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CIATION O F WOMEN
Founded 1905 Issue 08 - July 2013 In This Issue:
NAWP Members Comments Paracetamol: its dark side Member Profile: Kathleen Thornton Iodine in Pregnancy Long stormy spring-time, wet contentious April, winter chilling the lap of very May; but at length the season of summer does come Data Protection Act
NAWP holds on computer file, the names, postal and email addresses and information about payment
details of its members. This information is used solely to print address labels, to facilitate mailing within the organisation, to contact members about the Association affairs and to keep a record of fees paid. Under the Data Protection Act, a member may object to their name being on computer file. Objections should be sent in writing, to the Registrar. Cover Quote by: Thomas Carlyle (Scot ish Historian and Essayist) The President's Letter NAWP Annual Report 2012 Preconception counsel ing for women with diabetes: the first step in preparing for pregnancy RPS Workforce Summit - February 2013 NAWP Member Comments Paracetamol: its dark side Member Profile - Kathleen Thornton Return to the Register - building a portfolio Misoprostol in childbirth: can it save lives? Blue Pil , Pink Pil : another update Medical Optimisation The Self-selection of P medicines The Women's Library Iodine in Pregnancy Executive Committee Forthcoming Events Direct all correspondence to;
CIATION O F WOMEN
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The President's Letter Dear Colleagues,It is with some trepidation that others in both our professional and with the antibody response of I begin my first report as your vaccinations. My advice to new president. I have a hard act Mum's has always been "don't to follow in terms of literary For the second year we ran a give a dose unless the baby competence following Virginia student competition and had two needs it" rather than give it just in as I do. As you all know Virginia commendable presentations, case they need it. I recommend writes for a living, I don't, unless this in turn attracted four you all read the whole article as you call small notes on the side more students to attend the other interesting ideas of prescriptions writing. I would whole conference. This is very like to take this opportunity to encouraging and something we thank on your behalf, Virginia hope to build on in future years In October the 9th European for all she has achieved in her 3 Through the conference raffle Meeting of Women Pharmacists years as president. She has raised and donations we raised £175. will be held in Munich. Several the profile of NAWP not only This money has been given to members are going to attend so if within the profession by working Winston's Wish a worthy charity you would like to join them please with the new RPS, but also with close to Virginia's heart, her family see page 21 for more details. other professions particularly the having unfortunately needed to From experience it is always a Medical Women's Federation. use its facilities in the past few very enjoyable and informative I hope to build on these links.
years. The trip to the Bronte weekend and this year will come a Museum in Haworth, with guided little after the Oktoberfest, so may We had another successful talk, on Sunday morning was include some beer tasting.
conference in April, "Healthy very enjoyable.
As many of you know I recently Mothers and Babies" held in celebrated my daughter's Brighouse, Yorkshire. Thank you Numbers for the conference wedding. A wonderful day enjoyed to all who attended and those who were disappointingly low this by all and complimented by the organised it. The speakers were, year, for this reason we may weather. I now realise not only as usual, of very high standard, have to seriously think about the have I gained a son-in-law but I coming from Northern Ireland, weekend's viability and format have also become a mother-in- Devon, Yorkshire and Hamburg for next year. If anyone has any to talk on their specialist subjects. ideas or comments on the subject Pregnancy should be planned and please let myself or a member of With that sobering thought I will enjoyed, for those with diabetes, the committee know.
wish you a pleasant summer and along with "breast is best" were The article on paracetamol on may the sun decide to shine for at the main themes to emerge from page 10 of this edition of the least some of it.
the weekend. As many of us are Magazine makes interesting entering grandparenthood I think reading. It appears that it is something we can pass on to paracetamol may actual y interfere President of the National Association of Women Pharmacists NAWP Annual Report 20122012 saw a departure from the NAWP distinctive?' ‘what sort of As an RPS partner, NAWP norm for the Annual Conference. organisation are we?' ‘what do we continues to receive a weekly list Firstly it was the first time we currently do?' ‘what do we want to of consultation documents and the had hosted a joint conference do more of in the future?' ‘how can EC, along with individual NAWP with our European col eagues. we build on past success?' The members, have responded to Secondly we ran an abstract EC is currently working alongside issues relevant to the organisation. competition whereby 4th year Jennifer Archer and her daughter, students from Manchester NAWP maintains its links with our Sarah, to produce School of Pharmacy were European col eagues and Virginia a range of promotional material invited to submit abstracts Watson was invited to address and to update the present with the best submissions the 10th Anniversary information leaflets. being asked to present at the ‘Festsymposium' of the dpv, in Conference. Building on the Elsewhere during the year Berlin. Virginia took as her title success of this competition members of the EC have ‘Continuity within change'. this year it was opened up to represented NAWP at a number The EC is pleased to report that students from 3 Universities in of forums including the PDA one of our members, Mrs Jenny the area namely, Manchester, conference, the English summit Cobden, has agreed to represent Huddersfield and Bradford.
