The heart and stroke charity Croí, which is based in Galway, has recently expanded its multidisciplinary health team at the Heart and Stroke Centre in the city. The charity, which was founded in 1985 and continues to support the development of cardiac and stroke services in the region, is leading the way in designing and testing lifestyle and behaviour change models of care focused on disease prevention and rehabilitation.
As an example of this, Croí is engaged in developing a model of community cardiac rehabilitation, which could supplement existing programmes that are hospital-based. This is a HSE Health and Wellbeing Division-funded initiative to address the identified need for increased and standardised provision of cardiac rehabilitation, which is a priority of the Health and Wellbeing Division, for implementation under the HSE’s National Framework for Self-Management Support for Chronic Conditions. This project aims to examine the feasibility of providing community-based cardiac rehabilitation and determining the effectiveness and scalability of such a programme in an Irish setting. The initiative, which is based on the Croí MyAction Programme, meets the British Association of Cardiac and Pulmonary Rehabilitation (BACPR) standards and core competencies.
Mr Neil Johnson, CEO, Croi
A needs assessment of cardiac rehabilitation (phase 3) in Ireland, carried out in 2016, found that only 39 per cent of the need for cardiac rehabilitation is met by current capacity nationally, at the narrowest definition of need (ie, patients admitted to hospital with acute coronary syndrome; post-revascularisation; or heart failure). The gap in provision is variable around the country and similar in the Saolta Hospital Group to the national picture. When you broaden the criteria for referral to include patients with a wider range of conditions for which cardiac rehab is recommended, the deficit is even greater. Expansion of current capacity by a minimum of 61 per cent is required nationally.
Ideally, the development of a community-based cardiac rehabilitation programme should contribute to increased access and availability of cardiac rehab for the population and support current hospital provision, which is delivered by excellent cardiac rehab co-ordinators and staff who have been operating against a backdrop of significant cutbacks in recent years.
Leadership in prevention and recovery
In 2014, Croí launched the National Institute for Preventive Cardiology (NIPC), affiliated to the College of Medicine, Nursing and Health Sciences at NUI Galway. The aims of the Institute are to provide leadership through discovery, training and applied programmes in the prevention and control of cardiovascular disease; promote healthier living; raise the standards of preventive cardiology practice; and prepare leaders to advance preventive healthcare in Ireland. Currently, over 1,200 healthcare professionals, educators and researchers have joined the NIPC Alliance, which provides regular updates on latest research, highlights hot topics, and profiles upcoming training and education opportunities. Membership of the NIPC Alliance is free — see www.nipc.ie for further details and to sign-up for the monthly e-bulletin.
NIPC education and training opportunities include an MSc Degree and Postgraduate Diploma in Preventive Cardiology at NUI Galway, associated with the founding programme at Imperial College London. Applications are now open for the fifth year of this programme, which commences in September 2018. This level 9 course, which uses blended learning, is available as a one-year, full-time, in-service programme leading to an MSc, or a nine-month, full-time, in-service programme leading to a PG Diploma. Further details are available at www.nuigalway.ie/medicine.
Other upcoming NIPC education and training opportunities include a ‘Cholesterol Masterclass’, which takes place in the Herbert Park Hotel, Dublin, on Friday, 27 April. Key sessions include: Updates on ‘Lipid Guidelines for Optimal Management’ by Dr Patricia O’Connor, Consultant Physician and Clinical Pharmacologist, St James’s Hospital, Dublin; ‘Management of Lipids in Special Populations’ by Dr Dermot Neely, Consultant in Clinical Biochemistry and Metabolic Medicine, Newcastle upon Tyne NHS Trust; ‘Statin Intolerance — the Controversies’ by Dr Susan Connolly, Consultant Cardiologist, Western Health and Social Care Trust, Northern Ireland; ‘Familial Hypercholesterolaemia in Ireland’ by Dr Vivion Crowley, Consultant Chemical Pathologist, St James’s Hospital, Dublin; and ‘Challenges to Adherence’ with Dr Joe Gallagher, GP, Wexford. Register for free at www.nipc. ie/conferences.html.
Another upcoming NIPC course which may be of interest to GPs, hospital doctors, nurses and other healthcare professionals is a one-day workshop, ‘Demystifying the ECG’, which takes place in the Croí Heart and Stroke Centre, Galway, on Saturday, 24 March. This excellent training course is delivered by Dr Paul Nolan, BSc ASCST, Chief Cardiac Physiologist at Galway University Hospital. Registration is now open at www.nipc.ie.
