardiac failure. In this case, stop treatment immediately. Use with caution in patients with ischaemic heart disease, hypertension, epilepsy and migraine. Patients on long-term therapy: test testosterone concentrations, haemoglobin, haematocrit, liver function and lipids profile periodically. Possible increased risk of sleep apnoea especially if risk factors such as obesity or chronic respiratory disease present. Improved insulin sensitivity may occur in patients who achieve normal testosterone plasma concentrations following therapy. Irritability, nervousness, weight gain, prolonged or frequent erections may indicate excessive androgen exposure requiring dosage adjustment. If severe application site reactions occur, review therapy and discontinue if necessary. Testosterone may produce a positive reaction in anti-doping tests. Should not be used by women. If no precaution is taken, testosterone gel can be transferred to other persons by close skin to skin contact. Transfer to others should be avoided, especially pregnant women. See SmPC for precautions. Interactions: Changes in oral anticoagulant activity: increased monitoring of prothrombin time and INR is recommended, especially when androgens are started or stopped. Concomitant administration with ACTH or corticosteroids may increase the risk of developing oedema. Interaction with laboratory tests: androgens may decrease levels of thyroxin binding globulin resulting in decreased T4 serum levels and increased resin uptake of T3 and T4. Free thyroid hormone levels remain unchanged and there is no clinical evidence of thyroid insufficiency. Pregnancy and lactation: Testogel is intended for use by men only. Not indicated in pregnant or breast-feeding women. Pregnant women must avoid any contact with Testogel application sites (see SmPC). In the event of contact, wash with soap and water as soon as possible. Undesirable effects: Most common adverse effects are skin reactions (10%): reaction at the application site, erythema, acne, dry skin. Changes in laboratory tests (polycythaemia, lipids), headache, prostatic disorders, gynaecomastia, mastodynia, dizziness, paraesthesia, amnesia, hyperaesthesia, mood disorders, hypertension, diarrhoea, alopecia, urticaria. Other known adverse drug reactions of oral or injectable treatments containing testosterone are: weight gain, electrolyte changes during high dose and/or prolonged treatment, muscle cramps, nervousness, depression, hostility, sleep apnoea, in very rare cases jaundice and liver function test abnormalities, various skin reactions including acne, seborrhoea, and balding, libido changes, increased frequency of erections; therapy with high doses of testosterone preparations commonly reversibly interrupts or reduces spermatogenesis, thereby reducing the size of the testicles; testosterone replacement therapy of hypogonadism can in rare cases cause persistent, painful erections (priapism), prostate abnormalities, urinary obstruction, high dose or long-term administration of testosterone occasionally increases the occurrences of water retention and oedema; hypersensitivity reactions may occur. Hepatic neoplasms are a rare known side effect associated with excessive doses of testosterone. Data on prostate cancer risk in association with testosterone therapy is inconclusive. PA Number: PA 1054/2/2 PA Holder: Laboratoires Besins International, 3 rue du Bourg Lâ&#x20AC;&#x2122;AbbĂŠ, 75003 Paris, France. Prescription-only. Further information from: Bayer Ltd, The Atrium, Blackthorn Road, Dublin 18. Tel: 01 2999313. Date of revision: April 2011

L.WH.05.2011.0103

References: 1. Saad F, Gooren L, Haider A et al., Arch Androl 2007; 53 (6) 353 - 357. 2. Han TS, Bouloux PMG, Drug Evaluation, Aging Health; 4 (5) 517-528. 3. de Ronde W, Expert Opin. Biol. Ther.; 9 (2) 2009 249- 253.

Nebido Andrology IMT Ad.indd 1 MI14.2011July14th.indd 13

10/05/2011 14:35:49 08/07/2011 19:13

Targin N

news on this review and if the Executive could explain why the redevelopment of the NRH is dependent on its publication. However, at the time of going to print, this publication had not received a response to this query. Dr Carroll said that, with the go ahead from the HSE, work could begin on the new

There are currently just three beds allocated to the disorder of consciousness programme at the NRH

feature hospital in less than a month. Consultant-led rehabilitation programmes at the NRH are tailored to meet the individual needs of adult and paediatric patients in the following areas: Brain injury (including traumatic and non-traumatic brain injury, stroke, and other neurological conditions); spinal cord system of care (including traumatic and nontraumatic spinal cord injury); Prosthetic, Orthotic and Limb Absence Rehabilitation (POLAR) and paediatric-family centred rehabilitation. There are currently 110 beds available for in-patient admissions: 47 beds for patients with ABI, including stroke and 38 dedicated to

those with spinal injury. Seventeen beds are reserved for amputee and limb absence patients and the hospital also has eight paediatric beds.

Waiting times

The waiting times for the hospital’s four care programmes vary and while the overall wait time is not excessive, the low volume and high care needs of the most dependent patients mean that they are the ones who face the longest wait. Dr Carroll explained that the waiting time for admission to the NRH’s neuro-behavioural unit for patients with complex needs can be longer than other programmes and is currently approximately 18 weeks.

Even more striking however, waiting times for admission to the hospital’s disorder of consciousness service for individuals who have suffered very severe brain injuries, is up to a year Dr Carroll explained that those waiting to access the disorder of consciousness service at the NRH are very severely compromised and it is very unlikely that they would ever recover to a point where they would regain independence in their activities. However she said there is a lot that the hospital can do in terms of providing appropriate 24-hour positioning programmes and advice on management to avoid contractures and pressure sores.

For Dry Cracked Feet associated with

Diabetic Anhydrosis

Average Skin Hydration Levels

Heel Balm

Skin Hydration Level

Flexitol Heel Balm Proven Efficacy

25 20

In a controlled 14 day trial, 27 subjects suffering dry, cracked heels applied Flexitol Heel Balm twice daily. Results indicate that regular use of Flexitol Heel Balm increases the mean hydration levels in the heel skin and thus helps keep feet healthy and well moisturised.1

15 10 5

Efficacy of Flexitol Heel Balm on Skin Hydration Levels 16

12 8 4 Before Treatment After Treatment

10% Urea

25% Urea

In a double blind comparative study, 26 outpatients with evidence of bilateral anhydrosis applied a 10% Urea cream to the left foot and a 25% Urea cream (Flexitol Heel Balm) to the right foot, twice daily. Results indicate that the 25% Urea cream increased skin hydration levels significantly more than the 10% Urea cream.2

Day 0 Pre-treatment

Day 14 Post-treatment

Study conducted by the Australian Photobiology Testing Facility (APTF) at the University of Sydney, Australia in 2007

Baird S.A., Skinner C.M., Trail S., Frankis J.S., 2002, ‘A study to compare the efficacy of the use of 10% Urea cream and 25% Urea cream on the control of Anhydrosis in the diabetic foot’, Glasgow Caledonian University, Glasgow.

To receive trial products, samples and further information, please email Irelandinfo@flexitol.com Laderma Health (UK) Ltd., Second Floor, Cardiff House, Tilling Road, London NW2 1LJ. www.flexitol.com

LHINT Flexitol Ireland Heel Balm Medical Independant Now Ad 254x166mm IRPN-1.indd 1

www.medicalindependent.ie

MI14.2011July14th.indd 14

15/03/11 1:10 PM

Medication can also be revised to ensure that clients are not overly sedated and the NRH can also give advice on appropriate stimulation programmes.

‘These are the most vulnerable people in our society and our society really owes a duty of care to these individuals’ “The other thing is that we can assess these people objectively to say how much of them is still inside, which is very reassuring for family members because for the family members, the biggest fear is that these individuals have locked-in syndrome that they are inside but because of their physical disability they can’t communicate. That is their biggest fear. So a lot of what we do in these circumstances is in reassuring them that they are not locked in and that they have got a very severe disorder of consciousness. The amount of peace that that brings to family members is enormous

and it is very frustrating that we can not bring them that sort of peace earlier,” Dr Carroll stated. The reason why this invaluable peace of mind cannot be provided sooner is that there are currently just three beds allocated to the disorder of consciousness programme at the NRH. “It is very labour intensive because we have such a shortage of beds. We can’t justify anymore beds because you can make the argument that it is a much better investment of resources to invest that time and effort into individuals who are going to increase their functionality, reduce care costs, hopefully get them home, get them back to work. These are individuals who will never get to that point, so we have to limit the number of beds for that service to three.” “We need to raise the profile of rehabilitation medicine. We have gone through the Celtic Tiger years with no investment and no strategies being funded…and here we are, the Celtic Tiger is gone and we are still waiting. These are the most vulnerable people in our society and our society really owes a duty of care to these individuals. They have long been ignored and it really is time for a revolution in rehabilitation. This has got to change,” she concluded.

national Rehabilitation hospital (nRh) fact file ● Over the last 50 years the NRH has cared for more than 35,000 in-patients from throughout Ireland and has reviewed in excess of 250,000 persons in its outpatient services. ● Currently there are 110 in-patient beds available at the NRH: – – 47 beds for patients with ABI, including stroke – 38 beds dedicated to those with spinal injury – 17 beds for amputee/ limb absence – 8 paediatric beds ● There are 150 patients (all age categories) on the waiting list for in-patient rehabilitation within the following diagnostic categories: – Brain injury programme (including stroke) – Spinal cord system of care – Prosthetic, Orthotic and Limb Absence Rehabilitation (POLAR) – Other neurological conditions ● The average regional HSE % distribution of in-patient admissions is: – 33 per cent HSE Dublin Mid Leinster – 24 per cent HSE West – 24 per cent HSE South – 19 per cent HSE Dublin North East ● The average length of in-patient stay per programme is: – Brain injury programme: 57 days – Stroke: 91 days – Spinal cord system of care: 111 days – POLAR: 49 days ● The average discharge destination for patients who have completed their rehabilitation programme is: – Discharged home: 80 per cent – Back to acute hospital for non-medical reasons: 10 per cent – To residential /nursing care: 10 per cent ● 90 per cent of in-patient admissions come from the acute hospital sector and 10 per cent come from primary care services.

14 July 2011 | medical independent 08/07/2011 19:13

P t n t 5 h c ( c c S w a b l o p i r 5 o d p P h o 8 h t b s o f s w p y H a r h d o h R p h p a a i m i e

® ® ©

Targin NEW IMT May 2011(2F):Targin IMT Test 06/05/2011 12:00 Page 1

t o op h c a io o r id p p

Prescribing Information Republic of Ireland Presentation: Film-coated, oblong, prolonged release tablets containing oxycodone hydrochloride and naloxone hydrochloride, marked OXN on one side and the oxycodone strength on the other. Colours: Blue 5mg (oxycodone hydrochloride)/2.5mg (naloxone hydrochloride), white - 10mg (oxycodone hydrochloride)/5mg (naloxone hydrochloride), pink - 20mg (oxycodone hydrochloride)/10mg (naloxone hydrochloride) and yellow - 40mg (oxycodone hydrochloride)/20mg (naloxone hydrochloride). Indications: Severe pain, which can be adequately managed only with opioid analgesics. The opioid antagonist naloxone is added to counteract opioid-induced constipation by blocking the action of oxycodone at opioid receptors locally in the gut. Dosage and administration: Adults over 18 years: Usual starting dose for opioid naïve patients is Targin® 10mg/5mg, taken orally at 12-hourly intervals. Patients requiring a higher dose are recommended Targin 20mg/10mg tablets. Targin 5mg/2.5mg is intended for dose titration when initiating opioid therapy and individual dose adjustment. The dosage is dependent on the severity of the pain and the patient’s previous history of analgesic requirements. Patients already receiving opioids may be started on higher doses of Targin depending on their previous opioid experience. The maximum daily dose of Targin is 80mg oxycodone hydrochloride and 40mg naloxone hydrochloride. Targin tablets are not intended for the treatment of breakthrough pain. For the treatment of breakthrough pain, a single dose of “rescue medication” should amount to one sixth of the equivalent daily dose of oxycodone hydrochloride. Please refer to the SmPC for further details on dose titration. Targin tablets must be swallowed whole and not broken, chewed or crushed which leads to a rapid release and absorption of a potentially fatal dose of oxycodone. Children under 18 years: Not recommended. Contra-indications: Hypersensitivity to the active substances or excipients, any situation where opioids are contra-indicated, severe respiratory depression with hypoxia and/or hypercapnoea; severe chronic obstructive pulmonary disease, cor pulmonale, severe bronchial asthma, nonopioid induced paralytic ileus, moderate to severe hepatic impairment. Precautions and warnings: Respiratory depression, elderly or infirm, opioid-induced paralytic ileus, severely impaired pulmonary function, hypothyroidism, adrenocortical insufficiency, toxic psychosis, cholelithiasis, prostate hypertrophy, alcoholism, delirium tremens, history of alcohol and drug abuse, pancreatitis, hypotension, hypertension, galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption, pre-existing cardiovascular diseases, head injury (due to risk of raised intracranial pressure), epileptic disorder or predisposition to convulsions,

sia

TARGIN® 5mg/2.5mg, 10mg/5mg, 20mg/10mg and 40mg/20mg prolonged release tablets

lge

Targin® tablets contain an opioid analgesic

a uni qu e

ThePowerofTwo

PowerfulonPain reducedriskof opioid-induced constipation

patients taking MAO inhibitors, renal impairment, mild hepatic impairment, pre-operative use or within the first 12 – 24 hours post–operatively. Not suitable for the treatment of withdrawal symptoms. Not recommended in cancer associated with peritoneal carcinomatosis or sub-occlusive syndrome in advanced stages of digestive and pelvic cancers. Interactions: Substances having a CNS-depressant effect (e.g. alcohol, other opioids, sedatives, hypnotics, anti-depressants, sleeping aids, phenothiazines, neuroleptics, anti-histamines and antiemetics) may enhance the CNS-depressant effect of Targin (e.g. respiratory depression). Interaction with coumarin anti-coagulants may increase or decrease INR. Pregnancy and lactation: Not recommended. Sideeffects: Common adverse drug reactions are decreased/loss of appetite, restlessness, headache, vertigo, decrease in blood pressure, abdominal pain, diarrhoea, dry mouth, constipation, flatulence, vomiting, nausea, dyspepsia, increased hepatic enzymes, hiccups, altered mood, decreased activity, psychomotor hyperactivity, agitation, dysuria, pruritus, skin reactions, hyperhidrosis, dizziness, drug withdrawal syndrome, feeling hot and cold, chills, asthenic conditions. Some side-effects which are uncommon but could be serious are hypersensitivity, confusion, depression, hallucinations, disturbance in attention, somnolence, speech disorder, convulsions, syncope, visual disturbances, palpitations, angina pectoris, tachycardia, increase in blood pressure, dyspnoea, respiratory depression, biliary colic, erectile dysfunction, urinary retention, peripheral oedema, abdominal distension and chest pain. Please refer to the SPC for further details of other uncommon side-effects and oxycodone class-effects. Tolerance and dependence may occur. It may be advisable to taper the dose when stopping treatment to prevent withdrawal symptoms. Legal category: CD (Sch2) POM. Package quantities: Blisters of 56 tablets. Marketing Authorisation numbers: PA913/025/001-4. Marketing Authorisation holder: Napp Pharmaceuticals Limited, Cambridge Science Park, Milton Road, Cambridge CB4 0GW, UK. Member of the Napp Pharmaceutical Group. Further information is available from: Mundipharma Pharmaceuticals Limited, Millbank House, Arkle Road, Sandyford, Dublin 18, Tel: +353 (0)1 2063800. Date of preparation: April 2011. (UK/UNA-11115).