on Chronic Pain, Modernising NAWP on the ‘Medicines Pharmacy Careers, the Future Optimisation Advisory Group'. The Executive Committee (EC) of Pharmacy and Public Health, Most recently, our President, has been concerned for sometime a CPPE organised face-to-face Virginia Watson spent a day at about the fall in membership and workshop about return to practice the PDA and was able to discuss the lack of new members. To this and the Medical Women's many of the concerns raised by end an in depth discussion took Federation autumn Meeting place at the July meeting of the Articles about the work of NAWP EC, fol owed by a brainstorming NAWP continues to acknowledge have appeared in print in both session in September. The the input of PHOENIX in producing the Welsh and English Pharmacy areas covered in these sessions and mailing the Newsletter.
Review as well as being quoted in included subjects like ‘what makes the Daily Mail newspaper.

Preconception counselling for women with diabetes: the first step in preparing for pregnancy Pre-pregnancy care is associated with a reduction in the risk of adverse pregnancy outcome for women with diabetes, yet many women continue to receive suboptimal pre- pregnancy care. Lack of awareness of the risks associated with pregnancy and diabetes, and of the importance of planning pregnancy, impacts on engagement with pre-pregnancy care.
Preconception counsel ing is a discussion about future pregnancy plans, the importance of safe, effective contraception to avoid an unplanned pregnancy and an explanation of the risks associated with diabetes and how these can be reduced by pre-pregnancy care. Preconception counsel ing is essential for all women with diabetes of childbearing potential, not just those actively planning a pregnancy. "Women with Diabetes: Things you need to know (but maybe don't!)" is an innovative preconception counsel ing resource which healthcare professionals, such as community pharmacists, can use to help raise awareness of the importance of planning a pregnancy. The resource originates from a preconception counsel ing DVD funded by Diabetes UK, evaluated as highly acceptable to women and which significantly increased knowledge and improved attitudes of women to pre-pregnancy care.1 Featuring eight women with diabetes sharing their views and experiences, alongside an evidence-based commentary, the website covers issues such as ‘contraception', ‘risk', ‘why plan?' and features a ‘pre- pregnancy checklist'. Dr Valerie Holmes Queen's University Belfast 1. Holmes VA, Spence M, McCance DR, Pat erson CC, Harper R, Alderdice FA. Evaluation of a DVD for Women with Diabetes: Impact on knowledge and attitudes to preconception care. Diabetic Medicine 2012; 29: 950-6.

RPS Workforce Summit February 2013We probably all know the old joke about was rather that it was ‘done-and-dusted'; something the travel er who had lost his way to his that could certainly be queried. For example, the destination. When asking for directions, he speaker failed to mention the position of Dental Care was told - ‘well I wouldn't start from here'.
Professionals (DCPs; nurses, hygienists, technicians etc. registered with the General Dental Council). Unfortunately like the travel er, pharmacy is where it With four months to go, the number of DCPs who is; RPS can be congratulated for holding this summit may have to leave the register at the end of July on the future direction of the pharmacy workforce 2013 due to failure to complete their CPD, stood planning. Regrettably, the outcome suggested at over 14,0002. Also unreported was that dental there is still no clarity on how career patterns of graduates are experiencing severe problems in pharmacists already registered will develop over obtaining training places, in an analogous way to the medium term. Quite simply, there are too many pre-reg pharmacy students2. Just as importantly, the variables involved and not all pressures are acting in talk failed to highlight the fact that both dentists and the same directions. DCPs have the luxury of much more flexible work The meeting was held at the headquarters of the patterns than the pharmacy workforce has, and this BMA, now that RPS has no suitable meeting hal . limits comparability with our profession.
