veNTIlATIoN - Green Cross Publishing

The Journal of the Irish Practice Nurses Association
Issue 1 Volume 3 January / February 2010
NoN-INvAsIve
veNTIlATIoN
AN overvIew For The
PrImAry cAre Nurse
Noreen Donoghue
INTervIew:
NeTTA wIllIAms
FouNder member
oF The IPNA
chroNIc PAIN
IN older AdulTs
Nicola Cornally
Professor Geraldine McCarthy
exPlorINg The
exPerIeNce oF coPd
A PheNomeNologIcAl sTudy
Ursula Reilly Clarke
PosT NATAl
sexuAl heAlTh
Kate McCabe
The ImmuNe sysTem
ANd your guT: PArT 4
ProbIoTIcs serIes
Deirdre Jordan
Linda V Thomas

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Nurse Prescribing
editorial
It’s that time of year again — time to consider our professional development needs for
the coming year. Nurse prescribing has the potential to enhance and further develop
the practice nurse role and assist in providing holistic patient care. The education
component is now open to practice nurses in both RCSI in Dublin and UCC in Cork.
The two programmes vary slightly in terms of class contact time and assessments. The
programme in Dublin is available through sites in Galway, Cavan and Tullamore which
means that only four days attendance (including examinations) is required in Dublin.
Attendance on a fortnightly basis over a six month period is required at the local site. The
programme is open to all nurses irrespective of grade.
Other considerations which should be taken into account if a nurse is thinking about
undertaking this programme are:
Access to drugs and therapeutics committees (D &T) — these may be available in
your area. If not, you can set one up. The make up of these committees should include
a pharmacist, a GP, a practice nurse, a nursing manager and an independent medical
person. One of the functions of the D & T committee is to sign off on the Collaborative
Practice Agreement which includes the list of drugs the nurse may prescribe
Access to a medical mentor — this person can be your GP
Access to a prescribing site co-ordinator — this person can or may be the Professional
Development Co-ordinator for Practice Nurses in your area. She may also act as your
Nurse Manager for the project
Resources — HSE funding is currently not available to practice nurses for the
programme and the nurse will also need to negotiate study leave.
Access to all of the above at the time of completing the application form is required.
Should the D & T committee not be in place at the time of application, then it must be in
place on completion of the six month programme.
At the beginning of the educational programme, the nurse registers onto the Nurse
& Midwife Prescribing Candidate Register of An Bord Altranais. During the programme,
the practice must develop a Prescribing Protocol. It is advisable to start consideration
of the drugs the nurse is going prescribe early on in the programme. On successful
completion of the course, the nurse then submits the Collaborative Practice Agreement
(CPA) to An Bord Altranais to be admitted onto the Nurse & Midwife Prescribing register.
The CPA must be submitted to An Bord Altranais on a yearly basis. The nurse may submit
any changes to the list of drugs to the D & T throughout the year. The number of times
the D & T committee meets will be determined locally. The Registered Nurse Prescriber
(RNP) will have to continuously audit her prescribing and submit this to the Office of the
Nursing Services Director (ONSD).
The “Guiding Framework for the Implementation of Nurse and Midwife Prescribing in
Ireland” (ONSD, 2008) provides useful information if a practice nurse is considering nurse
prescribing.
Ruth Taylor
1

� Convenient to take ������� ������
� 20% more calcium than the market leader †
� Market leader is 41% more expensive †
for longer
lasting bones
calcium & vitamin D3
ABBREVIATED PRESCRIBING INFORMATION
(Please refer to Summary of Product Characteristics before prescribing)
CALTRATE* 600 mg/400 IU, fi lm-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 defi ciencies
in the elderly. As an adjunct to specifi c treatments for osteoporosis, in patients where combined vitamin D & calcium defi ciencies have been diagnosed or those at high risk of defi ciency. 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 diffi culties 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 calcifi cation must be considered. In severe renal insuffi ciency, 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 (paraffi n 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 fl uoride or fl uoroquinolone 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 aff ect the developing foetus. Calcium & vitamin D3 pass into breast milk, this should be considered
when vitamin D3 is given concomitantly to infants. Side-eff ects: Hypercalcaemia, hypercalciuria, constipation, fl atulence, nausea, abdominal pain, diarrhoea, pruritis, rash & urticaria. Legal Category: P. Pack Size: 90 tablets. PAH: Whitehall Laboratories Ltd T/A Wyeth
Consumer Healthcare, Taplow, Berks, SL6 0PH, United Kingdom. PA number: PA172/38/1. Further information is available upon request from Wyeth Consumer Healthcare, Blanchardstown Corporate Park 2, Dublin 15 or look up, www.medicines.ie PCRS Reimbursable.
Date of preparation: December 2009. † Source: MIMS September 2009. * Trade Mark.
Dec 09 Ref: Ca 09 108 Med.

The Journal of the Irish
Practice Nurses
Association
1 edITorIAl
4 News
12 brANch News
revIew
14 NoN-INvAsIve veNTIlATIoN —
AN overvIew For The PrImAry
cAre Nurse
Noreen donoghue
21 chroNIc PAIN IN older AdulTs
Nicola cornally
Professor geraldine mccarthy
26 PosT NATAl sexuAl heAlTh
Kate mccabe
30 exPlorINg The exPerIeNce oF coPd:
A PheNomeNologIcAl sTudy
ursula reilly clarke
EDITOR
Maura Henderson
CONSULTING EDITORS
Darina Lane and Ruth Morrow
SUB EDITOR
Tim Ilsley
DESIGNER
Barbara Vasic
PUBLISHERS
Graham Cooke
Maura Henderson
*GreenCross Publishing is a recently
established publishing house which is
jointly owned by Graham Cooke and
Maura Henderson. Between them Graham
and Maura have over 25 years experience
working in healthcare publishing. Their stated aim is to publish
titles which are incisive, vibrant and pertinent to their readership.
Graham can be contacted at
graham@greencrosspublishing.ie
Maura at
maura@greencrosspublishing.ie
Disclaimer
The views expressed in Nursing in General Practice are not
necessarily those of the publishers, editor or editorial advisory
board. While the publishers, editor and editorial advisory board
have taken every care with regard to accuracy of editorial and
advertisement contributions, they cannot be held responsible for
any errors or omissions contained.
Contents
35 INTervIew:
Nursing in General Practice is published by
GreenCross Publishing, Lower Ground Floor,
5 Harrington Street, Dublin 8.
Tel: 4789770 Fax: 4789764
Email: maura@greencrosspublishing.ie
Issue 5 1 Volume 2 3 september January / February / october2009 2010
NeTTA wIllIAms,
FouNder member oF The IPNA
38 ProbIoTIcs serIes
The ImmuNe sysTem ANd your guT: A closer
looK AT ThIs INTrIcATe relATIoNshIP. PArT 4
deirdre Jordan
linda v Thomas
44 PATIeNT’s PersPecTIve
cANcer — The role oF NuTrITIoN ANd dIeT —
A PATIeNT’s seArch
mJ murray
47 PosTer serIes
hyPerTeNsIoN mANAgemeNT:
The role oF The PrAcTIce Nurse
stella hogan and róisín doogue
FooT cAre ANd FooTweAr
Ann casey
50 AbsTrAcTs
osTeoPorosIs
womeN’s heAlTh
54 ProducTs
57 crossword
© Copyright GreenCross Publishing 2009
The contents of Nursing in General Practice are protected by copyright.
No part of this publication may be reproduced, stored in a retrieval
system, or transmitted in any form by any means – electronic,
mechanical or photocopy recording or otherwise – whole or in part, in
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the prior written permission of the editor or publishers
3

news
4
National measles outbreak
continues to escalate
Last year 144 measles cases were reported; this compares to
51 for the same time period in 2008. An increase in measles
incidence and an outbreak among traveler children and young
adults is causing particular concern.
Of the 144 cases reported since the beginning of the year, a
consistent increase was noted since September; 96 cases have
been reported since September, compared to 17 for the same
time period the previous year.
The first symptoms of measles occur after a 10-12 day
incubation period that follows airborne or droplet exposure.
Immunosuppressed person may have a prolonged incubation
period. The prodrome is heralded by the onset of fever, malaise,
conjunctivitis, coryza, and tracheobronchitis and lasts 2-4 days.
This clinical picture is characterized by fever, which increases
in a stepwise fashion, often reaching 40.6 0 C. Koplik’s spots,
found on the buccal mucosa are believed to be pathognomonic
for measle. These salt-grain-like spots appears on the buccal
mucosa 1-2 days before onset of rash and may be noted for an
additional 1-2 days after rash onset. The rash is an erythematous
maculopapular eruption that usually appears 14 days after
exposure and spreads from the head (face, forehead, hairline,
ears and upper neck) over the trunk to the extremities during
a 3-4 day period. The rash is usually most confluent on the face
and upper body and initially blanches on pressure. During
the next 3-4 days it fades in the order of its appearance, and
assumes a non-blanching brownish appearance.
The virus can be isolated from the nasopharynx and blood
during the latter part of the incubation period and during the
early stages of rash development. Viraemia generally clears
2-3 days after rash onset in parallel with the appearance of the
antibody. Individuals with measles are considered infectious 2
to 4 days before until 4 days after rash onset.
Complications of measles infection are common. In
industrialized countries the most commonly reported
complication is otitis media (7%-9%), pneumonia (1%-6%),
NEC NEWS
lIsA NolAN,
IPNA AdmINIsTrATor
Lisa Nolan, IPNA Administrator.
Tel: 042-9692403
e-mail: admin@irishpracticenurses.ie
2010 Nec meeTINgs
• Wednesday 3 rd February 2010 — Ashling Hotel, Parkgate
Street, Dublin 7.
• Wednesday 12 th May 2010 — Ashling Hotel, Parkgate
Street, Dublin 7 - please note this has changed from
original date of 5 th May.
• Wednesday 8 th September 2010 — Ashling Hotel,
Parkgate Street, Dublin 7.
• Friday 15 th October 2010 at IPNA Conference in Jacksons
Hotel, Ballybofey, Co Donegal.
diarrhoea (85), post infectious encephalitis (1 per 1000 to
2,000 cases), subacute sclerosing panencephalitis (SSPE) (1 per
100,000 cases) and deaths (1-3 per 1000 cases). Complications
are likely to be present if the fever has not decreased within
1-2 days of rash onset. The risk of serious complications and
death is increased in children less than 5 years of age and adults
greater than 20 years of age. Pneumonia which is responsible
for approximately 60% of deaths, is more common in young
patients, whereas acute encephalitis occurs more frequently
in adults. Pneumonia may occur as primary viral pneumonia
or as a bacterial super-infection. Other complications include
thrombocytopaenia, laryngotracheobronchitis, stomatitis,
hepatitis, appendicitis, ileocolitis, pericarditis and myocarditis,
glomerulonephritis, hypocalcaemia, and Stevens-Johnson
syndrome.
Preventing healthcare transmission
In order to prevent transmission of measles in the healthcare
setting, all healthcare workers (both clinical and non clinical)
are recommended to have either serological proof of immunity
or evidence of having received 2 doses of MMR. Those who are
on immune should receive 2 doses of MMR. Post vaccination
testing is not required.
Due to its high infectivity, suspect measles cases should
be quarantined. Clinical assessment should ideally be done
in the home, or if not possible the patient should be seen
at the end of the clinic to avoid exposing other patients to
the case. In the hospital setting, all suspect cases should be
isolated upon entry to the hospital and appropriate infection
control measures followed. Only those staff with documented
measles immunity should provide care to a suspect measles
case.
Non-vaccinated children, scheduled for elective hospital
admission in the areas where the outbreak is occurring should
be vaccinated prior to admission where possible.
DIARy DATE
caring for Patients with dementia and dysphagia
Nutricia Medical is hosting three free evening
educational seminars on caring for patients with
dementia and dysphagia.
• Wednesday 24th February, Radisson Hotel, Galway.
• Tuesday 2nd March, Ormonde Hotel, Kilkenny.
• Wednesday 3rd March, Maryborough Hotel, Cork.
For further information and to reserve a place call
Freephone 1800 300 414 or
email: events.ireland@nutricia.com.

First nurse prescribers
in addiction announced
The Drug Treatment Centre Board has announced the
successful graduation of two of its nurses as Nurse
Prescribers in Addiction.
Sheila Heffernan, General Manager of The Drug Treatment
Centre Board, said that, “Expanding prescriptive authority
to nurses has the real potential to enhance patient care and
deliver on the HSE Transformation Programme Priorities”.
Maureen Flynn, Assistant Director of Nursing, Office of
the Nursing Services Director, who presented the first
two Nurse Prescribers in Addiction with their certification
said, “The Drug Treatment Centre Board has played a
vital part in taking on the pioneering role of introduction
Nurse Prescribing in Addiction. This is truly an important
advancement and a great achievement for the Board.”
In 2008 and early 2009 BreastCheck provided free
mammograms to 92,061 women aged 50 to 64. Since the
screening programme began, BreastCheck has provided almost
560,000 mammograms to over 276,000 women and detected
over 3,500 breast cancers.
Of the 92,061 women screened, 4,119 were re-called for
further assessment. Six hundred and seventy two women
were diagnosed with breast cancer, representing 7.3 cancers
per 1,000 women screened, compared to six cancers per
1,000 women screened in 2007. The overall rate of acceptance
of invitation to screening was 77.4 per cent, in excess of the
programme target of 70 per cent.
Commenting on the results, Tony O’Brien, Chief Executive
Officer of the National Cancer Screening Service said: “During
2008 and early 2009, BreastCheck provided a fully quality
assured mammogram to the highest number of women since
the programme began. Ninety two thousand and sixty one
women aged 50 to 64 accepted their BreastCheck invitation,
representing a 38 per cent increase on the previous year. In
addition, BreastCheck was introduced to all remaining counties
in the expansion area during 2009, within 22 months of initial
expansion to the southern and western regions of the country.
Since screening began in the southern and western regions
in December 2007 to October 2009, over 67,000 women have
received a BreastCheck mammogram and I am delighted that
we can now offer a truly national breast screening service to
women in Ireland”.
In 2008, 39,802 of the women screened were new to the
programme and 52,259 women had previously received at least
one BreastCheck mammogram. The uptake of first screening
invitation continues to be highest in the youngest age group,
50 to 54, and the majority of women screened for the first time
are in this age bracket. For subsequent invitations (women who
have attended a BreastCheck appointment previously), there
is little difference between the age groups, with a high rate of
uptake recorded across all age groups.
back row: eamon Keenan, consultant Psychiatrist
in substance misuse, dTcb, claire loomes, Nurse
Prescriber, dTcb, dr John o’connor, clinical director
dTcb, Jane bridgeman Nurse Prescriber dTcb, mary
egan Pharmacist dTcb, seamus Noone, clinical
operations manager dTcb. Front row: maureen Flynn,
Assistant director of Nursing and midwifery hse, sheila
heffernan, general manager dTcb, christina murtagh,
clinical Nurse manager dTcb.
news
breastcheck reaches 92,000 women
The acceptance rate among women invited for a subsequent
screening is greater than 90 per cent i.e. of every 10 eligible
women re-invited for screening by BreastCheck, nine women
return. This reflects well on satisfaction of women with the
screening experience.
5

news
6
older people urged to look
after their mental health
As we are in the winter months older people in Ireland are being
encouraged to look after their mental health and to seek help
and support if they are feeling depressed most of the day, most
days. Leading Old Age Psychiatrist, Professor Brian Lawlor, and
advocacy group Age Action urged older people to address the
issue of their mental health at the launch of the ‘Mind Yourself
— Depression in Later Life’ leaflet recently. The leaflet, produced
by Lundbeck (Ireland) Ltd, provides useful information to help
people recognise the symptoms of depression in later life and
how to access support services and resources.
The leaflet was developed following research amongst over
65 year olds, carried out by Behaviour and Attitudes on behalf
of Lundbeck which shows that almost 60% of those surveyed
believe that people in their age group would be reluctant to
discuss depression with others. One quarter of respondents
said they believed that depression is a state of mind and not
an illness which could indicate a lack of understanding of
depression, resulting in many older people with depression not
being diagnosed or receiving the help they need.
Some 91% of respondents believed that depression can have
a very negative impact on a person’s life, with 82% believing
that depression is not well understood by many people. Well
over two thirds (70%) of those with depression think that
there is a lot or some social stigma associated with depression.
Irish pharmaceutical contract sales organisations (CSO)
Pharmexx Ireland Ltd and Alchemy Healthcare (Ireland) Ltd have
now merged. The new company, Pharmexx Alchemy, will have a
15% market share in the Irish pharmaceutical CSO market, which
is estimated to be worth €20 million overall.
The company provides outsourcing of skilled pharmaceutical
and retail representatives to most of the leading pharmaceutical
companies based in Ireland. It also offers specialised nursebased
patient support programmes, as well as more traditional
contract sales. Pharmexx Alchemy has set forth an ambitious
model for growth, with an aim to become the number-one
player in the CSO market by 2015. Pharmexx Ireland and
Alchemy both started business in 2008. Pharmexx, part
of the international Pharmexx group (owned by German
company Celesio, which is also represented in Ireland by
Cahill May Roberts, Movianto and Unicare), offers integrated
commercialisation services by combining warehousing and
special logistics services with CSO solutions for a broad range
of pharmaceuticals. Alchemy Healthcare, led by founders
and managers Mick O’Leary and Pat Kerley, provides a highly
The research also revealed that those most likely to suffer
from depression in this age group are older women who are
widowed.
“With older people, while their physical ailments may
be detected and addressed their depression can often be
overlooked and undertreated,” according to Professor Lawlor,
“Factors such as social isolation, bereavement and retirement
can be extremely distressing for older people and can lead to
depression. I would urge people to look out for warning signs.
Low mood or sadness, social withdrawal, increased fatigue,
loss of appetite, disturbed sleep, loss of enjoyment, feelings
of hopelessness or life not worth living can all point to the
presence of depression and should not be ignored.”
Eamon Timmins, Age Action welcomed the research saying,
“This research gives us a valuable insight into the attitudes
towards depression among the over 65s. Our ethos is to
empower older people so that they can enjoy their later years.
We would urge them to take account of their mental health as
well as their physical health. Depression is not an inevitable part
of ageing and can be treated successfully.”
The new information leaflet, ‘Mind Yourself — Depression in
Later Life”, is being launched today by Lundbeck (Ireland) Ltd to
help older people who may have depression. It is available free
by calling 01-468 9800 and will be distributed via GP surgeries.
Pharmexx Ireland and Alchemy Healthcare
merge to create Pharmexx Alchemy
motivated management team with long standing experience
and established contacts in the Irish pharmaceutical industry.
Mick O’Leary, managing director of Pharmexx Alchemy,
is confident that the range of services will appeal to the
pharmaceutical market in Ireland; “Alchemy Healthcare built
its success in the pharmaceutical market, supplying the
best people and strategies to our clients, whilst Pharmexx
has excelled in the retail/OTC space. The marriage of these
two critical service areas will ensure a compelling business
proposition for our existing and future clients. We look forward
to providing the most integrated and complete range of
services to the pharma industry in Ireland.”
James Quinn, Commercial Director of Celesio Ireland,
commented: “The newly created Pharmexx-Alchemy will allow
Movianto to grow strongly in the CSO market. We have an
ambitious goal of becoming the number-one player in Ireland
by 2015. This merger is the first, important step in achieving this
vision.
The strengths of both these companies complement each
other perfectly and provide an excellent platform for success.”