➞ ➞ ➞

Targin® provides pain relief that is as effective as oxycodone alone1 Targin® reduces the risk of opioid-induced constipation when compared to oxycodone alone1 Targin® is GMS re-imbursable Targin® is indicated for severe pain, which can be adequately managed only with opioid analgesics. The opioid antagonist naloxone is added to counteract opioid-induced constipation by blocking the action of oxycodone at opioid receptors locally in the gut.

References: 1. Simpson K, Leyendecker P, Hopp M, et al. Fixed-ratio combination oxycodone/naloxone compared with oxycodone alone for the relief of opioid-induced constipation in moderate-to-severe noncancer pain. Curr Med Res Opin 2008;24(12):3503-3512. 11144TRG

Adverse events should be reported to Mundipharma Pharmaceuticals Limited on 1800 991830

MI14.2011July14th.indd 15

08/07/2011 19:13

news

series

International health system profiles

James Fogarty

After the revolution In the final part of his series, James Fogarty looks at how universal health insurance has transformed the Slovakian health system since its introduction following the fall of the Soviet Union.

he Slovakian health system has undergone nothing short of a revolution in the past two decades in terms of both ideology and provision. Once part of the Soviet bloc, Slovakia provided universal access free of charge but now health is provided through universal health insurance. One of the fastest growing economies in the EU and OECD, the country’s transition from communist to capitalist has been impressive, a change mirrored in its health system. One of the most startling things about this change is the speed in which it has been accomplished; Slovakia could offer Minister Reilly a model of how to implement universal health insurance quickly and cost effectively. However, the nation has found that change can be both politically costly and unpopular, particularly within the medical profession; many doctors recently threatened to leave the country unless their pay was increased.

Structure

After the collapse of the Soviet Union and the breakup of Czechoslovakia, Slovakia’s health system underwent a massive ideological shift as the communist planned economy gave way to the open market and the re-introduction of social health insurance (SHI), a model which originated in 19th Century Germany under Chancellor Otto Von Bismarck. It was a bold move as the economy at the time was in a deep depression with spiralling unemployment and stagnant wages. There were serious doubts about the ability of the state to pay for the new system and cover, the so called, “economically inactive population”, around 3.3 million insured citizens or 61 per cent of the total population. In 1993, the state made no contributions to the health system and contributed only €1.11 per economically inactive insured person in 1994. Despite the lack of funds, the government continued its reform. In 1993 the National Insurance Fund was set up to fund health, social and pension funds and the National Insurance Fund Act was passed in the following year. This Act established numerous health insurance funds,

which were funded through a combination of co-payments and state subsidies. The responsibility for the management of these funds fell to the Ministry of Health. Initially 13 health funds were established, however, the stipulation that each fund would have to have a minimum of 300,000 insured patients soon reduced the number to three. The state through its insurance company, VŠZP, continues to dominant, with 68 per cent of the market in 2010. The change to universal health insurance is difficult and on-going. However Prof Adriana Liptakova, Chief State Counsellor and Director of the Healthcare Department, believes it has improved healthcare in Slovakia, although more needs to be done. “Major health reform occurred over the last number of years especially between 2002 and 2006. We made large improvements since the 1990s, especially regarding life expectancy, and decreased infant mortality. But still our health outcomes are substantially worse if you compare them with other European countries,” Prof Liptakova said.

Slovakia could offer Minister Reilly a model of how to implement universal health insurance quickly and cost effectively As well as establishing the apparatus of universal health insurance, the state also encouraged the private sector to become more involved in health. It was during the early 1990s that most pharmacies and ambulatory doctors went into the private sector. One of the consequences of this development was that the health system became disjointed with a high number of specialised healthcare providers. Furthermore state hospitals, which at the time made up

www.medicalindependent.ie

MI14.2011July14th.indd 16

One of the recurring problems in the Slovakian health system is the lack of co-ordination between the central and the regional governments. In 2007, a Ministry for Health proposal to reduce the number of beds in hospitals managed by self-governing regions was not supported.

Funding

Ivan Uhliarik, Slovakian Minister for health the majority of Slovakia’s hospitals, were burdened by an oversupply of healthcare staff and lack of investment from a cash-strapped government. All pharmacies in Slovakia are now privately owned and the number has increased to more than 1,900 in 2009. The lack of co-ordination between the central government and the insurance companies was another cause for the financial strain on the system. In the 1990s, responsibility for healthcare provision was transferred to the health insurance companies but effective regulatory control remained with the Ministry for Health, although it did not hold direct responsibility for its decisions. According to the WHO, this fragmentation resulted in huge debts to the system, but the situation was eventually solved by the healthcare reforms of 2004. Under these reforms the health insurance companies were given more influence and became purchasers of healthcare services instead of just payers. However the problem of debt and overfunding remained. The situation came to a head in 1999 when the Perspekita insurance fund went bankrupt due to lack of monitoring and mounting public debt. Despite attempts to rein in spending such as cutting the hospitalisation of nonacute patients and hospital budgets, the spending gap could not be bridged. Finally

in 2001, the World Bank said that Slovakia could no longer afford general free of charge care, and recommended that it restrict its basic benefit package. As part of a cost cutting programme, the state also began to shed its ownership of a number of hospitals. Between 1999 and 2002, 14 healthcare facilities turned from being contributory organisations under state management to being non-profit-making organisations. Well funded health services, such as biochemistry and dialysis, within state hospitals were also privatised, resulting in further cuts in public hospital budgets.

Monitoring

In 2003 the government transferred most of the hospitals to the regional and local government with the exception of tertiary and university hospitals. The central government retains responsibility for health and safety in all Slovakian hospitals through the Health Care Surveillance Authority (HCSA), which roughly equates to HIQA in Ireland. It deals with patient complaints as well as stress testing the insurance companies solvency, and purchasing and healthcare services. Risk adjustment between insurance companies also falls under its remit. It also has the power to ban, either temporarily or permanently, a healthcare provider or insurance company from the market. The

HCSA, although technically independent of the Ministry for Health, is subject to government control as it has the power to sack the Chairman of the HCSA. Its supervisory board is also elected by parliament, therefore limiting its independence. One of the most interesting things about Slovakia is the role of local and regional governments. As we have seen in 2003, the central government divested much of its responsibility to the provincial governments, who had been established the previous year. These responsibilities include issuing permits for the operation of healthcare facilities, appointing ethics committees, recruiting doctors, and issuing approvals for out-patient biomedical research. However the Ministry for Health still acts as the court of final appeal. The eight self-governed regions also took over the responsibilities for monitoring healthcare provision and can impose sanctions on healthcare providers for neglecting their duties. They also have the power to appoint the chief doctor, although again with the approval of the Ministry for Health. Most of the hospitals operating in the self-governed regions have now been changed into joint stock companies or not-for-profit agencies, or have been fully privatised, some of which have been rented out to the public sector.

Health spending in 2008 was 7.8 per cent of GDP, 7.6 per cent in 2009, well above its neighbours but a lot less than the EU average. Despite this, patients seem relatively satisfied with the standard of treatment they receive. A survey carried out by one of the health insurers found that patients rated the standard of care at around 90 per cent. Satisfaction with the standard of food and accommodation was lower at around 70 per cent. The lack of investment has been a problem since the establishment of SHI in 1994. The 2002-2006 reforms sought to remedy this by tightening budgetary restrictions, introducing more efficient use of existing resources and identifying internal reserves within the system. The reform included a transformation of health insurance funds from public institutions into joint stock companies, now called health insurance companies. However, despite these attempts, costs remain high particularly in relation to pharmaceutical costs which account for almost 30 per cent of spending. “In the case of pharmaceutical reimbursement, the law is now before the parliament. We would like to push pharmaceutical industries to give us the second lowest price in the EU. Certainly as you can imagine, this is a big issue and there are many opinions both positive and negative, mainly negative from the pharmaceutical industry of course,” Prof Liptakova said at the National Healthcare Conference, which took place recently in the Burlington Hotel in Dublin. Currently in out-patient care, a system with capitations and fees is applied for primary care, while hospital specialists are paid using capped fees for service. Insurance companies spend 7 per cent on primary care, 11 per cent on ambulatory secondary care and 27 per cent on tertiary care.

14 July 2011 | medical independent 08/07/2011 19:13

FS Com

vid

IRE a

t r it i o N

Med l

N D’S N

UE INNOVAT Q I I UN

N U TR I T I O N

First Time, Every Time

Fortisip Compact 125ml contains: • 300kcals per serving (2.4kcal/ml) • 12g protein... • ...condensed into just 125ml • 40% less volume, same nutritional content as a standard 200ml supplement • Extensively used in Irish hospitals

With 91% patient compliance, why use anything else? Fortisip 200ml is GMS approved

Nutricia Medical, Block 1, Deansgrange Business Park, Deansgrange, Co. Dublin. Fax: +353 1 289 0255 | Email: support.ireland@nutricia.ie

Visit our website

FS Compact GP IMT Advert.indd 1 MI14.2011July14th.indd 17

www.nutricia.ie

Compact

ON-APR11-01

For further information, samples and patient information call our customer care team on Freephone (ROI) 1800 923 404 or (NI) 0800 783 4379

15/04/2011 08:26:33 08/07/2011 19:13

news Despite owning the largest health insurer, the state is spending less and less on health. In 2002 the government spent 88.3 per cent on total health spending, falling to 76.7 per cent in 2010. Government restrictions on the private sector are also loosening. Between 2008 and 2011, health insurers were allowed to use their profit for healthcare purchasing only, however, following a formal warning from the European Commission, the Slovakian constitutional court ruled that the restriction was unconstitutional and nullified it.

Doctors

Relations between the Slovakian government and doctors have often been less then cordial. In recent years, the medical trade unions have intermittently organised strike action, demanding the government increase income levels and improve conditions. On the eve of Slovakia joining the eurozone in 2008, the President of the Slovak Union of Medical Specialists , Andrej Janco, asked all healthcare workers to join a joint protest, Health Day, calling for all compulsory payments in the healthcare sector to be doubled. Another reason behind the strike was the fear that this was the last chance for doctors to increase their

series salary – which was €1,346 a month in 2009 – before entering the eurozone. As part of the protest, Mr Janco advised the country’s ambulance drivers to go on an all-day work stoppage, while he encouraged hospital doctors to engage in a go-slow for one hour during Health Day. Although it was not supported by the larger healthcare professional trade unions, the protest went ahead on the 30th May 2008, but the Slovakian media reported that many hospital specialists did not actively support the strike. Although wages have increased by more than 17 per cent (2.3 times more than average salaries), pay remains a serious sticking point in Slovakia as doctors are painfully aware of how much their colleagues earn in the rest of the eurozone. In March of this year, the Slovakian Ministry for Health was increasingly alarmed at events in the neighbouring Czech Republic where the “Thanks, but we’re leaving” protest campaigns by doctors forced the Czech government to substantially increase salaries. The Slovakian government’s fears of a similar protest were realised when a trade union representing 2,000 of Slovakia’s 18,000 doctors warned that they would resign their po-

the Roma in Slovakia Slovakia has been heavily criticised for its alleged treatment of the 350,000-380,000 Roma gypsies who live within its borders. Worryingly in the last decade, several NGOs highlighted cases of alleged involuntary sterilisation of Roma women. Their investigations resulted in a report, Body and Soul, which was submitted to the United Nations. According to the report, Roma women were being sterilised for no reason and without prior consent in a hospital in Krompachy and in gynaecology departments of other hospitals. The Slovakian government responded and the General Prosecutor’s Office, in cooperation with the Ministry of Health and the Ministry of the Interior, started an investigation. However the investigation did not confirm the NGOs’ findings. According to the Slovakian government, sterilisations did take place but were performed in accordance with existing legislation, which stated that sterilisation due to health indications does not require informed consent. The state investigation also found that administrative discrepancies did occur in three cases of under-aged women, who were sterilised without the consent of their legal representatives. As a consequence of the scandal, the legislation was amended in 2005, making informed consent and a completed official application form prerequisites for sterilisation. The Roma population’s health status is worse than the rest of the population, which can be partly explained by their unfavourable social situation, racial prejudice and their long-term dependency on social benefits. In an attempt to tackle this situation, the government enacted the National Action Plan of the Slovak Republic and the Decade of Roma population inclusion 2005–2015. These plans will have four areas of priority: education, employment, health and housing, and three inter-related topics: poverty, discrimination and gender equality. They hope to create a verified database of health data and health inequalities between the Roma population and the majority population as well as among Roma communities, as a basis for effective health interventions; to improve the access to healthcare for the Roma population and to increase their knowledge of healthcare provision; to improve the reproductive health of the Roma population; and to improve the vaccination rate in the Roma population.

www.medicalindependent.ie

MI14.2011July14th.indd 18

sitions on mass in May. The Health Ministry, for its part, accused the union of holding patients hostage but the doctors have a very strong hand, they can simply move to somewhere that pays better.

