GP required for busy, four doctor, well established teaching practice in Sutton, Dublin 13. Varied workload, private and GMS patients. 8-9 sessions per week from January 2016. Partnership prospects available. Reply by email to suttoncrosssurgery@gmail.com please

Brendan McDermott

Irish College of Ophthalmologists

Administrative Assistant

Applications are invited for an admin position at the Irish College of Ophthalmologists

To apply please forward your CV by Friday November 13th

Further information available from siobhan.kelly@eyedoctors.ie

Brendan McDermott

Company: Consilient Health Ltd.

Legal category: Prescription. GMS reimbursable. Sport permitted.

Active ingredient: Colecalciferol (vitamin D3) 25000 IU/ml.

Description: Oral solution.

Presentation: 3 X 1 ampoules, €5.56.

Indications: Prevention and treatment of vitamin D deficiency. As an adjunct to specific therapy for osteoporosis.

Pharmacology: Vitamin D stimulates intestinal calcium absorption, incorporation of calcium into the osteoid, and release of calcium from bone tissue. In the small intestine it promotes rapid and delayed calcium uptake. The passive and active transport of phosphate is also stimulated. In the kidney, it inhibits the excretion of calcium and phosphate by promoting tubular resorption. It directly inhibits production of parathyroid hormone (PTH) in the parathyroids. PTH secretion is inhibited additionally by the increased calcium uptake in the small intestine under the influence of biologically active vitamin D.

Dosage: Adult: Preferably take with meal. Prevention or as adjunct to osteoporosis therapy: 25000 IU/month. Treatment: 50000 IU/week for 6-8 weeks, followed by maintenance therapy (may require 1400-2000 IU/day); measure 25(OH) D three to four months after initiating maintenance therapy. Children: Prevention: 0-1 years, 25000 IU every 8 weeks; 1-18 years, 25000 IU every 6 weeks. Treatment: 0-18 years, 25000 IU every 2 weeks for 6 weeks (followed by maintenance therapy of 400-1000 IU/day).

Contraindications: Hypersensitivity to the active ingredient or to any of the excipients. Hypercalcaemia/hypercalciuria, nephrolithiasis, nephrocalcinosis, severe renal impairment, hypervitaminosis D, pseudohypoparathyroidism. Pregnancy, lactation.

Special precautions: High risk patients may require higher doses and monitoring of serum 25(OH)D: Institutionalised or hospitalised patients, patients with dark skin or limited effective sun exposure, obesity, patients under evaluation for osteoporosis, malabsorption (including inflammatory bowel/coeliac disease), recent treatment for vitamin D3 deficiency requiring maintenance therapy. Caution: Renal impairment (monitor calcium and phosphate levels; consider risk of soft tissue calcification), sarcoidosis (monitor calcium in serum and urine). Risk for renal stones (consider calcium supplementation under close medical supervision).

Drug interactions: Caution: Digitalis and other cardiac glycosides. Anticonvulsants, barbiturates, thiazide diuretics, glucocorticoids, ion exchange resins, laxatives, actinomycin, imidazole antifungal agents.

Adverse drug reactions: None common.

Full prescribing information and references available from Consilient Health Ltd. Telephone: (01) 2057760.

Tara Sweeney

SGLT2 inhibitors include canagliflozin, dapagliflozin and empagliflozin alone or in combination with metformin, which are authorised for the treatment of type 2 diabetes mellitus.

Serious and sometimes life-threatening cases of diabetic ketoacidosis in patients treated with SGLT2 inhibitors have been reported, the majority of which required hospitalisation. Up to half of these cases occurred during the first two months of treatment and one third of the cases concerned off-label use in patients with type 1 diabetes. In some cases, just before or at the same time as the ketoacidosis occurred, patients experienced dehydration, low food intake, weight loss, infection, surgery, vomiting, a decrease in their insulin dose or poor control of diabetes. In a number of cases atypical moderately increased glucose values or glucose values below 14 mmol/l (250 mg/dl) were reported, whereas hypoglycaemia was reported in one case. There were also cases of ketoacidosis shortly after discontinuation of SGLT2 inhibitors.

The underlying mechanism for SGLT2 inhibitor-associated diabetic ketoacidosis is not established. Diabetic ketoacidosis usually develops when insulin levels are too low. Diabetic ketoacidosis occurs most commonly in patients with type 1 diabetes and is usually accompanied by high blood glucose levels (>14 mmol/l). However, in a number of cases described above, blood glucose levels were only slightly increased, in contrast to typical cases of diabetic ketoacidosis.