Butrans ® patches contain an opioid analgesic
PRESCRIBING INFORMATION
BuTrans ® 5µg/h, 10µg/h and 20µg/h Transdermal Patch
Presentation: BuTrans 5µg/h, 10µg/h, 20µg/h. Transdermal beige patches
containing buprenorphine. Indications: Treatment of non-malignant pain of
moderate intensity when an opioid is necessary for obtaining adequate
analgesia. BuTrans is not suitable for the treatment of acute pain. Dosage and
Administration: BuTrans should be administered every 7 days. Elderly and
adults over 18 years only: Use the 5 µg/h patch for at least the first 3 days of
treatment, before increasing the dose if necessary. Do not use more than two
patches at a time. Contra-indications: Known buprenorphine or excipient
hypersensitivity, opioid dependent patients, narcotic withdrawal treatment,
respiratory depression, us e of MAO inhibitors within the past 2 weeks,
myasthenia gravis, delirium tremens, pregnancy and lactation. Precautions
and Warnings: Convulsive disorders, head injury, shock, reduced
consciousness of uncertain origin, intracranial lesions or increased intracranial
pressure, severe hepatic impairment, history of drug abuse. Not
recommended immediately postoperatively or for situations characterised by
a narrow therapeutic index or for rapidly varying analgesic requirements. May
® Butrans is a Registered Trademark. © 2009 Napp Pharmaceuticals Limited. CODE 0924BTN. Date of item: April 2009
days
pain relief in
one BuTrans patch
BuTrans® matrix patches are Ireland’s first patches designed to provide 7 days’
continuous relief from moderate osteoarthritis pain. Good news for doctors,
good news for patients, good news for joints.
affect ability to drive or use machinery. Interactions: Monoamine oxidase
inhibitors (MAOIs), CNS depressants (e.g. benzodiazepines, opioid
derivatives, antidepressants, sedatives, alcohol, anxiolytics, neuroleptics,
clonidine). CYP 3A4 inhibitors and inducers, products reducing hepatic blood
flow (e.g. halothane). Side Effects: Common: anorexia, confusion,
depression, insomnia, nervousness, headache, dizziness, somnolence,
paraesthesia, vasodilation, dyspnoea, constipation, dry mouth, nausea,
vomiting, abdominal pain, diarrhoea, dyspepsia, sweating, tiredness, pain,
peripheral oedema, application site reaction, chest pain, pruritus, erythema,
rash, exanthema, asthenia. Potentially serious side effects also include: allergic
reactions, psychotic disorder, hallucinations, nightmares, drug dependence,
mood swings, dysarthria, migraine, syncope, visual disturbance, angina
pectoris, palpitations, tachycardia, hypotension, hypertension, aggravated
asthma, respiratory failure, diverticulitis, dysphagia, ileus, biliary colic,
myalgia, depersonalisation, memory impairment, respiratory depression,
urinary retention, decreased libido, pyrexia, rigors, alanine aminotransferase
increased, drug withdrawal syndrome, abnormal coordination, circulatory
collapse, wheezing. Please consult the SPC for details of other side-effects.
Legal Category: CD (Sch2) POM. Package Quantities: 5 µg/h transdermal
patch: 2 individually sealed patches. 10 µg/h transdermal patch: 4 individually
sealed patches. 20 µg/h transdermal patch: 4 individually se aled patches.
Marketing Authorisation Numbers: PA 913/24/1-3. Marketing
7 7 Days’ Days’
continuous continuous
relief relief from from
MODERATE MODERATE
OSTEOARTHRITIS
OSTEOARTHRITIS
PAIN
PAIN
Not suitable for the treatment of acute pain.
Authorisation Holder: Napp Pharmaceuticals Limited, Cambridge Science Park,
Milton Road, Cambridge CB4 0GW, UK. Further information is available
from: Mundipharma Pharmaceuticals Ltd, Millbank House, Arkle Road,
Sandyford, Dublin 18. Tel: +353 (0)1 2063800. Member of the
Mundipharma/Napp independent associated companies. Date of Preparation:
February 2009.
Adverse events should be reported to
Mundipharma Pharmaceuticals Limited on (01) 206 3800
When non-opioid analgesics aren’t enough

news
8
Diabetes Update Day
At the diabetes update day in donegal recently were
ms Pauline Kilcoyne (Practice Nurse), ms Abina o'Flynn
(msd), ms Tina bovaird (Practice Nurse) and
ms Kathleen mcKeague (community dietitian).
ms Abina o’Flynn (msd), ms Fiona gibbons (Practice
Nurse), ms Teresa woods (Practice Nurse) at the recent
diabetes update day in donegal.
youth suicide rates require action
One of the world’s leading experts on youth mental health has
warned that Ireland must act now if it is to reduce its alarmingly
high rates of youth suicide. Speaking at the young People’s
Health in Mind Forum at the Exchange recently Professor
Pat McGorry, Executive Director of ORyGEN Research Centre,
Melbourne, Australia and a director of Headstrong, the National
Centre for youth Mental Health, said that Ireland needs to
build on what is already underway in terms of working with
communities to develop appropriate supports to ensure young
people no longer fall through the large gaps which exist in the
current service system.
“Back in the late 1990s Australia’s suicide rates were at the
same rate as they are in Ireland today but thanks to significant
investment by the Australian Government in mental health
reform and an increase in public awareness about mental health
problems and the importance of getting help early, “Australia
Nurseline 24/7
celebrates 10 years
NurseLine 24/7 from Vhi Healthcare recently celebrated ten
years of service from its base in Navan, Co Meath. Staffed by
qualified nurses, NurseLine 24/7 has handled over 70,000 calls
relating to health and lifestyle queries from Vhi Healthcare
customers. It has proved to be very popular with parents calling
for free out-of-hours advice on a range of topics affecting child
health, with queries on swine flu near the top of the list.
NurseLine 24/7 has handled approximately half a million calls
since its launch in 1999. A pioneering service, NurseLine 24/7
remains unique in the Irish market as the only medical helpline
offered by a private health insurer that is located in Ireland, with
local professionals providing local knowledge. NurseLine 24/7
is also the only service to offer a pregnancy/paediatric support
line.
2009 saw a record number of calls to NurseLine 24/7 service
with an average of almost 250 callers each day ringing for
advice on a broad range of health issues. The top health
symptoms which customers call about are high temperature,
vomiting, rash, diarrhoea, coughs, abdominal pain, crying
children and cold/flu symptoms.
According to Vhi Healthcare Chief Executive Jimmy Tolan, “We
are delighted with the success of the NurseLine 24/7 service
and the fact that it adds so much value and reassurance for our
customers. The numbers calling the service each month clearly
demonstrates that when customers have a health query they
are reassured by the fact that they can talk to a qualified health
professional who knows and understands the Irish healthcare
system for advice and guidance.”
When the service first launched in 1999, a small number
of staff handled some 250 calls per month. Now the service
has expanded to more than 20 nurses working shifts to look
after the healthcare enquiries of over 80,000 callers annually,
24 hours a day, 365 days a year. The NurseLine 24/7 team
collectively has a wide range of medical experience not only in
areas such as maternity and paediatrics, but also cardiac care,
intensive care, occupational health, orthopaedics, theatre, and
accidentand emergency.
NurseLine 24/7 can be contacted by phone on CallSave 1850
247 724. Further information on Vhi Healthcare is available on
www.vhi.ie
has seen a reduction of its youth suicide rates by 55% in less
than ten years” said Professor McGorry, “There is some progress
being made here in Ireland but it is not enough and a great deal
more needs to be done now to provide support for a significant
and growing number of young people” he added.
The Forum was organised by Headstrong, the National Centre
for youth Mental Health. A central focus of Headstrong’s work
has been the development of their Jigsaw programme which
brings together those working to improve the mental health
of young people including healthcare providers, educators,
youth workers and the wider community to work together to
provide a range of accessible services and supports to young
people in an environment which works for them. In the past
12 months Jigsaw has been successfully rolled out in Galway,
and in Ballymun, Dublin. Further Jigsaw programmes are being
developed for Kerry, Meath and Roscommon.

Danone Actimel,
an ally for the elderly
in winter *
NEW NEWS
Age-related immunoscenescence
As we get older, the immune systems ability to react & adapt
declines due to an age-related phenomenon in the body’s
defences called immunoscenescence. This involves both the
host’s capacity to respond to infections and the development
of long-term immune memory, especially by vaccination.
How can Actimel help?
Actimel is a food product scientifi cally proven in 24 published
clinical trials to help strengthen your natural defences. New
research suggests that probiotics can also exert a benefi cial
effect not only within the gastrointestinal tract but more
widely within the immune system.
Effect after seasonal fl u vaccination
Emerging evidence suggests that Actimel (2x100ml) improves the immune response to seasonal fl u
vaccination in the elderly. Placebo controlled studies showed 1 ;
Higher antibody titres to seasonal fl u strains
H1N1**, H3N2 and B in the Actimel group
compared to the control and remained higher
at 9 weeks after vaccination.
GTM
A. B.
H1N1
120
100
80
60
40
20
0
Baseline 3w 6w 9w
Time post vaccination
GTM
120
100
80
60
40
20
0
Baseline 3w 6w 9w
Time post vaccination
Effect maintained on seroconversion for
B strain over time under Actimel consumption
at 3, 6 and 9 weeks post vaccination.
Antibody titre at 3, 6 and 9 weeks after vaccination. Boge T. et al 2009.
H3N2 B
120
100
80
60
40
20
0
Baseline 3w 6w 9w
Time post vaccination
“Vaxigrip, Sanofi-Pasteur MSD, season 2006-2007” A/New Caledonia/20/99 (H1N1) / A/Wisconsin/67/2005 (H3N2) B/Malaysia/2506/2004.
For more information on probiotics and Actimel, please visit www.probioticsinpractice.co.uk
* Actimel is scientifically proven to help strengthen the natural defences when consumed daily as part of a healthy diet & lifestyle. Studies on Actimel collectively
demonstrate that L. casei Imunitass survives in the gastrointestinal tract and exerts a beneficial effect on each of the 3 lines of “natural defence” (1)The intestinal flora,
(2)The intestinal mucosa and (3)The intestinal immune system or gut-associated lymphoid tissue (GALT) when consumed daily as part of a healthy diet & lifestyle.
** This is a seasonal H1N1 strain not the swine flu strain.
GTM C.
Actimel
Control
These results are further evidence that Actimel has a measurable impact on the immune system. Further research is needed to
understand the benefi ts of probiotic for different applications, in particular for how probiotics could help improve the immune response
to vaccination.
1 Boge T, et al. A probiotic fermented dairy drink improves antibody response to influenza vaccination in the elderly in two randomised controlled trials. Vaccine (2009),doi:10.1016/j.vaccine.2009.06.094

news
10
Irish breast cancer research well
received at global meeting of experts
At the recent annual San Antonio Breast Cancer Symposium,
ground-breaking research from the Breast Cancer Research
Group in NUI Galway was well received. The meeting is the
biggest breast cancer meeting in the world with more than
12,000 delegates and is a key step in the introduction of novel
and new initiatives in breast cancer.
The research from NUI Galway came from the National Breast
Cancer Research Institute (NBCRI) funded surgery programme
on the role of MicroRNAs in breast cancer. For the first time,
the work shows that MicroRNAs are measurable in the blood
of breast cancer patients and the levels of mir95 in particular,
suggests that it is a breast cancer specific tumour marker.
The work was led by NUI Galway’s Professor Michael Kerin,
presented by Dr Helen Heneghan and co-authored by Dr Nicola
Miller and Dr John Newell.
Dr Heneghan who is a Health Research Board funded Clinical
Research Fellow, is currently two years into her PhD programme.
Her work shows that microRNAs are measurable in the blood
of breast cancer patients, that levels of certain miRNAs drop
after breast tumours are surgically removed and that mir195 is
likely to be a breast cancer specific tumour marker. The novelty
involves a modification of standard techniques allowing these
little molecules to be reliably measured in blood from breast
Medical clothing supplier wins award
The Dublin City Enterprise Board Link! Best Business Plan Award for 2009
has been won by medical clothing supplier 'Happythreads'.
Happy Threads (www.happythreads.ie) provides personalised
garments through the importation of high quality fashionable
work uniforms and provides a personalisation service
(embroidery of names and logos). This embroidery service
is carried out in Ireland, adding real value to the products.
Additional items, such as fashionable ergonomic work footwear,
are also offered. New products are constantly being sourced
(such as medical theatre hats) as there will be ongoing market
research into all areas of professional garment requirements.
A sophisticated and creative website has been designed
which allows customers to order the uniforms and specify the
embroidery online. Exclusive distribution rights for Ireland and
UK for a number of brands is currently being negotiated.
Daniel Plewman, a chartered engineer, manages and operates
the business and Dr Abigail Moore, a paediatric dentist, acts
as a consultant. Both promoters have many contacts in the
healthcare industry.
During recent travels in the US, Daniel became aware of
the existence of personalised fashion scrubs to healthcare
professionals. Daniel’s wife, Dr Moore, purchased some of
these products through the internet, getting them shipped
to a colleague’s house in the US as the online stores do not
ship to Ireland or the UK. Many of her colleagues subsequently
expressed an interest in these garments, stating that nothing of
a similar nature is currently available in Ireland.
The garments are stylishly fitted, have a quality feel to
the material and are available in a large range of styles and
cancer patients for the first time.
Professor Kerin, Head of Surgery at NUI Galway, said that this
work opens up many corridors of scientific questioning: “In
particular, we may be able to trace tumour activity in breast
cancer using these markers and a combination of microRNAs
may function as screening tests for breast cancer allowing early
detection to become the norm. This early work suggests that a
combination of mir195 and Let7a are sensitive markers for the
presence of breast cancer in over 90% of cases. This raises the
possibility of their use in screening for breast cancer”.
Professor Kerin warned of the possibility of reading too
much into this discovery as it is still ‘early days’: “Our initial work
centres on 83 breast cancer patients and 44 controls. While it
is clear that we can now measure microRNAs in blood, much
more work has to be done. We have received amazing feedback
however, from the major breast cancer research centres around
the world and they want to collaborate with us to answer these
questions. The fact that microRNAs are small, robust and act on
multiple genes suggest that they may be very powerful factors
in breast cancer propagation and development. In addition,
we may be able to interfere with them and manipulate their
expression which may allow cancers which are refractory to
standard therapy to be made sensitive.”
colours and were delivered with a personalised name and logo.
Happythread’s research of a sample of healthcare professionals
confirmed that the current selection of garments available in
Ireland was found to be unflattering, uncomfortable and of
limited choice.
Happythreads supplies 3 brands; koi, Alegria and Hejco.
They are supplied through a website, www.happythreads.
ie and traditional distribution channels (direct sales). The UK
market will also be supplied through www.happythreads.co.uk
with similar products subject to licence. In addition exclusive
distribution rights are being negotiated, which will allow the
company to distribute to retail outlets.

112009PandemicInfluenza2377
Your Partner
in Pandemic
Protection
news
malnutrition in patients a very real issue
The first Irish “Nutrition Screening Week” took place Jan 12 th -
14 th 2010 with members of the Irish Nutrition & Dietetic Institute
(INDI) participating to establish current, accurate figures and
evidence on the prevalence of malnutrition among Irish patients
in hospitals and residential settings.
Nutrition Screening Week (NSW) is an initiative started by
the British Association for Parenteral and Enteral Nutrition
and involves taking simple heights and weights of patients
and monitoring their dietary intake whilst in hospital. This
assessment is also known as the MUST tool and is endorsed by
the Department of Health and Children.
In Ireland, studies in 2000 found that 11% of patients
admitted to hospital were malnourished and between 63 and
84% were at nutritional risk. In the UK, malnutrition affects 10-
55% of ill adults in hospital and in the community.
Other studies indicate that at any given time, about 93% of
malnutrition occurs in the community, about 2% in hospitals
and the remaining 5% approximately equally divided between
nursing and residential homes.
Malnutrition has a wide range of adverse consequences
including the following:
• Impaired immune responses with increased risk of infection
and reduced ability to fight infection once established.
• Impaired wound healing and delayed recovery from illness
• Reduction of appetite and impaired ability to eat
• Increased risk of admission to hospital and length of stay
• Higher rates of mortality
Malnutrition is a burden to patients, health and social services
and society in general, with an estimated public expenditure
Call to outlaw FMG in Ireland
It is one year since the launch of Ireland’s first National Action Plan
on Female Genital Mutilation (FGM). One year on the National
Action Plan is yet to be formally adopted by any government
agency and specific legislation outlawing this form of torture in
Ireland is still not in place.
The goals of the action plan are to prevent the practise of FGM
in Ireland; to provide high quality, appropriate healthcare and
support for women and girls who have undergone FGM and to
contribute to the worldwide campaign to end FGM.
It is estimated that over 2,500 women living in Ireland have
undergone the procedure and thousands of children are at risk of
this potentially fatal practice and violation of human rights.
The recommendations propose a law be enacted which will
outlaw FMG in Ireland. The Steering Committee is particularly
concerned about the gaps between the current UK legislation,
covering Northern Ireland, and our own. The Female Genital
Mutilation Act 2003 in the UK introduced extraterritoriality,
making it an offence, for the first time for UK nationals or
permanent UK residents to carry out FGM abroad, or to aid, abet,
counsel or procure the carrying out of FGM abroad, even in
countries where the practice is legal.
Salome Mbugua, Director of AkiDwA says “There is currently no
explicit legal protection against FGM in Ireland; neither is there
specific legislation to protect a child from being removed from
Ireland to have the procedure carried out overseas. We hope
that the Minister for Health and Children will get the appropriate
support from the Department of Justice, Equality and Law Reform
and the Attorney General in urgently progressing this matter.”
For more information contact Sioban O’Brien Green, AkiDwA,
Co-ordinator Migrant Women's Health Project, 01 814 8582.
that has recently been calculated at over £13 billion a year in the
UK.
Malnutrition can affect all age groups but the elderly and
those already suffering from various conditions and diseases are
at a higher risk.
“Identifying the prevalence of malnutrition in Ireland will
help stakeholders to identify where additional resources are
required to address this very real health issue in patients and
assist in creating care plans in health and residential centres”,
according to Margot Brennan PRO of the INDI .
“Malnutrition may not always be an obvious area of concern
among the general public, as attention is focused at levels of
obesity and overweight which continue to rise, but malnutrition
is a very real issue that exists not only to patients who suffer
with associated health problems but also to the public purse, as
it is a high cost to the health service.
“Healthcare practitioners and the statutory health services
need to become more acutely aware of the issues pertaining
to incidences of malnutrition and the data collated by National
Screening Week will provide all stakeholders with evidence
based information to provide a plan of action in the area of
patient malnutrition,” explains Brennan.
Many factors contribute to malnutrition and in this area,
which often has many complex socio/economic/educational
and health management factors contributing, it is essential that
qualified, highly experienced dietitians are involved at a very
high level to advise not only on patient care among multidisciplinary
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11

12
regional news
clAre
ANNE AKAMNONU
N E W S F O R I P N A B R A N C H E S C O U N T R y W I D E
We hope everyone had a good Christmas in spite of the prolonged inclement weather. Although pleasant to look at, the weather is
very difficult for our older population and we all should to be alert to their needs.
We wish all our practice nurse colleagues around the country best wishes for 2010 and hope we can look forward to a much
needed ‘summer of sunshine’.
The Clare branch had their last meeting of the year on 17th November 2009. It was well attended and Deirdre Jordan, who is the
Science Officer with yakult, gave us an in-depth and interesting talk on the health benefits of probiotic yogurts and drinks. Her
presentation was very scientific and gave us much food for thought.
Our Christmas night out was held on 12 th December and reports are that a good night was had by those who attended.
Morrissey’s Pub/Restaurant in Doonbeg was the venue and they hosted a wonderful meal. The weather was chilly but could not
dampen the festive spirit! The local pub, Comerford’s provided the entertainment for the remainder of the evening. For various
reasons, including the difficult weather conditions, the numbers attending the Christmas night out was quite small and we may
decide an Easter or summer outing might be a better option for 2010.
Our January meeting is scheduled for19 th , the third Tuesday of the month in the Old Ground Hotel, Ennis. We look forward to a
good attendance and we welcome any new members and new ideas for meeting topics.
doNegAl
ELSIE STEWART
Many thanks to Rhona Keaveney and Steven Wiliamson from Roche Pharmaceuticals who kindly sponsored our November meeting,
which was held in the Radisson Hotel, Letterkenny. Guest speaker for the evening was Katheen Credant, Community Diabetic Nurse
Specialist, who gave us a valuable presentation including an update on the latest diabetic drug therapy.
The December meeting was again held in the Raddisson Hotel. Many thanks to Margaret (Mags) Moran, Infection Control Nurse in
the Community, for her thought provoking presentation on infection control within the primary care setting.
As January’s weather generally tends to cause very difficult driving conditions, and indeed this year is no exception, it has been
decided to hold our next meeting in February; date and venue to be arranged at a later date.
May I take this opportunity to wish all members, both at branch and national level, a very happy, peaceful and prosperous 2010.
gAlwAy
MAUREEN DELANEy
On the 26 th November we gathered at the Radisson, our meeting was sponsored by Abbott. Geraldine Mannion, Rheumatology
Nurse Specialist, Merlin Park Hospital, gave us a presentation on ‘Biologics and the Practice Nurse’.
I would like to offer our sincere sympathy to Evelyn Browne on the death of her father, may he rest in peace.
We concluded our year in Cloonacauneen Castle with our Christmas meeting. Many thanks to Gillian Duggan of Astra Zeneca.
Catherine Kirrane, our Vice-chairperson, expertly demonstrated inhaler technique to a very well attended meeting. We hope we
have encouraged all members to keep up their attendance for the rest of the year’s meetings.
Sally Whelan, the Galway branch secretary has kindly offered to email the minutes of the meetings to anyone who wishes to keep
up to date with branch news but may find it difficult to attend some meetings.
Our next meeting will be in February, details to be arranged.
Happy New year from all in the Galway Branch, I would like to wish all a healthy and happy 2010.

