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’.
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.”
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.
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.
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.”
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
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.
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.
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.
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.
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.
Timing of vaccination vital for rheumatology patients
Rheumatologists need to consider what disease-modifying antirheumatic drugs (DMARDs) a patient is on when determining the appropriate time for vaccination, the Irish Society for Rheumatology (ISR) Spring Meeting in Kilkenny heard.
In a talk titled ‘Vaccinations: Timing and Targets for the Rheumatologist’, US-based infectious disease specialist Dr Kevin Winthrop said that while some DMARDs do not interact adversely with vaccines, others cause negative reactions.
“Rituximab, of course, ruins all vaccine response, so really it is about trying to pay attention to vaccine before rituximab, or at least six months after being on it, no matter what vaccine you are talking about,” Dr Winthrop told the Medical Independent (MI).
Dr Winthrop also spoke about how tofacitinib diminishes vaccine responses, in a similar manner to methotrexate.
This is especially significant for the influenza vaccine and pneumococcal vaccine.
“The big issue with JAK [Janus kinase] inhibitors is that there is this JAK-wide increase in zoster risk,” he said.
“It is a fairly big deal; it is a fairly large increase. It is a two- or three-fold higher risk than most of the other drugs. And so we are talking about using zostavax prior to using these drugs.”
Dr Winthrop, who is based at the Division of Infectious Diseases, Department of Medicine at Oregon Health and Science University, US, referred to research he was involved in that showed better responses are achieved for patients if methotrexate is stopped temporarily for two weeks prior to vaccination.
“That is a simple strategy that probably everybody here could use for flu vaccine, for pneumococcal vaccine and a lot of these patients are on methotrexate here,” he advised.
“This is a very clinically-relevant strategy that I think we should talk about.”
Dr Winthrop pointed out that rheumatologists rather than GPs are in the best position to vaccinate these patients as a result of their training and expertise.
“One problem we have, and I think you have it too, is that the GPs don’t really know what drugs these people are on, and they don’t know what their mechanisms are, and they don’t know how they would interfere with the vaccine,” he stated.
“And they don’t know if it is safe to give the vaccine to these people, usually. The best person to make that decision is usually the rheumatologist. They should know when it is safe, and they should know when the optimal time to vaccinate is. I think they are well-equipped to do that. And I think that is why this topic is so important, because it is important for the patient that this is done right.”
Need to avoid treatment target confusion for axial spondyloarthritis
There are a number of problems with the 2016 Assessment of SpondyloArthritis International Society/European League Against Rheumatism (ASAS/EULAR) recommendations for the management of the condition, according to Prof Nemanja Damjanov, Head of Clinical Department, Institute of Rheumatology, Belgrade, Serbia.
Speaking at the Irish Society for Rheumatology (ISR) Spring Meeting in Kilkenny, Prof Damjanov said that the guidelines, as currently configured, often result in “treatment target confusion”.
He argued that part of the confusion lies in the fact the guidelines state that disease activity can be measured by either the Ankylosing Spondylitis Disease Activity Score (ASDAS) or Bath Ankylosing Spondylitis Activity Disease Activity Index (BASDAI).
While ASDAS is a combination of patient-reported outcomes and C-reactive protein (CRP) levels, BASDAI is a fully patient-reported outcome.
“Increased ASDAS may lead to syndesmophyte formation, while this has not been proven for BASDAI alone,” Prof Damjanov said, citing research in the area.
“High BASDAI appeared to be a predictor for stopping TNF therapy, while a high ASDAS was a predictor for continuation of TNF, which can be seen as a surrogate outcome for efficacy.”
He also stated that frequently, there is a concordance between a BASDAI ≥4 and ASDAS ≥2.1, but in discordant cases, an elevated ASDAS was more predictive of a good response than an elevated BASDAI.
“ASDAS cut-offs for disease activity states and response activity criteria were based on a thorough validation process, while BASDAI cut-offs were arbitrarily chosen.”
Prof Damjanov also asked what is considered a “sufficient response” in phase 1 of treatment.
According to the guidelines, a decision should be based on continuous use of non-steroidal anti-inflammatory drugs (NSAIDs) to the symptoms of the patient rather than on a possible protective effect regarding structural progression.
The guidelines go on to state that if symptoms recur after stopping or dose reduction of an NSAID, continuous use should be advised.
“To avoid mistakes, we should use one best known way of disease management measurement,” Prof Damjanov said in conclusion.
“We should avoid using just change (delta) and define that a certain level of decrease of ASDAS is considered treatment success. We should define a preferred target (or targets) and use them as criteria for the treatment success or failure.”
Targeting autoantibodies could help RA patients
Recent evidence has shown that immune interventions targeting autoantibodies, in addition to inflammation, may provide additional therapeutic value in some rheumatoid arthritis (RA) patients.
At the Irish Society for Rheumatology (ISR) Spring Meeting, Prof Georg Schett, Head of the Department of Internal Medicine, Rheumatology and Immunology, Friedrich-Alexander University, Erlangen, Germany, spoke about the role of autoantibodies in the treatment of RA.
Prof Schett pointed out that bone erosion with no adequate bone response is a hallmark of RA and that “periarticular” osteoporosis is based on loss of intra-articular cortical and trabecular bone.