A survey carried out by one of the health insurers found that patients rated the standard of care at around 90 per cent

“We are very happy to be part of the European Union but on the other side, this free movement of people can cause problems in healthcare. This year I made a proposal to the Czech health board, I proposed that the healthcare professional would be treated like a hockey or a football player. It’s not easy to transfer a hockey player and you have to pay money to the club. Our doctors and nurses are excellently trained and they work in excellent hospitals. So a profit should be made for our hospitals not just for our excellent healthcare professionals,” said Prof Liptakova. Relations between doctors and patients have at times been equally tense, particularly after the introduction

of user fees in 2003. Aimed at reducing the demand for healthcare, the move was well received by doctors but was very unpopular with up to 74 per cent of the population. According to the World Health Organisation, the fees were set at €0.67 for a doctor’s visit in ambulatory care (both primary and secondary), €0.67 for a prescription, and €1.67 for each day of a hospital stay. The user fee for first aid services was set at €2. The constitutionality of user fees was upheld in court and resulted in a significant drop in visits to doctors. According to data from the General Health In surance Company, the number of physician visits in primary care dropped by 10 per cent in the second half of 2003

compared to the same period in 2002. Following the elections in 2006, a left-leaning opposition came to power but the user fees remained. They did however scrap fees for outpatient and in-patient care. Fees for first aid visits remained the same and the fee for a prescription was reduced to €0.17. The recent parliamentary elections returned a centre right coalition and it remains to be seen whether user fees will increase. Doctors may reject a patient due to work overload, if a conflict of interest arises, or if asked to perform certain procedures irreconcilable with their religious or other beliefs. However, GPs cannot decline a patient due to work overload if the patient is a permanent

Do your patients tire of milk and juice supplement Try the perfect anytime supplement... 3 High energy and protein (200kcal & 11.9g protein per serving)

3 Easy to swallow and digest 3 Convenient and patient-friendly 3 4 great tasting flavours 3 Great alternative to nutritional drinks

and in just 7 easy spoonfuls!

Reference: 1. IMS Data, May 2011.

For further information, samples and patient information, call our customer care team on Freephone 1800 923 404 Nutricia Medical, Block 1, Deansgrange Business Park, Deansgrange, Co. Dublin. Email: support.ireland@nutricia.com

Visit our website

www.nutricia.ie

14 July 2011 | medical independent 08/07/2011 19:13

news

series resident in the physician’s district or if the patient is in need of urgent care. Patients register with GPs through a written agreement for a period of at least six months, which can only be terminated in writing. After 2001 the number of doctors and nurses in Slovakia began to fall continually, mainly due to emigration. However their numbers remain high when compared with the EU average. The four medical schools produce about 500 doctors every year although many of them choose to work abroad. While exact data is not available, clues to the scale of the problem can be seen in the almost 4,000 professional qualification confirmations the Ministry of Health issued between

2004 and 2008, which allow doctors to work abroad under EU law. Furthermore, it is estimated that there are 1,000 Slovakian doctors working in the Czech republic. Numbers began to rise again after 2006, but migration and an ageing work force, the average age is 50, means the healthcare profession shortage remains a serious problem. In 2007, the total healthcare workforce was 109,829 or almost 5 per cent of the total workforce. There are around 18,000 doctors in Slovakia, although Slovakia is suffering from a lack of nurses. The implementation of the European Working Time Directive has led to increased recruitment, although trade unions have said that the increase is not

Main causes of death (ICD-10 classification) 1993

1995

2000

2005

2008

2009

Infectious and parasitic diseases (A00–B99)

n.a.

171

231

314

n.a.

– of which: Tuberculosis (A17–A19)

n.a.

Circulatory diseases (I00–I99)

27,543

29,023

28,985

29,131

28,502

28,265

Malignant neoplasms (C00–C97)

10,655

10,947

11,871

11,794

11,891

11,831

– of which: Neoplasms of larynx and lung (C32–34)

2,426

2,428

2,451

2,287

2,243

2,227

Diabetes mellitus (E10–E14)

796

668

758

722

625

674

Mental and behavioural disorders (F00– n.a. F99)

n.a.

Respiratory diseases (J00–J99)

4,188

3,643

2,912

3,114

2,981

3,179

Digestive diseases (K00–K93)

n.a.

2,669

2,787

3,033

n.a.

– of which: Chronic liver disease (K70–K74)

1,369

1,307

1,394

1,461

1,602

1,544

External causes (V01–y89)

3,849

3,642

3,115

3,132

3,174

2,957

– of which: Transport accidents (V01–V99)

931

923

850

764

535

Unknown, ill-defined causes by age (R96–R99)

198

190

451

523

548

621

total number of deaths

52,707,

52,686

52,724

53,475

53,164

52,913

Source: Infostat, 2010; NCHI, 2010b

pu m Ire #1 dd o la ing st nd su lov ’s pp ed le m

dispute with a healthcare professional. Most reported cases result from incorrect or late diagnosis or treatment procedures. The most severe cases are evaluated by an expert committee of the Chair of the HCSA, which attempts to put procedures in place to prevent a recurrence.

hospitals

t en

ments?

enough. The problem is further exacerbated by uneven medical manpower distribution with doctors choosing the Bratislava area over other regions in the country. Like in other countries, doctors are obliged to have liability insurance which is provided by commercial insurance companies. However, legal action against doctors is uncommon and the amount of required financial compensation for unsuccessful operations or death due to negligence is rarely more than €100,000. To receive compensation a patient must submit a complaint to the HCSA, who will then start an investigation. If the law was violated, the claimant has the burden of proof in a civil legal

nt...

In 2008 there were 138 hospitals in Slovakia, 73 were general hospitals and 65 were specialised. While this is an impressive number on the sur face, a study carried out in 2004 found that the technical infrastructure was out-dated and unsatisfactory. Hospitals at this time were composed of 30 buildings on average, although it was not usual for hospitals to consist of 80 buildings. The average age of a hospital in Slovakia is 34.5 years.

Pay remains a serious sticking point in Slovakia, as doctors are painfully aware of how much their colleagues earn in the rest of the eurozone

ON-JUNE11-01

medical independent | 14 July 2011 MI14.2011July14th.indd 19

In 2007, there were over 26,000 acute beds, 4450 psychiatric beds and 4403 longterm beds in Slovakia. All bed numbers have fallen over the last decade in accordance with a bed reduction plan, although in 2006 the Ministry for Health still spoke of a 6,500 bed surplus. However, there is significant diversity in quality of care across the system, with one in every nine patients migrating to another region to be hospitalised. One of the achievements of the Slovakian system has

been the reduction in the length of stay in hospital. In 2008 patients in Slovakia averaged a 6.9 day stay in acute care hospitals, falling below the averages of Germany and the Czech Republic. The lack of modern equipment is, however, a serious problem. While in 2007 there were 700 x-ray machines, just over half (450), were fully operational. These machines were on average 14 years old and some of them were outdated. Furthermore, much of the sophisticated machinery is owned privately.

Diseases

Slovakia has made significant improvements in both average life expectancy and infant mortality, cancer and cardiovascular disease mortality rates remain high when compared with the EU average. The most frequent causes of death in Slovakia are lifestylerelated, mainly non-communicable diseases, including cardiovascular diseases (52.9 per cent), cancer (22.1 per cent), gastrointestinal diseases (5.9 per cent) and respiratory diseases (5.5 per cent). While there has been a relatively slow increase in life expectancy, there has been rapid improvement in reducing the infant mortality rate, which has fallen from 12 per 1,000 live births in 1990 to an estimated 6.8 per 1,000 live births in 2009 – similar to that in Hungary, but behind Poland and the Czech Republic. Ireland and Slovakia have a lot in common. Slovakia’s decision to implement universal health insurance at a time of huge economic instability was a brave one. Now facing a similar situation, we can perhaps take some comfort from that, especially since Ireland continues to spend more on healthcare. However, the constant tension between healthcare professionals and the government, and the lack of funding from central government made the implementation of universal health insurance in Slovakia a far from easy option.

www.medicalindependent.ie

19 08/07/2011 19:13

editorial Dawn O’Shea

A future so bright “I see a bright future for Roscommon and other county hospitals”. So said soon-to-be Health Minister James Reilly on February 7th in the Irish Times. Yes, I know these words were spoken during that heady phase of pre-election campaigning and, as Enda has explained, there is much “rhetoric” at such times. Speaking to the Medical Independent just five months ago, the Minister said his party opposed the reorganisation of emergency services and pledged not to withdraw critical emergency services without essential transport links being put in place and local primary care services being upgraded first. However, we are nearing the end of the first week of Ireland’s new streamlined emergency services network. Roscommon General’s ED has been given a month’s reprieve, for reasons that are not exactly obvious, but other hospitals have not fared as well. How safe the experiment will turn out to be remains to be seen. I think we can all agree that the country cannot staff all 33 emergency departments sufficiently with the complement of NCHDs we have at present and the priority must be the provision of a safe emergency service for all citizens. But it has been the headless chicken, ill-prepared approach and the broken promises which are fuelling the palpable frustration and exasperation. Yet again, a slow-brewing problem has evolved into a monumental catastrophe as a result of poor planning and a lack of creative thinking. In the same week that Minister Reilly and the Taoiseach were defending the decision to rationalise emergency services, HSE CEO Cathal Magee was before the Public Accounts Committee (PAC) waxing lyrical about the Executive’s plans to create an uber ED system. He reported that 14 additional emergency medicine consultants and 34 new consultants in acute medicine will be appointed. A rake of Advanced Nurse Practitioners (ANPs) are to be recruited for the country’s emergency departments. Mr Magee told the PAC that a team of eight ANPs managed to treat 13 per cent of new attendances at St James’s Hospital in 2010. He said 15 further Acute Medical Assessment Units are to be developed and rapid access clinics are being established for epilepsy, COPD, heart failure and asthma in addition to the creation of specific measures to improve access to medicine for the elderly patients who present to EDs and AMAUs. It all sounds very reasonable and extremely promising, which begs the question... What in God’s name are we waiting for? There are dozens of qualified, experienced former SpRs across the country and across the globe who are waiting patiently for a consultant position at home. Having finished their specialist training in emergency medicine, they are currently in limbo, reluctant to go backwards and take a locum NCHD post because of its impact on future career prospects and unable to access a consultant post. Imagine the time and effort that has gone into flying 34 consultants and six HSE staff to India and Pakistan to interview 314 candidates and progress through five rounds of centralised recruitment, not to mention negotiations with the training bodies and the Medical Council about registration, and amending the Medical Practitioners Act. And after all that time, the crisis has still not been averted. Surely over the course of the last 12 months, when experts in all fields have been warning about the impending NCHD shortfall, surely we could have managed to recruit 48 consultants from the community of talented, Irish-trained and registered graduates who are scattered around the world. No need for visas. No need for PRES. And given the demand out there for consultant posts among our former SpRs, it can only be assumed that the acceptance rate among candidates would be substantially higher that those seem with the centralised recruitment process operating for nontraining NCHD posts where the acceptance rate fell from a dismal 22 per cent in round 1, to an appalling 9 per cent in round 2. Using the HSE’s rule that each consultant post requires the elimination of two NCHD posts, appointing 48 consultants in emergency and acute medicine would, theoretically, negate the need for 96 ED NCHDs. That’s without factoring in the additional ANPs, AMAUs and MIUs. I know it’s not a panacea for all our ED ills but it has to be more efficient that begging another country’s NCHDs to come and bail us out. So have at it lads, and let’s take a logical, nonreactive approach to emergency medicine once and for all. Let’s employ a little bit of lateral thinking with a sprinkling of creativity.

www.medicalindependent.ie

MI14.2011July14th.indd 20

Please send your letters to: The Editor, Medical Independent, Greencross Publishing Ltd, 7 Adelaide Court, Adelaide Rd, Dublin 2 or email dawn@greencrosspublishing.ie

letters to the editor

Seeing the big picture Dear Editor, We read, with interest, your article (Medical Independent 16/06/11) on the dilemma around choice of anti-VEGF agents in the treatment of retinal disease in Ireland. The article was biased towards a discussion on the merits of off label agents such as bevicizumab (Avastin) and licensed agents such as ranibizumab (Lucentis). This topic has been discussed at length by retina specialists in this country and, of course, globally. It has re-emerged as an issue since the publication recently of the National Institute for Health (NIH) sponsored CATT trial demonstrating non-inferiority of efficacy of Avastin when compared with Lucentis for treatment of neovascular age-related macular degeneration (wet AMD). There are limitations to the study regarding numbers of patients involved and possible systemic safety issues with Avastin. While not conclusively discounted, excessive safety concerns were not raised either. As outlined by the response from the Irish Medicines Board (IMB), Avastin is considered safe for use here and practitioners are covered to do so by the Clinical Indemnity Scheme (CIS). It was disappointing that the opportunity was not taken to discuss the wider issue of funding for patient care in this vulnerable group. One of this new Government’s stated