KIlKeNNy
PATRICIA MCQUILLAN
regional news
Our 18 th November meeting was sponsored by Kay Walsh from AstraZeneca. Our speaker on the night was our local CNS in
Respiratory, Kate Walsh, from St Luke’s Hospital, Kilkenny. Kate gave an excellent talk on asthma in relation to current diagnosis and
treatment. She reminded us of the Asthma Society of Ireland Guidelines available on www.asthmaireland.ie.
The Kilkenny Branch finalised a submission which was later sent to the Executive Committee of the IPNA and then sent on to
(among others), Dr Siobhan O’Halloran and Liz Adams in the Office of the Nursing Services Director. The submission concerned the
issue of the non-use of the HSE medication protocols for the supply and administration of the pandemic (H1N1) 2009 vaccines by
practice nurses. No reply has been received to date.
It was decided by the branch to hold a meeting before Christmas and so we met in Kilkenny on 16th December. Our sponsor for
the night was Caoimhe from Servier and the speakers came from the Kilkenny Clinic. Dr Claire Moran and Kathleen Chadra RN gave a
detailed and informative presentation on the work of the Kilkenny Clinic which is concerned with infertility treatment, gynaecology,
assisted conceptions, male health, female health and psychosexual therapy. We were reminded to forward our application forms for
membership of the IPNA for 2010 to Tracy.
souTh TIPPerAry
CATHERINE DELAHUNTy
Our AGM was held on 16 th November with a good turnout of nurses on the night. The meeting started with a talk on fertility,
sponsored by Brenda Ward of Bayer Schering, and given by Dr O’Leary. Once again this was a very informative talk which greatly
benefitted the audience. Many thanks to our sponsor and to Dr O’Leary.
Our AGM saw our very capable Chair, Rita O’Carroll, stand down. Many thanks to Rita who did both the Chair’s and secretary’s
job on her own for the last while. Rita, your superb efforts are greatly appreciated by all in the South Tipp Branch. We would like to
welcome in our new officers and we wish them all the best for the coming year.
Donations were collected from the attendees at the end of the AGM in honour of Kathy O’Brien, our recently deceased friend. This
money will be donated to the South Tipperary Hospice.
Hopefully everyone has survived our freezing weather, although we all love a bit of snow, as nurses we are in a position to see the
hardship it has caused. Many of our patients have suffered fractures and falls during the frost but we should also bear in mind the
isolation, loneliness and depression being confined to home has caused in many of our elderly patients. Hopefully now we have had a
thaw, we can all look forward to the spring and a bit of fine weather.
The South Tipperary Branch would like to wish everyone a very happy, healthy and peaceful New year and we look forward to
seeing everyone at our meetings in 2010.
wexFord
JUNE D’ARCy
Happy New year to you all. Congratulations to the Mayo branch and Grainne Lynch on the success of the annual conference. All your
hard work was evident in the enjoyment had by everyone who attended.
We had our last meeting on the 4th November. Our thanks to Marie Sheerin, Cow & Gate, for sponsoring our talk by nutritionist
Margaret Byrne entitled, Update in Nutrition.
Our AGM was postponed that night as we were informed of the death of our fellow member, Eithne Sinnott. It was a shock to us
all — whilst we knew Eithne was ill it just seemed unbelievable that she had gone from us. We will miss her greatly — her friendship,
her contribution to the group, her laughter and sense of humour. Our thoughts are with her husband and three children. We would
especially like to thank all of the many branches who sent their sympathies to us. These were passed on to Eithne’s family.
We would also like to extend our sympathies to our fellow member, Elaine Mc Carthy whose mother passed away recently.
We hope to have our next meeting in February. Good wishes for the times ahead.
13

clinical review
14
Non-invasive ventilation
— an overview for the primary care nurse
NoreeN doNoghue
RGN, RM, ICU CERT, H DIP NURSING (RESP), MSC NURSING (HONS),
RESPIRATORy CLINICAL NURSE SPECIALIST, UNIVERSITy HOSPITAL, GALWAy
Community nurses are meeting increasing numbers of patients on non-invasive
ventilation (NIV) in the home setting. This article aims to provide an overview of NIV
which may assist them in providing effective care to this cohort of patients. An outline
of the appropriate NIV equipment used in primary care, a troubleshooting guide of
common problems encountered, and the provision of some useful contact resources
are included.
Introduction
One of the most exciting developments in respiratory medicine
in the last two decades has been the development of noninvasive
ventilation (NIV) as a treatment modality for the
management of respiratory failure. The field of non-invasive
ventilation continues to expand rapidly in the management of
acute and chronic respiratory conditions, both in the hospital
and in domiciliary contexts. This advancement has major
implications for nursing practice, management and education
in both primary and secondary care. Many patients who
previously required hospitalisation with respiratory failure, can
now live at home using NIV with the support from the primary
care team.
NIv — definition
Non-invasive ventilation (NIV) refers to ‘the provision of
ventilatory support through the patient’s upper airway using a
mask or similar device’. ¹
This may be:
• Continuous positive airways pressure (CPAP) — where the
machine delivers a flow of air at a preset constant pressure
during inspiration and expiration, or
• Bi-level positive airways pressure (BiPAP) ventilation which
works on the principle of pressure support, delivering gases
at two levels of positive pressure — inspiratory positive
airway pressure (IPAP) which produces ventilation, and
expiratory positive airway pressure (EPAP) which increases
functional residual capacity and recruits under-ventilated
lungs, improving oxygenation.
These treatments may be used as the sole treatment, a
holding measure, a trial prior to intubation or the ceiling of
treatment² with the aim to produce:
• Decreased work of breathing
• Increased tidal volume
• Decreased respiratory rate
glossary
NIv: non-invasive ventilation (non-invasive positive
pressure ventilation)
cPAP: continuous positive pressure ventilation
IPAP: inspiratory positive airway pressure
ePAP: expiratory positive airway pressure
osAhs: obstructive sleep apnoea/hypopnoea
syndrome
coPd: chronic obstructive airways disease
‘It is important that
nurses in primary care
understand the nature
and consequences
of the patient’s
respiratory condition,
and the basic principles
of how the ventilator
works.’

During NIV the patient usually wears a tightly fitting nasal or
facial mask that is attached via wide-bore tubing to a portable
ventilator.
overview of indications for non-invasive respiratory
support
The use of NIV in acute care includes CPAP for patients with
acute hypoxaemic respiratory failure or cardiogenic pulmonary
oedema, whereas BiPAP is indicated for acute hypercapnic
respiratory failure, but may also be used in critical care areas in
weaning patients from mechanical ventilation.
The National Institute for Clinical Excellence (NICE) guidance
for the management of chronic obstructive pulmonary
disease (COPD) (2004)³ recommends the use of NIV in acute
exacerbations of COPD. The other major application of NIV
is in its longer-term use to support patients with chronic
hypoventilation.
Indications and benefits of domiciliary NIv
There are three main conditions that benefit from domiciliary
NIV:
1. Obstructive sleep apnoea/hypopnoea syndrome OSAHS.
2. Respiratory problems associated with neuromuscular
disease and chest wall deformities.
3. Chronic obstructive pulmonary disease (COPD).
Obstructive sleep apnoea/hypopnoea syndrome is a
condition in which a person experiences repeated episodes of
apnoea because of a narrowing or closure of the pharyngeal
airway during sleep.4 This is caused by a decrease in the tone
of the muscles supporting the airway during sleep. CPAP
treatment is the ‘gold standard’ treatment for OSAHS. A
CPAP device consists of a portable unit capable of delivering
pressures between 4cm-20cm H²O that generates airflow,
which is directed to the airway via a mask preventing airway
collapse. The overall benefit to the patient with OSAHS of
using overnight NIV is improved quality of sleep, with reduced
daytime lethargy and improved concentration.
clinical review
Neuromuscular disease/chest wall deformities
NIV is the treatment of choice to support patients with
restrictive lung diseases who develop chronic respiratory
failure. This varies from patients with chest wall abnormalities
such as kyphoscoliosis through to patients with neuromuscular
conditions such as motor neuron disease (MND) and Duchenne
Muscular Dystrophy. The application of NIV will potentially
improve tidal volumes, reduce the effort of breathing and thus
provide symptomatic support and possibly delay the onset of
end-stage respiratory failure.
chronic obstructive pulmonary disease
COPD patients with chronic hypercapnia and nocturnal
hypoventilation may benefit from domiciliary ventilator
support, but this remains controversial. However, the NICE
guideline (2004)³ recommends:
Optimally treated patients with chronic hypercapnic respiratory
failure, who have required ventilation during an exacerbation or
who are hypercapnic or acidotic on long term oxygen therapy,
should be referred to a specialist centre for assessment for longterm
NIV.
equipment for non-invasive ventilation: ventilators,
interfaces and accessories
The ventilator
This machine consists of a pump that draws air from the
room through a filter and blows it out under pressure. The
bi-level device delivers two levels of pressure: a higher level of
pressure on inspiration (inspiratory positive airways pressure)
and a lower level of pressure on expiration (expiratory positive
airways pressure). CPAP machines deliver a constant pressure.
The circuit
A flexible tube that allows the flow of air between the machine
and the mask.
The mask
15

clinical review
16
There are several different types of masks available. Full face
masks are most commonly used to cover the nose and mouth if
the patient tends to breathe through his mouth. Some patients
prefer a nasal mask that just covers the nose. [Nasal pillows or
the total face mask may be used in a small number of patients.]
Masks systems consist of a mask frame, headgear and a soft
cushion seal. Mask fitting is an essential element of a patient's
success with NIV because if affects compliance and treatment
efficacy.
warning: All masks should have an exhalation port (usually
small holes or a vent) to allow exhalation of carbon dioxide.
This must never be covered.
It is important to note that circuits and masks used in the
hospital are not suitable for domiciliary use. The reusable mask
and circuits provided with the ventilator for home use should
always be used.
Problem Advice
Poor mask
seal with
consequent
air leakage
Humidifier
A humidifier may be recommended with the NIV machine
to make the therapy more comfortable and tolerable, as
some patients can experience a sore nose, throat and mouth
dryness, and nasal congestion.
maintenance and care of the equipment should be in
accordance with manufacturer’s instructions. Particular care
should be paid to air inlet filters (hygiene and replacement)
and electrical safety.
supplementary oxygen
Supplementary oxygen may be added to the NIV therapy via
an oxygen entrainment port, as prescribed by the doctor.
Standard safety measures should be practised with oxygen
use.
Providing domiciliary non-invasive ventilation —
troubleshooting guide
The care issues which community nurses may encounter in
the provision of care to patients on domiciliary NIV therapy
revolve around two areas — compliance with the therapy
and equipment care. For device specific problems the
patient/carer should always refer to the equipment manual
supplied with the machine. If the problem is unresolved then
the service provider's helpline should be contacted.
There should be a leak from the vents/exhalation port on the mask, to allow exhalation of carbon dioxide.
Leak from the interface should be minimised by adjusting the head straps and adjustment clip (if
applicable) to ensure a good seal.
The machine will compensate for some leak but too much leak can compromise pressure delivery and the
therapy. If problems continue, contact service provider.
Eye irritation Adjust mask to eliminate leaks into the eyes.
Follow mask fitting instructions.
Nasal bridge
redness/
ulceration
Nasal and oral
dryness
Congestion
Missing mask
port plug
Ventilator
alarms/
problems
How to reset
alarms
Ensure correct application of mask — follow guidelines on mask fitting
Loosen headgear slightly to relieve pressure on the nasal bridge.
Adjust forehead clip (if present) to reduce pressure on nasal bridge.
Contact nurse specialist for advice on suitable dressings if appropriate for susceptible or broken skin.
Humidify flow
Re-hydrate
Consider nasal sprays
Not a major problem
Machine will compensate for small leak
Do not stick anything over port
Contact service provider
Ventilator settings are set as prescribed by the doctor and are locked into the machine, and should only be
adjusted on the advice of the doctor/appropriate healthcare professional.
Some common alarms include:
Blank display — check power connection
Patient disconnect alarm — check circuit, mask are appropriately attached to ventilator. Assess for leak in
system. Refer to fitting guidelines.
High or low pressure alarms — check mask fitting — too much leak can cause low pressure alarms. High
pressure alarms can result if there is a blockage — check that filters are clean and the tubing is free from
blockage.
The technician, on initial set up of domiciliary NIV, will have shown the alarm silence button and how to
reset the alarm on the machine. The patient is always advised to react to an alarm, try to identify the cause,
rectify the problem and reset.
Contact service provider if alarms are constant.

Abbreviated Prescribing Information
Victoza ® 6 mg/ml solution for injection in pre-filled pen (liraglutide). Please refer
to the Summary of Product Characteristics for full information. Victoza ® 2 x 3 ml
pre-filled pens. Victoza ® 3 x 3 ml pre-filled pens. 1 ml of solution contains 6 mg
of liraglutide. Indication: Treatment of adults with type 2 diabetes mellitus in
combination with metformin or a sulphonylurea, in patients with insufficient
glycaemic control despite maximal tolerated dose of metformin or sulphonylurea
monotherapy; or in combination with metformin and a sulphonylurea, or
metformin and a thiazolidinedione in patients with insufficient glycaemic control
despite dual therapy. Dosage: Victoza ® is administered once daily by
subcutaneous injection and can be administered at any time independent of
meals however, it is preferable that Victoza ® is injected around the same time
of the day. Victoza ® should not be administered intravenously or intramuscularly.
Recommended starting dose is 0.6 mg daily. After at least one week, the dose
should be increased to a maintenance dose of 1.2 mg. Based on clinical
response, after at least one week the dose can be increased to 1.8 mg to further
improve glycaemic control in some patients. Daily doses higher than 1.8 mg are
not recommended. When used with existing metformin therapy or in combination
with metformin and thiazolidinedione therapy, the current dose of metformin
and thiazolidinedione can continue unchanged. When added to existing
sulphonylurea therapy or in combination with metformin and sulphonylureas, a
reduction in the dose of sulphonylurea may be necessary to reduce the risk of
hypoglycaemia. Victoza ® can be used in the elderly (>65 years old) without dose
adjustment but therapeutic experience in patients ≥75 years of age is limited.
No dose adjustment is required for patients with mild renal impairment
(creatinine clearance ≤60-90 ml/min). Due to lack of therapeutic experience
Victoza ® is not to be recommended for use in patients with moderate (creatinine
clearance of 30-59 ml/min) and severe renal impairment (creatinine clearance
below 30 ml/min), patients with end stage renal disease, patients with hepatic
impairment and children below 18 years of age. Contraindications:
Once-daily Victoza ® (liraglutide), in combination with metformin,
impacts on multiple factors associated with type 2 diabetes
providing, from baseline: 1,2
Reductions in HbA1c: up to 1.30% 1,2
Reductions in weight: up to 2.8kg 1,2
Reductions in systolic blood pressure 1,2
Improvements in beta-cell function 1,2
Hypersensitivity to the active substance or any of the excipients. Warnings and
Precautions for use: Victoza ® should not be used in patients with type 1
diabetes mellitus or for the treatment of diabetic ketoacidosis. Limited experience
in patients with congestive heart failure New York Heart Association (NYHA)
class I-II and no experience in patients with NYHA class III-IV. Due to limited
experience Victoza ® is not recommended for patients with inflammatory bowel
disease and diabetic gastroparesis. Victoza ® is associated with transient
gastrointestinal adverse reactions, including nausea, vomiting and diarrhoea.
Other GLP-1 analogues have been associated with pancreatitis; patients should
be informed of symptoms of acute pancreatitis: persistent, severe abdominal
pain. If pancreatitis suspected, Victoza ® and other suspect medicinal products
should be discontinued. Thyroid adverse events, including increased blood
calcitonin, goitre and thyroid neoplasm reported in clinical trials particularly in
patients with pre-existing thyroid disease. Risk of hypoglycaemia in combination
with sulphonylureas; lowered by dose reduction of sulphonylurea. No studies on
the effects on the ability to drive and use machines performed. Patients should
be advised to take precautions to avoid hypoglycaemia while driving and using
machines, in particular when Victoza ® is used in combination with a
sulphonylurea. Substances added to Victoza ® may cause degradation; in the
absence of compatibility studies Victoza ® must not be mixed with other medicinal
products. Pregnancy and lactation: Victoza ® should not be used during
pregnancy or during breast-feeding. If a patient wishes to become pregnant, or
pregnancy occurs, treatment with Victoza ® should be discontinued; use of insulin
is recommended instead. Undesirable effects: During clinical trials with
Victoza ® the most frequently observed adverse reactions which varied according
to the combination used (sulphonylurea, metformin or a thiazolidinedione) were:
Very common: nausea, diarrhoea, hypoglycaemia when used in combination with
metformin and a sulphonylurea and headache when used in combination with
metformin; Common: hypoglycaemia when used in combination with a
thiazolidinedione, vomiting, constipation, abdominal pain, discomfort and
References: 1. Victoza ® Summary of Product Characteristics, July 2009.
2. Nauck M et al; for the LEAD-2 Study Group. Efficacy and safety comparison of liraglutide, glimepiride, and placebo, all in combination with metformin,
in type 2 diabetes: the LEAD (liraglutide effect and action in diabetes)-2 study. Diabetes Care 2009;32(1):84-90.
Victoza ® is a trademark owned by Novo Nordisk A/S.
Date of preparation: July 2009. IR/LR/0709/0268
distension, dyspepsia, gastritis, flatulence, gastroesophageal reflux disease,
gastroenteritis viral, toothache, headache, dizziness, nasopharyngitis, bronchitis,
anorexia, appetite decreased, fatigue and pyrexia. Gastrointestinal adverse
reactions are more frequent at start of therapy but are usually transient. Very
few hypoglycaemic episodes observed other than with sulphonylureas. Patients
>70 years or with mild renal impairment (creatinine clearance ≤ 60-90 ml/min)
may experience more gastrointestinal effects. Consistent with medicinal products
containing proteins/peptides, patients may develop anti-liraglutide antibodies
following treatment but this has not been associated with reduced efficacy of
Victoza ® . Few cases reported of angioedema (0.05%), acute pancreatitis
(

clinical review
18
organisation of home NIv in Ireland
The assessment for home NIV is performed in hospital by a
specialist respiratory team. Patients will be established on NIV
before their discharge into the community. An NIV service,
usually on a rental scheme, is organised by the area PCCC for
medical card holders. Patients eligible under the Drug Refund
Scheme may reclaim their monthly rental charge payments
from their local PCCC. The monthly rental fee includes initial
installation — set up, delivery and training, and annual service
and consumable replacement. An education programme for
the patient and carer, covering the rationale and practicalities
of use of NIV, equipment assembly and care, mask application/
removal and safety issues should be facilitated as part of the
hospital discharge planning for patients being initiated on long
term NIV therapy.
conclusion
Non invasive ventilation is increasingly being used in primary
care. Patients receive support from the service provider to
maintain this treatment, although they may also seek help from
the respiratory specialist centre and community nurses. It is
important that nurses in primary care understand the nature
and consequences of the patient’s respiratory condition, and
the basic principles of how the ventilator works, in order to
ensure informed practice, offer appropriate support, help
maintain compliance and ensure optimum patient safety. They
also need to be aware of how to contact help and seek advice
for patients who may be experiencing non-invasive ventilation
associated problems.
useful contact numbers
General practice nurses/community nurses may access
Respiratory Clinical Nurse Specialists/respiratory team in
appropriate hospital for advice and support.
Local PCCC
Air Products: 01 8091800
1850 240202
BOC: 09064 70910
1890 220202
Home Healthcare: 09064 74854
Medicare: 01 2014900
Respicare Ltd.: 01 8904020
Useful website/email addresses
www.airproducts.ie
www.homehealthcare.com
www.medicare.ie
email: sales@respicare.ie
www.irishthoracicsociety.com
www.brit-thoracic.org.uk
www.nice.org.uk
www.sleep-apnoea-trust.org
www.isat.ie (Irish Sleep Apnoea Trust)
The issues which
community nurses
may encounter in the
provision of care to
patients on domiciliary
NIv therapy revolve
around two areas
— compliance with
the therapy and
equipment care.
references
1. Royal College of Physicians, British Thoracic Society, Intensive
Care Society (2008) Chronic obstructive pulmonary disease:
non-invasive ventilation with bi-phasic positive airways pressure
in the management of patients with acute type 2 respiratory
failure. Concise Guidance to Good Practice series, No. 11.
London.
2. British Thoracic Society Standards of Care Committee (2002)
BTS Guideline: Non-invasive ventilation in acute respiratory
failure. Thorax; 57: 192-211
3. National Institute for Clinical Excellence Clinical Guideline 12
(2004) Management of chronic obstructive pulmonary disease
in adults in primary and secondary care. NICE: London.
4. National Institute for Health and Clinical Excellence (2008)
NICE technology appraisal guidance 139. Continuous positive
airway pressure for the treatment of obstructive sleep apnoea /
hypopnoea syndrome. NHS, London.