A key message of the presentation was how autoimmunity precedes RA.
Prof Schett explained that anti-citrullinated protein antibodies(ACPAs) and rheumatoid factors (RFs) in patients appear many years prior to RA onset.
IgA Rfs also appear in patients years prior to clinical symptoms.
He also explained how cytokines promote the differentiation of bone-resorbing osteoclasts.
“Autoantibodies stimulate osteoclast differentiation and trigger bone loss very early in the course of RA,” according to Prof Schett.
He was involved in recent research that showed disease-modifying antirheumatic drugs (DMARDs) targeting the adaptive immune response, such as abatacept and rituximab, significantly lowered anti-CCP2 IgG levels, while cytokine inhibitors and methotrexate had no significant effects on anti-CCP2 IgG levels. Rituximab is the only DMARD that also lowers total IgG level.
The purpose of the study was to show whether stable treatment with DMARDs affects anti-CCP2 antibody levels in patients with RA.
Difficulty filling rheumatology vacancies in the NHS
The NHS had difficulty filling rheumatology consultant posts last year, a UK-based consultant rheumatologist has said.
Prof Ashok Rai, who works in Worcestershire Acute Hospital, stated that some 30 per cent of consultant rheumatologist posts were not filled in 2017 and there is an ongoing supply and demand mismatch.
“At the moment, we have reached the situation whereby the number of posts we are trying to fill is greater than the number of suitable applicants,” Prof Rai told the Irish Society for Rheumatology (ISR) Spring Meeting in Kilkenny.
In relation to retirements, Prof Rai showed how 29 per cent of consultant rheumatologists in the UK are reaching the age of 65, while about 48 per cent will reach the age of 60 over the next decade.
Currently, there are approximately 870 consultant rheumatologists working in the NHS.
“We have a projected trend that approaches 1,000 to 2021, so we already have some issues about where we want to be,” he stated.
Prof Rai highlighted the importance of detailed workforce planning to adequately deliver future rheumatology services.
“The only way to do that planning is to have a database,” he told delegates.
“We do have a database of sorts in the UK, and that is the Royal College of Physicians dataset on workforce planning.”
The current salary for consultant rheumatologists in the UK for a basic 40-hour week is between £76,761 and £103,490, which is the equivalent to 10 sessions of four hours’ programmed activities (PAs).
There are also further payments for additional duties beyond 10 PAs/40 hours and through Clinical Excellence Awards.
Prof Rai said it is important to make posts as attractive as possible in order to recruit the best candidates.
At crisis point — delving into physician burnout
The topic of doctor burnout was the focus of a special presentation at the Irish Society for Rheumatology (ISR) Spring Meeting. Paul Mulholland reports
n the US alone, 400 physicians die by suicide each year. One of the main reasons behind these tragic events is burnout. In a wide-ranging and fascinating talk on the subject at the Irish Society for Rheumatology (ISR) Spring Meeting, which took place in Hotel Kilkenny on Friday, 23 March, Dr Paddy Barrett, Consultant Cardiologist in St Vincent’s University Hospital, Dublin, pointed out to delegates that this number is the equivalent of an entire graduating class taking their own lives annually. Those involved in healthcare are at substantially higher risk of suicide compared to the general population: Males are up to 2.5 times more likely to die by suicide, while females are four times as likely.
“When we think of suicide, people in healthcare don’t attempt suicide; compared to the general population people in healthcare ‘commit suicide’,” said Dr Barrett.
The severity of the issue was made plain to Dr Barrett when two physicians at the US hospital he was working in killed themselves over the course of a week. Since then, he has sought to understand the complex factors behind physician burnout and develop interventions to tackle the problem, which is endemic across the healthcare sector.
What is burnout?
Dr Barrett said that a strict definition of burnout is difficult to reach.
“When I thought of burnout, I thought of something where somebody collapsed at home, stayed in bed and really didn’t do anything, and who wasn’t a participant in actual medical practice, and doing their job on a day-to-day basis,” he said.
“But the reality is, the majority of people who are suffering from burnout are your colleagues, who are at work every single day. It is that angry person who is walking down the corridors and who is sometimes difficult to deal with and maybe that is the manifestation of them struggling with their job and maybe they are asking for help.”
Burnout was first described by the psychologist Herbert Freudenberger, but it is the work of Christina Maslach that has brought the term into the mainstream. Maslach, who is a social psychologist from the US, listed three core features of burnout: Emotional exhaustion; depersonalisation; and lack of efficacy.
Dr Barrett distinguished emotional exhaustion from normal fatigue. The latter could involve straightforward tiredness after a night on-call and needing to go to sleep.
“[Abnormal fatigue] is that you are depleted of all your energy levels, physical, emotional, spiritual levels, and that you really just have nothing left to give. Ultimately, that work takes more than you could ever hope to get back. So this is not regular fatigue. These are the descriptions you hear from people: ‘It is not that I don’t want to help, but it is that I can’t.’ And the analogy has been made to a bucket with large holes at the bottom, insofar as no matter how much you fill it, it still continues to drain. That is why when you take a day off, a weekend off, or even a week sometimes, it is not enough to address that problem.”
