Forum cover Jan 03 - Irish College of General Practitioners€¦ · ‘Roll-out’ is that dreaded...

ObesityThe public health timebomb

Journal of the Irish College of General Practitioners

FORUM, Ireland’s

Journal of Distance Learning

Volume 20 Number 1 January 2003

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up front

7 Editorial: The national treatment purchasefund reeks of political expedience rather thanrational planning, writes Medical Editor, DrNiall Maguire

news and views

8 News: Job demands force GPs to continueworking while sick…GP training sub-committees seek new members…Dr FionaBradley remembered…Patients respond wellto pilot alcohol programme… Global awardhonours family doctors’ achievements…GPsoftware accreditation overhaul…GP examsand training deadlines loom

NEWS

features

16 Cover Story: Obesity has reached epidemicproportions yet the public remains unawareof the health implications, writes DeborahCondon

19 My Place: This month Anne Henrichsenvisits a practice in Baltinglass which isparticipating in the Alcohol Aware Practicepilot study

23 Practice Management: Your practice-relatedquestions tackled by Dermot Folan

24 Health in Practice: The HiP programmeacknowledges the complex relationshipbetween a doctor’s occupation and theirattitude towards their own heath and theirhealth behaviour, writes Dr AndréeRochfort

37 Women’s Health: Polycystic ovary syndromeis a common endocrine disorder in womenof reproductive age, yet the development ofdiagnostic criteria has been controversial,writes Dr Eleanor McCarrick

52 Et cetera: Miscellany of medical matters

54 Diary: Round up of meetings and events ofinterest to GPs

Forum is circulated to all general practitioners in active practice in Ireland and to overseas members of the ICGP. Its contents in full are Copyright© ofMedMedia Limited. Annual Subscription e125 postage paid. The views expressed in Forum are not necessarily those of the ICGP.

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Management in Practice.....pg 13

Contents

Contents

EDITORIAL STATEMENT Forum is produced by professional medical journalists working closely with individual GPs and the ICGP. While we have manyadvertisers and sponsors, commissioning, editing and writing are undertaken independently, in line with internationally accepted best editorial practice.

clinical

39 Psychiatry: The optimal approach tomanaging bipolar depression is tosubdivide treatments into acute andprophylactic regimens, write Drs SukumarRajendran, Susan Keenan and DeclanLyons

42 Diabetes: Drs Cillian de Gascun and DonalO’Shea review current guidelines andrecent developments in the managementof type 2 diabetes

47 Vaccination: GPs need to be equipped toanswer parents concerns aboutimmunisation if Ireland is to increase itsuptake rate, write Dr Emma McDermottand Dr Alf Nicholson

54 Pharmaceutical Update: News of productintroductions, availability, discontinuationsetc. and other items of interest from theindustry

57 Clinical Review Service: A selection ofreviews of papers from the world’s leadingmedical journals, as chosen by our panelof GPs. Readers wishing to obtain copiesof the papers can email their requests withthe reference number for each article

second opinion

48 Doctor’s Diary: Could it be that a life ingeriatric medicine keeps you young? Ifthat is the case, based on his own practiceprofile, Dr Hugh Dennison* may bedoomed to live forever

50 Latham at Large: It is a challenge to mixclinical evidence, ethics, sensitivity andduty of care while avoiding ‘sizeism’ whenconfronting overweight patients, writes DrJohn Latham

51 UK View: The property price boom in theUK is a concern to GPs as high propertyvalues affect recruitment to partnerships,writes Dr Rob Walker

Physician – don’t heal thyself.....page 24

distance learningPain management: This month’s distancelearning programme for GPs deals withmanagement of non-malignant pain. Theprogramme is GMS study leave approved

See centre pages

Forum Editorial

Volume 20 – Number 1 (ISSN 0790-9977)

THE NATIONAL TREATMENT PURCHASE FUND has yet to relieveany of my patients of their suffering. I am not sufficientlyorganised to know which of my patients is waiting and forhow long, and so I have not systematically offered the Fundto waiting patients who attend me.

In two opportunistic contacts with the NTPF, one patienthas been refused because she has not been long enough onthe list for an operation, though she waited more than a yearfor a consultant appointment. The second patient, at 75years of age just can’t see herself travelling to the UK for hersurgery, which is what was offered.

I do hope that I may see some of my patients treated bythe Fund in the coming months, but I would share theapparent general lack of enthusiasm for the scheme in pro-fessional circles.

Why does the NTPF smell of political expedience ratherthan rational planning?

Is it that the brochures are just too glossy, somehow sub-liminally associated with the rest of the PR tat that has beenissued from Hawkin’s House and the ‘New Labour’ FiannaFáil government.

Is it not true that the NTPF is yet another example ofunfinished business, a sandbag against the flood ofdemand, the eddies of political pressure. As further exam-ples, we can also cite the supposedly national cervical andbreast screening projects.

Whether or not you value these screening programmesintellectually, even their greatest supporters must object tothe half-baked roll-out.

‘Roll-out’ is that dreaded phrase, the premature climax ofthe politician’s whim that follows ‘roll-over’ to interest grouppressure and ‘roll-in-the-hay’ with the PR machine.

It seems to me that there is little honour among some Irishpeople in their dealings with the state. Our modern history,essentially one of profound poverty by European standards,may have encouraged a culture in which we scramble andcheat for oversubscribed resources.

It is little wonder that our leaders reflect these attitudesin limiting the scope of their initiatives to the sort of give-away schemes which promise a rapid political dividend.

On the other hand, it seems to me that the current Minis-ter for Health is very sincere in his desire for an integratedand socially cohesive health system in Ireland. He knowsbetter than most that it takes more than a Celtic boom to fillthe gaps in the infrastructure of a new and, until recently, apoor Republic.

But it is he who has made the promises. He alone in mytime who has had two spells as health minister in a major-ity government. It is therefore he, and his boss theTaoiseach, who must be blamed if the legacy of 10 years inpower is no better than a series of politically correct ges-tures. I hope the work of the NTPF proves to be thepreamble to a sustained increase in capacity within our ownborders. What self-respecting society must send its childrenfor tonsillectomies abroad?

I still have great hopes for this government. Let it bebigger than the self-interest of its citizens and equal to theirneed. Let it show leadership. f

Editor Geraldine Meagan

Medical Editor Dr Niall Maguire

Deputy Editor Tara Horan Production Editor Sharon Murphy

Sub Editor Anne Henrichsen News and Features Moira Cassidy

Editorial Assistant Frances Vickers Design Paula Quigley,

Fiona Donohoe, Clodagh Noone, John O’Brien, Alan Keogh

Advertising Manager Niamh Gleeson

Editorial Board Dr Niall Maguire (chairman),

Dr Brendan O’Shea, Dr Ronan Boland, Dr Rita Doyle,

Dr Declan Bonar, Dr Domhnall MacAuley, Dr Mary Favier,

Dr Margaret O’Riordan, Prof Colin Bradley, Prof Tom O’Dowd,

Mr Fionan O’Cuinneagain, Mr Dermot Folan

Editorial and Advertising enquiries to the publishers:

MedMedia Ltd, 25 Adelaide Street, Dun Laoghaire, Co Dublin

Tel 01-280 3967 Fax 01-280 7076 E-mail [email protected]

ICGP correspondence to:

Fionan O’Cuinneagain, Chief Executive, ICGP, 4-5 Lincoln Place,

Dublin 2 Tel 01-676 3705 E-mail [email protected]

website www.icgp.ie

The Medical Editor may be contacted at Tel 046-21369

Design MedMedia Campaign Printing W&G Baird Ltd.

Forum, Journal of the Irish College of General Practitioners,

is registered at the GPO as a periodical. The title is Copyright©

to the Irish College of General Practitioners.

Political expediencevs rational planningNiall Maguire, Medical Editor

FORUM January 2003 5

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GP training sub committeesseeking new members

Dr Fiona Bradley – an appreciation

8 FORUM January 2003

MANY GPs experience problemstaking sick leave from work to attendto their own health needs, whether itis at short notice or planned inadvance, according to the director ofthe ICGP’s Health in Practice pro-gramme, Andrée Rochfort.

“Feedback from doctors over thepast two years indicates that manyhave had difficulties taking sickleave from work to have their ownhealth attended to”, she said.

However, the ICGP’s Health inPractice programme has had verypositive feedback from GPs, whohave indicated that the service hasgiven many GPs the impetus to dealwith their health concerns and thatthe service is much needed, she said.

ICGP members have been sent aninformation leaflet on the Health inPractice (HiP) programme and itstwo main elements – the HealthcareSupport Network, which is now upand running, and the Education,Information and Advisory Service.

Dr Rochfort is also keen to hearfrom GPs who have experienced dif-ficulties with issues such as finance,locum cover, local cover by col-leagues, personal guilt and feedbackfrom patients when taking sick leave

from work, witha view toaddressing theseissues anony-mously throughan article inForum.

“While I wantto look at howthese issueswere resolved, Iam also keen tohear about experiences of sick leavefrom work that could be used as goodexamples and, if so, what madethem so”, she said. “I would also liketo hear from GPs who have sugges-tions or advice that they would like toshare with colleagues on this issue”.

GPs who would like to contributeor who wish to discuss confidentialadvice on personal and occupationalhealth matters can contactDr Rochfort at 087-751 9307;Email: [email protected]

Further information on the HiPprogramme, including details of theservices provided and current net-work providers, is available fromMargaret Cunnane, HiP administra-tor at the ICGP, Tel: 01-676 3705;Email: [email protected]

Dr Andrée Rochfort: Keen to hear from GPshaving difficultiestaking sick leave

Demands of job force GPs tocontinue working while sick

THE ICGP is currently seeking GPs toact in one of a number of capacitiesaimed at ensuring that standards ofGP training are maintained at thehighest level.

GPs are needed to join the GPTraining Certification Sub Commit-tee, which reviews criteria for theCertificate of Satisfactory Comple-tion of Training by accreditedtraining programmes (CSCT). TheGP Training Certification Sub Com-mittee also makes recommendationsto the PGTC/Council on applicationsfor membership and certification ofspecific training, along with special-ist registration.

The College is also seeking GPs forthe Curriculum Development Sub

Committee, which reviews andmakes recommendations on thetraining programme curricula andcontent. It also reviews programmedirector/trainer/trainee contracts.

In addition, the College is seekingto recruit a number of assessors forthe general practice training pro-grammes.

These assessors will be responsi-ble for visiting and accrediting allpostgraduate training programmesin general practice.

Protected time and out of pocketexpenses will apply for all positions.For further details, contact SylviaBrowne at the ICGP, 4/5 LincolnPlace, Dublin 2, Tel: 01-676 3705;Email: [email protected]

NEWS

● A methadone treatment training course onmanaging drug users for Level 1 GPs and practicenurses will run at the ICGP as follows: Course 1,Part 1 – Thursday, April 17; Part 2 – Thursday, May22; Course 2, Part 1 – Tuesday, September 16; andPart 2 – Tuesday, October 21. Sessions will run from6.30pm-9.30pm. For further details, contact YvetteDalton at the ICGP, Tel: 01-676 3705; Email:[email protected]

● A new national documentation centre on drugshas been established at Holbrook House, HollesStreet, Dublin 2. Full text research material on druguse in Ireland is also available at www.hrb.ie/ndc

● The Women’s Health Roadshow continues toattract good attendance nationwide, according toroadshow co-ordinator, Eleanor McCarrick who hasrun three courses in Cork, Tullamore and also inGalway, as part of the National Association of GPTrainees conference. Ailís ní Riain has also run thefirst faculty roadshow for the Dun Laoghaire Faculty.

News in Brief

AT FIONA’S funeral service in the chapel at TrinityCollege Dublin her many friends and colleaguesgathered to pay their respects to her and her familyin a beautiful and moving ceremony which hadbeen planned by her. The range of her interests andinfluence could be gauged from the range of thosewho attended.

Her contribution to general practice, to medicineand to public life was considerable. She was acaring doctor committed to patient service in adeprived area and to improving the services avail-able to her patients.

Fiona was also a talented researcher who madeoriginal contributions in the area of care ofHIV/AIDS, domestic violence and cardiovascularhealthcare. She made a major difference to generalpractice and primary care services, along with hercolleagues in Ballymun in Dublin.

In the wider political sphere she made her con-tribution as a health advisor to Democratic Left andwas a member of Comhairle na nOispideal. She hadjust become a GP Unit doctor when her illnessforced her to resign from this position. Her life wasnot all work and she led a very active life, particu-larly being a keen sailor.

Fiona bore her illness with her typical direct andhonest approach and survived way beyond what anyof us would have thought possible throughwillpower and mental strength.

All of us who knew her have been privileged andour best memorial to her is to strive to improve gen-eral practice and primary care services, and to insistthat any changes are based on sound researchevidence.

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THE ALCOHOL Aware Practice pilotstudy has highlighted a major lack ofawareness among the public aboutwhat they can do about alcohol-related problems, according toalcohol counsellor, Donal Kiernan,who is participating in the pro-gramme at a Wicklow practice (seepage 19).

“I have concluded that there is notenough information about theresources available to people withalcohol problems”, he said.

Mr Kiernan is the only alcoholcounsellor involved in the pro-gramme and is currently involved intreating 12 clients at the practice –a larger number than he had origi-nally anticipated. He is also due tosee two more clients this month.

Mr Kiernan is located at the Balt-inglass practice for six hours a weekand he sees clients following an ini-tial assessment and referral from itsGPs, Cáit Clerkin and Pat Carolan.Some patients, including clients andtheir spouses, have also requested a

consultation having heard about theservice from others.

In general, he sees the client onceand reassesses them after threemonths. Three clients to date havesuccessfully stopped drinking com-pletely as a result of the programme,according to Mr Kiernan, and a fur-ther two clients have been kept outof inpatient treatment.

The majority of the clients havebeen in the over-25 age group,although two have been under theage of 20. “Interestingly, there are anumber of patients with cross-addic-tions involved”, he said. “Gamblingis a common second addiction”.

Being onsite at the practice whenclients are referred to him is veryimportant according to Mr Kiernan,who finds that they are less likely toget distracted or rethink the idea asa result. Mr Kiernan will work at theBaltinglass practice until March.

The Alcohol Aware Practice pilotstudy involves 10 practices aroundthe country.

Donal Kiernan, recently appointed alcohol counsellor with the Alcohol Aware Practicepilot study which involves 10 practices around the country

Pilot patients respond well tohelp with alcohol problems

DOCTÚIR NA nDAOINE (The People’s Doctor)was the fitting title of a recent TG4 docu-mentary on the life of Galway GP, EithneConway Magee, who spent 50 years caringfor three generations of people in Galwaycity and the Connemara Gaeltacht.

A past president of the ICGP, Dr ConwayMcGee spent three years as a dispensarydoctor in Spiddal in the early 1960s andis also remembered as the Travellers’doctor, having cared for three generationsof the Travelling community in Galway.

She also cared for the poorer and mar-ginalised sections of society in Galwayduring 30 years of immense social and

economic change. Now 74, Dr Conway

McGee only retired fouryears ago and is remem-bered by her patients as akind, down to earth womanfull of stories, who was asmuch a friend and confi-dante to her patients as shewas a doctor.

One of the last of the old-style family doctors, Dr Conway McGeewas featured on the Cogar documentaryseries which explores the lives of ‘ordinary’people who have led extraordinary lives.

The documentary was co-produced andco-directed by Dr Conway McGee’s son,Micheál, and Ros na Rún director BeartlaÓ Flatharta.

NEWS

Former ICGP president featured in TG4’s Doctúir na nDaoine

All-Ireland sports medicinetraining body established

A NEW All-Ireland Faculty of Sports and ExerciseMedicine has been established as a new trainingbody for sports and exercise medicine practitioners.The faculty will provide training on the provision ofa specialist health service for Irish athletes.

It will also devise and administer professionaleducation and training programmes for GPs andhospital consultants with an interest in sports andexercise medicine. Continuing professional devel-opment programmes and research in this area willalso be developed by the Faculty.

The Faculty, which is the first of its kind in Irelandand the UK, has been established jointly by theRCSI and the RCPI. At launch there are over 250fellows and members, including GPs, hospital con-sultants, university lecturers and professors withinterest, experience or expertise in the area of sportsand exercise medicine.

A NATIONAL working group to examine and considerregulatory issues in Ireland and advise Health Min-ister, Micheál Martin, on future measures for theregulation of complementary practitioners is to beestablished shortly, on foot of recommendations in arecent report. Currently in Ireland, practitioners ofalternative medicine are free to practise without anyState regulation. The Report on Regulations of Prac-titioners of Complementary and Alternative Medicinein Ireland was compiled by the Institute of PublicAdministration in response to increasing interest inthis area. Another main recommendation in thereport is the rapid development of self-regulation asa first step in the regulation process, in line withtrends and developments in other countries.

Steps being taken to regulatecomplementary practitioners

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THE ESTABLISHMENT of pilot studiesto further explore the use ofbuprenorphine in the treatment ofheroin addiction in a range of treat-ment settings, including GPsurgeries, was among recommenda-tions made following research carriedout by the National Advisory Com-mittee on Drugs (NACD) recently.

The research showed that buprenor-phine can be as effective asmethadone for the treatment of heroinaddiction. The NACD has called onthe government to view the drug asanother effective treatment option inthe management of heroin addiction.