1. DeFronzo RA, et al. Diabetes Care. 2009; 32(9):1649-55
2. Onglyza, Summary of Product Characteristics.
For your patients with type 2 diabetes struggling
to gain glycaemic control on oral monotherapy
ONGLYZA 5mg film-coated tablets (saxagliptin). Abridged
prescribing information. Consult Summary of Product
Characteristics (SmPC) before prescribing.Presentation: 5 mg
saxagliptin (as hydrochloride) film-coated tablets. Uses: Adults:
For Type 2 diabetes mellitus patients to improve glycaemic
control in combination with: metformin, when metformin alone,
with diet and exercise, does not provide adequate glycaemic
control; sulphonylurea, when sulphonylurea alone, with diet and
exercise, does not provide adequate glycaemic control in patients
for whom use of metformin is considered inappropriate; and
thiazolidinedione, when thiazolidinedione alone with diet and
exercise, does not provide adequate glycaemic control in patients
for whom use of a thiazolidinedione is considered appropriate.
Dosage: Adults: 5 mg once daily as add-on therapy with or
without food at any time of the day. When used in combination
with a sulphonylurea, consider a lower dose of sulphonylurea to
reduce the risk of hypoglycaemia. Children and Adolescents: Not
recommended. Moderate Hepatic Impairment: Use with caution.
Severe Hepatic Impairment: Not recommended. Moderate & Severe
Renal Impairment: Not recommended. Elderly ≥ 75 years: Use with
caution. Contraindications: Hypersensitivity to saxagliptin or to any
of the excipients. Precautions and warnings: Should not be used for
the treatment of Type 1 diabetes mellitus or diabetic ketoacidosis or
in patients who have had any serious hypersensitivity reaction to a
DPP4 inhibitor. Contains lactose, not recommended in patients with
rare hereditary galactose intolerance, the Lapp lactase deficiency or
glucose-galactose malabsorption. No experience in cardiac failure
(NYHA class III-IV) or immunocompromised patients. Recommend
monitoring for evidence of skin disorders. Interactions: Clinical
data suggest low risk for clinically meaningful interactions with
co-administered medicinal products. The metabolism of saxagliptin
is primarily mediated by cytochrome P450 3A4/5 (CYP3A4/5).
Caution with potent CYP3A4/5 inducers as glycaemic lowering
effect of Onglyza may be reduced. Pregnancy and lactation: Avoid
use during pregnancy unless clearly necessary. Risk to suckling
child cannot be excluded – either discontinue breast-feeding or
Onglyza therapy. Undesirable effects: In a pooled analysis, overall
incidence of adverse events in patients treated with Onglyza 5
mg was similar to placebo. Discontinuation of therapy due to
adverse events was higher compared to placebo (3.3% vs. 1.8%).
Common adverse reactions reported (regardless of causal
relationship) in clinical trials: Upper respiratory infection; urinary
tract infection; gastroenteritis; sinusitis; headache; and vomiting.
Nasopharyngitis was common in the add-on to metformin trial,
hypoglycaemia was very common in the add-on to sulphonylurea
trial and peripheral oedema (mild to moderate only) was commonly
reported in the add-on to thiazolidinedione trial. Hypersensitivity
and rash were more frequently reported in patients on Onglyza
compared to placebo. Adverse reactions considered to be
at least possibly related to Onglyza: Monotherapy: Common:
Dizziness and fatigue. Initial combination with metformin:
Common: Gastritis. Uncommon: Arthralgia, myalgia and
erectile dysfunction. Add-on to metformin: Common: Dyspepsia
and myalgia. Add-on to sulphonylurea: Uncommon: Fatigue,
Onglyza 5 mg improves the control
of the glucose triad (HbA 1c , PPG, FPG)
through a physiological pathway
with a low incidence of hypoglycaemia
and weight gain 1,2
dyslipidaemia and hypertriglyceridaemia. Laboratory tests:
Small decreases in absolute lymphocyte count were observed but
were not associated with clinically relevant adverse reactions.
Key: Very common (≥ 1/10), common (≥ 1/100 to

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clinical review
NIcolA corNAlly msc, bsc (hoNs), dIPN, rgN
RESEARCH ASSISTANT AND DOCTORAL STUDENT,
CATHERINE MCAULEy SCHOOL OF NURSING AND MIDWIFERy, UCC
ProFessor gerAldINe mccArThy Phd, msN, med, rNT, rgN
DEAN AND HEAD OF THE CATHERINE MCAULEy SCHOOL OF NURSING AND
MIDWIFERy, UCC
Chronic pain in older adults
The prevalence of chronic pain in the older adult is estimated at between 50-80%
(Helme and Gibson, 2001). With the population of older people expected to double
in Ireland in the next 20 years (National Council on Ageing and Older People, 2004)
chronic pain needs to be at the forefront of the government healthcare agenda. The
International Association for the Study of Pain acknowledged this issue when they
launched a campaign in 2006 against pain in the older adult, highlighting chronic pain
as one of the most significant problems facing future primary healthcare providers.
Osteoarthritis has been highlighted as the most
common cause of pain for the older adult (Tsai,
Tak, Moore and Palencia, 2002). This is an irreversible
disease and prevalence increases with age
(Symmons, Mathers and Pfleger, 2006). In addition
the World Health Organisation (2002) states that osteoarthritis
is the fourth leading cause of years lost due to disability (yLD)
at a global level. Research conducted by the Department of
Health and Children (DOHC) (2002) reported that the quality
of life index of Irish patients with chronic pain was lower than
that of people with terminal illness. Further to this, Breen (2002)
states that people living with chronic pain are more likely to
suffer from depression, anxiety and reduced activity.
uNder-rePorTINg oF PAIN
Pain remains the primary reason that a person goes to see their
GP (McCaffery and Pasero, 1999; Turk and Melzack, 2001) and
most pain conditions are treated in the primary care setting.
However, despite global advances in services and treatment,
chronic pain remains under-treated and largely under-reported
in the elderly population (Helme, 2001). Veale, Woolf and Carr
(2008) found that many Irish patients delay seeking treatment
for up to two years for chronic pain. Various international studies
also suggest that a significant proportion of patients who
experience chronic pain do not seek help (Elliott, Smith, Penny,
Smith and Chambers 1999; Watkins, Wollan, Melton and yawn,
2006; Mitchell, Carr and Scott, 2006; Bedson, Mottram, Thomas
and Peat, 2007; Veale et al., 2008).
yong (2006), has suggested that older adults help seeking
behaviour can be attributed to attitudes. It may be that
older people are self-medicating (Woolf, Zeidler, Haglund,
Carr, Chaussade, Cucinotta, Veale and Martin-Mola, 2004) and
deciding not to bother the doctor, nurse or their family with
aches and pains because they themselves believe that pain is ‘a
normal part of ageing?’ (Sarkisian, Hays and Mangione, 2002).
Schofield (2007) concurs with the latter explanation stating
that older people are less likely to seek help for pain as they are
resigned to the fact that it is part of the ageing process.
reseArch
This paper presents findings from research that attempts to
develop a better understanding about chronic pain in the older
person and explores some of the reasons why older adults do
not seek help. The study was conducted through two primary
care sites in the south of the country and a sample of 72 older
adults completed the Pain Attitudes Questionnaire (yong, Bell,
Workman and Gibson, 2003), the Pain Beliefs Questionnaire
(Edwards, Pearce, Turner-Stokes and Jones, 1992) and the Level
of Expressed Need Questionnaire (Smith, Penny, Elliott, Chambers
and Smith, 2001).
21

clinical review
22
Figure 1 Pain intensity distribution
PAIN severITy
The intensity of pain was described by participants in terms
of mild, moderate and severe and participants were asked to
rate their pain within these parameters. Findings presented
in Figure 1 demonstrate that there was an almost equal
distribution between the moderate and severe categories.
For example, 47% (n=34) of participants rated their pain as
severe, while 43% (n=31) rated it as moderate. Very few (n=6)
indicated that their pain could be categorised as mild. These
figures are somewhat similar to a pan-European study by
Breivik, Collett, Ventafridda, Cohen and Gallacher (2006) where
between 40-50% of respondents rated their pain as severe in
Spain, Italy and Israel.
PAINFul AreAs oF The body
Participants were asked to indicate the area(s) of their body
that were affected by pain. The lower back was the most
frequently cited painful area of the body by 45 people, with
almost equal distribution between the older adult (>65 year)
and the older old (75-85 years). This was closely followed by
knee pain (n=35). Shoulder and upper arm pain was reported
by 32 participants, 63% were aged between 60-74 years and
the remainder were aged over 75 years. Two hundred and fifty
six responses were summed across all areas, indicating that a
substantial number of participants, indeed if not all, had pain in
multiple areas of their body. Table 1 lists the six most common
sites of pain indicated by the older adult in this study.
Table 1
Areas of the body most commonly affected by pain in the
older adult
• Lower back
• Knees
• Shoulder and upper arm
• Hips
• Neck
• Wrist and hand
PAIN medIcATIoN
Preliminary analysis of the data revealed that 83% of
respondents had taken pain killers recently and 69% indicating
that pain medications were taken often. However, it is unclear
from the questionnaire whether these were over the counter or
prescribed medication. In some cases there may have been a
combination of both. Despite the apparent large percentage of
older adults who are taking pain medications, according to this
study, almost half were still experiencing severe pain on a daily
basis. There are major issues to consider here as many patients
may be taking pain medications that are ineffective. Also there
are safety issues to consider, especially in terms of over the
counter treatments which are not regulated together with the
prescribed medications from the GP.
coNceAlINg PAIN
The data suggested that people who were not willing to
disclose their pain to others (stoic-concealment) were less likely
to seek help from healthcare professionals. In this study, 78%
of respondents agreed that there was ‘no good in complaining
about their pain’ — indicating that participants may have
complained in the past and either treatment was ineffective
or nobody listened. Also, 68% of older adults agreed that
‘they hide their pain from other people’. Various reasons were
given by participants for this and some included not wanting
to worry family members and not wanting to be seen as a
complainer by health professionals. Similar findings were noted
by Cairncross, Magee and Askham (2007) in a long term care
setting where residence were reluctant to express their pain
to others for fear of being labeled a nuisance. It is evident from
this study that a large percentage of older adults were not
willing to disclose their pain to others which is an essential step
in seeking appropriate help.
PAIN ANd AgeINg
Over half (51%) of the respondents believed that ‘pain was
part of the ageing process’. This is of particular concern as
“patients beliefs are likely to influence the way patients present
their problem to healthcare professionals” (Edward et al., 1992
p. 271). In other words, if older people believe their pain is a
normal part of ageing they may in affect play down the pain
they are experiencing, rather than actively seeking a cure
(Calnan, Wainwright, O’Neill, Winterbottom and Watkins, 2007).
These beliefs may also influence the patient’s ability to adjust
to living with chronic pain or affect adherence with treatment
regimes.
dIscussIoN
The importance of detecting attitudes that may affect the
reporting of pain is an essential part of pain assessment and
management as it is unambiguous that the presence of stoic

A body

clinical review
24
attitudes can lead the patient to underreport their pain.
Inaccurate pain assessment and subsequent under treatment
of pain by nurses and doctors can have serious implications
for the older adult in terms of quality of life, sleep disturbance,
mood, deconditioning of muscles due to poor mobility,
increased risk of falls, social isolation and even depression
(Jones, Fink, Clark, Hutt, Vojir, and Melis, 2005).
Efforts in the past have focused largely on pain assessment
tools, such as, the visual analogue scale where a patient
rates their pain on a scale of 1-10. However, attitudes need
to be assessed first to determine if the patient is ‘at risk’ of
underreporting their pain. If these attitudes are present
patients need to be educated on the importance of precise
expression of pain so that correct analgesia can be prescribed,
resulting in better clinical and psychological outcomes. It is
acknowledged that other confounding variables may lead to
under-reporting such as, fear of medication (Davis, Hiemenz,
and White, 2002) and lack of knowledge regarding the negative
consequences of under-treated pain by older adults and
the exploration of these areas are recommended for future
research.
coNclusIoN
Healthcare professionals need to be more aware of people
that are ‘at risk’ of not seeking help and target these people
at opportunistic visits by asking the patient if they are
experiencing pain. Patients also need to be reassured that even
if they don’t have an organic cause for their pain they will be
believed and treated. A comprehensive assessment of older
adult’s pain needs to include attitudes and beliefs, because if
present these attitudes may affect the reporting of pain and
subsequent help seeking behaviour. Nurses and doctors also
need to demonstrate to older adults’ that asking for help is
not a sign of weakness. They need to educated them on the
importance of reporting pain, thereby reducing the negative
outcomes of under-treated chronic pain.
AcKNowledgemeNTs
The authors would like to thank all the patients who participated
in the study, the practice nurses, GPs and practice administration
staff at the Living Health Clinic, Mitchelstown and Townview
Medical Centre, Mallow for facilitating data collection.
references
Bedson, J., Mottram, S., Thomas, E. and Peat, G. (2007). Knee
pain and osteoarthritis in the general population: what
influences patients to consult? Family Practice 24 443-453
Breen, J. (2002). Transitions in the concept of chronic pain.
Advanced Nursing Science 24(4) 48-59
Breivik, H., Collett, B., Ventafridda, V., Cohen, R. and Gallacher, D.
(2006). Survey of chronic pain in Europe: Prevalence, impact on
daily life, and treatment. European Journal of Pain 10 287-333
Cairncross, L., Magee, H. and Askham, J. (2007). A hidden
problem: pain in older people. Picker Institute Europe www.
pickereurope.ac.uk (2nd January 2009)
Calnan, M., Wainwright, D., O’Neill, C., Winterbottom, A. and
Watkins, C. (2007). Illness action rediscovered: a case study of
the upper limb pain. Sociology of Health and Illness 29(3) 321-
346
Department of Health and Children (2002). Health Statistics.
Dublin: Government Publications
Edwards, L.C., Pearce SA., Turner-Stokes, L. and Jones, A. (1992).
The Pain Beliefs Questionnaire: an investigation of beliefs in the
causes and consequences of Pain. Pain 51 267-272
Elliott, A.M., Smith, B., Penny, K., Smith, W. and Chambers, W.
(1999). The epidemiology of chronic pain in the community.
Lancet 354 1248-1252.
Helme, R.D. (2001). Chronic pain management in older people.
European Journal of Pain 5 31-36
Helme, R.D. and Gibson, S.J. (2001). The epidemiology of pain in
elderly people. Clinical Geriatric Medicine 17 417-31.
Jones, K.R., Fink, R.M., Clark, L., Hutt, E., Vojir, C.P. and Melis,
B.K. (2005). Nursing home resident barriers to effective pain
management: Why nursing home residents may not seek pain
medication. Journal of the American Medical Directors Association
6(1) 10-17
McCaffery, M. and Pasero, C. (1999). Pain: Clinical Manual St.
Louis: Mosby
Mitchell, H.L., Carr, A.J. and Scott, D.L. (2006). The management
of knee pain in primary care: factors associated with consulting
the GP and referrals to secondary care. Rheumatology 45 771-776
National Council on Ageing and Older People (2004). Population
Ageing in Ireland: Projections 2002-2021 Dublin: National Council
on Ageing and Older People
Sarkisian, C.A., Hays, R.D and Mangione, C.M. (2002). Do Older
Adults Expect to Age Successfully? The association between
expectations regarding ageing and beliefs regarding healthcare
seeking among older adults. Journal of the American Geriatrics
Society 50(11) 1837-1843
Schofield, P. (2007). The management of Pain in Older People. UK:
John Wiley and Son
Smith, B. H., Penny, K. I., Elliott, A.M., Chambers, W.A. and Smith,
W.C. (2001). The Level of Expressed Need-a measure of helpseeking
behaviour for chronic pain in the community. European
Journal of Pain 5 257-266
Symmons, D., Mathers, C. and Pfleger, B. (2006). Global Burden of
osteoarthritis in the year 2000. www.who.int/entity/healthinfo/
statistics/bod_osteoarthrits.pdf (11 th March 2008)
Tsai, P.F., Tak, S., Moore, C. and Palencia, I. (2002). Testing a
theory of chronic pain. Journal of Advanced Nursing 43(2) 158-
169
Turk, C.D. and Melzack, R. (2001). Handbook of Pain Assessment
New york: the Guildford Press
United Nations Population Division (2002). World Population
Prospects: The 2002 Revision http://www.un.org/esa/
population/publications/wpp2002/WPP2002-HIGHLIGHTSrev1.
PDF (5th January 2009)
Veal, D.J., Woolf, A.D. and Carr. A.J. (2008). Chronic
Musculoskeletal Pain and Arthritis: impact, Attitudes and
perceptions. Irish Medical Journal 101 (7) www.imj.ie
Watkins, E., Wollan, P.C., Melton, J. And yawn, B.P. (2006). Silent
Pain Sufferers. Mayo Clinic Protocol 81(2) 167-171
Woolf, AD., Zeidler, H., Haglund., Carr, AJ., Chaussade,
S., Cucinotta, D., Veale, DJ. and Martin-Mola, E. (2004).
Musculoskeletal pain in Europe: its impact and a comparison
of population and medical perceptions of treatment in eight
European countries. Annals of the Rheumatic Diseases 63 342-347
World Health Organisation (2002). World Health Report 2002.
Reducing Risks, Promoting Healthy Life. www.who.int/whr/2002/
en/index.html (11th March 2008)
yong, H.H., Bell, R., Workman, B. and Gibson, S.J. (2003).
Psychometric properties of the Pain Attitudes Questionnaire
(revised) in the adult patients with chronic pain. Pain 104 673-
681
yong, H.H. (2006). Can attitudes of stoicism and cautiousness
explain observed age-related variation in levels of self-rated
pain, mood and disturbance and functional interference in
chronic pain patients? European Journal of Pain 10 399-407

in practice
26
Post natal
sexual
health
KATE MCCABE, PSyCHOSExUAL THERAPIST
A study in the Journal of Clinical Nursing 1 showed that postnatal
sexual problems can persist for lengthy periods and affect a
surprisingly large number of women. The report suggests that
nearly one-in-three women still experience painful intercourse
a year after their baby is born and more than half have at least
one sex-related health problem.
Some 482 women who had attended maternity units
in Birmingham, UK, took part in a self-administered
questionnaire at least one year after their most recent
birth. “Eighty seven per cent complained of at least
one health problem,” said midwife Amanda Williams.
“Asian women, who made up 15 per cent of the survey, were
more likely to complain of health problems than white women,
as were white women who were older and had larger babies
and longer labours.” She identified the three most common
problems:
• Sex-related health issues (55%).
• Stress urinary incontinence (54%).
• Urge urinary incontinence (37%).
Painful intercourse
Painful intercourse was reported by 19 per cent of women who
had caesareans, 34 per cent who had had a normal birth and 36
per cent of women who had an instrument-assisted birth, such
as forceps.
Sex-related problems were highest among instrument-
assisted births (77 per cent) and lowest among caesarean births
(51 per cent), with 64 per cent of women having had normal
births reporting at least one problem related to sex.
Women who had an instrument-assisted delivery also took
two weeks longer than women who had had caesareans and
normal births to resume sexual intercourse (ten weeks versus
eight) with figures ranging from one week to 52.
Problems with forceps delivery
Forceps deliveries were also associated with higher levels of
stress, urge, and continual incontinence.
Having an epidural did not lead to an overall increase in
health problems and this study did not support previous
research that identified increased stress incontinence and
frequent urinating as risk factors.
Asian women reported greater health problems than white
women. Perineal pain was more than two times higher (62 per
cent versus 28 per cent) and they experienced much higher
levels of continual urinary incontinence (35 per cent versus 20
per cent). However, Afro-Caribbean women displayed similar

levels of ill health to white women.
The women surveyed were aged 16 or over and from all
ethnic groups. They had had their babies at least 12 months
before the survey began and all had a live baby with no
congenital abnormalities at the time of survey.
“Our research has raised a number of issues,” says Amanda
Williams. “For example, it has highlighted concerns about the
long-term health effects resulting from forceps deliveries and
the variations in ill health between white and Asian women.
Both these areas could benefit from further research.”
“It’s also important to point out that while women who had
had caesareans reported fewer problems with the health issues
covered by this study, this delivery method is associated with
other problems that have a negative effect on women’s quality
of life, such as adhesions and wound infections.”
“We believe that our study points to the need for health
professionals to provide ongoing support for women who have
given birth, focusing on issues such as perineal problems and
sensitive health problems. This coupled with greater public
awareness of these issues, will hopefully make it easier for
women to get help for both short-term and long-term health
problems,” says Amanda Williams.
Factors influencing women’s emotions post childbirth
• Episiotomy or a repaired vaginal tear may take several
months to heal completely. Even without an episiotomy or a
tear, the perineal area (between the vagina and the anus) can
feel bruised and sensitive for some time.
• Vagina may lack natural lubrication due to low levels of
oestrogen following childbirth.
• Oestrogen levels may also remain low when breast-feeding.
• Trauma: having a baby pass through the vagina can be a
in practice
traumatic process for some women. Difficult or complicated
births can cause severe trauma.
• Vaginal discharge that smells unpleasant could indicate an
infection that requires medical attention.
• Low libido: many women say that their libido is low at this
time — they just don’t feel sexy.
• Hormonal changes.
• Body image — a woman’s body may feel so significantly
changed by the processes of pregnancy and childbirth
leading to a feeling that she needs time to recover and feel
like herself again.
• The shape and sensitivity of the vagina may have changed.
• Anxiety about her new baby and the new world of
motherhood.
• Distractions, such a a crying or unsettled baby.
• Life is different: even with an uncomplicated birth of a muchwanted
child, life is much more demanding for everyone in
the household, especially the new mother. Tiredness is an
overwhelming factor.
Looking after a baby 24 hours a day is exhausting physically
and emotionally, so when the mother gets into bed she may
just want to sleep. This is clearly what nature demands — it
ensures that the baby is well looked after. It takes priority and
may not leave much time for the mother or her partner.
role of the practice nurse
• Raise awareness
• Give information
• Normalising
There is a vital educational component here. Factual
information can be very helpful and very empowering for
women and their partners. It also serves to debunk some myths
and preconceptions e.g. that everything returns to normal
after the mother has had her six weeks postnatal check-up and
sexual relations may resume as normal. This kind of information
is as important as the other routine health information that she
will be given post childbirth.
It is most important to help ‘normalise’ what women
are experiencing and to make them feel listened to and
understood.
• All mothers and their partners need information about sex
after childbirth.
• Both partners should be aware of, and know how to cope
with, vaginal changes.
• Both partners need to know and understand the reasons why
intercourse may be uncomfortable.
• Both partners should be aware that there are no hard and
fast rules about when desire and comfort for sex will return
or when to resume sexual relations. It varies significantly for
each woman.
The parents should be encouraged to look at other ways
to show their love for each other. Lubricants such as K–y Jelly,
Liquid Silk or Pjur may help to overcome vaginal dryness.
It’s important to advise couples that it’s not recommended
that the man perform oral sex on the woman for the first two or
three months after chilbirth, for the following reasons:
• If she hasn’t healed completely (internally and externally),
there is a risk that it could introduce infection into the vagina
and womb.
• It rarely happens but it can lead to death. Air blown into the
vagina can easily get into the blood vessels of the newly
delivered womb and cause a fatal-illness called ‘air embolism.
Not long ago one such death was reported in the British
press.
With commonsense advice, a loving couple can usually get
things sorted out — though it may take some months. New
27

in practice
28
parents should be encouraged to take advantage of any offers
of babysitting that come from family and friends so that they
can go out together or even grab a few moments to be loving
and close with each other. Mothers should be encouraged
to meet other mothers to chat, share experiences, exchange
information and build up social contacts.
Time is a factor for medical personnel but taking a proactive
role in spotting mothers with potential problems would help to
get them the care and support they need.
Awareness raising is important so that women realise that
they can get help, thus preventing long-term sexual problems
developing. Women should be encouraged women to use
their GP, practice nurse and public health nurse. The GP will
check if there are medical problems that are contributing to the
difficulties.
If medical problems are ruled out, the woman and her
partner should be given the opportunity to familiarise
themselves with the advice and help available through
psychosexual therapy services.
Antenatal classes
An ideal opportunity to provide information to mothers and
their partners is during antenatal classes rather than the
postnatal period when adaptation to parenthood takes up their
entire enegy and involves profound changes in their lives.
This would give them an opportunity to familiarise
themselves with information, clarify any queries and ask any
questions they might have. Equally important, it would give
them the opportunity to discuss together how they as a couple
will manage the changes and challenges of parenthood while
keeping intimacy at the core of their relationship.
Psychosexual therapy
Briefly, psychosexual therapy offers help for people with sexual
problems. Some sexual problems are purely physical and some
are purely psychological. Many are a combination of both.
Psychosexual therapists are trained counsellors or medical
professionals who have undertaken special training to deal
with issues associated with sexual functioning. It’s not a
newfangled idea it has been in use for well over forty years.
Most referrals come from counsellors, GPs and other medical
professionals. Self-referrals are also welcome. Although the
likelihood that someone will consult a psychosexual therapist
has increased, many people still find it difficult to talk about
sex.
Therapist’s role
A woman may feel vulnerable and fragile post childbirth — a
warm caring supportive environment is important so that she
and her partner can build a comfort level to talk about their
difficulties. They both need to be assured that these problems
are normal, treatable and that they don’t have to live with them
for the rest of their lives.
Initially, the therapist will explain the process, give the couple
an opportunity to familiarise themselves with alternative
ways of addressing problems, clarify any issues and ask any
questions they may have.
The therapist will then get information about the sexual
problem and if she/he thinks that they could benefit from
pyschosexual therapy, an individual treatment plan will be
prepared to suit their individual needs.
Both partners are encouraged to attend sessions, but a
woman can attend and benefit from the treatment plan as an
individual. Attendance at sessions and the material discussed is
confidential.
Those who decide that a programme may suit their needs
will set their own goals at the beginning of therapy and will
work at their own pace until they are happy with what they
have achieved.
There is no physical examination and the work assigned
takes place in the privacy of one’s own home.
summary
Nearly one in three women still experience painful sexual
intercourse a year after their baby is born and more than
half have at least one sex related problem, according to
research.
Some recovery time is to be expected. Adjustment to
recovery and healing involves a process that does not follow a
set timetable with a specific deadline.
If problems persist, it is important to encourage the
couple to talk to a professional — practice nurse, GP , PHN
or psychosexual therapist. Antenatal classes are an ideal
opportunity to raise awareness, normalise and give information
to mothers and their partners.
reference
1. The prevalence of enduring
postnatal perineal morbidity
and its relationship to type
of birth and birth risk factors.
Williams et al. Journal of Clinical
Nursing. 16,549-561. (March
2007).

