Interview

Sarah Gallagher speaks to Prof Derek O’Keeffe before his upcoming talk at the RCPI’s St Luke’s Symposium about holding degrees in engineering and medicine, his work with NASA, and the future of artificial intelligence In October, the RCPI will be awarding Prof Derek O’Keeffe the inaugural St Luke’s Medal as part of the annual St…

The College of Psychiatrists of Ireland Winter Conference 2018 will be held in the Brehon Hotel/INEC in Killarney, Co Kerry, later this month on Thursday and Friday 15-16 November.

This year’s event is titled ‘From the Biome to Bipolar’ and has a wide range of speakers over the packed two-day schedule, on issues as varied as professionalism to prison work, from the future of personality disorder services in Ireland, to the writings of Kafka.

President of the College of Psychiatrists of Ireland Dr John Hillery told the Medical Independent (MI) that he is looking forward to the conference and believes that the eclectic range of talks and speakers will provide something of interest for all attendees.

The opening session on the Thursday of the conference is on ‘Professionalism and the Trainee’. During this session, three speakers will address the theme, including Prof Trudie Roberts from the University of Leeds, UK, who will talk on ‘Professionalism and Integrity: Challenges and Consequences of Modern Medical Training’.

As ever, professionalism remains an important topic, Dr Hillery said.

“Well, we are continuing the theme of professionalism and as you see [in the meeting programme], there is a long opening session on it;  I think that is always important,” said Dr Hillery.

“Probably, people might say it is more important now because of all the recent issues that there have been in the public discourse about the way doctors interact with patients. It is something that we are all reflecting on; the College has always taken a position on making it a core aspect of discussion for trainees.

“But in the last few conferences, we have also been [raising]…ideas of professionalism in psychiatry. It means that it is an important theme for us, and it is one that we will continue to do at all our conferences.”

Prisons and the homeless

Later on Thursday, there is a session on ‘Prisons and the Homeless’ delivered by Dr Damian Smith and Dr Kevin Kilbride, and on Friday, Dr Conor O’Neill from the Central Mental Hospital, Dublin, will talk on ‘Men with Psychotic Illness in Remand Prisons’.

Homelessness is very much in the news at the moment, and Dr Hillery said it has a particular mental health impact.

“The services for the homeless are rather geographically confined,” he said.

“But we know historically that people with mental illness are probably more at risk of homelessness.

“When you look at dealing with mental illness and the treatment of it, we have to look at society’s approach to vulnerable people, so it is something we want all our trainees and ourselves to be conscious of, of those needs, and to keep it out there.

“Why do people end up homeless? Can we have earlier interventions? As you probably know, it is a theme we have been putting out there to the public about resources, and lack of resources, and that interventions are not as early as they should be, which is leading to people getting more serious illnesses, leading to greater morbidity and possibly mortality.”

On Friday before lunch, there is a session on bipolar disorder, with some of the presentations including Dr John Cooney from St James’s Hospital, Dublin, talking on ‘Mood Disorders in Liaison Psychiatry’ and Dr Aditya Sharma from the Institute of Neuroscience, Newcastle University, UK, speaking on ‘Pharmacological Management of Bipolar Disorder in Under-18s’.

The day before, on Thursday, there is a series of NCHD research oral presentations spanning a wide range of topics.

 “The key to advances in psychiatry is research and the key to insuring that good research happens is by encouraging trainees to do it; it’s important that we support it. Of course, it is also important that their [NCHDs] contract supports it and their employers support it. So this is a manifestation of that, which is very good. It’s a key issue, and it’s great to see such interesting and quite varied papers coming through,” said Dr Hillery.

Sláintecare

Dr Hillery said that the College of Psychiatrists of Ireland remained concerned about the lack of representation of psychiatrists on the recently-established Sláintecare Implementation Advisory Council. “It’s quite disheartening,” he said. Dr Hillery added that he remains disappointed “and my colleagues support me on this, that we have a council dealing with the implementation of a 10-year plan for health, which doesn’t have any input from people who deal with people with serious mental illness.”

“By doing that, it is giving the message out that mental illness is not really part of what our health services are about. I think that’s unfair to the people who put together Sláintecare because the document does give a lot of thought to people who have mental illness,” according to Dr Hillery.

The College President was also not satisfied with aspects of the recent Budget 2019. “The Budget…was announced to great fanfare, about how much money was given [to mental health]. But if you do the math, it doesn’t actually increase the percentage of the health budget for mental health by much at all.”

“We are still of course expressing our disquiet with the lack of investment in the mental health services for people with mental illness.”

Recently, the College released a statement saying it was disappointed with recent findings from the Inspector of Mental Health Services. The College said the findings showed an  “increased use of seclusion and restraint in our hospitals”.

