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Irish Endocrine Society Annual Conference

Worse pregnancy outcomes in women treated for gestational diabetes at less than 24 weeks

A new study has determined poorer pregnancy outcomes occur in women treated for gestational diabetes at less than 24 weeks when compared to women diagnosed between 24 and 28 weeks’ gestation.

Titled ‘Gestational Diabetes (GDM <24 weeks) is Associated With Worse Pregnancy Outcomes Despite Early Treatment, When Compared with GDM Diagnosed at 24-28 Weeks’ Gestation’, the study from Galway Diabetes Research Centre, National University of Ireland, Galway, was presented by Mr Mustafa at the recent Irish Endocrine Society (IES) Annual Conference in Cork.

Mr Mustafa outlined that gestational diabetes is associated with more adverse pregnancy outcomes and that the World Health Organisation (WHO) recommends screening for the condition at 24-to-28 weeks’ gestation.

Gestational diabetes is increasing worldwide and it is known that treatment of gestational diabetes improves pregnancy outcomes.

The study aimed to examine the pregnancy outcomes of women diagnosed with gestational diabetes at less than 24 weeks, compared to those diagnosed between 24-to-28 weeks’ gestation in a large treated European cohort. A retrospective cohort study of more than 1,400 pregnancies was examined.

It was found that women with early (less than 24 weeks’) gestational diabetes had a higher BMI at diagnosis than women diagnosed between 24-to-28 weeks.

Women with early gestational diabetes are more likely to develop hypertensive disorder and have an operative delivery.

The study also revealed that stillbirths, preterm delivery and the need for neonatal unit care are more common in the babies of women with early gestational diabetes.

Women with early gestational diabetes were more likely to develop pre-eclampsia and post-partum haemorrhage compared to the other cohort of women diagnosed at a later stage.

Early gestational diabetes is common, at 19 per cent, Mr Mustafa said.

“In view of the greater number of early gestational diabetes women displaying abnormal OGTT [oral glucose tolerance test] post-partum, this may reflect a more advanced state along the pathway to diabetes,” the authors concluded.


Repeat newborn screening for congenital hypothyroidism in preterm infants

Two paediatric studies on the detection of congenital hypothyroidism (CHT) via newborn screening were highlighted at the IES inaugural paediatric symposium.

Dr Niamh McGrath, Consultant Paediatric Endocrinologist at Galway University Hospital, presented the first study, titled ‘Optimal Timing of Repeat Screening for Congenital Hypothyroidism in Preterm Infants to Detect Delayed TSH Elevation and Decompensated Congenital Hypothyroidism’.

Newborn screening for CHT has been in place since 1979 and has increased the rate of early detection and transformed outcomes for children with CHT, eradicating neurological complications, Dr McGrath said.

CHT is a preventable cause of severe neurodevelopmental disability. The reported incidence of CHT has significantly risen in Ireland in the last two decades.

Possible reasons for the rise include a lack of maternal iodine and/or environmental toxin and pentachlorophenol (PCP) exposure, Dr McGrath said.

The national newborn screening programme is run via Temple Street Children’s Hospital and the same thyroid stimulating hormone (TSH) cut-off point of eight and the same assay have been used in Ireland since the screening programme began, Dr McGrath said.

The atypical form of hypothyroidism is characterised by a delayed TSH elevation, such that preterm infants pass their first newborn screening test but are detected on repeat screening.

“The utility of second screening, its optimal timing and the optimal TSH cut-offs to be used remain subjects of active debate,” the authors state in the study.

Ireland has a relatively low cut-off point compared to other countries, Dr McGrath noted. CHT is detected in one-in-1,500 Irish children.

Ireland has been repeating screening in preterm infants for many years and is ahead of many other countries in this regard, Dr McGrath said.

Many preterm infants pass their first test but are then detected on a later test, but the best time to conduct a repeat screen is the subject of widespread debate.

The most recent consensus guidelines from the European Society of Paediatric Endocrinology in 2016 recommended repeat screening at two weeks of age or two weeks after their last screening result.

In Ireland, screening in preterm infants is repeated weekly until the infant is 36 weeks of corrected age or until they are discharged from hospital, Dr McGrath said.

The study reviewed the newborn screening records of all preterm infants with treated CHT between January 2004 and December 2016.

It found that 50 per cent of preterm infants born less than 33 weeks’ gestation who were diagnosed with CHT had delayed TSH elevation and would not have been detected on first newborn screen.

The study concluded that repeat screening for CHT in preterm infants is necessary to avoid missing cases of CHT with delayed TSH elevation.

“Current consensus guidelines to repeat screening once at two weeks of life will miss a significant number of infants with delayed TSH elevation and decompensated permanent CHT,” the authors stated.

Dr McGrath recommended, based on the study, that screening be conducted first, as usual, at between 72 and 120 hours, then at one week, two weeks, four weeks and at corrected term gestational age.

A separate but related study, also presented by Dr McGrath at the symposium, was titled ‘Permanent Decompensated Congenital Hypothyroidism in Newborns with Whole-blood TSH Concentrations Between Eight and 10mU/L — The Case for Lowering the Threshold’.


Hadden and McKenna lectures ‘highlight’ of IES meeting

A keynote lecture on the management of diabetes and therapeutic strategies, including first- and second-line options in type 2 diabetes management, was delivered by Prof Bernard Zinman, Mount Sinai Hospital and the University of Toronto, Canada. The Hadden Lecture, which is named after Prof David Hadden, who was one of the founders of the Irish Endocrine Society and who in 1998 was IES President, was titled, ‘The Impact of Recent CVOT on the Management of T2DM: Are We Ready for a Paradigm Shift?’

Prof Zinman is Professor of Medicine at the University of Toronto and the Stephen and Suzie Pustil Diabetes Research Scientist at the Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada.

Prof Zinman has authored more than 580 publications in national and international journals, and is among the top 1 per cent of researchers cited in the field of diabetes.

His main research interests include the long-term complications of diabetes mellitus, the development of new therapies for type 1 and type 2 diabetes, diabetes in Aboriginal communities, and studies directed at the prevention of diabetes.

Prof Zinman began his talk by outlining that individuals with type 2 diabetes have a decreased life expectancy of six years, which is greater if a person has had a cardiovascular event.

He noted that it “has been an incredible decade” since 2008, when the US Food and Drug Administration famously issued safety guidance, which expanded the scope and cost of research required for approval of drugs for type 2 diabetes by introducing the requirement for cardiovascular outcome trials (CVOTs).

This is because cardiovascular disease is prevalent in people with diabetes and a diabetes therapy that was believed to reduce cardiovascular events because it improved insulin resistance was actually associated with an increase in cardiovascular events, Prof Zinman said. He pointed out, however, that the meta-analysis used in the study was flawed.

Several CVOTs have been conducted since 2008 and Prof Zinman outlined that some have provided evidence of cardiovascular benefit and reductions in all-cause mortality.

He concluded by stating that huge progress had been made in the understanding of type 2 diabetes and in developing therapies that are associated with improved glucose control, no weight gain, less hyperglycaemia, and hopefully, better cardiovascular outcomes.

Dr Paula O’Shea, Consultant Clinical Biochemist and registered European Specialist in Clinical Chemistry and Laboratory Medicine (EuSpLM) based at Galway University Hospitals (GUH), delivered the IES McKenna Lecture.

She has more than 30 years’ experience in clinical laboratory science methodologies, practice and research, with over 40 publications in scientific and medical peer-reviewed journals, a PhD in clinical medicine awarded by Trinity College Dublin and is a Fellow of the Royal College of Pathologists United Kingdom (by examination). Her lecture was titled ‘Triumph in Testing Times’. She examined the total testing process by clinicians and the importance of laboratories in this process.

Dr O’Shea’s talk showcased collaborative research that led to significant service developments in the investigation of primary aldosteronism at GUH.

Research finds novel biomarker for pre-eclampsia in pregnant women

A presentation detailing a novel predictive biomarker for pre-eclampsia in pregnant women with diabetes was made at the IES meeting by Ms Alice Cheung.

Ms Cheung, a postgraduate research student at the Centre for Experimental Medicine, Queen’s University Belfast, noted that the pathophysiology of pre-eclampsia is still unclear.

Pre-eclampsia is characterised by hypertension and proteinuria that develops during pregnancy, usually after 20 weeks of gestation.

Diabetes is a risk factor for developing pre-eclampsia and the only cure is delivery of the baby.

Pregnant women with type 1 diabetes in particular have a four-fold increased risk of developing pre-eclampsia.

The condition can lead to maternal death and long-term complications for babies and women.

Ms Cheung noted there are already biomarkers used to detect pre-eclampsia on the market.

Her research looked at the biomarker Leucine-Rich alpha-2-Glycoprotein-1 (LRG1), a marker of inflammation and angiogenesis, and explored its role in pregnant women with type 1 diabetes.

The study examined 66 women — 23 with type 1 diabetes who developed pre-eclampsia, 24 women with type 1 diabetes who remained normotensive, and 19 healthy, non-diabetic women.

The two groups with type 1 diabetes were matched for age, duration of diabetes, HbA1c and parity and LRG1 was measured at each of the three trimesters.

The results showed that LRG1 protein levels were significantly increased in women with type 1 diabetes who subsequently developed pre-eclampsia compared to those who did not develop the condition.

“This significant increase preceded the clinical signs and symptoms of pre-eclampsia. LRG1 may therefore have utility as an early prediction of pre-eclampsia, and could provide novel insights into disease mechanisms for pre-eclampsia in diabetic women,” the study found.

Ms Cheung described the results as “very exciting and very promising” in helping to detect pre-eclampsia in diabetic patients.

“In conclusion, we can possibly use LRG1 as a diagnostic biomarker for pre-eclampsia in women with diabetes, specifically for diabetes. In the future, we are hoping to elucidate the potential mechanism in which LRG1 might be involved in pre-eclampsia in the hope to get a possible therapeutic intervention for pre-eclampsia,” Ms Cheung said.

Research collaborators also included centres in Australia, Norway and the US.

Broader conception of growth disorders needed

The recent Irish Endocrine Society meeting in Cork heard a presentation on ‘Growth Disorders in Puberty — Lessons to be Learnt from ACAN Deficiency and Other Genetic Growth Disorders’.  The talk was delivered by Prof Ola Nilsson, Professor of Endocrinology, Karolinska Institutet and University Hospital Stockholm, Sweden. Prof Nilsson is a leading international expert in growth disorders.

After he completed his MD, Prof Nilsson proceeded with research in the paediatric endocrinology field that resulted in the completion of his PhD thesis, titled ‘The Role of Oestrogen in Growth Plate Chondrogenesis’ in 2002. He performed post-doctoral research in the laboratory of Dr Jeffrey Baron, Section on Growth and Development, National Institute of Child Health and Development, National Institutes of Health (NIH), Bethesda, US. In 2006, Prof Nilsson received a junior faculty position at the Karolinska Institutet and started up his independent research group in parallel with a paediatric residency programme at the Karolinska University Hospital. After finalising his paediatric residency, he again relocated to the NIH in 2011 for clinical fellowship training in paediatric endocrinology in the NIH Inter-Institute Paediatric Endocrinology Training Programme. After completing his fellowship training, he accepted a position as an Associate Professor and Consultant in Paediatric Endocrinology at the Division of Paediatric Endocrinology at the Karolinska Institutet and University Hospital, Stockholm, Sweden. In 2015, Dr Nilsson was elected the Scientific Secretary of the Swedish Paediatric Society, and in 2016, was appointed Professor of Paediatrics at Örebro University, Sweden’s top-rated medical school. He is currently sharing his time between Örebro University and the Karolinska Institutet, working as a Senior Consultant in Paediatric Endocrinology and Professor of Paediatrics, heading a strong research group in the field of growth and skeletal biology. 

Prof Nilsson has published more than 50 journal articles related to skeletal biology and growth. He has authored several book chapters and organised international meetings and courses in paediatric endocrinology. He has served as Grant reviewer for: The Medical Research Council (MRC), UK; Shared Business Services (UKSBS), UK; the Israel Science Foundation, Israel; and the International Fund for Congenital Adrenal Hyperplasia, France. He is a member of the editorial boards for the Journal of Endocrinology, the Journal of Molecular Endocrinology, and ISRN Endocrinology, as well as an abstract reviewer for the annual meetings of the European Society for Paediatric Endocrinology (ESPE) and ad-hoc reviewer for several journals in the field, including Endocrinology and the Journal of Clinical Endocrinology and Metabolism.