study
exploring the
experience of
coPd:
a phenomenological study
ursulA reIlly clArKe, resPIrATory clINIcAl Nurse sPecIAlIsT,
RGN, H.DIP RESP, MSC RESP, MAyO GENERAL HOSPITAL
what is the lived experience of patients with coPd?
The aim of this study was to explore and delve into the
minutiae of the participant’s experience of living with coPd.
desIgN
A qualitative phenomenological study (Heidegger) was carried
out: phenomenology’s focus is on the meaning of experience
(Cohen et al, 2000).
seTTINg
The study setting was a single rural teaching hospital. Participants
for the study were purposefully selected from the
respiratory outpatient clinics.
PATIeNTs
The ethics committee granted permission to access eight individuals.
The study population were defined as: ‘Individuals
diagnosed with severe stage III (GOLD, 2005) chronic obstructive
pulmonary disease on optimum medical treatment’.
Stage III is severe COPD, where there is further worsening
of the airflow obstruction; the FEV 1 is now between 30-50%
of predicted, there is an increase in symptoms and it now has
an impact on the individual’s quality of life.
Individuals with other pulmonary or cardiac problems
and/or a diagnosis of a psychiatric illness were excluded.
The age range of four men and four women was 36-75 with
a mean age of 58.
meThod
Eight participants were interviewed using unstructured
interviews. Participants received posted information regarding
the study and a consent form. Interview times and locations
were agreed. Each participant was audio-taped with
their permission, with each interview lasting approximately
90 minutes.
mAIN FINdINgs
Three themes were identified, the physical effects of COPD,
the psychological effects of COPD and normality. Each
theme had sub-themes.
29

30
study
Theme 1 — PhysIcAl eFFecTs oF coPd
1:1 breathlessness
Breathlessness is a symptom of COPD and was a prominent
feature in all of the participants’ daily lives, which in turn
had a profound effect on their physical functioning and
lifestyle restrictions. One participant explained: ‘bending is
a major problem for me, causes shortness of breadth.’ Due to
their breathlessness they felt frustrated and tired which then
in turn leads to less social activity. The following excerpt is
an example of this ‘I just get breathless. I can only walk about
300 yards now, I would have to stop after 300 yards and in
2004 I could walk a mile and a half without (pausing). There
is no way in the world I would get around a golf course now.’
The participants also mentioned fear when discussing their
breathlessness as this woman explains ‘You see I get awful
breathless and then I’m afraid of what’ll happen to me.’
This, therefore highlights the need for a multi
disciplinary approach to care as breathlessness affects
the individuals physically and psychologically.
1:2 cough
Throughout the interview process, it was evident that six
of the participants had the symptom cough, however they
didn’t seem to acknowledge their day to day cough and only
discussed what caused them to cough. According to Halpin and
Rudolf (2006) many patients have a morning cough, which they
regard as normal for them. An excerpt from one participant
that portrays this: ‘So (coughs) that was alright…if anyone is
cleaning the house I go out the back into the garden, sit down,
maybe have a cup of coffee with me so if there is a load of dust, I
realise (coughs) why I am doing it. Because I don’t want to get this
dust on me chest and start coughing and coughing…I get episodes
of coughing but I can usually associate it with a chest infection.’
Most of the participants accepted that their COPD
was caused by smoking or related to their occupation.
Therefore they didn’t consider their cough a symptom
as they related it more to a ‘smoker’s’ cough.
Participants associated a cough with being unwell
and a flare up of a chest infection. In this study, while
many participants spoke about the awareness of a chest
infection due to an increase in volume of sputum, none
of the participants mentioned the word exacerbation
and only one participant spoke about self medicating.
1:3 Fatigue
Fatigue can vary with respect to its daily patterns, triggers
or contributing factors, and responsiveness to interventions.
Whilst fatigue has been recognised as an important problem
for individuals with COPD and is ranked by patients generally
as the second most important symptom, relatively little is
known about the specific nature of subjective fatigue and
its effects on daily life in the COPD population (Kapella
et al, 2006). Three of the participants’ reported concerns
in relation to fatigue, referring to tiring more easily.
This then raises the issue that if fatigue is the second
most important symptom mentioned by individuals with
COPD, there needs to be more research into how best to
manage this symptom and what options to recommend
to individuals with COPD who suffer from fatigue.
Results from Kapella et al’s (2006) study suggest a need
for further research on symptoms in people with COPD
and also to compare fatigue in healthy older people and
people with COPD in case fatigue increases with age.
Theme 2: PsychologIcAl ImPAcT oF TheIr IllNess
2:1 Fear of the future
Each exacerbation or infection can be perceived as a potential life
threat. The uncertainty in the progression of the disease and the
unpredictable nature of the attacks of breathlessness can leave
many patients fearing this attack could be their last;‘its just the not
knowing what tomorrow is going to bring…if I die tomorrow.’
Rather than her disease progressing to the next stage where she
may need continuous oxygen, she would rather ‘smoke a thousand
cigarettes a day...who would want to live five years on 24 hour oxygen
and all that. Why would you want to slow that down?” (laughs) You’d
want to speed that bit up (laughs)’
This therefore, has revealed the importance of the nurse patient
interaction as this patient attends outpatient clinics regularly and
has never highlighted these fears. A multi disciplinary team to
review how patients and their families are coping would work well
in overcoming this problem.
2:2 A feeling of loss
An area that is linked to the participants’ emotional response
to their illness is the feeling of loss of self. There are many losses
evident in the transcripts from the participants, from loss of job,
loss of hobbies, loss of independence to loss of confidence. One
participant describes her experience as follows:
‘I used to be into sports and different things gaelic and I had to
give it up…I used to love baking you know there’s days I wouldn’t be
able to make a dinner never mind make stand up and make a cake or
anything...I can’t even go for a walk’
Another participant experienced a loss of confidence as she explains
due to her COPD she doesn’t feel confident in driving alone,
she describes her experience by saying: ‘the COPD was hindering
me in getting into a car and just driving out which I would be very
used to for many a long day. I don't have he confidence. Do you know
before this happened I would drive to Kerry,..I wouldn’t dream of that
now’.
Studies in relation to COPD and pulmonary rehabilitation demonstrated
a heightened sense of control over their COPD resulting
in increased confidence and improving their overall emotional
wellbeing (Toms & Harrison, 2002; Camp, 2000). No participants
in this particular piece of research have been involved in any
pulmonary rehabilitation or education programme which leads
the writer to the point where pulmonary rehabilitation is the way
forward. It will not only improve patients' psychological outlook
on life it may also improve their physical ability, which in turn will
increase their independence.
2:3 guilt
All of the smoking participants felt guilty for smoking and were
aware that it caused their COPD, however two continued to
smoke. According to the Tobacco Free Policy Review group (2000)
quitting smoking is a complex issue for individuals with COPD.
The individuals are often not aware of the seriousness of their
lung condition until the disease is fairly advanced. The World
Health Organisation (WHO) as cited in the Tobacco Free Policy
Review Group (2000) has expressed the importance of delivering
non-smoking messages through every feasible channel possible.
Government officials, public health workers, and the general
public should encourage this. A counselling session of three
minutes relating to smoking cessation can be effective and should
be carried out for each individual at every GP visit by the GP or the
practice nurse and such advice and responses to the advice should
all be recorded (WHO, 2000). This three minute counselling session
should be carried out at each hospital presentation also.

COPD patients with severe COPD (FEV 1

32
study
Theme 3: NormAlITy
Moreover, normality surfaced as a key theme consistently.
Participants regarded the decline in activities of daily living
that healthy individuals take for granted as an effect of COPD.
COPD can interrupt the sense of who, where and what an
individual believes themselves to be in relation to norms
and expectations ascribed by society. This point cannot
be underestimated and its salience noted. In this study
participants made reference to how their COPD affected all
aspects of their normal activities of daily living and thereby
dramatically affecting their quality of life.
One participant explained how he is normally a very active
man but since he got the oxygen concentrator he doesn’t
understand how he will be able to go away for a night, as he
is supposed to wear it every night. He sees this machine as a
restriction on his social outings and an intrusion into his life.
coNclusIoN
Treatment for COPD should include a validated pulmonary
rehabilitation programme, yet only a minority of hospitals
have this available for their patients. Pulmonary rehabilitation
encompasses physical, psychological and psychosocial
needs with a multidisciplinary approach. This should be
made available to all patients, thereby leading to a more
holistic approach to care. This study identified the need for
psychological support to be made available during the various
stages of COPD as at present there is no psychologist input.
The need for patient education and counselling in relation to
the illness, the symptoms, the treatment and how to manage
an exacerbation has been identified. Occupational therapists
can help to reduce fatigue by careful education and a smarter
approach to daily activities by teaching patients to pace
themselves and conserve energy.
It is important to note that there is no national respiratory
strategy set out by the DOHC. A National Respiratory Strategy
would ensure that pulmonary rehabilitation is a necessary part
of the treatment of COPD and all respiratory multidisciplinary
teams throughout the country, are working towards the same
goal.
Moreover, there is a gap in the healthcare system between
the primary and secondary care system for these individuals.
This gap could be filled with the aid of community respiratory
nurses or multidisciplinary teams. Initiatives set up in England
that allow nurses to manage these patients in their own
homes such as the acute chest triage rapid intervention team
(ACTRITE) and acute respiratory assessment services (ARAS)
have been proven to be beneficial.
A counselling session of
three minutes relating
to smoking cessation
can be effective and
should be carried out for
each individual at every
gP visit by the gP or the
practice nurse and such
advice and responses to
the advice should all be
recorded (who, 2000).
reFereNce lIsT
Camp, P.G. (2000) Quality of life after pulmonary rehabilitation:
Assessing change using quantitative and qualitative methods,
Physical therapy, 80, (10), 986.
Cohen, M.Z., Kahn, D.L., and Steeves, R.H. (2000). Hermeneutic
Phenomenological Research: A Practical Guide for Nurse
Researchers, Sage Publications, London.
Global Initiative for Chronic Obstructive Lung Disease (2005)
Global Strategy for the Diagnosis, Management and Prevention
of Chronic Obstructive Pulmonary Disease, Executive Summary,
NHLB/WHO, Seattle.
Halpin, D., and Rudolf, M. (2006) Current COPD, 2 nd edn. Current
Medicine Group, London.
Kapella, M.C., Larson, J.L., Patel, M.K., Covey, M.K., and Berry,
J.K. (2006) Subjective fatigue, influencing variables, and
consequences in chronic obstructive pulmonary disease,
Nursing Research, 55, (1), 10-17.
Tobacco Free Policy Review Group (2000) Towards a Tobacco
Free Society: Summary of the Report of the Tobacco Free Policy
Review Group: Dublin.
Toms, J., and Harrison, K. (2002) Living with chronic lung
disease and the effect of pulmonary rehabilitation: patients’
perspective, Physiotherapy, 88, (10), 605-619.

E A R L I E R T R E AT M E N T active tomorrow 1-3
Sustained treatment benefi ts * for COPD patients with SPIRIVA ®1
* In the UPLIFT ® trial, while SPIRIVA ® did not alter the rate of decline in lung function, the primary
study endpoint, it achieved greater lung function improvements vs the control group. 1
References: 1. Tashkin DP, et al, on behalf of the UPLIFT ® (Understanding Potential Long-term Impacts on Function with Tiotropium) study investigators. A 4-year trial of tiotropium in chronic obstructive pulmonary disease. N Engl
J Med 2008;359:1543–54. 2. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: executive summary. Updated 2008.
http://www.goldcopd.com. Accessed November 6, 2009. 3. Casaburi R, et al. Improvement in exercise tolerance with the combination of tiotropium and pulmonary rehabilitation in patients with COPD. Chest 2005;127:809–817.
Prescribing Information (Ireland)
SPIRIVA ® (tiotropium)
Long acting, specific antimuscarinic agent, available as hard capsules of powder for inhalation, containing tiotropium bromide monohydrate equivalent to 18 micrograms tiotropium. Indication Tiotropium is indicated as a maintenance bronchodilator treatment
to relieve symptoms of patients with chronic obstructive pulmonary disease (COPD). Dose Adults only age 18 years or over: Inhalation of the contents of one capsule once daily from the HandiHaler® device. Contra-indications Hypersensitivity to tiotropium
bromide, atropine or its derivatives, or to the excipient lactose monohydrate which contains milk protein. Precautions Not for the initial treatment of acute episodes of bronchospasm, i.e. rescue therapy. Immediate hypersensitivity reactions may occur after
administration of tiotropium bromide inhalation powder. Caution in patients with narrow-angle glaucoma, prostatic hyperplasia or bladder-neck obstruction. Inhaled medicines may cause inhalation-induced bronchospasm. In patients with moderate to severe
renal impairment tiotropium bromide should be used only if the expected benefit outweighs the potential risk. Patients should be cautioned to avoid getting the drug powder into their eyes. They should be advised that this may result in precipitation or worsening
of narrow-angle glaucoma, eye pain or discomfort, temporary blurring of vision, visual halos or coloured images in association with red eyes from conjunctival congestion and corneal oedema. Should any combination of these eye symptoms develop, patients
should stop using tiotropium bromide and consult a specialist immediately. Tiotropium bromide should not be used more frequently than once a day. Spiriva capsules contain 5.5 mg lactose monohydrate. Interactions Although no formal drug interaction studies
have been performed tiotropium bromide inhalation powder has been used concomitantly with other drugs without clinical evidence of drug interactions. These include sympathomimetic bronchodilators, methylxanthines, oral and inhaled steroids, commonly
used in the treatment of COPD. The co-administration of tiotropium bromide with other anticholinergic-containing drugs has not been studied and is therefore not recommended. Pregnancy and Lactation No clinical data on exposed pregnancies are available.
The potential risk for humans is unknown. Spiriva should therefore only be used during pregnancy when clearly indicated. It is unknown whether tiotropium bromide is excreted in human breast milk. Use of Spiriva is not recommended during breast feeding.
A decision on whether to continue or discontinue breast feeding or therapy with tiotropium bromide should be made taking into account the benefit of breast feeding to the child and the benefit of tiotropium bromide therapy to the woman. Side-effects
Common (>1/100, 1/1,000,

34
interview
When Netta Williams started working
in general practice nursing back in
the early days of the profession in
Ireland she felt very isolated having
come from public health nursing in the
community. Not a woman to sit on her
laurels, she put out feelers for others
in the same situation and developed a
small educational forum which was to
become the nucleus of the Irish Practice
Nurses Association.
Netta Williams
INTERVIEW By mIchelle mcdoNAgh
Netta has seen the IPNA develop from an initial three
members to the formidable national organisation it
is today, and over that period, she has continued to
advocate tirelessly on behalf of practice nurses and
practice nurse education.
educational pioneer
She was also responsible for commencing standardised
practice nurse education through the Royal College of
Surgeons.
“They should put on my tombstone, 'she fought long and
hard for mandatory education for practice nurses',” she laughs,
self deprecatingly.
As of February this year, Netta is due to retire on the day
before her 65th birthday — after over 40 years in nursing,
however, she is as passionate and enthusiastic about practice
nursing as ever and plans to continue working in some way
with asthma and respiratory illnesses, which are her main area
of interest.
Netta started her nursing training in 1963 at the age of 18
and has not been out of the profession since then. “When I
went to my training school for interview, the three sister tutors
asked me, “why do you want to do nursing?”, I answered,
‘because I love helping people’. I thought it was the most
original answer at the time but I was being quite honest and I
still feel the same,” she explains.
Having married in Drogheda, Netta was working as a labour
ward sister in Our Lady of Lourdes Hospital which was run at
the time by the Medical Missionaries. However tragedy struck
when her husband died while she was expecting her second
child and she moved into public health nursing as she could no
longer keep up the hospital hours.
She worked in public health nursing in Drogheda until the
summer of 1988 when she started working as a practice nurse
in Dublin. She was invited by Professor Bill Shannon to tutor
on a part-time basis at the RCSI’s new Department of General
Practice.
She quickly recognised the need for specialised training in
general practice nursing which was not available in Ireland at
that stage. Along with Peter Harrington, she carried out a study
of all the practice nurses in the country at the time. There were
102 back in 1990, but this has risen to over 1,500 today.
As a result of this study, Netta set up the first Introduction to
Practice Nursing Course in 1991 which amazingly never had to
be advertised because the nurses were so anxious for training
that they put themselves forward.

The birth of the IPNA
She says: “I found practice nursing very interesting at that stage
but also quite isolating. I had come from public health where
I had a network of colleagues who I met every morning. That
was why I decided to put out feelers for other general practice
nurses who might be interested in getting involved in a little
educational forum, which turned out to be the nucleus for the
IPNA.”
Netta is particularly proud that general practice nursing is
now recognised as an advanced practitioner area and that
both of the advanced practitioner practice nurses in Ireland
started out on the course she developed. However, she says
it is “dreadful” that there is still no mandatory education
programme for practice nurses in Ireland.
Over the years, Netta and the IPNA continued to work with
the RCSI and the Irish College of General Practitioners in the
development of educational programmes for practice nursing,
including Diploma and Higher Diploma courses.
For the past number of years, she has worked in the role of
Professional Development Coordinator for practice nurses in
the Dublin south and Wicklow area.
“While working in practice nursing, I noticed how many
people we were seeing with asthma and respiratory conditions
and I took myself off to England to do a training course in this
area. I now teach that programme myself in Ireland. I really feel
there are areas of excellence in practice nursing but we must
keep ourselves up-to-date with best practice and evidencebased
skills,” Netta comments.
The best part about being a practice nurse for Netta is seeing
a patient come in with a condition, diagnosing and treating
them and keeping them well at primary level. If conditions
like asthma and chronic obstructive pulmonary disease are
recognised quickly enough, patients can be educated to
manage their condition and prevent hospital admission, she
points out, and this is a vital part of practice nursing.
“When I left general hospital care, at that stage if a child
came in with an asthma attack, they had an aminophylline
suppository put up their bottom and they were put in an
oxygen tent. How frightening must that have been for a child?
It was always an emergency situation and people died so
dramatically from asthma. That year salbutamol was developed
and things have changed hugely since. Patients are now being
taught to take control of their own illness and can be looked
after in the community.”
Professional challenges
In terms of the challenges facing the profession, Netta points
out that access to ongoing education is limited by virtue of the
fact that practice nurses are private employees and often have
to do additional training courses in their own time.
“I am very pleased that there is now a recognised postgraduate
diploma in practice nursing at the RCSI, but I am not
pleased that it costs €5,000 and the nurses have to go back to
the same job and salary afterwards. There are a lot of things
that have to be sorted out.”
She highlights the need for a team approach to patient care
in general practice comprising the GPs, pharmacists, nurses,
receptionists and cleaners — but it must never be forgotten
that the patient is a major part of the team too and should
dictate the care they get, she says.
“It’s not just about task achievement. Rather than see
somebody do 30 primary immunisations in a day, I would
rather see somebody do six and know that the mother went off
with her child feeling secure; that the nurse knew what she was
doing and that her practice cared for her and her family.”
interview
Nurse led clinics
Netta would like to see more nurse-led clinics such as asthma
clinics or walk-in clinics for nervous new mums, which she
points out would take a lot of pressure off the GPs. However,
she is not in favour of the tick-box style clinics being run in the
UK. She stresses that the practice nurse is not an assistant to the
GP, but brings the practice of nursing to the GP setting.
Having always had such a busy working life, Netta admits
that it’s going to be very strange having nothing to get up for
in the morning for the first time in over 40 years. She plans to
take a couple of months to think about her future, but would
definitely like to continue working in respiratory illness and
perhaps take up painting like her sister and daughter.
Having remarried a widower with three teenagers and with
two children of her own, Netta has also been kept very busy at
home with “our Brady bunch”. She now has nine grandchildren
from the age of 11 down to one year based in Ireland, America
and the UK who she adores, but she is determined not to
“become a granny with a house full of children”.
“I love children but like WC Fields said, I couldn’t eat a whole
one,” she jokes.
“I am very pleased
that there is now
a recognised postgraduate
diploma in
practice nursing at
the rcsI, but I am not
pleased that it costs
€5,000 and the nurses
have to go back to the
same job and salary
afterwards.”
35