The research found that buprenor-phine was at least as effective as

methadone when used inthe maintenance/substitu-tion treatment of opiatedependence and becauseof its particular properties,it is less likely thanmethadone to cause with-drawal symptoms afterabrupt discontinuation.This makes it suitable for

patients who wish to undergo detox-ification or to withdraw from amethadone maintenance programmeand become opiate-free, according toMary Teeling, the lead author of thereport.

Less than daily dosing, for exam-ple, one dose three times a week,has also been shown to be as effec-tive as daily dosing usingcomparable total weekly doses,although this may not be suitable forall subjects, she added.

“There is potential for abusebecause of its ability to induce opioideffects. Therefore, its administrationwould need to be supervised in thesame way as the current Irishmethadone protocol system”, she said.

It may cause withdrawal symp-toms when changing amethadone-maintained individual tobuprenorphine. Care must be takenwhen prescribing buprenorphinewith other drugs, including certainanti-HIV medications. Patients withliver disease also require closesupervision when on buprenorphine.

Pictured at the ninth IPHA Annual Dinner in the ShelbourneHotel, Dublin recently were (l-r): Fionan O’Cuinneagain, ICGPchief executive; Anne O’Cuinneagain; Dr Dan Murphy; andDr Deirdre Murphy, ICGP president

Call to include buprenorphinein heroin addiction treatment

Deadlines for GP exams and training

FRIDAY, JANUARY 24 is the absolute deadline forapplication to the following GP training pro-grammes, which start on July 1: Cork (12 places);Donegal (6 places); Eastern Region (10 places);East Coast/UCD (6 places); Midland Health Board(8 places); Mid-Western Health Board (6 places);North Eastern Region (6 places); RCSI and NAHB(8 places); Sligo (6 places); South East (6 places);and the Western Health Board (10 places).

For further details, contact the national directorof specialist training in general practice at the ICGP,Tel: 01-676 3705; Email: [email protected]

Applications are also invited for the 2003 MICGPexams. Dates for the exams are: written papers:April 29; oral examination: June 12-13; OSCEexamination: June 14.

The closing date for applications is February 15,2003. For further details contact Sylvia Browne atthe ICGP, Tel: 01-676 3705; Email: [email protected]

NEWS

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DOCTORS around the world areinvited to nominate colleagues forWonca’s ‘Global Doctor of the Month’award, which aims to encourage andhonour philanthropy and qualitymedical practices, particularly inthose providing quality resources tothe less fortunate.

The award was launched recentlyby Global Family Doctor – WoncaOnline and nominating doctors areasked to provide an outline of theirreason for nominating their col-league, along with a photo of thenominee if possible. Each winnerreceives a gift and a certificate tocommemorate the award.

Nominations can be sent to LesleyPocock, Global Family Doctor –Wonca Online, 572 Burwood Road,Hawthorn 3122, Australia; Email:[email protected]

GPs are also invited to send theirown stories and requests to theGlobal Family Doctor daily news andother news services at www.global-familydoctor.com

The service provides a daily news

service, weekly clinical reviews, jour-nal watch and a comprehensive CMEand CPD section. Several nationsuse the service as their full nationaltraining programme.

Global award honours familydoctors’ achievements

Pictured during a recent Management in Practice coursemodule on optimising practice income on state schemes werepractice managers (top, l-r): Lucia Wilde, Coombe HealthcareCentre, Dublin; Dermot Folan (programme director); and MarieCasey, Ballinasloe; (lower photo, l-r): Assumpta Gallagher,Palmerstown, Dublin; Muireann McGarry, Mercer’s HealthCentre, Dublin; and Carmel Donnelly, Naas

NEWS

THE NUMBER of deaths from Group Bmeningococcal disease has doubledsince last year, prompting the PublicHealth Department of the EasternRegional Health Authority to urgeparents and the public to remain vig-ilant for possible cases.

Four deaths from this strain of dis-ease have occurred between July andNovember, compared with twodeaths from the disease in 2001.However, the overall number of casesof Group B meningococcal diseasehas dropped in the Eastern regionfrom 95 reported in 2001 to 59reported cases in 2002 up toNovember. A total of nine cases ofGroup C meningococcal disease werereported in the East in 2002.

Meningitis B alert

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Certification system for GPsoftware to be overhauledA NEW certification system for gen-eral practice management softwarein use in Ireland is to be introducedin April by the national GPIT group.

This follows a review of the soft-ware accreditation process whichwas originally introduced in Irelandin 1994 jointly by the Department ofHealth and the ICGP. The reviewprocess was commenced by theGPIT group in 1998 and hasincluded extensive discussion andconsultation.

“After a considered review, theGPIT group felt it was time torestructure the entire process”, saidPeter Lennon, director of the GPITgroup. “In all of this, we were mind-ful of the need to create a systemthat would be flexible – to accomo-date change and innovation – andworkable, having regard in particularto the needs of GPs”.

He pointed out that it was essen-tial to consult widely with softwaresuppliers since they would ulti-mately be the parties who wouldhave to adjust to, and live with, anynew certification system introduced.

The review has been a long and

involved process but its culminationshows that work can be achieved ifall stakeholders, including the soft-ware suppliers, the health boardsand the ICGP, work together for thegreater good, Mr Lennon said.

“The successful implementationof these new software certificationarrangements will further illustratethe extent to which real progress inmoving forward is wholly dependentupon the individual parties to theprocess being prepared to give thenecessary commitment to commongoals, realistic standards andincremetalism”.

Evaluation of current softwareproducts will be carried out prior tothe new certification regime cominginto force. This time will allowsofware companies to make any nec-essary adjustments to their productsin order to meet the new criteria.

From April only systems that havebeen RFC02 accredited will be eli-gible for grant aid or funding byhealth boards.

Details of the new certificationarrangements will be posted on theGPIT website, www.gpit.ie

NEWS

● Guidelines on the clinical management ofcolorectal cancer have been published by the RCSI.They are the first Irish guidelines to be produced.

● A series of information leaflets on erectiledysfunction and its link to a number of primaryhealth conditions has been launched by the SexualDysfunction Information Bureau. The leaflets areavailable free from the SDIB, Tel: 1850 923 098.

● An estimated 12,000-20,000 older people livingin the community in Ireland may experience abuse,neglect or maltreatment, according to a recentreport on elder abuse, Protecting Our Future.

● The ICGP is planning a series of regionalmeetings nationwide to gather feedback on theICGP strategy and the Primary Care Strategy frommembers. The meetings will take place in Athlone,Sligo, Limerick, Cork, Portlaoise and Dublin inFebruary, March, and April. They follow regionalmeetings last year in Dundalk and Kilkenny, whichrevealed a need to focus on the needs of new andyounger members. A structured qualitative needsassessment of members will also be carried out.

● A number of ICGP Cardiovascular Strategy GP co-ordinators have been appointed, as follows: MartinWhite, Meath (NEHB); John Cox, Co Wexford(SEHB); David Reilly, Swords, (NAHB – ERHA);Brian Meade, Dublin 2, (ECAHB – ERHA); MichaelJoyce, Co Wicklow (SWAHB – ERHA); Eileen Coyne,Co Donegal (NWHB); David Boylan, Limerick(MWHB); Ronan Boland, Cork (SHB); SineadArmstrong, Co Mayo (WHB); Deirdre Collins,Athlone (MHB). The selection of 440 practices totake part in a prevention programme was also dueto conclude at the time of going to press.

● GP tutors and trainers in the West are invited to thefirst ‘Teachers in General Practice’ conference whichwill be held in the Ardilaun House Hotel, Galway, onFebruary 28-29. The meeting will be co-hosted by theDepartment of General Practice, NUI, Galway and theWestern Health Board Training Programme in GeneralPractice. For further details Tel: 091-750 470; orEmail: [email protected]

● The ICGP Suicide Prevention in General Practiceproject is to continue, following the announcementof further funding. Project director, Conor Geaney isavailable to act as a resource for and to attend GPeducation groups throughout the country.

● The Diploma in Women’s Health by distancelearning is due to commence this autumn. Asessional course co-ordinator is currently beingselected and is due to take up the position shortly.

● The first semester of SCALES, the Short CourseAimed at Late Entrants to general practice hasconcluded, having attracted 26 doctors. The courseis being overseen by Zita O’Reilly and Maria Wilson.

● A total of 10 doctors completed the course forcertification as Instructing Doctors in FamilyPlanning recently.

News in Brief


Obesity – a public healthtimebomb

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A CHILD IS BROUGHT INTO surgery with a straightforwardproblem, a dose of the flu or an ear infection. The child isoverweight, perhaps moderately. What do you do? Intervene,explain the vast implications linked to being overweight orobese, or hope that the parent has the problem in hand?

With obesity figures soaring worldwide, including in Ireland,this is a scenario which most, if not all, GPs will increasinglycome across. The cost of this disease to the nation’s health,its health service and indeed the economy as a whole, isincalculable. And yet it is preventable, a fact that inevitablywill have to be taken on board by the health services and bygeneral practice in particular.

Some years ago, a UK documentary on the rising levels ofobesity opened with: “Look at America and see our future.”

The cost to the US economy of obesity related problemssuch as cardiovascular disease, diabetes, cancer and hyper-tension, just some of the conditions that research has linkedto obesity, is now in excess of $100 billion a year, accordingto the National Institutes of Health.

In tandem with this, $33 billion is spent on weight-lossproducts and services. It appears that Americans are notpaying a blind bit of attention and are actually eating more.Obesity in Ireland

Here in Ireland, we are rapidly moving in the same direction.According to a major survey of Irish adults, carried out by theFood Safety Promotion Board in 2000, over 20% of men werefound to be obese. In 1990 this figure was just 8%. In women,the rate of obesity was found to be 16%, up from 13%. How-ever the highest prevalence of obesity in any group was inwomen over the age of 50, at almost 30%. More recently, asmall consumer survey into the diet and lifestyle of Irishpeople, found that 51% of men and 32% of women are over-weight.

“This survey provides a very important insight into how inac-tive we have become as a nation. Furthermore people are notaware of the level at which obesity begins for themselves andit is clear that a lot of people who think they are slightly over-weight, are in fact obese”, said Dr Donal O’Shea, consultantendocrinologist at St Vincent’s Hospital, Dublin.

In fact, the study found that 41% of men over the age of50 do not take any physical exercise whatsoever. Of men overthe age of 25, 18% watch, on average, between 16 and 20hours of television per week, compared to 8% of women. Thiscould partly explain why being overweight or obese is morecommon in Irish men than women. Alcohol intake in this

country may contribute to the problem. Of those who watch20 hours or more of television per week, 33% said they didnot engage in physical activity as they do not have the time!These figures concur with the FSPB’s 2000 study, whichfound that the average Irish adult watches around 19 hoursof television per week and yet spends only one to two hoursper week in ‘vigorous activity’, such as jogging or aerobics.

Furthermore, Dr O’Shea’s belief that people are unawarewhen they cross the line from overweight to obesity, is alsoreflected in the 2000 study. Of the 1,000 people questioned,not one person described themselves as obese, despite thefact that 12% were found to be clinically obese.

The entire way in which obesity is approached by the healthservices needs to be examined, according to Dr Tony O’Sulli-van, project director of the ICGP’s task force on diabetes.

“In the past, obesity was very much seen as a social con-dition. It was someone’s fault if they developed it andresolving the problem was left in their hands. However now itis very important that we see obesity as a medical condition.It is a condition worth ‘medicalising’ for two reasons; one,because it has so many negative health implications and two,because it is preventable”, he said.Childhood diabetes

While both studies focused on adults, the implications forchildren are clear. Raised in an environment where a seden-tary lifestyle and an unhealthy diet are prevalent, they arelikely to adopt these habits themselves and carry them on intoadulthood. Nowhere can this be seen more than in the diag-nosis of type 2 diabetes in children, something that wasunheard of in the past.

“There used to be a huge divergence in the diagnosis ofdiabetes. Type 1 was generally seen in five to 20-year-olds,then there was a big gap and type 2 was found in 50 to 80-year-olds. Now there is no gap and children as young as 12are being diagnosed with type 2”, Dr O’Sullivan said.

“If an overweight or obese person, including a child,comes into surgery with an unrelated health problem, it isabsolutely within the remit of a GP to approach them or theirparent about their weight. This is opportunistic screeningand I think the vast majority of GPs would agree with usingit”, said North Dublin GP James Reilly, who has a specialinterest in obesity. Dr Reilly is adamant that GPs interven-tion is a key weapon in the fight against obesity.

“It is essential for patients to recognise and admit the prob-lem. As a result, it is extremely important that things such as

Is obesity a condition worth medicalising?Deborah Condon reports on a healthproblem of epidemic proportions and asks

how general practice can tackle this


BMI and the health implications of obesity are explained tothem”, he said.Strong forces at play

Other strong forces are at play when it comes to over eating,many of these of an economic if not political nature. A recentFinancial Times article explored some of these underlyingissues. The US food industry produces far more food than itneeds and therefore, forceful marketing is needed to sell theexcess to the American public. At the root of this marketingdrive is everyone from farmers to fertiliser manufacturers torestaurants and food companies. In addition, social changeshave affected how we eat. Western society has become a fastfood culture and the breakdown of family units and familymeal times has led to an ‘on the hoof’ approach to food. Thearticle cites the most basic of marketing ploys; putting softdrinks vending machines into schools. Have you lookedaround your local Irish secondary school recently?

Experience from the Harvard School of Public Health whereintervention programmes are designed for overweight chil-dren, has indicated that time spent in front of the TV, or theconsumption of sugar sweetened drinks is a strong predica-tor of obesity in children.Affects of lifestyle

Speaking in Dublin recently, international obesity expert,Dr David Ludwig of Harvard University and the Children’sHospital in Boston, warned that an epidemic of obesity inchildren is on the way, underpinned by environmental factors.Television viewing is displacing physical activity and encour-aging the ‘passive consumption of energy dense foods’ amongchildren, he said.

This view is echoed by Dr Lean O’Flaherty, senior nutri-tionist with the National Dairy Council, who believes thatparents need to reduce childrens’ television watching andincrease the amount of physical activity they take part in.

Dr O’Flaherty also criticises the idea that banning or taxingparticular foods, an idea recently mooted in the US as a pos-sible solution to childhood obesity, will reduce the problem.

“There is a place in the diet for all foods including, in mod-eration, junk food and other avenues should be explored beforeany particular foods are banned or taxed. Obesity is a multi-fac-torial condition and it would be very difficult to pinpointsomething specifically in the diet and ban it”, she said.

Another issue of concern with obesity is the fact that gen-erally, people are unaware of the major health implications ofthe disease. The consumer study found that in general, Irishpeople are aware that an unhealthy diet and lack of exerciseare contributing factors to obesity. However, there is a starklack of awareness of serious diseases and health risks associ-ated with overweight. Just 26% of respondents were aware thatdiabetes could be caused by excessive weight.

“The fact that the public are unaware of the gravity of thissituation underlines the urgent need for a major health pro-motion campaign”, said Dr O’Shea.

This is an issue echoed by Dr O’Sullivan, who believes thatwhile GPs have an essential role, there needs to be a broaderapproach to the problem from many different quarters.

“If a person is already obese, the work of the GP is in a way,shutting the door after the horse has bolted. I would like tosee a major public health approach, with advertisements pro-moting a healthy lifestyle, diet and exercise and education inschools aimed directly at children. Legislation to make a

healthier lifestyle more accessible is also important, such asthe introduction of cycle lanes on our roads to encouragepeople to cycle and ensuring there are enough playgroundsfor our children”, he said.Actions and initiatives

So with obesity-related problems gobbling an increasingchunk of total health expenditure the Government is proba-bly planning a major campaign to raise awareness and reduceobesity rates, right? Well it’s hard to say. According to theNational Health Strategy, ‘actions on major lifestyle factors’,including diet and lifestyle ‘will be enhanced’ and suchactions are ‘ongoing’. However no specifics are given.

Furthermore, ‘initiatives to promote healthy lifestyles in chil-dren will be extended on an ongoing basis’, with full extensionto all schools by December 2005. Let’s hope this date does notfall by the wayside in light of recent spending cuts.

The first GP element of the Cardiovascular Strategy beginssoon. This first phase will be aimed at people who have hada cardiac event and are therefore considered to be at risk,according to Dr Sean Maguire, who is ICGP co-ordinator.

Over 400 GP surgeries have been selected throughout thecountry as part of the project. All patients within eachselected surgery who are deemed to to be at high risk for CHDwill be identified and then invited to attend the practice everythree months. At these consultations, all of their risk factorswill be assessed and depending on the facilities availablewithin each health board area, extra services, such as exer-cise advisors, will also be made available.

The programme hopes to be in a position to see its firstpatients by the end of January 2003. “This is extremely sig-nificant, as it is the first nationally standardised preventativecare programme”, Dr Maguire said.Issues to be addressed

“This is the biggest epidemic of the 21st century and GPsare on the frontline. It is essential that a person recognisesthe problem and when they admit it, the GP can explain thefull implications of it and offer broadly based advice on howto deal with it. We can provide advice on management of thecondition. It is also essential to offer support”, he said.

Referrals to a specialist are rarely required unless there is anunderlying endocrine problem for example, he added.

However two issues that need to be addressed are the lackof dietitians in the health service and the lack of supportgroups for obese people. “There is definitely a need for moredietitians in the service and more accessibility to them. Iwould also like to see more attention given to the GMS pop-ulation, as studies show, obesity tends to be more prevalentamong the less well-off. Therefore it is essential to target theGMS population as a preventative measure”, Dr Reilly said.