 “The College is very disappointed to see the data… on levels of restrictive practices in hospitals. This is another manifestation of the under-resourcing of services for people with serious psychiatric illness,” the College said in its statement.

“Seclusion and restraint should only be necessary in extreme circumstances, as early intervention and support should prevent any individual becoming so unwell that their safety or the safety of others requires such intervention.

“Unfortunately, the experience of frontline psychiatrists in Ireland currently is that they lack the resources in trained personnel to ensure all people in need get the variety of evidenced-based, individualised interventions they require.”

Literature

The upcoming Winter Conference in Killarney, ends on an interesting and unique topic. Prof Femi Oyebode from the University of Birmingham, UK, will talk on ‘Abnormalities of the Self and Embodiment in the Writings of Franz Kafka — Lessons for Psychiatry.’

“This is something we want to bring in more,” said Dr Hillery.

“Dr Femi Oyebode has been writing for many years on the area of literature and mental illness…we are delighted she is coming to speak on this. It looks far too intellectual for me,” he laughs.

“But I’m looking forward to hearing it. Once again, there has been a long history going back to the 1800s of people in psychiatry, or whatever it was called at that stage, being involved in the arts.

“Also, when I was training, several of my trainers pointed me towards people, writers such as Dylan Thomas and Frank O’Connor, to look at the development of people’s inner thinking. So it is something we have to be very careful about in psychiatry, that we promote the scientific aspects of things, but we don’t lose that other side of it either.

“Because if we are trying to work out how humans behave and how individuals behave, the writings of the great writers are really important from that point of view.”

In terms of its own publications, last month the College announced the Irish Journal of Psychological Medicine (IJPM) was successful in its application for indexing on Medline, the “largest and most prestigious” internet search engine for medical research.

As the official research journal of the College, much of the research published in IJPM is relevant to an Irish audience, “although the journal has a large international readership and maintains the high publication standards worthy of an international journal.”

According to a College spokesperson, this indexing will “result in Irish-based mental health research being more visible and widely-read by clinicians and researchers, both in Ireland and around the world. It will also increase the likelihood that this research will be used by people to inform clinical practice through internet searches.”

Dr John Lyne, Editor-in-Chief for the IJPM, explained what this indexing could mean for the delivery of services. “The journal aims to advocate for better mental health services for all by highlighting key topics of current relevance to mental health. By reaching a wider audience, IJPM can act as a forum for positive change in how mental health services are delivered, both in Ireland and internationally.”

The Gathering Around Cancer 2018 conference will take place in Croke Park Convention Centre, Dublin, on Thursday 8 and Friday 9 November. The conference is one of the major oncology events of the year and will feature presentations from a wide panel of experts, who will give their perspective on the major developments within their specialty. 

The inaugural meeting took place in 2013 to coincide with the Gathering events being held that year to mobilise the Irish diaspora. Since then, the event has gone from strength-to-strength.

“We had a very large meeting, a three-day meeting, at that time,” according to organiser and Consultant Medical Oncologist in the Mater Misericordiae University Hospital, Dublin, Prof John McCaffrey, who co-founded the event with Consultant Medical Oncologist in St James’s Hospital, Dublin, Prof David Gallagher.

“And it was so successful that we decided to carry on. It became a meeting that wasn’t disease-specific, but covered everything. It is mainly medical oncology but we take in radiation and surgery and paramedical also, so I think it satisfies all the things we needed and has become the meeting that people want to have.”

Speaking to the Medical Independent (MI) ahead of the 2018 meeting, Prof McCaffrey said he is delighted by the positive response the meeting has generated among the oncology community.

“Myself and David Gallagher continually get very positive feedback that people like the way we do it. We want stay fresh, so we try to change things a little bit each year,” according to Prof McCaffrey.

“But I think the formula we have now suits people.”

After the welcome address on Thursday, the first session of the conference will be devoted to presentations from ‘Young Investigators’. The topics in this session will range from immunotherapy in breast cancer to overcoming EGFR TKI’s resistance in lung cancer. Prof McCaffrey said that this is always one of the most popular sessions.

“A lot of these people will be known to the community in Ireland, and then to see the step up that people take when they go abroad is quite impressive,” Prof McCaffrey stated.

“And these are the people who will be our future leaders, so it is great to see it happening.”

Burnout

The following session will be on the subject of ‘Global Oncology’. CEO of the Irish Cancer Society (ICS) Ms Averil Power will begin the session with a talk on patient advocacy. The next speaker, Dr Patricia Scanlon, Muhimbili University, Dar Es Salaam, Tanzania, will deliver a talk on the challenges of running an oncology programme in the developing world. Other talks concern ‘The Future of AYA Oncology’ and ‘Burnout in Oncology: A Global View’, which will be delivered by Dr Scheryll Alken, St James’s Hospital and Our Lady’s Children’s Hospital Crumlin and Dr Blanaid Hayes, Dean of the Faculty of Occupational Medicine, RCPI, respectively.

