Dr Tony Holohan

By Lloyd Mudiwa. Chief Medical Officer Dr Tony Holohan, who chaired the National Substance Misuse Strategy Steering Group, has requested doctors to participate in the public debate on alcohol, following the publication of the group’s radical report yesterday (February 7th).

In a letter addressed to individual doctors, the public health specialist said: “It is my intention in publishing this report that it facilitates a healthy public debate, following which we will bring final proposals to the Government in the next two to three months.

“As a medical practitioner, you will be aware of the devastating effects of alcohol use and misuse on the health and social wellbeing of the people of Ireland. The report of the Steering Group sets this evidence out very clearly.”

According to the report, alcohol was responsible for 88 deaths each month in 2008. It was a contributory factor in half of all suicides and deliberate self-harm, was associated with 2,000 beds being occupied every night in Irish hospitals, and related illness cost the health system €1.2 billion in 2007, with alcohol-related crime costing an estimated €1.19 billion in the same year.

Dr Holohan said the purpose of writing to the doctors was to encourage them to participate locally and nationally, either on an individual basis or through their professional colleges, in the public debate. He added that the healthy and constructive input of medical practitioners who were well placed to understand the issues involved was essential to balanced debate.

The report has recommended a ‘social responsibility’ levy on the drinks industry, and that the sponsorship of sport and other large events by drinks companies should be phased out by 2016.

“Doctors in Ireland are fully aware of the dreadful effects of alcohol on people,” said the CMO. “They see the harm that alcohol misuse causes and therefore, with the publication of the report on alcohol from the Steering Group, it is important that they contribute to the debate — providing their unique experience into treating adults and children affected.”

Dr Holohan asked the various medical colleges, the HSE and the Defence Forces to help disseminate the letter to all doctors in Ireland.

lloyd.mudiwa@imt.ie

By Dara Gantly.

The ICGP launched today (February 8th) a new publication — ICGP Guidance Document for GPs on National Referral Form to Secondary Care — which presents a new referral letter format as a national standard.

Developed by HIQA in collaboration with the College, the standardised referral form promises to streamline the referral process, save GPs’ time, avoid duplication errors, and facilitate further referral process development, including electronic referrals.

The four GPIT accredited practice management systems (Complete GP, Health One, Helix Practice Manager and Socrates) can produce the national referral form from the patient’s file, enabling GPs to use this new format in paper form instead of their current referral letter.

In March 2010, the ICGP GPIT facilitators began the process of improving the generation of referral letters from GP practice management software. They sought to develop a nationally-accepted dataset that would present the information in a standardised format.

HIQA’s ‘Report and Recommendations on Patient Referrals from General Practice to Outpatient and Radiology Services, Including the National Standard for Patient Referral Information’, released in June 2011, contained the final version of the collaboration of the GPIT and HIQA work.

Today’s document – prepared by Dr John MacCarthy, GPIT Coordinator — also contains guidance for GPs on how to complete the new referral form.

Recommendation 4 in HIQA’s report states that GPs should address referrals in the first instance to a central point within a hospital, then to the relevant specialty/service, followed by a named consultant, if relevant. This, the ICGP document points out, will result in a change for GPs. “It is recommended to refer to specialties, e.g. cardiology, rather than specific consultants. We do retain the option to specify our preferred consultant,” it stated.

The National Cancer Control Programme (NCCP) has set a target of doubling the number of GPs referring patients online to the eight designated cancer centres this year.

A collaboration between the NCCP, ICGP, GPIT Group and the HSE ICT Directorate, the new referral system for breast, lung and prostate cancer aims to eliminate the use of GP letters and faxes, increase efficiency and provide more rapid access for urgent cases that need to be seen within two weeks of referral.

It should ensure that — regardless of where a patient lives — the referral pathway they follow is of the same quality and standard, and should eliminate a repeat of the Tallaght referrals debacle.

GPs can contact the ICGP for advice and support through Niamh Killeen at niamh.killeen@icgp.ie, and more information on the GPIT group can be viewed at www.gpit.ie.

To download the document visit www.icgp.ie/referral.

Minister Róisín Shortall

By Gary Culliton. The Minister for Primary Care Róisín Shortall has requested a report from the HSE on its policy in relation to compensating those whose medical card renewals are delayed.

Following recent discussions with the HSE on the matter, Minister Shortall said that a medical card holder who genuinely engages with the review of their medical card should not have their entitlement withdrawn before that review is complete, and the Executive was taking steps to ensure that this rule was properly implemented.