According to Dr O’Sullivan, there is a higher rate of depres-sion, unemployment and remaining single among obesepeople, yet little support for them.

However there is light at the end of the tunnel as evidencesuggests significant reduction in medical consequences ispossible. A study of dietary change in Finland for examplerevealed a CHD mortality decrease by 55% among men and68% among women.1 If we don’t act now the implications willbe grave.fReference1. Pietinen P, Vartiainen E, Seppanen R, Aro A, Puska P. Changes in diet inFinland from 1972 to 1992: impact on coronary heart disease risk. PrevMed 1996; 25: 243-250

Forum Cover Story

WHEN CÁIT CLERKIN AND HER HUSBAND PAT CAROLAN movedinto their purpose-built practice premises four years ago itnot only transformed their working conditions but was adream come true.

Finding a new location was not easy as it was just beforethe property price boom and there were few houses on themarket. For the previous 14 years they rented the oldSchoolmaster’s Lodge in Baltinglass, which although pic-turesque had become unsuitable as a busy surgery. Thecouple spent three years looking for a suitable site andfinally they found and bought the premises at Weaver’sSquare, Baltinglass in West Wicklow.

Judging from the outside the practice deceptively lookslike any other of the terraced houses on the street. Howeverthe original house was knocked to the ground and the facadethen rebuilt to match the streetscape.

Hidden behind, with a backdrop of Baltinglass Hill dottedwith sheep, lies a modern practice with three consultationrooms, a nurses treatment room and a large waiting areawith a kiddies corner. The second floor is equipped with anoffice, an extra consulting room and an apartment, for prac-tice use only.

In designing the practice the couple referred to ICGPguidelines Building for General Practice – an introductoryguide to designing your practice premises which they gaveto the architect.

“We wanted as much light and wood as possible and todesign it in such a way as to have possibilities to adapt itsfunction in the future”, says Pat. The past was also consid-ered in the design as they left the ruins of the original 200year old stone cottage at the back of the practice untouched.Alcohol project

Since September 2002 the team has been one of the par-ticipants in the Alcohol Aware Practice pilot study whichinvolves 10 practices in each health board area around thecountry.

As part of their involvement in the study the practice waslucky to be appointed an alcohol counsellor Donal Kiernanwho works from the practice every Thursday from 9.30amto 4.00pm. Regular patients within the practice are offeredthe service and can be referred to Donal for a one hour con-sultation in a private consultation room upstairs in thepremises.

Most of the patients referred to Donal are known to thepractice. Having an alcohol counsellor on site means thathe can zone in on the problem quickly and proceed withassessment and intervention, according to Cáit and Pat.

“Initially we did have reservations because of the time

The facade of the building, which matches the streetscape,hides a modern, purpose built practice

Practice staff (l-r): Pat Carolan, GP; Deirdre Cleary, practicenurse; Cáit Clerkin, GP; and practice secretaries Deirdre Bradyand Mary Owens

The kiddies corner in the waiting room at the practice


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factor in a busy practice, but it has been a real eye openerand a great addition to our services. It is very interesting tolearn about the counselling techniques”, says Pat.

“The fact that the counsellor is not local is a big factor ina small local area. People feel safer going to see him andare more open about their problems”.

Receiving feedback from the counsellor is also an impor-tant aspect to the study. “It’s a revelation and hopefullywhen Donal is gone we can use some of the strategies hehas taught us”.GP role

The GPs also play a large part in the project which involvescompleting an alcohol questionnaire, based on the CAGEquestionnaire, with every sixth patient who presents. Thescreening questionnaire consists of 10 questions relating toa person’s drinking habit and attitudes to health and work.The points amassed identify hazardous drinking practices.

“Screening one in six won’t necessarily pick up all alco-hol abusers as they don’t come to the surgery frequentlyenough. The purpose is to focus GPs minds in a construc-tive way rather than casually, and to take an accurate alcoholhistory”, says Cáit.

Patients under 16, over 70 or acutely ill are excluded fromscreening. Apart from the extra time it takes it also has tobe a voluntary, confidential and co-operative process accord-ing the couple. “There are some patients who refuse toanswer the questionnaire, including some young people,who are perhaps aware that they have an alcohol problem”.Local support

Alcohol counsellor Donal Kiernan also liaises with localgroups, schools, the AA and the local health board. “Hope-fully this support network will remain after his six monthshere”, says Cáit.

The local Kiltegan Missionary Society run a counsellingservice, Slí an Chroí, organised by Father Seamus Whitneywhich provides a location for bereavement groups or thosewith psychological problems. Cáit and Pat can refer patientsto the counsellor, which they find of huge benefit for sup-port and back-up for those patients who need it.Practice staff

The practice is also supported by a full time practicenurse, Deirdre Cleary and one full time secretary DeirdreBrady, and one part time secretary, Mary Owens, whom theyemployed as soon as they moved into the new premises.

Although supervised the practice nurse works from her

own appointment list and looks after the immunisation anddiabetes clinics as well as antenatal and follow-up appoint-ments. “She assesses the urgency of a consultation whichis very helpful for us when we are very busy”, says Cáit.

Locum GP John Gaynor is also employed to cover thebusiest months which are December to March. He hasworked as a locum with Cáit and Pat since 1985.Caredoc

Cáit and Pat are part of the on-call co-op Caredoc, the firstof its kind, which since 1999, has provided GPs in the sur-rounding Carlow and West Wicklow area with out-of-hourscover. While Carlow is the nucleus of the service Baltinglassacts as the northbase.

The local district hospital in Baltinglass, a 92 bed unitdealing mainly with assessment, long-stay, rehabilitationand respite care patients, also acts as a minor traumacentre. Cáit and Pat are both part-time medical officers atthe hospital, along with local GP Magdalene Coyle.

“The rota works very well and has taken a lot of the pres-sure off”, says Pat who adds that Caredoc has also served tointegrate rural GPs.

All calls are triaged and the practice receives a report ofthe previous night’s events, the details of which are faxed tothe surgery every morning. “It is a very efficient system”,says Cáit.Mixed rural practice

Baltinglass is interestingly positioned in the toe of WestWicklow, surrounded by three counties; Kildare, Carlow andWexford. As a busy market town it has seen its populationincrease and diversify over the last five years.

The local community now comprises many Latvians andRomanians working on the farms, refugees and Dublinerswho commute to the city to work. “The town is big enoughto accommodate new people and for the most part peopleare happy”, says Cáit.GPs as managers

As general practice becomes busier GPs are increasinglyfeeling the pressure of managing a practice in businessterms. “Nowadays you need a structure to survive”, saysCáit. “You have to learn to be a manager and be able to weardifferent hats. It is not complicated but time-consuming”.

Both feel that there is a big gap in GP education on thepractice management side of things. Cáit recently com-pleted an ICGP practice management course which shefound very helpful. f

The two-story extension at the back Cáit’s consulting room with a view of the ruins of the 200year old cottage to the back which now acts as an outhouse

The main entrance, which is at the side of the building

Your questions answeredDermot Folan offers advice on some commonquestions which arise in day-to-day practice

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Study and annual leave: Claiming allowances Q. Could you clarify the position regarding study leave andannual leave provisions as we are attempting to get up to datewith our claims for both, which have fallen behind. Are theseallowances claimed on the same year basis as other claims?With regard to annual leave, it is dependent on panel size(minimum panel size is 100), the leave entitlement being aminimum of 14 days. Study leave is 10 days and again theminimum panel size is 100.

The leave year is still based on an April-March year end(unlike the practice staff subsidies which operate on the cal-endar year basis). You need to make sure that the copies ofthe P60, the P35 and the P35 L are all submitted to theGMS Payments Board before the end of January. It is worthnoting that if you are late in claiming for the other supports,you should still send them in and the arrears will be paid.

To optimise income from state schemes it is best to havesomeone in the practice fully trained and updated on allprocedures and forms, with the target of claiming all workundertaken by the practice and monitoring that all claimsmade are paid and received.

It is worthwhile assigning protected time to a staffmember to undertake this on a weekly basis. It is also impor-tant that everyone in the practice views this as a priority andcooperates with the necessary form filling.

It is a question of cash flow – services are provided dailywith attendant costs incurred (light, heat, salaries, etc) whileat the same time claims may not be up to date. As not allstate scheme payments are not received immediately thepractice can end up carrying the shortfall.

Capitation payments are monthly but other revenues fromstate schemes are paid on a longer ‘time line’. The worstscenario for a practice from a budgetary perspective isbundles of claim forms lying unprocessed while at the sametime the practice runs an overdraft with the bank.

Part-time staff: Public holiday entitlementsQ. We employ two part-time practice receptionists. One isrostered to work Monday to Wednesday. What is the positionwith regard to payments for bank holidays where the persondoesn’t work the holiday. Are they still due payment?Questions relating to part-time staff and public holidaysseem to be a cause of concern both to GPs and staff alike.

Employees who do not normally work on the day a publicholiday falls are entitled to payment of one fifth of theirnormal weekly wages for the day.

In order to be eligible to payment for public holidays thepart-time employee must have worked for the employer forat least 40 hours during the period of five weeks on the daybefore the public holiday.

Note: Public holidays are not the same as bank holidaysand there are nine public holidays in total.

GMS contract: Medical indemnity refundQ. I have recently taken up a GMS contract and applied forrefund of my medical indemnity. Am I entitled to the full refund?No, unfortunately, the refund of medical indemnity pre-miums is based on panel size as follows:

Panel size: 100-250 10%251-500 25%501-1,000 50%1,001-1,500 75%1501 + 95%

Health and Safety: Needle-stick near missesQ. We had a ‘near miss’ needle-stick injury recently and as aresult we wish to review health and safety in the practiceoverall. Are there any guidelines we should follow?Managing Health and Safety in the Practice by Dr AndréeRochfort, published by the College, provides detailedinformation on drafting a health and safety statement andrisk assessment in the practice. This includes informationon dealing with needles and sharps.

It is important to have the right type of incinerator bin andalso to look at the practice procedure for handling and dis-posing of needles, eg. the bin should be elevated and out ofthe reach of children. Do not fill by more than two thirds. Itshould only be carried by the handle, not by body of con-tainer, (hospital porters wear lead lined gloves when carryingsharps bins!) and you should insure that there is no risk instoring full bins awaiting collection. It is important that GPs,practice nurses and non clinical staff are made aware ofthese issues and follow the appropriate protocol. The GP’sbag is also a potential hazard. Sharps should never be car-ried loosely in a bag or pocket. There are small portable minibins available which will easily fit into the doctors bag andshould be available from your regular supplier.

Power of Attorney: Attendance feeQ. What is the fee charged for attending a meeting with apatient, their solicitor and family members?

As far as I am aware there is no specific recommended feefor this work. Charging a fee related to your professional timewould be one way of computing the fee. It might also beviewed that the report you compile is analogous to amedico/legal report and you could use this as your referencepoint. The current recommended fee for medico legal reportis e245. f

Have you more questions?The questions in this column represent a sample of the type of enquiryreceived from members by the ICGP Management Services Unit eachmonth. Of necessity some details of the questions selected have beenomitted and the answers condensed into a concise format. For furtherinformation please contact: Dermot Folan, ICGP, 4-5 Lincoln Place,Dublin 2. Tel: 01-676 3705, Fax: 01-676 5850, email: [email protected]



THE ICGP HAS BECOME INCREASINGLY AWARE of the need fora co-ordinated system to enable GPs to address their per-sonal and occupational health needs.

The Health in Practice programme was set up by the ICGPin 2000. At the core of the programme is the acknowledge-ment of the existence of a complex relationship between adoctor’s occupation, their attitude towards their own healthand their health behaviour. HiP Needs Assessment Survey

In 2001, a National Survey of Irish GPs was conducted bythe programme to ascertain how and where GPs accesshealthcare when they get ill, their personal experiences ofbeing sick and the effects their work has on their health.

The survey found that most GPs do not use the services ofGPs at all! Instead, they either ignore their illness com-pletely, carrying on working and caring for patients, or theyadmit to diagnosing, treating and managing their illnessesthemselves.

Ireland is not alone; similar patterns of healthcare behaviourin doctors have been shown to occur among doctors in othercountries. We encourage patients to treat self-limiting, minorillnesses, and that any illness beyond this should be discussedwith a doctor. We should apply this advice to ourselves.

Picture this: You do not feel well. You ask yourself per-sonal questions, listen to your own answers, examineyourself, take your own blood tests, prescribe treatment foryourself and come back to yourself for a check-up…thisactually happens within the medical profession!

Common sense indicates that this could not be used as anexample of good healthcare for anyone. Indeed, it appearsthat, in general, the standard of healthcare that doctorsaccept for themselves is lower than the standard of care theydeliver to their own patients.

We know from this survey that these and other deficien-cies in GPs’ healthcare are accepted as the norm by GPswhile they continue to: • Provide care for others, listening to patients’ stories and

dilemmas, offering advice and empathy, assessing symp-toms, making decisions which have potential to have farreaching effects for many people

• Deal with responsibilities to staff as their employer• Deal with extensive responsibilities in running a small

business as a self-employed doctor• Deal with requirements to update knowledge and skills in

addition to long working hours• Deal with personal needs as a human being to engage with

family and friends • Meet their own personal needs as individuals.

Being a doctor offers no immunity to illness. GPs, beinghuman as all doctors are, may develop any medical condi-tion in the same way their patients do. Doctors may sufferfrom asthma, back pain, angina, anxiety, or depression. Weknow also that doctors have a higher incidence than the gen-eral population of some conditions, including suicide,depression, cirrhosis of the liver, etc.What is wrong with you, a doctor, treating yourself?

Medical literature and anecdotal evidence both acknowl-edge that doctors ignore or deny their own symptoms of illhealth. Invariably this causes an initial delay in diagnosisand treatment, so it is important that, once initiated, treat-ment is appropriate and of the highest quality possible.

Consider the difficulties you face when treating patients,including those who have a medical or paramedical back-ground. The challenge is considerably greater if you becomeyour own doctor.

Every doctor has gaps in their medical knowledge. Whendoctors treat themselves without the opinion of anotherdoctor, they may make errors of judgement. They may over-treat (eg. unnecessary antibiotics) as well as under-treat (eg.delay arranging necessary procedures), as it is easy to loseobjectivity when a doctor is treating themselves. If doctorsdo not confide in another doctor they will not receive adviceor an explanation, they will not have the opportunity to dis-cuss treatment options and they cannot be comforted.

Doctors are reluctant (for many reasons) to take time offwork when sick. Even if a doctor is seriously ill, work issometimes used as a means of denying the illness is pre-sent, of keeping up appearances. ‘Work’ sometimesbecomes the sole reason for survival, being more importantto ‘get the work done’ than to switch over to paying atten-tion to oneself or one’s family. Much illness in doctors goesunrecognised and is poorly managed.

The ICGP HiP programme is designed to address GPs’overall healthcare, encompassing their:• Physical health• Psychological health (work-related and personal issues)• Occupational health (how our health and our work inter-

act).For further information on the programme, contact

Margaret Cunnane, ICGP HiP administrator, Tel: 01-6763705, Email: [email protected] f

Andrée Rochfort is director of the ICGP Health in Practiceprogramme

When doctors treat themselves,they leave themselves open toerrors and neglect, writesAndrée Rochfort

Physician– don’t healthyself!

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forum distance learning programmein association with the ICGP

PAIN IS ONE OF THE MOST COMMON reasons people consulttheir family doctor. Acute pain is a symptom in a variety ofmedical and surgical conditions, eg. myocardial infarction,renal or biliary colic, appendicitis, or following trauma.Chronic pain is not a single entity but may have myriadcauses and perpetuating factors. It is a feature of manychronic diseases such as osteoarthritis, peripheral vasculardisease, diabetes mellitus, multiple sclerosis, migraine,sickle cell disease and others. Chronic pain may also becaused by injuries or surgical operations, repetitive trauma,infections or inflammation. Recent studies have shown thatremodelling within the central nervous system (plasticity)may result in persistent pain after correction of pathology,hyperalgesia, allodynia and the spread of pain to areas otherthan those involved with the initial pathology. Non-malig-nant, chronic pain is associated with physical, emotionaland financial disability.

Acute and chronic painUnderstanding the differences between acute and chronic

pain is a necessary prerequisite for successful pain man-agement. Acute pain is a biological warning signal alertingus to actual or potential tissue damage. To some degree,there is a correlation between the stimulus and the level ofpain. On the other hand, pain intensity is also affected bymany psychological factors, eg. the significance given to thepain. Causal therapy is the treatment of choice and proac-tive analgesia provides satisfactory pain relief in most cases.There is growing evidence that insufficient control of acutepain may play a role in development of chronic pain.

In comparison, chronic pain lacks an obvious biologicalrole and is not directly associated with the amount of tissuedamage. Symptom control and disease modulating therapyare equally important components of treatment. Pain reliefis just one goal of supportive therapy beside functional reha-bilitation and improvement of quality of life.

