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INNOVATION NEWS & VIEWS HEALTHCARE PHARMACY
Northern Ireland
Healthcare
Review
19TH NI HEALTHCARE
AWARDS
GET YOUR APPLICATIONS IN NOW
TIME IS TICKING
THE DETRIMENT OF POLITICAL DELAY
CARDIOVASCULAR RISK
A NEW ERA OF OPTIMISM
2017
WINTER
FEEDING FOR THOUGHT
ENTERAL NUTRITION: FROM HOSPITAL
TO HOME
SPECIAL
A YEAR IN REVIEW
ISSUE 106 - 2017
VISIT US AT WWW.NIHEALTHCARE.COM
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NIHR WELCOME
ISSUE 106 – 2017
MEDCOM
www.nihealthcare.com
www.pharmacy-life.co.uk Sarah Nelson Editor
EDITOR
sarah.nelson@medcom.uk.com
SARAH NELSON
sarah.nelson@medcom.uk.com
NATIONAL ACCOUNTS MANAGER
CHRIS FLANNAGAN
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EDITOR'S LETTER
ACCOUNTS MANAGER
DONNA MARTIN
accounts@nimedical.info
EVENTS MANAGER
BRIDGET MCCABE
bridget.mccabe@nimedical.info
Welcome to the latest edition of Northern Ireland
STUDIO MANAGER
DECLAN NUGENT
design@nimedical.info
Healthcare Review!
MANAGING DIRECTOR
ADRIAN MAGINNIS
Every single year – without fail – I achieved over the last 12 months, and a
adrian.maginnis@nimedical.info experience one moment of sheer seasonal reminder of the importance of optimism
IF YOU WISH TO CONTACT US BY panic. and unification as 2018 approaches.
TELEPHONE – 02890 999 441 It’s when I’m grappling with my What better way to put this theory
While every care has been taken in compiling
weekly grocery shopping list in the into practice than by asking a few of our
this magazine to ensure that it is correct at the
time of going to press, the publishers assume
supermarket (tackling the age-old debate friends to round-up their 2017 highlights
no responsibility for any effects from errors or
omissions. The opinions of contributors are not
of Jaffa Cakes vs Jammie Dodgers) and (page 10), and delving into Consultant
necessarily those of the publisher. No part of this
publication may be reproduced, stored in a retrieval
I realise that where only weeks before, Cardiologist, Dr Ian Menown’s, overview
system, or transmitted in any form, or by any means,
mechanical, electronic, photocopying, recording or
sunscreen lined the shelves; Christmas of the year’s current and emerging
otherwise without the prior permission of Medical
Communications 2015 Ltd. All rights reserved.
stockings and festive cards lie, awaiting trials for reducing cardiovascular risk
Data Protection - Please note, your mailing details
and copies of any articles supplied will be held
our perusal instead. (beginning on page 12)?
on a database and may be shared with associated
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And every single year, I shake my There’s more – our seasonal special
from, or made available to, external companies for
marketing purposes. If you do not wish your details
head, completely maddened by it because is helping you banish patients’ winter
to be used for this purpose, please write to: Database
Manager, Medical Communications 2015 Ltd, 142-148
it’s a swift transition; too swift. Just worries with advice on asthma,
Albertbridge Road, Belfast, BT5 4GS. Subscription:
£120 a year
like the year itself. And I suddenly feel gastroenteritis, dry eye, and more
panicked that the final couple of months (beginning on page 27), and we’re excited
are closing in on me faster than the to launch the 19th Northern Ireland
Hogwarts Express before I’ve completed Healthcare Awards – turn to page 15 to
even half of what I was supposed to. find out how you can enter for a chance
Somehow, the memory of any to win.
milestones reached vanishes like the Don’t forget to check in with our
subject of a David Copperfield magic columnists, including Dr Gavin Lavery,
INNOVATION TECHNOLOGY HEALTHCARE PHARMACY
act, and instead all I can think about are Consultant in Critical Care Medicine
Northern Ireland those curtains I was supposed to buy; (page six), and Co3 (page 40), who
Healthcare
Review
that language which I promised myself reflect on the region’s latest political
I’d learn; the book that I still had to read. happenings (or lack thereof ).
Yes, I undoubtedly have a long
HYPEREMESIS GRAVIDARUM
NEW CALLS FOR NATIONAL ACTION
way to go (beginning with a curtain Happy reading – and see you on the
DAY IN THE LIFE poles purchase), and yes, healthcare in other side!
BACK TO
OF A PRACTICE PHARMACIST
Northern Ireland obviously does too.
PSORIATIC ARTHRITIS
RECENT REVELATIONS OF BIOLOGIC
DRUGS SCHOOL However, this edition of NIHR is a
SEARCHING FOR BETTER
IS OUR RELIANCE ON INNOVATION
UNWISE?
SPECIAL celebration of all that has in fact been
Which medical tools and
tips have made the grade
ISSUE 105 - 2017
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To access the previous edition
of NIHR online, visit @MEDCOMni Medical Communications Ltd
www.nihealthcare.com/
previous-issues/
NIHR | Oct 2017 | 1
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CONTENTS
ISSUE 106 – 2017
6 SEARCHING FOR BETTER
Dr Gavin Lavery, Consultant in Critical Care Medicine,
and Quality Improvement Trainer, reflects on the danger
of overlooking our experts
10 A YEAR IN REVIEW
Various friends of NIHR pinpoint their favourite moments
of 2017
»» p.15 12 A HEART-TO-HEART
Consultant Cardiologist, Dr Ian Menown, on 2017’s
current and emerging trials for reducing cardiovascular
risk
15 19TH NORTHERN IRELAND
HEALTHCARE AWARDS
Do you have what it takes to be a 2018 winner?