Prescribers should inform patients of the signs and symptoms of metabolic acidosis (such as nausea, vomiting, anorexia, abdominal pain, excessive thirst, difficulty breathing, confusion, unusual fatigue and sleepiness) and advise them to immediately seek medical advice if they develop such signs and symptoms. It is recommended that patients taking SGLT2 inhibitors should be assessed for ketoacidosis when they present with signs or symptoms of metabolic acidosis in order to prevent delayed diagnosis and management. If ketoacidosis is suspected, treatment with SGLT2 inhibitors should be discontinued. If ketoacidosis is confirmed, appropriate measures should be taken to correct the ketoacidosis and to monitor glucose levels.

This information was recently highlighted in a Direct Healthcare Professional Communication (DHPC) from the marketing authorisation holders. The Health Products Regulatory Authority (HPRA) is currently participating in an EU evaluation of the risk of diabetic ketoacidosis with SGLT2 inhibitors and any new advice following completion of this review will be communicated promptly. In the meantime, healthcare professionals are requested to report any suspected adverse reactions associated with use of these products to the HPRA, preferably via the online report form accessible from the website at www.hpra.ie.

Advice for Healthcare Professionals

• Serious, sometimes life-threatening cases of diabetic ketoacidosis have been reported in patients on SGLT2 inhibitor treatment for type 2 diabetes.
• In a number of these reports, the presentation of the condition was atypical with only moderately increased blood glucose levels observed. Such atypical presentation of diabetic ketoacidosis in patients with diabetes could delay diagnosis and treatment.
• Prescribers should inform patients of the signs and symptoms of metabolic acidosis and advise them to immediately seek medical advice if they develop relevant signs and symptoms
• Patients on SGLT2 inhibitors should be tested for ketones when they present with symptoms of acidosis in order to prevent delayed diagnosis and patient management.
• Cases of diabetic ketoacidosis were also reported in patients with type 1 diabetes who were given SGLT2 inhibitors. Prescribers are reminded that type 1 diabetes is not an approved indication for this drug class.

Key message

• Serious, sometimes life-threatening cases of diabetic ketoacidosis have been reported in patients treated with SGLT2 inhibitors, some of which have presented atypically, with only moderately increased blood glucose levels observed
• If ketoacidosis is suspected, treatment with SGLT2 inhibitors should be discontinued. If ketoacidosis is confirmed, appropriate measures should be taken to correct the ketoacidosis and to monitor glucose levels.
• Any suspected adverse reactions associated with SGLT2 inhibitors should be reported to the HPRA

*Brands include Invokana, Vokanamet, Forxiga, Xigduo, Jardiance and Synjardy

Caroline McDermott

Donepezil* is a specific and reversible inhibitor of acetylcholinesterase which has been authorised in Ireland since 1997 for use for the symptomatic treatment of mild to moderately severe Alzheimer’s dementia.

Reports of rhabdomyolysis associated with donepezil were recently reviewed by the EMA’s Pharmacovigilance Risk Assessment Committee (PRAC). Rhabdomyolysis is a clinical and biochemical syndrome that results from the breakdown of skeletal muscle and the release of intracellular contents into the circulatory system. Rhabdomyolysis can cause serious and sometimes fatal abnormal heart rhythms, kidney damage and kidney failure, but is generally treatable if recognised promptly.

The PRAC considered cases of rhabdomyolysis from post-marketing spontaneous reports and clinical trials. Whilst the individual cases do not provide strong evidence of a causal association between donepezil and rhabdomyolysis, based on the cumulative information from 11 cases in particular, a causal or contributory role for donepezil in these cases of rhabdomyolysis and other less serious muscle disorders including weakness and pain cannot be excluded.

Rhabdomyolysis has been reported to occur independently of Neuroleptic Malignant syndrome (NMS) and in close temporal association with donepezil initiation or dose increase.

Rhabdomyolysis can also be a feature of NMS, a potentially life-threatening condition characterised by hyperthermia, muscle rigidity, autonomic instability, altered consciousness and elevated serum creatine phosphokinase levels. NMS has been reported to occur very rarely in association with donepezil, particularly in patients also receiving concomitant antipsychotics. Additional signs may include myoglobinuria (rhabdomyolysis) and acute renal failure. If a patient develops signs and symptoms indicative of NMS, or presents with unexplained high fever without additional clinical manifestations of NMS, treatment should be discontinued.

Advice for Healthcare Professionals

• Rhabdomyolysis has been reported very rarely in patients treated with donepezil and has occurred independently of NMS and in close temporal association with donepezil initiation or dose increase.
• Patients and carers should be made aware of and advised to immediately report any signs or symptoms of rhabdomyolysis experienced (e.g. muscle weakness, tenderness or pain particularly, if at the same time, they feel unwell, have a high temperature or have dark urine.)
• The product information for donepezil (Summary of Product Characteristics (SmPC) and Package Leaflet (PL)) will be updated accordingly shortly.