Depersonalisation often arises as result of physicians trying to protect themselves from the pressures of their job, stated Dr Barrett.
“We hear lines that you change, that you become tough, hard and cynical in order to survive,” he said.
“And sometimes without realising it, you act that way all the time, even with your wife and kids. And this is a feature that I think is worth stating, that just because you are having challenges at work doesn’t mean that these things can’t translate into challenges at home. It is an important feature to identify.”
On lack of efficacy, Dr Barrett said that someone who is burned-out comes to believe that nothing changes, no matter how hard they try.
“That was certainly an issue for me: You are doing procedures, you are putting in stents, but patients aren’t taking their medication, they are having in-stent thrombosis and you wonder, ‘why should I do this at all?’ But I think that is when you begin to lose sight of the reasons why you do what you do.”
He considered that the “acid test” for whether someone is burned-out is their attitude to going to work.
“It is the front door of your hospital,” said Dr Barrett. “It is the front door of your clinic, it is the front door of the place that you work. If you walk up to the front door of the place that you work and all you want to do is walk straight back out that door, then there is the likelihood that you are at risk of burning out, and that if everything and everyone who asks you to do anything is seemingly in your way, there is the likelihood you are burned-out.”
Dr Barrett stressed that the causes for burnout are complex and vary from country-to-country, institution-to-institution and from hospital department to hospital department. As extremely conscientious individuals who hold themselves to high standards, Dr Barrett said doctors tend to blame themselves rather than their environment when they begin to feel stressed or burned-out. However, environmental or organisational factors are the chief reasons behind the problem. While Dr Barrett said workload is an important factor, it is not the chief predictor of burnout.
“It is the biggest problem for those who are burned-out, but not the strongest predictor,” according to Dr Barrett.
“Therefore when we start addressing this by reducing hours, it is unlikely to make the biggest difference.”
Other contributors are a lack of rewards, a perception of unfairness in the workplace and no alignment between the values of the person and that of the hospital.
“But the number-one factor is a lack of control,” Dr Barrett told ISR delegates.
“This is control over our time, how we structure our schedules, how we are able to bring resources to bear over certain clinical scenarios, over the environment that we actually work in, and most importantly, our futures. Again, it is that state of weary indifference.”
What can be done?
Dr Barrett said that it is important to recognise that burnout cannot be treated in and of itself.
“The reason you can’t treat burnout is because burnout is a symptom of a problem that is driven largely by the ecosystem that we work in.”
Similarly, he explained that interventions focusing on the individual will not lead to lasting results, and that organisational change was required.
Shining a spotlight on burnout is the first part of addressing the problem, according to Dr Barrett, who added there is already evidence this is working. New figures in the US from Medscape show that the upward trend in physician burnout has stopped and the numbers are now going down.
“Although these figures are still way too high, it does demonstrate that the attention being brought on this area is making a difference and that meaningful reductions have been achieved,” he argued.
Also, Dr Barrett said there was a need for clinicians and healthcare managers to come together and start making the type of organisational changes that can make a difference for employees.
“Certainly, in the US, there’s the perception that this is an ‘us versus them’ problem,” he stated.
“It can feel that way, no matter where people are. But we are all part of the same system. We all have to work collaboratively and collectively together to make a difference. For anyone who runs an organisation, the first thing you can do is take the temperature… whatever survey tool you use, find out if it is a problem. After that, you can do a root cause analysis.
“There are a variety of different tools that you can use and they will give you an idea of where the true drivers are coming from. Now, you have something to aim for. When you have something to aim for, you have got a test that will take the temperature, you can find out the root cause, you can design an intervention, and then you can ‘rinse, wash and repeat’. And this requires organisational change.”
While Dr Barrett said there was no ‘silver bullet’ to reducing burnout, strong leadership and building communities were absolutely vital to improving the working lives of medical and healthcare professionals. A hospital’s occupational health department is also a good and under-utilised resource, he feels, for physicians who are burned-out.
“Their role is to provide the emotional wellbeing and support and actually have safe working environments for people who work within their organisations… they are very much attuned to dealing with this problem. So for anybody struggling in the immediate sense, this is an under-utilised resource that most people have an incredibly positive experience with.”
Reducing hours can be helpful but Dr Barrett does not believe this is the most important issue.
“If you decrease hours from 100 to 80 a week, it is not going to make a difference. But if you look at this idea of people working less than 70 hours a week, there is a difference. You need to recognise it is not simply about hours. Hours are a big problem for people who feel burned-out, but if people feel engaged and motivated and passionate about being in their work, the hours are less of a problem, so I feel we should focus less on them.”
Dr Barrett said career breaks can be a good thing, but stressed something has to change when the doctor returns to work.
Funding is required to make the necessary organisational changes to prevent burnout and make workplaces better for employees, Dr Barrett argued. Some hospitals, however, are reluctant to invest sufficiently to address the issue. Dr Barrett, who throughout his talk repeated that burnout was a quality and safety issue that affected patients as well as staff, said there were many benefits for those who put the necessary resources in place.
“It is not cheap, but it is worth it,” he said.