It was attended primarily by representatives from: During the afternoon session, attendees discussed schools of pharmacy, the NHS, the Department of what they saw as the major factors that are shaping, Health, RPS, a few big employers, and organisations or should shape, future pharmacy careers and the such as the PDA, and NAWP. It was designed to workforce to match them. It was at this point that the hear opinions and col ect ideas. In this sense it was scale of the difficulties became apparent. Engaging successful and by highlighting a range of views, it with new services and the delegation of some duties identified key issues. For example, a contribution is widely seen as the way forward, but a coherent from Prof Robert Dewdney from Cardiff School of plan for implementing this and the finance for Pharmacy provided a perspective on pharmacy doing so remain to be found. Furthermore although education rarely heard in pharmacy circles. This was pharmacists who engage with these reforms are supplemented by comment on the opportunities ‘good pharmacists' we know there are col eagues that schools of pharmacy have to train students who have refused to implement some specific new from overseas, with a view to providing pharmacy work practices because they believe them to be services in home countries where they are currently unsafe or inappropriate. In the brave new world, are inadequate. A presentation from Nazim Khan of these ‘good' or ‘bad' pharmacists? the Centre of Workforce Intel igence, comprised an updated analysis of the pharmacy workforce, By the end of the meeting, provision of a set of clear submitted as a report to the Department of Health roles and career patterns for the pharmacy workforce in August 20121. This was thorough and non- was general y seen as essential. Nevertheless there was a perceptible difference between those who were keen to provide directions for the ‘lost travel er', In contrast, the Postgraduate Dental Dean from and those who preferred to design maps.
the London Deanery, might have had a more chal enging reception from other audiences. The picture that was painted of dental practice reform 1. Pharmacy workforce: Education commissioning risks summary from 2012 Centre for Workforce Intel igence, August 2012. 2. News, Dental Practice, February 2013, Vol 51, No.1. Before my visit to the PDA in January, I sent an Having shared the compiled comments with the email to some of our NAWP members (selected at Executive at a subsequent committee meeting, it random) asking for any views, personal experiences was suggested that these were published in the and concerns on the current pharmacy working Magazine. I thank the respondents for giving their environment as I wanted to get a feel for any permission for the fol owing to be published.
concerns of the membership. Anonymity of the responder was assured. NAWP Member Comments I feel concern about the imbalance between student A friend has retired early as a result of work related numbers and pharmacy posts available and feel stress - he was a manager for one of the multiples.
this may adversely affect women who take a career break as it will be difficult to obtain new employment. I haven't any direct experience of the consequences of over production of pharmacists but have a lot of After I retired from my part-time job I decided feedback from others including: not to look for locum work as I had read in the pharmaceutical press that locum work is scarcer • No longer receiving cal /texts from multiples about than before.
locum vacancies.
• Locum rates being pushed down, as low as £18 I was a locum for several years and I never received an hour - this resulting not only from too many any offers of training even when Boots switched to graduates but also from thze employment of a completely different computer system. I felt I was responsible for my own training and attended CPPE meetings and also did two distance learning courses I have a friend who is a ful -time locum who will from Keele University at my own expense.
no longer work for multiples as he feels that their demands for weekly Medicine Use Reviews I heard from a friend recently who was struggling (MURs) is excessive. Fortunately there are sufficient to find good locum work. He was reluctant to work independents in the area to keep him employed.
for multiples and there are few independents left in this area.
The problem of eastern European locum pharmacists coming in to the UK and being prepared to work for I was shocked to see a job advert in PJ 22/29th Dec ridiculously low rates seems to be more serious. We quoting a rate of £16 - £17.50 depending on had an English chap for the summer who claimed Romanians and Poles were working in Essex for £12 manager or team manager. Added to that, there is to £15 per hour.
a target for New Medicine Service numbers (NMS), again a very important source of income.
About locums - I haven't had many extra requests in the past year and I hear rates are fal ing; I've not put I do know of cases where pharmacist/managers and mine up for 3 years now.
non-managers have ‘moved on' due to pressure of work brought about by reductions in staffing hours. The multiple for which I work adopted a policy of In both cases they were both women. I confess that not employing locums about 2 – 3 years ago, and I haven't read ‘Modernising Careers in Pharmacy' recruited eastern European pharmacists as relief but I would question whether there is, or ever has pharmacists, sending them over a wide area at a been in the last twenty years, a career in community time when most had no car and had to rely on pharmacy. There appears to be no access to the public transport.
company pay structure or clear progression path for new recruits of whatever gender or age. The reduction in counter staff has made the pharmacist's life very difficult as we are expected As a locum it was becoming more of a chal enge to cover the counter as wel . Whilst happy to do that to keep accreditation current and up to date with because I have always tried to deliver the very best adding services i.e. NMS, MURs, Smoking Cessation pharmaceutical care and advice to prescription Service, Emergency Hormonal Contraception and counter customers, it appears that this is not Service, and Minor Ailments Services etc. The appreciated by the other staff and that the culture bureaucracy was annoying as some of these is only to offer a rapid (and accurate) dispensing services would only apply to one PCT area and I service. I estimate that on an average day 95% of couldn't offer them in other areas. my day has no customer contact because of the requirement for checking, wrapping and filing. The I found that locum co-ordinators could be SOPs for receipt of prescriptions are widely ignored disorganised and would go to a job to find another by the staff, with the exception of checking if we have locum had been booked, so several phone cal s the stock, resulting in much of my time in handing out ensued to clear this up.