Key message

• Rhabdomyolysis has been reported very rarely in patients treated with donepezil and has occurred independently of NMS and in close temporal association with donepezil initiation or dose increase.
• Patients and carers should be alerted to signs and symptoms of these conditions and told to inform their doctor immediately if any experienced.

*Brands include Aricept, Donesyn, Dozept, Donecept. See www.hpra.ie for further details.

Caroline McDermott

Download PDF

Key Recommendations on Management of Type 2 Diabetes

• Individualise glycaemic targets and glucose-lowering therapies.
• Diet, exercise, and education remain the foundation of all type 2 diabetes treatment programmes.
• Metformin is the optimal first-line drug in the absence of contraindications.
• After metformin, it is reasonable to consider combination therapy with an additional 1-2 oral or injectable agents with the objective of minimising side-effects where possible.
• For many patients insulin therapy alone or in combination with other agents will ultimately be required to maintain glucose control.
• All treatment decisions, where possible, should take into account the patient’s preferences, needs and values.
• A major focus of therapy must be comprehensive cardiovascular risk reduction.

Diagnosis of Type 2 Diabetes

Diabetes may be diagnosed based on HbA1c criteria or plasma glucose criteria, either the fasting plasma glucose (FPG) or the 2-h plasma glucose (2-h PG) value after a 75-g oral glucose tolerance test (OGTT). Diabetes may be identified in seemingly low risk individuals who happen to have glucose testing, in symptomatic patients, and in higher-risk individuals who are tested because of a suspicion of diabetes.

Table 1. Criteria for Diagnosis of Type 2 Diabetes

Testing for Diabetes or Prediabetes in Asymptomatic Adults

Consider testing in all adults who are overweight (BMI≥25kg/m² or ≥23 kg/m² in Asian Americans) and have ≥1 risk factor:

• Physical inactivity
• First-degree relative with diabetes
• High-risk race/ethnicity
• Women who delivered a baby weighing >9lb or were diagnosed with gestational diabetes mellitus
• Hypertension (≥140/90mmHg or on therapy for hypertension)
• HDL cholesterol level <35mg/dL (0.90mmol/L) and/or a triglyceride level >250mg/Dl (2.82mmol/L)
• Women with polycystic ovary syndrome
• HbA1c ≥5.7%, IGT, or IFG on previous testing
• Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans)
• History of cardiovascular disease

For all patients, particularly those who are overweight or obese, testing should begin at age 45 years. If results are normal, testing should be repeated at a minimum of 3 year intervals, with consideration of more frequent testing depending on initial results (e.g., those with prediabetes should be tested yearly) and risk status.

Table 2. Glycaemic Targets for Non-pregnant Adults with Diabetes

Click on image to enlarge

Assessment of Glycaemic Control

Two primary techniques are available to assess the effectiveness of glycaemic control: Patient self-monitoring of blood glucose (SMBG) or interstitial glucose and A1C. Continuous glucose monitoring (CGM) may be a useful adjunct to SMBG in selected patients. SMBG results may help guide treatment decisions and/or self-management for patients using less frequent insulin injections or noninsulin therapies. CGM may be a supplemental tool to SMBG in those with hypoglycaemia unawareness and/or frequent hypoglycaemic episodes.

Patients on multiple-dose insulin or insulin pump therapy should perform SMBG prior to meals and snacks, occasionally postprandially, at bedtime, prior to exercise, when they suspect low blood glucose, after treating low blood glucose until they are normoglycaemic, and prior to critical tasks such as driving.

Multiple Agents Needed for Most People with Diabetes

Initial therapy: Most patients should begin with lifestyle changes – healthy eating, weight control, increased physical activity, and diabetes education. When lifestyle efforts alone have not achieved or maintained glycemic goals, metformin monotherapy should be added at, or soon after, diagnosis (in patients intolerant, or with contraindications for, metformin, select initial drug from other treatment options).

Advancing to dual combination therapy: If the HbA1c target is not achieved after ~3 months with metformin, there are six drug choices including a second oral agent (sulfonylurea, TZD, DPP-4 inhibitor, or SGLT2 inhibitor), a GLP-1 receptor agonist, or basal insulin. The higher the HbA1c, the more likely insulin will be required. Shared decision making with the patient is important to help in the selection of therapeutic option. The choice is based on patient and drug characteristics, with the over-riding goal of improving glycaemic control while minimising side-effects. Consider beginning at this stage when HbA1c ≥9%.