Eczema the ‘primary factor’ in allergy development
Eczema is the primary factor in the development of allergies in patients with eczema, heard the eczema symposium at the recent Primary Care Dermatology Society of Ireland (PCDSI) Annual Scientific Meeting.
PCDSI Chairperson GP Dr Finbar Fitzpatrick, speaking to the Medical Independent (MI) following the symposium, explained that speakers highlighted a number of important aspects, including a changed perspective in the aetiology of childhood eczema.
“The eczema is the primary factor and the allergy is the secondary development. Because the skin barrier isn’t intact allergens can be absorbed through the skin and you can get an altered immune response and then you develop the allergy because of that, rather than the allergy being primary, which is what most lay people think,” Dr Fitzpatrick related.
This issue was highlighted in a talk on allergy in atopic dermatitis by Dr Deirdre Buckley, Consultant Dermatologist, Royal United Hospital, Bath, UK.
Dr Buckley relayed the importance of a normal diet in infancy and early childhood, including peanuts and eggs. Having peanuts as a normal component of diet reduces the risk of developing allergic atopic eczema, rather than increasing it, Dr Buckley said.
Limerick GP Dr Johnny Loughnane, in his presentation on topical anti-inflammatory therapy in eczema, looked at the use of topical steroids and their appropriate role in the management of eczema and the emerging role of tacrolimus ointment in moderate eczema and the maintenance of eczema.
He also highlighted the maintenance role in some patients of a weekend topical steroid regime, ie, using steroid cream two days a week.
A number of speakers noted the risk of ‘steroid phobia’ in the community and on the Internet, but outlined that in reality most dermatologists feel topical steroids are being under-used in primary care, Dr Fitzpatrick said.
Dr Loughnane highlighted the value of ointments and advised that GPs prescribe 90 per cent ointments and 10 per cent creams, as there are fewer preservatives in ointments and they are 10 per cent more effective than creams.
Dermovate is the most potent steroid and hydrocortisone is the weakest. Dermovate is 600 times more potent than hydrocortisone. Mild and moderate steroids, such as Eumovate and hydrocortisone, are relatively safe to use in children, the meeting heard.
Infection in eczema, mainly seen in primary care, was also covered. GPs were advised on how to identify herpetic eczema and treat it as a medical emergency during a presentation by Dr Rosemarie Watson, Consultant Paediatric Dermatologist, Our Lady’s Children’s Hospital, Crumlin.
Dr Watson also mentioned the CREAM study in the UK involving 300 children, which found there was no benefit seen in oral or topical antibiotics over steroids in eczema.
Mr Paul Herriot from Lyric FM provided an absorbing insight for delegates into the patient experience and psychological impact of living with severe eczema all his life.
This was the first time a patient spoke at the PCDSI conference and there are plans to include patients in the line-up at future conferences.
Delegates also heard that 1-to-2 per cent of the EU population is allergic to fragrances. Methylisothiazolinone is a preservative found in sunscreen, soaps and detergents and can cause allergic reactions in patients.
Huge turnout at PCDSI conference
Around 400 doctors attended the Primary Care Dermatology Society of Ireland (PCDSI) Annual Scientific Meeting in Limerick recently.
The three-day event saw an average of 200 doctors in attendance each day, with a day-long eczema symposium featuring 11 presentations opening the event on Thursday 8 March.
According to PCDSI Chairperson, GP Dr Finbar Fitzpatrick, eczema is an every day presentation in general practice and GPs are the mainstay of the management of eczema in clinical practice.
It is understood that around 12 per cent of general practice consultations are skin-related and for GPs with an interest in dermatology, this can rise to as high as 20 per cent.
Traditionally, at undergraduate level, there has been a gap in dermatology education and some doctors on GP training programmes feel that their dermatology education is incomplete, Dr Fitzpatrick said.
“This is a place where the PCDSI can fit in, completing a GP’s education in dermatology,” he advised.
A further 10 presentations took place on Friday 9 March, and 14 talks were held on Saturday 10 March, when advanced and basic sessions were run concurrently for GPs with varying skills and expertise in dermatology.
Dr Fitzpatrick paid tribute to Limerick GP Dr Johnny Loughnane, who put together the programme for the event.
Next year’s meeting will take place in Galway at the Galmont Hotel on 21-23 February.
Topical treatment more effective than oral tablets in fungal nail infections
Research shows that some 82 per cent of fungal nail infections are clinically cured at six weeks with Canespro, Dr Rachel Morris-Jones, Consultant Dermatologist, King’s College Hospital, London, told the recent Primary Care Dermatology Society of Ireland (PCDSI) Annual Scientific Meeting.
Canespro (40 per cent urea), used for the treatment of onychomycosis, can be purchased over-the-counter (OTC) and applied by the patient to the affected nail plate. The nail is then covered and left overnight. This is repeated daily for four-to-six weeks.
Dr Morris-Jones, who favours the treatment, said the advantages are that the patient can apply the treatment themselves, no tablets are involved, the treatment is pain free and there is an immediate improvement in nail appearance.
While there has been promise in regard to laser treatments for fungal nail infections, unfortunately the relapse rate is high, Dr Morris-Jones noted.