prescription is taken up with getting the prescriptions When I had been locuming for a long time with taking payment.
a company I would get a letter asking if I would consider being a manager. Once I indicated I The appointment of a new Pharmacy Director in preferred being a locum I found I wasn't securing May 2012, after apparently not having one for five any bookings with that company anymore.
years has done nothing that I can see to improve the pharmaceutical service and standards, particularly Being a locum in the East London area started to in basic dispensing, which are in my opinion, quite prove problematic in that I was being asked if I sloppy! However, he did promise that no-one would spoke any other language – general y Asian – and as telephone and harass the manager/pharmacist on I didn't the work for that shop wasn't available.
a daily/ weekly basis to deliver MURs at the two a day rate. As far as I know the telephone cal s do not happen, but the targets are still there for the branch to achieve and reminders roll in by email or via the In my hospital pharmacy days the more senior employment could not be found for them. There will posts were usual y occupied by men. There was be more redundancies amongst cancer network then a trend which started in about 1996 to employ pharmacists soon and these are people who are pharmacy technicians in preference to pharmacists experts in chemotherapy and related drugs. Others by simplifying the jobs and thus saving money in have been down-banded so after a protected period salaries. I feel this probably did a lot of damage to will have a salary reduction. These mergers and the prospects of pharmacists like myself who wanted cutbacks are quite commonplace.
part time work and found only low grade posts were available. I have found more recently that the Pharmacy graduates have the double whammy of employment of checking technicians as pharmacy the vast increase in graduates combined with a managers has now reached community pharmacy reduced number of jobs and they are also having to and wonder how this will affect the quality of service compete with some excel ent European pharmacists in the future.
(we have pharmacists from Lithuania, Norway, Germany, Italy etc.) and mothers working full time I also note that most employees involved in (which was less common twenty odd years ago). administration of the large companies are not We also have a few technicians who are qualified pharmacists and wonder if lack of knowledge of pharmacists in their own countries waiting to start the pharmacy law may result in slick business plans conversion courses.
which are either unethical, il egal or both.
Medical schools have control ed their intake fairly I am one of those pharmacists who has been able to tightly to ensure employment so why not pharmacy combine part time work in hospital/retail with raising schools although even if this happens immediately a family without any major problems - something I do it will take five years to have any effect but better not see happening to my younger col eagues.
late than never. We had a knee jerk reaction of rapid expansion after the pharmacist shortage fol owing I work in hospital and our current batch of pre- the fal ow year caused by the change from the three registration students are very worried about what year course to the four year course. There are also happens after August, out of last year's group of five conversion courses for overseas pharmacists four only one has obtained a permanent job, with something which doesn't happen in the opposite two back with us on one year contracts to assess direction. I feel the student places have to reduce to whether it is better to do FP10s in house, the fourth make up for the increased supply from elsewhere had to return to Hong Kong to obtain work.
chasing fewer jobs.
Several women returning from maternity leave have asked to go part time - recently this has not Current hospital situation in Wales: been al owed so several have returned for the - most jobs are now temporary three months (effectively less than this because of accrued annual leave) to avoid having to refund their - giving out 3-24 month contracts maternity pay and have then left but have not been - the hospital at which I work is not advertising replaced anyway.
band 8 posts and those in band 8 post have had to re-apply for their own jobs If a pharmacist leaves they are not automatical y replaced but a case for their job replacement - of my friends with Clinical Diplomas one has has to be put forward to the directors - it is often managed to get a 12 month contract and one successful but there is often a six month delay without diploma has managed to get a 3 month because recruitment takes so long. In some cases the job is downgraded to a lower salary band - even - they are using Band 7 staff to cover Band 8 to recruiting a technician and a technician leaving would be replaced by a pharmacy assistant.
- there are a decreasing number of pre- We had three pharmacist redundancies shortly registration and clinical diploma places on offer before Christmas - these were senior posts and - some trusts are only recruiting internal y due to the merger of three trusts and suitable When I was working I felt there was a lot of stress involved due to the many different demands to be met (MURs PGDs etc.) although I did not feel that I was put under pressure by Lloyds in any way. If anything I felt more under stress from the PCT and of course certain patients. I felt that men and women were probably both affected by stress but individuals react in different ways according to their personality.
Despite the reduced number of staff at the hospital there are still the same or more patients and of course the work still has to be done and those of us left have to cover the work of those who have gone. I am trying to do some of the work of three people who have left/retired/been made redundant and it would be wonderful to have the assistance of one of the newly qualified pharmacists who is currently unemployed. I am finding this very stressful.