Advancing to triple combination therapy: Evidence suggests that there is some advantage in adding a third noninsulin agent to a two-drug combination not achieving the glycaemic target. However, the most robust response will usually be with insulin. Since diabetes is associated with progressive beta-cell loss, many patients, especially those with long-standing disease, will ultimately need to be transitioned to insulin. Insulin should be preferred in circumstances where the degree of hyperglycaemia (e.g. ≥8.5%) makes it unlikely that another drug will be sufficiently effective. In using triple combinations the essential consideration is obviously to use agents with complementary mechanisms of action.

Combination injectable therapy: If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables; (2) on GLP-1 RA, add basal insulin; or (3) on optimally titrated basal insulin, add GLP-1 RA or mealtime insulin. In refractory patients consider adding thiazolidinedione or SGLT2 inhibitor. Consider beginning at this stage when blood glucose is 16.7 – 19.4mmol/L and/or HbA1c ≥10 – 12%, especially if symptomatic or catabolic features are present.

Figure 1. Overview of Approach to Starting and Adjusting Insulin in Type 2 Diabetes (Sequential Insulin Strategies)

Click on image to enlarge

Table 3. Different Types of Insulins Available in Ireland

Click on image to enlarge

Abbreviations:

HbA1c, glycated haemoglobin; FBG, fasting blood glucose; OGTT, oral glucose tolerance test; SMBG, self-monitoring of blood glucose; CGM, continuous glucose monitoring; TZD, thiazolidinedione; DPP-4, dipeptidyl peptidase-4; SGLT2, sodium glucose co-transporter 2; GLP-1-RA, glucagon-like peptide-1 receptor agonist; GLP-1 receptor agonist; hypo, hypoglycemia; PPG, postprandial glucose

References:

1. Inzucchi SE et al. Management of hyperglycemia in type 2 diabetes 2015: a patient-centered approach. Update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2015;38:140-149 [adapted].

2. Inzucchi SE et al. Management of hyperglycemia in type 2 diabetes: a patient-centered approach. Position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2012;35:1364-1379 [adapted]

Caroline McDermott

Dr Ray Walley, IMO

The IMO has urged the Minister for Health to declare a manpower emergency in the Irish health services, accusing the Government of showing more concern over the emigrating national boxing coach than over a generation of relocating doctors.

IMO President Dr Ray Walley also requested that Dr Leo Varadkar undertake an overhaul of recruitment policy, involving an overhaul of pay structures for new consultants and a new contract for GPs, so as to attract back Irish doctors now working abroad.

The doctors’ leader said that the manpower crisis was now endemic across the medical specialties citing a shortage of 1,380 GPs, one Cork consultant covering for four colleagues, only 22 per cent of NCHDs committed to staying in Ireland and almost 300 vacant hospital consultant posts countrywide. “This is now an emergency and needs to be addressed as such by our politicians,” Dr Walley said.

The doctors’ union has also called for urgent action to address the “unacceptable crowding situation” in the Emergency Department (ED) of Beaumont Hospital, revealing that it had written to the hospital on three separate occasions in the past two months asking for engagement on this issue with a view to ensure the ED was in a position to cope with the typical surge in activity during the winter. But this was to no avail. On the morning of Friday, October 24, there were 39 admitted patients in the ED, representing almost 200 per cent occupancy heading into the busy October Bank Holiday weekend.

“Given the clear lack of will, or capacity, among hospital management to deal with this issue, it is imperative that senior management in the HSE, including the Director General, intervene to take the necessary steps to ensure that patients presenting at Beaumont Hospital receive the care that they need, without having to endure inordinate delays,” the IMO stated.

Patient health was being directly impacted by manpower shortages and ED crowding, the IMO added.

lloyd.mudiwa@imt.ie

william.bourke

Dr Grainne Flannelly, Clinical Director of CervicalCheck

CervicalCheck hopes to be among the first screening programmes in the world to switch to using primary human papillomavirus (HPV) DNA testing instead of the conventional Pap smear.

At the request of the National Screening Service (NSS), the Health Information and Quality Authority (HIQA) will begin a health technology assessment (HTA) before the end of the year to assess the clinical and cost-effectiveness of the switch.

Clinical Director of CervicalCheck Dr Grainne Flannelly told IMT that it was important to consider the change now because the population of women eligible for screening would change in the coming years. The first cohort of women who received the HPV vaccination as part of the catch-up programme in 2011 will turn 25 in 2018.