Pain modelsPatient’s model

Most patients have a concept of a one-to-one relationshipbetween the amount of tissue damage and the amount of

pain experienced. This implies that when pain is sensedthere is always damage causing it. Stopping the stimulus orcutting the transmitting wire is the way to stop the pain. Inthe management of chronic pain this model is rather detri-mental, therefore patient education plays an important role. Gate control theory

Melzack and Wall’s gate control theory1 postulated spinal‘gates’ controlling the transmission of peripheral impulses.Successful transmission through the gate was affected notonly by the intensity of the stimulation, and competing localstimuli (pain, heat or touch), but also by descendingimpulses from the higher central nervous system. Thismodel was a milestone in the understanding of pain and thefirst to recognise that physiological, psychological and otherfactors modulate nociceptive input and its transmission. Plasticity of the nervous system

During recent decades pain research discovered that thenervous system is subject to structural and functionalchanges following tissue damage or nerve injury. This phe-nomenon is called plasticity.2 Structural changes includereceptor up- or down-regulation and modification of thereceptive field of neurons. Neurotransmitters (eg. glutamate,aspartate, substance P, calcitonin gene-related peptide)mediate a variety of peripheral and central sensitisationprocesses leading to clinical phenomena such as sponta-neous pain (paraesthesia) or increased sensitivity tonociceptive stimuli (hyperalgesia) and to non-nociceptivestimuli (allodynia). Biopsychosocial model

The traditional medical model describes diseases ascaused by certain pathology and diagnosed by means ofclinical symptoms and physical signs. It also implies a dual-istic view of disease (or pain) being either physical orpsychological. This narrow model fails to explain the enor-mous variability in the response to pain.3 There is no directrelationship between structural abnormalities and pain.

Boos et al demonstrated that 76% of asymptomatic vol-unteers had disc herniations at one or more levels in MRIstudies of their lumbar spine.4 Studies in behavioural psy-chology identified functional and dysfunctional responses todisease, pain or incapacity.

Pain managementManagement of non-malignant pain Module 65: January 2003

2hours

study leave approved

studyleave approved

It is essential that GPs understand the differences between acute and chronic pain for the successful management of pain in general practice

(This module was facilitated by Kristin Ullrich)

DISTANCE LEARNING Management of non-malignant pain

We have to recognise that understanding a patient’s painbehaviour, beliefs and feelings are necessary to understandthe patient’s pain, and that social and economic factors alsoplay an important role. The acceptance of the biopsychoso-cial model of pain was prerequisite for the development ofmultidisciplinary pain management programmes.

Pain assessmentSpecific pain history and thorough physical examination

as shown in Table 1 are necessary for a pain diagnosis. Dis-tinction between nociceptive and neuropathic pain hasmajor consequences for the treatment plan. In acute painand acute changes of chronic pain care must be taken toensure that urgent causal treatment is not be delayed. Pain diary

Ask your patient to keep a diary on their pain (intensity,duration and accompanying symptoms), analgesic intakeand its effect. This is especially advisable for all forms ofheadaches, fluctuating pains and unclear self-medication.Adding the parameter ‘physical activity’ helps to evaluateprogress in an exercise programme and the effect of anal-gesics on functional improvement.

Current issues in the pharmacological treatmentof non-malignant painNSAIDs and coxibs

The mechanism of the NSAIDs is to inhibit both periph-eral and central cyclooxygenase (COX). There are two mainforms of cyclooxygenase: COX-1, which is constitutive (nec-essary for normal physiologic function of stomach, kidneyand platelets), and COX-2, which is inducible and involvedin inflammation. The advent of highly selective COX-2inhibitors (coxibs) has generated great excitement becauseof the possibility that these would be safer than non-selec-tive COX inhibitors (classical NSAIDs). The COX-2 inhibitorscelecoxib and rofecoxib lower the risk of adverse gastroin-testinal effects compared with NSAIDs, however thisadvantage was eliminated by concurrent use of low doseaspirin.5 Furthermore, NSAIDs and coxibs have similar detri-mental effects on cardiac (exacerbation of congestive heartfailure) and renal function (increased risk of acute renal fail-ure) especially when used in older patients.6,7

Opioids in non-malignant painConsiderable controversy exists regarding the use of opi-

oids (especially of strong opioids) in chronic non-malignantpain. In the past, long-term opioid administration for thisindication was regarded as ineffective and inherentlyunsafe.8 However, the extensive history of the use of opioidsin chronic cancer pain has shown that opioids are effective,and neither tolerance nor physical dependence is a signifi-cant problem. Further, aberrant drug-related behavioursassociated with addiction are extremely infrequent amongpatients with no prior history of abuse. On the other hand,studies in patients with non-malignant pain show inconsis-tent results regarding long-term efficacy of opioids.9,10

Consequently, it is important to monitor pain intensitybefore opioids are commenced, and throughout the courseof treatment. For some clinicians, pain reduction with opioid

therapy is meaningless if there is no noticeable improve-ment in function. Functional capacity is a very importantoutcome parameter in chronic non-malignant pain; in gen-eral practice, self-assessment and collateral history of familymembers should be used for evaluation.

Furthermore, the possible psychological effects of treat-ment with opioid must not be underestimated. In somepatients it may reinforce a very narrow physical model ofpain and their maladaptive beliefs. Depending on personal-ity and coping skills patients may be enabled to take controlof their lives, or conversely become more reliant on thehealthcare system. Opioid treatment could possibly interferewith the motivation for a pain management programme.Regardless of opioid therapy, patients who have high scoresof catastrophising or passive coping, or who demonstrate lowself-efficacy regarding their ability to manage their pain areat greatest risk for poor treatment outcome.11 It is suspectedthat patients who have unrealistic beliefs about their condi-tion are poor candidates for opioid therapy, but no existingdata consistently confirm this hypothesis.

FORUM January 2003

Essential components of painassessment14

Assess pain intensity and character • Onset and temporal pattern• Location• Description• Intensity (using a numeric rating scale 0-10 or a verbal

rating scale)• Aggravating and relieving factors• Previous treatments and its effects• Effect of pain on physical and social function

Evaluate the psychosocial status of the patient • What the pain means to the patient • The patient’s typical coping responses to stress or pain• The patient’s overall knowledge of, curiosity about,

preferences for, and expectations for pain managementmethods

• Uncover patient’s concerns about use of analgesics• The economic effects of the pain and its treatment• Has the pain caused changes in mood, such as

depression or anxiety

Perform physical and neurologic examinations: • Examine site of pain and evaluate common referral

patterns • Perform pertinent neurologic evaluations

– Cranial nerve and fundoscopic evaluation for head andneck pain – Motor and sensory function in limbs, rectal andurinary sphincter function, also enquire about sexualfunction

Further diagnostic evaluation limited to red flag indicationsor if necessary for causal treatment:• Laboratory evaluations (?malignancy, ?infection)• Radiologic/Imaging studies (see back pain guidelines)• Referral to specialist according to working diagnosis

Frequently re-assess the pain and side effects of treatment:• At regular intervals after starting the treatment plan • With each new report of pain • At intervals after each pharmacologic or non-

pharmacologic intervention

Table 1


Survey data suggest that opioid therapy can be beneficialin certain chronic pain patients. Unfortunately, most stud-ies that discuss the optimal candidate for long-term opioiduse are anecdotal in nature. Therefore at present, appropri-ateness of opioid therapy should be evaluated on acase-by-case basis, and if deemed appropriate, treatmentcan be initiated on a trial basis. Portenoy has proposedguidelines for the management of opioid therapy for non-malignant pain (see Table 2).12

Adjuvant analgesicsTricyclic antidepressants (eg. amitriptyline) and anticon-

vulsants (eg. gabapentin, carbamazepine) are used for theiranalgesic effects in neuropathic pain and in other chronicpain conditions (tension type headache, migraine prophy-laxis, fibromyalgia and others). Patients often need somereassurance on the reason for their prescription, and thatthese medicines are safe in long-term use. Tranquillisers(usually benzodiazepines) are often prescribed for nightsedation or for their muscle relaxing effect, but should onlybe used in short term. Local applications of local anaes-thetics or capsaicin can be beneficial in certain neuropathicpain syndromes, the latter also in chronic back pain andwhiplash related injuries.

Management guidelines for acute back pain ingeneral practice

In all western countries the incidence of back pain hasbeen continuously rising.13 This appears to be due tochanged attitudes and expectations, as there is no evidence

of changing pathology. The British Clinical Standards Advi-sory Group has claimed that the implementation ofmanagement guidelines may have considerable cost-savingeffects on the healthcare system, for example they estimate10%-20% reduction in GP consultations.14 The proposedguidelines are summarised in Table 3. Further recommen-dations on management of acute and chronic low back painare available from the guideline website of the US Agencyof Healthcare Research and Quality (www.guidelines.gov).

Management of non-malignant, chronic pain ina multidisciplinary teamCognitive behavioural therapy (CBT)

Patients’ beliefs about their condition as well as copingskills have a major impact on their experience of pain, alsoon disability and quality of life. Changing maladaptivebeliefs and learning positive coping skills are goals of CBT,which is a central component of pain management pro-grammes. Counselling and psychotherapy

A number of patients with chronic pain have a history ofphysical or psychological trauma (accidents, assaults, sexualabuse), major losses or life crises. Often these issues needto be addressed by a trained person to enable the patient toregain control. Pain clinic and interventional treatment

In a number of hospitals all over the country anaesthetistswho specialise in pain therapy operate pain clinics. Besidespharmacological treatment they use anaesthetic techniques

FORUM January 2003

Guidelines for management of opioid therapy for non-malignant pain12

1. Opioid therapy should be considered only after all other reasonable attempts at analgesia have failed.

2. A history of substance abuse, severe character pathology and chaotic home environment should be viewed as a relativecontraindication.

3. A single practitioner should take primary responsibility for treatment.

4. Patients should give informed consent before the start of therapy.

5. Doses should be given on an around-the-clock basis; initial dose titration should be several weeks.

6. Failure to achieve at least partial analgesia at relatively low initial doses in the non-tolerant patient raises questions aboutthe potential treatability of the pain syndrome with opioids and should prompt reassessment.

7. Emphasis should be given to attempts to capitalise on improved analgesia by gains in physical and social function; opioidtherapy should be considered complementary to other analgesic and rehabilitative approaches.

8. In addition to the daily dose determined initially, patients should be permitted to escalate dose transiently on days ofincreased pain; two methods are acceptable: (a) prescription of an additional four to six ‘rescue doses’ to be taken asneeded during the month; (b) instruction that one or two extra doses may be taken on any day, but must be followed by anequal reduction of dose on subsequent days.

9. Initially, patients must be seen and drugs prescribed at least monthly. When stable, less frequent visits may be acceptable.

10. Exacerbations of pain not effectively treated by transient, small increases in dose are best managed in the hospital, wheredose escalation can be observed closely and return to baseline doses can be accomplished in a controlled environment.

11. Evidence of drug hoarding, acquisition of drugs from other physicians, uncontrolled dose escalation, or other aberrantbehaviours must be carefully assessed. In some cases, tapering and discontinuation of opioid therapy will be necessary.Other patients may appropriately continue therapy within rigid guidelines. Consideration should be given to consultationwith an addiction medicine specialist.

12. At each visit, assessment should specifically address: (a) comfort, (b) opioid-related side effects, (c) functional status(physical and psychosocial), and (d) existence of aberrant drug-related behaviours.

13. Use of self-report instruments may be helpful but should not be required.

14. Documentation is essential and the medical record should specifically address comfort, function, side effects and theoccurrence of aberrant behaviours repeatedly during the course of therapy.

Table 2


such as diagnostic and therapeutic nerve blocks, regionalsympathetic blockades, epidural and intrathecal therapies,neuroablative procedures, and implantation of intrathecalpumps or spinal cord stimulators for certain indications.There is a growing recognition that interventional treatmentsshould be provided within the context of the patient’s over-all treatment plan, preferably within a multidisciplinaryapproach. Unfortunately, hospital resources for multidisci-plinary pain management programmes are still very limited. Occupational therapy

Occupational therapists assess the impact of pain on the

patient’s daily activities both at home and in the work place,and offer specialist knowledge to facilitate rehabilitation andreturn to work. Physiotherapy

Physiotherapy plays an important role in multidisciplinarypain management, including assessment of the functionalcapacity of the patient, development of exercise pro-grammes and specific functional rehabilitation. Applicationof analgesic physical modalities is useful in acute pain con-ditions. Transcutaneous electrical nerve stimulation (TENS)is a very effective analgesic treatment patients can use athome. Social worker

Chronic pain is often associated with social and econom-ical disability. Social workers evaluate this issue and advisepatients on support available to them.

Pain management in general practiceThe GP is confronted with a great variety of acute and

chronic pain conditions. Management in general practiceincludes causal and symptomatic therapy as well as identi-fication of patients who would benefit from specialisttreatment (see Table 4). Therefore the GP has a key positionin the prevention of pain chronification and in the continu-ation of processes initiated in pain managementprogrammes.

Kristin Ullrich is Pain Fellow at the Department of Anaethes-tics, University College Hospital, Cork

Further readingMcQuay H. Relief of chronic non-malignant pain. In: The Oxford PainInternet Site.www.jr2.ox.ac.uk/bandolier/booth/painpag/wisdom/493HJM.htmlMain CJ, Spanswick CC. Pain Management. An interdisciplinary approach.Churchill Livingstone 2000Waddell G. The back pain revolution. Churchill Livingstone 1998

References on request

FORUM January 2003

Which patients should bereferred to a pain clinic?

1. Early referral:

Acute neuropathic pain syndromes (eg. postherpeticneuralgia)

Complex Regional Pain Syndrome (CRPS, previouslyReflex Sympathetic Dystrophy)

Acute radicular pain on waiting list for surgery or whensurgical intervention was ruled out

2. Referral after treatment trial in general practice:

All patients who would benefit from interventionaltreatment or multidisciplinary management (notavailable in all pain clinics), ie:• Children and young patients with chronic pain• Patients with pain-related disability• Candidates for long-term opioid therapy (esp.

working age)• Chronic back pain (> six weeks)• Chronic neuropathic pain • Chronic refractory angina pectoris• Pain and uncontrolled spasticity in multiple

sclerosis

Overview of managementguidelines for acute back pain16

Initial consultation (diagnostic triage)

1. Simple backache2. Nerve root pain => urgent referral

Red flags: Progressive neuromotor deficit pain withdistal numbness or leg weakness/loss of bowel orbladder control

3. Serious spinal pathology => urgent referralRed flags: Unrelenting night pain/fever over 38°C for> 48 hours

Early management strategy

Aims: symptomatic relief of pain, prevent disability

Prescribe simple analgesics, NSAIDs• Avoid opioids if possible and never more than two weeks

Arrange physical therapy if symptoms last more than a fewdays• Manipulation• Active exercise and physical activity (modifies pain

mechanisms, speeds recovery)

Advise rest only if essential: 1-3 days• Prolonged bed rest is harmful

Encourage early activity• Activity is not harmful• Reduces pain• Physical fitness beneficial

Practise psychological management• Promote positive attitude to activity and work• Distress and depression

Advise absence from work only if unavoidable• Prolonged sickness absence makes return to work

increasingly difficult

Biopsychosocial assessment at six weeks• Review diagnostic triage• ESR and lumbar spine x-ray if specifically indicated• Psychosocial and vocational assessment

Active rehabilitation programme• Incremental aerobic exercise and fitness programme of

physical reconditioning• Behavioural medicine principles• Close liaison with the work place

Secondary referral• Second opinion• Vocational assessment and guidance• Pain management

Final outcome measure: maintain productive activity;reduce work loss

Table 3 Table 4

NB: Please attach this form to the Certificate of Participation which is supplied as a loose leaf insert with this issue.

How the scheme worksManagement of non-malignant pain Module 65: January 2003

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Pain managementManagement of non-malignant pain Module 65: January 2003


1. In chronic pain a direct relationship exists between theseverity of tissue damage and the amount of painexperienced:

True

False

2. Which of the following statements is true:

Lumbar spine x-ray is always necessary in theinitial assessment of acute back pain

Lumbar spine x-ray may be necessary at the six-week assessment of acute back pain

3. If acute back pain or sciatica is associated with acuteurinary retention an urgent referral to a neurosurgicalservice is indicated:

True

False

4. The detrimental effects on renal and cardiac function aresimilar with COX-2 inhibitors and classical NSAIDs:

True

False

5. Which of the following statements is false?

Addiction is a common problem with the use ofopioids in pain management.

If there is evidence of drug hoarding,considerations should be given to consultationswith an addiction medicine specialist.

6. Which of the following conditions is a relative contra-indication for opioid therapy in chronic non-malignant pain:

History of substance abuse

Chronic illness with normal life expectancy

7. Tricyclic antidepressants and anticonvulsants areprescribed for their analgesic effect in neuropathic pain:

True

False

8. Physical activity and work must be avoided with acuteback pain:

True

False

9. A history of physical or psychological trauma, majorlosses or life crises may have an impact on chronic pain:

True

False

10. Patients suffering from acute postherpetic neuralgiashould be referred to a pain clinic for a treatment withnerve blocks:

True

False

Multiple question assessment form. Please complete all 10 questions below (tick correct answers).

This form is for completion and return.

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Forum Women’s Health

WITH A PREVALENCE IS AROUND 6%, polycystic ovary syn-drome (PCOS) is one of the most common endocrinedisorders in women of reproductive age and the commonestcause of symptoms of androgen excess.

The definition of PCOS and development of diagnostic cri-teria have been the subject of much controversy. PCOS is adiverse syndrome where not all features may be present inevery patient.

The original description of classic PCOS by Stein-Leven-thal in 1935 included amenorrhoea and polycystic ovarieswith half of affected women being obese and two thirdshaving hirsutism. In the UK ultrasound confirmation of poly-cystic ovaries (ovaries with 10 or more follicles per ovary)and characteristic symptoms are necessary for the diagno-sis; in the US diagnosis is on the basis of clinical featuresand ovulatory dysfunction.