Women with asthma who only use short-acting asthma relievers take longer to become pregnant than other women, according to a new study published in the European Respiratory Journal.
However, the study of more than 5,600 women in Ireland, Australia, New Zealand and the UK also shows that women with asthma who use long-acting asthma preventers conceive as quickly as other women.
While maternal asthma has been consistently associated with significant perinatal morbidities and mortality, impacts on fertility are conflicting, according to the study authors. In light of limited and conflicting evidence, the aim of the study (‘Asthma treatment impacts time to pregnancy: Evidence from the international SCOPE study’) was to examine the impact of asthma and asthma medication use on fecundability and time to pregnancy.
The researchers examined data from the international Screening for Pregnancy Endpoints (SCOPE) study, which recruited more than 5,600 women expecting their first babies in the early stages of pregnancy.
Ten per cent of women in the study said they had asthma and, overall, these women took longer to get pregnant.
When researchers separated this group according to the types of asthma treatments they were using, they found no difference in fertility between women using long-acting asthma treatments and women without asthma.
Women using short-acting reliever medication (beta-agonists) took 20 per cent longer to conceive on average. They were also 30 per cent more likely to have taken more than a year to conceive, which the researchers defined as the threshold for infertility.
This difference remained even after researchers took other factors known to influence fertility, such as age and weight, into account.
The study was led by Dr Luke Grzeskowiak from the University of Adelaide’s Robinson Research Institute, who said that the results provide reassurance for asthmatic women that using inhaled corticosteroids to prevent symptoms does not appear to reduce fertility.
“Five-to-10 per cent of all women around the world have asthma and it is one of the most common chronic medical conditions in women of reproductive age. Several studies have identified a link between asthma and female infertility, but the impact of asthma treatments on fertility has been unclear,” Dr Grzeskowiak said.
“Studying the effect of asthma treatments in women who are pregnant or trying to get pregnant is important, as women often express concerns about exposing their unborn babies to [the] potentially harmful effects of medications.”
While the study showed that women using short-acting asthma relievers take longer to get pregnant, “on the other hand, continued use of long-acting asthma preventers to control asthma seems to protect fertility and reduce the time it takes women with asthma to become pregnant. This could lead to a reduction in the need for fertility treatments”.
“There is plenty of evidence that maternal asthma has a negative impact on the health of pregnant mothers and their babies, and so our general advice is that women should take steps to get their asthma under control before trying to conceive,” he said.
“What we don’t yet know is exactly how asthma or asthma treatments lead to fertility problems. As well as affecting the lungs, asthma could cause inflammation elsewhere in the body, including the uterus. It could also affect the health of eggs in the ovaries.
“Inhaled corticosteroids suppress the immune system, whereas short-acting asthma treatments do not alter immune function. In women who are only using relievers, it’s possible that, while their asthma symptoms may improve, inflammation may still be present in the lungs and other organs in the body.”
The researchers plan further studies involving women with asthma who are undergoing fertility treatments, to see whether improving asthma control could also improve fertility outcomes.
Meanwhile, a separate study presented at the 2017 European Respiratory Society International Congress in Milan found that women with asthma are more likely to have fertility treatment before giving birth than non-asthmatic women.
Among 744 pregnant asthmatic women enrolled in the ‘Management of Asthma During Pregnancy’ programme at the Hvidovre Hospital, Hvidovre, Denmark, and who gave birth between 2007 and 2013, 12 per cent had received fertility treatment compared to 7 per cent of the 2,136 non-asthmatic women in the control group.
Although the study does not prove that asthma played a role in reducing fertility in some women, the researchers said it suggests that improving women’s asthma control might help them to become pregnant more easily.
Prof Charlotte Suppli Ulrik, from the Department of Respiratory Medicine at Hvidovre Hospital, who supervised the study, said: “We don’t have the hard-core evidence but based on what we know, it seems very likely that good asthma control will improve fertility in women with asthma by reducing the time it takes to become pregnant and, therefore, the need for fertility treatment.
“However, when it comes to fertility for women, age is a crucial factor — so the message, particularly for women with asthma, is don’t wait too long, as it might reduce your chances of having children.”
Prof Suppli Ulrik and colleagues are setting up studies to investigate further the association between asthma and fertility, including a study addressing the impact of good asthma control on fertility. “Further studies are needed to confirm our findings,” she said.
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