“If you apply cytology to women who have been vaccinated, you still get the same number of abnormal smears, but the percentage of high-grade CIN in those women is really low. The predictive value of the cytology is actually affected by the population,” Dr Flannelly said.

The NSS wants to examine the possibility of doing a HPV test first and using cytology as a secondary test to identify women who need further monitoring or colposcopy, effectively changing the order of the tests. “In practical terms, a woman would go to her GP and have exactly the same test and the laboratories would do the tests in a different order,” she explained.

Although terms of reference have yet to be decided, it is expected the HTA would also consider a change to the screening interval.

International evidence suggests that a negative HPV test confers greater protection from the development of CIN3 in the following five years. It may also consider whether any changes to the screening interval should apply to particular age groups, and whether the exit age should change.

Dr Flannelly said the HTA would also look at what other modifications might be required to improve risk assessment, as up to 20 per cent of women aged 25-30 would test HPV positive, but they would not all need to be sent for colposcopy.

The incidence of high-grade CIN in women who had a positive test was as low as 5 per cent, she added. “Having a HPV infection is neither here nor there, irrespective of the type. It is a persistent infection that you do not want.”

HIQA is due to start work on terms of reference in November. An expert advisory group will be formed and the process is expected to take six to eight months.

By Niamh Mullen
niamh.mullen@imt.ie

admin

Dr Ken Egan

The Irish Association of GP Co-operatives (IAGPC), which represents all GP after-hours services nationwide, has said the proposal of the NAGP that advocates against additional investment in emergency departments (EDs) in favour of an extended GP out-of-hours service as a solution to the ongoing ED crowding crisis would be “totally opposed by co-op GPs”.

Calling for inclusion in the ED Taskforce, the NAGP made the proposal in a comprehensive submission, delivered on September 17 to the offices of the Minister for Health Dr Leo Varadkar, Minister of State with responsibility for Primary Care Kathleen Lynch, and Director General of the HSE Tony O’Brien.

Warning that an ‘extended GP co-op service’ could have a negative impact on general practice, IAGPC Chairman Dr Ken Egan last week told IMT that representatives at the Association’s recent meeting were concerned at the NAGP call for co-ops to be extended to provide daytime services, which they had opposed previously.

Co-ops, he added, were not malleable to being integrated with hospital EDs in order to provide facilities for ED staff to work in the community.

“We were surprised that they [NAGP] came out with that proposal in the week a review of co-ops had been announced by the HSE National Director for Primary Care Services John Hennessy, and it’s very bad timing for GPs to be seen to be calling for co-ops to be extended to daytime services,” the Mayo GP said.

“The HSE has been striving… since the co-ops began to get co-ops to provide ED services and we have resisted this at all times.”

Dr Egan said GPs had enough work to do without providing ED services, adding: “We do not wish to be involved in providing hospital services or increased diagnostic out-of-hours services.”

Mr Fergal Hickey, spokesperson of the IAEM, which was represented on the ED Taskforce, previously responded to IMT on the NAGP’s submission by stating that the ED crowding crisis was a crisis of admitted inpatients, so it was “entirely illogical” to suggest that investment in primary care would have an impact on the problem. “Not investing in EDs will not resolve the problem, but will certainly make it a lot worse for patients.”

Dr Egan added: “It’s just not from the point of view of crowding, it’s from a point of view of viability. To extend the co-ops into daytime services, it means the co-ops are competing with GPs. That will be totally opposed by co-op GPs.”

lloyd.mudiwa@imt.ie

Lloyd Mudiwa

Dear Editor,
The Institute of Public Health in Ireland (IPH) launched a new online resource, The All Ireland Public Health Repository, at its annual seminar Open Access Resources for Public Health last week. The seminar, which was hosted in collaboration with RIAN, Pathways to Irish Research, explored ways in which an Open Access approach to health data and information can be used to support work in the areas of population health and well-being across the Island of Ireland.

The All Ireland Public Health Repository was developed by the IPH and is part of its The HealthWell website. It offers public health workers and those working in voluntary and community organisations free and easy to use tools to access online public health information.

By opening up access to a network of Open Access portals, including RIAN and the European portal OpenAire, it allows anyone with an internet connection who is interested in public health to get a wider range of up-to-date health data and contextual publications on public health issues, including obesity, chronic conditions and mental health and well-being.

This new resource is part of the Institute’s work in improving everyone’s access to sources of health information. It has been carefully developed with the needs of users in mind and provides free access and easy-to-use search tools to help anyone engaged in the area of public health to get up-to-date data and information from a huge range of sources.

By making this data and information easier to access we hope to help those engaged in health and community work, but also to stimulate public debate on how we can tackle health inequalities and build a healthier society.