Prof McCaffrey told MI that meeting organisers felt that it was essential to cover the theme of burnout, given the enormous workload pressures those working in the field of oncology face.

“The inability of male and female doctors to disconnect from work isn’t something we pay a great deal of attention to,” according to Prof McCaffrey.

“Our only fear is that we are not giving it enough time on the programme. It is a huge issue and a topic that needs to get more air-time than is currently the case.”

Dr Sean Ennis from Genomics Medicine Ireland will give the last talk of the session on population genetics, industry and academic collaboration.

Screening

The final session of the day will be on the timely and controversial subject of cancer screening.

Head of Services and Advocacy at the ICS Mr Donal Buggy will talk about screening from the patient’s perspective. There will also be a presentation specifically on cervical cancer screening, which will be delivered by Prof Grainne Flannelly, St Vincent’s University Hospital, Dublin. Given the recent controversy concerning CervicalCheck and the publication of the Scally Report, these talks are sure to be of extreme interest to delegates.

Two of the presentations will be on the subject of breast cancer screening. Prof Fidelma Flanagan, Mater Hospital, will deliver the first talk, while Prof John Crown, St Vincent’s University Hospital, Dublin, will talk about the “benefits and pitfalls” of breast cancer screening.  Colon screening will also be covered by Prof Diarmuid O’Donoghue, St Vincent’s University Hospital.

“I think it is to reaffirm the importance of screening in the various areas; to take a look at what has been achieved, to hopefully show that we are saving lives,” according to Prof McCaffrey.

“If we are doing something not right, that will come up at the meeting, and what are the steps that can be taken to reassure us as the practitioners and the wider public that there are clear benefits to doing it [screening].”

The first session on Friday will concern ‘Updates in Medical Oncology’. Prof Donal Brennan, University College Dublin, will start the session with a talk on gynaecology cancer surgery. This will be followed by a talk on ovarian cancer by Dr Dearbhaile O’Donnell, St James’s Hospital. Other subjects to be covered in the session include: Cervical/endometrium cancer; radiation therapy gynaecology; renal cell carcinoma; the central nervous system; and lung cancer.

GI, breast and prostate cancer

The next session will discuss aspects of GI cancer specifically. Presentations will cover upper GI cancer and lower GI cancer. Dr Steven Hochwald, Roswell Park Cancer Centre, New York, US, will speak about ‘Advances in Surgery for Gastro-oesophageal Malignancy’ in an eagerly-anticipated talk.

Dr Hochwald’s research focuses on technical advances in minimally-invasive oesophageal and GI surgeries and developing new targets and agents for treatment of pancreatic and other GI cancers. He has lectured both nationally and internationally on Western approaches to minimally-invasive oesophageal and gastric resection for malignancy and has published broadly on these topics. He has taught several courses and organised symposiums on minimally-invasive oesophagectomy. He serves as Editor of the book titled Minimally Invasive Foregut Surgery for Malignancy, which was published by Springer in 2015.

Prof John Reynolds, St James’s Hospital, will also give a presentation on the interesting topic of the relationship between obesity and cancer, while Prof Frank Sullivan, NUI Galway, will talk about diet and weight loss in cancer.

The final session of the conference is on both prostate and breast cancer. Subjects under discussion will include prostate surgery, radiation therapy, and systemic therapy. Prof David Gallagher will deliver a presentation on the role of the BRCA gene in prostate and breast cancer. Genetics will also be the subject  of talks by Dr Janice Walshe, St Vincent’s University Hospital, who will discuss ER + HER2- stage IV breast cancer and Dr Cathy Kelly, Mater Hospital, who will talk about HER 2+. Dr Con Murphy, Bon Secours Hospital, Cork, will also deliver a presentation on triple-negative breast cancer.

Cancer strategy

The event comes just over a year since the National Cancer Strategy 2017-2026 was published. Prof McCaffrey believes that implementation of the strategy over the past 12 months has been “steady”.

“I think we are all encouraged by the need to improve manpower, especially in medical oncology centres, but also supportive staff, including dietetics and psycho-oncology and the nurse specialty. I think they are all important things. A 10-year plan always needs to be given time to work. Now in its third iteration, I think we have made huge progress in the time since we have had the strategies. Of course, you don’t get to where you need to be every time, but that’s the nature of the evolving landscape. Things like genetics and genomics need to be incorporated into the management of cancer also. Overall, I think on-the-ground resourcing is the most important thing to achieve in terms of implementation.”

In 5-6 October in the Convention Centre Dublin a dedicated two-day meeting hosted by BMS/Pfizer on stroke prevention in non-valvular atrial fibrillation (NVAF) and the prevention and treatment of venous thromboembolism (VTE) will take place. The event will feature presentations from leading multidisciplinary international experts from Europe and Canada, as well as local expert Dr Rónán Collins, about the latest clinical advances in anticoagulation and practical guidance on how to apply this knowledge in patient practice.