27 OUT IN THE COLD
»» p.12 »» p.38 Dr Andy Whittamore sheds light on the role of winter
asthma action plans
32 GASTROENTERITIS
The lowdown on the condition – from likely causative
organisms, to rare complications and consequences
38 DAY IN THE LIFE
Pharmacist Paul McGimpsey – of Andersons Pharmacy –
provides an insight into his current daily diary
»» p.27
40 A RACE AGAINST TIME
Why furthur delays to resolving the political impasse may
prove terminal
46 ADHD AND INNOVATION
The impact of therapeutic advances and greater
neurological understanding
61 INFECTION AND BEYOND
Recent diagnostic and treatment guidelines for
»» p.10
managing wound-related sepsis
NIHR | Oct 2017 | 3
WWW.NIHEALTHCARE.COM
NEWS
Dr Gavin commented, ‘We
anticipate a 65 per cent increase in
LAUNCH OF
new cancer cases by the year 2035. CONSULTATION
‘That is a significant rise and
underlines the importance of ON SALE OF
having a strong, effective strategy
in place to implement targeted
E-CIGARETTES TO
cancer prevention programmes, to OVER 18S
ensure early diagnosis, and to have The Department of Health has
better and timely treatments for launched a public consultation on
local patients.’ draft regulations which will make it an
Meanwhile, the APG Chair, offence to sell e-cigarettes to anyone
Paula Bradshaw (Alliance) under the age of 18 in Northern
MLA, said, ‘We have had a Ireland, while a further offence
Paula Bradshaw MLA, Roisin Foster, Chief very productive first new term of proxy purchasing in relation to
Executive of Cancer Focus NI, and Dr Anna meeting of the APG with a good e-cigarette products is also proposed.
Gavin turn-out of MLAs, showing the The regulations will be made
commitment there is to keep under powers granted in the Health
URGENT CALLS FOR NORTHERN
cancer at the top of the political (Miscellaneous Provisions) Act which
agenda. was passed by the Northern Ireland
IRELAND CANCER STRATEGY
‘We plan to write to the Assembly in 2016.
Permanent Secretary, Richard The consultation process is seeking
Pengelly, in the absence of an views on detail of the regulations,
The Assembly All Party Group process of, updating their cancer Executive and minister to get an
(APG) on Cancer has issued strategies. The exception is including proposed exemptions, such
update. We acknowledge that there as nicotine products which have been
calls regarding the immediate Northern Ireland, which published have been many achievements over
necessity for a new cancer strategy its last strategy almost 10 years ago. licensed as medicines suitable for use
the last 10 years but the world of by under 18s, and licensed products
to improve cancer outcomes for Presenting to the APG, Dr cancer is ever-changing. With new
people in Northern Ireland. Anna Gavin from the Northern available on prescription.
medication, technology, and with Launching the consultation,
The action has been undertaken Ireland Cancer Registry, updated an ageing population, we need a
in the wake of all jurisdictions MLAs with the latest cancer the Chief Medical Officer, Dr
strategy to reflect all of this if we Michael McBride, explained, ‘While
in the UK and the Republic of statistics and trends, as well as want to see change for people in
Ireland having, or being in the projections to 2035. e-cigarettes are certainly less harmful
Northern Ireland.’ than tobacco and have a role to play
in helping smokers to quit, the long-
UNIQUE INNOVATION FOR COWS’ MILK term health impact of using them is
largely unknown. Therefore, I strongly
discourage their use by all non-smokers
ALLERGY ANNOUNCED
Nutricia has unveiled an exciting by a healthcare professional.
and, particularly, by children and
young people.
particular, its capabilities ‘At present, Northern Ireland is the
new app which has been designed The MyNeocate app provides encompass recipes – which can be only UK country where there are no
for parents of children who have various tools and tips to help filtered by meal types, by allergens, legal restrictions on the age of sale for
been prescribed a Neocate product manage a child’s allergy. In or by Neocate product – and a e-cigarettes.
diary, which enables parents to ‘The introduction of this legislation
record and track changes, and will protect our young people by
discover patterns. Parents can bringing e-cigarettes into line with
also input data based on a baby’s other age-restricted products, such as
sleep, mood, and food and drink tobacco and alcohol.’
intake – and they can subsequently Children and young people in
share this with their healthcare Northern Ireland were questioned
professional. on e-cigarette use for the first time
Additionally, the app allows in the Young Persons Behaviour and
parents to create a bespoke allergy Attitudes Survey 2016. The results,
card to print or email to friends, published earlier this year, revealed
family or carers to help them high levels of awareness concerning
understand their child’s allergy these products, with 94 per cent of 11
and requirements, and is equipped to 16-year-olds claiming to have heard
with other tips and resources, such of them.
as videos and articles to support Furthermore, 20 per cent of
parents with weaning and beyond. children were reported to have tried
The app can be downloaded for e-cigarettes at least once, with five per
free from the App Store. cent stating that they used one within
The MyNeocate app the past week.
4 | NIHR | Oct 2017
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NEWS
NUTRICIA UNIVERSITY REVEALS
‘Our modern lifestyles are also
having a significant impact. Even
mildly short-sighted eyes are at
LAUNCHES CONNECTION BETWEEN future risk of a number of serious,
sight-threatening conditions, such
SLEEP HORMONE AND as glaucoma, retinal detachment,
NEOCATE
macular degeneration and
cataracts.
SHORT-SIGHTEDNESS ‘Our research suggests that the
JUNIOR
body clocks’ of the short-sighted
A team of scientists from Ulster The findings, which follow on adults in our study were different,
University has successfully proven from previous research released which is exciting because if these
for the very first time in humans by Ulster University showing that differences are also found in
that there is a connection between there are now twice as many post- children, they may help us better
short-sight (myopia) and the primary school-aged children in understand which aspects of
melatonin levels which control the the UK diagnosed as short-sighted modern lifestyles are causing more
natural body clock. than there were 60 years ago, children to become short-sighted
In the study, Ulster University build a strong platform for future than ever before. If, as we suspect,
researchers assessed a group of research. disruptions to the natural body
young adults over a period of Professor Kathryn Saunders, clock are shown to be influential
18 months, during which their lead researcher at Ulster University, in the development of short-
melatonin levels were measured explained, ‘While having a short- sight, modifications to lifestyle
first thing in the morning after sighted parent plays a big part in that target strengthening healthy
fasting. It was found that those determining whether or not a child sleep and activity patterns could
people who were short-sighted had becomes short-sighted, the rate positively affect both general and
over three times more melatonin at which children are becoming eye health.’
in their system than those who short-sighted tells us that it is not
were not. just simple genetics at play.