The absence of clearly defined diagnostic criteria poses achallenge for GPs, particularly as milder cases can fall intothe extremes of normal. Table 1 summarises the spectrumof clinical findings and hormonal features of the syndrome.Cause of PCOS

The underlying cause of PCOS is unknown. Good evidencesupports the hypothesis that insulin resistance leading tohyperinsulinaemia is central to the pathogenesis of PCOS.Hyperinsulinaemia stimulates androgen production in the

ovaries and reduces the levels of sex hormone binding glob-ulin produced by the liver. These factors lead to increasedfree serum testosterone. Weight gain causes increasedserum insulin and can exacerbate the features of PCOS.Complications

PCOS has been long recognised as a cause of anovulatoryinfertility. However, the complications associated with thecondition extend beyond reproduction.

In particular, women with PCOS are more likely to haverisk factors for cardiovascular disease. Women with PCOSare at increased risk of obesity, central fat distribution,hypertriglyceridaemia, reduced HDL concentrations andhypertension.

They are also more likely to develop diabetes mellitus: 8%of lean and 11% of obese women with PCOS have abnormalglucose tolerance. They are three times more likely to havea stroke or transient ischaemic attack.

Women with PCOS have a three times increased risk ofdeveloping endometrial cancer.Management

Treatment is directed at symptoms. Management shouldalso include identification and modification of risk factorsfor diabetes mellitus and cardiovascular disease. Thus, allwomen with PCOS should be given advice on the importanceof exercise, avoidance of smoking, diet and, where appro-


New developments in themanagement of PCOSThe absence of clearly defined diagnostic criteria for polycystic ovarysyndrome poses a challenge for GPs, writes Eleanor McCarrick

Clinical findings and hormonal features ofpolycystic ovarian syndrome

Clinical features Hirsutism Affects approximately 70%. Retain normal secondary sexual characteristics Acne in PCOS

Obesity Up to 70% affected

Menstrual dysfunction Up to 70% affected. PCOS occurs in 90% of women with oligomenorrhoea and 30% with amenorrhoea

Infertility Up to 70% affected

No symptoms 20%

Hormones LH Elevated >10 IU/l in 40%

Testosterone Raised in 30% of women with PCOS in the region of 2.6nmol/l-4.8nmol/l. Levels above this or signs of virilisation should raise the suspicion of other diagnoses such as an androgen secreting tumour or Cushing’s syndrome

FSH LH:FSH ratio of 3:1 supports the diagnosis of PCOS

FSH is usually normal in PCOS

Prolactin, TFTs, FSH To rule out other causes if there are menstrual disturbances. They are usually normal in PCOS

hCG To rule out pregnancy

Table 1

Forum Women’s Health

priate, weight loss. Weight loss in itself can improve symp-toms by improving insulin sensitivity and thus reducinginsulin levels. It will also reduce testosterone levels (seeTable 2).Androgen excess

Symptoms of excess androgen can be effectively treatedwith an oestrogen. An oral contraceptive pill containing aless androgenic progestogen is appropriate for those notwanting to conceive.

Alternatively, an oestrogen-cyproterone acetate combina-tion (as in Dianette) is useful in such women. Cyproteroneis a progestogen which is also an androgen antagonist. Italso suppresses LH secretion which will result in reducedovarian androgen production. Response to treatment can beslow: three to six months for acne and hirsutism. Male pat-tern baldness may take longer or may not improve at all.

Other treatments for hirsutism include local measuressuch as electrolysis, depilatory creams, shaving and waxing.Other treatments for acne include topical and oral antibi-otics, keratolytics and retinoids.Menstrual disturbance

Treatment for oligomenorrhoea or amenorrhoea of itself isnot necessary if it is not problematic and the woman herselfcan tolerate the uncertainty of irregular cycles. Treatmentwith a combined oral contraceptive will provide a regularwithdrawal bleed. If oestrogen is contraindicated, cyclicalprogestogens are an alternative. Both will prevent endome-trial hyperplasia.

There is an association between oligomenorrhoea/amen-orrhoea and endometrial hyperplasia and cancer. The DTBrecommends annual ultrasound to check for endometrialthickening and the need for endometrial biopsy.Infertility

The management of infertility is a complete topic in itselfand will not be comprehensively covered in this article.

For infertility, weight reduction should be tried first.Weight loss can improve cycle regularity and ovulation. Also,drug treatment of infertility is less effective in those who areoverweight.Medical management of infertility

Metformin: The use of metformin stemmed from the recog-nition of the role of insulin resistance in the pathogenesis ofPCOS. It has been shown to increase spontaneous ovulation,enhance ovulation induction by clomifene and increasepregnancy rates. However, metformin is not licensed for usein PCOS.

Metformin can restore menstrual regularity in up to 90%treated for four to six months; ovulation occurs in up to 40%with metformin alone; 20% can conceive within six to 12months.

The starting dose is 500mg daily. Many women will getregular ovulatory cycles at this dose. Dosage can beincreased according to response. The main side effects ofmetformin treatment are mild nausea, diarrhoea and abdom-inal bloating. The gradual increase in dose minimises these.Metformin is stopped when the woman becomes pregnant.Surgical management of infertility

Ovarian diathermy: This involves drilling the ovary to formaround 10 holes per ovary with the aim of reducing ovariansteroid production. It is considered in women where use ofmetformin and clomifene has failed to induce ovulation. f

Eleanor McCarrick is co-ordinator of the ICGP Women’sHealth Roadshow

This article is based on a presentation prepared for the Women’s HealthRoadshow. Explicit use of two papers is made throughout this article(References 1 and 2). The Women’s Health Roadshow, run by the Irish College of GeneralPractitioners, aims to bring practical, up to date and relevant informationon new and changing issues in women’s health to GPs and practice nurses.The Roadshow is a three-hour meeting combining short presentations,workshops and plenary sessions. Upcoming dates: South Western Area, Eastern Regional Health Authority: Feb 8, 2003;North Western Health Board: March 8, 2003

References1. Tackling Polycystic Ovary Syndrome. Drug and Therapeutics Bulletin2001 (January); 39: 12. Hunter M, Sterrett J. Polycystic Ovary Syndrome: It’s not just infertility.Am Fam Physician 2000; 62: 1079-88 3. Cahill DJ, Wardle PG. Management of Infertility. BMJ 2002; 325:28-324. Solomon Hu et al. Menstrual cycle irregularity and risk for futurecardiovascular disease. J Clin Endocrinol Metab 2002; 87: 2013-20175. Phipps WR. Polycystic ovary syndrome and ovulation induction. ObstetGynecol Clin North AM 2001;28(1):165-82

Androgen excess Weight loss

Combined oral contraceptive pill (COC)

Cyproterone+oestrogen

Menstrual disturbance Weight loss

COC

Cyclical progestogens

Infertility Weight loss

Metformin

Ovarian drilling

Weight loss to reducetestosterone levels

Table 2

• PCOS is an endocrine disorder that causes increasedrisk for the development of diabetes, cardiovasculardisease and endometrial cancer

• Management of the disorder must involve identificationand management of cardiovascular risk factors

• Weight loss improves disease parameters in PCOS andis a cornerstone of treatment

• Metformin is effective in the management of infertilityin PCOS but is not yet licensed for this

Management of polycysticovarian syndrome

Table 3


Forum Psychiatry

BIPOLAR AFFECTIVE DISORDER, according to the ICD defini-tion, is characterised by at least two episodes of eitherhypomania or mania alone, or interspersed depressiveepisodes with mania or hypomania.

Two clinical pictures have been described in DSM IV (theUS classification system), known as bipolar disorder I andII. Bipolar disorder I is where a patient has either manicepisodes alone (accounting for 10%-20% of all bipolar dis-orders), or manic and depressive episodes. Bipolar disorder IIis a recently recognised diagnosis where patients havepredominantly depressive episodes interspersed with hypo-manic episodes. This article will focus on depression inbipolar disorder, its diagnosis and management. Epidemiology

Bipolar disorder I has a lifetime prevalence similar to thatof schizophrenia – about 1%, however, the prevalence ofbipolar disorder II is not yet clear. It occurs equally in menand women and there appears to be no difference in ratesacross races, though it has been suggested that it is under-diagnosed and schizophrenia overdiagnosed in its place. Itoccurs at as early as five to six years of age and as late as50 years or more. Higher than average incidence of the dis-order among upper socio-economic classes may be aproduct of biased diagnostic practices. Aetiology

The most accepted hypothesis is that major depressionand bipolar disorder are distinct disorders, but it has beensuggested that the latter is a more severe expression of theformer. The definitive cause of mood disorder is unknown.Aetiological factors have been divided into biological,genetic and psychosocial aspects, however such divisionsmay be artificial due to their interaction.

Biological: In explaining mood disorders, data is most con-sistent with the hypothesis that they are caused byheterogeneous dysregulations of biogenic amine metabolites,the two most implicated being norepinephrine and serotonin.It has also been theorised that mesolimbic dopamine pathwaydysfunction may be responsible for mood disorder, and thatD1 receptors may be hypoactive in depression. Drugs such as

reserpine and diseases such as Parkinson’s that reducedopamine concentrations, are associated with symptoms ofdepression. Conversely drugs that increase dopamine levels,such as tyrosine reduce depressive symptoms.

Mood disorders have also been hypothesised to involvepathology of the limbic system (the brain’s emotionalcentre), the basal ganglia and hypothalamus (regulatingsleep, appetite and biological functions). Abnormalities inneuroendocrine axes (such as the thyroid, adrenal andgrowth hormone axis) observed in mood disorders may alsobe the result of dysfunction of biogenic amine containingneurones.

Genetic: Genetic data points to a complex mode of inher-itance. Some 50% of all bipolar disorder patients have atleast one parent with mood disorder, usually unipolardepression. If both parents have bipolar disorder, then thereis a 50%-75% chance that a child will have some mood dis-order. The concordance rate for bipolar disorder is33%-90% in monozygotic twins and 5%-25% in dizygotictwins. Genetic markers for bipolar disorder have beenreported on chromosome 5 (location of D1 receptorgene),11 (location of gene for tyrosine hydroxylase), and 10.

Psychosocial: Stressful life events may more often precedethe first episode in bipolar disorder rather than occursubsequently. The first episode may cause changes to neuro-transmission resulting in neuronal loss and excessivereduction in synaptic contacts, predisposing to futureepisodes even in the absence of external stressors. There area number of psychoanalytic and psychodynamic models toexplain bipolar depression. One model describes the tensionbetween a person’s aspirations and their reality, resulting in acollapse of self-esteem when ideals are not met. Others dealwith the loss or perceived destruction of a loved object result-ing in self-inflicted deprecation or guilt. Mania would beregarded as the defence mechanism to restore the lost ordestroyed object.

Cognitive theory of causation behind depression statesthat negative misinterpretations of life, self and the futurebecome learned and eventually lead to depression.


Careful adjustment andmonitoring of drug regimensis vital in the managementof bipolar affectivedisorder, write SukumarRajendran, Susan Keenanand Declan Lyons

Effective management ofbipolar depression


Forum Psychiatry

Adjustment and monitoring of pharmacological treatmentThe depressed phase of bipolar affective disorder is a sig-

nificant cause of morbidity and mortality. Approximately90% of people who experience an episode of mania will atsome point also suffer from a major depressive episode.

Mood stabilising agents: The pharmacological treatmentof bipolar depression is critical and mood stabilising agentsare regarded as firstline treatment. Virtually all patients withbipolar depression will need to be placed on a mood stabil-ising agent for subsequent prophylaxis anyway and some ofthese agents actually have acute phase antidepressant ratesof 30%-50%. There is virtually no risk of accelerated cyclingor treatment emergence mania associated with their use.

With regards to the mood stabilising agents, lithium hasbeen the primary pharmacological treatment. Ten doubleblind placebo controlled trials confirm that prophylacticmaintenance treatment with lithium reduces the frequency,duration and severity of depressive episodes. However, 10%of patients started on lithium cannot tolerate its side effectsand long-term complications include hypothyroidism, dia-betes insipidus and psoriasis. Monitoring of serum lithiumlevels is necessary to ensure efficacy and avoid toxicity.

Other mood stabilising agents include the anticonvulsantssodium valproate, carbamazepine and divalproex. In terms oflong-term tolerability, valproate then lithium are recommendedas firstline choices while carbamazepine as second line.

Antidepressants: Despite optimal use of mood stabilisingagents, antidepressants are often necessary for acute or pro-phylactic treatment, however caution is needed. Patientswho do require antidepressant treatment should receive thelowest effective dose for the shortest time necessary.

Selective serotonin reuptake inhibitors (SSRIs) or bupro-pion are recommended as firstline antidepressants. SSRIsare associated with less incidence of manic switches andare safer in overdose. Bupropion, an aminoketone derivativeis coequal to SSRIs for treatment of bipolar depression buthas the advantage of absent weight gain and sexual sideeffects. It has a lower risk of inducing manic switches.

At the initial trial stage of antidepressants, 30%-50% ofpatients do not respond adequately. For these patients it isadvised to push the dose to maximum as recommended forunipolar depression and persist for six to 12 months. A sub-sequent trial of an alternative firstline antidepressant is thenrecommended. Useful alternatives for these patients includevenlafaxine, nefazodone and mirtazapine.

Tricyclic antidepressants are regarded as third or fourthline agents and are to be avoided, especially in patients witha history of antidepressant induced mania or rapid cycling.Monoamine oxidase inhibitors are regarded by someresearch experts as preferential second-line agents in thesetting of severe depression. However, the side effect pro-file and dietary interactions relegate these agents to third orfourth line.

Neuroleptics: Severe psychotic states of bipolar depres-sion often warrant treatment with neuroleptics. Atypicalneuroleptics olanzapine and risperidone are gaining increas-ing favour with less side effects and notable moodstabilising effects. These agents should not, however, bethought of as primary treatments for bipolar depression. Newapproaches to resistant cases described in preliminaryreports include the use of anticonvulsants which may be

antidepressant and mood stabilising. These include lamot-rigine and gabapentin.

ECT: Electroconvulsive therapy (ECT) is a highly effectivetreatment for bipolar depression and is typically used afterfailure of one or more antidepressant trials. Fifty per cent ofbipolar patients with acute depression who have failed atleast one antidepressant showed clinical improvement afterECT. It should be considered whenever rapid clinicalresponse is required.

Psychotherapeutic treatments: These include cognitivebehavioural therapy, interpersonal functioning and familytherapy (with education on illness and emotional support).Studies confirm combination psycho- and pharmacothera-pies as being more effective than either used alone.Acute and prophylactic regimens

In practice the optimal approach to managing depressionis to subdivide treatments into acute and prophylactic regi-mens, bearing in mind the subcategories of bipolar I and II.

Acute phase treatment of bipolar I depression depends onwhether psychotic symptoms are present and on the severityof the current depressive episode. In psychotic depression therecommended treatments are either ECT or the combinationas mentioned before of an antipsychotic, mood stabiliser andan antidepressant. For severe depression without psychoticfeatures the treatment of choice is the combination of a moodstabiliser and an antidepressant. For milder depressiveepisodes a mood stabiliser as monotherapy or combined withan antidepressant is recommended. Psychotherapy added tomedication is a highly rated second-line treatment.

The recommended acute phase treatments for bipolar IIdepression are similar to those for type I, however psy-chotherapy is more useful and occasionally mood stabiliserscan be cautiously omitted in patients who have had minimalhypomania. The continuation treatment phase lasts two tosix months after acute symptoms have resolved. The treat-ment regimen in this phase aims to continue the moodstabilising agent while trying to taper other medications (anti-depressants, antipsychotics). It is advised to taper theantidepressant sooner than one would in unipolar depression.Pitfalls in general practice

Virtually every antidepressant agent has been associatedwith the emergence of mania in bipolar patients. In othercases there has been an association between the use of anti-depressants and the development of rapid cycling andmixed affective states. Unfortunately the phenomenon ofantidepressants inducing the switch to mania, hypomania,rapid cycling or mixed affective states has not been sys-tematically evaluated in most studies of antidepressants andbipolar depression. It is therefore unknown whether differ-ent antidepressants are more or less likely to induce theswitch process. Recent preliminary data suggest that bupro-pion may be less likely than TCADs.

In general it is advised to use antidepressants with cau-tion and in those who require such treatment to use thelowest effective dose for the shortest time necessary. Thesimultaneous use of a mood stabilising agent is recom-mended to reduce the risk of switch. f

Sukumar Rajendran and Susan Keenan are registrars in psy-chiatry and Declan Lyons is a consultant psychiatrist at StPatrick’s Hospital, Dublin


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TYPE 2 DIABETES MELLITUS (DM2) is expected to affect 200million people worldwide in the near future. Unlike type 1diabetes, which is an autoimmune disease, and therefore todate can be treated but not prevented, type 2 has recentlybeen shown to be a preventable illness in a significant pro-portion of susceptible people.

This represents a significant step in our understanding ofthe pathogenesis of type 2 diabetes, and bodes well for thefuture. The aim of this article is to review current guidelinesand recent developments for the management of type 2 dia-betes to ensure that patients currently diagnosed with type2 are receiving optimal treatment.

Type 2 diabetes was traditionally a disease that affectedadults. This has changed in recent times as more childrenare being diagnosed with type 2 each year. Currently in theUS, the number of children being diagnosed with type 2 dia-betes is practically equal to the number being diagnosedwith type 1 disease.

The simple reason for this is the increasing prevalence ofsedentary lifestyles with a decrease in physical activity anda corresponding increase in obesity in young people. Thegene pool has not changed.