In an interview with the Medical Independent (MI), Dr Collins stressed the need to increase awareness of atrial fibrillation, and its connection to stroke among both clinicians and the general public and the best ways to clinically manage it.

Dr Ronan Collins

“Atrial fibrillation is the commonest cardiac arrhythmia and affects about 5 per cent of people over the age of 60, and about 10 per cent of people over the age of 75, so therefore it is a very common condition and it is a growing problem because of our demography in Western Europe and also particularly in Ireland. Because of the huge risk factor for stroke, particularly in Ireland where about 35 per cent, a bit over one-in-three, strokes are caused by atrial fibrillation, it is crucially important in any stroke strategy that we pay attention to prevention.”

Dr Collins was involved in the development of the newly revised European Heart Rhythm Association (a branch of the European Society of Cardiology (ESC)) Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation (2018).

This Practical Guide, like its predecessors from 2013 and 2015, supplements ESC guidelines on how to use non-vitamin K antagonist (VKA) oral anticoagulants (NOACs) in specific clinical situations for stroke prevention in patients with atrial fibrillation (available at www.NOACforAF.eu).

“We extended it this year beyond the traditional remit of just atrial fibrillation in general to consider special populations with atrial fibrillation, for example, those who are frail and quite old who may be quite prone to falling, they may have co-existent dementia, have age-related kidney issues, have lower body weight, etc. So for those reasons it was important that the document focused on special populations this year. It is within that context, as one of the authors of the guidelines that I will be speaking at this week’s meeting about optimising treatment management, with particular reference to older people, frail people, people who have just had a stroke and the importance of multidisciplinary working as well,” he explained.

Dr Collins stressed that a multidisciplinary approach to atrial fibrillation “is a critical point” that has been “an ESC recommendation for the last two years”.

“We are probably one of the few places in Europe that have an interdisciplinary atrial fibrillation clinic. In Tallaght Hospital our atrial fibrillation clinic is a joint effort between cardiology, geriatric and stroke medicine, clinical nurse specialists and pharmacy. We think that is the right way forward to deal with atrial fibrillation.”

Awareness

Awareness of atrial fibrillation among the general population is poor in Ireland. Dr Collins noted the Irish Heart Foundation has run campaigns to try to address this but awareness still remains quite low; according to the most recent data less than 30 per cent of surveyed people in Ireland had heard of the condition. “Which is amazing as it is so common. The awareness is slightly higher in older people, which is good as older people are more likely to have it and it is slightly higher in higher socio-economic groups,” he said.

In addition, in people who have heard of atrial fibrillation most do not realise the connection with stroke, which is quite worrying, Dr Collins commented.

“Public awareness is low and we know it is even low in people who have atrial fibrillation; we know from a paper from Birmingham on people attending an atrial fibrillation clinic that less than half of them knew what it is. So if that was in a specialist clinic you can imagine what it [awareness] is like among the general public. Basically we know that only 25 per cent of people know anything about atrial fibrillation and only half of those are aware it is associated with a risk of stroke. So there is a lot to be done. I don’t think Ireland is very different from other European countries. There is a taskforce to get European Parliament engagement on this as a public health issue but we have a lot to do.”

Anticoagulation

In relation to anticoagulation of those who are at risk of stroke, Dr Collins said that while more people are being treated, there is still much unmet need. He noted that the use of NOACs has increased dramatically in the last five years in Ireland and that it is now well-established that warfarin is no longer the gold standard of care with the newer NOACs being the first choice for anticoagulation as per the ESC guidelines.

“To be fair I think we are doing much better in this regard. If you look at the pharmacoeconomic data there has been a huge increase in the use of NOACs. Therefore, there are a lot more prescriptions being written… Clearly these drugs cost and I’m not saying pharmacoeconomics aren’t important, but stroke is our third leading cause of death and our leading cause of acquired neurological disability. That’s a fact and atrial fibrillation is one of the major causes of stroke in Ireland and in Western Europe and that is also a fact. So therefore the pharmacoeconomics have to be set in the context of what the drugs are actually doing. The country has a lot of expenditure on drugs and it is important that we police it, but these are effective drugs. Sometimes I do wonder when it comes down to discussing drugs, for example, cancer, because cancer can be such an emotive issue, the pharmacoeconomics might get looked at, but it doesn’t get the same drilling as a preventative drug, so paring atrial fibrillation back to its core message: It is very common, the consequences of atrial fibrillation can be very severe. Atrial fibrillation can be detected before it causes any major health problems and the health problems can be prevented by effective intervention. The effective intervention is relatively cheap and relatively well-tolerated and there is a huge economic gain in preventing stroke to the health service and a huge personal gain in preventing stroke for people who have suffered one.”