Editor: News Editor: Journalists:

Clinical journalist: Sub-Editor: Web Editor: Photographer: Sales: Designer: Circulation: Publishers:

aims was retention of health, dignity and independence for the elderly in this country. There is no doubt that sight loss is a major contributor to loss of independence. With a dramatic rise in blind registrations for AMD, available treatments must be sought and given in a timely manner. Patients and practitioners are in a far more fortunate position now than six years ago when the beneficial effects of anti-VEGF agents in AMD were first described. Indeed the first injection clinics were set up in Ireland in 2005. Since then there has been an exponential rise in treatment levels across the country in all our eye care units. In the Mater University Hospital the rate of increase of injections given jumped 82 per cent from 2008 to 2010. That pattern is replicated across the country, with no increase in resources (financial or personnel) to manage it. The individual departments are managing this out of existing budgets with a knock-on effect to cataract and other ophthalmic services. To put it in context, prior to the advent of effective treatments a patient presenting with wet AMD may have two to three clinic visits in a year, with a 65 per cent chance of a drop in vision to <6/60 (blind). Now a patient presenting in a timely manner (usually within two weeks of onset of symptoms will be assessed and treated, requiring eight to 10 visits in the year

Dawn O’Shea dawn@greencrosspublishing.ie Ailbhe Jordan ailbhe@greencrosspublishing.ie June Shannon june@greencrosspublishing.ie James Fogarty james@greencrosspublishing.ie Judith Leavy judith@greencrosspublishing.ie Ciarán Egan ciaran@greencrosspublishing.ie Mary O’Keeffe mary@greencrosspublishing.ie Brid Ni Luasaigh bridniluasaigh@yahoo.ie Graham Cooke graham@greencrosspublishing.ie Barbara Vasic design@greencrosspublishing.ie Daiva Maciunaite daiva@greencrosspublishing.ie Maura Henderson maura@greencrosspublishing.ie Graham Cooke graham@greencrosspublishing.ie

The Medical Independent is published by GreenCross Publishing, 7 Adelaide Court, Adelaide Rd, Dublin 2. Tel: 01 418 9799. Fax: 01 4789449, www.medicalindependent.ie

but with only a 5 per cent chance of dropping vision to <6/60. With 1,600 new cases presenting in Ireland every year, that is 16,000 appointments compared with 3,200 previously. With anti-VEGF treatment (Avastin or Lucentis) there is a 70 per cent chance of improving vision. That is worth fighting for and the resources are required. It is also incumbent on us, as care givers, to modify practice to optimise throughput. This has already started across the country with many hospitals having already set up dedicated units. The role of the National Institute of Clinical Excellence (NICE) in the UK was mentioned in the original article. NICE were responsible for sanctioning the use of Lucentis for AMD. It must be pointed out that that decision not only released the funds for Lucentis but also led to the development of the required infrastructure to deliver the care. Dedicated units were developed with appropriate personnel and capital resources. In the UK they have aimed to have one medical retina consultant in place for every 300,000 people. We have 10 vitreo-retinal (covering medical retina) and three medical retina consultant surgeons in the HSE for four million patients. We are approximately eight consultants short of need in this one area alone. We are massively underserved to meet the clinical demand. That is even be-

fore the introduction of a National Diabetic Retinopathy Screening Programme which itself will generate 30,000 to 50,000 referrals to retinal eye care services in the first year, with 2,000 requiring intra-ocular injection treatment for diabetic macular oedema. In summary, we feel that the correct discussion is not taking place around provision of medical retina care in Ireland and while we delay, patients are unnecessarily losing vision and independence. The issues do not just relate to choice of agent, a full service provision has to be catered for. To this end, a collective drive by all interested parties, patients, practitioners, patient groups, colleges and drug companies, to appoint a national clinical lead with responsibility to develop a national strategy for retinal and ocular disease care in Ireland is required. Sincerely yours, Patricia logan President, Irish College of Ophthalmologists, Irish College of Ophthalmology 121, St Stephens green Dublin 2 David Keegan Consultant Vitreo-retinal Surgeon Mater University hospital Eccles St Dublin 7

Medical

InDEPEnDEnt The Medical Independent endeavours to ensure accuracy of information given and of claims made in articles and advertisements. Nevertheless, no responsibility is accepted in respect of such information or claims. Any opinions expressed by contributors are entirely their own and do not purport to be the views of the Medical Independent. © Copyright GreenCross Publishing 2010 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 publishers. GreenCross Publishing was established in 2007. It is jointly owned by Graham Cooke and Maura Henderson. Between them Graham and Maura have over 30 years experience working in healthcare publishing. Their stated aim is to publish titles which are incisive, vibrant and pertinent to their readership.

14 July 2011 | medical independent 08/07/2011 19:13

comment

Dr Muiris Houston READ MORE from Dr Muiris Houston at www.medicalindependent.ie

giving the gift of life Dr Muiris houston profiles two projects which have used social network sites to link donors and transplant receipients

ocial media is impacting on health initiatives in a unique way. Take for example the ‘Live life. Pass it on’ campaign which was launched in April by BC Transplant, an agency of the British Columbia provincial health services authority in Canada. This particular campaign started with Eva Markvoort, a recipient of a double lung transplant, and her friend Cyrus McEachern, a medical student at the University of British Columbia, Vancouver. Using a photo of Markvoort with a human heart painted on her chest, they entered and won a cardiology-themed art contest. Building on the success of their initial idea they decided to ask other transplant recipients to become involved in a larger project. Pictures were taken of seven people, on each of whom Eva had painted the organ they had previously re-

ceived. And so was born a social media campaign that resulted in the doubling of online donor registration rates in BC. Using these images, BC Transplant sought the help of Rethink, a Vancouver-based ideas and advertising agency. Putting together the photos with advertisements, they developed a Facebook application that allows registered organ donors to tag their profile picture with the line “I Gave My Heart”. Alisa Brown, Project Director at Rethink is quoted as saying: “When you make that commitment to sign up, you really are giving your heart… not necessarily the organ itself, but your gift of life and your soul.” In addition to the Facebook campaign, advertisements on public transport and TV feature the photographs taken by MacEachern and Markvoort.

Tragically Eva Markvoort died last year at the age of 25 while awaiting a second lung transplant. She had previously highlighted the need for organ donation through her personal blog, while on the waiting list for her first double lung transplant. She also featured in a documentary film, 65 RedRoses, which won three awards at the Vancouver International Film

Festival. Through the web her vision continues to be an inspiration to the transplant community and an encouragement to those who might want to be a donor. Another organisation that has made social media work to its advantage is OneMatch Stem Cell and Marrow Network. A Canadian organisation, it is one of an international network of registries

that match donors to patients needing transplants. Using Facebook, this branch of the Canadian Blood Service organisation is encouraging donors to register. According to Huw Williams, a father of three from Ottawa, without the social network site he would not be alive today. An athlete and black belt in karate, Williams was diagnosed in 2007 with leukaemia, following routine blood tests. As his condition did not respond to medication and no family match was found, he was entered on the register with the OneMatch network in the hope that a suitable donor would be found. Two years ago, 21-yearold Mike Hogman, a student from Vancouver Island, was alerted to this Facebook site by a friend. He registered and, as luck would have it, he turned out to be a perfect match for Williams. Last

months, in a surprise phone call, Hogan got to talk to the man whose life he had saved. Hogman’s personal Facebook wall chronicles the journey that started with him sending in cheek swabs to the network to register. In December 2009, Hogman, a Canadian Armed Forces reservist, spent six hours at Vancouver General Hospital for the stem cell/bone marrow transplant. The pair finally got to make contact after they both agreed to have their contact information released to the other, an option that doesn’t come into effect until a year after a transplant. While we frequently hear of the negative aspects of social media, it’s good to hear it can also be a force for good. For those awaiting organ or marrow transplant, the internet has certainly turned out to be a very positive thing indeed.

comment

Dr Anthony O’Connor READ MORE from Dr O'Connor at www.medicalindependent.ie

thanks for the memories As he prepares to leave his old stomping ground in AMNCH, Dr Anthony O’Connor reflects on the lessons he has learned during his four-year stay

his week I am going to break with convention and write about my place of employment, the Adelaide and Meath hospital incorporating the national Children’s hospital, tallaght. Its Orwellian title notwithstanding (you try putting it on a conference poster), the hospital provides remarkable service to the population of tallaght and its hinterland. It seems apt to write about ‘tallabama’ this week both as I am leaving the hospital after a four-year stay and also, as I write, it is being announced that a platoon from hIQA are sharpening their blades for a “significant investigation” into standards of care at the Emergency Department. I arrived at AMNCH in 2007 as a 27-year-old swinging bachelor gastroenterolo-

gy novice with aspirations to return to Cork at the earliest opportunity. I will be departing in 2011 as what feels like a 64-year-old, slightly cynical but much more enlightened, stone-and-a-half lighter established trainee with a track record of publications and presentations who is about to embark on that most perfidious actions by a Corkonian, namely mixed marriage with a Dubliner, trained in the hospitals Occupational Therapy Department. Along the way I have made, what I hope will be, lifelong friends, both medical and non-medical. I have been the recipient of the most patient and comprehensive mentoring and of a kindness thoroughly unbefitting of my frequently grumpy and exhausted demeanour. I must single out my mentor Professor Colm O’Morain who retired last week. I think I can safely say he is one of the most remark-

medical independent | 14 July 2011 MI14.2011July14th.indd 21

able Irishmen, let alone Irish medics, of the early 21st Century. He has enhanced the lives of thousands of his own patients with his humanity, innovation and unparalleled clinical acumen, and millions of patients he has never met with his groundbreaking research and leadership of international organisations. It has been a true honour in my time there to serve him and learn from him and his band of disciples in our department, namely his consultant colleagues Drs O’Connor, Ryan, Breslin, McNamara, Qasim and Byrne. In the wider hospital, innovation and dedication is omnipotent, making for a stimulating working environment, from Prof O’Morain’s work on bowel cancer screening to Mr Paul Neary’s work on minimally invasive colorectal surgery. The pancreatic unit, under the stewardship of Prof Kevin Con-

lon, delivers staggeringly good outcomes that place it on the very highest centile internationally. Prof Des O’Neill is the most tireless advocate and champion that Ireland’s elderly have, as well as being a pioneer in medical humanities. His colleague Dr Ronan Collins is pushing the boundaries of both stroke care and science-fiction with his work on telemedicine. Almost every clinical department has a progressive CV. I know less of the management side other than annoying it as chief NCHD rabble-rouser but I was always treated with the utmost respect and, almost uniquely when it comes to the treatment of NCHDs in the Irish health service, as an adult with valid opinions and ideas. I would also like to point out that running a 600-bed hospital with the highest number of ED attendances in the country

in a socially disadvantaged area on a budget slightly less than twice that which the NTPF spends on a few thousand minor operations, is a remarkable feat of public administration. I hope (with absolutely no confidence) that this will be borne in mind the next time somebody who has never had anything like the responsibility those involved in the administration of healthcare involves, decides to decry them as incompetent. Finally the patients of AMNCH never fail to challenge your mind and lift your spirits. Ordinary people are ignored in this country because they understand things in a way that discommodes the schemes of the elite. Let me give you an example. When I’ve been booking people for surveillance procedures five years from now, the common refrain from the patients has not been wheth-

er they’ll be here in five years time but whether the hospital will be here. HIQA has been sent in as outlined in the opening paragraph. Readers from rural Ireland will recognise the pattern here by which this is the prelude to a downgrading of services. Let me save HIQA a load of time and money and tell them that, having worked in a load of other places, the inequalities and deficiencies that they will find in AMNCH are a direct product of its underfunding and the practices in the ED corridor there mirror those everywhere else in the country. The extraordinary staff and patients of this fine institution deserve better. When the Red Luas line opened, Bertie Ahern cryptically remarked that it would be a great service for the people of Tallaght to get to St James’s Hospital. How chilling those words sound today.

www.medicalindependent.ie

21 08/07/2011 19:13

professional development

mcqs

Prostap BLOpress Actos Banner Banner Banner D3:Layout D4:Layout D3:Layout 1 116/12/2010 1 16/12/2010 16/12/2010 18:03 18:02 18:03 Page Page Page 1 11

Sponsored by

makers of

Sony VAIO F Series laptop (VPC-F21Z1E/BI) the Best of 3D Anywhere!