Stress was becoming an issue too – the need to achieve targets for, say, MUR's, was paramount and I had to give up a Saturday locum as the company I was employed by set targets for my Saturdays along with addition tasks of filing the whole weeks prescriptions, putting away large orders from Friday and so on. Staff on Saturdays were general y the minimum and often had a high turnover rate. I had locumed in that branch for 8 years and had been happy up until then when this type of pressure was put on me.
I am currently in receipt of a NHS pension which was built up working full time in hospital when I first qualified and part time when I had children. I hope that the present generation of female pharmacists will have the same opportunity.
I have been very impressed with everything that has flowed from the PDA and I think they are developing a strong lobby which somehow gets heard louder than the RPS. They need our support and any research into gender implications of the work they are doing would be interesting Although I sound gloomy I am glad I became a pharmacist, it was one of the few professions that opened on Saturdays so I could keep my skil s going and the children still had a parent at home with them while they were small and I was able to gradual y return to full time and a senior position as they got older. Despite some problems at the moment with the volume of work, I still love what I do on a day to day basis if I could go back to 1975 would do the same thing.
Disil usionment I think was the main motivating factor for me to make the huge move to a new professional career. I have been in pharmacy many years but was starting to feel that the support frameworks were going and it all seemed to be about "procedure, protocols and form-fil ing", and less about the actual job of communicating with customers. It is good to offer enhanced services but make training and provision for this structured, organised, and in accessible form. Companies need to have the staff levels to cope while pharmacists and managers provide these services.
Paracetamol: its dark sideSeemingly with the intention of fostering in terms of morbidity associated with paracetamol innovation under the Liberating the NHS agenda,1 use, hepatotoxicity on overdose may be just a minor the GPhC has indicated its intention to al ow issue: paracetamol has a far more sinister dark side the self-selection of P medicines where, in the that is now revealing itself. And when the potential professional judgment of the pharmacist, this enormity of the emerging issues is contemplated, would not compromise patient safety. Perhaps pharmacists should find themselves wondering not surprisingly, the Pharmacists' Defence whether the time has not now come to move all Association is seeking to resist this change.
paracetamol preparations behind the counter, including GSL packs, and even to begin pressing If / when this change happens, a planogram update for a recall of all GSL packs of paracetamol from Head Office could well place 200ml bottles products from non-pharmacy outlets. of Paracetamol Oral Suspension next to the 100ml The fol owing explains why: bottles on the open shelves, and boxes of 32 Paracetamol Tablets next to the boxes of 16.
A. Prophylactic paracetamol administration at
the time of vaccination may interfere with the
We would hope that such a change in the planogram antibody response to, and hence compromise the
will have received the blessing of the Superintendent effectiveness of the vaccine.
Pharmacist. But that would not be enough. It would surely be down to the Responsible Pharmacist on It is not unusual to see prescriptions written by GPs the day to decide whether or not any particular P for paracetamol or ibuprofen for post-immunisation medicine would be suitable for self-selection. And pyrexia in accordance with BNF guidelines. Indeed, that decision would itself be coloured by the level of it is probable that small bottles of paracetamol training and competence of the medicines counter or ibuprofen oral suspension are bought for this and general sales staff.
purpose by self-selection from both larger pharmacy stores and from non-pharmacy outlets. BNF In a perfect world, with properly implemented guidelines advise that a dose of paracetamol or standard operating procedures (SOPs) against ibuprofen may be given IF pyrexia develops after which support staff have been properly trained by an childhood immunisation AND the infant seems accredited and named trainer, one could envisage distressed, and that a second dose can be given but the safe supply of some P medicines by self- only if necessary. The common experience of many selection from open shelves. But would paracetamol pharmacists will be that parents / carers of children products fall into this category? administer antipyretics for fever (even when there is We all know why over-the-counter pack sizes for minimal or no fever) because they are concerned paracetamol tablets were limited to 32 in pharmacies that the child must maintain a "normal" temperature. and to 16 elsewhere. Whether or not this pack Moreover, there is a common misconception size limitation was responsible for the reduction in amongst parents / carers that antipyretic use suicide rates that fol owed is not clear.2,3 However, prevents febrile convulsions.4 In a study funded by a major vaccine producer In an Australian prospective study (published in (GlaxoSmithKline Biologicals) and published in 2010)12 of a birth cohort of 620 children at high 2009,5 the authors concluded that prophylactic risk of developing atopic conditions, who were administration of antipyretic drugs at the time of fol owed from birth to 2 years of age, and then to vaccination should not be routinely recommended age 7 years, it was concluded that in children with since antibody responses to several vaccine a family history of al ergic diseases, there was no antigens were seen to be reduced. Whilst the study association between early paracetamol use and risk involved only paracetamol, it is probably safe to of subsequent al ergic disease after adjustment for assume, until proved otherwise, that ibuprofen would respiratory infections or when paracetamol use was similarly reduce the effectiveness of the vaccination. restricted to non-respiratory tract infections. It should It would be interesting to know how many cases in be noted that 30% of this cohort of children had recent epidemics of whooping cough and measles asthma at age 7 years, and that a weak association have occurred in vaccinated individuals and whether was found between the frequency of paracetamol inappropriate use of paracetamol (and/or ibuprofen) use and increased risk of childhood asthma.