Screening

Dr Collins pointed out that the World Health Organisation (WHO) criteria for screening programmes is based on the 1968 Wilson and Jungner criteria that if “a condition is common, that it is easily detectable by an acceptable means, that if you do not detect it, it causes a major health problem, that if you do detect it you can intervene to prevent that major health problem and that it is cost-effective, and atrial fibrillation ticks all these boxes”.

“This is something that causes one-in-three strokes in Ireland. And stroke is our third leading cause of death and leading cause of adult acquired disability so I think atrial fibrillation is a massive public problem.”

He commented that diseases like breast cancer “do not affect 5 per cent of people over the age of 60 or 10 per cent of people over the age of 70, but we have screening programmes. And I’m not saying we shouldn’t have screening programmes for that; that’s not the point I’m making. The point I’m making is that atrial fibrillation is a very serious problem but because it is not directly associated with something with the same emotive or terrifying understanding of cancer [it is overlooked]”.

“So there are other important things we should be screening for and atrial fibrillation is one of them. But in order to have an effective screening programme you must have public knowledge of the issue as well, so that is the starting point. And then we must get engagement with the HSE to look at this for screening. I have to say in Ireland we did a health technology assessment (HTA) of pulse screening [in a general practice setting] under Dr Breda Smyth [Consultant in Public Health, Department of Public Health Galway, HSE Health and Wellbeing Division] in the West of Ireland and the Dáil has approved the pulse check. It is not a comprehensive screening programme, but it has been approved by the HTA, by the Department of Health to be included in the health programme and it is probably part of the ongoing GP contract negotiations.”

However, Dr Collins reiterated that the medical community must further collaborate to raise awareness of the importance of atrial fibrillation. “We have to do our job better, we have to work out a way as to how we get this message across, how do we get people to understand. Once you get public engagement the rest of it tends to fall into place. If you don’t have public engagement you don’t have anything.”

Coming back to this week’s meeting, Dr Collins expressed his excitement at the “world class speakers” who will be giving presentations, including Prof Stefan H Hohnloser, Professor of Medicine and Cardiology at the Johann Wolfgang Goethe University in Frankfurt, Germany, where he is the Head of the Department of Electrophysiology; and Prof Giancarlo Agnelli, Professor of Internal Medicine and Director of the Department of Internal, CV Medicine and Stroke at the Perugia University Hospital, Italy. “They are at the top of their game. It would be hard to get a group of people with such expertise in one room as is being brought to Ireland for this meeting.”

A full exclusive meeting report from the event will appear in a future edition of MI.

Dysphagia can have a “huge impact” on a person’s life, according to Dr Margaret Walshe, Associate Professor in Speech Language Pathology, Trinity College Dublin and Vice President of the European Society for Swallowing Disorders (ESSD).

Difficulty feeding and swallowing is a common problem in preterm infants, children with various neurological problems and craniofacial anomalies, such as cleft palate. It is also frequently associated with acquired neurological conditions, such as motor neurone disease; stroke; multiple sclerosis; Parkinson’s disease; dementia; as well as head and neck cancer.

Speaking to the Medical Independent (MI) from the ESSD Annual Congress in Dublin, attended by around 1,000 delegates on 25-29 September, Dr Walshe said that being unable to eat or drink normally has a profound impact on a person’s quality-of-life and can lead to depression and anxiety.

“It has huge implications socially but it also has implications in terms of aspiration pneumonia, which is the biggest consequence of a swallowing problem, and that is probably the biggest single cause of death in Parkinson’s disease and conditions such as motor neurone disease. It is also strongly associated with malnutrition, dehydration and choking. ”

Aspiration pneumonia in people with dysphagia is often preventable, certainly in the case of acute stroke patients. Research confirms that people with dysphagia following stroke have longer length of hospital stay and poorer outcomes overall than those unaffected by dysphagia, noted Dr Walshe.

Dr Walshe said there has been “a lot of focus” on early screening for dysphagia. However, in terms of patient access to stroke unit rehabilitation, Ireland is “lagging way behind” many other developed countries.

The Burden of Stroke in Europe published in 2017 suggests  that less than 30 per cent of patients had access to a stroke unit. Furthermore, according to the report Irish Heart Foundation/HSE National Stroke Audit – Rehabilitation Units 2016, bed access to rehabilitation units was age-restricted for patients in almost half of sites surveyed, while only around 40 per cent of sites had a stroke specialist responsible for the management of stroke patients’ rehabilitation.

According to Dr Walshe, another major issue is lack of access to specialised care following discharge from acute services.

“We have a dysphagia centre  in Trinity where, with postgraduate students, we can see patients intensively. With intensive therapy – the patients doing exercises daily and we could see them for four-to-six weeks – they can return to oral feeding. So change is possible and it is even possible a long time after stroke.”