He has been invited to serve as chairman and speaker at several international conferences, including at the European Society of Paediatric Endocrinology, Endocrine Society, European Growth Plate Workshop, International Paediatric Nephrology Association Symposia on Growth and Nutrition, and has received several awards in paediatric endocrinology, including the European Society of Paediatric Endocrinology’s Research Fellowship Award, the Ronald McDonald Children Foundation’s Award in Paediatric Medicine, and the Researcher Award from the Swedish Association of Endocrinologists. Prof Nilsson was the recipient of the Human Growth Foundation Award selected by the Paediatric Endocrine Society (formerly named the Lawson-Wilkins Paediatric Endocrine Society), both in 2013 and 2014.

In his presentation, Prof Nilsson spoke of how recent findings in basic molecular and cellular biology, clinical genetics and large-scale genomics have uncovered a vast array of regulatory systems that control skeletal growth and that can cause disorders of linear growth.

As a result, the traditional view of short or tall stature that is centered on the GH-IGF-I axis is now far too narrow to encompass the ever-growing number of defects that cause abnormal linear growth. A much broader conceptual framework can be based on the simple concept that linear growth disorders are necessarily due to dysfunction of the growth plate, the structure responsible for bone elongation and therefore overall body size. Consequently, short stature can more generally be conceptualised as a primary or secondary disorder of the growth plate chondrocytes. The wide array of defects, many newly-discovered, that affect growth plate chondrocyte function and thereby cause childhood growth disorders were reviewed in his talk, with special focus on Aggrecan deficiency, a newly-discovered short-stature syndrome with advanced bone age and early growth cessation.

Prof Nilsson stated that a novel concept that has emerged from recent findings is that sequence variants in a single gene can produce a phenotypic spectrum that ranges from a severe skeletal dysplasia to disproportionate or proportionate short stature, to normal variation in height, to tall stature. The recent advances reviewed in this paper are steadily diminishing the number of children who receive the unhelpful diagnosis of ‘idiopathic short stature’ or ‘tall stature’.


Lifetime achievement medal awarded to Prof Barry Ferriss

Prof Barry Ferriss, retired consultant from University College Cork and Cork University Hospital, was awarded a lifetime achievement medal by the Irish Endocrine Society (IES) at its 42nd annual meeting in Cork recently.

Prof Ferriss was recognised as one of the founders of the IES and for his long and distinguished services to endocrinology in Cork.

According to IES President Prof Finbarr O’Harte, Prof Ferriss was an excellent mentor to numerous endocrine and diabetes specialists.

The IES, founded in 1976, brings together clinical and basic science researchers from all over the island of Ireland.

At the meeting, 25 oral presentations were made and 150 posters were featured, highlighting the wide range of ongoing research in the field.

Dr Mary Jane Brassill, Consultant Physician based in South Tipperary General Hospital, was the local organiser for the Cork meeting.

Prof Finbarr O’Harte, a Professor of Endocrinology and Metabolism at Ulster University, Coleraine, Northern Ireland, stepped down from his role as IES President at the end of the 2018 IES meeting.

Prof O’Harte is replaced by Prof Brendan Kinsley, Consultant in Endocrinology at the Mater Misericordiae University Hospital, Dublin, and Coombe Women and Infants University Hospital, Dublin.  

Prof Kinsley is a native of Cork city and has an interest in diabetes mellitus and endocrine disorders in pregnancy, autonomic dysfunction in diabetes and hypoglycaemia. He will take on the role of IES President for the next three years.

The IES Annual Study day in endocrinology and diabetes will take place on 1 February 2019 at the RCPI in Dublin.

The next IES Annual meeting will be held in Galway on 10-11 October 2019. The local organiser will be Dr Marcia Bell.

Inaugural IES Paediatric Symposium held at Cork meeting

The inaugural IES Paediatric Medal was awarded to Dr David Kinlen for his presentation titled ‘Childhood Obesity Causes Dysregulation of MAIT Cells and Monocytes Driving Production of Cytokines Linked to Insulin Resistance’.

Dr Kinlen is based at the Obesity Immunology Group, Education and Research Centre, St Vincent’s University Hospital, University College Dublin. 

The research examined the problem of obesity in Ireland. Dr Kinlen outlined to delegates that around 25 per cent of Irish children are overweight or obese.

Obese children have higher infection rates, a higher risk of developing cancer as adults and poorer vaccine responses, Dr Kinlen said.

They are also at risk of developing insulin resistance and in time, type 2 diabetes. Inflammation and immune dysregulation are believed to be key players in this process, he added.

The research aimed to examine this dysregulation and following the collection of blood samples from 33 lean and 51 obese children, it was confirmed that interleukin (IL)-17A-producing MAIT cells are more abundant in obese children than in lean children.

The study spanned two years and children aged between six and 18 years were included. Serum factors associated with increased IL-17A were examined and it was found that soluble CD163, a marker for inflammatory myeloid cells, was increased in obese children.

An investigation was subsequently conducted on myeloid cytokine production, which revealed IL-1β was also elevated in obese children. Through selective removal of monocytes, the researchers also showed MAIT cell IL-17A production is dependent on monocyte cross-talk.

The researchers concluded childhood obesity drives dysregulation in monocytes, which then contribute to MAIT cell dysregulation.

IES Meeting winners

Three research grants were awarded at the IES annual meeting, with winners taking away grants worth €15,000 each.

The Clinical Sciences Award was presented to Dr Julie Martin Grace, Beaumont Hospital, Dublin, for her project titled, ‘Impact of Inhaled Glucocorticoids on Adrenal Function’.

The IES Basic Sciences Award was presented to Dr Fiona McGillicuddy of University College Dublin, who works with Prof James Gibney, Tallaght University Hospital, Dublin, for her project titled, ‘High-density Lipoprotein Particles as Metabolic ‘Hormones’ — Does Diabetes Alter the Signalling Pathways Induced by These Particles to Increase Cardiovascular Risk?’

The third grant was given to Dr David Kinlen for his presentation, ‘Childhood Obesity Causes Dysregulation of MAIT Cells and Monocytes Driving Production of Cytokines Linked to Insulin Resistance’.

Meanwhile, the O’Donovan Medal for Best Oral Presentation was awarded to Dr Tómas  Griffin, Galway University Hospital.

His presentation was titled ‘Defining Reference Intervals for a Plasma Dephosphorylated-Uncarboxylated form of Matrix Gla-Protein Assay in a Caucasian Population and its Utility in Diabetic Kidney Disease.’ The study aimed to explore the potential utility of the dephosphorylated-uncarboxylated form of Matrix Gla Protein (dp-ucMGP) in diabetic kidney disease in an Irish caucasian population.

The study concluded that “Dp-ucMGP distinguishes patients with moderate/severe DKD from healthy volunteers and patients with no/mild DKD. This may reflect increased risk of vascular calcification that occurs as renal function declines.”

The Montgomery Prize for Best Poster was awarded to Dr Ultan Healy, Connolly Hospital, Blanchardstown.

The poster was titled ‘Circadian Rhythm Disturbance, as Indicated by Increased Night-Time Activity, is Associated with Higher BMI in Subjects with Type 2 Diabetes Mellitus’.

The research noted that circadian rhythm synchronises various metabolic processes but disruption to this rhythm has been shown to have deleterious metabolic consequences.

The study concluded that “subjects with T2DM are more prone than control subjects to circadian disruption. This could have an adverse outcome on glycaemic control”.

The winning posters for case studies were as follows: 

Dr Mark Quinn, for his case, ‘A Remarkable Case of Thyrotoxicosis Initially Caused by Graves Disease Followed by a TSH-oma’, and Dr Julia Iona, for her case, ‘Type 1 Diabetes due to Treatment with Anti-Programmed Cell Death-1 Antibodies: A Case Report’.

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Irish Cardiac Society Annual Scientific Meeting and AGM

Some physicians staying abroad is ‘the price we pay’ for top-class Irish cardiologists — new ICS President

The incoming Irish Cardiac Society (ICS) President Dr Jim Crowley has said that the chance that cardiologists in training may not return to Ireland is “the price we pay” for the high levels of expertise among Irish cardiologists.

Speaking to the Medical Independent (MI) at the recent Irish Cardiac Society Annual Scientific Meeting and AGM in Galway, Dr Crowley explained that while some cardiologists who travel abroad in their final two years of training may decide not to come back to Ireland, this is a necessary risk to allow the cardiologists of the future to provide the best services for Irish patients.

“Almost every one of our trainees ends up going to world-class centres abroad in the last two years of their training,” he said. “When they are trained, they have developed the expertise that we hope they will bring back to Ireland. Many of them do come back; some of them remain in other countries, but that is the price we pay for getting people of such excellent quality coming home and bringing back the superb skills that they acquire.”

This system has a significant positive knock-on effect for the Irish health service as a whole, he explained. “A lot of the growth and the advances in cardiology in Ireland have come from these trainees bringing back what they have seen and learned abroad in these world-class centres and insisting on developments occurring in Ireland, which makes sure the general population is treated with the best techniques and technologies,” he told MI.

Describing trainee placements as a “double-edged sword”, he continued: “Ireland is a very small country… we want our trainees to learn in the best centres in the world. We find that the feedback we get from these centres — I am one of the trainers myself — is that they are delighted with the Irish [trainees] that they receive and they say that the training the Irish people have received in basic cardiology and management is top class, so they are also very happy to take them in.”

The risk is that the centres abroad will want to hire Irish trainees as consultants. Yet many Irish cardiologists retain a desire to return home, especially to the larger care centres, said Dr Crowley. “However, in some of the facilities that are not tertiary referral centres, it can be difficult to come back to those centres because they have been trained to such a high level; we may need to look at that in terms of modifying the training programmes.”

Dr Crowley said that for the next two years of his tenure as President, among his priorities will be to maintain the momentum the ICS has built up and to expand contacts at international level with organisations abroad, particularly with the European Society of Cardiology and the American College of Cardiology, among others. “We already have close relationships with these bodies and these must continue to be fostered,” he said. “Many of the representatives from these societies want to come to our meetings. We must also continue to foster developments for our trainees.”

In terms of the ICS’s prestige internationally, he lauded outgoing President Dr Albert McNeill for his work in this area: “He has been a great ambassador for the ICS abroad. This is a very important role for the President and it helps to improve access for trainees to centres abroad, which is very important for them.” 

Meeting hears ‘sobering overview’ of cardiac imaging in Ireland

A presentation at the recent Irish Cardiac Society (ICS) Annual Scientific Meeting and AGM provided a thought-provoking overview of the provision of cardiac imaging in Ireland and how this aspect of care faces multiple deficits.

Dr Caroline Daly, Cardiologist at St James’s Hospital, Dublin, told attendees that there is an “unmet need” in this field, in particular ECHO, cardiac CT and cardiac MRI, where there are “the greatest gaps in our service that we need to fill,” Dr Daly told the conference.

“We need to look at what is required in providing these services, such as the equipment — part of the problem is the initial installation cost; ECHO is obviously relatively cheap compared to CT or cardiac MRI, but nonetheless it requires a robust system of image storage, analysis and reporting software, which needs to be updated and maintained as time goes on,” said Dr Daly.

“We must also consider that the digital storage management systems involved in having a comprehensive solution for your cardiac imaging needs are costly. Furthermore, you need technical staff, and that is perhaps an issue that we are really grappling with at the moment in terms of sonographers and specialist radiographers — certainly in Dublin, it has been apparent that a relatively limited number of graduates from Kevin Street [Dublin Institute of Technology] over the last number of years have chosen cardiology as their subspecialist area of interest; they have perhaps chosen respiratory clinical measurement or urology, and that has made it difficult to create a new ‘pool’ of sonographers providing ECHO services,” according to Dr Daly.

She said that last year, some cardiac units “almost ground to a halt” because of the limited number of radiographers and the delays in having trained radiographers accredited with their respective professional bodies. “And that’s before we even get to the issue of cardiologists and the radiologists, and how they communicate with each other,” she added.

Dr Daly referred to the lack of data to accurately assess the specific gaps in ECHO services, despite the best efforts of the Irish Heart Foundation and ICS. However, she cited services in the UK as providing the best statements on what the optimal service should be.

Dr Daly told the attendees that based on a 1995 report, it was estimated that between 42,000-to-47,000 transgraphic ECHOs were required per million population in Ireland per annum, and around 2,000 per million population of transesophageal echocardiograms were required.

“With some ‘back-of-an-envelope’ calculations, I would say we are doing between — generously — one-half, and less generously one-tenth, of those numbers per million population,” Dr Daly told the attendees. “In terms of staffing levels, that report suggested we should have about 30 stenographers per million population; we certainly don’t have that in Ireland, even if you combine public and private sectors. Consultants specialising in ECHO — 10-to-13 per million population [was recommended]; again, we are nowhere near that.”

She pointed to the paradox that waiting times are actually higher in regions where there are more sonographers and higher throughputs, which reflects the differences in unmet demand.

 “So you won’t have a waiting list if the referrers don’t know what the service is or what they can expect to have from it,” she said. “So paradoxically, there is such an unmet demand for ECHO in places that are under-served, if you put more ECHO technicians in and put a service in place, you will actually initially have longer waiting lists until that backlog has been dealt with.”