at the time of vaccination has been a contributory In a study carried out by the New Zealand Asthma and Al ergy Cohort Study Group (published in B. Whilst the incidence of Reye's syndrome has
2011), which involved 914 individuals fol owed in decreased, an epidemic of asthma and eczema6
a birth cohort study to age 6, the findings led the seems to have emerged following upon a switch
authors to suggest that paracetamol has a role in in the mid 1980s from aspirin to paracetamol for
the development of atopy and in the maintenance of treating childhood fever.7
asthma symptoms.13 In a questionnaire study8 (published in 2005) The association between paracetamol consumption involving a population of 13,492 subjects in the US and asthma was investigated in Phase Three of with an average age of 45 years, paracetamol use the International Study of Asthma and Al ergies in was found to be associated with an increased risk Childhood (ISAAC) programme.14 This involved of asthma and COPD. From a subsequent study in 205,487 children aged 6–7 years from 73 centres in Mexico9 (published in 2006) involving 3,493 children 31 countries. aged between 6 & 7 years, it was concluded that This study (published in 2008) found that: frequent paracetamol exposure was associated with a significantly increased risk of wheezing and rhinitis • use of paracetamol for fever in the first year of life and probably eczema. Essential y identical findings was associated with an increased risk of asthma have been reported from two Spanish studies symptoms when aged 6–7 years; (published in 2010 & 2012), the first10 involving 13,908 children aged 6–7, the second11 involving more than 20,000 children and adolescents.
• current use of paracetamol was associated with worrying because a mother-to-be who regularly self- a dose-dependent increased risk of asthma medicates with paracetamol during pregnancy may well become a mother who regularly medicates her • use of paracetamol was associated with the risk of child with paracetamol (and/or ibuprofen).19 severe asthma symptoms; and that C. And did the switch from aspirin to paracetamol also
• paracetamol use, both in the first year of life trigger an epidemic of autism?
and in children aged 6–7 years, was also A thought-provoking article20 published in 2009 associated with an increased risk of symptoms of provides a rather compel ing suggestion that the rhinoconjunctivitis and eczema.
autism epidemic, which mirrors the epidemic In response to the findings of the ISAAC Phase Three of asthma and eczema in terms of its onset in Study Group, the MHRA issued the the 1980s, may actual y be linked to the use of paracetamol to treat fever and pain fol owing D. And does paracetamol exposure in utero, lead to
"reduced masculinisation" or even "feminisation
of males"?
In the wider world outside pharmacy, there is an ongoing discussion as to the causes of the observed demasculinisation and/or feminisation of males, not only of humans but also of other animals. A number of environmental / xenobiotic endocrine disruptors have been identified, including the herbicide atrazine, bisphenol A and various phthalates used in the manufacture of plastics, phyto-oestrogens, certain pesticides, etc,21 but human evidence linking these substances to developmental disorders is scarce.22 Nevertheless, these endocrine disruptors have been implicated not only in the obesity epidemic, metabolic syndrome, and in interference with thyroid function but also as causes of cryptorchidism and hypospadia, or in more general The results of this new study do not necessitate any terms, testicular dysgenesis syndrome.23 In human change to the current guidance for use in children. terms, the latter represents a spectrum of altered Paracetamol remains a safe and appropriate developmental states ranging from effeminate but choice of analgesic in children. There is insufficient otherwise normal males with poor semen quality evidence from this research to change guidance to "intersex" conditions (i.e. individuals with genital regarding the use of antipyretics in children.
ambiguity), and in its widest sense encompasses Notwithstanding the conclusions from all of these genetic disorders24 as well as developmental studies, a direct causal link between paracetamol disorders brought about by putative xenobiotic exposure and the development of asthma and eczema has not been properly established. Indeed, Question marks have been raised over whether it would be unethical to carry out a definitive study the levels of bisphenol A that people are routinely capable of demonstrating such a link.