In terms of oral tablets, she advised that amorolfine has a 20 per cent cure rate at three-to-four months and terbinafine has a 56 per cent cure rate at 10 months.
Key signs of fungal nail infection include thickening of the nail, nail discolouration and crumbling of the nail.
The presentation by Dr Morris-Jones on fungal skin infections examined tinea pedis, corporis and cruris, tinea capitis, pityiasis versicolor, seborrhoeic dermatitis, onycomycosis and vulval candida.
She advised delegates at the PCDSI meeting to take a sample (skin and/or nail scrapings) from the affected area at a patient’s first visit, if time and resources allow.
Dr Morris-Jones noted that tinea pedis, or athlete’s foot, is incredibly common and most patients will treat themselves using OTC products. But it can be recurrent and is characterised by itchy skin and mascerated skin in toes with no spaces.
“Tinea pedis is incredibly common. It’s obviously itchy and it tends to start in the fourth toe web… this is a really good place to look for the start of tinea pedis,” Dr Morris-Jones advised.
She highlighted that some patients have toes that fit close together with no air or gap between them and that efforts should be made to try and change the environment and dry-out the skin to avoid tinea pedis recurring.
A number of OTC products can do this and patients can be in charge of their own foot management going forward, she advised.
Rapid access photo-triage for haemangiomas
A new rapid access national photo-triage investigation pathway for infantile haemangiomas is available for primary care healthcare professionals, heard the Primary Care Dermatology Society of Ireland (PCDSI) Annual Scientific Meeting in Limerick.
Dr Rosemarie Watson, Consultant Paediatric Dermatologist, Our Lady’s Children’s Hospital, Crumlin, noted the development in her presentation on common lesions in the newborn.
The service, established by Cork-based Consultant Dermatologist Dr Michelle Murphy and the HSE, allows GPs to send a photo of a haemangioma along with the baby’s date-of-birth and date of the photo.
Dr Murphy reviews the image and decides if referral is advised. She also provides the contact details for the local dermatology team for referral. The email is email@example.com.
New parents can be concerned about skin lesions, but they are very common in newborns and many fade and disappear spontaneously, Dr Watson said.
“It’s our job to reassure, when it’s appropriate to reassure and to investigate or refer when that is appropriate also,” Dr Watson noted.
It is important to be aware of precursor lesions in haemangiomas as one may need to act on these quickly, Dr Watson outlined.
The first aspect noticed is blanching and a bruised appearance, Dr Watson said. Classic infantile haemangiomas are not present at birth and this is an important point to state in the history, when referring. They usually develop in the first four weeks of life.
Four weeks to three months is the most worrisome time in terms of proliferation. Some 90 per cent stop growing by six months and accelerated growth occurs between 5.5– seven weeks.
Periocular haemangiomas need instant referral and haemangiomas on the upper eyelids have more complications. Deep haemangiomas with retrobulbar extension and squint require early treatment.
Meanwhile, large haemangiomas can be very troublesome, but respond excellently to propranolol treatment, Dr Watson noted.
Haemangiomas on the beard location, cheek, chin and lower lip areas are linked to a risk of airway involvement and require referral. Referral is also recommended in children with multiple haemangiomas.
Port wine stains (PWS) affect one-in-300 babies and the majority are on the face. They can vary from 1cm to covering half the body.
Parents are often concerned about their cosmetic effect. Dr Watson said that laser in early childhood is recommended. Some 70 per cent of patients will get 50 per cent lightening with laser. But 10 per cent won’t get significant lightening, therefore it is “not a magic wand”, Dr Watson cautioned.
Dr David Paige, Consultant Dermatologist, Barts Health NHS Trust, UK, followed up with an informative talk on common rashes in newborns.
Recognising psychocutaneous disease in general practice
The psychocutaneous area is a relatively new sub-specialty interest in dermatology, Dr Bart Ramsay, Consultant Dermatologist, University Hospital Limerick, told delegates at the Primary Care Dermatology Society of Ireland (PCDSI) Annual Scientific Meeting.
His presentation on psychocutaneous disease aimed to enhance recognition of the condition and treatment.
“Managing patients in this cohort can be challenging and the aetiology of psychocutaneous disorders can be quite complex,” Dr Ramsay explained. “We looked back at recent years’ experience with these patients and when we referred patients to our clinical psychologist, we find that there can be distress associated with an underlying skin condition, just like psoriasis. There can be repetitive behaviours causing damage to the skin…then there can be things that have happened in the patient’s life that led to the development of skin disease.
“The assessment that we find from our clinical psychologist… can uncover issues including past physical and emotional abuse; psychological trauma of different types, sometimes grief, but sometimes suicidal ideation; and often, these are issues that are rarely uncovered in the initial referral.”
Dr Ramsay spoke about four areas: Cutaneous signs of eating disorders; body dysmorphic disorder (BDD); delusion of parasites; and dermatitis artefacta (DA).
Dr Ramsay detailed the cutaneous signs of eating disorders, including: Disordered diet/malnutrition (lanugo hair); vomiting-related signs (acute tears or erosions of the knuckles, callosities, parotitis); laxative/drug abuse (pruritus); and psychocutaneous disorders (self-inflicted trauma).