There is a huge unmet need in respect of early supported discharge for patients with dysphagia and a lack of access to speech and language therapy services in the community. 

“Some of  the acute hospitals in Ireland – including those  in the Dublin area – don’t have an outpatient speech and language therapy service, so [patients] go home and they get nothing if the community services can’t pick them up. They might have been on a thickened liquid diet in a hospital, and we see them a year or two later and they are still on a thickened liquid diet, and they no longer need to be. This is especially true for  people who have had a stroke or traumatic brain injury.”

Ireland’s only dysphagia research centre runs within the Department of Clinical Speech and Language Studies in Trinity College. The centre has a long history of clinical research in dysphagia, attracting international students to Trinity in order to develop specialist skills in swallowing disorders at a postgraduate level.

Speech and language therapists in Ireland are heavily involved in research around dysphagia, according to Dr Walshe, who feels the next step must be making these projects more multidisciplinary.

“In clinical practice, without a doubt, we have really good multidisciplinary teams; in our research [around dysphagia] we tend to be working in our silos a little more,” noted Dr Walshe.

She added that Dublin’s hosting of the ESSD conference should have a positive impact in this regard. 

The Congress heard the latest topical news and views on swallowing disorder research from national and international speakers.

The ESSD is the leading European forum for dysphagia research and is rapidly becoming one of the world’s foremost platforms for the dissemination of clinical dysphagia research.

Among the topics under special focus were approaches to managing aspiration; rehabilitation in dysphagia; new tools to assess swallow function; innovations in dysphagia assessment; interventions in chronic respiratory disease; dysphagia in chronic respiratory disease and dysphagia rehabilitation in critical care.

One-in-five people will develop heart failure (HF) in their lifetime. There are up to 90,000 people in Ireland living with HF and the estimated cost of the condition is €660 million per annum.

The Irish Heart Foundation has launched a new campaign, ‘Pay Attention to the Signs’, to raise awareness of HF symptoms. The campaign, supported by Novartis, aims to encourage those aged 50 and over to be aware of the signs of HF, as early detection of the symptoms can significantly improve a patient’s prognosis.

Swollen ankles, fatigue and shortness of breath are warning signs that should never be ignored in patients, according to the campaign.

Due to Ireland’s ageing population, the condition is set to increase dramatically, leading to a rise in HF hospitalisations of more than 50 per cent over the next 25 years.

Dr Angie Brown, Consultant Cardiologist and Medical Director, Irish Heart Foundation, said that HF can often go unnoticed because its symptoms come on gradually. “It’s easy to attribute tiredness to a busy lifestyle, and breathlessness to being out of shape. These are signs we need to watch out for.”

One-in-five people over 65 years presenting to their GP with breathlessness will have unrecognised HF, Dr Brown told the Medical Independent (MI). Furthermore, the incidence is expected to increase substantially over the next 30 years, but despite this, Ireland’s public awareness of the signs, symptoms and causes of HF is very low, she noted.

“This is why our campaign is aimed at the general public. In addition to the discussions on the radio, our campaign materials include posters, leaflets and a brochure; there is also information on our website or via the nurses helpline, 1800 25 25 50. Any GP can get in touch and receive the materials or download from our website [www.knowyourheart.ie].”

General practice

Dr Brown said it is important that GPs remain aware of how common HF is. She said that while GPs are well aware of HF symptoms, it can often be difficult to diagnose.

“Some of the main symptoms are breathlessness and fatigue, which are quite non-specific and can be due to other things, such as a chest infection or underlying lung disease, or even in some people due to deconditioning. It is therefore important to have a high index of suspicion, particularly in patients with risk factors such as ischaemic heart disease, hypertension, valve disease or diabetes. If  heart failure needs to be excluded, a blood test to measure the natriuretic peptides (BNP) is very useful, as it is elevated in heart failure. Patients can then be referred for an ECG, ECHO and specialist review.”

Dr Angie Brown

Once a diagnosis of HF has been made, the patient will be started on several types of medication (ACE inhibitors, beta-blockers, angiotensin receptor blockers (ARBs), hydralazine with nitrate, diuretics, aldosterone antagonists, sacubitril/valsartan, ivabradine and digoxin, etc) to improve the heart function, control blood pressure and heart rate, and remove any fluid from the lungs. These medications can improve symptoms as well as heart function and lower mortality. “Other treatment may be necessary, depending on the cause of heart failure — for instance, if it is due to a narrowed heart valve, this may need replacing, or if it is due to blocked heart arteries (ischaemic heart disease) then the patient may need a stent or a heart bypass. Some people may need a special sort of pacemaker. All of the treatment available now means that people’s symptoms and prognosis if they have heart failure has improved compared to years ago, when these weren’t available,” Dr Brown said.