The HSE is undertaking significant changes to how it conducts reviews so that there is “far less administrative burden” placed on most medical card holders and so that reviews take far less time, Deputy Shortall informed the Dáil.

From this month, the HSE is easing the review process for pensioners, which means that reviews for medical card holders who are 66 years or over will operate on a self-assessment basis, as currently happens with over-seventies. The self-assessment review model will also be extended to medical card holders under 66, who were granted their medical card on the basis of a means assessment, where the HSE is satisfied that the client has not passed away and is living in this jurisdiction.

The Executive is also standardising eligibility periods from two to three years for those aged under 66, with a new four-year eligibility period for medical card holders aged 66 or over.

The Minister added that in addition, from February 1, the HSE is implementing a new system that provides additional functionality to GPs to maintain the eligibility of their patients where a patient is going through the renewal process.

gary.culliton@imt.ie

Enda Connolly, HRB CEO

By Dara Gantly. The first European-wide research strategy to tackle Alzheimer’s and other neurodegenerative diseases was launched yesterday (February 7th) in Brussels by European Commissioner for Research, Innovation and Science Máire Geoghegan-Quinn.

The major strategy will effectively direct the focus and funding of EU and Member State research efforts regarding neurodegenerative diseases over the next five to 10 years.

The EU Joint Programme in Neurodegenerative Disease Research (JPND) is the first of the European Joint Programming initiatives designed to address the ‘grand challenges’ facing EU society in the coming years — problems considered beyond the scope and resources of any one country to tackle.

Welcoming the JPND strategy, Máire Geoghegan-Quinn said: “I am delighted to welcome this common strategy, agreed under this unprecedented collaborative initiative in research, to channel participating countries’ scientific competencies, medical strengths and social approaches to tackle this important challenge. The JPND strategy can not only make research efforts more effective in the area of neurodegenerative diseases but can also have very wide benefits for society, health and the research community in Europe.”

The goals of the European-wide strategy, which has been endorsed by 24 countries, include: to develop new treatments and preventive strategies; to improve health and social care approaches; to raise awareness and de-stigmatise Alzheimer’s and other neurodegenerative disorders; and to alleviate the economic and social burden of these diseases.

Chief Executive of the Health Research Board (HRB) Enda Connolly, who leads Ireland’s role in the Joint Programming Initiative, commented: “Dementia affects more people than cancer and heart disease combined. In Ireland alone it is estimated that 42,000 people are affected by some form of dementia and 4,000 new cases arise every year.  Recent estimates indicate that dementia-related care in Ireland costs €1.7 billion per annum.”

Given that dementias were strongly age-related, and Ireland has a rapidly-ageing population, Connolly added that the number of people with a neurodegenerative disease like Alzheimer’s was expected to more than treble across the EU over the next 30 years. This would pose a serious challenge for healthcare providers and society in general, he added.

“To date, neurodegenerative disease research doesn’t have the same level of international profile, co-ordination or funding as research in areas such as cancer. This strategy seeks to address that imbalance, and for the first time bring cohesion and focus to European research in this field,” said the HRB CEO.

Ireland is taking a lead role in JPND, and Connolly is one of a five-member Executive Board that has overall responsibility for the development and implementation of the entire initiative. Science Foundation Ireland also has an active role in driving Irish involvement, through participation on the JPND Management Board and co-funding of projects.

“Ireland has a strongly developed expertise and research agenda in this area. This will place Irish scientists in a strong position to participate in new research initiatives, which in turn will benefit Irish patients who will be at the forefront of new care models and therapies,” added Connolly.

dara.gantly@imt.ie

By Lloyd Mudiwa.

Poor communication is the top risk to healthcare in more than 99 per cent of all general practices, a new analysis by the Medical Protection Society (MPS) has shown.

Risks with healthcare are not limited to clinical issues but also relate to concerns with administration, training, policies and procedures and communication, both internally and externally, according to the results of the analysis.

The other risks in general practice making the top five in order of priority are: confidentiality (98.7 per cent of practices identified confidentiality as a risk), health and safety (97.4 per cent), prescribing (87.8 per cent), and record-keeping (87.2 per cent).

The analysis was based on Clinical Risk Self Assessments (CRSAs) conducted in 150 practices in the UK in 2011. CRSAs involve a pre-visit questionnaire, staff patient safety culture survey, a full-day visit by a trained MPS risk assessment facilitator, confidential discussions with key members of staff, and a follow-up report detailing the findings.

A spokesperson for the Society told Irish Medical Times: “Although there were only a couple of CRSAs carried out in Ireland, it may be useful to get an overview of the risks general practices face.”