exposed to are high enough to cause the diseases Perhaps most importantly, none of these studies that have been linked to this chemical.25 Similar appears to have control ed for pre-natal (in utero) questions might also be raised for other putative exposure of the child to paracetamol in pregnant xenobiotic endocrine disruptors. But the same women. So, a worrying finding is that in a study of cannot be said for exposure to paracetamol, which in an adult can amount to 1 gram taken up to four times 16 it was found that use of paracetamol in middle to late (but not early pregnancy) seems a day, possibly for several days at a time. This is why to predispose the child to respiratory symptoms we should be concerned to read that maternal intake in its first year of life. The authors of this study of acetaminophen for more than 4 weeks during identify two other publications, one published in pregnancy, especial y during the first and second trimesters, may moderately increase the occurrence 17 the other in 200218 describing essential y the same phenomenon. These observations are of cryptorchidism;26 or that intrauterine exposure to mild analgesics is a risk factor for development of male reproductive disorders in human and rat;27 or that paracetamol (acetaminophen), aspirin (acetylsalicylic acid) and indomethacin are antiandrogenic in the rat foetal testis;28 or the conclusion reached in the Generation R study29 that intrauterine exposure to mild analgesics, primarily paracetamol, during the period in pregnancy when male sexual differentiation takes place, increases the risk of cryptorchidism.
The picture that is emerging is that paracetamol is not safe to use in pregnancy (except perhaps only as very occasional single doses) and should perhaps be categorised as a potential teratogen. Nor is it as safe as has hitherto been believed for use in children. New guidelines30 are urgently required.
Readers are invited to add the topic "Paracetamol: its dark side" to their CPD portfolios. Paracetamol needs to be more widely recognised as the [likely] cause of significant but avoidable morbidity. The associated cost to the NHS of this morbidity is also a matter that should concern us al . The tide will not turn whilst paracetamol products remain accessible on self-selection as GSL medicines.
Richard J. Schmidt Locum community pharmacist For ease of access references have been provided as weblinks, a full reference list is available on request 12. ht p://dx.doi.org/10.1136/bmj.c4616 Member Profile – Kathleen ThorntonWell, here goes…… signed by a practising pharmacist I now work as a part-time locum of good standing. But who to for some local independents and I was asked if I would share some ask? We had moved to the North I LOVE IT! of my experiences in my journey to of Scotland and I did not know Return to Practice, and which I am A brief panic again when my CPD any pharmacists. Then I realised delighted to do.
record was cal ed for review this that I had to compile a portfolio, year, but I have been recording After obtaining my degree from to satisfy the GPhC that I was this on the official site, as I have Leicester School of Pharmacy competent and fit to practise. The done it, since being back on the in 1982, I completed my pre- challenge was on! register. I was unsure registration year at Boots I studiously worked the Chemist in New Street, through many distance Birmingham. After qualifying, learning courses, I went to work for a smal er which I obtained company, Bannister and Thatcher, through NES, the working as a second pharmacist, Scottish equivalent relief manager and then later of CPPE. NES were manager. Later on I returned fantastic and a lovely to Boots, preferring to be a lady cal ed Valerie vocational pharmacist, rather than a manager.
queries. They let me I married a chemical engineer order courses using cal ed Kevin in 1990. When I found my RPSGB number out that we were expecting our as I was not yet first child, I intended to return to registered with the GPhC.
work on a part-time basis. I had I read up on everything I could. if I had recorded not taken into account that I may I then contacted Boots and enough examples of how I have feel differently after my son was shadowed pharmacists in three put each piece of learning into born. How could I leave him, even branches. I also went to the Return practice, but sent in the required to go to work? So I became a stay- to Practice course at Strathclyde number, plus three extra. The relief at-home mom and this was to be University, which was excel ent. when I had actual y clicked the my life for the next eighteen years. There were also some evening tab to send it. The even greater It was early in 2011, after my courses, the first one I went to relief when I received confirmation husband had been out of work being on Pal iative Care. I was so that all was fine - 100% of the for a year that I began to think nervous, but people were very assessable criteria met. Phew!! seriously about work again but nice and made me welcome.
I feel so blessed to have had all I had "retired" from the register those years at home, but able to The portfolio was sent off to the some years before. We had six work as a pharmacist once again.
GPhC at the end of February children, plus a dog and two 2012. I heard on 10th April that I would just like to say a huge rabbits, so I was pretty busy. I had been successful and thank you to all those who I had Sunday school teaching registered on April 15th 2012. encouraged me, especial y and a toddler group which I I was so delighted.
the team at NES, the tutors at helped run, to fill in any spare Strathclyde, NAWP of course and time, along with serving on the But now, what should I do? the three pharmacists I shadowed. local parent council.