Other factors that influence capacity and utilisation are demographics and appropriateness of referral, she added.

At the moment, there is an ongoing national review of specialist cardiac services in Ireland, which is focusing on acute cardiac syndromes, heart failure and cardiac arrhythmias, and “it is important that we include our imaging requirements [in the review] that pertain to all of these three,” said Dr Daly. “Imaging affects all of those, be it for structural heart disease, preparation for valve implantation, dealing with rare diseases, or cardiac risk in the young, so we really need to make the case strongly to that specialist review.”

The lack of services is probably greatest in CT and MRI, she said, and Dr Daly cited NIMIS as a source of data. “There are very small numbers there; obviously, that doesn’t include the private hospitals or certain centres… but the numbers are very small [in most of the NIMIS hospitals],” said Dr Daly, who also referred to NICE guidelines in 2016 that emphasised the need for cardiac CT and angiography as an initial test required for chest pain.

The SCOT-HEART study published this year also showed that early use of CT is useful in preventing myocardial infarctions by instituting earlier treatment. This leaves Ireland with “a great challenge ahead of us in providing this level of service for patients, but the data is there to show it is beneficial,” said Dr Daly.

“In Ireland, we have no dedicated cardiac MRIs in the public sector,” continued Dr Daly. “That excludes St Vincent’s and Cork, where they do have a cardiac MRI service, but the numbers in need of those services are so large that it would skew the data… we are saved slightly, in that there are active centres in the private sector and if possible, we can purchase on order a number of cardiac MRI for public patients… we have increased our numbers in St James’s Hospital but those numbers pale in comparison to what you would have if there was a dedicated magnet just doing only cardiac MRI, so we are always on the back-foot.”

Dr Daly concluded: “This is a very sobering overview of where we are with cardiac MRI services… our numbers need to be developed — and rapidly.”

Reducing the risk of cardiovascular disease by lowering lipids

The recent Irish Cardiac Society (ICS) Annual Scientific Meeting and AGM heard from Prof Chris Packard, Professor of Vascular Biochemistry and Senior Research Fellow at the University of Glasgow, UK, who addressed the attendees on the topic ‘Horizons in Lipid-Lowering Therapy’.

Prof Packard traced the history of lipid therapy, where “we have seen fashions come and go. He stated: “Just last week, we got some results from the REDUCE-IT study in triglyceride-lowering [therapy]… after several somewhat depressing years of HDL-raising trials, the horizon actually looks quite nice at the moment; the vista is very good.”

He asked the conference: “LDL cholesterol and its association with atherosclerosis — are we in the end-game; have we reached the end of that story? And if that’s the case, what are the new targets and therapeutic approaches that we can look forward to in the next five-to-10 years to give cardiologists new tools in preventing coronary disease?”

He told the attendees that there is a coalescence of evidence to show that LDL cholesterol is the “smoking gun” in the development of atherosclerosis. He pointed out: “Where it [cholesterol] goes is important; it can end up in the wrong places, such as in the artery wall, where it can build up for decades.

“Lipid-lowering is like blood pressure-lowering — there’s a host of evidence to support our use of drugs and there are some exciting genomic findings that give us extra therapeutic potential,” he said, displaying slides to illustrate progression lines to the conference. “The trials tell us that if you reduce LDL by 1mmol/l, you reduce cardiovascular disease risk by 22 per cent. That’s a good rule of thumb — if you are sitting with a patient and you see the lab result come back 1mmol/l lower, that patient is better off; a 2mmol/l reduction will reduce the risk by approximately 40 per cent, and so it goes on.”

Prof Packard explained that there are between 30 and 40 genes that affect LDL — such as PCSK9, apolipoprotein B and sortilin — and these are the “strongest markers”, he said. “When you look at these genes and know that they lower LDL cholesterol, and if you have one variant that lowers LDL compared to another variant that raises it, you then look at the cholesterol-lowering variant and the risk in people who have that variant — you know their risk [of cardiovascular disease] is lower,” said Prof Packard. “This is part of the genetic underpinning for the causation of LDL cholesterol and atherosclerosis. If a person has a disease like familial hypercholesterolaemia (FH), the risk goes up manifold.”

Prof Packard presented a range of data and slides to illustrate that regardless of the genetic risk factors for raised LDL cholesterol, if a reduction is achieved, genetically or pharmacologically, a similar risk reduction is also observed. “However, if you have the right genetics, a 1mmol/l drop in LDL from birth gives you a 54 per cent risk reduction. The earlier we can lower the LDL, the bigger the impact on risk.”

With regard to treatment strategies in clinical practice, Prof Packard told the conference: “PCSK9 inhibitors are now being widely used for secondary prevention… for a PCSK9 inhibitor, you need to have a high risk to qualify for their use and it is now being used more and more. In some countries, it is only used for FH, but in other countries, it can be used in high-risk individuals and these people get a benefit, as shown by the analysis in the FOURIER trial in those who have had multiple events, those who have had a recent myocardial infarction, patients with peripheral artery disease, with multi-vessel disease and patients with diabetes… you get big risk reductions, small numbers needed to treat, and therefore you are moving into a cost-effective scenario with regard to the use of PCSK9 inhibitors.”

He concluded by telling the attendees that “profound risk reduction” is possible with little or no risk to the patient and it is important to consider LDL exposure in terms of how long LDL has been at a certain level. Knowing this will enable a strategy for primary prevention, he said. “Better genetics and biomarkers will be the clue to more intelligent primary and secondary prevention and more effective lipid-lowering,” he summarised.

Study on AF wins Young Investigator Award

The prestigious Brian Maurer Young Investigator Award, presented at the recent Irish Cardiac Society Annual Scientific Meeting and AGM in Galway, was won by Dr Alan Hanley — who recently received his certificate of satisfactory completion of specialist training — for his presentation titled ‘The Role of ZFHX3 in Atrial Fibrillation (AF).

Dr Hanley and colleagues sought to identify the role of ZFHX3 in the pathophysiology of AF and hypothesised that cardiac-restricted knock-down of this gene in a mammalian model organism would perturb normal cardiac development and function, and illuminate the role of ZFHX3 in AF.

Knock-down was confirmed by organ specific genotyping, said Dr Hanley, and among the study mice, increased inducibility of atrial arrhythmias was observed at in vivo electrophysiology testing when the mice were three months old.

Cardiac structure and function was normal in the knock-down mice at three months, the researchers observed, and premature mortality was noted. MRI revealed severe cardiomyopathy prior to death, with impaired left ventricular function and atrial enlargement. The histology of the affected hearts revealed severely dilated and fibrosed atria containing a large mass consistent with thrombus, the team reported.

Immunofluorescence of mouse hearts from early embryonic to adult stages confirmed cardiac expression of ZFHX3, with a marked atrial predominance, Dr Hanley told the conference.

In his conclusion, Dr Hanley explained: “We have uncovered a role for ZFHX3 in the left-right patterning of cardiac atria. Disruption of this developmental process predisposes to atrial cardiomyopathy, affects atrial electrophysiology properties, and may lead to AF.”

The history and contributions to treatment of arrhythmias and syncope

The Irish Cardiac Society (ICS) Annual Stokes Lecture was this year delivered by Dr Janet McComb, Consultant Cardiologist at the Freeman Hospital in Newcastle, UK, on the topic of ‘Stokes, Adams, Ward and Many Others: Arrhythmias and Syncope’. Dr McComb’s talk was warmly received by delegates, who heard about the historical importance of the work of Prof Robert Adams, a pioneering surgeon in the 1800s, and she presented a number of case studies to illustrate the treatment methodologies at that time.

Dr McComb also outlined some of the work of Prof William Stokes, including historical case studies in patients with recurrent syncope and suspicious cardiac pathologies that, even at that time, “presented red-flags for cardiovascular disease,” Dr McComb told the packed auditorium. This early work formed the genesis of diagnostic criteria for Stokes-Adams Disease, she told the attendees.

She also provided a brief outline of the work of Prof Conor Ward, who made many significant contributions to the field of paediatric cardiology. “Prof Ward was called ‘an irrepressible advocate for patients’, which I think is a lovely and fitting tribute and must be one of the highest compliments that can be given in medicine,” Dr McComb told the meeting.

She also outlined the early diagnostic and trial-and-error nature of historical pharmacological treatments for arrhythmias and syncope and the early identification of familial syndromes.

“Adams attacks were originally described as attacks of recurrent syncope with little or no warning, possible injury, quick recovery and profound bradycardia. AV [atrioventricular] block was shown and that was assumed to be the only mechanism. Subsequently, however, other arrhythmias — particularly sinus arrest, self-terminating ventricular tachycardia and/or fibrillation — were shown to cause identical symptoms,” she explained.

Dr McComb also traced the development of early pacemaker implantation and displayed the large size and cumbersome nature of these devices, which presented unique challenges to cardiologists at the time of their introduction, and the learning process for physicians implanting them. Dr McComb herself, who trained in Belfast, was one of the physicians who pioneered the use of these devices.

“The original description of Stokes-Adams attacks — made by Stokes, and before him Adams, and before him others almost 200 years ago — still stands,” Dr McComb concluded. “More recently, about 100 years ago, it was recognised that arrhythmias other than heart block can cause these attacks and whether we continue to call them ‘Stokes-Adams attacks’ or ‘arrhythmic syncope’, I don’t know. We shouldn’t just call them ‘cardiac syncope’, because obviously other things related to the heart, such as obstruction, can cause cardiac syncope.

“It is our role to teach and train those who treat patients with syncope to recognise cardiac syncope, and in particular arrhythmic syncope, and to encourage early referral for specialist advice to ensure equity of access to appropriate investigation and therapy.”

Expertise without borders in cardiology

The International Session of the Irish Cardiac Society Scientific Meeting and AGM, held recently in Galway, heard lively and informative presentations from Dr C Michael Valentine of the American College of Cardiology; Prof Pepe Zamorano of the European Society of Cardiology; and Prof Nick Linker from the British Cardiovascular Society.

Dr Valentine presented a case study on ‘Secondary Prevention in Acute Cardiac Syndrome’. At the end of each presenter’s talk, attendees were invited to participate via an electronic voting system that allowed them to indicate what treatment course they would pursue for each patient in the case studies.

Dr Valentine’s case study focused on a 76-year-old patient with complex comorbidities, including permanent atrial fibrillation with rate control on oral anticoagulants, who recently suffered a small, non-Q wave myocardial infarction. She had received a long drug-eluting stent, had moderate diffuse disease in her right coronary artery descending from the left anterior descending artery, and was taking a number of different medications.

Following voting by participants, Dr Valentine explained that considering the patient’s particular circumstances and medications, ischaemia must be balanced against bleeding risk, which could be significantly reduced by removing one anticoagulant or antiplatelet therapy. 

“The take-home message is, double-therapy leads to less bleeding than triple-therapy,” said Dr Valentine. “If you look at three different trials of almost 3,000 patients, there is no increased risk of stent thrombosis; you therefore have the ability to switch to double-therapy [from triple-therapy] with a fairly low risk, so triple-therapy should be kept as short as possible — at between one-to-six months. Use PPI [proton pump inhibitors] to protect against bleeding risk and after one year, stop all antiplatelet therapy and continue on oral anticoagulants with permanent atrial fibrillation in this patient.”

However, he added a cautionary note on depression in these patients. “There is a greater risk of depression after acute coronary syndrome,” said Dr Valentine. “It leads to lower compliance, worse outcomes, and screening results are uncertain for outcome improvements… we are now screening all of our patients in our clinics for depression and getting help for those who need it. It is leading to better medications compliance.”

He urged the attendees to consider depression screening in heart failure patients and for those in difficult social circumstances to improve medications compliance and enhance overall quality-of-life among this patient cohort.

Dr Zamorano presented the case of a 42-year-old male who was overweight, had hypertension, a history of tobacco use, had undergone a cobalt prosthetic hip replacement, and had a range of other comorbidities and risk factors for cardiovascular disease. He reported experiencing shortness of breath within the past two weeks. A further two weeks after presenting, the patient entered cardiogenic shock and developed acute heart failure with instability and extremely elevated levels of cobalt.

The cobalt-based hip prosthesis was removed and replaced with a ceramic one.  Prominent, delayed enhancement in the lateral cardiac wall is very common in cases of cobalt cardiomyopathy, explained Dr Zamorano.

“ECHO definitely helps in such cases,” he told the attendees. “But don’t forget, ECHO has no brain — you will need to use your own in order to clearly identify the course of treatment in such cases.”