Neocate Junior
PrEP MUST BE ROLLED OUT TO TACKLE
Nutricia has introduced Neocate
ALARMING NUMBER OF NEW HIV DIAGNOSES
Junior to the market – an amino the fight against HIV.
acid based formula (AAF) for ‘We understand that this will
children over the age of one-year- be a three-year project which
old with a cows’ milk allergy, a will inform follow-on routine
multiple food protein allergy, or commissioning. There is still some
other conditions that require an way to go, but we must welcome
AAF. the fact that this development is
The product can be used taking place.’
for both oral and tube feeding, Jacquie continued, ‘HIV is
employed as a sole source of increasing in Northern Ireland,
nutrition or as a supplement to with around 100 new diagnoses
the diet, and will replace Neocate each year. We want to make sure
Active and Neocate Advance that everything can be done
by April 2018. It’s also available to support those in need, or
in the three flavours of vanilla, ensure that those at most risk,
strawberry, and unflavoured. Jacquie Richardson have opportunities to prevent
A wide range of Neocate Junior themselves from contracting HIV.
resources are available, including The Chief Executive of Positive to provide HIV prevention drugs ‘HIV is indiscriminate and
product information, parent packs, Life, the only dedicated HIV to people at high risk of HIV we have a real opportunity to
and product samples. charity in the region, has warned infection. empower people to take charge of
that we risk being years behind PrEP will now be provided their own sexual health and reduce
in the fight against HIV if Pre- by the NHS through an initial the instances of HIV diagnoses
exposure Prophylaxis (PrEP) is three-year trial to an estimated here.
not extended to Northern Ireland 10,000 people, in what will be the ‘We are encouraged to hear
soon. largest single study of its type in this announcement and will be
Jacquie Richardson has the world. following the outcomes of the
communicated her concern in She said, ‘The announcement trial closely. Rolling out PrEP to
response to the announcement by NHS England in bringing Northern Ireland needs to happen
that NHS England has kicked off forward the extensive trial from as soon as possible as it will lead to
a pioneering implementation trial September is a pivotal moment in the improvement of many lives.’
NIHR | Oct 2017 | 5
WWW.NIHEALTHCARE.COM
OPINION
SEARCHING FOR BETTER
RECOGNISE AND LISTEN TO YOUR EXPERTS
In this issue’s column, Dr Gavin Lavery, Consultant in Critical Care Medicine, Quality Improvement Trainer
at Belfast Health and Social Care Trust, and graduate of Intermountain Institute of Healthcare Research,
reflects on how lessons for healthcare can be garnered from sailing ships, the space shuttle, and Brexit.
supervision of Henrik Hybertsson. led to fears it might capsize. and position of the cannon and
It took over two years to Despite these misgivings being its height above the water relative
complete; three to four times the communicated indirectly to the to its displacement) and had a
usual build time for ships of the king (he was abroad), the response (lower) gun deck quite close to the
period, and (then) was probably was to press on. The Vasa would water-line. These factors led to the
the most expensive ship ever built. be launched on time – after all instability that was demonstrated
The king viewed the Vasa (and it was very expensive and was prior to its maiden (only) voyage.
its soon-to-be-started sister ships) badly needed to teach the Polish Unfortunately, the king was
as essential to Swedish fortunes in / Lithuanians a lesson. The result abroad and ignored any warnings
their war with Poland-Lithuania was a disaster with loss of life, he received – and no one was brave
and he was keen to get it into national reputation, resources and, enough to challenge. This was an
service. ultimately, the war. example of poor design and lack
Dr Gavin Lavery On 10th August 1628, a large How did this come about? of corrective action. I hope some
crowd watched as the Vasa sailed The Swedish king wanted a ship parallels are becoming ever clearer.
They say that travel broadens
away and as per protocol, all the to strike fear into his enemies Despite knowing the above,
the mind and on a recent trip to
gun positions were open so that with elaborate carvings and the captain found himself
Stockholm, my wife and I visited
every cannon could be fired in emblems, designed to intimidate operating outside the usual limits
the Vasamuseum. The first thing
salute. It had sailed just over 1,200 the opposition. He had engaged of performance asked of any ship
I learned that afternoon was that
yards when it encountered a gentle one of the world’s most expert – something that doesn’t happen
the Baltic is probably the earth’s
breeze, keeled over, and sank ship-builders, Henrik Hybertsson, even in battle. A ship under full
‘least salty’ sea (a function of the
within minutes. So embarrassed who supervised the project sail with all gun positions open
relatively high volume of fresh
were the Swedes that a few days until falling ill in 1627. His and cannon firing. Once out of the
water that flows into it) and so
later they sent out a team to cut off subordinates continued oversight shelter of the harbour, the gentle
is free of seaworm (a maritime
the masts of the Vasa which were of construction. The king had wind pushed the ship over so far
version of the woodworm), which
still projecting above the surface – ordered 72 brass cannon for his laterally that sea-water could enter
requires higher salt concentrations
and still flying the Swedish flag. ship and these could not be housed through gun positions on the lower
to survive. This means that
But the tragedy of the Vasa, on a single gun deck. So a second deck side and the fate of the Vasa
wooden shipwrecks in the Baltic
which cost 30 lives, was not a gun-deck was included in the was sealed.