The spokesperson said the analysis showed that communication was the top risk — MPS’s claims data and international research consistently demonstrated that it is patient dissatisfaction with communication by their doctor that fuelled the majority of complaints.

Dr Richard Stacey, Medico-legal Adviser at MPS and a former GP, said traditionally, confidentiality had been the highest risk in general practice, but last year communication overtook it by a small margin. “In recent years, practices have embraced electronic communication, offering greater convenience and flexibility for both patients and doctors — but it does bring with it new problems,” he commented.

“The important message here is to embrace the benefits but be aware of the pitfalls of electronic communication.”

lloyd.mudiwa@imt.ie

Research published in the American Journal of Gastroenterology indicated women who have taken 30 or more courses of metformin have roughly half the risk of developing pancreatic cancer (CI 0.23-0.80), but found no such relationship in men.

The results contradicted a 2009 study that associated five years’ or more metformin therapy with a 70 per cent decreased risk of developing pancreatic cancer, regardless of sex (CI 0.13-0.69).

The authors of the new research — the subjects of which had an average age of 70 — pointed out that with only 29 exposed cases and 27 controls, the former study was small compared with the 2,763 patients and 16,578 matched controls of the new.

That the earlier study did not stratify according to gender was another limitation, the authors added.

They said the result was unexpected and “could not be explained by use of oestrogens”. Since there was “no obvious patho-physiological explanation”, the results should be taken with caution, they said.

Consistent with earlier findings, the researchers found the long-term use of sulfonylureas was associated with a roughly doubled risk of pancreatic cancer (CI 1.32-2.720) and long-term insulin use with a more than doubled risk (CI 1.34-3.92).

However, short-term use of metformin, sulfonylureas, or insulin was not related to increased pancreatic cancer risk, they said.

American Journal of Gastroenterology, 2012; doi: 10.1038/ajg.2011.483

‘What do you mean I'm funny? You mean the way I talk? What? Funny how? You mean funny, like I'm a clown? Like I’m here to amuse you? What the f*** is so funny about me? Tell me, tell me what's funny!’ The famous scene featuring Joe Pesci and Ray Liotta from Goodfellas may be an example of a less benign form of humour

By Pat Kelly. Psychologists have reignited the debate over what actually makes something amusing and have come up with a formula to explain it.

Peter McGraw and Caleb Warren from the University Colorado-Boulder subjected a group of volunteers to a range of situations and attempted to quantify how ‘funny’ these were and they concluded that a situation is normally only funny if it is deemed to be benign.

For example, one situation involved a rabbi being hired as spokesperson for a range of pork products, as opposed to a farmer. The “moral violation” of having the rabbi sell the products was classified as ‘funny’ — but less so for a person of the Jewish faith who held their convictions deeply.

Likewise, in another experiment where a church raffled a new SUV to attract extra numbers to its flock, this was repugnant to regular church-goers, but was found to be rather funny to those who attended church less regularly.

The authors found that the greater the person’s distance from the “moral violation,” the more likely they were to find a situation amusing. They encapsulated the concept with the formula: “Humour comes from a violation or threat to the way the world should be that is at the same time benign.”

“We laugh when Moe hits Larry because we know that Larry’s not really being hurt,” said McGraw in the Journal of the Association of Psychological Science. “It’s a violation of the social norms. You don’t hit people, especially a friend, but its okay because it’s not real. When I was first told about an internet video of an Indonesian chain-smoking toddler, I laughed because it seemed unreal — what parent would let their kids smoke cigarettes? The fact that the situation seemed unbelievable made it benign. Then when I saw the video of the kid smoking, it was no longer possible to laugh about it.”

pat.kelly@imt.ie

By Pat Kelly

The psychologists, based at the Lakehead University in Canada, postulated that potent oestrogen levels found in fatty tissues directly translated into better moods among overweight women.

The Lakehead University team conducted research examining the BMI of two groups of women. They then correlated the respective BMIs with symptoms of depression in both groups. Their results showed that the higher the BMI, the less symptoms of depression were evident in the overweight group. Moreover, the thinnest in the group exhibited the most signs of depressive tendencies.

They then utilised biochemical data to suggest a possible link between oestrogen, mood and serotonin to conclude that the higher the amount of fatty tissues present, the greater the oestrogen levels and therefore the more serotonin.

This and other off-centre medical research has been compiled in Death can be Cured and 99 Other Medical Hypotheses by Roger Dobson and published by Cyan.

pat.kelly@imt.ie

‘Patients given combined therapy from the start of treatment responded better than those given monotherapy’

Prof Eoin O’Brien looks at the benefits of aliskiren in the treatment of hypertension but says it should not be prescribed with ACE inhibitors or ARBs in diabetic patients.