The fully searchable online resource currently contains more than 2,000 tagged resources from a wide range of partner websites such as IPH, Department of Health, Social Services and Public Safety (NI), Department of Health (ROI), Public Health Agency (NI), safefood and Public Health England.

The new resource was launched as part of Open Access Week (October 19-25 2015), which provides a great opportunity to learn more about the benefits of open access to information.

Prof Kevin Balanda,
Research Director,
Institute of Public Health in Ireland.

admin

Dear Editor,
Minister for Health Dr Leo Varadkar will take an important first step towards tackling Ireland’s harmful relationship with alcohol in the coming weeks, when he brings the Public Health (Alcohol) Bill back to the Houses of the Oireachtas.

This Bill contains important evidence-based initiatives that can save lives and reduce the health harms caused by alcohol that affect virtually every family in Ireland. Every day, three people die in Ireland as a result of alcohol use, some as a result of drink-driving.

Actions have consequences. Personal responsibility regarding alcohol and driving is undermined by the low level of successful prosecution for individuals brought before the courts.

We have taken great strides to make our roads safer with the introduction of random breath-testing and other legislative initiatives that have reduced the number of deaths related to alcohol.

It is very disappointing and shocking to learn that only 40 per cent of drink-driving cases listed before the country’s district courts since January 2013 resulted in convictions (“More than half of drink-drive cases escape conviction”, October 19). This compares to 97 per cent in England. Furthermore, the rate of successful prosecution was highly variable from court to court.

Finally, many of those found guilty did not have their licence numbers noted in court for endorsement.

I believe that many more lives could be saved and catastrophic injuries avoided with better enforcement of road traffic legislation with regards to alcohol use.

Legislation to save lives such as drink-driving is only effective if it is implemented. I propose that a review be undertaken to identify and eliminate barriers to successful prosecution and endorsement, and to simplify the process if necessary.

Reducing harm to health due to alcohol requires many initiatives to be effective. It is essential that drink-driving has consequences that are detected and enforced effectively and consistently.

Prof Frank Murray,
President,
RCPI,
Dublin 2.

admin

Dear Editor,
In relation to your recent excellent article ‘Cutting down on medication errors’ (IMT, October 23, 2015), I would like to point out that the Irish Medication Safety Network hosted the medication safety course and summit referred to in the piece, with the support of the HSE and the Rotunda Hospital.

The IMSN has been working on a voluntary basis for many years to improve awareness about medication safety issues and to provide guidance to minimise medication errors and patient harm arising from medication.

The partnership between the IMSN, ISMP, Rotunda and HSE led to these events and we look forward to continuing to collaborate in the future, together with representatives from hospitals, to ensure the learning from the course and summit leads to improved medication safety nationally.

Ciara Kirke,
Clinical Lead,
Medication Safety Programme,
HSE.

admin

              ‘Excellence in Patient Care’

Senior House Officer – Surgery

One year surgical rotation at SHO level at the Galway Clinic and Surgical Professorial Unit, Beaumont Hospital / RCSI commencing in January 2016. The rotation will be in general surgery, colorectal, breast and urology. Great importance will be given to operative experience, teaching and clinical research.

The ideal candidate should have internship recently finished and be eligible for application to the national BST scheme and also be registered in the General Register of the Irish Medical Council.

Interested applicants will have the opportunity to submit an application for an MD/MCh degree by thesis based on research at the Galway Clinic. 

To apply please refer to www.galwayclinic.com or contact the HR Dept humanresources@galwayclinic.com

Closing date for receipt of applications:

Friday 27^th November 2015 at 3pm

Informal enquiries to:

Prof W.P. Joyce, Consultant General Surgeon, 091 720020.

The Galway Clinic is an equal opportunities employer.

Brendan McDermott

School of Medicine

GRADUATE ENTRY MEDICINE
OPEN DAY

Saturday, November 14, 2015
   10.00-13.00

Are you interested in pursuing a career in Medicine?
Do you hold, or expect to hold by July 2016, an Upper Second Class Honours (2H:1)
in your first Level 8 Honours Degree?
If so, find out more at the UCC Four-year Graduate Entry Medicine (GEM) programme Open Day

OPEN DAY HIGHLIGHTS
• Introduction, Overview and Admissions Information
• Clinical Skills Workshop
• Clinical Simulation Workshop
• Tour of School of Medicine including FLAME Anatomy Laboratory
• Meet the Teachers and Students for refreshments 

Reserve your place by emailing: gem@ucc.ie
http://www.ucc.ie/en/medical/prosstud/gem/
https://www.youtube.com/watch?v=MQqWa-R7Owc

Brendan McDermott

Ed Madden, BL, looks at a recent Employment Appeal Tribunal case in which a carer appealed a Rights Commissioner decision that found her dismissal from her post fair.