A detailed outline of skin, hair and nail signs were highlighted, including telogen effluvium and androgenic alopecia; brittle nails and digital clubbing; and enamel erosion, among others.
BDD is quite common and could be present in up to 13 per cent of the general population. Patients are said to be rich in symptoms, but poor in signs, Dr Ramsay related.
Up to 15 per cent of people who attend cosmetic surgery may have BDD. The condition is under-recognised in dermatology, Dr Ramsay added.
It is important to be aware of the disorder, as almost 60 per cent of BDD patients will think about suicide and 25 per cent attempt suicide, Dr Ramsay said.
Patients with delusions of parasites have a psychiatric disorder, but they present to dermatologists. Patients often look well but usually reject psychiatric referral. They have sensations of crawling, biting and stinging, Dr Ramsay explained.
DA refers to self-inflicted cutaneous lesions and is seven times more common in women. It may be symmetric, but can be asymmetric and often in reach of the dominant hand.
It can be seen as facial rashes and linear lesions and can be induced by cutting, rubbing, picking, etc. Dr Ramsay said meditation is being explored to help patients with DA.
Many viral skin diseases ‘vaccine preventable’ — consultant
In MMR (measles, rumps, rubella) vaccine given to an unvaccinated person or a person who has been partially vaccinated within 72 hours following exposure to measles has been shown to prevent infection.
Dr Catherine Fleming, Consultant in Infectious Diseases, University Hospital Galway, made the remark regarding post exposure prophylaxis during her presentation, ‘What’s New in Viral Skin Disease’, at the Annual Scientific Meeting of the Primary Care Dermatology Society of Ireland (PCDSI), which recently took place in Limerick.
Dr Fleming focused on several viruses in her address, including measles, zoster and HPV.
She highlighted specific cases with each virus and noted that many of the viruses are vaccine-preventable infections and a greater focus on prevention is required.
In relation to measles, she related that Limerick is in the midst of a measles outbreak. On 17 February last, there were 20 cases of measles in the Limerick area, Dr Fleming advised.
Nine of the 20 were under the age of five and all were unvaccinated. Eleven of the 20 were aged five-to-34 and two had at least one MMR vaccine dose, Dr Fleming said.
Some 95 per cent vaccination in the community is required for herd immunity to prevent transmission. If vaccination rates are lower than that, one case can spread.
At age 24 months, the MMR vaccine rate in Limerick city is 88 per cent, and 93 per cent in the Mid West.
If measles is suspected, the advice is to isolate the patient immediately and obtain a sample for diagnosis, Dr Fleming said.
Turning to shingles (herpes zoster) and chicken pox (varicella), Dr Fleming pointed out that chicken pox does not cause shingles, but that shingles can occasionally cause chicken pox.
Chicken pox patients under the age of one year and over the age of 12 years should receive treatment, as well as patients with chronic skin or lung disease, pregnant women and immunosuppressed patients.
Dr Fleming recommended GPs treat shingles as early as possible, within 72 hours of the onset of rash. She outlined that everyone should be treated and definitely if over 50 years of age. Once the rash is present for over 72 hours, it is not clear that treatment makes a difference, she said.
“In adults, we are now advocating varicella vaccination to prevent shingles. The idea is to boost this waning T-cell immunity to the varicella zoster virus. The idea is to reduce the risk of shingles,” Dr Fleming noted.
Managing the skin barrier
In informative presentation titled ‘Managing the Skin Barrier — Moisturisers, Bandaging and Wet Wraps’ was delivered at the Primary Care Dermatology Society of Ireland (PCDSI) eczema symposium, which took place during its Annual Scientific Meeting in Limerick.
Ms Sheila Ryan, Dermatology Advanced Nurse Practitioner, University Hospital Limerick, give a detailed talk on how health professionals can educate patients and parents on protecting the skin and limiting irritation and itching.
She recommended that people with eczema avoid bubble baths, soaps, toilet wipes and baby wipes, especially where the latter contain the chemical Kathon, which can cause allergic skin reactions.
Ms Ryan advised that children should sleep in their own bed to minimise excessive heat, pets should be kept out of the bedroom, and fluffy toys should be minimised and placed in the fridge to keep cool.
Paraffin-based creams have been linked to 37 deaths from fire across the UK since 2010, Ms Ryan highlighted. She noted that there is an increased risk with impregnated clothing/dressings, smokers, elderly/disabled, airbeds and other medical devices.
Turning to the use of bath oils and washing products in the management of eczema, Ms Ryan explained that they are used to cleanse and hydrate the skin.
Patients should bathe in lukewarm water for 10-to-15 minutes. Recommended bath oils include Oilatum, Aveeno and Hydromol. Oilatum also has a shower gel formulation. Meanwhile, antiseptic bathing options for eczema include Emulsiderm emollient and Milton bleach baths (120ml or four capfuls per 100 litres).
In relation to how to use moisturisers, Ms Ryan advised that patients consider using cream from pumps and tubes to avoid contamination. She also recommended that cream be applied in downward strokes in the direction of hairs and that massage should be avoided, as it can generate heat on the skin and possibly lead to folliculitis.