The Sony Viao F Series Laptop is not only a beautiful and comfortable laptop but it has also been built for all out performance! Coming with active shutter 3D glasses and full HD 3D entertainment with frame sequential technology and 3D Blu-ray, this Sony F series has the most comprehensive and most effective laptop 3D Blu-ray bundle you can buy. • Convert 2D movies to 3D with a touch of a button • Play amazing 3D Blu-ray movies and games with high performance NVIDIA® DX11 graphics • Powers entertainment and computing with 2nd Generation Intel® i7 Quad Core™ processor The Sony Viao F Series Laptop is the ultimate high definition experience – on your laptop. Boasting phenomenal HD screen resolution, Bluray disc playback technology is your ticket to first-class entertainment. Blu-ray disc media burning capabilities let you store content in a format that provides up to five-times the capacity of standard DVDs.

iPhone Bluetooth Keyboard Case

• • • • •

Dimensions (WxDxH): 39.8cm x 27.1cm x 4.5cm Built-in devices: Stereo speakers, wireless LAN aerial, Bluetooth aerial Processor: Intel Core i7 2630QM ( Quad-Core ) Cache Memory: 6MB – L3 Cache RAM: 8GB (installed)/8GB (max) – DDR3 SDRAM – 1333 MHz – PC3-10600 (2 x 4GB) • Card Reader: Yes • Hard drive: 640GB – Serial ATA-150 – 7200rpm • Optical storage: BD-RE – integrated • Display: 16” LED backlight TFT 1920 x 1080 ( Full HD ) – 16:9 • Graphics controller: NVIDIA GeForce GT 540M • Video memory: 1GB • Audio output: Sound card • Networking: Network adapter – Ethernet, Fast Ethernet, Gigabit Ethernet, IEEE 802.11b, IEEE 802.11g, IEEE 802.11n, Bluetooth 3.0 HS • Notebook camera: Integrated – 1.3 Megapixel • Input device: Keyboard, touchpad • Battery: Lithium Ion • Operating system: Microsoft Windows 7 Home Premium 64-bit Edition • Microsoft Office pre-loaded: Includes a pre-loaded image of select Microsoft Office 2010 suites. Purchase an Office 2010 product key card or disc to activate pre-loaded software on this PC. • Bundled with: Active shutter 3D glasses • Environmental Standards: ENERGY STAR qualified • Manufacturer warranty: 1 year warranty Available for €1,999 from www.right-click.ie/shop

i-helicopter

If you have an iPhone you will know that they really are a marvellous piece of kit. However, you may notice that using the touch screen is good for short texting but it is very easy to hit the wrong keys, which can be a little frustrating. And if you use your iPhone for long texts and emailing, then the touch screen keys can be a bit slow. This is now sorted with this wonderful leather case for iPhone 4. It comes with a built in Bluetooth Keyboard to make all your emailing and texting much easier and even faster. The keys are nicely spaced and soft touch for easy typing. €59.95 @ www.thegadgetstore.ie

Fish Eye lens

It had to happen at some point, and now it has. A first again for B Cool! The Gadget Store. The most popular boys toy over the last few years has now been joined to one of the most popular gadgets of all time, the iPhone. The i-Helicopter is a Gyroscope helicopter that uses a free App from the iTunes app store to turn your iPhone into the helicopter’s remote control. In the box is a slick RC helicopter, an small IR connector for your iPhone, and spare blades. The IR connector connects into the ear phone jack and this allows the iPhone to send signals to the helicopter. All you need to do is plug in the IR connector, download the i-Helicopter App, give the helicopter a quick charge, and your away to run missions all over the house. €69.95 @ www.thegadgetstore.ie

iPhone 4 Microscope

With this detachable lens, you can transform your iPhone into a cool fisheye camera faster than you can say ‘cheese!’ Simply attach the slim-line protective case provided onto the back of your handset and screw in the fisheye lens to shed a whole new perspective on your picture or video taking experience! Snap widescreen 160° angle shots, take cool videos of parties, document travel footage in a funky new way, or zoom in on your mate’s face for laugh-out-loud effects! What’s more, the high quality protective case that clips onto the back of the iPhone is lightweight, durable and discreet enough to be left attached to your handset permanently.

Continuing our iPhone accessory theme for this week, here is another great piece for your iPhone. You can fit this nifty little gadget to your iPhone 4 and transform your camera into a mini microscope capable of 60x magnification! Ever wondered what a teeny-weeny dust mite looks like close up? Or just how intricate a leaf is? Not to mention how seriously freaky human skin looks under a microscope? Well, if you’re the proud owner of an iPhone 4, you’re in luck – this pocket-sized gizmo is your passport to getting your zoom on!

€24.95 @ www.thegadgetstore.ie

€29.95 @ www.thegadgetstore.ie

Editorial contributed by

BCool! The Gadget Store, The Gallery, Dundrum Town Centre, Dublin 16.

Right-Click, 15 Dawson Street and 70 Camden Street, Dublin 2 Tel. 01 4759681 Email: support@right-click.ie

For more gadgets log on to www.medicalindependent.ie medical independent | 14 July 2011 MI14.2011July14th.indd 31

www.medicalindependent.ie

31 08/07/2011 19:13

PRI105

life

sports quiz/diary

Medical Independent Sports Quiz ISSUE 14 – JUly 14 Q.1. the British Open tees off this morning at Sandwich. Who is hoping to defend their title? Q.2. Who won the leinster hurling Championship last week? Q.3. next week’s german grand Prix will be staged at which famous circuit? Q.4. Which nation will Ireland open their rugby world cup account against? Q.5. the galway racing festival commences next week. What is the name of the racecourse? Q.6. the Irish soccer team will try to extend their four match unbeaten run in August with a friendly fixture at home to whom? Q.7. Where will the 2012 heineken Cup final be staged?

Please send your answers to the Editor, Medical Independent, GreenCross Publishing, 7 Adelaide Court, Adelaide Rd, Dublin 2. Closing date for entries: July 22nd 2011. Winner will receive €50.

Q.8. Which league of Ireland soccer club play their home fixtures in Flancare Park?

The winner of last issue’s Sports Quiz was Dr Sean Dunne from Newbridge.

AnSWERS tO ISSUE 13– JUnE 30 1. Q. Wimbledon 2011 is well under way. Who holds the record for winning the most men’s singles titles and how many has he won? A. Pete Sampras – 7 2. Q.Ireland will travel to play France in a rugby world cup warm up match later in the summer. Which city will the game be staged? A. Bordeaux 3. Q.golf’s British Open will take

july Thursday 14th Assessment workshop on the principles of musculoskeletal assessment for rheumatology health professionals. Our Lady’s Hospice, Harold’s Cross, has launched a new blended learning course on musculoskeletal assessment, which will combine both online eLearning modules and a formal workshop assessment. The online modules have been designed to complement clinical practice by demonstrating the correct technique to use when conducting a musculoskeletal assessment. The online modules should take approximately 2.5 hours to complete. On completion of the online course, participants will be able to register for a practical skills workshop at Our Lady’s Hospice in Harold’s Cross. The elearning modules are now available for completion at http://roche.aurionlearning.com Places are limited. Please visit http://roche.aurionlearning.com or contact Eileen Shinners at 01-406 8700 or eshinners@olh.ie for more information or to register for the course. august Tuesday 23rd and Thursday 25th RCSI heritage Week 2011

As part of National Heritage Week the RCSI will organise tours of the College on Tuesday 23rd and Thursday 25th August 2011. Participation is free of charge but booking a tour is essential as places are limited. For more information please contact communications@rcsi.ie or see www. rcsi.ie/heritageweek Monday 15th August to Monday 26th September Diploma Course in tropical Medicine. Run by the RCSI, this intensive six-week course in clinical tropical medicine is designed to give candidates an insight into a wide range of diseases in resource-poor settings and to provide preparation for working in developing countries. Application forms are available from: Mrs Mairead Lamb, Dept. of Tropical Medicine, Royal College of Surgeons, 123 St. Stephen’s Green, Dublin 2. Tel: +353 (0)1 4022186 E-mail: mlamb@rcsi.ie september Saturday 03rd the Football Association of Ireland (FAI), in association with the RCSI is to host the Inaugural Football Medicine Conference. The event will focus on assessment, imaging, surgical and non-surgical management of soft tissue groin disorders and intra-articu-

www.medicalindependent.ie

MI14.2011July14th.indd 32

Winners’ cheques will be sent out within 45 days.

place on which famous golf links? A. Sandwich 4. Q. the 2011 tour De France commences on Saturday. nicholas Roche will aim to emulate his father and take the title back to Ireland. What year did his father Stephen win the tour? A. 1987 5. Q. the Munster football final takes place on Sunday. Who are

the defending champions? A. Kerry 6. Q. Manchester United will kick of their campaign to win league title no.20 aginst whom on August 13th? A. West Bromwich Albion 7. Q. Which horse won the gold Cup at Royal Ascot earlier this month? A. Fame & glory 8. Q. Who won golf’s 2011 US Open? A. Rory McIlroy

lar hip disorders. The conference will take place at the Lady Martin Auditorium at Cappagh National Orthopaedic Hospital in Dublin. For more information please contact Ursula Gormally email: ursula.gormally@cappagh.ie Sunday 4th to Friday 9th European Conference on Biomaterials . The Network of Excellence for Functional Biomaterials (NFB) at NUI Galway will host the European Society for Biomaterials (ESB) in the Dublin Convention Centre. The ESB is a non-profit organisation whose key objective is to encourage, foster, promote and develop research and provide information concerning the science of biomaterials in Europe. The NFB at NUI Galway will also host a special industry day as part of the conference on Monday September 5th, which will focus on translating biomaterials and combination products. The event is specifically designed to bring together the leading organisations in the medical device sector, multi-national corporations, small and medium enterprises and entrepreneurial academics who will share their experiences in taking innovative biomaterials concepts to both the clinic and to the market. Co-sponsored and co-organised by Covidien, the Industry Day and the Europe-

Name: Address:

Email:

an Conference on Biomaterials this is the first time in the conference’s 24-year history that it is taking place in Ireland. For more information see www.esb2011.org Friday 9th to Saturday 10th the 8th Annual Scientific Conference of the Faculty of Sports and Exercise Medicine, RCPI and RCSI, will take place at the RCSI in Dublin. Friday’s lectures will focus on: Team Preparation, medico-legal aspects, nutrition for medical service providers and blood doping. Saturday’s lectures will look at therapy and the future of tendon pathology in athletes, ultrasound, achilles tendinopathy and rehabilitation, and concussion. The full programme is available on www.rcsi.ie/fsem For more information please contact: Fiona McGarry, Conference Partners. Tel: 01 296 9397 Saturday 10th Asthma Society of Ireland regional Asthma health Day tour visits Athlone. During the day, asthma nurse specialists will be on hand to speak one-to-one with patients confidentially about asthma management, allergies and inhaler technique as well as peak flow monitoring and spirometry. There will also be talks from guest speakers on asthma management and childhood asthma. Admission

to the event is free. The event will be held from 1pm to 4pm. Visit www.asthmasociety.ie for updates. Tuesday 20th to Thursday 22nd An introduction to management for doctors and SpRs three-day course (9am to 5pm daily) will take place at the Institute of Leadership and Healthcare Management, RCSI, Reservoir House, Ballymoss Road, Sandyford, D18 . Fees: €1,200. Participants will discuss how management theory relates to the healthcare environment; develop management skills that allow them to manage themselves, their department and their healthcare team effectively; and recognise the need to enter into constructive dialogue with key hospital stakeholders. CPD points: 18. For more information please contact: niamhcarroll@rcsi. ie or (01) 402 8655. See www. rcsileadership.org. Friday 23rd Assessment workshop on the principles of musculoskeletal assessment for rheumatology health professionals. Our Lady’s Hospice, Harold’s Cross, has launched a new blended learning course on musculoskeletal assessment, which will combine both online eLearning modules and a formal workshop assessment. The online modules

have been designed to complement clinical practice by demonstrating the correct technique to use when conducting a musculoskeletal assessment. The online modules should take approximately 2.5 hours to complete. On completion of the online course, participants will be able to register for a practical skills workshop at Our Lady’s Hospice in Harold’s Cross. The elearning modules are now available for completion at http://roche.aurionlearning.com. Places are limited. Please visit http://roche.aurionlearning.com or contact Eileen Shinners at 01-406 8700 or eshinners@olh.ie for more information or to register for the course. Tuesday 27th to Wednesday 28th nB Medical ‘hot topics’ Ireland gP Update, led by Dr Simon Curtis will be held in Belfast on the 27th and Dublin on the 28th. Price: £195 (approx €220). Book online at www.nbmedical.co.uk october Saturday 08th the Carlow Kilkenny Annual ICgP Study day will take place at the Lyrath House Hotel, Kilkenny from 10am to 4 pm. For more information please contact Dr Tom Foley at email: drtomfoley@eircom.net

14 July 2011 | medical independent 08/07/2011 19:13

A P a L p S P s 1 d le fi t P c M d a u P p a M s n P in w T m s p

PRI105 C2 Consultant Ad 297x210 AW 19/04/2011 15:21 Page 1

come as standard When it comes to the treatment of prostate cancer, look no further than Prostap

Abbreviated Prescribing Information. PROSTAP *SR, 3.75 mg / PROSTAP *3, 11.25 mg Powder and solvent for prolonged-release suspension for injection Leuprorelin Acetate 1 month / 3 month Depot Injection Before prescribing PROSTAP SR/PROSTAP 3, please refer to the full Summary of Product Characteristics (SmPC). PRESENTATION: PROSTAP SR: Vials containing 3.75 mg leuprorelin acetate in a sterile, white microsphere powder. Pre-filled syringes containing 1 ml sterile solvent for reconstitution to provide a one month depot injection. PROSTAP 3: Vials containing 11.25 mg leuprorelin acetate in a sterile, white microsphere powder. Prefilled syringes containing 2 ml sterile solvent for reconstitution to provide a 3 month depot injection. INDICATIONS: PROSTAP SR and PROSTAP 3: - Management of prostatic carcinoma for which suppression of testosterone is indicated. Management of oestrogen dependent gynaecological disorders including the management of pain and lesions associated with endometriosis. - Preoperative management of uterine fibroids to reduce their size and associated bleeding. PROSTAP SR is also indicated for: - Endometrial preparation prior to intrauterine surgical procedures including endometrial ablation or resection. DOSAGE AND ADMINISTRATION: Male adults: PROSTAP SR: 3.75mg administered as a single subcutaneous or intramuscular injection every month. Do not discontinue when remission or improvement occurs. PROSTAP 3:11.25mg administered as a single subcutaneous or intramuscular injection every 3 months. Do not discontinue when remission or improvement occurs. Female adults: Treatment should be initiated during the first 5 days of the menstrual cycle. PROSTAP SR: 3.75mg administered as a single subcutaneous or intramuscular injection every month for a period of 6 months (endometriosis), for a maximum of 6