probiotics
36
Part 4
deIrdre JordAN bsc ANutr (SCIENCE OFFICER, yAKULT IRELAND)
lINdA v ThomAs bsc Phd FIFsT (SCIENCE DIRECTOR, yAKULT UK LTD)
There is now a reasonable body of evidence to
indicate that certain probiotic strains may help
support the immune system and, in general, the
body’s natural defences. In this four part series
on probiotics we have looked at the evidence for
probiotics (i) as a risk reduction measure against antibioticassociated
diarrhoea and Clostridium difficile infection; (ii)
in reducing the effects of irritable bowel syndrome and
associated symptoms, and more recently (iii) in the general
health benefits of probiotics for the elderly. A fundamental
aspect of regular probiotic consumption is their modification
of the intestinal microflora such that numbers of beneficial
bacteria are maintained or increased, and the effects or
numbers of harmful or pathogenic bacteria are decreased. This
is associated with a range of positive effects on the health and
functioning of the digestive system, as well as modulation of
immune function. 1 Probiotics can also have many related and
more specific modes of action. By supporting the beneficial
bacteria in the commensal flora, they may help inhibit the
growth and reduce any harmful effects of other bacteria,
antigens, toxins and carcinogens in the gut. In addition,
and very importantly, probiotics can influence the immune
system via the gut-associated lymphoid tissue, with positive
modulation reported for the innate and even the acquired
immune system (Box 1).
The gut is the most vulnerable site in the body, which is
why the majority of the immune system is based there in the
form of the gut-associated lymphoid tissue (Figure: GALT).
The small intestine contains hundreds of Peyer’s patches
(concentrations of lymphoid tissues), but lymph nodes are
found through the whole length of the gut (in fact, 85% of
the body’s lymph nodes are estimated to be in the gut). This
immune network must recognise and tolerate the commensal
microflora (otherwise inflammation results), and it must also
tolerate food antigens. But importantly, it must recognise and
deal with pathogenic microbes. Studies with germ-free animals
have clearly shown that the commensal microflora is important
in educating and supporting the immune system; animals
without any gut bacteria have a poorly developed immune
The immune
system and
your gut:
a closer look at an
intricate relationship
(Part 4 of a 4 part series)
system with significantly fewer antibody-producing cells.
Probiotics can support the work of the commensal flora
in interacting and supporting the immune system, which
explains why certain probiotics have been shown to benefit
the health of the whole body, not just that of the gut.
box 1: Innate and acquired immune system
• The innate or non-specific immune response
defends the host from infection in a non-specific
manner. Cell surface receptors (Toll-like receptors)
on tissue recognise and bind different microbial
components. This can trigger phagocytosis and
production of pro-inflammatory cytokines, which
attract a local increase in white blood cells. The innate
immunity is an immediate response but it does not
confer long-lasting or protective immunity. Example
constituents of this system are natural killer (NK)
cells and phagocytic cells such as neutrophils and
macrophages. Examples of Toll-like receptors are TLR-4
(recognises lipopolysaccharide, the cell wall of Gramnegative
bacteria) and TLR-9 (recognises bacterial
DNA).
• The acquired/adaptive or specific immune
response recognises and remembers specific
pathogens and is thus able to mount a rapid and
stronger defence when the pathogen is next
encountered. Lymphocytes (T and B cells) recognise
specific and different parts of a pathogen, and then
can activate different pathways against it. Humoral
immunity is an antibody-mediated specific response
by B cell production of immunoglobulins (antibodies)
such as IgA, IgG and IgE. (Humoral refers to the bodily
fluids and comes from the old idea of ‘humors’ of the
body). The other response is cell-mediated, mainly
involving antigen-specific T cells.

Figure: Structure of GALT (Gut-associated lymphoid tissue)
Figure: structure of gAlT (gut-associated lymphoid tissue)
Food particles, bacteria (antigens)
Epithelium
T
T cells
B
T
B cells
Blood system
Dendritic cells
B
B
M cell
ProbIoTIcs ANd NATurAl KIller (NK) cells
NK cells, part of the innate response, target tumour cells
and virally-infected cells 2,3 and their activity can be
influenced by the activity of the intestinal microflora. 4,5,6
One epidemiological study has shown that cancer rates
are significantly higher in people with low NK cell activity,
compared to those with intermediate or high NK cell activity.
7 .Low levels of NK cell activity have also been shown to be
directly linked to an unhealthy lifestyle. 8,9 This may even have
psychological impact: one study showed that NK cell activity
declined in medical students on the day of examinations
compared with one month before examinations, suggesting
that mental stress can affect NK cell activity. 10
In a randomised, double-blind, placebo controlled study of
99 male smokers, probiotics were shown to restore their NK
cell activity. Subjects in the treatment group and the control
group were matched in terms of age, BMI, number of cigarettes
smoked and health state. The intervention was a three week
daily fermented milk drink containing 4x10 10 live cells of
Lactobacillus casei Shirota, or a placebo drink with no bacteria.
The study found that the number of cigarettes smoked every
day was linked to the reduction of NK cell activity that was
observed. The probiotic intervention maintained NK cell
activity during the intake period compared to the placebo
group in which the NK activity dropped (p=0.0002). 11
Similar results with this probiotic strain were found in another
study which investigated nine healthy subjects (30-45 years),
and 10 elderly subjects (55-75 years) who had relatively low
levels of NK cell activity (

probiotics
38
immune cells. Further evidence that an increase in salivary
sIgA may be a beneficial mode of immune modulation for this
probiotic, came from an open-label study in nine healthy adults
(20-45 years), who consumed two bottles of the drink (each
with 6.5 x 10 9 live cells of L. casei Shirota) daily for four weeks.
Saliva samples were collected and analysed at baseline, during
the intervention and two weeks later. This showed that there
was a significant increase in the mean sIgA secretion rate after
four weeks, in comparison to baseline levels (Fig 1). Secretion
of both subtypes of IgA (types one and two) was also increased
at week four and remained elevated two weeks after cessation
of L. casei Shirota consumption (Fig 2). Consumption of certain
probiotic strains may be linked to a reduced duration and
severity of winter respiratory infections, therefore from this
study one mechanism involved may be a probiotic-associated
increase in IgA and IFN-γ secretion. 19
Figure 1
Mean Secretion Rate (mg/minute)
Mean Secretion Rate (µg/minute)
0.30
0.25
0.20
0.15
0.10
0.05
0.00
Figure 2
20
15
10
5
0
sIgA
IgA1 & IgA2
P=0.02
Week 0 Week 1 Week 2 Week 4 Week 6
P=0.03
P=0.03
P=0.02
P=0.01
IgA1
IgA2
Week 0 Week 1 Week 2 Week 4 Week 6
ProbIoTIcs ANd AllergIc resPoNses
The composition of the gut flora of infants who later develop
allergy has been reported to differ from infants who do not
develop allergy. These differences are evident very early in life
before any clinical signs of atopy 20 (a disease characterised
by a tendency to be hyperallergic). There appears to be a
strong hereditary component to this: one study concluded
that the general risk of developing atopic dermatitis and
atopy increases by a factor of two with each first-degree
family member already atopic. 21 Disturbances of the gut flora
have also been documented in patients with asthma and
allergic rhinitis. 22 These studies indicate that the gut flora may
influence allergy. 23 Allergic responses are linked to T-helper
glossary
cytokines are proteins that act as chemical messengers in
the immune system.
IFN-γ is a cytokine made by T-cells. It has antiviral activity,
is able to activate macrophages and has many other
immune effects
IgA is the major antibody produced at mucosal lymphoid
surfaces; it can be sub-divided in to IgA1 and IgA2.
Interleukins (IL) are cytokines produced by leukocytes.
Il-12 is a cytokine produced by antigen-presenting cells
that induces differentiations of virgin T-cells into Th1 cells
and activates NK cells.
sIgA is the secretory form of IgA and is the main
immunoglobulin in mucus secretions.
Th1 secretes IL-4, IL-5, IL-10 and IL-13. Th1 cells are mainly
involved in activating macrophages and defending against
intracellular pathogens.
Th2 secretes IL-4, IL-5, IL-10 and IL-13. Th2 cells are mainly
involved in stimulating B cells to produce antibodies, but
also important in the allergic response
type 2 (Th2) lymphocytes that produce high levels of IL-4, IL-5
and IL-6 that promote IgE synthesis.24 Probiotics have the
potential to re-direct this response back to a healthy regulated
balance.
Hay fever is an allergic reaction to pollen or fungal spores,
most commonly grass pollen. The immune system mistakes the
spores for harmful invaders and produces excessive amounts
of the antibody IgE to bind to them and fight them off. IgE
stimulates the release of histamine to flush out the spores,
and this irritates the airways making them swell and produce
the symptoms of hay fever. A placebo-controlled probiotic
study was conducted during the hay fever season in 20 people
with a history of seasonal allergic rhino-conjunctivitis. All had
detectable levels of pollen-specific IgE antibodies in the blood
before the start of the pollen season. The volunteers drank
a daily drink with or without live probiotic bacteria (L. casei
Shirota) over five months. Blood samples were taken before
the grass pollen season, then again when it was at its peak
(June), and four weeks after the end of season. There were no
significant differences in levels of IgE in the blood between the
two groups at the start of the study, but IgE levels were lower in
the probiotic group both at the peak season and afterwards. At
the same time, levels of IgG were higher; this antibody plays a
protective role against allergic reactions. 25
ProbIoTIcs IN resPIrATory TrAcT ANd
gAsTroINTesTINAl TrAcT INFecTIoNs
Thirty million working hours are lost every winter in Ireland
due to sickness when the weather gets colder and the days
get shorter. Statistics released earlier this year show that nearly
60% of the Irish workforce will miss work days though winterrelated
health issues and that 85% of Irish people suffer from
the winter blues. 26
A study in Sweden which recruited 181 day and shift workers

Looking for the low down on current
probiotic research and development?
Interested in reports and summaries
by independent scientifi c experts?
Want all the facts on the latest probiotic
events, conferences and symposia?
Then register now to join the thousands
of other healthcare professionals
currently receiving the FREE, peeracclaimed
Probiotic Bulletin newsletter.
Published three to four times a year, the Probiotic Bulletin
provides a comprehensive digest of developments in the fi eld –
from research to events, symposia to awards.
Free Resource for
Healthcare Professionals
“This is a trusted source of information on current
developments within the probiotic fi eld. Presented in
an engaging and authoritative manner, it is a must for
anyone with a professional interest in probiotics.”
Compiled by the science team at Yakult, the newsletter also
regularly includes articles by independent scientifi c experts –
previous contributors have included Professor Eamonn Quigley,
Dr Michael Millar, Professor Mike Gleeson and Catherine Collins.
Professor Glenn Gibson
Head of Food Microbial Sciences, University of Reading
Each professionally designed, six-page newsletter contains a
wide range of articles, generally including:
• a conference / event report, often guest
authored by an independent expert
• an interview with a scientist or
healthcare professional
• a round up of the latest probiotic
research from around the world
• an update on any new resources
provided by the Yakult science team
• a notice board, detailing events at
which you can meet the Yakult team
• a review of any recent Yakult awards.
To receive your copy of the most recent newsletter and sign
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Yakult Ireland
Berkeley House, 21 Cookstown Ind Est, Tallaght, Dublin 24
+353 (0)1 459 9580 science@yakult.ie

probiotics
40
‘In addition, studies have
shown that probiotics
have the potential to
enhance the strength of
vaccination, with data
showing that people
taking probiotics having
a reduced incidence
of influenza after
vaccination compared to
those on a placebo.’
in a factory examined whether the probiotic L. reuteri Protectis
could improve health in the workplace by reducing short term
sick leave caused by respiratory or gastrointestinal infections.
In this double-blind placebo-controlled trial, workers were
randomised to receive a daily intervention of 10 8 live cells of
L. reuteri or a placebo for 80 days. During this time, a record
was kept of any symptoms of respiratory tract and/or the
gastrointestinal tract infections resulting in sick-leave, and
the duration of this. Data from a cohort of shift workers were
extrapolated from the results of all subjects, as shift workers
are known to be at significantly higher risk to contract shortterm
illnesses such as colds and gastroenteritis. 27 The results
showed that 26.4% of those in the placebo group reported sick
for work compared with 10.6% in the probiotic group (p

TODAY WE CAN DO MORE
GARDASIL®
CAN PREVENT
Cervical cancer*,
ABRIDGED PRESCRIBING INFORMATION
GARDASIL® (Human Papillomavirus Vaccine [Types 6, 11, 16, 18] (Recombinant,
adsorbed)). Refer to Summary of Product Characteristics for full product information
before prescribing. Additional information is available on request. Presentation: Gardasil
is supplied as a single dose pre-fi lled syringe containing 0.5 millilitre of suspension.
Each dose of the quadrivalent vaccine contains highly purifi ed virus-like particles (VLPs)
of the major capsid L1 protein of Human Papillomavirus (HPV). These are type 6 (20
µg), type 11 (40 µg), type 16 (40 µg) and type 18 (20 µg). Indications: Prevention of
premalignant genital lesions (cervical, vulvar and vaginal), cervical cancer and external
genital warts (condyloma acuminata) causally related to HPV types 6, 11, 16 and 18.
Gardasil is indicated for 16 – 26 year old females and 9 – 15 year old children and
adolescents. Dosage and administration: The primary vaccination series consists of 3
separate 0.5 millilitre doses administered according to the following schedule: 0, 2, 6
months. If an alternate schedule is necessary the second dose should be administered at
least one month after the fi rst and the third dose at least three months after the second.
All three doses should be given within a 1 year period. The need for a booster dose has
not been established. Administration at the same time as Hepatitis B vaccine has been
shown to not interfere with the immune system. The vaccine should be administered by
intramuscular injection. Contraindications: Hypersensitivity to any component of the
vaccine. Hypersensitivity after previous administration of Gardasil. Acute severe febrile
illness. Warnings and precautions: As with all vaccines, appropriate medical treatment
should always be available in case of rare anaphylactic reactions. The vaccine should
be given with caution to individuals with thrombocytopaenia or any coagulation
disorder because bleeding may occur following an intramuscular administration
Gardasil® the quadrivalent
HPV cervical cancer* vaccine for
protection against a wide range of
genital diseases causally related
to HPV 6, 11, 16, & 18
High-grade cervical intra-epithelial neoplasia,
More than 40 million doses distributed worldwide 2
03/09 UK12606
* Related to HPV 16, 18
High-grade vulvar and vaginal intra-epithelial neoplasia,
and genital warts,
causally related to HPV 6, 11, 16, 18. 1
Information about adverse event reporting can be found at www.imb.ie.
Adverse events and inadvertent vaccination during pregnancy should also be
reported to Sanofi Pasteur MSD by calling 0044 1628 785291
in these individuals. Syncope, sometimes associated with falling, has occurred after
vaccination with Gardasil, vaccinees should be carefully observed for approximately 15
minutes after vaccination. There is insuffi cient data to recommend use of Gardasil during
pregnancy therefore the vaccination should be postponed until after completion of the
pregnancy. The vaccine can be given to breastfeeding women. Gardasil will only protect
against diseases that are caused by HPV types 6, 11, 16 and 18 and to some limited extent
against diseases caused by certain related HPV types. Vaccination is not a substitute for
routine cervical screening. There are no data on the use of Gardasil in subjects with
impaired immune responsiveness. As with any vaccine, vaccination with Gardasil may
not result in protection in all vaccine recipients. There are no safety, immunogenicity
or effi cacy data to support interchangeability of Gardasil with other HPV vaccines.
Undesirable effects: Very common side effects include: pyrexia and at the injection site,
erythema, pain and swelling. Common side effects include bruising and pruritus at the
injection site. Very rarely, bronchospasm has been reported. Guillain-Barré Syndrome and
hypersensitivity reactions including anaphylactic/anaphylactoid reactions have also been
reported. For a complete list of undesirable effects please refer to the Summary of Product
Characteristics. Package quantities: Single pack containing one 0.5 millilitre dose prefi
lled syringe with two separate needles. Marketing authorisation holder: Sanofi Pasteur
MSD SNC, 8 rue Jonas Salk, F-69007, Lyon, France Marketing authorisation number:
EU/1/06/357/007 (pre-fi lled syringe with two separate needles) Legal category: POM ®
Registered trademark Date of last review: November 2008
References: 1. Gardasil: Summary of product characteristics 2009. 2. Sanofi Pasteur MSD.
Data on fi le 2009.

probiotics
42
references
1. Calder PC, Kew S. The immune system: a target for
functional foods? Br J Nutr 2002; 88 (Suppl 2):S165-S177.
2. Herberman RB, Oltaldo JR. Natural killer cells: Their roles in
defences against diseases. Science. 1981;214:24-30.
3. Talmadge JE, Meyers KM, Prieur DJ, Starkey JR. Role of NK
cells in tumour growth and metastasis in beige mice. Nature.
1980;284:622-4.
4. Bartizal KF, Salkowski C, Batish E. The influence of a
gastrointestinal microflora on natural killer cell activity. J
Reticuloendothel Soc. 1983; 33:381-90.
5. Bartizal KF, Salkowski C, Pleasants JR, Balish E. The effect of
microbial flora, diet, and age on the tumoricidal activity of
natural killer cells. J Leukoc Biol. 1984; 36: 739-50.
6. Cebra JJ, Periwal SB, Lee G, Lee F, Shroff KE. Development
and maintenance of the gut-associated lymphoid tissue
(GALT): the role of enteric bacteria and viruses. Dev
Immunol. 1998;6:13-8.
7. Imai K, Matsuyama S, Miyake S, Suga K, Nakachi K. Natural
cytotoxic activity of peripheral-blood lymphocytes and
cancer incidence: an 11-year follow-up study of a general
population. Lancet 2000;356:1795-9.
8. Morimoto K, Takeshita T, Inoue-Sakurai C, Maruyama S.
Lifestyles and mental health status are associated with
natural killer cell and lymphokine-activated killer cell
activities. Sci Total Environ 2001;270:3-11.
9. Kusaka y, Kondou H, Morimoto K. Healthy lifestyles are
associated with higher natural killer cell activity. Prev Med
1992; 21:602-15.
10. Chiang BL, Sheih yH, Wang LH, Liao CK, Gill HS. Enhancing
immunity by dietary consumption of a probiotic lactic acid
bacterium (Bifidobacterium lactis HN019): optimization and
definition of cellular immune responses. Eur J Clin Nutr
2000;54:849-55.
11. Morimoto K, Takeshita T, Nanno M, Tokudome S,
Nakayama K. Modulation of natural killer cell activity by
supplementation of fermented milk containing Lactobacillus
casei in habitual smokers. Preventive Medicine 40 (2005)
589-594.
12. Takeda K, Okumura K. Effects of a fermented milk drink
containing Lactobacillus casei strain Shirota on the human
NK-cell activity. The Journal of Nutrition. Suppl Effects of
Probiotic s and Prebiotics. 791S-793S.
13. Bunout D, Barrera G, Hirsch S, Gattas V, de la Maza MP,
Haschk F, Steenhout P, Klassen P, Hager C, Avendano M,
Petermann M, Munoz, C. Effects of a nutritional supplement
on the immune response and cytokine production in
free-living Chilean elderly. Journal of Parenteral and Enteral
Nutrition (2004) 28(5):348-354.
14. Olivares M, Diaz-Ropero MP, Sierra MBSS, Lara-Villoslada
F, Fonolla J, Navas M, Rodriguez JM, xaus J. Oral intake of
Lactobacillus fermentum CECT5716 enhances the effects of
influenza vaccination. Nutrition (2007) 23:254-260.
15. Matthews CE, Ockene IS, Freedson PS et al. Moderate to
vigorous physical activity and the risk of upper-respiratory
tract infection. Med Sci Sports Exerc 2002;34:1242-1248.
16. Nieman DC. Exercise, infection and immunity. Int J Sports
Med 1994;15:S131-S141.
17. Cox AJ, Pyne DB, Saunders PU, Fricker PA. Oral
administration of the probiotic Lactobacillus fermentum
VRI-003 and mucosal immunity in endurance athletes. Br J
Sports Med doi: 10.1136/bjsm.2007.044628
18. Gleeson M. (Ed). Immune Function in Sport and Exercise.
Edinburgh. Elsevier, 2005.
19. O’Connell EJ, Allgrove JE, Pollard LV, xiang M, Harbige LS.
A pilot study investigating the effects of yakult fermented
milk drink (L. casei Shirota) on salivary IFN- γ, sIgA, IgA1
and IgA2 in healthy volunteers. (Poster Presentation).
International Yakult Symposium 18-19 th June 2009
20. Björksen B, Sepp E, Julge K, Voor T, Mikelsaar M. Allergy
development and the intestinal microflora during the first
year of life. J Allergy Clin Immunol 2001;108:516-520.
21. Küster W , Petersen M, Christophers E, Goos M, Sterry W.
A family study of atopic dermatitis (December 12, 2004).
Archives of Dermatological Research (Springer Berlin /
Heidelberg) 282 (Number 2 / January, 1990): 98–102.
22. Powell N, Huntley B, Beech T, Knight W, Knight H, Corrigan
CJ. Increased prevalence of gastrointestinal symptoms in
patients with allergic disease. Postgrad Med J 2007; 83:
182-6.
23. Smith DW, Nagler-Anderson C. Preventing intolerance: the
induction of nonresponsiveness to dietary and microbial
antigens in the intestinal mucosa. J Immunol 2005; 174:3851-
7.
24. Foley S, Hamid Q. Inflammatory patterns in allergic rhinitis.
Clin Exp Allergy Rev 2006; 6:91-5.
25. Ivory K, Chambers SK, Pin C, Prieto E, Arques JL, Nicoletti
C. Oral delivery of Lactobacillus casei Shirota modifies
allergen-induced immune responses in allergic rhinitis.
Clinical and Experimental Allergy, 1-8 doi:10.1111/j.1365-
2222.2008.03025.x
26. Onepoll survey of 1,000 Irish workers, July 2009.
27. Mohren D, Jansen N, Kant I, Galama J, Van Den Brandt
P, Swaen G. Prevalence of common infections among
employees in different work schedules. JOEM 2002,44:1003-
1011.
28. Tubelius P, Stan V, Zachrisson A. Increasing work-place
healthiness with the probiotic Lactobacillus reuteri: A
randomised, double-blind placebo-controlled study.
Enviornmental Health:A Global Access Science Source
2005,4:25.
29. Guillemard E, Tondu F, Lacoin F, Schrezenmeir J.
Consumption of a fermented dairy product containing
probiotic Lactobacillus casei DN-114004 reduces the duration
of respiratory infections in the elderly in a randomised
controlled trial. BJN (2009) doi:10.1017/S0007114509991395
30. Stadlbauer V, Mookerjee RP, Hodges SJ, Wright G, Davies
NA, Jalan R. Effect of probiotic treatment on deranged
neutrophil function and cytokine responses in patients with
compensated alcoholic cirrhosis. Journal of Hepatology 48
(2008) 945-951.