disintegrate very slowly. In 1961,
surprise to all in the Swedish plans even though Hybertsson The story of the Vasa shows
the Vasa, a 330-year old wooden
capital. An early warning had had never built a ship with two the danger of failing to heed your
ship, was raised from the depths
occurred weeks before. The captain gun-decks. Equipment from the experts. You may create something
of Stockholm harbour with 98
had used the standard way to time also show that two differing which is impractical or unworkable
per cent of the original wooden
demonstrate the stability of the units of measurements were being despite the best efforts of front-line
structure preserved. If you are
ship by getting 30 men to run used in construction, both Swedish workers. Trying to operate beyond
struggling to see the relevance of
back and forth across the upper feet (12 inches) and Amsterdam the accepted limits of the system
all this to healthcare, I beg your
deck to start the ship rolling. The feet (11 inches) which resulted in just compounds the dangers.
indulgence.
test normally had up to 20 deck some asymmetry. Thus the ship The Vasa could have been saved
The Vasa had been built at
crossings but was stopped after was slightly heavier on the port if problems had been addressed
the request of the Swedish king,
only three as the rolling of the ship side, top-heavy (due to the weight through redesign or possibly just
Gustavus Adolphus, under the
6 | NIHR | Oct 2017
WWW.NIHEALTHCARE.COM
OPINION
has evolved without any conscious be described as the Challenger
thought? How often are such disaster of the 17th Century (or
systems asked to perform beyond vice-versa). As with the Vasa, there
their agreed capacity? When such were experts who were saddened
a system is in danger of ‘sinking’, but not necessarily surprised at
how often are front-line staff or the fate of the Challenger. Their
patients involved in the discussion legitimate scientifically-based
about the underlying problems or concerns had fallen on deaf ears.
potential remedies? The lesson for leaders is to
To state that this approach know WHO and WHERE your
is often simple and not ‘rocket experts are. Some are those who
science’ reminds me of how we are have detailed knowledge of how
still not listening to expertise in our system functions – when it
the modern world. The technicians works well and when (and how)
who knew all about the behavior mistake are made. These are the
of rubber seals (o-rings) at subzero staff who deliver services direct
The Vasa At first, the competence, and
temperatures during the launch to patients – and the patients
even the sobriety, of the captain
of the US Space-Shuttle were themselves. They may not look or
and crew were questioned. After
by adding more ballast low down experts. But they were somewhat behave like the ‘experts’ normally
prolonged investigation, it was
and / or removing some cannon removed from the shuttle engaged by the organisation. They
concluded that Hybertsson, the
high up in the ship. It was never programme, not involved on may not be as corporate in their
ship-builder, was at fault despite
going to be saved by the heroic launch day, not cognizant with all outlook, but we must listen to
being absent through illness and
attempts of the captain and crew the competing priorities familiar to their wisdom, often accumulated
not party to decisions which
on the day when its inherent lack key senior figures – so their expert over years immersed in a small part
departed from his original design.
of suitability became manifest. advice went unacknowledged, of a complex system. They know
The fact that he had died
It was the failure to accept there unrecognised, unheeded. things we don’t! If these voices are
from the same illness prior to the
was a problem which proved its The result was the loss of the continually excluded or ignored,
investigation was fortuitous. As
death knell. Was the Swedish king Space Shuttle Challenger and its they may stop speaking up and
for the king and his advisors, well
advised by a Scandinavian ancestor crew of seven in January 1987. merely wait for the inevitable
they were hardly experts and so not
of Michael Gove, the government Rubber seals on its rocket booster adverse event. Such events may
responsible.
minister who said during the Brexit failed because they were not not be as high profile as those
In the same way that humble
campaign, ‘We have had enough of designed to operate effectively described above but they may
Swedish sailors were the experts
experts’? at the subzero temperatures have a devastating impact on those
on ship stability (or lack of it),
In a further parallel, which associated with an early morning involved.
those who deliver healthcare or
should be familiar, there was an launch time in winter. This Whether it’s about cold
experience healthcare delivery
investigation into the Vasa debacle. allowed liquid fuel to escape and o-rings, a second tier of cannon,
have expertise on ‘their part’ of the
After all, a huge amount of money engulf the shuttle in an explosive staffing levels, poor handovers, or
complex system. How often do
was lost and severe reputational fire within a minute of blast-off. something else – LISTEN and
healthcare staff work in a system
damage done to the Swedish Navy. Indeed, the story of the Vasa could ACT.
which is poorly designed or which
NIHR | Oct 2017 | 7
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glargine or any excipients. Precautions and warnings: Switch from adjustment. Cases of cardiac failure have been reported when Legal category: POM. MA holder: Sanofi Aventis Deutschland GmbH,
twice daily NPH: To reduce the risk of nocturnal and early morning pioglitazone was used in combination with insulin, especially in D-65926 Frankfurt am Main, Germany. MA Numbers: Lantus
hypoglycaemia, patients who are changing to a once daily patients with risk factors for development of cardiac heart failure. cartridge: EU/1/00/134/006. Lantus SoloStar: EU/1/00/134/033. Full
regimen with Lantus should reduce their daily dose of basal insulin Patients on this combination should be observed for signs and prescribing information is available from: Sanofi, One Onslow Street,
by 20-30% during the first weeks of treatment. Switch from Toujeo symptoms of heart failure, weight gain and oedema. Pioglitazone Guildford, Surrey, GU1 4YS. Tel: 01483 505515 or the Sanofi Diabetes
(insulin glargine 300 units/ml): Lantus and Toujeo are not should be discontinued if any deterioration in cardiac symptoms Care Line 08000 35 25 25.
bioequivalent and are not directly interchangeable. To reduce the occurs. Pregnancy and lactation: No clinical data on exposed Date of PI Revision: July 2016
Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be
reported to the Sanofi drug safety department on 01483 554242.