Dr Linker concluded the session by presenting the case of a patient for whom there is little trial data to support a treatment course and therefore, the attendees were challenged to use their clinical judgement alone. The patient was female, born in 1970, who experienced two brief instances of syncope in 1996 but was discharged from hospital. On further investigation, it was discovered that her father had an implantable cardiac device (ICD) inserted in 1992 after being diagnosed with idiopathic ventricular tachycardia fibrillation.

Following a complex treatment pathway for both the lady in the case study and her father, as well as thorough investigation of her family history, an electrophysiology study was conducted on the lady and Brugada syndrome was ruled out.

In 2001, the lady was asymptomatic but experienced two more instances of syncope and polymorphic complications and her examination made physicians more suspicious that Brugada syndrome may in fact be the correct diagnosis. Prof Linker then installed an ICD. “Bear in mind, people with ICDs still die from sudden cardiac death; there is still an incidence,” cautioned Prof Linker, “and people with channelopathies [such as Brugada syndrome] tend to die more frequently from sudden death related to ventricular arrhythmias. ICDs do not provide a guarantee for these patients.”

In 2005, the woman, who by that time had two children aged 12 and 13 years — one of whom was asymptomatic and both of whom had normal ECGs — visited Dr Linker and insisted that both children be fitted with ICDs. After he refused, he later received a letter from a paediatric cardiologist, asking him to assume care of the lady’s two children, who had by now been fitted with subpectoral ICDs without Dr Linker’s knowledge.

The lady is now symptom-free but Dr Linker said he is due to meet her to discuss a strategy to replace or repair a failing ICD lead, he explained. This may be complicated by the fact that the lady is petite and thin, with a small subclavian vein. “There is no right or wrong way to approach this ICD problem with the lead,” Dr Linker concluded. “A lot will depend on what the patient herself will want to do.”

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Irish Endocrine Society Annual Meeting 19-20 October 2018

The present and future of endocrinology

The 42nd Annual Meeting of the Irish Endocrine Society (IES) will take place in the Clayton Hotel, Cork, on 19-20 October. As usual, the meeting will feature a mix of the best international and national research in endocrinology from both clinicians and clinical scientists.

At the Paediatric Symposium, which is taking place on the Friday morning, Prof Ola Nilsson, Professor of Endocrinology, Karolinska Institute and University Hospital Stockholm, Sweden, will deliver a talk titled  ‘Growth disorders in puberty — lessons to be learnt from ACAN deficiency and other genetic growth disorders’.

The ACAN gene provides instructions for making the aggrecan protein, which is known as a proteoglycan.

According to the US National Library of Medicine, aggrecan attaches to the other components of cartilage, organising the network of molecules that gives cartilage its strength. These interactions occur at a specific region of the aggrecan protein called the C-type lectin domain (CLD). Aggrecan attracts water molecules and gives cartilage its structure as a result of the attached sugars. This feature enables the cartilage to resist compression, protecting bones and joints.

Although its role is unclear, aggrecan affects bone development. The US National Library of Medicine describes two conditions associated with short stature: Spondyloepimetaphyseal dysplasia, aggrecan-type; and spondyloepiphyseal dysplasia, Kimberley-type, which are caused by mutations in the ACAN gene. People with spondyloepimetaphyseal dysplasia, aggrecan-type, have extremely short stature, short fingers and toes, and distinctive facial features. This condition is caused by a mutation that changes the amino acid at position 2,267 in the aggrecan protein from aspartic acid to asparagine (Asp2267Asn or D2267N). The amino acid change, which occurs in the CLD, alters aggrecan’s interaction with at least one component of the cartilage network.

Spondyloepiphyseal dysplasia, Kimberley-type, is characterised by short stature and early development of osteoarthritis, particularly in the knees, ankles and hips. This condition is caused by a mutation in which a single DNA building block is inserted into the ACAN gene, which could disrupt the gene’s instructions and lead to the production of an abnormally short aggrecan protein that is missing the CLD.

Prof Nilsson is sure to provide an insight into the relationship between the ACAN gene and growth disorders.

IES Hadden Lecture and McKenna Lecture

The Hadden Lecture, which is always delivered by an international expert, will be given by Prof Bernard Zinman, Mount Sinai Hospital and the University of Toronto, Canada. Prof Zinman, a clinician-scientist at Mount Sinai, is a recognised leader in the field of diabetes. His research focuses on the prevention of the long-term complications of diabetes, new treatments for diabetes, and diabetes in high-risk populations. His research holds promise for increased understanding of how to deal with this growing, global epidemic.

For more than 25 years, Prof  Zinman has played a key role in the Diabetes Control and Complications Trial, the largest and most comprehensive diabetes complications study ever conducted in type 1 diabetes. This pivotal study demonstrated that keeping blood glucose levels as close to normal as possible slows the onset and progression of eye, kidney, and nerve complications caused by diabetes. One of the most cited diabetes studies in the world, this study had a global impact on treatment of type 1 diabetes patients and the occurrence of complications.

Prof Zinman is Director of the Leadership Sinai Centre for Diabetes, a unique, multidisciplinary outpatient unit that is one of the largest diabetes clinical research units in Ontario. Under his leadership, the Centre integrates clinical practice, research and education for those with diabetes and their families.

The title of his talk is ‘The impact of recent CVOT on the management of type 2 diabetes: Are we ready for a paradigm shift?’ In December 2008, the US Food and Drug Administration issued guidance to the pharmaceutical industry setting new expectations for the development of anti-diabetes drugs for type 2 diabetes. The FDA was responding to prevailing concerns about the potential for increased CVD risk associated with certain anti-diabetes drugs.

This guidance expanded the scope and cost of research necessary for approval of such drugs by mandating long-term cardiovascular outcomes trials (CVOTs) for safety. Since 2008, nine CVOTs have been reported, 13 are under way, and four have been terminated. As of the beginning of this year, each of the completed trials demonstrated the non-inferiority of their respective drugs to placebo for their primary cardiovascular (CV) composite end-point. Notably, four additionally provided evidence of CV benefit in the form of significant decreases in the primary CV composite end-point, two suggested reductions in CV death, and three suggested reductions in all-cause mortality.

Dr Paula O’Shea, Consultant Clinical Biochemist, Galway University Hospital, will deliver the McKenna Lecture. She has more than 30 years experience in clinical laboratory science methodologies, practice and research, with over 40 publications in scientific and medical peer-reviewed journals, a PhD in clinical medicine awarded by Trinity College Dublin and is a Fellow of the Royal College of Pathologists United Kingdom (by examination). She was recently awarded the Professional Diploma in Professional Regulation undertaken at the Peter Sutherland School of Law, University College Dublin. She is a past-president of the Association of Clinical Biochemists in Ireland (ACBI) and current member of its Council and Scientific Committee.

The title of Dr O’Shea’s talk will be ‘Triumph in testing times’. This talk will highlight the importance of clinical biochemistry and interdisciplinary working to the patient journey and will showcase collaborative research that led to significant service developments in the investigation of primary aldosteronism at GUH.

Oral presentations

The meeting will also hear presentations from clinicians on the best research in endocrinology currently taking place across the island of Ireland. These presentations will be delivered by both clinicians and clinical scientists.

One anticipated presentation, based on research from the Galway Diabetes Research Centre, examines whether gestational diabetes (GDM) diagnosed before 24 weeks is associated with worse pregnancy outcomes despite early treatment, when compared with GDM diagnosed at 24-to-28 weeks’ gestation. For the study, a retrospective cohort study was carried out of 1,471 pregnancies from women with GDM diagnosed using IADPSG (International Association of the Diabetes and Pregnancy Study Groups) criteria.

Another presentation on GDM will examine ‘Predictor factors of hypertension induced in pregnancy in women with gestational diabetes mellitus’. GDM is associated with an increased risk of pregnancy-induced hypertension (PIH). Ambulatory blood pressure monitoring (ABPM) has been used to screen for PIH and pre-eclampsia. Currently, little is known in GDM about the role of inflammatory biomarkers in PIH development and their impact on perinatal morbidity. With this study, the aim was to identify in women with GDM inflammatory markers and BP profiles (detected by ABPM) that could define a population at higher risk of developing PIH and pre-eclampsia.

Presentations will be delivered on a range of other subjects, including: Microwave ablation of the adrenal gland for treatment of functioning adrenocortical tumours; the effect of sodium glucose co-transporter-2 inhibition on the aldosterone/renin ratio in type 2 diabetes mellitus; and an examination of galectin-3 levels in lean and obese adults and children.

At the end of the meeting, the presentation of Irish Endocrine Society O’Donovan Medal will be made for the Best Oral Presentation, along with the Montgomery Medal for Best Poster Presentation.

IES Summer Student Award Presentations

The IES Summer Student Award Presentations see other presentations on interesting endocrinology-related research. This year, the presentations are as follows: ‘The impact of diabetes mellitus on bone marrow progenitor cell number and proliferative capacity’ (Mr Alan Keane, Galway University Hospital); ‘Does diabetic ketoacidosis at diagnosis of T1DM predict poor long-term glycaemic control?’ (Ms Louise Kelly, University College Cork); and ‘Phenotype, genotype and glycaemic variability in subjects with activating mutations in the ABCC8 gene’ (Ms Fionnuala Reilly, University College Dublin).

All in all, the meeting promises to offer a fascinating perspective on the current state of research in endocrinology.

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Irish Society of Rheumatology Annual Meeting 2018

Record-breaking attendance and leading international and national scientific updates

A record 225 delegates attended this year’s 2018 Irish Society for Rheumatology (ISR) Autumn Meeting in Naas on 19-21 September.

The meeting featured leading international speakers on a range of rheumatic-related topics, covering genetics and genomics, metabolic aspects of spondyloarthritis, early detection of psoriatic arthritis, mechanical stress and effects on MRI and the care of rheumatic patients pre and peripartum, as well as an expanded programme of Irish research presentations.

Speaking to the Medical Independent (MI), ISR President Dr Sinead Harney thanked her colleagues Dr John Ryan and Dr Grainne Murphy for helping her put together the varied and interesting programme.

“The Society is going from strength-to-strength. This was our biggest meeting to date, with 225 participants, and I think the venue and central location meant that all parts of Ireland were represented, including our colleagues from Belfast, Derry, west of Ireland, south of Ireland, and obviously Dublin.”

One particular highlight of the meeting was the lecture by Professor of Biochemistry at Trinity College Dublin (TCD) Prof Luke O’Neill on the role of the re-programmed Krebs cycle in the therapeutics of inflammatory disease, she said.

“I think Prof O’Neill is at the start of really good, exciting work. I think the whole understanding of glycolysis and the role it has to play [is very important] and we have seen therapeutic targets that might come out of the TCD group.

“I think the level of the scientific and oral presentations were probably better than any other year, and this has all evolved over the last 20 years to quite a high standard. Our Belgian colleague here [Prof Dirk Elewaut] was surprised at the numbers and standards of the science. I think there is a lot of good work being done, a huge amount from TCD and UCD, and also pockets of work being done in Cork, Galway, Sligo, Limerick and Belfast. I think the continued unrestricted funding from UCB for this Rheumatology Patient Improvement Fund (RPIF) also means that junior researchers who would not have been funded before to do clinical projects that affect patient care are getting funded, from all corners of Ireland.”

Another highlight of this year’s meeting was the awarding of the ISR Lifetime Achievement Award to leading Irish consultant rheumatologist and researcher Prof Oliver Fitzgerald at the gala dinner. “He has been known on the international circuit for years and is the new President of GRAPPA [Group for Research and Assessment in Psoriasis and Psoriatic Arthritis]. There has never been an Irish President of a European organisation so while he is retiring from clinical practice, he will be keeping up our profile abroad.”

Welcoming the new National Model of Care for Rheumatic and Musculoskeletal Disorders document, which was officially presented to the ISR at the meeting by National Clinical Programme for Rheumatology lead Prof David Kane, Dr Harney said its implementation would need significant manpower and resources for the specialty.

Dr Harney also commented on the importance of the meeting’s Private Practice and Clinical Advisory Group meetings: “The private practice rheumatologists are as important as the public practice and are very much part of the Society, and then the Clinical Advisory Group, with Prof Kane, is advocating the doubling of consultant numbers.”

So all in all, a lot of work to do to ensure rheumatology receives the attention it deserves to deal with ever-increasing demand.

“The downside for me is the persistent lack of infrastructure. It is particularly bad in the southern region; Cork, Kerry is a real black-spot with no political will to do anything down there, so that is the only real negative, but I think with time and energy, that will change. We have an awful lot of younger female and male trainees coming through so I think the specialty is in a really good place. And the addition of the Bernard Connor Student Medal means we are identifying younger doctors who want to come into our specialty,” she told MI.


Bernard Connor Medal 2018

The ISR established the Bernard Connor Medal to encourage medical student participation in rheumatology during their undergraduate education and to support student engagement with its activities.