MJ MURRAy
Cancer:
the role of nutrition —
a patient’s search
patient’s perspective
“Prostate cancer is often slow to develop and spread and so
strategies that can influence its progression have considerable
potential. For those living with the condition, a controlled diet may
provide the only means of active treatment.” That’s the underlying
premise of Healthy Eating: The Prostate Care Cookbook.
The book has relevance to people with other forms of cancer and other life-threatening diseases as well.
43

44
patient’s perspective
Fighting cancer with food
Taking responsibility for one’s diet, the book says, gives the
patient a positive sense of control, known to enhance the
immune system. A cancer patient like myself, who also likes
cooking and eating, gets added benefits: 100 wonderfully
varied and imaginative recipes and up-to-date scientifically
researched explanations of the benefits for cancer prevention
and treatment of specific ingredients. Interestingly, the book
is a collaboration between a scientist, a dietitian, cancer
researchers and leading chefs.
Another book, Foods to Fight Cancer, concentrates on the
causes of cancer and, as the title suggests, the role played
by food in combating it. In the introduction, it explains the
challenge posed by all forms of cancer and outlines the path
of progression from the initial stages to metastasis: “… trying
to destroy these primitive cells is like trying to snuff out the
very adaptation skills and strengths that allowed us originally
to evolve into what we are now. It means trying to destroy the
forces that lie at the very heart of life.”
The best hope of counteracting cancer, say the authors, is
when and where it is at its most vulnerable: at the early stage
of angiogenesis, when the tumour is attempting to consolidate
its oxygen and nutrition supply through setting up a network
of feeder capillaries. And, of course, as the authors show,
significant quantities of anti-angiogenic molecules are present
in fruit and vegetables. Consuming these allows small doses of
natural cancer agents to be ingested daily — fighting cancer at
the source.
An insight into the subtle chemistry at work was the
presentation of research showing the synergistic anti-cancer
power of combining ingredients like turmeric and peppers;
tomatoes and olive oil etc. Of course, this makes the case for
the use of a broad range of ingredients in cooking.
science of nutrients
The science of this is clearly explained, starting with drawing
a distinction for the lay reader between macronutrients
(carbohydrates, proteins, fats), micronutrients (usually defined
as vitamins and minerals) and phytochemicals (essentially the
plant’s protective chemistry).
The latter target the processes used in the development
of a tumour, both in the anti-angiogenic process — already
mentioned and apoptosis — the amazing process by which
cells, compromised by disease, are programmed to selfdestruct.
In other words, the right nutrition provides a nontoxic
chemotherapy.
The author’s conclusion is as follows: “A diet based on a
regular intake of foods containing high levels of phytochemical
compounds represents the strongest weapon currently at our
disposal in the prevention of cancer ... cancer no longer has
to be a fatal disease; it can become a chronic one, requiring
constant and continuous treatment ... This is achieved over and
above all through diet.”
These ‘wonder foods’ are actually well known: cabbages,
broccoli, sprouts, cauliflower, garlic, the onion family, soya,
turmeric, green tea, berries, red tomato, oily fish, and citrus
fruit. These foods provide a virtual cocktail of anti-cancer
phytochemicals, vitamins and minerals. Red wine and dark
chocolate are also listed, but are only of benefit when eaten in
very modest quantities.
china syndrome
In The China Study by Colin Campbell, the topical example of
the promotion of lycopene by pharma companies as the latest
magic bullet is examined. Lycopene is a phytochemical which
gives tomatoes their red skin and is now known to have anticancer
properties. Campbell calls this promotion of isolated
qualities ‘scientific reductionism’.
“Consuming one carotenoid (in this case, lycopene) in the
form of a pill will never be the same as eating the whole food
which provides the natural network of health-supporting
nutrients.” Campbell has a right go at the food, agriculture
and pharma industries for what he perceives as their negative
influence on the formulation of health and nutrition policies
in the US. This is an issue not addressed in the other books
and one which ought to be of great interest to policy makers,
including the general public.
At the centre of The China Study is a report on an
international study of death rates from cancer across 2,400
Chinese counties: the New York Times called it the Grand Prix
of Epidemiology. On prostate cancer, the study found the
lowest death rates correlated with the lowest intake of meat,
dairy and other saturated fats, and vice versa. The book has
been criticised for advocating an extreme vegetarian diet,
even though Chinese cuisine includes, albeit small quantities
generally, meat and fish.
The clincher for me was the statement that migration from
all Asian to Western countries (and diets) is reflected in higher
prostate cancer rates, which also occurs amongst those Asians
who stay at home and migrate socially whereby they are able
to afford more meat in their diet.
On the theme of the quick fix of popping pills to counteract
an inadequate or inappropriate diet, a reviewer summed up
the importance of The China Study as follows: “If you want to
eat bacon and eggs for breakfast and then take cholesterollowering
medication, that’s your right. But if you truly want to
take charge of your health, read this book.”
conclusion
It is clear from all three books that prevention is the best cure.
That may be small consolation when you already have been
diagnosed with the disease. However, you have to start out
from where you’re at. In attempting to glean a sense of not
being entirely hopeless — that I can have some influence or
control over my cancer — I believe, these three books can help.
What’s in it for the health professional is accessible, up-todate
information on the science of identifying the optimal
health-promoting substances to be found in a range of foods.
Further reading
Healthy Eating: The Prostate Care Cookbook. Margaret Rayman,
et al. Kyle Cathie, London, 2009.
Foods to Fight Cancer. Richard Beliveau, Dennis Gingras. Dorling
Kindersley, London, 2007.
The China Study. T Colin Campbell, Thomas M Campbell. Ben
Bella Books, Dallas, 2006.

poster series
Hypertension management:
the role of the practice nurse
Optimal management of hypertension could have a profound impact on reducing stroke, heart attack and other
cardiovascular manifestations (yusuf, 2002). O’Brien (2007) argues that if patients with hypertension in Ireland had their
blood pressure reduced to optimal levels, stroke could be reduced by at least 50%. Management of most patients with
hypertension takes place in general practice. Unfortunately this management has not been optimal with poor control
of blood pressure.
Reasons for this sub-optimal management are multifaceted, including lack of time, resources, equipment e.g. ambulatory blood
pressure monitors (ABPM) and structured care pathways.
The practice nurse is ideally placed to manage the care of persons with hypertension with the goal of reducing stroke, heart
attack and other cardiovascular manifestations of hypertension. In a review of the literature, Bengtson and Drevenhorn (2003)
found that nurses promoted blood pressure reduction, weight loss, decreased sodium intake, smoking cessation and increased
physical activity in their hypertensive patients. The holistic approach by nurses in these studies helped improve patient outcomes.
However, additional well-designed, larger controlled studies are needed to further evaluate the nursing role.
A structured management plan for patients with hypertension was introduced into a rural general practice. Patients with
hypertension were referred to a practice nurse led hypertension clinic. Each patient’s blood pressure management was reviewed
including:
• Measurement of blood pressure i.e. office blood pressure reading, seven day blood pressure monitor or 24-hour ABPM
(European Society of Hypertension (ESH), 2003; O’Brien et al, 2002)
• Risk factor score
• Patient education
• Lifestyle advice given
• Laboratory investigations: plasma glucose, serum total cholesterol, HDL, LDL and fasting tryglycerides, serum creatinine,
serum uric acid, serum potassium, haemoglobin and haematocrit, Urinalysis and electrocardiogram (ESH, 2003).
• Current treatment i.e. lifestyle modification and pharmaceutical therapy.
Following practice meetings, a practice protocol was developed providing integrated structured care pathways to optimise the
care of patient’s with hypertension. The practice nurse reviewed her scope of practice (An Bord Altranais, 2000) ensuring that the
protocol reflected best practice, enhanced patient care and the competence of the practice nurse.
A handheld blood pressure card was developed in the practice (Hogan, 2007) and introduced to enhance patient education,
continuity between primary and secondary care and to encourage patient involvement in their care. This handheld card is used as
a visual aid for patients when educating them about lifestyle risk factors, medications and blood pressure readings. It also reminds
them to make an appointment for their next visit. Communication between primary and secondary care has previously been
deficient. The handheld card is useful in providing information on blood pressure readings to all healthcare providers, especially
results of 24-hour ABPM.
Audit of outcomes is important to measure the results of any new practice initiative. An audit of the records of patients attending
the practice nurse led service will be undertaken after one year. The audit will examine if blood pressure readings are improved and
within target, lifestyle modifications, overweight and obesity reduction and risk factor reduction. These will be compared with base
line readings.
This presentation aimed to illustrate best practice in the management of hypertension in primary care. The role of the practice
nurse was explored and a care pathway described. A tool for audit was proposed. The development of a handheld blood pressure
card has helped improve patient satisfaction and blood pressure management.
references
An Bord Altranais (2000) Scope of Nursing and Midwifery Practice Framework. An Bord Altranais, Dublin.
Bengtson A. and Drevenhorn E. (2003) The Nurse’s Role and Skills in Hypertension Care: a Review. Clinical Nurse Specialist 17(5), 260-
268.
European Society of Hypertension (2003) Practice Guidelines for Primary Care Physicians: 2003 ESH/ESC Hypertension Guidelines.
Journal of Hypertension 21(10), 1779-1786.
Hogan S. (2007) A patient held blood pressure record card as an adjunct to continuous care of hypertensive patients. Irish College
of General Practitioners (ICGP) Quality Improvement Awards. ICGP Annual General Meeting 2007, Galway.
O’Brien E. et al (2002) Working Group on Blood Pressure Monitoring of the European Society of Hypertension International Protocol for
validation of blood pressure measuring devices in adults. Blood Pressure Monitoring 7, 3-17.
O’Brien E. (2007) Getting things under control. Cardiology Professional 2(3), 11-14.
yusuf S. (2002) Two decades of progress in preventing vascular disease. Lancet 360, 2-3.
Abstract submitted by Stella Hogan and Róisín Doogue, IPNA Kildare/Carlow Branch.
This was an entry for the IPNA Branch Poster Award 2007
45

46
poster series
Foot care and footwear
Do you feel that you’re under pressure every day
of the week, every week of the month and every
month of the year? Well your feet are! Just imagine
that there was between 65 and 80 kilos of weight
pressing down on you every day and you’ve
got an idea of how those metatarsals are feeling every day.
That’s before we even mention high heels or the fact that we
squeeze our feet into ill-fitting shoes and that we don’t let our
feet breath. Each of these practices leads to a whole host of
problems and our feet suffer the consequences. Skeletal shock,
produced by walking, can be the cause of back, foot, ankle,
knee and hip pain, as well as other joint ailments (Johnson J.,
1994). Even as we drive we are putting pressure on our feet
without realising it; a pressure that they were not designed to
cope with.
However, we often do not pay our feet any attention until
they start to cause us trouble, despite the abundance of advice
available regarding foot care, (Dhara et al., 2001; Bansal et al.
2006, McGuire, J.B., 2006; Rosen, J. 2007). “The most common
foot problems are calluses, corns, fungal infections, toenail
conditions and foot injuries. Conditions such as diabetes and
peripheral vascular disease increases the risk of more serious
foot problems.” (Maher, C. 2002) As well as certain health
conditions, lifestyle choices can often be the cause of foot
problems, such as blisters, cracked heels, sweaty and aching
feet, ingrown toenails and bunions. Many holistic treatments
are being promoted in relation to the feet, with reflexology
now being provided as part of patient care.
With this in mind, the aim of this poster was to provide
professionals with a clear and concise visual aid to highlight to
patients the problems arising from inadequate and unsuitable
foot care and footwear. A brief description of the above
mentioned foot problems and treatments available was listed.
Hallux Valgus Bunion
This is a painful enlargement of the joint of the big toe. The
skin overlying the joint becomes tender and swollen. In severe
cases the joint itself often becomes deformed and the big toe
deviates laterally either under or over the second toe. Poorly fitting
shoes are often a causitative factor. Treatment include wearing
shoes that conform to the shape of the foot thereby relieving pressure
and reducing pain .Surgery is also an option to improve
appearance and reduce pain.
Ingrown Toenail
This condition is more often seen on the big toe. The
edges of the nail become painfully embedded into the
skin. This may happen due to incorrect nail cutting or
from shoe or sock pressure within the shoe. Cutting the toe
nail straight across and relieving pressure on the foot with wide toe
box footwear may prevent the problem. Untreated ingrown toenails
often become infected and painful requiring antibiotic treatment.
Removal of the toenail under local anaesthetic is some times
required to relieve pain.
Hammer Toe
This toe deformity results in a sideways
bend in the middle toe joint often as a
result of narrow tipped shoes. It is a painful
condition especially on the bony prominence on the
top and end of the toe. Corns often develop over this bony prominence.
Sized footwear may prevent this problem.
Morton’s Neuroma
This condition is caused by a nerve between the third and forth toes
becoming pinched as a result of tight fitting shoes resulting in pain.
The nerve responds by forming a neuroma, this is a build up of tissue
in the nerve. This extra tissue results in pain often radiating into
the toes. Wearing correctly fitted wide footwear will relieve pain and
oral medication to reduce the inflamination around the nerve.
Planter Fascilitis
This condition is the inflammation of the connective tissue of the
sole of the foot where it attaches to the heel bone resulting in pain.
This may happen without injury but often as a result of unsupportative
light weight footwear causing pain and swelling in the area.
Medication to reduce pain and swelling along with supportative
shoes are recommended.
references
Bansal, M.K., Kadambande, S.; Khurana, A.; Debnath, U.; Hariharan, K. (2006). Comparative
anthropometric analysis of shod and unshod feet. Foot; 16(4): 188-91.
Dhara, P.,Manna, I.; Pradhan, D.; Ghosh, S.; Kar, S.K. (2001).A comparative study of foot dimension
between adult male and female and evaluation of foot hazards due to using footwear. Journal of
Physiological Anthropological Applied Human Science. 20; 241-6.
Johnson, J. (1994) Footwear alleviates aches, fatigue through better fit, shock absorption. Occup
Health Saf 63(3),68-9.
Maher, C. (2002). A Step in Time… The World of Irish Nursing. June 2002. (25).
McGuire, J.B. (2006). Pressure redistribution strategies for the diabetic or at-risk foot. Advances in Skin
& Wound Care; 19 (5): 270-9.
Rosen, J. 2007. Health matters. Soothe sandal sores. Alternative Medicine Magazine 98, 20.
Abstract submitted by Ann Casey, IPNA Cork Branch. This was an entry for the branch poster award 2007.
Corns
A corn is a circular painful area of traumatised
hyperkeratotic skin. Common sites for
digital or hard corns are the big and fifth toes
as a result of pressure on the skin from incorrect
fitting stockings or footwear. Soft corns occur between the toes,
often corns on opposing toes resulting from sweaty feet can
become painful and develop secondary infections. Professional
advise regarding paring, filing or over the counter treatments is
advised.
Calluses
These are caused by friction and or exact
pressure on the skin over laying the
metatarsal heads of the feet. The skin becomes
thickened and hard resulting in further pressure
and pain when walking. Calluses are the result of inappropriate
footwear, unusual gait (walking pattern) or a foot bone deformity.
Treatment includes identifying the underlying problem, advice
on thick soled footwear or padding and skin care to relieve pressure
and provide shock absorption from underfoot.
Onychomycosis
Fungal nail infections resulting in thickened
painful and difficult to trim nails. The unsightly
appearance of the nail rather than pain is the reason
for seeking treatment. This condition is difficult and slow to
treat requiring compliance with antifungal treatment to prevent
reinfection. A sample of nail clipping is often requested for analysis
prior to treatment.
Tinea Pedis
Commonly known as Athletes foot a scaly,
itchy skin rash occurs between the fourth and
fifth toes firstly then developing onto the sole of
the foot. The skin between the toes becomes
inflamed, swollen and smelly. This is a contagious infection, easily
spread through shower and pool areas or shared footwear. Tinea
pedis initially may develop from the exclusive use of synthetic type
(plastic) footwear and (nylon) stockings resulting in hot sweaty feet.
Good skin hygiene especially between the toes, compliance with prescribed
treatments and wearing leather shoes or sandals with cotton
socks will keep the feet cool.
Copy of original poster

fOCUs On: OsTeOpOrOsis
Update on male osteoporosis
Khosla s
Journal
of Clinical
Endocrinology
and
Metabolism
2010 Jan; 95
(1): 3-10
abstracts
Osteoporosis in men is becoming an increasingly important public health problem. One in five men over the
age of 50 years will suffer an osteoporotic fracture during their lifetime, and men who sustain fractures have an
increased mortality risk.
Evidence for this American study from the College of Medicine, Mayo Clinic, Rochester, Minnesota, was
obtained by PubMed search and the author’s knowledge of the field.
Studies using computed quantitative tomography and high-resolution peripheral computed quantitative
tomography have provided new insights into the bone structural changes with aging in men, including the
somewhat surprising demonstration of significant, ongoing trabecular bone loss starting in young adult life. In
addition, there are now data demonstrating that serum oestradiol levels are important predictors of fracture
risk in men and that there is a threshold oestradiol level below which not only bone loss but also fracture risk
increases markedly.
Criteria for diagnosing and managing osteoporosis in men are also evolving, including the application of
the fracture risk assessment tool to derive 10-year fracture risks in men. Three bisphosphonates (alendronate,
risedronate and zoledronic acid) and teriparatide are currently US Food and Drug Administration approved for
the treatment of osteoporosis in men, with a number of new compounds, including a monoclonal antibody
against receptor activator of nuclear factor-kappaB ligand, selective oestrogen receptor modulators and
selective androgen receptor modulators in varying stages of development.
Despite significant advances, there remain a number of key unresolved issues regarding the pathogenesis
and management of male osteoporosis, not the least of which is increasing public awareness of this important
cause of morbidity and mortality in men.
The value of calcaneal bone mass measurement using a dual
X-ray laser Calscan device in risk screening for osteoporosis
Kayalar g,
cevikol A,
yavuzer g
et al
Clinics (Sao
Paulo) 2009; 64
(8): 757-62
The objective of this Turkish study from the Ministry of Health, Educational and Research Hospital PMR Clinic,
Ankara, was to evaluate how bone mineral density in the calcaneus measured by a dual-energy x-ray laser
(DxL) correlates with bone mineral density in the spine and hip in Turkish women over 40 years of age and to
determine whether calcaneal DxL variables are associated with clinical risk factors to the same extent as axial
bone mineral density measurements obtained using dual-energy x-ray absorptiometry (DxA).
A total of 2,884 Turkish women, aged from 40-90 years and living in Ankara, were randomly selected.
Calcaneal bone mineral density was evaluated using a DxL Calscan device. Subjects exhibiting a calcaneal DxL
T-score < or = -2.5 received a referral for DxA of the spine and hip. Besides DxL measurements, all subjects
were questioned about their medical history and the most relevant risk factors for osteoporosis.
Using a T-score threshold of -2.5, which is recommended by the WHO, DxL calcaneal measurements showed
that 13 per cent of the subjects had osteoporosis, while another 56 per cent had osteopenia. The mean
calcaneal DxL T-score of postmenopausal subjects who were smokers with a positive history of fracture,
hormone replacement therapy (HRT), covered dressing style, lower educational level, no regular exercise
habits and low tea consumption was significantly lower than that obtained for the other group (p