SAGB.TJO.17.04.0468 | Date of preparation: April 2017Toujeo® COACH – For adults with Type 1 and Type 2
diabetes who have been prescribed Toujeo1
Over the years, diabetes treatment
However, health complications arising from poorly managed diabetes
has improved immensely and to help
continue to rise. Possible reasons include patients:6
with effective management, NICE
recommends people with diabetes Not fully understanding the benefits of, or not being able to attend,
be offered education programmes support and education sessions
at the time of diagnosis and on an
Difficulties following or understanding the information provided
on going basis.4,5
Difficulties learning to effectively titrate insulin doses
Toujeo® COACH can help Getting your patients started
Toujeo® COACH works with you to There are three easy ways to get
help your patients get the most out your patients started on
of their treatment by providing: Toujeo® COACH:
• 1:1 coaching from a specialist team of 1. By post using our pre-paid envelope
Diabetes Specialist Nurses, Psychologists 2. Call our Freephone number: 0800 206
& Dieticians 1252 (8.30am to 5pm, Monday to Friday)
• Behavioural and emotional support 3. Fax the enrolment form to Ashfield
to overcome negative thoughts and Healthcare on: 01530 562 364
reinforce positive behaviour
• Easy access to educational resources
and lifestyle advice tailored to each
patient’s needs
4. Diabetes UK, State of the nation report 2016. Available from: www.diabetes.org.uk. Date accessed: April 2017. 5. NICE. Quality standard for diabetes in adults.
March 2011. 6. Garcia-Perez, LE. Diabetes Ther. 2013;4(2): 175–94
Toujeo® (insulin glargine 300 U/ml). Please refer to Summary of ranges for plasma glucose levels. When switching from Toujeo to 1000 pregnancy outcomes with a medicinal product containing
Product Characteristics prior to use of Toujeo. Toujeo Solostar pre- insulin glargine 100 units/ml, the dose should be reduced insulin glargine 100 units/ml (Lantus)) indicate no specific adverse
filled pens each contain 450 Units of insulin glargine in 1.5 ml of (approximately by 20%) to reduce the risk of hypoglycaemia. Close effects on pregnancy and no specific malformative nor feto/
solution for injection, equivalent to 10.91 mg/ml. Indications: metabolic monitoring is recommended during the switch and in the neonatal toxicity of insulin glargine. Animal data do not indicate
Treatment of diabetes mellitus in adults. Administration: Toujeo is initial weeks thereafter. Toujeo is not the insulin of choice for treatment reproductive toxicity. The use of Toujeo may be considered during
administered subcutaneously once daily, at any time of the day, of diabetic ketoacidosis. In case of insufficient glucose control or a pregnancy, if clinically needed. Insulin requirements may decrease
preferably at the same time every day. Do not administer intravenously. tendency to hyper/hypoglycaemic episodes, the patient’s during the first trimester and generally increase during the second
Insulin glargine dose regimen (dose and timing) should be adherence to the prescribed treatment regimen, injection sites and and third trimesters. Immediately after delivery, insulin requirements
individually adjusted. In type 1 diabetes mellitus, Toujeo must be proper injection technique and all other relevant factors must be decline rapidly (increased risk of hypoglycaemia). Careful monitoring
combined with short-/rapid-acting insulin to cover mealtime insulin reviewed before dose adjustment is considered. Insulin administration of glucose control is essential. It is unknown if insulin glargine is
requirements. In patients with type 2 diabetes mellitus, Toujeo can may cause insulin antibodies to form. Rarely, this may necessitate excreted in breast milk. Adverse reactions: Very common:
also be given together with other anti-hyperglycaemic medicinal dose adjustment. Particular caution should be exercised, and Hypoglycaemia. Prolonged or severe hypoglycaemia may be life-
products. Close metabolic monitoring is recommended during the intensified blood glucose monitoring is advisable for patients in threatening. Common: Lipohypertrophy, injection site reactions,
switch and in the initial weeks thereafter. Dose and timing of other whom hypoglycaemic episodes might be of clinical relevance and in including redness, pain, itching, hives, swelling, or inflammation.
antidiabetic medicines may need to be adjusted. Dose adjustments those where dose adjustments may be required. Warning signs of Uncommon: Lipoatrophy. Rarely: Immediate-type allergic reactions;
may also be required if the patient’s weight or lifestyle changes, the hypoglycaemia may be changed, less pronounced or absent in which may be associated with generalised skin reactions, angio-
timing of insulin dose is changed or other circumstances arise that certain risk groups, potentially resulting in severe hypoglycaemia and oedema, bronchospasm, hypotension and shock and may be life
increase susceptibility to hypo- or hyperglycaemia. Toujeo must not loss of consciousness. Risk groups include patients in whom threatening; visual impairment, retinopathy and oedema. Very rare:
be mixed or diluted with any other insulin or other medicinal products. glycaemic control is markedly improved, hypoglycaemia develops Dysgeusia, myalgia. Insulin administration may cause insulin
Mixing or diluting Toujeo changes its time/action profile and mixing gradually, an autonomic neuropathy is present, or who are elderly. antibodies to form and may, in rare cases, necessitate adjustment of
causes precipitation. Insulin requirements may be diminished in the The prolonged effect of subcutaneous insulin glargine may delay the insulin dose. Overdose may lead to severe and sometimes long-
elderly or patients with renal or hepatic impairment. The safety and recovery from hypoglycaemia. Cases of cardiac failure have been term and life-threatening hypoglycaemia. Please consult Summary of
efficacy of Toujeo have not been established in children and reported when pioglitazone was used in combination with insulin, Product Characteristics for full details of the recognised side effects
adolescents below 18 years of age. No data are available. especially in patients with risk factors for development of cardiac with Toujeo. NHS price: £33.13 for pack of x3 1.5ml pens Legal
Contraindications: Hypersensitivity to insulin glargine or any heart failure. If the combination is used, patients should be observed category: POM. MA holder: Sanofi Aventis Deutschland GmbH,
excipients. Precautions and warnings: Insulin glargine 100 units/ml for signs and symptoms of heart failure, weight gain and oedema. D-65926 Frankfurt am Main, Germany. MA Numbers: SoloStar: 3
and Toujeo are not bioequivalent and are not directly Pioglitazone should be discontinued if any deterioration in cardiac Pen pack: EU/1/00/133/034 Full prescribing information is available
interchangeable. When switching from insulin glargine 100 units/ml symptoms occurs. Pregnancy and lactation: No clinical data on from: Sanofi, One Onslow Street, Guildford, Surrey, GU1 4YS. Tel: 01483
to Toujeo, this can be done on a unittounit basis, but a higher Toujeo exposed pregnancies from controlled clinical trials are available. A 505515 or the Sanofi Diabetes Care Line 08000 35 25 25.