MI14.2011July14th.indd 33

months (uterine fibrosis). Vary the injection site periodically. PROSTAP 3: 11.25mg administered as a single subcutaneous or intramuscular injection every 3 months: for a period of 6 months (endometriosis), for a maximum of 6 months (uterine fibroids). Vary the injection site periodically. Elderly: As for adults. Children: Use in children not established. CONTRAINDICATIONS: Hypersensitivity to any of the ingredients or to synthetic GnRH or GnRH derivatives. Men: Use in patients insensitive to endocrine therapy or postorchidectomy. Women: Use in women who are or may become pregnant, in women who are breastfeeding or who have undiagnosed abnormal vaginal bleeding. PRECAUTIONS AND WARNINGS: Diabetic patients may require more frequent monitoring of blood glucose. Development of diabetes may occur. Hepatic dysfunction and jaundice with elevated liver enzyme levels have been reported. Therefore, close observation should be made and appropriate measures taken if necessary. Spinal fracture, paralysis, hypotension and worsening of depression have been reported. Men: Should only be used under the direction of a clinician having appropriate facilities for monitoring response to treatment. Testosterone should fall to castrate levels within 6 weeks; failure to do so requires reassessment. Initial transient rise in levels of testosterone may be associated with tumour “flare” manifesting as systemic or neurological symptoms. Patients at risk of ureteric obstruction or spinal compression should be carefully considered and monitored during initial weeks of treatment. An anti-androgen may be administered to reduce the risk of “flare” (see SmPC). Any urological or neurological complications which occur should be treated symptomatically. Women: Menstruation should stop during treatment; therefore the patient should notify her physician if regular menstruation

persists. Spotting/breakthrough bleeding may occur with Prostap treatment. An increase in clinical signs and symptoms may be observed during the initial days of therapy as sex steroids temporarily rise above baseline. In the case of uterine fibroids, it is mandatory to confirm the diagnosis of fibroids and exclude ovarian mass, before therapy is instituted. May cause an increase in uterine cervical resistance. The induced hypooestrogenic state results in a clinically significant loss in bone density over the course of treatment, some of which may not be reversible. In patients with major risk factors for decreased bone mineral content such as chronic alcohol and/or tobacco use, strong family history of osteoporosis, or chronic use of drugs that can reduce bone mass, therapy may pose an additional risk. Treatment options for vasomotor symptoms and bone mineral density loss should be considered, SIDE EFFECTS: Very rare cases of pituitary apoplexy have been reported following initial administration in patients with pituitary adenoma. Due mainly to the pharmacological action, adverse events which have been reported include peripheral oedema, pulmonary embolism, hypertension, palpitations, fatigue, muscle weakness, diarrhoea, nausea, vomiting, anorexia, fever/chills, headache (occasionally severe), arthralgia, myalgia, dizziness, insomnia, paraesthesia, visual disturbances, weight changes, increases in liver function test values and irritation at the injection site. Changes in blood lipids and alteration of glucose tolerance have been reported. Thrombocytopenia and leucopenia have been reported rarely. Hypersensitivity reactions including rash, pruritus, urticaria and, rarely, wheezing or interstitial pneumonitis have also been reported. Anaphylactic reactions are rare. Men: Impotence and decreased libido, hot flushes, sweating, orchiatrophy and gynaecomastia. Initial exacerbation may occur in symptoms or

signs due to disease, e.g., bone pain, urinary obstruction, weakness of lower extremities and paraesthesia, which should subside on continuation of therapy. Women: Due mainly to hypo-oestrogenism, adverse events which have been reported include: hot flushes, mood swings including depression (occasionally severe), and vaginal dryness. Breast tenderness or changes in breast size and hair loss have been reported occasionally. Loss in bone density induced by the hypooestrogenic state (see PRECAUTIONS AND WARNINGS). In women who have submucous fibroids; there have been reports of severe bleeding following the administration of PROSTAP SR/3 as a consequence of the acute degeneration of the fibroids. LEGAL CATEGORY: SIA. PACKAGE QUANTITIES: PROSTAP SR: Vial containing 3.75 mg leuprorelin acetate as microsphere powder and pre-filled syringe containing 1ml sterile vehicle. PROSTAP 3: Vial containing 11.25mg leuprorelin acetate as microsphere powder and pre-filled syringe containing 2ml sterile vehicle. PRODUCT AUTHORISATION NUMBER: Prostap SR PA 1547/3/1; Prostap 3 PA 1547/3/2. PRODUCT AUTHORISATION HOLDER: Takeda UK Limited, Takeda House, Mercury Park, Wooburn Green, High Wycombe, Bucks. HP10 0HH, UK. DATE OF PREPARATION: 22nd January 2010 Full prescribing information is available on request from: Takeda UK Limited, Takeda House, Mercury Park, Wooburn Green, High Wycombe, Bucks. HP10 0HH, UK. Tel: (+44) 01628 537900 * Trademark of Takeda

Date of preparation: April 2011 PT110404a

08/07/2011 19:13

life

picture gallery

launch of new learning course for rheumatology health professionals Pictured at the launch of a new blended learning course for rheumatology health professionals entitled Principles of Musculoskeletal Assessment for Rheumatology health Professionals, developed in partnership by Our lady’s hospice and Roche Products (Ireland) ltd, were (l-R): Frances galvin, Roche; teresa Atkinson, Roche; and Catherine Barker, Our lady’s hospice

Also at the launch were (l-R): Aleyamma Mathew, Baltasar Sanchez and Eimear noone, all Our lady’s hospice Dr Suzanne Donnelly, Consultant Rheumatologist, Mater hospital and Director of Clinical Education, School of Medicine and Medical Sciences, UCD; Ms Eileen Shinners, Clinical Facilitator at Our lady’s hospice and Care Services, harold’s Cross; and Frances galvin, Roche Dr Suzanne Donnelly, Consultant Rheumatologist, Mater hospital and Director of Clinical Education, School of Medicine and Medical Sciences, UCD; Prof Oliver Fitzgerald, Consultant Rheumatologist, St Vincent’s hospital; and Ms Eileen Shinners, Clinical Facilitator at Our lady’s hospice and Care Services, harold’s Cross

Daiichi Sankyo Emergency Medicine Meeting

Mr Jason Quinn, Daiichi Sankyo; and Mr James Binchy, Consultant in Emergency Medicine, galway

Dr Abel Wakai, Midland Regional hospital, tullamore; Mary Maguire, Daiichi Sankyo; Dr John Cronin, Crumlin hospital; Mr Jason Quinn, Daiichi Sankyo; Dr David Menzies, Crumlin hospital; Dr Fergal hickey, Sligo; and Dr tomás Breslin, Mater hospital

www.medicalindependent.ie

MI14.2011July14th.indd 34

Dr Una geary, St James’s hospital; and Mr James Binchy, Consultant in Emergency Medicine, galway

14 July 2011 | medical independent 08/07/2011 19:13

life

picture gallery

Festschrift to honour Prof Colm O’Morain Attending the recent Festschrift and symposium to honour Prof Colm O’Morain’s contribution to Irish medicine were: Dr Patricia lorigan, Dr gerry lorigan, Prof Colm O’Morain, Mr Cillian O’Morain, Dr Kate Mcgarry and Mrs Marcelle O’Morain

Dr Paul O’Regan, Dr liam Bannan and Prof Fergus gleeson

Prof Dermot Kelleher, Mr Paul Ridgway, Prof Colm O’Morain, Prof David Kane and Prof Kevin Conlon

Prof Dermot O’toole, Prof Kieran Sheehan, Prof Padraic MacMathuna and Dr Richard Farrell

Dr John Barragry, Mr Paul Ridgway and Mr James geraghty

Dr niall Swan, Ms terry Byrne, Prof Colm O’Morain and Prof Franco Bazzoli

Dr Aidan McCormick, Dr Asshar Qasim and Dr nasir Mahmud

Mr David McAvinchey, Prof Brendan Drumm and Prof humphrey O’Connor

Mr Kieran O’Malley, Dr Conor Keane and Dr Fredrick Falkiner

Prof Conor O’Keane, Prof Colm O’Morain and Prof Des O’neill

medical independent | 14 July 2011 MI14.2011July14th.indd 35

www.medicalindependent.ie

35 08/07/2011 19:14

RxDx Sporting bodies join forces to Abbott Clonmel hosts Kanchi MSD launches new class of atrial launch Infections in Sport booklet Network event for local employers fibrillation agents in Ireland Four of Ireland’s best-known sporting stars joined forces to launch a unique health awareness campaign that aims to help all those involved in sporting activities to avoid the threat of infections in sport. Irish rugby legend David Wallace, Dublin corner forward Bernard Brogan, Shamrock Rover’s star Stephen Rice and Irish hockey star Julia O’Halloran, were on hand to help launch the sports health booklet, which is the first of its kind in Ireland. Sponsored by Sanofi Pasteur MSD, the guide has been endorsed by the IRFU, FAI, GAA and the Irish Hockey Association. The booklet offers advice on practical preventative and addresses a series of infections that can be acquired through track and field activities, including hepatitis B (HBV) and tetanus. Speaking at the launch, Medical Director of the GAA, Dr Danny Mulvihill, said: “Although, the incidence of bloodborne infection in sport is low, the potential risk is always present. Therefore, it is extremely important to educate all those involved in Irish sports, at all levels and regardless of age, about high-risk behaviour and how to avoid any possible exposure.” Dr Conor McCarthy, Medical Director of the IRFU, said: “In sport, it is important that blood injuries are treated appropriately and safely to prevent any possible spread of infection. Maintaining a safe and hygienic environment in the team room and around the field of play must be the goal of all those involved in injury management at sporting events. Even though the chance of spreading infection through sports participation is low, the information provided in this booklet will help to educate all those involved in this area and keep these risks as low as possible.” FAI Medical Director, Dr Alan Byrne, also present at the launch, said: “Education is a key component of illness prevention. Players with a suspected infection should be fully assessed and treated appropriately. Prevention strategies to minimise the risk of transmission to team mates and support staff need to be employed whilst at the same time respecting the strict confidentiality of the doctor-patient (player) relationship.” The booklet is available on the websites of all endorsing bodies and the Irish Sports Council website www.irishsportscouncil.ie. Copies of the booklet can also be found in various student unions throughout the country and GAA, rugby and soccer clubs nationwide.

Shamrock Rover’s star Stephen Rice, Dr Danny Mulvihill (Chairman of the gAA Medical Scientific and Welfare Committee), lisa Mc laughlin (Marketing Manager of Sanofi Pasteur MSD), Dr Alan Byrne (FAI Medial Director) and Dublin corner forward Bernard Brogan, pictured at the launch of a health awareness sports booklet entitled Infections in Sport… Prevention is key which is sponsored by Sanofi Pasteur MSD and endorsed by the gAA, IRFU, FAI and IhA.

www.medicalindependent.ie

MI14.2011July14th.indd 36

Abbott’s vascular facility in Clonmel recently hosted the second ever Kanchi Network event, a forum whereby local employers and organisations are invited to network and explore best practice in the inclusion of people with diverse needs into the workplace. More than 100 delegates attended from local businesses in the area including representatives from Boston Scientific, MSD, Aviva, Dell and Citi. Abbott is one of the founding members of the Kanchi Network. According to Claire O’Callaghan, Kanchi Network Manager: “This is a business membership network whose purpose is to create a leadership group of companies in Ireland that will revolutionise the relationship between business and disability, so that people with disabilities will be recognised and valued as consumers, talent, suppliers and members of the community.” Ger Cronin, Divisional Vice President at Abbott, outlined the company’s approach to celebrating diversity and disability within the workplace. “Abbott focuses on people’s abilities, not their disabilities. We are committed to celebrating disability equality because we believe that diversity is a key contributor to business success. As a healthcare company, innovation is central to business success and having a diversity of ideas, perspectives and experience is critical to finding innovative new solutions. In 2009 Abbott received a gradireland award for being an ‘Employer of Choice for Graduates with Disabilities’ and in 2010 Abbott was named Overall Winner in the Private Sector at the O2 Ability Awards for demonstrating best practice in including people with disabilities in their business. To date, partnership with AHEAD’s Willing, Able & Mentoring (WAM) programme has resulted in the appointment of 15 graduates to permanent positions within the company.

New ACT-RAY data on tocilizumab in arthritis presented at EULAR New data from the ACT-RAY study have shown demonstrated that in people with moderate-to-severe active rheumatoid arthritis (RA), tocilizumab alone has comparable clinical efficacy to tocilizumab (RoActemra) plus methotrexate. The results, presented at the European League Against Rheumatism congress (EULAR), also found that the safety profile of tocilizumab was consistent with previous clinical trials. However, up to 40 per cent of people given methotrexate do not adequately respond to treatment or experience adverse events and require other drugs to help control inflammation. Data from the ACT-RAY study demonstrated that tocilizumab provided clinical benefit, regardless of whether it was given in combination with methotrexate or as a monotherapy. “The findings of the ACT-RAY study provide further evidence of the meaningful benefits of tocilizumab monotherapy,” said Dr Adrian Kilcoyne, Medical Director, Roche Products (Ireland) Limited. Results from the ACT-RAY study build on a previous Phase 3 study (AMBITION) which showed that, compared to methotrexate, patients receiving tocilizumab alone achieved a greater reduction of signs and symptoms of RA (e.g. swollen and tender joints) at six months and nearly three times as many patients achieved DAS28 disease remission. Tocilizumab is the first and only biologic to have demonstrated superiority as monotherapy treatment over methotrexate. RoActemra (tocilizumab) is the first in a class of treatments for rheumatoid arthritis which target interleukin-6 receptors. RoActemra, in combination with methotrexate, is indicated for the treatment of moderate-to-severe active RA in adults who have either responded inadequately to, or who were intolerant to, previous therapy with one or more DMARDs or TNF antagonists. In these patients, RoActemra can be given as monotherapy in cases of intolerance to methotrexate or where continued treatment with methotrexate is inappropriate.