The initial effects of this change in demographic for type2 diabetes will not be felt immediately. However, it is knownthat the incidence of vascular complications in type 2 isdirectly related to the duration of disease. This means thatall the young people currently developing type 2 diabeteswill be at a significantly increased risk of cerebrovascularaccident (CVA), myocardial infarction (MI), retinopathy,nephropathy and neuropathy by the time they reach their30s. This is a frightening prospect.

As a profession, we need to act now to prevent this out-come. Recent studies1-3 have proven that prevention ispossible. Until a cure becomes available, this is our onlyoption.Physical activity

Physical activity has moved centre stage in the manage-ment of type 2 diabetes. In the recent studies, physicalactivity combined with dietary intervention is capable of pre-venting the onset of diabetes. It also has a positive impacton lipid profile and cardiovascular risk profile.

However, the recommendations for physical activity haveevolved with time. Most patients will be satisfied to walk afew times a week but what has become apparent over timeis the need to achieve target heart rates while exercising inorder to obtain the desired results.

In order to ensure patients are exercising properly, it isimportant that they be seen and assessed by a physical ther-apist. In some patients, it is necessary to perform anexercise stress test prior to commencing an exercise pro-gramme for safety reasons.Aspirin

All patients with type 2 diabetes over the age of 50 yearsshould be taking low dose aspirin daily. This is to reducethe well-documented risk of CVA and MI in people withdiabetes. Any patient with another documented cardio-vascular risk factor – raised cholesterol, cigarette smoker,hypertension or family history – should commence aspirinat time of diagnosis, even if diagnosed before the age of50 years.

• It is essential that people with diabetes be assessed bya dietitian at diagnosis and at least annually thereafter

• The dietitian is a vital member of the multidisciplinaryteam approach to the management of type 2 diabetesand has input relating not only to improving glycaemiccontrol but also to weight management – which relatesto insulin resistance, and to fat intake – which relates tocholesterol levels

• It has recently been shown in the type 2 diabetesprevention trials that dietary intervention with physicalactivity can decrease the incidence of type 2 diabetesin patients at risk

Dietary therapy for patientswith type 2 diabetes

Type 2 diabetes:prevention andcontrol

There is a lot that GPs can do to ensurethat type 2 diabetes does not become themajor cardiovascular killer of the future,write Cillian de Gascun and Donal O’Shea


Forum Clinical Review

Blood pressureOne of the most impressive findings of the UKPDS

(United Kingdom Prospective Diabetes Study) was thatblood pressure (BP) control was as important, if not moreso, as blood glucose control in the prevention of complica-tions. The current recommended guideline for BP in peoplewith diabetes is <135/75mmHg. Good BP control decreasesboth the cardiovascular risk profile in these patients andalso decreases the risk of hypertensive renal damage.

Firstline agents for the treatment of BP in people with type2 diabetes are typically angiotensin converting enzymeinhibitors (ACEI) as they have the added benefit ofdecreasing the severity of microalbuminuria. They also havebeen shown to decrease all cause mortality in normotensivepeople with diabetes.

Recently, angiotensin II receptor antagonists (AIIRA) havebeen shown to have similar benefits. The majority ofpatients will require more than one medication for good BPcontrol, and this is to be encouraged where necessary. Otheragents available are beta blockers, calcium channel block-ers, thiazide diuretics and alpha blockers. A combination ofthese should achieve good control in most people.

It should be pointed out that it is advisable to commencetreatment on the basis of two abnormal BP readings.Twenty-four hour ambulatory BP monitoring is not compul-sory but can be a useful diagnostic tool, as quite frequently,the earliest indicator of hypertension is the loss of thenormal nocturnal dip in systolic BP. Twenty-four hour ambu-latory BP is useful in monitoring effectiveness of therapy. Microalbuminuria

Microalbuminuria is defined as the presence of more than30mg of microalbumin in a 24-hour collection of urine. Thepresence of microalbumin in the urine has been shown tobe an early marker of renal impairment and requires treat-ment.

All people diagnosed with type 2 diabetes should bescreened for microalbumin at the time of diagnosis and atleast twice yearly thereafter. Once present, it is an indica-tion for ACEI or AIIRA treatment. Those with persistentmicroalbuminuria should be further investigated for signifi-cant proteinuria and should also have a renal ultrasound andtheir creatinine clearance measured. These patients mayrequire referral to a nephrologist if not responding to first-line medication.Hyperlipidaemia

Total cholesterol in type 2 diabetes should be below5mmol/L with the LDL less than 2.6mmol/L. A fasting lipidprofile should be taken following diagnosis once the imme-diate hyperglycaemia has settled and at least annuallythereafter. If the initial cholesterol is not greater than6mmol/L, it is appropriate to try non-pharmacological mea-sures to bring it back into the normal range. However, threemonths of a low fat diet is sufficient to establish whetherdietary intervention alone will be successful.

If the cholesterol is still elevated following this period, astatin should be commenced. This family of medication willlower cholesterol and decrease the risk of CVA and MI inpeople with diabetes. The latter explains why it is inappro-priate to persist with dietary therapy alone for a protractedtime period. Cholesterol-lowering treatment is for life andpatients should be actively discouraged from self-discon-

tinuing their medication when cholesterol levels fall into thenormal range.Diabetes specific therapy: when to start and what to use?

The above information, while being of the utmost impor-tance in the management of diabetes, has not in fact doneanything directly to improve glycaemic control or to lowerthe glycated haemoglobin (HBA1c). However, all of theabove measures will have a beneficial effect, and indeedthey may preclude the need for diabetes-specific treatmentin a substantial proportion of people.

Not all newly diagnosed people with type 2 diabetes needglucose-lowering treatment in the initial months after diag-nosis. They do still need regular review by a diabetologisthowever, and they need assessment in all of the above-men-tioned areas. They should also be educated in the practiceof checking their own blood sugars at home, and be encour-aged to keep a record of these for review during their clinicappointments.

The normal range for glycated haemoglobin has beenrevised downwards and it is now felt that less than 6% (ie.normal) is the goal aspired to in all patients with DM2. Thiscan often be achieved with the non-pharmacological mea-sures already described. However, as soon as the HBA1cbegins to rise above the normal range, treatment is indi-cated.

Again, not all patients with type 2 diabetes will requireinsulin (as in the case of type 1), but should be started ontreatment in a logical step-wise progression through the drugclasses available. Should they fail to be adequately managedwith tablets, insulin may then be required, either with orwithout tablets. Maintaining patients on their insulin sensi-tisers can reduce the dose of insulin required for goodglycaemic control.Insulin resistance

As discussed earlier, the pathogenesis of type 1 diabetesis quite straightforward. It is an autoimmune disease. Type2 is not as straightforward. However, we do know that thepathogenesis of type 2 diabetes relates to insulin resistance.The logical thought then is that if we can lower endogenousresistance to insulin, we should be able to affect the diseaseprocess.

The recent studies have essentially proven this, but not allpatients treated with an insulin sensitising agent were pre-vented from developing type 2 diabetes so there is morehappening at a molecular level than has yet been clarified.One of the benefits of insulin sensitisers in type 2 diabetesis that they do not cause hypoglycaemia, as they have noeffect on endogenous insulin production. They merely makethe body more sensitive to the insulin that is already beingproduced.

Insulin sensitisers are still the firstline medication in thetreatment of type 2 diabetes when medication is required.The two main options available are the biguanides, eg. met-formin, and the thiazolidinediaones, eg. rosiglitazone.Metformin has been around for a long time and works well.It is better in patients who are overweight (body mass index>27.5kg/m2 ) and can help with weight loss and improvinglipid profile.

Rosiglitazone is from a newer class of medication that actsas an insulin sensitiser in all patients, including those witha normal BMI. It also has beneficial effects on the lipid


Forum Clinical Review

profile, and studies are ongoing to investigate how it mightimpact on other aspects of the cardiovascular risk profile inpeople with type 2 diabetes. To date, in Ireland, it is onlylicensed as an adjunct medication, with either metformin ora sulphonylurea. In the US, it is licensed for use as a singleagent, with other oral agents or with insulin. Indeed a com-bination tablet with metformin is available in the US.

Liver function tests (LFT) should be monitored in patientson rosiglitazone as a previous member of the drug class(troglitazone) had to be withdrawn from the market as aresult of hepatic failure. That does not appear to be a classeffect though, as early experience with rosiglitazone hasbeen very positive and a submission has been made to theFDA to remove the need to monitor liver function whereinitial tests are acceptable.Oral hypoglycaemic therapy

When patients cease to be controlled with diet and insulinsensitisers, the next course of action is to try to increase theamount of circulating insulin in the body, with a view toovercoming the insulin resistance that lies at the core oftype 2 diabetes. There are two main methods of achievingthis aim. The first is by stimulating the pancreas with hypo-glycaemic agents and the second is by administration ofsubcutaneous insulin.

The main hypoglycaemic agents in use are the sulphony-lureas. They can be given once or twice daily in long-actingform or three times daily before meals in short-acting form.Although they work well in the majority of patients, they docarry the risk of medication-induced hypoglycaemia and canover time lead to weight gain. That said, many people withtype 2 diabetes will put on weight over time anyway, as theirinsulin resistance increases.

Sulphonylureas are not ideal in patients in whom there isa high risk of hypoglycaemia or in those in whom modestweight gain is undesirable. From a compliance perspective,once daily dosing is preferable, especially as many of thesepatients will be on multiple medications.Insulin

Endogenous insulin production is never zero. There isalways a basal rate of insulin secretion to ensure adequateglucose supplies to the brain and nervous system. When aglucose load is then ingested at meal times, this rate ofinsulin secretion increases in response. The most excitingdevelopment in recent times in the management of diabetesis the introduction of relatively peak-less long acting insulin.

The principle behind it is that one injection a day of long-acting insulin is given. This acts as a depot and mimics thepancreatic basal insulin secretion rate mentioned earlier.When the dose of this insulin is titrated correctly, it causesa lot less hypoglycaemia. The only minor inconvenience isthat it has to be administered at the same time each day.Recent studies suggest that the best time to administer theinjection is in the morning, rather than at night.

Although the major application of peak-less insulin islikely to be in the treatment of type 1 diabetes, it has to beappreciated that many type 2 patients will, over time, fail tobe adequately controlled on even a combination of tablets.One reason for this is that essentially, the pancreas fails,having been hyper-stimulated by hypoglycaemic agents fora prolonged period of time. Beta cells reach a stage wherethey cannot produce any more insulin.

When this happens, many type 2 diabetes patients will beelderly and may not want to start a complicated insulinregime. They may also lack confidence and insight into theseverity of their disease and the potential consequences ofincorrect dosing. Many will be living alone. The advantageof a once daily injection in these patients is that:• There is no complicated insulin regime to learn• They do not get hypoglycaemic attacks (when dose is

titrated slowly) • The injection can be given by a district health nurse or an

educated family member (eliminating the potential forage-related dosing errors).

Insulin analoguesInsulin therapy has advanced significantly in the past

number of years. The main reason for this is the synthesisof insulin analogues. These are man-made versions of theinsulin molecule. They differ from naturally occurring insulinby as few as one or two amino acids.

Multiple studies into these forms of insulin revealed thatthey closely mimic endogenous insulin activity. However, byaltering their structure, their activity is changed. Some actmore rapidly than the fast-acting insulins previously avail-able which means that patients can now take their injectionat meal times or even immediately after, when they knowhow much food they have eaten. Previously, the injectionhad to be given half an hour before meals.

The long-acting insulin described above is one such ana-logue whose structure was also specifically designed.Previous long-acting insulins carried a risk of nocturnalhypoglycaemia but with the newer agent this risk is signifi-cantly less.

Insulin analogues at the moment have a greater role toplay in the management of type 1 diabetes, but in thefuture, as the number of people with type 2 increases, theywill be just as important in the latter disease.Recent trials

The important message from the recent randomisedplacebo-controlled trials looking at the prevention of diabetesmellitus is that type 2 is preventable. This can be achievedthrough lifestyle modification alone3 or in combination withmedication.2,3 An internationally accepted description of thelifestyle intervention required has also been previously pub-lished.1 In the trials referenced, the enrolled patients havehad impaired glucose tolerance at baseline.Gold standard

It is a very exciting time to be involved in the managementof people with type 2 diabetes mellitus. Specialist care isstill the gold standard for treatment and recommended forall patients with newly diagnosed type 2 diabetes. However,there is a lot each of us can do in our own practice to ensurethat diabetes does not turn out to be the major cardiovas-cular killer of the future. f

Cillian De Gascun is a registrar and Donal O’Shea isconsultant at the Department of Endocrinology,St Columcille’s Hospital, Loughlinstown, Co Dublin

References1. Diabetes Prevention Program Description of Lifestyle InterventionDiabetes Care 2002 (Dec);25(12): 2165-21712. Chiasson et al. Acarbose for prevention of type 2 Diabetes Mellitus: theSTOP-NIDDM randomised trial. Lancet 2002 (Jun); 15; 359:2072-20773. Knowler et al. Reduction in incidence of type 2 Diabetes Mellitus withlifestyle intervention or metformin. NEJM 2002 (Feb 7);346(6): 393-403

Forum Vaccination

A STATED OBJECTIVE of the World Health Organisation wasthat by the year 2000 there should be no indigenous casesof poliomyelitis, diphtheria, neonatal tetanus, measles,mumps or congenital rubella in European Union memberstates. However, this aim was not achieved.

While high uptake rates of primary immunisation are beingrecorded in most EU countries, there is a very vocal minor-ity that seizes upon possible associations of particularvaccines with adverse effects. Addressing parental concerns

It is important that GPs are aware of parental concernsand can answer any questions posed, such as the following:• Why should children be immunised when most vaccine-

preventable diseases have been eliminated in Ireland?Sadly our uptake rates are still too low (70%-80%) to

confer community immunity and we still have outbreaks ofmeasles and pertussis and a rise in tuberculosis.• Do immunisations work? Haven’t most people who get a

vaccine-preventable disease been immunised?Most childhood vaccines are 90%-95% effective. There-

fore while some immunised children will develop thedisease, the vast majority are protected. The higher theimmunisation rate, the greater the level of protection.• Are some vaccine lots more dangerous than others?

All vaccines are licensed and monitored both before andafter release and there is no evidence that individual lotsdiffer in safety.• Isn’t giving young infants multiple vaccines at one time

dangerous?Numerous studies have shown that the current immunisa-

tion schedule (in particular the 5:1 vaccine at two, four and sixmonths) is safe and effective. Vaccines are designed tostrengthen the infant’s immune system, not to weaken it. TheMMR vaccine contains 24 different antigens and this numberis minute compared to the total number that the child’simmune system is capable of responding to (up to 100 billion). Immunisation policies

The strategic objectives of immunisation are:• Prevention of the disease at an individual level• Control of the disease at a population level• Eradication or elimination of the disease.

There are a number of immunisation policies that may beconsidered to achieve this. Not to immunise is not really anoption as it runs counter to scientific evidence and bestmedical practice, and it would inevitably lead to a decreasein population immunity. Compulsory immunisation wouldrun counter to the principle that vaccines should be admin-istered on a voluntary basis. Deferral of immunisation (eg.deferral of MMR beyond 15 months) is not recommendedas it leaves children unprotected and at greater risk of infec-tion for longer than is necessary.

A case for making single vaccines available by popular

choice, as opposed to recommendations by health profes-sionals cannot be sustained based on current scientificevidence. Single vaccines involve more jabs, more revisitsto immunisation clinics and there is no proof whatsoeverthat they are in any way safer or better.Comparisons with other EU countries

Although the immunisation schedule is broadly similarthroughout the EU, uptake of immunisation varies consid-erably (see Table). Figures for 2000 from the NationalDisease Surveillance Centre show that MMR uptake in Ire-land dropped to 75%-80%. Polio, Hib and diphtheriauptake rates were 85% and pertussis uptake rates remainedat 82%. These figures fall well short of the 95% uptake raterequired to confer herd immunity to the childhood popula-tion as a whole.

All but four EU countries (Ireland, Italy, Greece and Ger-many) achieve over 90% uptake rates for the DPTa vaccine.In relation to MMR uptake, Ireland, Belgium, the UK, Italyand Germany again fail to achieve 90% uptake rates.

Uptake rates are independent of GNP figures and the per-centage of spending on health. We therefore should followthe model adopted by the Scandinavian countries and theNetherlands as they have most impressive immunisationuptake rates. Reasons put forth for poor uptake rates amongpre-school children in Ireland include difficulties in reach-ing certain groups (such as the urban poor and ethnicminorities), poor interaction between healthcare profes-sionals, lack of integrated health information systems andpoor access to health services. f

Emma McDermott is a senior registrar and Alf Nicholson is aconsultant paediatrician at Our Lady of Lourdes Hospital,Drogheda


Strategic immunisationGPs need to be equipped to answer parental concerns about immunisation ifIreland is to increase its uptake rate, write Emma McDermott and Alf Nicholson

BCG DPTa Hib MMR

Austria n/a 90 n/a 90

Belgium n/a 95 n/a 75

Denmark / Sweden n/a 99 98 98

France 78 97 97 98

Germany n/a 85 80 75

Greece 90 80 n/a 90

Ireland n/a 85 87 75

Italy n/a 85 n/a 70

Netherlands n/a 97 96 96

Portugal 94 97 95 96

Spain n/a 95 87 95

UK 5 92 92 88

EU comparison of vaccinationuptake rates (%)

Beware of the gap betweenmyth and reality

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Dr Hugh Dennison* may have gained entrance to the land ofyouth but he remains sceptical about certain attitudes toteething

TO UNIVERSITY COLLEGE CORK for the unveilingof the results of the PROSPER study on the use

of pravastatin in the elderly. It is gratifying to see that high-quality research can be carried out in real people in generalpractice given adequate resources and the success of thisproject bodes well for the future.