dose (approximately 10–18%) may be needed to achieve target large amount of data on pregnant women (more than Date of PI Revision: May 2015
Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported
to the Sanofi drug safety department on 01483 554242.WWW.NIHEALTHCARE.COM
2017 HIGHLIGHTS
A YEAR As the end of 2017 edges increasingly closer, a few of NIHR’s friends
take a moment out of their hectic schedules to reflect on their standout
highlights over the last 12 months – as well as their aspirations for the
IN REVIEW year ahead.
Dr Nigel Hart
GP and Senior Clinical Lecturer, Queen’s
University, Belfast
‘This year we have been working medical students in 2017 / 18 is
together to transform the medical an additional two-week placement
curriculum at Queen’s in response in general practices throughout
to the changing healthcare Northern Ireland. Students get
landscape. hands-on experience to enhance
‘In October 2016, the report their clinical skills by consulting
by Professor Rafael Bengoa with patients with undifferentiated
highlighted many of the challenges illness. This type of opportunity
facing healthcare in Northern is vital in supporting our medical
Ireland and the need to ‘embrace students to become rounded and Fifth year medical student, Rachael Henderson, from Queen’s
transformation and work to create grounded doctors, irrespective University (middle), is undertaking a placement at Woodbrooke
a modern, sustainable service’. of whether they will eventually Medical Practice supported by Dr Nina Craft (right) and Dr
Central to these proposals is a become GPs. We aim to provide Nigel Hart (left)
focus on enhancing community students with the best possible way to encourage more medical students to enter this challenging, but
delivery of health services. training to fully prepare them for rewarding, profession.’
‘Undergraduate medical their future medical career. ‘Rachael Henderson, a fifth year medical student, said, ‘I’ve thoroughly
curricula must reflect the needs ‘These exciting initiatives enjoyed the opportunity to be given the independence to learn as if on the
of society. In 2017, we welcomed supported by the Department job. It has given me the confidence to diagnose and treat patients and I’m
the Department of Health’s of Health also depend on the now considering a career as a GP.’
endorsement of a five-year Queen’s willingness and the commitment ‘Looking towards 2018 and beyond, we will implement more aspects of
University plan for increased of GPs, such as Dr Nina Craft of the five-year plan, agreed with colleagues in the Department of Health, to
delivery of the undergraduate Woodbrooke Medical Practice, increase curriculum time in general practice. These changes, together with
medical curriculum in primary care who said, ‘This type of training other innovations in the curriculum and an emphasis on multidisciplinary
/ general practice. is so important to give medical education (medicine, nursing, pharmacy, and others), high-fidelity
‘As part of our response at students a real insight into the life simulation training, and novel assessment techniques using method
Queen’s, a change implemented of a GP and I am confident that acting, will ensure that Queen’s University continues to stay at the leading
in the curriculum for all final year this excellent scheme will go a long edge of education in healthcare.’
Roisin Foster
Chief Executive, Cancer Focus NI
‘Cancer Focus NI is the longest times are growing. Time is often
established cancer charity in of the essence in patients getting a
Northern Ireland. We’ve been good outcome.
working to reduce the impact of ‘We are concerned that the
cancer on people in Northern Northern Ireland cancer strategy
Ireland since 1969. All the funds is now 10 years old. Treatment
we raise are spent locally. develops rapidly. We need an
‘Over the past year we up-to-date strategy that commits
supported over 5,000 local cancer to prevention, takes account of
patients and helped more than developments, and plans for the
100,000 people reduce their risk of impact of population change.
cancer – yet there is so much more ‘Our hopes for 2018 are a new
to do. cancer strategy and our ability as
‘As our population ages, we a charity to develop our work so
see more people diagnosed with we can reduce waiting times and Cancer survivor, Tracy Martin, and Cancer Focus NI Chief
cancer. Services – including Cancer continue to serve people across Executive, Roisin Foster, deliver the charity’s new manifesto
Focus NI services – are under Northern Ireland.’ to Stormont calling for a fresh, ambitious vision for cancer
increasing pressure and waiting prevention and cancer services
10 | NIHR | Oct 2017WWW.NIHEALTHCARE.COM
2017 HIGHLIGHTS
Pharmacy Forum NI whole. The forum has continued to strive to provide responsive and robust
leadership.
‘We are committed to utilising collaborative approaches to
‘The past 12 months has seen the developing initiatives and improving and enhancing practice.