MSD has announced today that Brinavess (vernakalant) IV formulation has been approved in Ireland. The full indication for Brinavess is for the rapid conversion of recent onset atrial fibrillation to sinus rhythm in adults: for non-surgery patients with AF of seven days or less and for post-cardiac surgery patients with AF of three days or less. Brinavess has a unique mechanism of action from other antiarrhythmic medicines and is the first product in a new class of pharmacologic agents for cardioversion of AF to launch in Ireland. According to Dr Richard Sheahan Consultant Cardiologist & Electrophysiologist in Beaumont Hospital, “Brinavess is an exciting addition in the management of recent onset atrial fibrillation. It can be used in the emergency room where the patients are carefully monitored. Sinus rhythm will be restored in over 50 per cent of patients with acute atrial fibrillation and can be discharged within two hours of receiving an infusion of Brinavess. This will result in fewer admissions and a reduction in hospital patient days being required for the management of patients with atrial fibrillation. It is worthwhile to note that Brinavess can be used in patients with structural heart disease, an area where several current medications were contraindicated. For patients within the first 48 hours of onset of atrial fibrillation, Brinavess can be given with appropriate anticoagulation. However, the aniticoagulation status of patients presenting with atrial fibrillation of less than 48 hours duration will need to be confirmed prior to using vernakalant.” The approval of vernakalant is based on the results of three randomised, double-blind, placebo-controlled studies (ACT I, ACT II, and ACT III) and an active comparator trial (AVRO). In ACT I, vernakalant cardioverted 51.0 per cent of patients with short duration AF versus 4.0 per cent of patients taking placebo. In ACT III, vernakalant cardioverted 51.2 per cent of patients with short duration AF versus 3.6 per cent of patients taking placebo. In responders, the median time to conversion was 10 minutes from start of first infusion based on pooled results from the ACT I and ACT III studies. ACT II included 150 patients with sustained AF (three hours to 72 hours duration) that occurred between 24 hours and seven days post coronary artery bypass graft and/or valvular surgery. Treatment with vernakalant effectively converted 47.0 per cent of patients from AF to sinus rhythm versus 14.0 per cent with placebo. In the AVRO study, vernakalant was significantly more effective than amiodarone IV in providing rapid conversion to sinus rhythm within 90 minutes of initiating therapy. Before initiating therapy, the full prescribing information should be consulted at medicines.ie

Positive Phase 2 trial results for trastuzumab emtansine in HER2positive metastatic breast cancer Roche has announced topline results of its first randomised trial of trastuzumab emtansine (T-DM1) in HER2-positive metastatic breast cancer. The Phase 2 trial, known as TDM4450g, compared trastuzumab emtansine single agent to the combination of Herceptin (trastuzumab) and chemotherapy (docetaxel) in previously untreated patients. The results showed that patients treated with trastuzumab emtansine in this study had increased progression-free survival and experienced fewer side effects typical of chemotherapy. “These encouraging data support our ongoing development programme for trastuzumab emtansine in first-line HER2positive metastatic breast cancer,’’ said Dr Hal Barron, Chief Medical Officer and Head of Global Development. “Trastuzumab emtansine is a novel treatment with the potential to improve outcomes for patients with HER2-positive breast cancer due to its efficacy and favourable safety profile.” Data from the TDM4450g study will be submitted for presentation at a future medical congress. An earlier analysis of this study presented at the 35th Congress of the European Society of Medical Oncology (ESMO) in 2010 showed encouraging results in overall response rate in patients with a minimum of four months follow-up. In addition, the study showed that trastuzumab emtansine significantly reduced the burden of typical side effects associated with conventional chemotherapy.

14 July 2011 | medical independent 08/07/2011 19:14

MI14.2011July14th.indd 37

08/07/2011 19:14

recruitment and classifieds To place your advert here, contact Louis O’Hegarty on 01 4189799 or louis@ greencrosspublishing.ie

gp required gP required for new purpose built computerised practice in Portarlington, Co. Laois. Interest in women’s health preferable. Approx. 24 hours/week. Please email CV to drs. montague@eircom.net

practice nurse required

medical practice to let/for sale

Full time experienced practice nurse required for maternity leave cover from 19/09/2011, in a large, fully computerised, city centre general practice (www.mercersmedicalcentre.com), operated by the Royal College of Surgeons. Clinical skills in immunisation and phlebotomy essential. Experience in women’s and travel health an advantage. Enquiries: Nurse Carol Kelly, 01-4022300.

gP Consulting Rooms, Brookwood Rise, Artane. 1st floor premises consisting of four consulting rooms. Densely populated mature area. Front door opening onto street, on-street parking. Located on busy strip of shops, adjacent to Dart etc. Suitable as a second surgery for an existing practice or a new surgery for a new general practitioner. Very competitive terms. Replies directly to: Judy McDonald, 42 Brookwood Rise, Artane, Dublin 5. Phone 086 60770774.

TO LET Medical Surgery adjoining Pharmacy Main Street Naas Co Kildare 045 856604

oneillandco.ie

to let house to let in limerick area, 3 bed house in Dooradoyle area. Near the regional hospital. Excellently maintained with all mod cons please contact 087 6403863.

Fort lorenzo taylor’s hill/Salthill galway Delightful 2 bedroom duplex in prestigious complex overlooking Galway Bay. Close to UCHG. Living/dining with south facing patio in manicured mature grounds. Well equipped kitchen. Downstairs bedroom en suite, nice sized upstairs bedroom, separate full size bathroom. Extras: open fireplace, storage shed, free parking. Private letting – well worth viewing. Call Agnes 086 857 5922.

for sale

National Programme Director for Traffic Medicine A National Programme Office for Traffic Medicine has recently been established by the Road Safety Authority and the Royal College of Physicians of Ireland

A National Programme Director for Traffic Medicine is now to be appointed The National Programme Director for Traffic Medicine will lead the development and implementation of a national framework for standards in traffic medicine in Ireland. Applicants for this position must be practising clinicians with an interest in traffic medicine. Candidates must hold a full-time clinical/ specialist appointment and be on the Specialist Division of the Register of the Irish Medical Council. This post is part-time (17.5 hours per week). Enquiries or requests for a detailed job description can be directed to Mr Leo Kearns, Chief Executive of the Royal College of Physicians of Ireland, at college@rcpi.ie.

The closing date for applications is Friday 22 July 2011

1999 Bentley Arnage – Beautiful car with full service history. British racing green, cream leather upholstery with wooden trim and wooden steering wheel, mint condition, cc 4,398. Many extras including air conditioning, bluetooth, parking sensors front and rear. NCT October 2011. Mileage 60,000. Must be seen. €49,500. Tel 087 262 1818 Holiday deals thE BREhOn & AngSAnA SPA Killarney **** Romance on the Lakes 2 Nights B&B & Dinner in Danu Cruise on the Lakes of Killarney Cocktails in The Brehon Bar Complimentary Relaxation Time in the Angsana Spa From €189pps **** Subject to Availability t&C Apply 064-6671543 www.thebrehon.com

************* 4* hOtEl WEStPORt leisure · spa · conference **************** OVER 50s 5 Nights Dinner, B&B August €409pps / September €369pps 2 Nights B&B + 1 B&B FREE Available Sun – Fri incl August €229pps / September €199pps ****** 2 FAMIly hOlIDAyS AVAIlABlE tEEn FAMIly hOlIDAy or PAnDA FAMIly hOlIDAy 3 Nights from €529 Includes a choice of 2 Days in Westport House Cycle Hire / Killary Cruise Panda Club Activities or Teen Activities

thE MARItIME hOtEl Bantry, West Cork 4* Luxury on the Bay Summer Family Adventure 1 Bedroom Suite (sleeps family of 4) from €180 B&B per night Stay 4 nights or more from ONLY €160 per night 2 Bedroom Suite (sleeps family of 6) from €240 B&B per night Stay 4 nights or more from ONLY €220 per night Complimentary Summer Kids Club Leisure Centre Entertainment Nightly Call 1890 300 107 www.themaritime.ie

****** SEPtEMBER gOlF WEEKS 5 Dinners, B&B + 3 Days Golf 18th – 23rd September OR 25th – 30th September ONLY €399pps / €449 Single Includes FREE Upgrade to Premier Room ****** nOVEMBER BRIDgE hOlIDAyS Sunday 6th – Friday 11th November Sunday 13th – Friday 18th November Sunday 20th – Friday 27th November Includes: 5 Dinners, B&B + Bridge Competitions €339pps / €389 single No Single Supplement All offers Subject to Availability ***** Terms & Conditions Apply Call today 098 25122 www.hotelwestport.ie Call gerti 098a 25122 Dingle Skellig hotel & Peninsula Spa Co Kerry **** For great offers & tailor made packages **** Call 066 9150200 Or log on to www.dingleskellig.com

REnVylE hOUSE hOtEl Connemara, Co. Galway. Bridgestone Guide 2011 ‘100 best places to stay in Ireland’ ****** JUly BREAKS 2B&B1D from €197pp 3B&B 2D from €359pp 10% discount for over 55’s JUly FAMIly BREAKS 3B&B 2D (adults); 3B&B 3 teas (kids) from €728. (2 adults + 2 kids sharing) All JUly & AUgUSt BREAKS InClUDE FREE Weekly Activities for ALL including a weekly Scubadive Lesson, FlyFishing Academy, Tennis Tournaments, Kids Club, Drama & more & FREE use of all on site facilities including Golf, Fly-Fishing, Boating, Canoeing, Tennis Courts, Cycling, Beach & lots more. ******* tel: 095-43511 or 087-4177465 loCall 1850 773355 Email:info@ renvyle.com www.renvyle.com

It’s Magic!

www.medicalindependent.ie

MI14.2011July14th.indd 38

14 July 2011 | medical independent 08/07/2011 19:14

recruitment and classifieds

RCSI Courses

Royal College of Surgeons in Ireland

Department of International Health and Tropical Medicine

Basic Course in Travel Health

IPLOMA COURSE 2nd,D 3rd & 4th March 2011IN TROPICAL MEDICINE 15th August – 26th September 2011 This course is suitable for Doctors, Nurses and other Health Care Professionals working in the This intense six-week course in clinical tropical medicine is designed to field of Travel and International Health.

give candidates an insight into a wide range of diseases in resource-poor settings and Medicine to provide preparation Emergency Forumfor working in developing countries healthcare. 27th,in28th & 29th April 2011

The Departments of Emergency Medicine at Columbia University, St. Luke’s/ Roosevelt Hospital Center, New and Beaumont Hospital are pleased to announce their tenth in a Application formsYork from: series of hands-on interactive Mrs Mairead Lamb, courses for SHOs and Registrars in surgery, medicine, and those interested inTropical pursuingMedicine, a career in Emergency Medicine. Dept of Day 1& 2: Ultrasound as a Bedside Tool Royal College of Surgeons, Day 3: Stephen’s Ultrasound Training & Scenarios in Emergency Medicine & Critical Care 123 St Green, Dublin 2

Tel: +353Course (0) 1 4022186 Diploma in Tropical Medicine

15thE-mail: Augustmlamb@rcsi.ie - 26th September 2011 +353 1 4022462 ThisFax: intense six(0) weeks course in clinical Tropical Medicine is designed to give candidates an Website: www.rcsi.ie insight into a wide range of diseases in resource-poor settings and to provide preparation for working in developing countries in health care. Application forms from: Mrs. Mairead Lamb, Dept. of Tropical Medicine, Royal College of Surgeons, 123 St. Stephen’s Green, Dublin 2. Tel: +353 (0)1 4022186 E-mail: mlamb@rcsi.ie

WHERE WOULD YOU LIKE YOUR CAREER TO HEAD TO?

TTM Medical (www.ttm.ie) is one of Ireland’s leading healthcare recruiters with offices in Ennis, Cork, Dublin, Warsaw and Budapest. We work in partnership with a huge range of public and private hospitals to recruit Medical Doctors across all grades and disciplines. We provide fully screened and vetted candidates to Healthcare settings across Ireland, UK, Australia and New Zealand.