Earlier this year the Employment Appeals Tribunal (EAT) considered an appeal by an employee against a decision of a Rights Commissioner that her dismissal from her post as a home help and carer was fair.

Margaret (not her real name) was employed by a company providing home help in the Dublin area. The company in question is fully funded by another body. That body’s code of governance requires Garda clearance for employees of any organisation in receipt of funding.

To that end, a service-level agreement was entered into between the company and the funding body in 2009. As part of that agreement, Garda vetting of new employees would commence that year and of existing employees the following year.

When the matter came on for hearing the Tribunal was told Margaret had been employed by the company since 2006. The manager of the company provided Garda vetting forms to her and other members of staff in 2010 and gave them instructions to complete them “in full and in detail”. In the event, Margaret did not return her form until September 2011.

Previous convictions
The vetting forms having been considered by the Garda authorities, they were returned to the company in May 2012. The form relating to Margaret detailed 10 convictions that she had not disclosed. The matter was referred to the Board of the company and she was placed on suspension pending an investigation. In the meantime, the manager was requested to conduct a risk assessment.

In conducting the assessment the manager considered the vulnerability of clients visited by Margaret. She found that she would not pose a risk if she was supervised. However, the reality was that Margaret visited clients’ homes unsupervised. In any event, trust had broken down by virtue of the fact that she had failed to disclose all of her convictions. Three of those were received during the period of her employment with the company. Given the circumstances, the manager could not recommend that Margaret continue in employment.

In due course, the Board took a decision to dismiss Margaret from her post. There was a particular concern around the issue of non-disclosure. They found it was not credible that she did not remember the dates on which she received the three most recent convictions. Margaret’s appeal to an independent person agreed with her union was unsuccessful and the decision to dismiss her was upheld.

Under duress
It was Margaret’s evidence to the Tribunal that when she completed the vetting form she genuinely could not remember details such as dates and relevant years. She claimed that she had answered honestly that she had received convictions and had outlined two offences, the details of which she could remember.

Pic: Getty Images

She claimed that she had become upset when speaking to the manager and told her that “more items would be returned [by the Garda authorities] on the form than she had outlined”. This was refuted by the manager who told the Tribunal that she recalled Margaret being concerned “that ‘something’ would be on the form that she had not outlined”.

For her part, she had reiterated to her that she should complete the form in full and that they would consider the matter when the form was returned to the company by the Garda authorities.

Margaret told the Tribunal that “despite her fear of losing her employment”, she had listed in full the addresses at which she had resided in the knowledge that the vetting form would be returned by the Garda authorities with details of all of her convictions.

She alleged that at the time of the convictions she was suffering domestic violence and that matters giving rise to those convictions “occurred under duress from her husband”. She had since become divorced.

Giving its determination in the case, the Tribunal said that in the course of hearing evidence, it became apparent “that the situation that [Margaret] endured during her married life and the pressure exerted on her by her husband, was such that her life was made a misery during that period and that her future life will be marred by the record established through no real fault of her own”.

The Tribunal was of the opinion that there should be some remedy for people in her position “to expiate such a record when the influence exerted on her ended”.

However, the Tribunal reached the conclusion “reluctantly” that Margaret was not “unfairly dismissed” on the basis that the company had acted reasonably in all the circumstances. It was a very difficult decision for the Tribunal to reach in the knowledge “that [Margaret] had undergone difficulties in the past not of her making and that it was natural and reasonable for her not to disclose the offences she had been convicted of”.

Rejecting the appeal, the Tribunal upheld the decision of the Rights Commissioner.

Reference: UD691/2014

admin

Marc Thornton, Medserv

Marc Thornton, a Group Manager with Irish medical billing company Medserv, tells Lloyd Mudiwa of challenges facing consultants to get their end-of-year tax returns ready on time.

Some medical consultants are in panic mode over submitting their end-of-year tax returns for the current financial year into Revenue by the statutory deadline (either October 31 or November 12), particularly as the taxman is currently focusing on medical consultants.

According to one leading medical billing services company, Medserv, it is indeed a very busy time of the year for consultants as they try to file their tax returns, as it is difficult to get their claims invoices together resulting in a good number of them “panicking” as they battle to meet the deadlines.