For young children, Ms Ryan encouraged ointments, bathing and covering with clothing. For older children, she suggested creams/moisturisers during the day and ointments in the evening. Healthcare professionals should also encourage self-application and parental involvement.
For adults, care depends on disease severity and lifestyle. Cream should be applied daily (ointment if severe) and a bath/shower regimen followed to avoid irritation.
With older adults, application of creams can depend on dexterity, but pumps/tubs and tubes are advised, Ms Ryan outlined. Slippage from greasy creams/oils in baths is a risk and smokers should be aware of fire hazards from paraffin creams. Heavier emollients should be used and advice given on washing.
Finally, wet wraps can also be used in the management of eczema due to their cooling effect, enhanced moisturisation, enhanced steroid penetration and protection from scratching, Ms Ryan advised.
Leg ulcers a ‘huge psychosocial burden’
Leg ulcers are a huge problem and 1 per cent of the population in developed countries will have leg ulcers at any one time, delegates at the recent Primary Care Dermatology Society of Ireland (PCDSI) Annual Scientific Meeting heard.
The majority of leg ulcers are managed in primary care and are due to venous disease. They place a huge financial burden on society and in the UK, it is estimated they cost £168-to-198 million annually, Ms Sheila Ryan, Dermatology Advanced Nurse Practitioner, University Hospital Limerick, advised in her presentation on leg ulcers.
She noted that leg ulcers have a big psychosocial burden, as they can cause social isolation.
When assessing an ulcer, she recommended physicians examine how it started, comorbidities, medications, allergies and general presentation.
It should also be noted whether or not the patient has diabetes, rheumatoid arthritis, vasculitis or peripheral vascular disease.
Other important factors are pain and nutrition, as it will be necessary to optimise the nutritional status for healing. The patient’s ability to undertake self-care and compliance should also be assessed.
Around 70-to-80 per cent of leg ulcers are venous, 10-to-20 per cent are mixed venous and arterial and 10 per cent are arterial, Ms Ryan stated.
A clinical examination should look at the site of the ulcer, as 90 per cent of venous ulcers are in the gaiter area and arterial ulcers are dorsal and plantar.
If a patient is in a lot of pain, this could suggest an arterial ulcer. Meanwhile, the size of the ulcer should be measured, surrounding skin examined and evidence of any exudate documented.
Investigations should include an ankle brachial pressure index, bloods, swab for culture (if relevant) and a biopsy if required, Ms Ryan said.
General skin care of leg ulcers includes cleaning the entire leg using water and a soap substitute. The leg can be soaked in Hydromol and moisturised using an ointment base. Removal of hyperkeratotic scales is advised.
The antiseptic drying agent potassium permanganate is effective for infected legs, Ms Ryan noted. She recommended using one permitab for a local soak in a tub and two in the bath for a 10-minute soak.
Oedema management, meanwhile, is a huge problem and services for people with leg oedema are not abundant, Ms Ryan noted. She advised getting patients to elevate legs, exercise, avoid standing and optimise skin care. Support stockings and compression should also be used where appropriate.
Arterial leg ulcers will often have a ‘punched-out’ appearance, increased pain and are typically associated with the toes, heels and bony prominence of the foot.
Surrounding skin will have a dusky erythema, be cool to touch and there will be loss of hair. There may also be decreased or absent pulses, reduced capillary refill, thickened or absent toenails and gangrene of the extremities.
Arterial management involves several factors, including vascular assessment, stopping smoking, diabetes control, blood pressure, lipids and foot and leg skin care. Avoid compression and the dressing used will be determined by the ulcer, she said.
Some 95 per cent of venous ulcers are located in the gaiter area. Pitting oedema, haemosidern deposits and lipodermatosclerosis should be noted.
Compression therapy is the gold standard for venous leg ulcers and the only treatment proven to work, she said.
Dr Sinéad Harney has succeeded Dr Sandy Fraser as President of the ISR.
Dr Harney graduated from University College Galway in 1994 and did her specialist training in rheumatology and general medicine in Dublin. She completed her training in Oxford in 2005 and was awarded a DPhil by thesis titled ‘Major Histocompatibility Genetics of Rheumatoid Arthritis’. She was appointed to a Consultant Rheumatologist post in Cork University Hospital in 2005 and has worked there since. She completed a Masters in Sports and Exercise Medicine in University College Cork in 2007. Her research interests include the genetics of inflammatory arthritis and occult cardiovascular disease in rheumatoid arthritis and she has over 90 publications.
Dr Sinéad Harney
Leading the charge for rheumatology
The molecular and cellular pathogenesis of autoimmune diseases, and the reality of physician burnout, will be among the diverse topics presented at the upcoming Spring Meeting of the Irish Society for Rheumatology (ISR) on 23 March in Kilkenny.
The Spring Meeting is a key event in the calendar of the ISR, which organises and hosts regular platforms and conferences allowing members to present and hear updates on clinical and scientific matters. The organisation of this year’s Spring Meeting has been led by Consultant Rheumatologist Dr Maurice Barry.
The event will be preceded by a meeting of the Clinical Advisory Group of the National Clinical Programme for Rheumatology, whose Clinical Lead is Prof David Kane. The specialty has witnessed some improvements in provision of allied healthcare professionals in recent years, but manpower and infrastructural issues still loom large, according to ISR President Dr Sinéad Harney.