The main conclusions are that pravastatin significantlyreduces serious adverse cardiac events, both fatal and non-fatal, in the elderly. Somewhat disappointingly, there is noeffect, for better or worse, on cognitive function and the inci-dence of stroke remains the same in both placebo and activegroups. As a small decrease in the incidence of TIAs isnoted, it is felt that the length of the study – three years –was too short to have an effect on stroke and possibly if thestudy had been extended for up to five or six years animprovement might have been noticed.1 But that is anotherday’s work.

In the audience there is a goodly sprinkling of geriatri-cians, both active and emeriti. The latter are all sprightly,intellectually vibrant and belie their age, and it is hard todistinguish them from their younger equivalents. Could it bethat a life in geriatric medicine keeps you young? If that isthe case, based on my practice age profile, I may be doomedto live forever.

The splendid corporate area at Leopardstownracecourse is the venue for the College’s recently

renamed ‘Winter Meeting’. As usual, there is much for dis-cussion, debate and controversy.

The first session deals with different types of evolvingpractice: the merging of three practices in a rural areawith one proposed main centre; the trials and tribula-tions of part-time (usually female) general practice;and the chaotic state of current general practice inNew Zealand.

The last word fittingly goes to the ever-wise MichaelBoland, who warns of the difficulties of going too rapidlyfrom cottage industry practice to what can so easily becomea polyclinic, and advises that progress should be incremen-tal. A presentation on the medical care of asylum seekersand the unveiling of the revamped College website is fol-lowed by papers on the prevalence of diabetes in ruralpractice and on how to deal with the growing problem of sui-cide, especially in young men.

After lunch, as is often the case, there is a good deal ofattrition as many delegates defect to attend what looks like

a water polo match, except that the ball is oval, between Ire-land and Argentina at the aquatic centre formerly known asLansdowne Road.

Those of us remaining in Leopardstown hone up on con-tinuing medical education and diabetes, learn how to keeplocums happy, compare and contrast the health needs of thepeople of Tallaght and Docklands, and discover that ourmedical records aren’t really ours any more. This last work-shop is resourced by the mega-talented, multidisciplinarySimon Mills. All in all, it has been a worthwhile day with asignificant social element which binds colleagues from thefour corners of Ireland in the common pursuits of knowledgeand friendship.

Teething, like male-pattern baldness and men-struation, is not a disease. It is a necessary and

uncomfortable physiological process, but which of us hasnot been complicit in the pseudodiagnosis of the ‘teethingbronchitis’ or ‘teething nappies’ offered by parents when wedon't exactly know what is wrong with an infant, but weknow at least that it’s probably transient and not serious?

A quarter of a century after the BMJ declared the death ofteething as an illness, and despite evidence-based studiesbacking it up, the evidence is that the gap between mythand reality is still huge.

In a recent Australian study, a questionnaire to nurses,dentists,

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Forum Doctor’s Diary

paediatricians, GPs and pharmacists on attitudes to teethingshowed that nurses attributed more conditions to teething,such as nappy rash, feeding difficulty, pulling at ears, diar-rhoea, UTIs and smelly urine than other groups.2

Paediatricians were the most sceptical and we GPs weresomewhere in the middle, hedging our bets, as is secondnature to us in our daily work.

Today I get a letter from an obstetrician thankingme for referring a patient. Nothing unusual about

this, you might say, except that I did not refer the patientand this is my first time to hear of this particular transac-tion. My irritation would be slightly mitigated if my colleaguewere more honest and admitted that I did not refer thispatient but this does not happen. Spontaneous referrals tosecondary care are uncommon and generally acceptableonly in attendance at A&E, at some psychiatric clinics andat some chronic paediatric facilities. Most specialistsrespect our role as gatekeepers but we are in more and moredanger of being bypassed.Obstetricians are the worst offend-ers in taking unreferred patients and midwives are the worstculprits at self-referral. It is as if they have some proprieto-rial right to hike themselves off to their training hospital assoon as the blue line is visible.

As GPs, we are often inundated with protocols from spe-cialists and hospitals advising us when, what, how and whyto refer so as to minimise inappropriate attendances at over-burdened outpatients. I am even more perplexed when Iread that the Irish Hospital Consultants’ Association is con-sidering relaxing the ban on self-referral. Surely this will lead

to chaos if uninformed patients can decide themselveswhere to go? Or would I be wrong in thinking that this liber-alisation will apply to the private sector only?

You never know when even the most casualthrowaway remark or word can cause grief and

upset. I think it was Tweedledum (or was it Twee-dledee?) who said that a word means what we want it tomean, regardless of what it actually means. Sixteen-year old,six foot six inch Willie attends with low back pain and hismother in tow. The pain is not sciatic, his spine is fullymobile and I am sure that the pain is caused by a combi-nation of slouching, carrying a heavy bag on his back, andsitting at a school desk that was designed 50 years ago forsmaller pupils. I mention that I think his pain is postural.

At this, his mother goes pale, slumps into a chair andbecomes quite upset. When she recovers, she tells me thatsome years ago her nephew, a contemporary of her son,complained of headaches which his doctor attributed to poorposture. Three weeks later he was dead from a brain tumour.Ever since, she has linked the word ‘postural’ with this tragicevent. I assure her that there is no connection betweenthese two consultations but it shows me we can never be toocareful with what we say. f

Dr Hugh Dennison (a pseudonym) is in practice in a rural area

References1. Shepherd J, Blauw GJ, Murphy MB et al. Pravastatin in elderlyindividuals at risk of vascular disease: a randomised controlled trial. Lancet2002; 360: 1623-30.2. Wake M, Hesketh K. Teething symptoms: cross sectional survey of fivegroups of child health professionals. BMJ 2002; 325: 814.

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Health in Practice Programme

A System of Healthcare Support for GPs

Irish College of General Practitioners

Information on Health in Practice is also available on the ICGP website: www.icgp.ie

For confidential advice contact:

Dr Andrée Rochfort,Director, Health in Practice Programme,ICGP,4/5 Lincoln PlaceDublin 2Tel: 01-676 3705Fax: 01-676 5850Mobile: 087-751 9307Email: [email protected]

For information, contact:

Margaret Cunnane,HiP Administrator, ICGP, 4/5 Lincoln PlaceDublin 2Tel: 01-676 3705Fax: 01-676 5850Email: [email protected]

“HE LARDS THE LEAN EARTH AS HE WALKS ALONG”. So saidPrince Hal about the fat old knight Sir John Falstaff in Shake-speare’s King Henry IV Part One. Yet Falstaff remains one ofthe most lovable figures in the huge cast of characters.

He is used as a roguish but lovable foil to the serious busi-ness of princely duty and murderous powerpolitics in Henry IV Part One and as a centralfigure of great sympathy and pathos in theMerry Wives of Windsor. In another snide,sizeist insult, Hal calls his old friend “a greatcloak bag of guts, a Manningtree ox with apudding in his belly”.

This reflects the dichotomy of feelingswhich obesity arouses. Warmth and sympa-thy for the larger than life, clownish, fatperson on the one hand, and cruel ridiculefor the grotesque physical reality of obesityon the other. I’m sure if Shakespeare had hadknowledge of the medical consequences ofobesity, he would have embellished Sir Jack’slife with a clever background narrative of car-diovascular disability, dietary restrictionbecause of type II diabetes and inability tofight in the Battle of Shrewsbury due to bilat-eral knee osteoarthritis rather than because“discretion is the better part of valour”.

As a clinician in primary care, obesity is an everydayoccurrence, either as an issue for preventive care or a prob-lem for consideration where a patient’s self esteem isseriously lowered by dissatisfaction with body image and fit-ness. Yet there is some tension for the doctor in approachinga matter so personal and so central to a person’s being astheir shape and size.

If you feel that a patient’s ears are too large or that theyhave a bulbous nose that may be correctable by cosmeticsurgery, you will not feel constrained to voice your opinion.Yet in the matter of excess body fat, the evidence now sug-gests that we may be as negligent in not confronting obesitywith a patient as we would be if we ignored consistent bloodpressure readings of 180/110.

This needs to be discussed in the context of our growingrole as health police. We should acknowledge the diminish-ing freedom of individuals to be who they want to be and toremain the shape and size they are and to enjoy a good life(if a shorter one) without let or hindrance from an increas-ingly meddlesome (or useful) medical profession.

Can we balance the increasing scientific evidence basewhich strongly suggests that adjusting lifestyle and lipids,

weight and diet, tobacco and alcohol consumption confersa greater chance of a long life of great quality with our viewson freedom of choice and democracy?

Our practice has had its first diagnosis of childhood type IIdiabetes recently. In this case the patient is an 11 year old

who has been very overweight for years andhas struggled (with the help of parents, dieti-tians and GP) to reduce body mass index butall to no avail. It is very likely that endocrineand metabolic anomalies (including insulinresistance) have been at work in this very sadsituation where a child who has struggled athome, at school and in the doctor’s surgerywith obesity, is now afflicted with a seriousand life altering condition as well.

I wonder if we could have done better forthis young patient with an enormousappetite, especially since (atypically) theweight problem was identified by parents anddoctors at an early stage but was never suc-cessfully resolved.

On a more cheerful note a gentleman whohas successfully lost five or six stone overrecent months is very enthusiastic about hisnew body shape. During a recent consulta-

tion he gleefully told me that he no longer has to book twoairline tickets for himself and that normal (off the rail)trousers now cover his reduced lower frame.

Yet I had mixed emotions as I looked at his sleeker jowlsand looser shirt. I realised that I rather missed the largerthan life persona which this previously bulky man had por-trayed. However, I also relished a future professionalrelationship which may involve much less chronic illnessand disability.

If I have any doubts about tackling obesity head on, Isimply go back about 18 years and remember a 30 year-oldfemale patient who broke my surgery weighing scales byexceeding its maximum of 22 stone. Despite dietingattempts and ‘slimming tablets’ she never succeeded inlosing an ounce. Two months after wrecking the springs inmy scales she dropped dead suddenly. The autopsy reportstated that the cause of death was cardiomyopathy withgross obesity as a contributing factor.

It will be a challenge to mix clinical evidence, ethics, sen-sitivity and duty of care with a desire to avoid ‘sizeism’ andthe overzealous creation of more worried well. f

John Latham is an inner city GP in Dublin

The trouble and strifeof the larger than life

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While many obese patients are lovable characters, GPs mustconfront them with the grave medical consequences of beingoverweight, writes Dr John Latham


THE UK IS IN THE MIDST of another property price boomwhich may be good for some but the property price fluctua-tions are a concern to GPs as high property values affectrecruitment to partnerships. The reason why lies in NHSarrangements for financing GP surgery premises.

In 1948 when the NHS came into being it made no pro-vision for the costs of surgeries – the fee structure simplypaid for the clinical care. Through the 1950s and early1960s, several reports by the government and by the newRCGP pointed out the poor facilities available to GPs withrun down buildings and minimal investment.

In 1965 the new GP contract introduced the first schemefor subsidy of GP premises. Known as the Cost Rent Schemethis allowed GPs to borrow money to build or refurbishpremises from either a bank or from a government fundedGP finance corporation. The NHS then reimbursed the inter-est payments on the loan and the GP paid off the capital. Atthe end of the loan the GP owned the new premises and theNHS then continued to reimburse ‘notional rent’ for use ofthe facilities for NHS care. So in effect a GP became theirown landlord with the NHS as the tenant.

This additional income allowed the premises to be main-tained and equipment replaced as and when necessary.From 1965 surgery premises improved dramatically. Thegovernment controlled expenditure through this scheme byapplying cost limits according to the size of the practice.

The Cost Rent Scheme was a worthwhile investment forthe individual doctor since on retirement a GP could selltheir portion of the building to an incoming partner. The newpartner used their share of the ‘notional rent’ to finance thepurchase and the retiring partner realised a capital sum toaugment the pension.

This scheme has continued largely unchanged until now.In the early 1990s, however we saw the first signs of prob-lems when booming property values meant that the share ofthe real value of a surgery became too much for an incom-ing GP to afford – the notional rent not being sufficient tocover the costs. So retiring partners found their asset diffi-cult to sell and this in turn began to affect the ability ofpractices, particularly in affluent areas, to find replacementpartners. When the property boom subsided and the marketreversed, some practices which had embarked on expensive‘cost rent’ funded schemes also found that they had nega-tive equity.

The government became concerned and signalled a

change to these 1960s arrangements. The Cost RentScheme has been wound down and new surgery premisesare now to be financed under the Private Finance Initiative.Under a PFI scheme a practice gets a private developer tobuild the surgery and then leases it on a long lease. Thedeveloper has the security of knowing that the NHS will beunderwriting the cost of the rent and so the tenant isunlikely to default. GPs no longer own premises and so newpartners no longer have to buy a share of the building.

After some initial caution the PFI scheme seems to beworking and developers are queueing up to offer their ser-vices. For those GPs stuck with premises that they cannotsell some developers will include buying out the property aspart of the deal but this does not always solve the negativeequity problem. In the negotiations for the new GP contractto be introduced this year, the government has signalled thatit might be willing to underwrite any potential loss if a prac-tice wishes to enter into a PFI scheme.

The next decade will see a major change in one of thegreat traditions of UK general practice in that fewer andfewer GPs will own their own buildings.

It is probably a timely development since very soon womenGPs will out number men and many male GPs will not nec-essarily wish to work full time. Both these trends mean thatthe property owning tradition would be hard to sustain.

The link with pensions is also interesting. We now have asituation within the NHS where virtually all GPs will haveworked sufficient number of years to qualify for a reasonablyhealthy pension on retirement. Unlike the 1960s there ismuch less need to have the cushion of the investment inproperty at retirement.

The government has been criticised for its PFI scheme forfinancing public buildings because the big costly projectssuch as hospitals have run into all sorts of financial prob-lems. However, in general practice it seems to be a successlargely because smaller projects are easier to control.

The NHS schemes for subsidising premises have been asuccess and those who negotiated them in 1965 had greatforesight. It is probably this above all else that has per-suaded GPs to draw back from threats to resign from theNHS when periodic disputes have occurred. There was toomuch to lose! f

Rob Walker is medical director of the West Cumbria PrimaryCare Trust

Property price boomprompts less focus onsurgery ownership

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Under a new NHS initiative, GPs can now lease their surgery buildingrather than having to find the money to buy it, writes Rob Walker


Have you come across an item that you think might be of interest to colleagues? If so, please drop a note to:

The Editor, Forum, 25 Adelaide Street, Dun Laoghaire, Co Dublin

or email to ‘[email protected]’ (please mark it ‘Etcetera’)

● While dog bites were the most prevalent injuries in areview of over 100 Medical Defence Union case files onpatients who were bitten, some cat bites were also prettyserious – enough to lead to the amputation of a finger and,in one case, a whole arm. However, insect bites causedthe most deaths, according to the MDU. Medico-legalproblems ranged from complaints about treatment anddelays in referral, to negligence claims. Which leads us towonder if doctors should in future be more cautious whentreating such injuries. Once bitten, twice shy, perhaps?

● GP visits could be replaced by email, according to theresults of a new study that examined a new type oftechnology involving online consultations. Almost eightin 10 of the online patients said that the service waseither good or excellent, when compared with a surgeryvisit or phone call. Around half of the patients alsoindicated that they would rather an email consultationto a surgery visit, if the problem was not urgent. Over60% of doctors involved with the study also felt thatthe service was satisfactory, as the number of surgeryvisits was reduced, as were overall costs. However, asone clever clogs has since pointed out, given thepressures on GPs’ time already, it could be weeksbefore they received a reply!

● Not such a clever dick was the 50-year old scientist whosustained burns to his nether regions while using a laptoprecently. He felt a burning sensation after spending anhour writing a report using the computer on his lap andexperienced redness and irritation the following day.However, he only realised the extent of the damage afteran examination by his doctor. The wound subsequentlyblistered, became infected and then crusted but thescientist is now reported to be ‘healing quite rapidly’.Perhaps he might have benefited from an emailconsultation with his GP in the first instance. And theemail address? Why hotmail.com, of course!

● A report suggesting that MS is sexually transmitted hasbeen dismissed as ‘a crackpot theory’ by a leadingneurologist here. The report had also suggested thatMS in young people might result from child abuse.

● For the first time ever, cancer has been treated byremoving an organ from the body, subjecting it toradiotherapy and then re-implanting it, according to NewScientist. Originally, the patient had had a colon tumourremoved but the cancer spread to his liver. Surgeonsdecided to remove the entire liver, place it in a Teflon bag,irradiate it with neutrons and re-implant it, just as in anormal liver transplant operation. One year later, the manis alive and well. His liver is functioning normally andscans have not revealed any signs of tumours.

● Playboy magazine centrefolds have become moreandrogynous over the past 50 years, according torecent research. Selfless researchers pored over 577consecutive issues of Playboy, from the first edition inDecember 1953 to December 2001. Data on heightand weight, and bust, waist and hip measurementsaccompanied the photographs, and the researchersfound that over time, the bust and hip size of themodels decreased, while waist size increased. Althoughweight remained fairly stable, height also increased.