This year’s Bernard Connor Medal winner, Mr Dylan McGagh, a third-year graduate-entry medical student at Magdalen College, University of Oxford, UK, who graduated from Trinity College Dublin in 2016 with a gold medal and first-class honours degree in Human Health and Disease, gave a very well-received presentation at the ISR 2018 Autumn Meeting on his research, titled: ‘Could patient-reported outcomes help to inform a holistic treat-to-target approach in rheumatology?’


Mr Dylan McGagh, Bernard Connor Medal Winner

Mr McGagh explained how while undertaking a shadowing placement of a rheumatology clinic during medical school, he came to believe that the standard rheumatic disease measurement tools (BASDAI, the DAS-28 and the PsARC scoring tools) and their usage led to opportunities for discordance between treatment targets and disease activity. Essentially, they did not give a true picture of the patient’s individual experience or tie in with the concept of treat-to-target.

From one-to-one discussions with patients, he found that placing an emphasis on patient-reported outcomes (PROs) and individual treatment goals as a core foundation of the patient journey was the best approach. Such an approach is especially suited to the specialty of rheumatology because of the effects rheumatic conditions can have on daily life, such as the pain, stiffness and fatigue associated with conditions such as rheumatoid arthritis and psoriatic arthritis (PsA), and ankylosing spondylitis, Mr McGagh stated. “The consequences that these symptoms can have on a person’s confidence, independence and functioning provides a unique opportunity to measure these factors and provide an objective evaluation on subjective inputs, ultimately guiding holistic recovery, which is valued by those most important — the patient and their families and carers.”

Mr McGagh reiterated that in order to best treat these chronic and complex conditions, patients should be placed at the centre of their care, also saying there is scope to utilise more detailed PRO questionnaires.

Summarising his research findings, Mr McGagh said: “For true targets to be reached in a holistic treat-to-target approach placing the patient as the central participant, the patient’s perceptions need to be integrated with current objective measures of disease activity. As I had the privilege of exploring, people with rheumatic conditions have fears and desires for treatment regimens, which are integral to their sense of self. In order to truly treat these chronic and complex conditions, accounting for these individual factors, there is scope to utilise more detailed PRO questionnaires, either on digital platforms while patients await their consultation or via a regular diary between consultations.

“If the tools we employ work effectively and barriers to their functionality are removed, there is an opportunity to bridge the gap between the clinical and the patient worlds, only elevating the value we place on the clinical history and human interaction.”

Thus, rheumatology clinicians should outline individualised goals with their patients early on and “target sustained remission or low disease activity in every patient”, he concluded.

ISR President Dr Sinead Harney then presented Mr McGagh with the Bernard Connor 2018 Medal to a round of applause.

The meeting also heard from the ISR Young Investigator Award 2018 winner Dr Sarah Wade, who gave a presentation on her research project.

Dr Wade is an Arthritis Ireland postdoctoral researcher in the Molecular Rheumatology Research Lab at Trinity College Dublin. Her project proposed that microRNA, miR-125, modulates endothelial cell (EC) bioenergetics and orchestrates joint angiogenesis as characterised by ex vivo associations, in vitro assays and novel CRISPR/cas9 in-vivo zebrafish models.


Dr Sarah Wade, Young Investigator Award winner

The findings to date are that decreased expression of miR-125 in PsA synovium and in vivo models is strongly associated with pro-angiogenic mechanisms. Elevated glycolysis following miR-125 inhibition enabled ECs to meet the increased energy demands for new vessel formation. Correcting these miRNA deficiencies and their resulting metabolic shift, either by conventional pharmacological or as novel drug targets, may provide therapeutic benefit, especially in early disease, she said.


New national rheumatology model of care presented to ISR

The new HSE National Model of Care for Rheumatic and Musculoskeletal Disorders document was officially presented to the Irish Society for Rheumatology (ISR) at its 2018 Autumn Meeting in Naas.

Prof David Kane, National Clinical Lead of the National Clinical Programme for Rheumatology, and Consultant Rheumatologist at Tallaght University Hospital, Dublin, made the presentation. He also officially presented the document to patient support organisation Arthritis Ireland at the meeting.

The model of care has had a long gestation period taking seven years to complete, with Prof Kane taking over the reins from former National Clinical Lead Prof Oliver Fitzgerald in 2015 to oversee the finalisation of the document, which received input from a large multidisciplinary stakeholder group.

The new model of care for rheumatology and musculoskeletal (MSK) disorders aims to ensure that every rheumatology and MSK patient is seen, assessed and treated by the right person in the right place and in the timeliest manner.

It notes that Ireland has one of the lowest ratios of rheumatologists-to-population in the EU, but when implemented, the model of care will bring service provision for arthritis and allied conditions in Ireland in line with evidence-based practice and international standards of care.

The document foreword acknowledges that currently, the delivery of care to these patients is largely limited by deficiencies in resources, including staffing and infrastructure in the specialty across both primary and secondary care, and by the absence of clear management guidelines and integrated care pathways.

These deficiencies have led to significant access issues, with lengthy waiting lists and delays in assessment, diagnosis and treatment for rheumatology and MSK patients. The document also points to the predicted dramatic increase in the prevalence of rheumatic and MSK disorders in the next decade due to an increasing and ageing population.


Prof David Kane

The “ambitious and achievable” model of care envisages expansion of rheumatology services in a ‘hub-and-spoke’ model of tertiary centres operating within six rheumatology networks as per the HSE Hospital Group structure, integrated with primary care services through the HSE’s Community Healthcare Organisations (CHOs). “This will provide co-ordinated care and uniform standards of service delivery for patients across the networks and across primary, secondary and tertiary care, which is supported by the development of clear referral protocols, pathways and therapeutic standards,” the document states.

Key secondary care waiting list targets outlined by the model include the reduction of all rheumatology referrals to under six months within a year’s time, and to under three months within two years. It also wants to allow ‘fast-tracking’ of early inflammatory arthritis and systemic disease to reduce waiting times for such urgent referrals to under two weeks within a year’s time.

Staffing wise, the model wants to increase consultant rheumatology time by 40 per cent within a year, through taking all rheumatology consultants off general internal medicine call and by appointing new rheumatology consultants (double the current numbers). It also seeks to increase multidisciplinary team staffing — only one third of the recommended nurse specialists and occupational therapists are in place nationally — and to further develop the scope of team members to increase their care and management of rheumatology and MSK patients.

The model also proposes a number of value solutions, such as the development of national guidelines for the use of biologic medicines, including biosimilars; a review of usage of drugs within the GMS, in particular those where efficacy is unproven; the introduction of a fracture liaison programme, including a falls risk assessment; measures to reduce MSK-related disability costs to the State; and the reduction of  ‘did not attend’ rates in rheumatology outpatient departments to 12 per cent, as per national targets.

In a nutshell, the model recommends an integrated approach across primary and secondary care, which encourages the development of an appropriate role for all members of the multidisciplinary team within the model.

Current rheumatology manpower and service deficits are highlighted throughout the document and will have to be addressed for the model’s implementation. “While some of the costs involved could be met through identifying inefficiencies within the system, it is without doubt that investment, both in staffing and in infrastructure, will be required to facilitate the implementation of this model of care and in shaping future rheumatology services,” Prof Kane and Prof Fitzgerald wrote jointly in the foreword to the document.

Speaking to the Medical Independent (MI), Prof Kane said the National Programme for Rheumatology plans to have an official launch for the model of care shortly and they have asked Minister for Health Simon Health to officiate. “We now have consensus on what we would see as optimal quality metrics in rheumatology and also consensus on what we would need to achieve those and it is clear there is a well-recognised deficit in the numbers of consultant rheumatologists, specialist nurses, physiotherapists and other allied health professionals needed to deliver rheumatology care to the standards that Ireland needs.”

He said the next step is to get support to implement the model of care, with two strands already on the way to being successfully implemented. These include the roll-out of specialist physiotherapy access and advanced nurse practitioners in rheumatology, with 23 in training. “They will see patients at a high level, equivalent to a doctor, thereby expanding our capacity, so consultants can see newer and more acute patients and that will help with the waiting lists. Though ultimately we need more consultants, and we are aiming to get it up to one per 79,000 of population, which is the UK equivalent,” Prof Kane told MI.

An economic analysis of the costs of implementing versus not implementing the model will now go ahead, he confirmed, which should take about a year, though he stressed this should not delay the implementation of the document’s proposals.

In addition, the Programme is also now working on the development of clinical guidelines and treatment pathways for a number of rheumatic diseases, Prof Kane said.


Irish research to the forefront of ISR Autumn Meeting

rish research was a key focus of this year’s ISR Autumn meeting, with a significant number of oral basic science and clinical presentations from local researchers who had submitted their projects to the ISR for consideration for the research prizes.

One of those to present was Best Scientific Presentation prize-winner Dr Charlene Foley, National Centre for Paediatric Rheumatology, Dublin, who outlined her project on the comparison of B- and T-cell subsets, cytokine expression and synovial pathology in Down’s arthritis (DA) and juvenile idiopathic arthritis (JIA).

Dr Foley explained how a pathological feature of Down syndrome (DS) is dysregulation of the immune system, which almost certainly contributes to the observed high incidence of autoimmune diseases in this cohort: Previous work by her group suggests that the prevalence of DA is 18-to-21 fold greater than JIA.

Children with DA often follow an erosive, polyarticular course of disease, with small joint involvement observed in a significantly greater proportion of children than expected in a typical JIA cohort, Dr Foley noted. The DA clinical phenotype may be distinct from JIA, however little is known about the differences in synovial pathology or immunological regulation. No studies to date have examined these entities in DA, thus Dr Foley and colleagues examined B-cell subsets and T-cell cytokine profiles; and characterised and compared the synovial membrane immunohistochemistry in children with DA and JIA.

The study found that there are significant differences in B-cell populations, T-cell cytokine production and immunohistochemical features of synovial tissue in children with DA and JIA but more work is required to verify these results.

Dr Foley highlighted the need for awareness of the risk of DA in children with DS, as they are often diagnosed very late, by which time they have suffered irreversible joint damage.

“So in summary, DA does appear to be a distinct clinical phenotype with an increased risk compared to JIA. The majority of children present with a polyarticular rheumatoid factor-negative arthritis with predominance in the small joints of the hands and wrists… DA and JIA represent distinct conditions with different clinical features, immunology and synovial histology.”

The meeting also heard from the five inaugural (2017) winners of the new ISR research funding initiative, the Rheumatology Patient Initiative Fund (RPIF).

The initiative is intended for innovative researchers undertaking a body of research in rheumatology in Ireland that will directly impact on patient care and quality of life.

One of the RPIF 2017 winners was Prof Gerry Wilson, Consultant Rheumatologist in the Mater Misericordiae University Hospital and Professor of Rheumatology at UCD, who gave an update on the work of the Irish Arthritis Research Coalition (ARC). The ARC was established in 2016, and he highlighted how clinicians can help classify and stratify subtypes of diseases and identify patient cohorts to improve research quality and impact in Irish rheumatology. He briefly outlined the impressive research outputs already underway through ARC, including a number of projects in paediatric rheumatology, and a planned one on rheumatoid arthritis, with the primary aim of the ARC biobank to recruit patients with common rheumatic diseases, and obtain biosamples that will underpin clinical research. A secondary aim is to increase national involvement in clinical trials of novel therapeutic agents.

“The aim of ARC is really to undertake good clinical translational research, which we have seen in the great presentations here, highlighting the importance of having well-characterised clinical cohorts for undertaking patient-centred research,” Prof Wilson commented.


The growing role of genetics in healthcare highlighted

Human genes hold the key to unlocking new disease treatments and cures and we now have the technology to unlock that information in Ireland, the ISR 2018 Autumn Meeting heard.

Dr Jeff Gulcher, a neurologist and co-Founder of Genomics Medicine Ireland (GMI), gave a topical presentation on the role of genetics in healthcare.

GMI is a privately-funded Irish genomic studies company, with its own purpose-built genome sequencing laboratory in Dublin that is working in partnership with the medical community, patients, academic researchers and the global biotech and pharmaceutical sectors to obtain new insights to help with the development of new treatments and diagnostics across a spectrum of chronic health conditions for the people of Ireland and beyond.

It uses large gene-sequenced well-characterised cohorts for its work on drug target discovery and validation, and is currently recruiting 45,000 patients across seven diseases in a collaboration with AbbVie. Ireland’s population structure and relative homogeneity increases the power of gene discovery, he said.

Dr Gulcher highlighted some of the projects GMI is currently partnering on in Ireland, including one looking at the genomic basis of chronic respiratory conditions, such as asthma and asthma-COPD overlap (ACO), in collaboration with St Vincent’s University Hospital, Dublin, and University College Dublin (UCD).

Recently, the company announced its collaboration with the Department of Clinical Neurosciences at the University of Cambridge, UK, to expand GMI’s research examining the underlying genetic factors contributing to multiple sclerosis (MS).