abstracts
48
first fractures among postmenopausal women with
osteoporosis
sontag A,
Krege Jh
Journal of Bone
and Mineral
Metabolism, 7
January 2010
After the occurrence of the first fracture, osteoporosis is no longer a ‘silent’ disease, and the patient’s risk for
future fracture is increased several-fold. The authors from this US study from LLC, Lilly Corporate Center, Indianapolis,
assessed the location of first osteoporotic fractures among women with osteoporosis.
The Multiple Outcomes of Raloxifene Evaluation (MORE) trial was a fracture outcomes study of
postmenopausal women with osteoporosis. All subjects received supplements containing 500mg elemental
calcium and 400-600 IU vitamin D. Sontag and colleagues assessed the location of first fractures among
women with osteoporosis and no previous fractures at baseline from the placebo group of this trial after three
years of follow up. Prespecified fracture sites included vertebral fractures and nonvertebral fractures as defined
in the MORE study protocol.
Among 875 women (mean age, 64.5 +/- 7.4 years) with no prevalent vertebral or nonvertebral fractures, nine
per cent experienced their first fracture event during the trial. Fractures of radius and spine each occurred in
three per cent of patients. Fractures at other individual sites included ankle (0.6 per cent), metatarsal (0.6 per
cent), humerus (0.5 per cent), rib (0.5 per cent), patella (0.3 per cent), leg (0.2 per cent), hip (0.2 per cent) and
clavicle (0.1 per cent).
These data suggest that, for postmenopausal women with osteoporosis but no previous fractures, skeletal
care should include a focus on preventing spine and radius fractures.
fOCUs On: WOmen’s HealTH
Barriers to the use of hydrotherapy in labour
stark mA,
miller mg
Journal of
Obstetric,
Gynecologic
and Neonatal
Nursing 2009
Nov-Dec; 38
(6): 667-75
The objective of this US study from the Bronson School of Nursing, Western Michigan University, was to determine
nurses’ perceived barriers to the use of hydrotherapy in labour. While effective in relieving pain, reducing
anxiety, encouraging relaxation and promoting a sense of control, hydrotherapy is rarely used during labour.
Intrapartum nurses (n=401) attending a national convention (Association of Women’s Health, Obstetric and
Neonatal Nurses, 2007; n=225) and members of perinatal listserves (n=176) were recruited. A questionnaire
was designed for this study (Nurses’ Perception of the Use of Hydrotherapy in Labour).
Institutional but not individual characteristics (age, education and role) were associated with Nurses’
Perception of the Use of Hydrotherapy in Labour. Nurses who reported higher epidural rates (r=0.45, p=0.000)
and Caesarean section rates (r=0.30, p=0.000) reported more barriers. There was no difference in perception
of barriers for nurses at hospitals providing different levels of care; there were significant differences when
primary care providers were considered. Intrapartum nurses in facilities where certified nurse-midwives do
most deliveries reported significantly fewer barriers than nurses who worked in facilities where physicians
attended most deliveries (F=6.84, df=2, p=0.000).
The culture of the birthing unit in which nurses provide care influences perception of barriers to the use of
hydrotherapy in labour. Providing hydrotherapy requires a supportive environment, adequate nursing policies
and staffing, and collaborative relationships among the healthcare team.
patient perceptions of arm care and exercise advice after
breast cancer surgery
lee Ts,
Kilbreath sl,
sullivan g,
refshauge
Km, beith Jm
Oncology
Nursing Forum
2010 Jan; 37
(1): 85-91
The purpose of this recent Australian study from the Royal North Shore Hospital, Sydney, was to describe in
greater detail women’s experiences receiving advice about arm care and exercise after breast cancer treatment.
A total of 175 patients with breast cancer were recruited 6-15 months after their surgery from three hospitals
in the Sydney area. The patients completed a survey about their perceptions of arm activity after breast cancer
and were asked to respond to an open-ended question about their experience receiving advice about arm
care and exercise. Comments from 48 women (27 per cent) who volunteered responses were collated and
categorised.
Topics raised by respondents included perceptions of inadequate and conflicting advice, lack of
acknowledgment of women’s concerns about upper limb impairments, an unsupported search for information
about upper limb impairments, fear of lymphedema (also known as lymphatic obstruction), women’s demand
for follow-up physiotherapy and some positive experiences with supportive care.
Upper limb impairments are problematic for some breast cancer survivors and these concerns are not always
taken seriously by health professionals. To date, standardised advice is provided that does not meet the needs
and expectations of a cohort of women after breast cancer surgery.
Health professionals could better address patients’ concerns about upper limb impairments by providing
accurate advice relevant to the surgery.

CALCICHEW-D 3 FORTE CHEWABLE TABLETS PRESCRIBING INFORMATION
(Please refer to full Summary of Product Characteristics when prescribing)
Presentation: Chewable tablet containing 1250mg calcium carbonate (equivalent
to 500mg of elemental calcium) plus 400IU colecalciferol (equivalent to 10
micrograms vitamin D 3 ). Uses: Treatment and prevention of vitamin D/calcium
deficiency. Supplementation of vitamin D and calcium as an adjunct to specific
therapy for osteoporosis, in pregnancy, in established vitamin D dependent
osteomalacia and in other situations requiring therapeutic supplementation of
malnutrition. Dosage and administration: Oral (suck or chew). Adults and elderly:
Two tablets daily. Children: Not intended for use in children. Hepatic impairment:
No dose adjustment required. Renal impairment: Should not be used in patients
with severe renal impairment. Contraindications: Diseases and/or conditions
resulting in hypercalcaemia and/or hypercalciuria, renal stones, hypervitaminosis
D, hypersensitivity to ingredient(s) especially soybean oil and peanut. Precautions:
Monitor serum calcium and creatinine levels, particularly in elderly patients on
cardiac glycosides or diuretics and in patients with high tendency to calculus
formation. Use with caution in patients with impaired renal function. Take into
account risk of soft tissue calcification. Avoid in patients with phenylketonuria or
sugar intolerance. Prescribe with caution in patients with sarcoidosis. Use with
caution in immobilised patients. Additional doses of calcium or vitamin D should
only be taken under close medical supervision. Interactions: Tetracyclines (take
HELP PROTECT THE
FRAGILE ELDERLY
Calcium and/or vitamin D deficiency in the elderly can lead to loss
of muscle tone and an increase in falls and osteoporotic fractures. 1-5
Calcichew-D 3 Forte is indicated for the treatment and
prevention of calcium and vitamin D deficiency. 6
2 hours before, or 4 to 6 hours after Calcichew-D 3 Forte), bisphosphonates or
sodium fluoride (take 3 hours before Calcichew-D 3 Forte), thiazide diuretics,
corticosteroids, cardiac glycosides, ion exchange resins (cholestyramine), laxatives
(paraffin oil). Calcichew-D 3 Forte should not be taken within 2 hours of eating
foods high in oxalic acid (e.g. spinach and rhubarb) or phytic acid (e.g. whole
cereals). Side effects: Hypercalcaemia, hypercalciuria, constipation, flatulence,
nausea, abdominal pain, diarrhoea, pruritus, rash, urticaria. Use in pregnancy and
lactation: Can be used in case of calcium and vitamin D deficiency. Daily intake
in pregnancy should not exceed 1500mg calcium and 600IU colecalciferol (15
micrograms vitamin D 3 ). Avoid overdose as permanent hypercalcaemia affects
developing foetus. Calcium and vitamin D 3 pass into breast milk so consider this
when giving additional vitamin D to the child. Pharmaceutical precautions: Do
not store above 30°C. Keep container tightly closed. Legal category: Pharmacy
product. Product Authorisation No: 535/1/3. Product Authorisation holder:
Shire Pharmaceuticals Ltd., Hampshire International Business Park, Chineham,
Basingstoke, Hampshire RG24 8EP UK. Distributed in Republic of Ireland by: Cahill
May Roberts, P.O. Box 1090, Chapelizod, Dublin 20, Republic of Ireland. Further
information is available on request. Date of revision: July 2007.
CALCICHEW is a registered trademark of Shire Pharmaceuticals Ltd in the
Republic of Ireland.
Their strength is our forte
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 may also be reported to Shire
Pharmaceuticals Ltd on +44 1256 894000.
References: 1. Perez-Lopez FR. Maturitas 2007;58: 117-137. 2. Dawson-
Hughes B & Bischoff-Ferrari HA. J Bone Miner Res 2007; 22: S2; v59-v63.
3. Lin JT & Lane JM. Phys Med Rehabil Clin N Am 2005; 16: 109-128.
4. Heaney RP. Endocrinology and Metabolism Clinics 1998; 27(2): 255-265.
5. Hunter DJ & Sambrook PN. Arthritis Res 2000; 2(6): 441-445. 6. Calcichew-
D 3 Forte. Summary of Product Characteristics. July 2007.
Date of preparation: January 2009. IRE/CDF/09/0001
®

product news
50
New product information: Combineb Nebuliser Solution and Ipravent Nebuliser Solution
Breathe Pharmaceuticals have announced the launch of a
further two nebuliser solutions in the family of respiratory
drugs for delivery by a nebuliser from Breathe Pharmaceuticals
in Ireland Combineb (Ipratropium Bromide/Salbutamol)
0.5mg/2.5mg per 2.5ml nebuliser solution.
Combineb is indicated for the management of
bronchospasm in patients suffering from chronic obstructive
pulmonary disease (COPD) who require regular treatment
with both ipratropium bromide and salbutamol. Combineb
nebuliser solution can be administered using the same
nebuliser as the originator brand of Ipratropium Bromide/
Salbutamol solution.
Ipravent (Ipratropium bromide 250mcg/1ml,
500mcg/2ml) nebuliser solution.
Ipravent is indicated for reversible bronchospasm associated
with chronic obstructive pulmonary disease (COPD) and the
treatment of reversible airways obstruction as in acute and
chronic asthma, when used concomitantly with inhaled beta 2 -
agonists.
Clonmel Healthcare has announced the launch of Lochol –
Fluvastatin 20mg & 40 mg Capsules. This product will join
the other cardiovascular medicine product listings within the
Ethical Prescription Division of Clonmel Healthcare.
Lochol is indicated for hypercholesterolaemia. Its mode of
action is the reduction of elevated total cholesterol (total-C)
and elevated low-density lipoprotein cholesterol (LDL-C). It is
also indicated for the secondary prevention of major adverse
cardiac events in patients with coronary heart disease.
Lochol 20 mg & 40 mg Capsules are 48% cheaper than the
brand originator.
Breathe Pharmaceuticals is a joint venture between Breath Ltd,
specialists in the anti-asthmatic field already marketing nebule
products in the UK, and Clonmel Healthcare Ltd, who have been
providing high quality, affordable medicines in Ireland since
1970. Together as Breathe Pharmaceuticals, we hope to build on
the vast experience of both companies to provide the best levels
of service and care possible in this specialist field.
combineb and Ipravent have been approved for
reimbursement by the general medical services as of 1st
November 2009, see codes below:
• Combineb 0.5mg/2.5mg per 2.5ml x 60 – 18745
• Ipravent 250mcg/1ml x 20 - 77507
• Ipravent 500mcg/2ml x 20 - 77509
To access the SPCs please go to www.clonmel-health.ie.
Ipravent and Combineb join Budesitan in the family of
respiratory drugs for delivery by a nebuliser from Breathe
Pharmaceuticals in Ireland. If you require any additional
information on any of these Breath products please contact
Clonmel Healthcare on 01 620-4000.
Clonmel Healthcare launch LOCHOL – Fluvastatin 20mg, 40mg hard capsules
www.your
Please contact Clonmel Healthcare on 01-6204000 if you
require any additional information on Lochol – Fluvastatin
20mg & 40 mg Capsules.

Coversyl Arginine Plus
Servier Laboratories have announced that Coversyl Arginine
Plus 10mg/2.5mg will be available for prescription in Ireland
from January 2010. Produced in Arklow, Coversyl Arginine Plus
10mg/2.5mg contains 10mg of perindopril arginine and 2.5mg
of indapamide, extending the range and providing more
powerful antihypertensive efficacy.
Coversyl Arginine Plus 10mg/2.5mg provides a high level
of control with 68% of hypertensive patients normalized at 8
weeks. The uptitration to Coversy Arginine Plus 10mg/2.5mg
provides incremental and progressive blood pressure
reductions reaching -23mmHg/15mmHg.
The renal benefits of Coversyl Arginine Plus 10mg/2.5mg
are greater than those for the lower dose Coversyl Arginine
Plus 5mg/1.25mg, with albumin excretion rate reduced by
48%. Further confirmation of renal and cardiac benefits are
demonstrated in the ADVANCE trial of over 11,000 patients with
Type II diabetes, of whom 70% also had hypertension.
Coversyl Arginine Plus 10mg/2.5mg is indicated as
a substitution therapy for the treatment of essential
hypertension in patients already controlled with perindopril
arginine and indapamide given concurrently at the same dose
level.
Coversyl Arginine Plus10mg/2.5mg is
taken once daily and will be available
in pots containing 30 tablets
providing one month of treatment
and will be available on the GMS
scheme.
For full prescribing information
see www.medicines.ie or please
contact Servier Laboratories
Ireland Ltd, Block 2, West Pier
Business Campus, Old Dunleary
road, Dún Laoghaire, Co Dublin or
on (01) 6638110.
Landmark 100th worldwide license for Cervarix
GlaxoSmithKline (GSK) announced in October that the US Food
and Drug Administration (FDA) has approved Cervarix for the
prevention of cervical pre-cancers and cervical cancer related
to human papillomavirus (HPV) types 16 and 18. The vaccine
will be licensed for use in girls and young women (aged 10-25).
This approval makes the US the 100 th country to grant
licensing for Cervarix, following a recent approval in Japan
and previous licenses obtained around the world, including in
the 27 member states of the European Union, Australia, Brazil,
South Korea, Mexico and Taiwan.
“We are extremely proud to know that our cervical cancer
vaccine will soon be available to millions of young women
product news
Flibanserin demonstrates efficacy and
tolerability in pivotal phase III trials in
pre-menopausal women with hypoactive
sexual desire disorder
Data from pooled, pivotal Phase III clinical trials demonstrate
that flibanserin 100 mg taken once daily at bedtime
significantly increased the number of satisfying sexual events
(SSEs) and sexual desire while significantly decreasing the
distress associated with hypoactive sexual desire disorder
(HSDD). Flibanserin is an investigational compound that is
being developed by Boehringer Ingelheim for the treatment of
pre-menopausal women with HSDD.
HSDD is a medical condition characterised by a decrease
in sexual desire associated with marked distress and/or
interpersonal difficulties. Women with HSDD often feel a loss of
intimacy and closeness that they used to enjoy. The condition
can negatively impact a woman´s life and her relationship with
her partner.
The complete flibanserin pivotal trial programme was
presented recently at the 12th Congress of the European
Society for Sexual Medicine in Lyon, France. It included an
analysis of three pivotal Phase III North American trials (DAISy,
VIOLET and DAHLIA) and the pivotal Phase III European data
(ORCHID). In addition results from a pooled analysis of two
pivotal Phase III North American trials (DAISy and VIOLET) and
a pooled analysis of the North American and European data
(DAISy, VIOLET and ORCHID) were presented, assessing the
safety and efficacy of flibanserin 100 mg in pre-menopausal
women suffering with HSDD.
"Despite studies demonstrating that HSDD is a common form
of female sexual dysfunction, there is currently no approved
prescription treatment for pre-menopausal women suffering
from the condition” said Professor Rossella Nappi, director of
the Gynaecological Endocrinology & Menopause Unit at the
Maugeri Foundation, University of Pavia, Italy, and primary
investigator of the European pivotal trial. "Flibanserin is a novel,
non-hormonal compound, that has been investigated as a
treatment for pre-menopausal women with HSDD. Based on
the clinical trial results presented at ESSM it has the potential to
help many women suffering from their lack of sexual desire."
across the US,” said Jean Stéphenne, President and General
Manager, GSK Biologicals. “Alongside our existing access
programmes in Europe, Australia, across emerging markets
and Asia Pacific, this approval marks an important turning
point in our dedicated mission to provide women everywhere
with effective protection against the world’s second-most
common female cancer.”
It is estimated that in 2009, approximately 11,000 women
in the U.S. will be diagnosed with cervical cancer and 4,000
women will die from the disease. Worldwide, these numbers
are estimated at more than 500,000 diagnoses per year and
globally, cervical cancer kills one woman every two minutes.
medicines.ie
51

product news
52
Micardis (telmisartan) approved by the
EC to reduce the risk of cardiovascular
morbidity in high risk patients
Micardis is now indicated by the European Commission for
the reduction of CV morbidity in patients with manifest
atherothrombotic CV disease or type 2 diabetes with
documented target organ damage.
• Micardis (telmisartan) is the ONLy treatment in its
class with this indication, demonstrating proven
cardiovascular (CV) protection in patients at high
CV risk
• This new indication is based on a review of clinical
trials, including results from the ONTARGET trial
• Patients at-risk of heart attack and stroke can now
benefit from this new indication.
Ingelheim, Germany, 27 November 2009: Boehringer
Ingelheim announced today that the European
Commission has approved Micardis (telmisartan) for the
reduction of cardiovascular morbidity in patients with:
I. manifest atherothrombotic cardiovascular disease
(history of coronary heart disease, stroke, or
peripheral arterial disease) or,
II. type 2 diabetes mellitus with documented target
organ damage.
Micardis is the first treatment in its class to be approved
for this indication.
Professor Giuseppe Mancia, Professor of Medicine and
Chairman of the Department of Clinical Medicine of the
University of Milan, Bicocca, Italy said, “This new indication
of telmisartan is a significant development for physicians
and their at-risk patients. Prevention of CV events is vital
as these are the primary causes of pathological death
in Europe, due to lack of proper control of treatable risk
factors and disease. The approval of telmisartan offers
patients a well-tolerated treatment option which also
provides CV protection.”
The European Commission approval is based upon a
review of clinical trial results, including the ONTARGET
trial involving 25,620 patients and confirmed Micardis
as the only treatment option in its class with proven
cardiovascular protective effects in patients with high CV
risk. The results also demonstrated that Micardis is better
tolerated than the previous gold standard ramipril and is
associated with higher treatment adherence.
Approximately 10,000 people in Ireland die each year
from cardiovascular disease making it the leading cause of
death in Ireland, accounting for 36% of all deaths.
Micardis is one of the most studied antihypertensives
in clinical trials and is widely used with over five million
patient years since its approval. Its safety profile is similar
to that of placebo.
Cubitan, new evidence demonstrates
faster healing of pressure ulcers in
nourished patients
Nutricia Advanced Medical Nutrition has
announced seminal research on Cubitan,
the only oral nutritional supplement
(ONS) specifically indicated for the dietary
management of wounds, which could
change the way healthcare professionals
treat patients with pressure ulcers. Results
from a randomised controlled trial (CUBE
trial) reveal that Cubitan promotes faster
healing of pressure ulcers in nourished
patients compared to standard wound
care treatment. Cubitan also results in
significantly fewer dressings and less
nursing time spent on wound care which suggests potential
cost savings with its usage.
Professor Jos Schols, the lead investigator from Maastricht
University, The Netherlands, comments that, “It is an
important trial for us as previous studies on ONS in pressure
ulcer healing have focused on malnourished patients, which
meant it was difficult to establish whether the benefits seen
were a result of correcting malnutrition. As the CUBE trial
focused on non-malnourished patients we know that the
benefits seen are a result of Cubitan affecting the wound
itself and not due to correcting deficiencies. Not only are
these results interesting from a clinical point of view, but
the data on wound dressings indicates there may be an
economic benefit of using Cubitan – something we are keen
to investigate further”.
This new research was announced just weeks after further
data from Italy demonstrated more effective wound healing
with Cubitan over a standard enteral nutritional formula.
Cubitan is the only nutritional intervention specially
indicated for the dietary management of wounds and it
should be used in both the prevention and treatment of
wounds. At €2.07 Cubitan is the same price as all other high
protein oral nutritional supplements but it contains the
highest amount of wound specific nutrients; zinc, vitamin C,
vitamin E and arginine.
Clonfolic 0.4mg 28 pack
Clonmel Healthcare wish to inform you that from 1 st February
2010 Clonfolic 0.4mg 28 pack will no longer be available as a
GMS reimbursable Product. Clonfolic 0.4mg 28 pack will still be
available as an OTC product only.
Please rest assured that the 98 pack size of Clonfolic 0.4mg
remains GMS reimbursable.
If you have any queries please contact 01-620 4000.
www.yourmedicines.ie

Across
6. Crack drug produced by oceanic
variation(7)
7. Disprove backward tuber (5)
9. Norwegian city in Chechoslovakia! (4)
10. I toot, we hear or K9, we hear (3,5)
11. Vocal sewing machine, perhaps (6)
13. It hath no fury like a woman scorned (4)
15. University for locksmiths? (4)
16. Cold spell in academic eagerness (3,3)
18. Ax with citric compound leaves scar of
healed wound (8)
21. Imitates mushy peas (4)
22. Cigarette of ship of the desert! (5)
23. Rushdie’s verses from 13 across (7)
dowN
1. Code for a T.V. inspector! (5)
2. Pirate radio station fit for a princess! (8)
3. Is this the housemaid’s joint? (4)
4. Imperial Roman fiddler! (4)
5. Let us up diversely for skin blemish
containing pus (7)
8. The last vehicle a person would travel in!
(6)
12. Thyroid enlargement, or I get
confounded (6)
13. December 31st in Scotland (8)
14. Vain act converted the papal state (7)
17. ‘Lukewarm’ in Israelite pidgin English (5)
19. When it comes to prayer, this is the last
word! (4)
20. See-through photo examined by
radiologist (1,3)
Caltrate is a trademark. PA 172/38/1.
Full prescribing information available from
Wyeth Consumer Healthcare, Plaza 254, Ballycoolin, Dublin 15
or from www.medicines.ie
Name:
Address:
Email:
1 2 3 4 5
6 7
9 10
15
14
11 12 13
18 19 20
21
22 23
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8
crossword
ANswers To lAsT moNTh’s crossword
ACROSS: 1. Mohawk 4. Swig 8. Arm 9. Tendons 10. Arch 11. Hyena
14. Posed 16. Pubs 18. Shipman 20. Rib 21. Stye 22. Choose
DOWN: 1. Moan 2. Humerus 3. Witch 5. Who 6. Gasman 7. Inch
12. Embargo 13. Spasms 15. Dome 16. Punch 17. Able 19. Ivy
Congratulations to the winner of last month’s crossword,
Ann Casey, Carrag Mervue Family Practice, College Road,
Carrag na Bhfear, Co. Cork.
Please send your answers to the Editor,
Nursing in General Practice,
GreenCross Publishing, Lower Ground Floor,
5 Harrington Street, Dublin 8.
Closing date for entries: 10 March 2010.
Winner will receive v50.
Please note: the winners’ cheques will be sent out
within 45 days.
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