● Food buffs should be advised to avoid black pudding priorto screening for faecal occult blood, following research inBury, in the UK, the “black pudding capital of the world”,according to researchers. Faecal occult blood tests werecarried out on participants, who then “eagerly ate alocally produced 7oz black pudding” and subsequentlyhad a further FOB test performed. The boffins found thatingestion of black pudding resulted in a significantlyhigher proportion of positive test results. Nice to seeresearchers with a keen appetite for their work.

● Scientists have also found that cold stimulation of thepalate when scoffing ice cream more than doubled thelikelihood of ice cream headache among middle schoolstudents in the UK, even in cold weather and even insubjects who ate their ice cream slowly.

● It’s amazing the uses patients will find for various bits ofmedical paraphernalia. We came across two amusingexamples recently. One contributor to the New Scientistwebsite reported using his daughter’s umbilical cordclamp to seal his muesli bags. It lasted for several yearsuntil it eventually broke and he and his wife were forced tohave another child to rectify the problem. Apparently, thesecond clamp is still going strong. The other curious casewe came across involved a 92-year-old woman, whodeveloped a novel use for her diuretic tablets, as picturedin the BMJ recently. The lady in question was using themas buttons to secure her suspender clips, thereby holdingup her stockings! We are assured, however, that thisunorthodox approach caused no apparent ill effects.

● Hardly surprising news then that Irish people spend moremoney on sweets and chocolates than on medicines,according to IPHA. Four main therapy areas make uptwo-thirds of the total Irish market for prescribedmedications – the cardiovascular, nervous, respiratoryand GI systems. Interestingly, however, diuretics were notspecifically mentioned...

● And finally, some good news (if you’re a mouse). Eating alow calorie diet may slow down ageing and protect theheart, research on mice has revealed.f

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Jan 14, TuesdayMerrion Faculty Meeting, Geriatric –The medico-legal aspects, EPA, wardof court and driving competence,Beaufield Mews, 8pm

Jan 21, TuesdayAdministrators workshop, HeritageHotel Portlaoise. Further details fromSylvia Browne, Tel: 01-676 3705

Feb 1, SaturdayICGP Executive meeting, Athlone

Feb 27-28, Thursday-FridayICGP National Trainers Workshop,Woodlands House Hotel, Adare,LImerick. Further details from SylviaBrowne, Tel: 01-676 3705

Feb 28-March 1, Friday-SaturdayTeachers in General Practiceconference for GP tutors and trainers,Ardilaun hotel, Galway. Further details available from Tel: 091-750470, Email:[email protected]

Forum Diary

The Irish College of General Practitioners

General Practice Training CommitteeGP Training Certificate Sub CommitteeCurriculum Development Sub CommitteeThe ICGP is seeking to recruit suitably qualified persons for the above sub-committees.Protected time and out of pocket expenses will apply.GP Training Certification Sub Committee• To review criteria for certificate of satisfactory completion of training by accredited trainingprogrammes (CSCT) • To make recommendations to the PGTC/Council on applications for:Membership; Certification of specific training under EU Directive 93/16; Specialist registration.Curriculum Development Sub Committee• To review/recommend on training programme curricula/content • To review programme direc-tor/trainer/trainee contracts in the context of the aims and objectives of GP specialist training.For further details please contact: Sylvia Browne, ICGP, 4-5 Lincoln Place, Dublin 2Tel: 01-676 3705, Fax: 01-676 5850, Email: [email protected], www.icgp.ie

The Irish College of General Practitioners

General Practice Training CommitteeThe ICGP is seeking to recruit a number of General Practice Training ProgrammeAssessors. These assessors will be responsible for visiting and accrediting all post-graduate training programmes in general practice. Protected time and out-of-pocket expenses will apply.Further details from: Sylvia Browne, ICGP, 4-5 Lincoln Place, Dublin 2Tel: 01-676 3705, Fax: 01-676 5850, Email: [email protected], www.icgp.ie


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This month’s contents at a glance:1453 Preoperative cardiac risk assessment1454 Coronary artery bypass surgery vs stent implantation1455 Controlling hypertension in patients with diabetes1456 Management of diabetic foot ulcers1457 Effect of abdominal aortic aneurysm screening1458 Malaria - an update1459 Valsartan in patients with type 2 diabetes1460 Pravastatin in the elderly1461 Suicide risk: a nested case-control study1462 Cardiovascular outcomes of antipsychotic drugs1463 Vaccination for genital herpes 1464 Emergency contraception: a WHO multicentre

randomised trial

Cardiology1453 Preoperative cardiac risk assessment. Karnath BM. AmFam Physician 2002; 66(10): 1889-1896. www.aafp.org/afpSynopsis: This paper presents and compares guidelines fromthe American College of Cardiology (ACC) and American HeartAssociation (AHA) assessing preoperative cardiac risk as wellas those from the American College of Physicians (ACP). Ituses a variety of clinical predictors to stratify patients into riskcategories. These are shown in a series of tables and flow dia-grams which are very clear and easy to use.GP commentary: I doubt if these are useful for the averageGP but their clarity makes them interesting.

Reviewer: Genevieve McGuire

1454 Coronary artery bypass surgery versus percutaneouscoronary intervention with stent implantation in patients withmultivessel coronary artery disease (the STENT or SURGERYtrial). Lancet 2002: 360: 965-970. www.thelancet.comSynopsis: Percutaneous transluminal coronary angioplasty(PTCA) has been shown to give similar rates of death andmyocardial infarction when compared to coronary arterybypass grafting (CABG), but with an increased requirementfor additional bypass procedures. This trial assessed the useof stents as an adjunct to PTCA, and almost 1000 sympto-matic patients with multivessel coronary artery disease wererandomised to either CABG or stent-assisted percutaneousintervention (PCI). At median two year follow-up the primary

end point of rate of revascularisation procedure was signif-icantly higher in the PCI group (HR 3.85, 95% CI 2.655.79), with a similar cumulative rate of death or non-fatalQ-wave myocardial infarction in both groups.GP commentary: The accompanying editorial points out thatalthough there is still a higher risk of need for revasculari-sation procedures in the PCI group, the rate has been morethan halved compared to previous trials of PTCA comparedto CABG, and that although surgery is likely to remain thepreferred choice for complex anatomical subsets, as thesafety and durability of angioplasty continues to improve,the gap in choice will continue to narrow.

Reviewer: Robert Jarvis

Endocrinology1455 Controlling hypertension in patients with diabetes. KonzelSL et al. Am Fam Phys 2002; 66:1209-1214. www.aafp.org/afpSynopsis: Hypertension is twice as common in diabetics asin others. Autonomic dysfunction may be responsible for thisas well as the more obvious role of obesity. The target BP asrecommended by various American bodies is 130/80mmHg.As with non-diabetics, lifestyle measures and drug therapyare required. Sodium intake reduction is particularly impor-tant in diabetics due to its hindrance of the renoprotectiveeffect (and antihypertensive effect) of some agents. ACEinhibitors are firstline largely because of their beneficialeffects on diabetic nephropathy. Calcium channel blockers

Forum Clinical Review Service© – helping you to stay on top of your clinical reading! FORUM January 2003 57

Number 92 (1453-1464) January 2003 Edited by Anne Henrichsen

Clinical Review Service

If you would like to join thereview panel contact:[email protected] you wish to receive a full copy of the papersreviewed this month for the purpose of privatereading and research, please email your requesttogether with the reference number for each articlerequired to [email protected]. Papers will be sentto you in PDF format via email.

This month’s reviewers:Cormac O’Dubhghaill, Conor Geaney, RobertJarvis, Genevieve McGuire, Muriel Mulcahy

58 FORUM January 2003 Forum Clinical Review Service© – helping you to stay on top of your clinical reading!

and thiazides follow. Beta blockers can also be used as theyhave a proven record in reduction of cardiovascular disease.Carvedilol has less undesirable effects on glucose and lipidlevels than other beta blockers. Combination therapy is usual.GP commentary: This article is short, to the point and as wellas giving references, the authors indicate the level ofstrength of the available evidence for most of its recom-mendations (eg. Evidence level A – RCT).

Reviewer: Cormac Ó Dubhghaill

Foot health1456 Diabetic foot ulcers – pathogenesis and management.Fryherg R. Am Fam Physician 2002; 66(9): 1655-1662.www.aafp.org/afpSynopsis: Approximately 85% of all diabetics-related lowerextremity amputations are preceded by foot ulcers. A recentmulti-centre study attributed 63% of these to the criticaltriad of sensory neuropathy, trauma and deformity. Otherfactors include ischaemia, callous formation and oedema.Loss of protective sensation in the lower limbs is a veryimportant pre-disposing factor. Ulcers should be inspectedfor sinus formation and odour. The exudate and underlyingosteomyelitis should also be noted. Limb threatening infec-tions can be defined as cellulitis extending beyond 2cmfrom the ulcer perimeter, abscess-formation or criticalischaemia. Aerobic and anaerobic cultures should be takenfrom any purulent drainage or curetted material. Wound clo-sure is the goal of treatment of all diabetic foot ulcers.Management is largely determined by its severity, vascular-ity, and the presence or absence of infection. It can besummarised as regular foot inspection, rest, elevation andpressure relief (eg. pressure relieving footwear). A mainstayof therapy is debrisment of all necrotic callous and fibroustissue. Topical applications are not recommended – a warm, moistenvironment, and protection from external contamination are. GP commentary: A very clear-cut and interesting article. Wellworth a read.

Reviewer: Muriel Mulcahy

Health screening1457 The multicentre aneurysm screening study (MASS) intothe effect of abdominal aortic aneurysm screening on mortalityin men: a randomised controlled trial. Lancet 2002; 360: 1531-1539. www.thelancet.comSynopsis: Almost 70,000 65-74 year old men were ran-domly allocated to either receive an invitation for ultrasoundscan, or not. Men with aneurysms of 3cm-5.5cm were fol-lowed up for a mean of 4.4 years and surgery wasconsidered for larger aneurysms as well as those expandingmore than 1cm per year. There was a risk reduction ofaneurysm related death of 42% (Cl 22-58, p=0.0002) inthe invited group (80% ‘take-up’ figure).

GP commentary: This well designed English multicentre trial,which followed a pilot study reported in 1995 provides evi-dence of the potential benefit of screening men of this agegroup for aortic aneurysm, a condition which causes almost7,000 deaths annually in England and Wales. It will beinteresting to see whether it results in screening initiatives!


Infectious diseases1458 Malaria. Whitty CJ et al. BMJ 2002; 325 (Nov 23): 1221-1224. www.bmj.comSynopsis: An excellent clinical review of the latest in malaria.Much work has been done but vaccines are still a long wayoff and the immediate future seems to rest with netsimpregnated with insecticide and drug resistance is beingcombated by drug combination.GP commentary: A good review of an old problem and veryuseful for anyone wishing to refresh their knowledge.


Prescribing1459 Microalbuminuria reduction with valsartan in patients withtype 2 diabetes mellitus. Viberti G, Wheeldon N for the microalbu-minuria reduction with VALsartan (MARVAL) study investigators.Circulation 2002; 106: 672-678. www.circulationaha.orgSynopsis: There is growing evidence that reduction and nor-malisation of proteinuria is a key treatment goal for renalprotection and possible cardioprotection. Inhibition of theRenin-Angiotensin System, (RAS), either by ACE inhibitorsor Angiotensin 11 antagonists prevents the development, orreduces the level of proteinuria in the diabetic animal model.Similarly ACE inhibitor treatment lowers albuminuria inpatients with type 2 diabetes. Selective blockade of the AT1receptor by angiotensin 11 antagonists also lowers microal-bumunuria to the same extent. However because of theblood-pressure lowering effect of the blockade of RAS, it isdifficult in previous studies to establish whether the antipro-teinuric effect was specific to the type of drug or the effect oflowering the BP. The purpose of this study was to investigatewhether the effect of valsartan on microalbuminuria was inde-pendent of its BP-lowering effects. This study involved 332patients with type 2 diabetes and microalbuminuria, with orwithout hypertension. They were randomly assigned 80mg val-sartan per day, or 50mg amlodipine per day for 24 weeks. Atarget BP of 135/85 was aimed for by dose doubling, or bythe addition of bendrofluazide and doxazosin, wheneverneeded. The relevant urinary albumin excretion in the patientstreated with valsartan was significantly lowered compared tothose on amlodipine. Valsartan lowered urinary microalbu-minuria in both hypertensive and normotensive patients withtype 2 diabetes. Both drugs reduced BP similarly. However,valsartan reduced raised microalbumunuria independently ofany BP lowering effect of the drug in type 2 diabetes. GP commentary: An interesting but difficult read for busy GPs.


1460 Pravastatin in elderly individuals at risk of vascular dis-ease (PROSPER): a randomised controlled trial. Lancet 2002;360:1623-1630. www.thelancet.com

Synopsis: This multicentre randomised controlled trialof almost 6,000 men and women aged 72-80 set outto discover if the well established benefits of statinsin middle aged patients is enjoyed in the more elderly.Pravastatin 40mg daily was given over an average of3.2 years to a cohort of patients with a history of, orrisk factors for, vascular disease as in previous PROS-PER trials. The primary composite end point of coronarydeath, non-fatal myocardial infarction, and fatal or non-fatal stroke was reduced, with a hazard ratio of 0.85(95% Cl 0.74-0.97, p=0.02), mainly through coronarydeath and infarction reduction (stroke unaffected).GP commentary: This trial result extends to elderlypatients the treatment strategy currently used inmiddle aged people.


Psychiatry1461 Suicide risk in relation to family history of com-pleted suicide and psychiatric disorders: a nestedcase-control study based on longitudinal registers.Qin P, Agerbo E, Mortensen PB. Lancet 2002; 360:1126-1130. www.thelancet.comSynopsis: This is a Danish nested case control studyof 4262 people who took their own lives compared toa group of age and sex-matched control group. Themain finding was that a family history of completedsuicide is a risk factor for suicide, independent of psy-chiatric illness or socioeconomic status.GP commentary: The study highlights the importanceof having a personal identification number fromwhich they were able to link information on 80,000people from a number of large databases. This kindof research would never be possible here with thispersonal number (eg. which John Murphy is that?).

Reviewer: Conor Geaney

1462 Cardiac arrest and ventricular arrythmia inpatients taking antipsychotic drugs: cohort studyusing administrative data. Hennessy S et al. BMJ2002; 325: 1070. www.bmj.comSynopsis: Participants were patients with schizo-phrenia treated with clozapine, haloperidol,risperidone or thioridazine, a control group ofpatients with glaucoma; and a control group ofpatients with psoriasis. The main outcome was thediagnosis of cardiac arrest or ventricular arrhyth-mia. The cohort groups were selected becausethey require periodic prescriptions and are notthought to be associated with any cardiovascularoutcomes. Three sets of models were used – oneset of patients taking antipsychotic drugs plusglaucoma patients; one set taking antipsychoticdrugs plus psoriasis patients; and another set onlypatients taking antipsychotic drugs. The authorsconsidered that 2.5mg of haloperidol, 50mg ofclozapine, and 0.75mg of risperidone were equiv-alent to 100mg of thioridazine.The study showedthat patients on antipsychotic drugs for schizo-

phrenia had higher rates of cardiac arrest and ven-tricular arrhythmias and of death than of controlpatients. However the authors agree that it is difficultto establish whether this is due to schizophrenia or toits treatment. Overall, the risks of cardiac arrest werenot higher with thioridazine than haloperidol, but athigh doses thioridazine may carry a higher risk.Patients should be treated with the lowest doses ofthioridazine required to treat their symptoms.GP commentary: Helpful for GPs treating schizophrenicpatients.


Vaccination1463 Glycoprotein – D adjuvant vaccine to preventgenital herpes. Stanberry LR et al. N Engl J Med2002; 347 (21): 1652-1660. www.nejm.orgSynopsis: This is a very technical paper describingthe outcome of phase 3 testing of a vaccine forgenital herpes (HSV2) in two multi-centre ran-domised double blind control trials on 847 and1867 subjects whose partners were infected withHSV2. The vaccine was found to have 74% effi-cacy in women who were sero-negative for bothHSV1 and HSV2 but was not effective in womenwho were sero-positive for HSV1 at baseline or inmen. They postulate that this may be due to theroute of infection and because women have amore marked helper T-cell response.GP commentary: Not for the average GP but if youenjoy reading statistics this is for you.


Women’s health1464 Low dose mifepristone and two regiments of lev-onorgestrel for emergency contraception: a WHOmulticentre randomised trial. Von Hertzen H et al.Lancet 2002; 360: 1803-1810. www.thelancet.comSynopsis: This well designed trial compared singledose mifepristone 10mg with levonorgestrel, eitheras a single dose of 1.5mg, or as a standard two doses0.75mg 12 hours apart, in over 4000 women whohad requested emergency contraception within 120hours of a single unprotected coitus. Pregnancy rateswere similar in the three groups at 1.5%, as were sideeffects. Statistical analysis included an estimation ofthe projected pregnancy rate, and of the preventedfraction of each method (the latter was statisticallysimilar, ranging from 77% to 81% across the three).GP commentary: Previous studies indicated thatmifepristone might be more efficacious in prevent-ing pregnancies than progestagens in thesesituations, but this study has not demonstrated this,and, from a practical point, endorses current use oflevonorgestrel, but indicates that a single dose of1.5mg is as effective as our current regime. Timewill tell if such a regime is licensed, it might wellimprove compliance.


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