The collaboration will leverage up to 15,000 DNA-extracted MS samples from a biobank the University has established. This large dataset, when combined with samples already being collated via GMI’s ongoing Irish cross-border MS research study, will result in one of the world’s largest MS-focused genomic studies ever conducted.

In the field of rheumatology, GMI is working in partnership with University Hospital Limerick on a landmark genomic study on ankylosing spondylitis and non-radiographic axial spondyloarthritis with the objective of identifying commonalities and linkages that can help diagnose the diseases early on, predict their severity, and suggest personalised treatments — or even a cure.

During his presentation, Dr Gulcher discussed the results of his own gene sequencing, and the particular risk factors and familial disease links his genome data uncovered. He explained how he had altered his lifestyle, losing weight, and became more active to offset his risk of diabetes as identified in his data, and was also aware of the importance of screening for particular cancers and diseases that he had a higher risk of developing.

He posited the health risk-prediction value of everyone having their genome sequenced, though privacy concerns and the potential for abuse of this data were raised by some audience members during the Q&A session.

Meanwhile, in the final presentation of the conference, Dr Lihi Eder, Assistant Professor of Medicine, University of Toronto, Canada, discussed cardio-metabolic diseases in psoriatic arthritis (PsA).

Quoting a number of studies, she said it is now known that PsA is associated with a much higher risk of cardiovascular (CV) events — over 40 per cent higher than the general population. She said this is likely due to a complex mix of traditional risk factors and systemic inflammation. Dr Eder said raising awareness of this particular risk in PsA patients is very important and they should be CV risk-stratified and screened where appropriate. She also noted that TNF inhibition (ie, suppressing inflammation) may be associated with a reduction of CV risk.


Management of rheumatic diseases during pregnancy update

The management of pregnant women with rheumatic diseases is evolving, with medication continuance now an increasing practise for some drug classes, the ISR 2018 Autumn Meeting heard.

Dr Ian Giles, Consultant Rheumatologist, University College Hospital London, UK, and lead author of the British Society for Rheumatology (BSR) 2016 guidelines on prescribing anti-rheumatic drugs in pregnancy and breastfeeding, addressed the meeting on changing practise in the area.

He noted the management of these patients is complicated by several factors, including an increased burden of pregnancy morbidity compared to the general population, which is partly due to increased disease activity. Some studies have shown an increased risk of adverse pregnancy outcomes in the presence of elevated levels of TNF-alfa.

Dr Giles also maintained that pregnancy does not induce remission in as many rheumatic patients as commonly believed, showing some recent data to support this.

He also commented that pain and discomfort during pregnancy is normal and it is important to remember this when trying to distinguish normal aches and stiffness from actual arthritis activity.

While traditionally, women have been advised to discontinue their medications prior to conception and during pregnancy, this is now changing as discontinuing biologics, for example, can have potentially worse outcomes for the pregnancy than continuing them.

Now, many patients continue biologic therapy for at least a portion of pregnancy, ie, first trimester at least, and international guidelines are changing to reflect this, with recent data showing supportive and reassuring results for some biologics, noted Dr Giles. He pointed out that certolizumab pegol (CZP), a novel anti-TNF agent that is used for patients with moderate-to-severe active rheumatoid arthritis (RA), recently had its EU approval extended to include women who are pregnant or breastfeeding following a number of positive studies showing a lack of adverse pregnancy outcomes.

However, there remains a general lack of data on medication usage during pregnancy, with most data looking at foetal as opposed to maternal health, while very few drugs are specifically licensed for usage during pregnancy. Thus, safety concerns around some drugs persist, while in others, not enough is known about the long-term safety profile. As a result, many potentially beneficial drugs are still being unnecessarily withdrawn in pregnancy due to a mistaken belief that the drugs themselves may be harmful, thus allowing an increase in disease activity, which is itself more harmful to the pregnancy.

Careful pre-conception planning with rheumatic patients is key and some medications, such as methotrexate, remain contraindicated, while dosage and compliance are also very important, said Dr Giles.

The BSR guidelines advise stopping methotrexate, leflunomide, mycophenolate mofetil and cyclophosphamide pre-conception, and during pregnancy, switching patients on warfarin to low molecular-weight heparin and starting aspirin in lupus patients. In the second and third trimesters, the guidelines say to consider stopping anti-TNF therapies, Dr Giles summarised.

Prompt post-partum care and appropriate re-initiation of rheumatic therapies are also key, as flare risk is high, but if mothers are breastfeeding, therapies must be compatible, he concluded.


Gut linked to both inflammatory bowel disease and axial spondyloarthritis with high cross-risk ratio

There is a clear link between gut inflammation, axial spondyloarthritis (SpA) and the development of inflammatory bowel disease (IBD), the ISR 2018 Autumn Meeting heard.

Prof Dirk Elewaut, Professor of Rheumatology and Immunology, Ghent University, Belgium, discussed the link between the gut in SpA versus the joint in IBD. Prof Elewaut posited that gut inflammation is a driver of joint inflammation in SpA. His research team has found that about 50 per cent of patients presenting to rheumatologists with a clinical presentation of SpA have microscopic gut inflammation, regardless of subtype, and unrelated to clinical gastrointestinal symptoms.

Subclinical gut inflammation is associated with long-term outcomes of joint symptoms, more extensive disease and, conversely, remission of gut inflammation is associated with disappearance of joint symptoms, he maintained.

Persistence of gut inflammation has been specifically linked to the evolution of Crohn’s disease and ankylosing spondylitis (AS) and is also associated with an accelerated need for biologic therapy, the professor stated.

He also quoted Icelandic genealogy data highlighting the common genetic background for IBD and AS, with a three-fold elevated cross-risk radio of developing IBD if a first-degree relative has AS, and vice versa.

The findings suggest that one or more undiscovered genetic variants may underlie the risk of both diseases.

Meanwhile, a separate meta-analysis suggested that up to 20 per cent of IBD patients can have axial spondyloarthritis, though he cautioned that it was based primarily on imaging and was uncertain if it would be replicated if it was analysed in a prospective manner by rheumatological experts. “So it is common, but I think a little bit less common than this study suggests.” Prof Elewaut added that detection can be hampered by the fact that when IBD patients are placed on steroids and immunosuppressants, they can mask/alleviate any relevant joint symptoms so clinicians need to investigate such symptoms during the diagnosis period.

Concluding, Prof Elewaut said further refinement and validation of biomarkers (including multiparameter sets) are needed for the optimal management of arthritic diseases.

Speaking to the Medical Independent, Prof Elewaut said it is important that clinicians are aware of the presence of gut inflammation and how it can determine severity of disease. “In patients with IBD and SpA manifestations, there are common pathways but also different pathways, so you can have a disconnect between what is happening in the gut and what is happening in the spine or peripheral joints, so that is something to be aware of when treating a patient with SpA or IBD.”

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ICS Preview

Hundreds of delegates attending the 2018 Irish Cardiac Society (ICS) Annual Scientific Meeting and AGM will converge in Galway from 4-6 October to hear the very latest in cardiovascular research and developments. 

The meeting, in association with the Irish Nurses Cardiovascular Association, Cardiac Clinical Physiologists and Irish Atherosclerosis Society, is the all-island society’s 69th meeting and will include presentations from some of the world’s foremost experts in cardiology.

The meeting will feature an international element, with speakers from the US and Europe in attendance.

Dr Janet McComb, consultant cardiologist, Freeman Hospital, Newcastle, UK, will deliver the keynote presentation of the event, the Stokes Lecture. Dr McComb will speak on the topics of electrophysiology and pacemakers.

Another important aspect to the event is the presentation of around 60 local abstracts, which gives young Irish cardiologists working in Ireland or abroad the opportunity to present their research and highlight the level of research taking place inside and outside of Ireland.

Dr Albert McNeill, consultant cardiologist at Altnagelvin Hospital, Derry has been President of the Irish Cardiac Society for two years.

Last year’s ICS meeting was held in Derry and was regarded by many delegates as an academic and cultural high point, Dr McNeill told the Medical Independent (MI).

“We were very pleased to have among others Dr Mary Norine Walsh who was the president of the American Society of Cardiology. We had several other international speakers. We always have an international array of speakers; American, European and British speakers,” Dr McNeill said.

“During the course of the year the international activity of the society continues when I represent the society at the American College of Cardiology, British Cardiovascular Society and at the European Society of Cardiology meeting and those are in March, June and August respectively.”


Dr Albert McNeill, President ICS

Joint sessions

The ICS enjoys a very warm relationship with the American College of Cardiology, according to Dr McNeill. 

The ICS and British Cardiovascular Society hold a joint session with the American College of Cardiology at their annual meeting in March. The theme of this year’s session was electrophysiology.

“At that we have a reception for Irish American cardiologists, both people who have trained in Ireland and gone to America and some of whom have stayed and American cardiologists who have an Irish background,” Dr McNeill stated.

“That’s always very useful socially and gives us a chance to network with our American colleagues. We have some presentations about the opportunities for Irish trainees in America and that’s really an opportunity for cardiologists of the future to get to know what happens in American cardiology.”

Similar joint sessions are held at the British Cardiovascular Society meeting. The European Society of Cardiology (ESC) meeting was held in Munich this year, which provided the ICS with an excellent opportunity to network with other cardiologists, Dr McNeill said.

“We want to encourage Irish cardiologists to get involved at a clinical level in terms of submitting abstracts and chairing sessions and also to get involved in some of the administrative roles within the ESC. The more that we network with people and get a flavour and handle of what’s happening in Europe the better that is for Irish cardiology.”

The ESC meeting is of particular benefit to Irish patients and clinicians, Dr McNeill explained, as the ICS “buys into and ratifies ESC guidelines for use within the island of Ireland”.


This year guidelines launched at the Munich meeting include four new ESC clinical practice guidelines on: Arterial hypertension; syncope; myocardial revascularisation; and cardiovascular diseases during pregnancy. 

Local meetings that run under the ICS’s auspices include an annual update in Enniskillen and an annual aortic valve meeting, while ongoing training aspects take place nationally throughout the year.

International speakers

Turning to the upcoming event in the Galway Bay Hotel, international speakers include Dr Michael Valentine, President of the American Society of Cardiology; and Prof Pepe Zamorano, Vice President from the European Society of Cardiology.

They will speak at the international session alongside Prof Nick Linker of the British Cardiovascular Society on Saturday morning. The session will be chaired by incoming ICS President Dr Jim Crowley.

The three-day event begins on Thursday morning with the meeting of the Irish Nurses Cardiovascular Association. 

On Thursday evening two parallel sessions on electrophysiology and interventional cardiology will take place.  

On Friday a day-long meeting of the Irish Cardiac Clinical Physiologists is scheduled while further ICS sessions will take place. 

Prof James Moon, Professor of Cardiology at University College London, will deliver a session on: “Myocardial tissue characterisation to improve outcomes” on Friday morning.

The 2018 Stokes Lecture will take place on Friday afternoon before a special gala event that evening where Dr McNeill will hand over the presidency to Dr Jim Crowley, Consultant Cardiologist, Galway. Scientific sessions will continue on Saturday morning before the event closes.

Travelling Fellowship

Also in attendance will be this year’s Travelling Fellowship recipients. The Travelling Fellowships provide financial support to trainees during their first year abroad training at international centres of excellence.

This year’s Travelling Fellowship recipients are supported by Bristol Myer Squibb and Daiichi Sankyo. The Brian McGovern Travelling Fellowship is supported by Bayer.

Meanwhile, any trainees who are abroad and have an abstract accepted are eligible for travel home sponsorship, which is provided by MSD. There are nine recipients this year.

Brian Maurer Award

There are four finalists for the Brian Maurer Young Investigator Award.

There are two American-based finalists and two finalists based in Ireland hoping to win the award for their work on the “Role of zfhx3 in atrial fibrillation”, (Dr Alan Hanley); “The Clinical Course of Heart Failure Patients Managed in a Disease Management Programme”, (Dr Robbie Murphy); “Factors Contributing to Left Atrial Remodelling and the Development of Atrial Fibrillation in Hypertrophic Cardiomyopathy”, (Dr Sarah Cuddy); and “An Investigation of Global Longitudinal Strain in Primary Mitral Regurgitation: A retrospective cohort of patients with mitral regurgitation”, (Dr Ros Lavery).

For the first time, the Society this year has a prize for best moderated poster supported by Daiichi Sankyo. 

Looking at developments in cardiovascular care in Ireland, Dr McNeill said “a big change in management” that occured over the past few years was the 32-county roll-out of primary percutaneous coronary intervention (PPCI).

“We have provided that for the last two years on a cross border basis for people from Donegal,” Dr McNeill explained.

“In a way that is fitting that my Irish Cardiac Society president role mirrors my clinical role where I have an involvement in the management of patients from both sides of the border.”