Gender

Women often have different cardiac symptoms to men and can underplay their symptoms, Dr Brown noted. “Women are protected in part by their hormones but after the menopause, the risk of developing heart disease increases and catches up with men, so it is equally important for women to be investigated for heart failure if they present with fatigue, dyspnoea, swelling of the ankle [and] some may complain of ‘gasping’ or inability to lie flat in bed or wake up at night breathless. Some may have palpitations or dizzy spells.”

In summary, Dr Brown said it is important for everyone to be aware of their HF risk factors, “so to get blood pressure, cholesterol and blood sugar checked, try and keep to a healthy weight, eat a healthy diet, cut down on alcohol, stop smoking and if a person has breathlessness, fatigue or swollen ankles, that they get a check-up with their GP”.

Patient information meetings

The Irish Heart Foundation will hold two public information meetings on HF in the coming weeks. The meetings are suitable for people with HF and their families, healthcare staff and anyone with an interest in HF.

Waterford

The evening will feature talks by leading medical experts from University Hospital Waterford, including Consultant Cardiologist Dr Pat O’Callaghan, to increase awareness and understanding of the condition. The Foundation will launch a HF support group at this meeting.

Date: Thursday, 19 April.

Time: 6.30pm-9pm.

Location: Woodlands Hotel, Dunmore Road, Waterford.

Dublin

The evening will feature talks by leading medical experts from the Mater Hospital, Dublin, including Consultant Cardiologist Prof Niall Mahon, to increase awareness and understanding of the condition.

Date: Thursday, 12 April

Time: 6.30-9pm

Location: Ashling Hotel, Parkgate Street

Resources

The Irish Heart Foundation also runs a National Heart and Stroke Helpline staffed by specialist nurses. Freephone 1800 25 25 50, Monday to Friday, 9am-5pm. A range of patient support and information booklets are available at https://irishheart.ie/publications/.

Dr Neil Martin is a medical advisor to the world-class performance programme for British swimming and many other UK national teams and elite sports, and manages asthma for a number of international athletes and sports teams.

He attended medical school in Edinburgh before training as a chest physician through the UK’s Royal Navy in Edinburgh and served as a Medical Officer with the Royal Navy, where he developed specialist interests in diving medicine, submarine medicine and undertook a tour of Afghanistan.

Dr Martin started as a Consultant Physician in 2011 at the Glenfield Hospital, Leicester, where he continues to carry out clinical duties one day per week, while he also works for GSK’s Global Medical Expert Team of the Respiratory Franchise. He was in Ireland recently on behalf of the company to talk to respiratory physicians in a number of hospitals about treating refractory asthma and how to use the new anti-interleukin-5 (IL-5) biologics to do so.

In an interview with the Medical Independent (MI), he emphasised that having asthma should not prevent athletes from reaching their full potential, once properly managed, and that all patients should aim for optimum asthma management, whatever their circumstances.

“I think asthma in general is something we need to get better at managing. I think if we look at the last 10-to-15 years in the general asthma population, we have had good guidelines and good medications for asthma… but we have had no impact on the prevention of asthma deaths in the same time point, so we are at a bit of an impasse. We are making the same mistakes again and again and we are trying to push and develop better treatments for asthma patients but actually, fundamentally, we need to be making sure we are using the treatments we’ve actually got to the best of our abilities,” he said.

Compliance

Dr Martin noted that medication compliance is a key issue in optimum asthma management and that therapies must be as straightforward to use as possible.

“Patients’ adherence to medication is a big factor in terms of asthma control. How we structure asthma services and communicate to patients is another big factor. But I think in asthma in general, doing the basics well is what we need to do. So we have good guidelines and good medicines but what we need to do is translate those good guidelines into good clinical practice.

“The things we need to do are educate our clinicians better, so that is [in] primary care in terms of GPs and nursing staff, educate our patients better in terms of what the disease is and how we treat it, and really look at control as a key thing we concentrate on, so we want a control-centred approach.

“The last thing is to tackle non-adherence to asthma medication, because non-adherence to medication is by far one of the biggest risk factors for asthma deaths or serious exacerbations of asthma,” he told MI.

Dr Neil Martin

Dr Martin pointed out that while some children can ‘grow out’ of asthma in adolescence, “as an adult, growing out of your asthma is a rare thing. So asthma is a life-long condition. The challenge for asthma patients is that once they feel better, they stop taking their treatment and invariably, there will be a period of time where they are building up inflammation of their lungs, they have an exacerbation and they go back onto their treatment. People will continue to do that.

“The idea for patients is, feeling like you don’t have asthma is entirely what we are trying to achieve with your medicine, so the whole point is that we are trying to remove barriers to your daily life.