Marc Thornton, Medserv’s Group Sales and Marketing Manager for Ireland and the UK, said: “It’s reflected in the amount of people who are ringing us. We get a few in January and February, but these days we are getting say 20 requests a day for this financial information, which luckily we are able to produce within the working day owing to our automated electronics billing systems. “But, sometimes we have consultants ringing us in the middle of their meeting with their accountants, for some of their figures.”

Pic: Getty Images

Automated billing
Marc Thornton said there were benefits to having an organised automated billing company because it allowed consultants to avoid unnecessary stress, and it was financially significant as they could be penalised and taxed more if they filled in their invoicing details incorrectly.

“Revenue would be all over them, and would be more demanding if the form is not completed precisely.”

For their tax returns consultants need two key things: one is an amount of how much they invoiced/claimed from the insurers in the previous 12-month period. “Not what they have been paid. That’s quite a different figure,” Thornton explained.

“That to them is a challenge because they have six different insurers. Gathering the information is the challenge, whereas the billing company will have all the information in one place.”

Consultants also need to indicate what withholding tax has been paid by the insurers on their behalf and sent into Revenue.

Cost
Thornton said electronic billing services cost a “very low” percentage — much less than the cost of hiring a full-time secretary.

“We had a consultant the other day who is a brand new client and he couldn’t believe how much he is saving compared to having a medical secretary doing the billing for him.”

Also the billing system in Medserv’s case worked smartly, thereby allowing the consultant to spend more time on patient care.

The consultant takes a photograph of the patient’s details and claiming address and he records the procedure performed and can send this information via an App to the billing company, which then generates claims that go to the insurers. “We had a consultant today that said he has 26 procedures a day and he is able to do the procedures, and send off the invoice and information generated immediately after and by the time he finishes his last procedure for the day he only has one more invoice to do.

“Now, he used to stay back for several hours, because the process was much more demanding on him or somebody else who helped him,” Thornton illustrated.

Withholding tax
Another cumbersome aspect for doing this process manually was the requirement to gather all the F45 forms, which is the professional services withholding tax form, every time a claim goes into the insurer, they deduct the tax at source and issue a certificate separately for each claim.

The billing company would receive the F45, on behalf of the doctor, scan them and store them, for submission in bulk to their accountants at the end of the year.

Thornton said: “It’s a nightmare… Can you imagine every time you perform a procedure on somebody and there was a form to pay tax on that, and you had to hold on to every single one of your tax forms. Unless you are very organised, you would face great difficulty in trying to stay on top of things and put all your tax forms together.”

Lloyd Mudiwa

   announces

Mr Richard Hanson
has recently commenced practice as Consultant Plastic Surgeon at Suite 35, Blackrock Clinic
Please contact Marie Gallagher at
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Dr Tom Walsh
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Brendan McDermott

Temporary Specialty Doctor – Community Paediatrics (2 posts)

Post 1:
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Post 2:
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This post will require vetting
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Brendan McDermott

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The use of superlatives to describe cancer drugs in news articles as “breakthrough,” “revolutionary,” “miracle” or in other grandiose terms is common, even when drugs are not yet approved, have no clinical data or do not yet show overall survival benefits, according to an article in JAMA Oncology.

The omission of medical context or the use of inflated descriptions can lead to misunderstandings among readers, according to Dr Vinay Prasad of the Oregon Health & Science University, Portland, and co-authors in the paper published online last week.

The authors searched for 10 superlatives (breakthrough, game changer, miracle, cure, home run, revolutionary, transformative, life saver, groundbreaking and marvel) in conjunction with the term “cancer drug” in a Google news search earlier this year between June 21 and June 25. The authors found 94 articles from 66 news outlets with 97 superlative mentions meeting the study criteria and referring to 36 specific drugs. Half of the drugs described had not yet received approval from the US Food and Drug Administration for at least one indication.

The most common class of drugs referenced was targeted therapy (17 of 36), nine cytotoxic drugs, five immunotherapy checkpoint inhibitors, three cancer vaccines, one radiotherapy and one gene therapy. Superlatives were used most often to refer to targeted therapy and an immunologic checkpoint inhibitor. For five of the 36 drugs (14%), superlatives were used in the absence of clinical data, according to the results.

Most of the 97 superlatives were used by journalists (55%); physicians (27%); industry experts (9%); patients (8%) and one member of Congress (1%). In 55 per cent of the cases, the superlative was used by the author of the article without any other attribution.

“A range of speakers used superlatives but the majority were journalists (55%), who may not have the expertise to identify the most promising medical therapies, or what magnitude of benefit warrants a superlative. The use of superlatives is common in cancer research news articles. Some of this use may be questioned,” the authors conclude.

JAMA Oncol. Published online October 29, 2015. doi:10.1001/jamaoncol.2015.3931.

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