Work in Australia and New Zealand Are you looking for a change in lifestyle and location or simply interested in combining travel with a working holiday in a beautiful location? We are recruiting Doctors at all grades, for permanent and contract appointments throughout Australia and New Zealand. Enjoy fabulous professional and lifestyle opportunities, excellent working conditions and competitive remuneration. Based in the UK with strong links to Australian and New Zealand employers, we are easily contactable and will provide you with a responsive, professional service. We have a wealth of experience in this market so contact us now for a confidential discussion on how we can assist you. Call Anna Payne on +44(0)131 625 9644 or email: anna@headmedical.com Head Medical, 2 Manor Place, Edinburgh, EH3 7DD

www.headmedical.com

medical independent | 14 July 2011 MI14.2011July14th.indd 39

We currently have a number of locum and contract opportunities both in Ireland and internationally at GP, SHO, Registrar and Consultant level. Ireland Hospitals: Consultant Anaesthesiology – 2 weeks – July 18th – Cork Consultant Paediatrician – 6 month contract – South West SHO Medicine – Private Hospital – 6 month contract – Dublin SHO General Surgery – Dublin & South West – 6 month contract Registrar Obstetrics & Gynaecology – South East – 12 month contract SHO Emergency Medicine – Dublin & South East Registrar Anaesthesia – Nationwide Registrar Emergency Medicine – Nationwide Registrar Paediatrics – Nationwide General Practice: Locum – Waterford – July/August dates

Locum – North Tipp – July dates Permanent – Primary Care Centre – South East Permanent – Australia/New Zealand UK Consultant Ophthalmologist Consultant Anaesthetist – London – 6 months International: RMO Emergency Medicine – Australia SMO Emergency Medicine – Australia Consultant Emergency Medicine – Australia RMO Psychiatry – Australia SMO Psychiatry – Australia RMO General Medicine – Australia SMO General Medicine – Australia House Officer – New Zealand

For more details on these and other interesting opportunities, please contact Seamus Tobin at seamus.tobin@ttm.ie or on +353 02586000 with updated CV at your earliest convenience to set up an immediate interview. For more permanent & locum opportunities visit,

www.jobs4doctors.ie

www.medicalindependent.ie

39 08/07/2011 19:14

the dorsal view

A round-up of medical news and oddities from left field by Dr Doug Witherspoon

the Bridgestone guide approach I

siast Ruairi Hanley. Wait for it... “hospitals need farmers’ markets”. The increasingly beleaguered and long-suffering Mrs Witherspoon tells me she knows I must be reading the Irish Times if she hears the words “Jesus” and “Wept” from behind the paper three times within an hour, but this definitely broke the record with a liberal sprinkling of ‘f’s’ thrown in for good measure. It might not be as daft as it seems though. Hardpressed NCHDs could make a few bob selling fruit and veg to delayed patients. Moore Street would have nothing on it: “Last of the trolley turnips now folks“, “get yizzer waiting list watercress folks, three for a yoo-roh!”. And it would undoubtedly be worth it to see the looks on the faces of the infection control jet set.

t seems everyone is weighing in on the NCHD debate these days, but I was particularly tickled by a piece by John McKenna of The Bridgestone Guide fame in a recent edition of the Irish Times Health Supplement. McKenna’s niece is an Irish NCHD who described to him the on-call rituals of midnight pizzas and M&S microwave meals long after the hospital canteen has closed: ...“the young doctor living on takeaways, whose culinary skills extend no further than pushing the button on the microwave, isn’t in the right position to ask that question (asking a patient what did you eat for your last meal), or to deal with the answer.” The food critic then went on to offer a solution to this crisis that was as practical and rooted in reality as the indentured service scheme suggested by well-known Irish Times commentator Chris Luke and Irish Times enthu-

Down memory lane

Freedom like never before

It was in the company of my colleagues on those well-remembered days where doctors were forged in the heat of on-call battle, that we swapped stories over soggy slices of pizza. My own favourite one related to my dim and distant past as a surgical SHO in a city hospital overseas which did a nifty line in looking after prisoners from a nearby institution. One unfortunate inmate seemed quite taken with the hospital and presented frequently with various aches, pains and grumbles which eventually resulted in the excision of both his appendix and gallbladder on what turned out to be shaky grounds. His adventures were soon rumbled by our eagle-eyed older consultant who spotted his plan. After another late night admission from the ‘Big House’ our hero pleaded the case on the following morning’s ward round that he definitely, definitely had a stomach ulcer and that the excision of part of his stomach was simply the only thing that would do. But the wily old professor new better and said to him “Now, my good man, if you think I am going to help you get out of that prison one organ after another you have another think coming”. Suitably chastened, what was left of him was discharged back to the care of the governor.

It’s the way I tell ‘em

YAZ® is the first everyday contraceptive pill with drospirenone l l l l

24+4 dosing regimen (24 active tablets + 4 placebo tablets) Positive effects on premenstrual symptoms and skin1,2

Greater ovarian suppression compared to a traditional 21+7 regimen3,4 Good safety profile and high user satisfaction5

See full Summary of Product Characteristics (SmPC) before prescribing. Yaz 0.02 mg / 3 mg film-coated tablets. Each pink active tablet contains 0.02 mg ethinylestradiol (as betadex clathrate) and 3 mg drospirenone. The white placebo tablet does not contain active substances. Indication: Oral contraception. Dosage and administration: One tablet daily for 28 consecutive days in order shown on blister pack. Missed tablets, gastro-intestinal disturbances, concomitant medication: may reduce efficacy (see SPC for guidance). Contraindications: Combined oral contraceptives (COCs) should not be used if any of the conditions listed below are present. If any of these conditions appear for the first time during use, stop Yaz immediately: past or present venous or arterial thrombosis or cerebrovascular accident (CVA); presence of prodromal conditions; severe or multiple risk factors (diabetes mellitus with vascular symptoms; severe hypertension; severe dyslipoproteinemia), hereditary or acquired predisposition for venous or arterial thrombosis; past or present pancreatitis with severe hypertriglyceridemia; past or present severe hepatic disease until liver function values return to normal; severe renal insufficiency, acute renal failure; past or present liver tumours (benign or malignant); known/suspected sex steroid-influenced malignancies (e.g. of genital organs or breasts); undiagnosed vaginal bleeding; history of migraine with focal neurological symptoms; hypersensitivity to any of the ingredients. Precautions and Warnings: Medical examination before treatment: medical history, family history, BP, physical examination, exclusion of pregnancy. Monitor as appropriate. If any of the following conditions/risk factors are present, consider individual risk/benefit. Consider discontinuation in case of aggravation, exacerbation or first onset of any of these conditions/risk factors. COC use is associated with increased risk of venous and arterial thromboembolism. Excess risk of venous thromboembolism (VTE) is highest during first year of use. Studies have shown that the risk of VTE for drospirenone-containing OCs is higher than for levonorgestrel-containing OCs and may be similar to the risk for desogestrel/ gestodene-containing OCs. Risk of venous or arterial thrombotic events or CVA increases with increasing age; smoking; positive family history (refer to specialist before treatment); obesity; dyslipoproteinemia; hypertension; migraine; valvular heart disease; atrial fibrillation; prolonged immobilisation, major surgery, surgery to the legs, major trauma (discontinue COC, at least 4 weeks in advance in case of elective surgery; consider antithrombotic treatment if not discontinued in advance; do not resume until 2 weeks after complete remobilisation). No consensus about the role of varicose veins and superficial thrombophlebitis. Advise patients to contact physician in case of possible symptoms of thrombosis. Discontinue use if suspected/confirmed thrombosis and initiate adequate alternative contraception. Increased risk of thromboembolism in the puerperium. Other conditions associated with adverse vascular events: diabetes mellitus, systemic lupus erythematosus, haemolytic uremic syndrome, chronic inflammatory bowel disease, sickle cell disease. Consider immediate discontinuation if increased frequency or severity of migraine. Some reports of increased risk of cervical cancer in long-term COC users (>5 years). Slightly increased relative risk of breast cancer diagnosis in current COC users. Rare reports of benign and malignant liver tumours. In isolated cases these have lead to life-threatening intra-abdominal haemorrhage. Test for serum potassium during the first cycle in patients with mild/moderate renal impairment and concomitant use of potassium-sparing medications. Hypertriglyceridemia or family history thereof may increase the risk of pancreatitis. Small increases in blood pressure reported but rarely clinically relevant. Discontinuation of COC justified in these rare cases. Use in pre-existing hypertension: withdraw COC if constantly elevated BP values or significant increase in BP do not respond to antihypertensive therapy. Conditions which may occur/deteriorate with both pregnancy and COC use: jaundice and/or pruritus related to cholestasis; gallstones; porphyria; systemic lupus erythematosus; haemolytic uremic syndrome; Sydenham’s chorea; herpes gestationis; otosclerosis-related hearing loss. Hereditary angioedema: exogenous estrogens may induce/exacerbate symptoms. Acute or chronic liver dysfunction may require discontinuation until liver function returns to normal. Discontinue in recurrence of cholestatic jaundice and/or cholestasis-related pruritus which previously occurred during pregnancy or sex steroid use. Monitor diabetic patients carefully. Worsening of endogenous depression, epilepsy, Crohn’s disease and ulcerative colitis have been reported. Chloasma may occur, especially with history of chloasma gravidarum. Contains lactose, should be taken into account by patients with hereditary galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption. COCs do not protect against HIV/sexually transmitted diseases. If bleeding irregularities persist or occur after previously regular cycles, exclude malignancy or pregnancy. If COC not taken according to directions prior to a first missed withdrawal bleed or if two withdrawal bleeds are missed, rule out pregnancy before continued use. Interactions: Interaction with other drugs may lead to breakthrough bleeding and/or contraceptive failure. Interactions can occur with hepatic-enzyme inducers, e.g. phenytoin, barbiturates, primidone, carbamazepine, rifampicin, bosentan, ritonavir and nevirapine; possibly oxcarbazepine, topiramate, felbamate, griseofulvin, products containing St. John’s Wort. Maximal enzyme induction seen after 10 days and lasts for at least 4 weeks after cessation of therapy. Contraceptive failures have occurred with antibiotics. Short term treatment with the above drugs: take additional precautions during treatment and for 7 days after treatment stopped (28 days for rifampicin). If treatment runs beyond end of active tablets, discard the placebo tablets and start next pack right away. Long-term treatment with hepatic enzyme-inducers: non-hormonal method is recommended. OCs may affect plasma levels of certain drugs e.g. cyclosporin, lamotrigine. Concomitant use with aldosterone antagonists or potassium-sparing diuretics has not been studied. Yaz may influence results of laboratory tests. Pregnancy and lactation: Pregnancy: Not indicated; withdraw immediately if pregnancy occurs. Lactation: Not recommended. Undesirable effects: Common: emotional lability; headache; nausea; breast pain; metrorrhagia; amenorrhea. Uncommon: depression; libido decreased; nervousness; somnolence; dizziness; paresthesia; migraine; varicose vein; hypertension; GI disturbances; acne; pruritus; rash; back pain; pain in extremity; muscle cramps; vaginal candidiasis; pelvic pain; breast enlargement; fibrocystic breast; uterine / vaginal bleeding; genital discharge; hot flushes; vaginitis; menstrual disorder; dysmenorrhea; hypomenorrhea; menorrhagia; vaginal dryness; suspicious Pap smear; asthenia; increased sweating; edema; weight increase. Rare: candidiasis; anemia; thrombocythemia; allergic reaction; endocrine disorder; increased appetite; anorexia; hyperkalemia; hyponatremia; anorgasmia; insomnia; vertigo; tremor; conjunctivitis; dry eye; eye disorder; tachycardia; phlebitis; vascular disorder; epistaxis; syncope; abdomen enlarged; GI disorder; GI fullness; hiatus hernia; oral candidiasis; constipation; dry mouth; biliary pain; cholecystitis; chloasma; eczema; alopecia; dermatitis acneiform; dry skin; erythema nodosum; hypertrichosis; skin disorder; skin striae; contact dermatitis; photosensitive dermatitis; skin nodule; dyspareunia; vulvovaginitis; postcoital bleeding; withdrawal bleeding; breast cyst; breast hyperplasia; breast neoplasm; cervical polyp; endometrial atrophy; ovarian cyst; uterine enlargement; malaise; weight decrease. Frequency not known: hypersensitivity; erythema multiforme. Further information available from: PA Holder: Bayer Limited, The Atrium, Blackthorn Road, Dublin 18 Tel. 01-2999313. PA No.1410/56/1. Classification for sale or supply Prescription only. Date of preparation: June 2011. References: 1. Yonkers KA et al; Obstet Gynecol 2005; 106(3): 492-501. 2. Koltun W et al; Contraception 77 (2008) 249-256. 3. Klipping C et al ; Contraception 78 (2008) 16-25. 4. Sulak PJ et al; Obstet Gynecol 2000; 5(4):256-64. 5. Bachmann G et al; Contraception 2004; 70(3): 191-8. L.WH.06.2011.0140.

www.medicalindependent.ie

MI14.2011July14th.indd 40

Without breaking any confidences, it might interest a few of you to know that Ronan Keating recently walked into a colleague’s office. The receptionist asked him what he had. Ronan said, “shingles”. So she took down his name, address, medical insurance number and told him to have a seat. Ten minutes later an intrigued practice nurse came in eager to meet her teenage pin-up and asked him what he had. He said, “shingles”. So she gave him a blood test, a blood pressure test, an ECG, told him to take off all his clothes and wait for the doctor. Fifteen minutes later the doctor came in and asked the now naked crooner what he had. He said, “shingles”. A thorough inspection of the singer revealed not a vesicle to be seen. Exasperated, my colleague asked him where he had the shingles. A clearly frustrated Ronan replie: “Inshide my bag doc, and I’ve a few shigned copies outshide in the car if you want one.”

One more thing In honour of the first paragraph and the concerned people at The Bridgestone Guide, I feel obliged to share just one more joke with you. A patient walks into a doctor’s office with a cucumber crammed into one ear, a bouquet of parsley jammed into his mouth, and surprisingly large carrots hanging from his nostrils. He manages to mumble, “Doc, you gotta help me. I feel awful. What’s wrong with me?” The doctor replied, “You’re not eating properly.”

If you have any similar gems, thoughts or observations that you would like to share, please email Dr Doug at medindependent@gmail.com. Your insights on the lesser-spotted side of medicine are welcomed and appreciated.

14 July 2011 | medical independent 08/07/2011 19:14