“When you talk to most asthma patients and you ask them ‘how’s your asthma?’ [They answer] ‘it’s fine’. But actually, when you ask them a structured question about control of their asthma, many of these patients will have poor control and the reason their control is poor is because they have adapted their lifestyle to their asthma.

“They’ve stopped doing things that will set-off their asthma symptoms. They no longer exercise, they no longer go into dusty environments, they don’t play with their grandkids, they don’t run around with their kids.

“So they adapt their life around poor asthma control and they think they are fine, that ‘well, I should be like this, I’ve got asthma’. But realistically, our goal of asthma treatment and the international guidelines is that you feel you don’t have asthma, and you feel you don’t have any side-effects from your medicines. And in many patients, that guideline-defined total control is possible. But we just need to get patients and doctors to understand that that is where we need to be… ”

Sports

In relation to asthma in sports, Dr Martin acknowledged that while there had been some concern over asthma medication and performance enhancement, the World Anti Doping Association (WADA) in 2012 decided that none of the asthma inhalers created performance advantage, that they “were standard asthma medications” and did not need therapeutic use exemptions, just a threshold for their use.

“Pretty much now most standard asthma medications you can use in competition without any significant paperwork and I think that is the right thing to do. Still, among children, talking about pre-school and infant school children, a diagnosis of asthma links into a life-long level of inactivity. So little kids running around getting wheezy and instead of effectively treating them, again they adapt their lifestyle.

“Parents, teachers — everyone is well-meaning but they limit what they do in case it might set-off their asthma. That generates into life-long physical inactivity. We have an obesity epidemic in adults anyway, and therefore those kids will go on to be less active adolescents and adults…

“What we need to be doing is maximising their treatments and allowing them to do what they like, and that is exactly what we do with athletes — we maximise the therapy that they require to allow them to continue to compete at the highest level, and that is what [all] asthma patients should be trying to achieve for themselves.”

Guidelines

Dr Martin also noted that the British Thoracic Society (BTS) guidelines on asthma had recently seen a major revision across a number of areas, including a significant update to the section on pharmacological management of asthma, and updates to the sections on supported self-management.

“The BTS guidelines last year moved to treatment with inhaled corticosteroids for six weeks, with a structured clinical assessment before and afterwards to try and assess asthma control… open-ended questions such as ‘how do you feel?’ are very ineffective in all areas of medicine… we need objective measurements, such as an asthma control score, evidence of lung function change, reduction in exacerbation frequency, so we need to move to that structured assessment for all patients,” which allows for a step-wise approach to management.

Some long-diagnosed asthmatics never gain proper control of their asthma, he pointed out, and this needs to be addressed, with a reassessment of their diagnosis vital.

“Einstein’s definition of insanity is doing the same thing over and over again, expecting a different result. So by the time you are on your fourth or fifth asthma medication and they haven’t got better, maybe we’re not treating asthma.”

Exacerbations for refractory patients are a significant issue and are costly, both economically and physically on the patient. So while working to reduce exacerbations has a cost, “it is cost-effective” as there are long-term savings.

About 5 per cent of asthma patients are refractory, which can be due to incorrect diagnosis, non-adherence to therapy or unsuitable therapy, or they may have a comorbid disease, Dr Martin explained.

Once a patient is determined to be truly refractory, however, there is now the option of biologic treatment, he outlined, describing it as “the dawn of a new era for respiratory medicine”.

New era

“It has been a very complex pathway [to biologic use] … with unmet need for patients with recurrent exacerbations and hospital admissions, some of them life-threatening admissions, driven by eosinophilic inflammation, and we have no effective therapy for that.”

He said the development of the anti-IL-5 agent mepolizumab, a humanised monoclonal antibody used for the treatment of severe eosinophilic asthma, for example, sought to address that.

“We are at the stage now where we have more and more biologics for asthma coming onto the market. We are probably a decade behind our rheumatology colleagues [regarding biologics]. I think we are, as a group of clinicians, cautious. We tend to look for things that are cost-effective. We don’t want to spend the taxpayer’s money unnecessarily, but I think there is a groundswell of opinion now that these biologic agents really are the answer for a lot of the complex things we’ve seen at the severe end of the asthma spectrum.”

It is hoped that anti-IL-5 therapy will finally be reimbursed for severe asthma in Ireland this year by the HSE. It has been available in many other European countries for a number of years, Dr Martin noted.

“I think there is certainly a need for anti-IL-5 therapy for patients in Ireland. The academic centres we have been to [in Ireland] have all expressed a desire to get going. They have patients who are waiting for treatment… ”

However, he acknowledged that healthcare budgets are under increasing pressure, “so there is a challenge there for us physicians to use the medicines correctly, there is a challenge for us to do the simple things well so the patients don’t necessarily need the complex medicines and there is a challenge back to the pharma industry to make things more cost-effective, to reduce the costs of medicines, so we have to work together to do that… the balance has to be right”.