Aliskiren (available in Ireland as Rasilez and Rasilex HCT) is the first in a class of drugs called direct renin inhibitors. The earliest efficacy studies were conducted by my department in Beaumont Hospital in 2001 for Speedel Pharma.

When its efficacy in reducing blood pressure over 24 hours was established, Novartis marketed aliskiren as a new class of drug for the treatment of hypertension, which was approved by the US Food and Drug Administration (FDA) in 2007 either as monotherapy or in combination with other medications.

The efficacy and safety of aliskiren has been investigated in clinical studies in more than 57,000 patients.

Renin cleaves angiotensinogen to angiotensin I, which is converted by the angiotensin-converting enzyme to angiotensin II. Angiotensin II increases blood pressure by causing vasoconstriction and increased production of aldosterone from the adrenal cortex, which causes the tubules of the kidneys to increase reabsorption of sodium and water, leading to an increase in plasma volume. Aliskiren prevents the conversion of angiotensinogen to angiotensin I, thereby lowering blood pressure.

ACCELERATE and ALTITUDE
The ACCELERATE study, reported in The Lancet last year, was a double-blind, randomised, parallel-group superiority trial performed in 10 countries, in which hypertensive patients were randomly assigned to treatment with aliskiren plus placebo, the calcium-channel blocker (CCB) amlodipine plus placebo, or aliskiren plus amlodipine.

Patients given combined two-drug therapy from the start of treatment responded better than patients initially given monotherapy, and those who later switched from monotherapy to combination therapy improved their response, but not to the same level as those who began with combination therapy.

In an accompanying comment in The Lancet, ACCELERATE was heralded as the first study to show that starting on combination therapy helps patients to achieve blood pressure goals faster than initial monotherapy.  So the stage was set for Novartis to combine aliskiren with other blood pressure-lowering drugs and approval for this was given by the FDA.

Despite this, aliskiren has been prescribed generally as a fourth-line hypertensive agent in patients with resistant hypertension. Nonetheless, total sales of aliskiren-based products for the first nine months of 2011 were US$449 million (€348.1 million, 1 per cent of Novartis Group sales).

So far, so good. But just before Christmas, Novartis announced termination of the multinational ALTITUDE study to evaluate the potential benefits of aliskiren with an angiotensin-converting-enzyme-inhibitor (ACEI) or an angiotensin-receptor-blocker (ARB) to reduce the risk of cardiovascular and renal events in 8,606 patients (recruited from 36 countries) with type II diabetes, reduced renal function and a previous cardiovascular event.

In December 2011, the data safety and monitoring board (DSMB) recommended termination of the study because the aliskiren-treatment group experienced an increased incidence of non-fatal stroke, renal complications, hyperkalemia and hypotension. The DSMB concluded that patients were unlikely to benefit from aliskiren added to standard antihypertensive therapy. These findings represent a major setback for a drug that had once been considered to have significant potential as a new class of treatment for hypertension.

Prof Eoin O'Brien: 'The recent introduction of flexipills providing a range of doses for combinations of ARBs or ACEIs with other drug classes makes combination treatment very much easier for the patient'

Aliskiren with ACI or ARB
A press release from Novartis stated: “Novartis is in ongoing discussions with health authorities worldwide about the implications of the findings from ALTITUDE for patients.” But, “as a precautionary measure, Novartis will cease promotion of Rasilez-based products for use in combination with an ACE inhibitor or ARB”.

The Irish Medicines Board refers website queries to the European Medicines Agency (EMA) Press Release (22 December, 2011), which states that the EMA “is reviewing aliskiren-containing medicines, to assess the impact of data coming from the ALTITUDE study on the balance of benefits and risks of these medicines in their approved indication” and recommends in the meantime “as a precautionary measure, that doctors should not prescribe aliskiren-containing medicines to diabetic patients in combination with ACE inhibitors or ARBs”.

The message is therefore clear for diabetic patients. Patients with diabetes on aliskiren alone or in combination with HCTZ, who are not on an ACEI or ARB, need not modify treatment if blood pressure control is satisfactory. However, diabetic patients who are on aliskiren alone or in combination with HCTZ and are also on an ACEI or ARB, should stop the aliskiren-based drug.

The question to be answered in the ongoing analysis is what the implications are for non-diabetic patients who are on treatment with aliskiren in combination with an ACEI or ARB. The results of the ALTITUDE study must raise the question as to how suitable these combinations are in the overall treatment of hypertension.