Pharmacy Forum NI celebrate ‘The forum continues to chair a working group of Pharmacy
its fifth anniversary. Professional Bodies (PPRB), which is a collaboration between
‘In an often uncertain the Pharmacy Forum NI and our colleagues, CPNI, NPA,
and changing political PDA, and UCA. In 2016 / 17, this valuable approach to joint
and socio-economic working and to identifying and addressing areas of mutual
environment, the role of a interest and co-operation led to one of the highlights of the
strong, focused professional year – a very successful event held at the Hilton Templepatrick
leadership body has seldom Golf and Country Club on 9th May.
been more relevant or ‘Entitled ‘Inspiring Change’ and focused on quality, safety
important. and innovation, the conference, convened by the PPRB, was
‘Whether advocating the first of its kind in Northern Ireland. Bringing together
for the role of pharmacists colleagues from across the profession, the event was supported
as a key component of by the Department of Health and the Health and Social Care
patient-centred care, ensuring Board. A number of key issues currently facing the profession
that the profession’s voices are were highlighted, including rebalancing, outcomes-based premises
The ‘Inspiring
heard in the context of wider standards, professional standards for reporting and quality assurance and
Change’ conference
changes to healthcare in Northern clinical governance. Feedback from participants was overwhelmingly
Ireland, developing guidelines commitment to driving leadership positive, with colleagues enjoying the opportunity to learn, network and
and initiatives on a range of issues and to ensuring that pharmacists share knowledge. We hope that, going forward, this will be the first event
to better assist and support the play a key role in helping to shape of many that will be organised by the PPRB.
work of pharmacists, or rewarding the future of the profession. It ‘In the year ahead the forum will continue to strengthen and evolve,
excellence and innovation, the has been a year of considerable so that it continues to be at the forefront, as we work to ensure that our
Pharmacy Forum NI continues to achievement, progress and profession has the leadership it needs to continue to deliver both for
make an impact. challenge, with elections to our pharmacists and for those we seek to serve.’
‘Our members continue board ensuring that we remain
to bring their enthusiasm and representative of the profession as a
Dr Grainne Doran
Chair of the Royal College of General
Practitioners Northern Ireland
‘It has been a very difficult year on frontline GP services to prevent
for general practice in Northern collapse.
Ireland. We continue to face ‘Looking towards 2018, I
recruitment challenges, increasing am keen to see our political
workload, and growing patient leaders coming together to take
demand, without any additional forward health and social care
support or investment in general reform. We must put patients
practice services. Despite making first and collectively address the
significant inroads in 2016 with challenges within our health
the publication of the GP-led service. This mammoth task must
Care Report and the Health be approached strategically and
Minister accepting the report’s there are tough decisions ahead
recommendations in December – however, without necessary
of Health. But without a Health Minister to take decisions and allocate
2016, political stalemate has led reform, our services will continue
budgets, I fear that work will stagnate – and we will yet again see an
to little progress in implementing to deteriorate.
opportunity for healthcare reform wasted. I am still optimistic that
necessary key actions. We must ‘RCGPNI has been involved in
together we can deliver transformation.’
address these pressures in a a number of transformation work
strategic manner to impact directly streams, led by the Department
NIHR | Oct 2017 | 11WWW.NIHEALTHCARE.COM
CARDIOVASCULAR RISK
HOW TO REDUCE CARDIOVASCULAR RISK:
CURRENT AND EMERGING STRATEGIES 2017
This year, three landmark trials have helped advance the understanding of the mechanisms underlying residual
cardiovascular risk and present potential treatments to lower it. Dr Ian Menown, Consultant Cardiologist at the
Southern Trust, and President of the Irish Atherosclerosis Society, details their journey – as well as their possible impact
on practice.
and moderate exercise (to the 1.8 – 2.0mmol/l. For patients therapy in IMPROVE-IT?
point of slight breathlessness) for in Northern Ireland, it is often In March 2017, the FOURIER
20 to 30 minutes on most days is possible to achieve this level of study (Further Cardiovascular
associated with improved outcome. control using high intensity statin Outcomes Research with PCSK9
Blood pressure targets vary across alone (atorvastatin 40 – 80mg Inhibition in Subjects with
different guidelines and sub- or rosuvastatin 20 – 40mg). For Elevated Risk)(3) reported that
populations butWWW.NIHEALTHCARE.COM
CARDIOVASCULAR RISK
FOURNIER randomised primary end point of CV death,
27,564 patients with prior MI or stroke (P=0.02075; figure
myocardial infarction (MI) stroke 5). Just as it appears ‘lower is
or peripheral arterial disease better’ for lipid lowering, patients
and already receiving statins, to in CANTOS who responded
the subcutaneous monoclonal with an hs-CRP reduction greater
antibody Evolocumab (given as than or equal to the median had a
140mg every two weeks or 420mg 27 per cent reduction in the risk
monthly) vs. placebo. of major adverse cardiac events
Evolocumab is one of two (P=0.0001), suggesting that on-
PCSK9 inhibitors, the other being treatment hs-CRP targets may be
Alirocumab, recently approved by useful to guide therapy.
NICE for treatment of patients Canakinumab was associated with
with very high LDL-C levels. a small increase in deaths due to
After a median follow-up of 26 infection (0.31 vs 0.18 events
months, Evolocumab vs placebo per 100 person-years; P=0.02),
Figure 3: Reduction of CV death, MI, or stroke with the PCSK9
was associated with a 15 per cent most commonly in older patients
inhibitor evolocumab vs placebo in the FOURNIER study
reduction in the composite of with diabetes. If canakinumab
CV death, MI, stroke, coronary LDL-C to levels well below that in well stabilised with 93.4 per cent is approved for use in CV
revascularisation or unstable current guidelines. However, while on high-dose statins and two disease, patients will thus require
angina hospitalisation (PWWW.NIHEALTHCARE.COM
CARDIOVASCULAR RISK
analysis of cancer events (5), there
was a clear reduction in cancer
ANTI-
mortality that reached 51 per cent THROMBOTIC
with the 300mg dose (P=0.0009;
figure 6). The large majority of this THERAPY
benefit was due to a 67 per cent In current practice, most patients
reduction in incident lung cancer with stable CV disease receive
(P=0.00008), and the 300mg low-dose aspirin monotherapy for
dose was associated with a 77 per antithrombotic protection.