Dr Harney says there is approximately one consultant rheumatologist per 125,000-200,000 population, whereas it should be one per 80,000, suggesting a doubling of numbers, at the least, is required.
However, there has been a “welcome” recent expansion in specialist nursing provision and musculoskeletal physios, says Dr Harney, a Consultant Rheumatologist at Cork University Hospital (CUH).
“There has been a small consultant expansion in Sligo, Galway, Kerry – other than that there has been very little. We are well below the European average and lack of consultant manpower is a huge issue,” she tells the Medical Independent (MI). Around 90 per cent of rheumatologists in Ireland also provide a general medicine service, which restricts their availability to manage rheumatology caseload.
There is also lack of access to day beds for infusions and this greatly hampers rheumatologists’ ability to treat patients in a timely fashion. The State has been “remiss” in its funding of rheumatology infrastructure, according to Dr Harney.
“In our hospital, since I arrived 13 years ago, there have been no infrastructure investments [in rheumatology]… we got one infusion centre we share with six other departments, funded by industry and other than that my patients are on a waiting list to come in for infusions and we have to admit people overnight for infusions … so the lack of HSE infrastructure has been probably the biggest problem.”
One of the most anticipated talks at the ISR Spring Meeting will focus on the molecular and cellular pathogenesis of rheumatic and autoimmune diseases. This presentation will be delivered by Prof Georg Schett, Professor at Cytokine Signalling Forum, University of Erlangen, Germany.
Prediction of remission is a topic of huge interest to the specialty and their patients.
“I think predictors of remission is really important if we are going to be using expensive drugs; if you don’t need to use them, you don’t need to use them, if you do need to use them, you should. I think the right drug for the right patient at the right time is the panacea.”
Drug development in rheumatology “is unrecognisable now from what it was 25 years ago when I started”, notes Dr Harney. She says a positive feature of the Irish health system is that access to high tech medicines is “better than most places – so our patients get access to drugs quite quickly and that doesn’t happen everywhere, and as a result, people do better”.
One of the most interesting and recent drug developments has been licensing in Ireland of oral Janus kinase (JAK) inhibitors for treatment of RA, namely baricitinib (Olumiant) and tofacitinib (Xeljanz).
“[JAK inhibitors] have been used in the States quite extensively, but we have very little clinical use in Ireland so far and they got into the EULAR [European League Against Rheumatism] guidelines for the management of RA [as a second-line treatment] very quickly,” notes Dr Harney. “They are of particular interest.”
Biosimilars is another emerging area. CUH has a biosimilars group chaired by Consultant Rheumatologist Dr Gráinne Murphy “and in principle we are going to be introducing biosimilars over the next year with inherent cost savings”.
According to Dr Harney, “some of our colleagues across Ireland have been introducing them gradually, so I think they are here to stay… ”.
The plan at CUH is that biosimilars will be introduced with physician autonomy as a precondition, such that clinicians would employ their clinical judgement on a case-by-case basis in deciding on their use.
“So it is not going to be imposed by the hospital, but it is going to be advocated by this committee,” outlines Dr Harney. In the UK, she adds, designated nursing staff have had a key role in educating patients on biosimilars “and we would need staff to do that here as well, so hopefully that would happen”.
Another interesting presentation focusing on vaccination will be delivered by Dr Kevin Winthrop, Department of Infectious Disease, Oregon Health and Science University Infectious Diseases, US.
Often patients with autoimmune conditions on disease-modifying antirheumatic drugs do not take up recommended vaccination and this issue requires further awareness-raising.
“They should have a vaccination against the flu every year and vaccinations against pneumonia every five years…
“We are trying to improve awareness, and we have it on our letter going out from the department [in CUH]. There is increasing awareness on that and I think we are improving because we are certainly focusing on it.”
An important area of focus among Irish rheumatologists is cardiovascular risk in RA patients. Research is being led by Dr Miriam O’Sullivan, Our Lady’s Hospital, Manorhamilton, along with Prof John Carey in Galway University Hospitals and involving Dr Harney at CUH.
The research is part of a wider EU initiative.
“It is basically about the necessity to think about people’s cardiovascular risk, treat the treatable risks and also acknowledge and increase public awareness of the risk, that rheumatoid arthritis is an independent risk factor for heart disease and you could probably say the same for psoriatic and ankylosing spondylitis,” adds Dr Harney.
Meanwhile, physician burnout is a “really relevant” topic for the profession, says Dr Harney, and a presentation on the matter will be delivered at the Spring Meeting by Dr Paddy Barrett, Consultant Cardiologist, Blackrock Clinic, Dublin and founder of My Heart Health.
Also on the agenda will be opportunities for graduates in the UK and a focus on ‘problems with the 2016 ASAS/EULAR recommendations for management of axial SpA’, as outlined by Prof Nemanja Damjanov, Professor of Internal Medicine, Head of Clinical Department, Institute of Rheumatology, Belgrade, Serbia.
Paul Mulholland reports on the recent ISMO Fellowship and Bursary Awards 2018