The gold standard treatment for a major heart attack (ST Elevation Myocardial Infarction-STEMI) is primary percutaneous coronary intervention (PPCI).

Since 2016 Donegal patients have had access to the life-saving service at Altnagelvin Hospital, Derry.

The service has been hugely successful and further improvements are planned in the North, Dr McNeill said.

“The big things we’re looking for, certainly within the North, is the roll-out of a preventative cardiology service for patients, both with established coronary disease and patients at high risk of coronary disease. That’s going to be analogous to a programme which works out of Galway under the auspices of CROÍ,” Dr McNeill said.

“Within the North we’re going to look at how can we replicate and put resources towards preventive cardiology, both for high risk primary prevention, people who don’t as yet seem to have the disease and for secondary prevention for people that have established disease.”

He said the plan was to imitate the work of the CROÍ heart and stroke charity in the west and use it “as an exemplar” and potential template to try and replicate for similar preventive work in the North.

Ongoing future research that may have an impact on cardiovascular practice in hospitals is particularly promising, Dr McNeill added.

New ways to manage heart failure, stratified medicine where therapies are individualised to an individual patient, translational medicine and gene therapy are among the areas to watch out for based on current research, Dr McNeill stated.

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Gastroenterologists to gather in Killarney

Pivotal issues facing gastroenterology will be debated and discussed at the upcoming Irish Society of Gastroenterology (ISG) Summer Meeting in the Great Southern Hotel, Killarney, Co Kerry, on 24-25 May.

The focus of the first major clinical session will be advances in gastrointestinal surgery, with Ms Aisling Hogan, Consultant Surgeon at University Hospital Galway, due to speak on pelvic floor dysfunction; and Prof Calvin Coffey, Professor of Surgery at University Hospital Limerick, presenting on mesenteric resection in Crohn’s disease.

ISG President Prof Laurence Egan told the Medical Independent (MI) that Crohn’s disease surgery is “complicated by recurrence of the disease afterwards in many cases”.

Currently, surgeons do not have any particular operative strategies to minimise risk of recurrence, other than to try and remove all the segments affected by Crohn’s. The presentation by Prof Coffey will propose that an oncological type of resection of the affected bowel, rather a standard resection, may lead to a lower risk of postoperative occurrences.

Later in the afternoon (24 May), there will be a session on endoscopy and colon cancer. This will open with an update on the Gastrointestinal Endoscopy National Quality Improvement Programme (NQIP) as presented by Prof Steve Patchett, Consultant Gastroenterologist, Beaumont Hospital, Dublin. This will be followed by a talk on enhanced adenoma detection techniques by Prof Ralf Kiesslich, Professor of Internal Medicine/Gastroenterology, Johannes Gutenberg University of Mainz, Germany.

The NQIP has been collecting data from most Irish colonoscopy centres to assess standards of practice. “And there has been a huge improvement; it is a ‘good news story’, I would say,” said Prof Egan.

However, the ISG President confirmed there are major pressures on colonoscopy services.

“There is absolutely massive demand for colonoscopy, and rightly so — it is all warranted.”


Prof Laurence Egan, ISG President

A big part of this demand emanates from the bowel screening programme, with polyps picked up in about 60 per cent of patients who undergo colonoscopy.

 “All of those patients who are discovered to have polyps that are removed at colonoscopy have to come back for periodic follow-ups, say in three or five years’ time. The demand is growing hugely because of that. We certainly don’t at the moment have sufficient capacity in the country to meet the demands, both of the symptomatic population and the screening population — it is a big problem.”

Prof Egan said BowelScreen is leading to identification of cancer at a much earlier stage compared with those “diagnosed on the basis of reporting symptoms through their doctor and undergoing investigation after that”.

It would be concerning if the CervicalCheck controversy affected people’s confidence in BowelScreen, he said. As it stands, 40.2 per cent of the eligible people (60-to-69 year-olds) take part in the bowel screening programme.

 “We know for sure that BowelScreen is downstaging colon cancer to an earlier stage, which is more amenable to curative surgery and even if chemotherapy is needed, it is much more likely to be successful… ”

There is a long pre-clinical stage where the tumour is growing and the patient is asymptomatic, “and the virtue of BowelScreen is, it can detect those tumours before any symptoms have developed”.

The initial screening test is very simple, as it only requires a stool sample being returned by post, underlined Prof Egan. The other unique feature of BowelScreen is that, for individuals who have a positive stool test, the colonoscopy can both determine whether there are bowel polyps or bowel cancers present and facilitate removal of polyps.

The morning of 25 May will open with a much-anticipated session on new developments in inflammatory bowel disease (IBD).

Prof Julian Panes, Chief of the Gastroenterology Department, Clinic de Barcelona, Spain, will present on utilising mesenchymal stromal cells in the treatment of fistulising Crohn’s disease.

This will be one of the meeting’s highlights, according to Prof Egan. Prof Panes is the lead investigator on a study published last year, which showed that mesenchymal stromal cell injection into the perianal fistula tract in Crohn’s disease patients was effective, where standard therapy had been ineffective.

“So, it is a whole new treatment paradigm for perianal fistulas that occur in Crohn’s disease patients.”

As to availability of this treatment in Ireland, he said “the mesenchymal stromal cells are not yet available in Ireland; they will be sometime in 2019. But it remains to be seen how good it will turn out in routine day-to-day clinical practice. It is a totally new therapy, totally different from any therapy we’ve had up to now. And for patients who don’t respond to standard therapy, it’s a promising avenue to explore. It is very novel and interesting but it has only really been examined in the clinical trials setting; there is really no real-life data in terms of how effective it’s going to be in routine clinical practice”.

Prof Glen Doherty, Consultant Gastroenterologist, St Vincent’s University Hospital, Dublin, will present on ‘Stopping IBD Treatment — Can We Do It?’

“We know a lot about starting treatment in IBD patients and how effective that is, but in patients who are doing very well on treatment, there might be five years without any symptoms on treatment, no evidence of any active IBD; is it safe to stop those patients’ treatment and how will they get on after the treatment has been stopped?” said Prof Egan.

“There is very little known about it, but Prof Doherty is heading a working group on that at the European Crohn’s and Colitis Organisation.”

Following the session on IBD, there will be ‘Hot Topics in Pancreatic Cancer’. Prof Dermot O’Toole, Consultant Gastroenterologist, St James’s Hospital, Dublin, will deliver a presentation titled ‘Pancreatic Cancer Trends and Staging’; and Prof Anne Marie Lennon, Associate Professor of Gastroenterology, Johns Hopkins Hospital, Baltimore, US, will speak on ‘Liquid Biopsies on the Pancreas — Potential for Cancer Diagnosis and Management’.

A segment titled ‘Outstanding Controversies in Pancreatic Cancer’ will look at endoscopic stenting (presented by Dr Finbar McCarthy, Consultant Gastroenterologist, St James’s Hospital, Dublin) versus trans-hepatic stenting (presented by Dr Ronan Ryan, Consultant Radiologist, St Vincent’s University Hospital, Dublin).

To complete this session on pancreatic cancer, Mr Justin Geoghegan, Consultant Surgeon, St Vincent’s University Hospital, Dublin, will discuss modern surgical approaches.

“Pancreatic cancer is one of the most deadly cancers we have and the processes around detecting it, diagnosing it and treating it are advancing incrementally, I would say. But it still has an overall very poor prognosis, unfortunately,” outlined Prof Egan. “So really, this session is a review on those points, how can we diagnose it better, how can we manage it better clinically, and what kind of both palliative and curative approaches are available.”

The final major session of the conference will focus on hepatology and specifically on hepatitis C virus (HCV). Prof Aiden McCormick, Clinical Lead of the HSE National Hepatitis C Treatment Programme and Consultant Hepatologist at St Vincent’s University Hospital, Dublin, will present on ‘HCV in Ireland — Where to Next?’

Prof Egan said the advent of direct-acting antivirals (DAAs) had meant that HCV is now highly curable in respect of most patients. However, he added there are two significant problems. “One is that the drugs are expensive and can we afford it, and all of that. The other problem is reinfection.”

Prof Egan noted that HCV has a particularly high prevalence in the IV drug-using population “and reinfection can be a problem. So, Prof McCormick is going to be talking about his perspective on the future treatment of hepatitis C in Ireland.”

Clinical cases and oral presentations will also feature at the meeting.

ISG in focus

The Irish Society of Gastroenterology (ISG) comprises medical specialists working in the field of gastrointestinal and liver disease and associated research. The Society also caters for specialist trainees and non-medical scientists. The majority of members are located in Ireland or have links within this country.

The ISG organises and hosts regular platforms and conferences, allowing members to present clinical and scientific material.

The Society has a varied membership, encompassing consultants and trainees in various specialties. These include gastroenterologists, surgeons, pathologists, radiologists, immunologists, physicians and others with an interest in gastroenterology.

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College of Psychiatrists of Ireland Annual Conference – Spring 2018

NOSP in talks with Medical Council

Physician suicide is catastrophic for not only the individual doctor’s family and friends, but also for their patients, the Spring Meeting of the College of Psychiatrists was told. At the meeting, which was held in Athlone, Consultant Psychiatrist Dr Justin Brophy stressed the need for doctors to care for one another, especially in the context of challenging working environments.

During his presentation on doctor suicides, Dr Brophy, who is clinical advisor to the National Office of Suicide Prevention (NOSP), said there are about 400 physician suicides in the US every year, the equivalent of one medical school output per annum.

“There is a growing awareness and alarm globally around this,” he said, citing efforts by the Association of American Medical Colleges, JAMA, and The Lancet to address the escalating crisis of depression, burnout and suicide among doctors.

Doctors, as well as other medical professionals, are at high-risk of suicide, as they have both the knowledge and access to means to take their lives.

According to the proportional mortality ratio (PMR), male doctors are at a high-risk of suicide; however, this is contradicted by the standardised mortality ratio (SMR), which indicated that the risk was low.

Yet according to a 2008 paper by Meltzer et al, there was a higher incidence of suicide among female health professionals in the UK. In Australia, a higher suicide rate in female versus male doctors was also found in 79 doctor suicides in Australia. The suicide risk for female doctors is a particular problem, the meeting heard, as they had significantly higher rates than those in the educational profession.

More recent data from Australia has indicated that the suicide rate may be rising, in both male and female doctors, to such an extent that both genders may have a greater suicide rate than the general population. Again this research indicated that there was a disproportionately higher risk in females.

For psychiatrists, there was perhaps slightly higher risk, said Dr Brophy, but he added that the specialty does very well in surveys of general professional happiness.

He also cautioned that the profession needed to be mindful of retired colleagues and that the number of suicides among healthcare professionals as an occupational group as a whole was not known.

Medical students are also at risk, with suicide being the most common cause of death for the group after accidents.

“That extends to interns as well,” he said. Prospective medical students and residents were also very unlikely to disclose a history of depression because of the fear of how it might impact on their career.

The issue of burnout and doctor mental health received widespread media coverage following the IMO conference, where it was estimated that one-third of doctors in hospitals were suffering from burnout.

Several factors contribute to this including: Workplace bullying, oversight and scrutiny, coupled with an increasing workload. Also, greater bureaucracy means that doctors were spending more time at the ‘screen’ than with their patients.

This was worrying as the “one thing that protects us in this maelstrom is patient contact”, said Dr Brophy.

Other factors include the immersion in human suffering, an ever-present part of a doctor’s work, as well as the “dread” of making mistakes. Debt is also a growing issue for doctors, who are borrowing to fund their medical education. This was particularly relevant to graduate entrants.

“Ironically the EWTD [European Working Time Directive] hasn’t necessarily improved job satisfaction in graduates,” said Dr Brophy. “There is a disruption to continuous patient care and seeing people through an episode of illness.”

While he stressed that he is not a supporter of long working hours, “the idea that we can pop in and pop out of medical care in a shift-work paradigm is not helpful to our mental or physical health”.

Doctors also have a number of occupation-specific hazards and doctors at job-transition points are especially exposed to risk. Authors have found that most resident suicides took place during the months of July to September and January to March

Career progression obstacles can also trap doctors in unhealthy working environments “because people get into a sense of jeopardy and they tolerate and take on more stress”. Many doctors are also very pessimistic of recovery, particularly non-psychiatrists.

Furthermore, complaints to the Medical Council or employers can take the joy from medicine and as doctors are very judgemental of themselves, complaints can cause doctors to shut down their emotional availability. It can also lead to avoiding patients “which is the worst thing for us to do”, said Dr Brophy.

“It is in everyone’s interest that these doctors are dealt with compassionately and receive the appropriate support because burnt-out, unhappy, depressed, and compassion-depleted doctors make more mistakes.”

This, unfortunately, can lead to a situation of multiple jeopardy where the physician is being investigated by multiple bodies. Even when resolved, the stigma of complaint can linger a long time.