Pending the results of further analyses, perhaps the wisest course would be to keep aliskiren in reserve only for hypertension that has proven resistant to combination treatment with diuretics, ACEIs and ARBs, CCBs and the newer beta-blockers in non-diabetic patients.

The recent introduction of flexipills providing a range of doses for combinations of ARBs or ACEIs with other drug classes makes combination treatment very much easier for the patient, with the likelihood of improved compliance and more efficient blood pressure control.

• Prof Eoin O’Brien, Professor of Molecular Pharmacology, Conway Institute, University College Dublin.

Dr Muiris Houston

Dr Muiris Houston looks at the implications of new research, which examined whether physician body weight is a barrier to care in overweight and obesity.

When it comes to giving lifestyle advice to our patients, does it really matter what sort of shape we are in? And are doctors role models for their patients?

These are interesting questions that are now being asked by medical researchers.

According to new research on the topic, a doctor’s BMI can in fact impact on how they treat their overweight and obese patients. Sara Bleich and her colleagues from the Johns Hopkins Bloomberg School of Public Health and Medical Institutions in Baltimore found that doctors with a normal BMI were more likely to initiate a discussion on weight loss with their overweight patients compared with doctors who were overweight or obese themselves.

The researched, published online in the journal Obesity, also found that these physicians with normal BMIs demonstrated more confidence in their ability to provide advice on diet and exercise compared with their overweight or obese colleagues.

Commenting on their study, the authors said: “Physician body weight may be a barrier to obesity care. Understanding how a doctor’s BMI influences his or her treatment decisions regarding weight management is critical, given the important roles practitioners play in helping their patients lose or gain weight.”

The study involved a cross-sectional survey of general practitioners and hospital physicians. Participants completed a questionnaire on how they recorded an obesity diagnosis, initiated weight-loss discussions, rated self-efficacy for providing counselling, and prescribed weight reduction medication. The researchers also looked at how participants differed in their outlooks on the value of modelling healthy behaviours and whether the doctors believed that a patient’s trust in medical advice might be influenced by the weight of the doctor giving it.

The results showed that doctors with a normal BMI were more likely to believe that doctors should model weight-related behaviours, such as maintaining a healthy weight and exercising regularly compared with their overweight or obese medical colleagues.

Those within normal BMI limits also said they believed that overweight or obese patients would be less likely to trust advice given by a physician who also was overweight or obese.

Interestingly, doctors were found to be more likely to record a diagnosis of obesity or start a weight-loss conversation if they perceived the patient’s body weight met or exceeded their own.

This is something Dr Arabella Onslow, a GP in Cumbria, England, would probably agree with. Having successfully lost over 10 stone in 14 months, she is quoted as saying: “I can see in hindsight that my idea of what constituted normal weight was massively skewed… when I weighed 22st, if I saw a patient who weighed 18st I found myself thinking they weren’t that overweight — while, of course, they were.”

‘Not everyone agrees with the need for doctors to be role models’

Example to patients
Commenting on her reasons for losing weight in the Daily Mail, Dr Onslow commented: “At the back of my mind was the knowledge that I wasn’t providing the best example that I could to my patients. I really care about them and I wanted to be the best doctor I could for them.

“I knew that at the very least, I was giving tacit approval to someone who was overweight. If their own doctor, the person they went to for health advice, could be that fat, then surely it was okay for them to be fat too.”

In the same article, Dr Michael Wilks of the British Medical Association and Chairman of the Sick Doctors Trust is quoted as saying that “previously, people accepted what doctors said without question…now, however, people are more likely to look at their doctor with questioning eyes”.

And backing up Dr Wilks’s theory is a UK survey carried out by the Department of Health, which found that fewer than half of those questioned would readily accept health advice from a health professional who appeared to have an unhealthy lifestyle. A third would actively not accept that advice. But despite the research results, not everyone agrees with the need for doctors to be role models when it comes to weight and fitness.

Dr Daniel Sokol, a Medical Ethicist at Imperial College London, is of the opinion that: “Doctors must be trustworthy, competent and professional, but this does not mean they must lead healthy lifestyles or be thin or good-looking.”

Meanwhile, a spokesman for the Royal College of General Practitioners said that as long as the doctor acts professionally, there is no dilemma. “When the patient leaves the consulting room, they must feel that the doctor has listened to them, addressed their needs and was kind. This is the best way to ensure that the next time they visit their GP, they can trust them enough to talk about their eating, drinking or any other personal concerns,” they added.

But as Dr Onslow says: “I don’t think I am a better doctor because I am no longer obese. But I do think I am a better role model for my patients.”