cent reduction in fatal lung cancer Dual antiplatelet therapy is
(P=0.0002). It is well-recognised usually limited to short-term use
that inflammation in the tumour after acute coronary syndromes,
micro-environment impacts upon although the combination of
tumour initiation, progression, aspirin and reduced dose ticagrelor
invasiveness, and metastatic (60mg bd) has been approved by Figure 7: Reduction of CV death, MI, or stroke with the
progression and sub-clinical NICE as an option for patients combination of very low dose rivaroxaban plus aspirin vs
chronic inflammation is associated one to three years after ACS at aspirin alone in the COMPASS study
with increased cancer risk. While lower bleeding risk. (6) Use of
the cancer findings in CANTOS anticoagulation monotherapy has
can only be considered hypothesis not shown net clinical benefit over bd alone; or aspirin 100mg od concurrent peripheral arterial
generating, they do support aspirin alone and a previous trial alone. was stopped early after a disease are likely to have most to
consideration of prospective of aspirin plus full-dose apixaban mean follow-up of 23 months gain.
trials of anti-inflammatory agents (APPRAISE-2) was halted due at which point CV death, MI or
excessive bleeding.
such as canakinumab along with
other immunomodulators in lung In August 2017, the
stroke was reduced by 24 per cent
in those receiving the combination
CONCLUSION
COMPASS study reported While marked strides have
and other cancers potentially treatment vs aspirin alone (4.1 vs
intriguing findings of a been made to reduce CV risk in
responsive to immunotherapy. 5.4 per cent; pVISIT WWW.NIHEALTHCARE.COM/AWARDS TO KEEP UP-
TO-DATE ON THE LATEST AWARDS NEWS
DOING THE HONOURS
Once again drawing on the sector’s success over the last 12 months,
we’re proud to launch the 19th Northern Ireland Healthcare Awards. Why
not get involved?
Striving to serve and showcase the industry’s abundance of talent, the Northern
Ireland Healthcare Awards has asserted itself as an unmissable annual event – and
this year it’s set to be even bigger and better.
The 2018 gala will be taking place on 22nd February at the Europa Hotel,
Belfast, in which a host of industry giants and budding sector-shapers will be putting
in an appearance and enjoying the dining and networking opportunities on offer.
Whether it’s to demonstrate your prowess, or simply boost your profile, there
are a stream of benefits to being shortlisted for, or clinching, one of the top award
titles.
With this in mind, we’re thrilled to reveal that entry for the award categories is
now officially open – and the entry process couldn’t be easier.
The 12 accolades up for grabs are:
• Asthma / COPD Project of the Year
• Community Pharmacy Practice of the Year
• Dental Hygienist / Therapist of the Year
• Hospital Pharmacy Team of the Year
• Innovations in Atrial Fibrillation Management
• Innovations in Ophthalmology
• Innovative Developments in the Management of Inflammatory Bowel
Disease
• Intimate Care Clinical Nursing Team of the Year
• Most Innovative Use of an eHealth Solution to Improve Patient Care and
Safety
• Pharmacy Student Leadership Award
• Diabetes Project of the Year
• Special Recognition Award
Read on to find out how you can get involved. Good luck!
NIHR | Oct 2017 | 15VISIT WWW.NIHEALTHCARE.COM/AWARDS TO KEEP
UP-TO-DATE ON THE LATEST AWARDS NEWS
ASTHMA / COPD PROJECT OF THE YEAR
SPONSORED BY: TEVA RESPIRATORY
Currently in Northern Ireland there are 117,613 people living with asthma (6% of the population) and 38,530 people
living with COPD (2% of the population). In 2015, diseases of the respiratory system accounted for 14% of all deaths,
6 deaths per day (2,236) – note this figure excludes lung cancer. In the same year, 6% (934) of deaths registered in
Northern Ireland were due to COPD. This accounts for 42% of all respiratory deaths.
This award has been sponsored by Teva Respiratory to promote the excellent work being developed and implemented in asthma and COPD in both primary and second-
ary care in Northern Ireland.
1. Prevalence data in the Quality and Outcomes Framework Disease Prevalence (2015 / 16 data) http://www.ninis2.nisra.gov.uk/public/Home.aspx
2. Data tables on deaths registered in NI in 2015
http://www.nisra.gov.uk/demography/default.asp101.htm
WHO CAN ENTER?
Are you working to improve the care of your asthma and COPD patients within your clinic, practice or pharmacy, or with a partner organisation? Projects or working models
are welcome where the applicants can give evidence of improved outcomes for their patients in helping them to live with, and improve, their wellbeing and management of
their disease. Teva Respiratory are committed to being a long-term key partner to NHS organisations where we work together to improve healthcare outcomes for patients
with asthma and COPD. Sharing best practice for the benefit of your patients and others in Northern Ireland is the focus of this award and one we are delighted to sponsor.
Applications welcome from primary and secondary care.
JUDGING PROCESS:
The finalists will be shortlisted based upon the written application and judging of these entries will take place in mid–late January. The finalists must be available to meet the
judges on a date agreed with the judges in advance.
JUDGING PANEL:
ANNE MARIE MARLEY DR KEITH MCCOLLUM
RESPIRATORY NURSE CONSULTANT, BHSCT CLINICAL GOVERNANCE LEAD, WILLOWBANK SURGERY
JOHN HAMILL DR TERRENCE MCMANUS
LEAD PRACTICE PHARMACIST SOUTH BELFAST FEDERATION CONSULTANT RESPIRATORY PHYSICIAN, WHSCT
HOW TO ENTER:
If you require an application/nomination form or further information please contact:
Bridget McCabe: Tel: 02890 999 441 or email: bridget.mccabe@nimedical.info
DEADLINE FOR ENTRY:
The closing deadline for completed entries is 12.00pm on Friday 15th December 2017 SPONSOR:
and entries must be accompanied by a digital photograph, at least 500KB for printing TEVA RESPIRATORY
quality.
THE AWARDS PRESENTATION:
The finalists will be announced in Northern Ireland Healthcare Review and invited,
with guest, to attend the black tie awards ceremony at Belfast's Europa Hotel on
Thursday 22nd February 2018. The winner will be announced at the awards
ceremony and will receive a unique crystal trophy to mark the occasion.
16 | NIHR | Oct 2017You can also read