The UK GMC reported that there were 28 doctor suicides over eight years before the fitness to practise committees, which caused a reform in GMC procedures.

“And we have begun an important discussion under my auspices in NOSP. We’re speaking to the Medical Council, Dental Council and the pharmacy regulator, to try and ensure that investigator processes here meet high and compassionate standards of care for those subject to that.”

Contrary to public opinion, doctors are no more or, no less likely to suffer from depression, anxiety and substance misuse “but sleep deprivation particularly for young trainee doctors is a big driver of mood dysregulation. Depression in high-functioning people is often well-masked and compensated for”.

This means that as doctors are “masters of disguise” when they do reach out for help it is generally in extremis.

Dr Brophy also highlighted the lack of self-compassion and peer-compassion in the medical profession. “We judge ourselves very harshly and we judge our colleagues equally harshly,” he said. “We must look after each other.”

During the question and answer session, the role of the Medical Council as a stressor was highlighted. Dr Brophy again stated that the NOPS is in dialogue with all the medical, dental and pharmacist regulators regarding all of their procedures.

“The councils are open and we intend to begin a detailed process to try and look at not just disciplinary and fitness to practise procedures,” he said. Doctors as a profession just want fairness, “and all we want is that”, he added.

President ‘disappointed’ at no meeting with Minister Daly

The President of the College of Psychiatrists of Ireland has expressed his disappointment that the Minister responsible for mental health has not yet met with the College. Minister of State at the Department of Health with special responsibility for Mental Health and Older People Jim Daly took up his post in June of last year.

Speaking to this paper at the College’s Spring Conference, Dr John Hillery said that the training body had been in contact with Minister Daly’s predecessors in office.

“We had a lot of interaction with Kathleen Lynch and interaction with Helen McEntee, but none with him so far,” said Dr Hillery. “We haven’t met him despite efforts. I wrote to him when he was appointed and it is disappointing we haven’t met.”

He added that as the College is the main body for the medical treatment of mental health problems, it is important that it and the Minister interact.

During his welcoming address to the more than 300 colleagues who attended the Athlone conference, Dr Hillery also raised concerns about the future of the mental health directorate as National Director Ms Anne O’Connor is now being asked to take over non-mental health duties.

The lack of clarity on what this might mean for services was concerning, Dr Hillery said, particularly as the College and Ms O’Connor had a good working relationship, and as A Vision for Change called for a mental health ‘czar’, something which had worked well elsewhere. Dr Hillery also called for a fully resourced statutory oversight of the implementation of A Vision for Change, which he described as a very good document.

While he welcomed the 5 per cent increase in BST trainees for the College, he expressed frustration at the haggling which had to be done to accomplish this.

“We shouldn’t have to play these games, it’s about delivering a service to the public, especially at a time when many of our NCHDs are leaving,” he said. “Our trainees are telling us that they see Ireland as not a good place to work because of the conditions, the biggest part of that is probably the work setting and quality-of-life.”

He also stressed at the conference that Ireland needs to value doctors if it is to encourage people to study medicine and stay in Ireland.

During the two-day conference, the concept of ‘zero suicide’ was discussed and criticised by psychiatrists who feared that it may be used to condemn doctors whose patients take their own lives.

Dr Hillery also expressed his own reservations about the idea, saying “suicide is a hugely complex, medical, philosophical and psychological issue”.

“We have to take every step we can to make sure that people are getting the supports they need and time to make proper decisions, because one of the big issues with suicide is the impulsivity of it towards the end,” he added. “But I don’t know how you can prevent everyone from taking their own life.”

He said mental health services have to ensure that people’s right to treatment is always met.

He also highlighted that many societal problems end up being dealt with by psychiatry, rather than by the State as a whole.

“Figures from the OECD state that Ireland has the highest rate of untreated chronic depression in the OECD. That’s not about psychiatric services, it’s about something in Irish society,” he said. “People feel excluded and unable to get help.”

Furthermore, service provision is being impacted by resource constraints and the consequent ‘moral distress’ for doctors is a contributing factor in burnout. Despite this and other challenges, he agreed that the specialty was maintaining its compassion for its patients. He also expressed hope that while doctors were traditionally poor at looking after their physical and mental health, this is changing.

The President of the College said he was delighted with the conference, particularly the posters which reflected the high quality of the trainees. He also praised Vice President Dr William Flannery for organising the conference.

Speaking to the Medical Independent, Minister Daly said he was open to meeting with Dr Hillery and the College in matters relating to mental health services.

Concern over reported suicide figures

There is increasing concern that suicide numbers are not accurately reflected in CSO data, the Chief Scientist of the National Suicide Research Foundation told the recent Spring Conference of the College of Psychiatrists of Ireland. Concern was also highlighted about an emerging pattern, where there is increasing lethality of self-harm attempts in shorter spaces of time.

Prof Ella Arensman said that late-registered deaths, not included in CSO data, impacts negatively on the accuracy of published suicide figures and the use of suicide figures for evaluation purposes.

In 2013, while 487 suicides were officially reported, when late-registered deaths are taken into account, this number increases to 543, an increase of 11.5 per cent.

In her presentation, Prof Arensman said it is not surprising that during the time of recession and austerity there was a peak in self-harm. However, there was a 30 per cent increase in self-harm in males aged 15-29 years old over a four-year period between 2009-2013.

She said that in her many years working in this field, she had never seen an increase of this scale before. Females in this age bracket also saw an increase, though not nearly to the same extent.

“Rates of self-harm are going down, but are not yet as low as the year prior to the recession,” she added.

“Unfortunately, in recent years, via our hospital-based self-harm rate, we are seeing an ongoing increase in highly lethal methods being used by young people in terms of self-harm. We all know when people use these kinds of methods, when there is a repeat act the lethality is likely to go up.”

There are many shared risk factors associated with self-harm in adolescents of both genders, including bullying and substance abuse.

“Sleep problems are one of the recently emerging factors,” Prof Arensman added. “And while you might think that’s down to depression, it seems to be related to insufficient sleep hygiene very much instigated by needing to be on-call for the world, online, 24 hours a day.”

The role of social media and the Internet was a particular concern of the presentation. According to a Biddle et al population survey of 21-year-olds published in 2016, of the 248 participants who had made suicide attempts, 6 per cent of the overall sample, almost three-quarters reported some kind of suicide-related Internet use at some point in their lives.

One-in-five had accessed sites giving information on how to harm oneself or take one’s life. The impact of the Netflix show 13 Reason Why was also highlighted. The show revolves around the suicide of a girl who takes her own life after suffering a series of demoralising events brought on by fellow pupils at her school.

“We still don’t know the extent in the increase of copycat suicides globally,” said Prof Arensman, but she added that via the International Association for Suicide Prevention, striking examples of clear copycat incidents were reported.

“Very recently, via our National Self-Harm Registry, we have identified a peak of hospital-reported self-harm in young people in the fifth week after the launch of this programme,” she said.

However, she also highlighted positive developments, such as the Youth Aware of Mental Health programme. This programme, which is aimed at improving pupils’ coping skills, has seen a reported greater-than-50 per cent reduction in incident-suicide attempts.

“This is clearly a programme to be recommended to be implemented,” she said.

Prof Arensman stressed that there is a wide variety of motivations for people self-harming, which need time to be identified. Recognising this ambivalence was crucial for those working with people who self-harm, the meeting heard.

Working closely with coroners since 2008, the Foundation examined the main characteristics of people (307 consecutive cases) who had died by suicides found that most were men (80 per cent) and a high percentage were unemployed at the time of death (33.1 per cent).

Nearly two-thirds had a history of self-harm (65.2 per cent); 69.1 per cent were diagnosed with depression and alcohol/and or drug abuse was present among 60.7 per cent. Certain employment sections, such as construction and production, also stood out where 48.6 per cent of men worked. Among women 26.5 per cent had worked in a healthcare setting.

New data from the national registry on self-harm on repeat episodes of self-harm have identified a subgroup of about 650 people who had self-harmed and who have presented to emergency departments over 13,000 times.

“Each time in there is a slight increase in their lethality,” she added.

In terms of evidence-based interventions, dialectical behavioural therapy among men who engaged in high-risk self-harm has not yet shown consistently positive results in reducing repeated self harm.

Speaking to this paper following her talk, Prof Arensman again highlighted her concerns about the increasing lethality of methods used in a shorter space of time.

“That is new, concerning information,” she said. “Since 2004 each year by young people there is a step-by-step increase in engaging in non-lethal self-harm but using highly lethal methods.”

If that person does not get the appropriate assessment they may move on to more lethal methods, she warned.

“Exposure by young people of lethal methods via social media is certainly a factor,” she said. “We have identified that people via social media make arrangements to go somewhere to end their lives, but we have also recently discovered that there are certain spots, including spots in Ireland and other counties, where people frequently go to take their lives. So you could say there is inappropriate promoting of these sites and the big question is who controls that in social media?”

She also urged the media and programme-makers to adhere to new WHO guidelines regarding suicide.

“I think the Department of Communications should re-enforce that. A number of first studies have already found adverse effects of the show 13 Reasons Why, which was released last year, and on top of that there has been very specific copycat cases of suicide.”

Drive for ‘unachievable’ muscularity and leanness a concern

Eating disorders (ED) in men are much more common than thought and male patients continue to feel marginalised in what is traditionally thought of as a female-centric issue, the Spring Conference of the College of Psychiatrists of Ireland was told. It also heard that a disproportionate number of men who identify as gay, bi-sexual or having the same-sex partner have higher instances of diagnosed and subclinical eating concerns.

Furthermore, the drive for increased upper body muscularity coupled with leanness is an increasing concern for psychiatrists and other healthcare professionals.

Until the 1970s there was a conspicuous absence of males in research and men were often excluded from clinical trials, and less than 1 per cent of peer-reviewed publications related to male patients.

However, there is a growing awareness amongst clinicians that it has been a myth that eating disorders do not affect a significant number of males, Prof Fiona McNicholas of Our Lady’s Children’s Hospital, Crumlin, told a session on the subject.

It is estimated from clinical populations that one-in-10 presentations is male, she said, adding that it is well recognised that as males are poor at help-seeking, these figures are probably an underestimation.

This number drops to four-to-one if the research is broadened to community surveys and epidemiological work, and “looking at prepubertal children, in Crumlin we see far more boys than girls relatively to what you would in adolescence”, the consultant psychiatrist said.

Anorexia is the least common eating disorder in males but the epidemiological prevalence would suggest that maybe 0.1 per cent or 0.2 per cent would have anorexia, she said.

“Over a lifetime, 25 per cent of cases of anorexia are in the male population, but only 10 per cent are help-seeking,” Prof  McNicholas said.

“Bulimia is more common in both males and female and community estimates place it over 1 per cent, which is quite significant, and 33 per cent of the lifetime diagnosis of bulimia is in young males.”

In males with bulimia, binges are “very common”, but there is not the same associated loss of control seen in female patients and they are much less likely to purge.

Binge eating is more gender neutral and has about the same number of males as females presenting based on both clinical help-seeking and community surveys. However, in males it is more likely to be accompanied with substance abuse disorder and other mental health disorders.

In terms of subclinical concerns, Prof McNicholas said that the desire for an upper body musculature and reduced body fat in order to assist with visibility was prevalent in college students, and it is estimated by Eisenberg et al, that 10 per cent of community samples in universities are using synthetic muscle enhancers. The drive for the so-called perfect male physique is also affecting very young children, the meeting heard.

However, there is a contradiction at the core of this ideal as muscularity is about the over-eating of specific foods, while the drive for leanness is associated with a reduction in calories, particularly in carbs and in fats.

“And this is what young boys and young males are oscillating between,” said Prof McNicholas. The media is contributing to this development through its depictions of the ‘perfect’ body and even brief exposure to such images has been associated with psychological distress. However, these dimensions of musculature, which many aspire to are unachievable, she said.

The presentations are also different between males and in females, she added. “You don’t have the same preoccupation with the need to reduce weight or a fear of fatness, they are much more concerned about increasing upper body mass.”

As well as affecting a disproportionate number of gay and bi-sexual men, the transgender group is a particular concern regarding ED, and surveys of young individuals from this group have shown there is a very high rate of eating concerns.

Prof McNicholas cautioned that ED is complex when it presents in a prepubertal girl or boy. Multifactoral issues can be involved including OCD and autistic spectrum disorder.

“We cannot use the same assumptions about the relation between social ideals and eating disorders that we give to adolescents and adults to the younger preschool, prepubertal children. They are just not correct,” she said.

In conclusion, she said that while Ireland was in the midst of an obesity epidemic, healthcare professionals and society needed to address this without slipping towards an overemphasis on body-image ideal. She also stressed the need to understand issues from a male perspective at all ages.

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