I still felt quite nervous about Especial y also to my long- actual y going out and "being I found that I could join the RPSGB suffering husband who had to put a pharmacist" again. It was a as a "retired" member, which up with my saying that I would veterinary friend who said last gave me access to much support, never do it and who has cooked, summer, "you have a degree, this resources etc. The GPhC had cleaned, looked after the home shows you can find information," taken over the regulatory role and and supported me so that I could which gave me the confidence to I had to have my application form study and now work again.
apply to pharmacies.
Kathleen Thornton PHOENIX PI
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Return to the register – building a portfolioPharmacy professionals who apply to return to event, Return to the register-Building a portfolio, the GPhC register after an absence of more than available as a workshop or webinar. See CPPE 12 months are now required to submit a portfolio website for the next available event.
of evidence to demonstrate current professional competence within their intended scope of practice. The CPPE are offering help in the form of a new Misoprostol in childbirth: can it save lives?Misoprostol, a synthetic prostaglandin, is it is available as an oral formulation, does not require licensed in the UK for the treatment of benign cold chain transport and storage, and can be stored gastric and duodenal ulceration and for the for 3 years at temperatures up to 30 ºC.
prophylaxis of NSAID-induced gastric and duodenal ulcers. The BNF also mentions the unlicensed use of misoprostol (orally or vaginally) to induce labour, in postpartum haemorrhage and in medical and surgical abortions. Post-partum haemorrhage (PPH) is a leading cause of maternal death. It is reported that this affects more than eight mil ion women each year and accounts for one in four of all maternal deaths . (Pre-eclampsia and eclampsia are the second most common cause of maternal death). Deaths from PPH in the UK are fortunately rare; five deaths were reported in the UK for 2006-2008 . However, the situation is very different in the developing countries especial y the countries of sub-Saharan Africa and South Asia which between them account for 90% of all maternal deaths. In these two regions more than half of the women do not have access to even skil ed birth attendants let alone emergency obstetric services. Therefore, misoprostol has a place in the treatment One of the United Nations Mil ennium Development and prophylaxis of PPH in those women who Goals is to reduce maternal mortality by 75% by have limited access to modern and wel -equipped 2015. A significant reduction in deaths from PPH obstetric facilities. would make a major contribution to this goal.
The WHO makes a number of recommendations for Oxytocin is the drug of choice for the prevention the treatment and prevention of PPH . In brief, for and treatment of PPH. It may be given alone or the prevention of PPH it recommends that women in conjunction with ergometrine. However, one of should be offered i.m. or i.v. oxytocin 10 IU during the drawbacks with oxytocin in the developing the third stage of labour. In settings where oxytocin countries is that at high temperatures its shelf life is unavailable, patients should be offered injectable is considerably reduced: it is stable for 5 years at ergometrine/ methyl ergometrine, fixed dose oxytocin 2-8ºC, but at room temperatures up to 30 ºC it must ergometrine combinations, or a single oral dose of be discarded after 3 months. Thus the practicalities misoprostol 600 µg. For women without access to of distribution and storage are a problem for many skil ed birth attendants the WHO recommends that local facilities in these countries. Misoprostol, which if oxytocin is not available health care workers may like oxytocin is an uterotonic, has the advantage that administer oral misoprostol 600 µg. Similar recommendations are made for treatment Although not recommended by the WHO, of PPH with i.v. oxytocin being the preferred option. consideration is being given to implementing a Misoprostol 800 µg may be administered if oxytocin project in sub-Saharan Africa in which pregnant is unavailable, but only if it has not been given women without access to adequate healthcare prophylactical y.
support during labour would be provided with a Supplies of suitable medication to developing single dose of misoprostol for self-administration countries may be intermittent, of unknown or variable during labour. However, one of the major concerns is quality, licensed or unlicensed. Distribution to to be able to control the supply chain of misoprostol birthing centres and to remote communities may to ensure that it does not become available for be difficult. There is also a paucity of good quality unsafe or inappropriate use.
research into the efficacy and safety of misoprostol in There are several organisations, charities and prevention and treatment of PPH in birthing centres ministries of health already developing programmes and remote communities. for using misoprostol in this way, but there are many chal enges ahead for people working in this field.
Acknowledgement: I would like to thank Trudi Hilton of International Health Partners (www.ihpuk.org) for drawing NAWP's at ention to the situation in sub-Saharan Africa and for reviewing this article. 1 Working paper prepared for the United Nations Commission on Life Saving Commodities for Women and Children 2012 2 D. Fleming, R. Gangopadhyay, M. Karoshi and S. Arulkumaran. Maternal Deaths from Major Obstetric 3 Hemorrhage in the UK: Changing Evidence from the Confidential Enquiries (1985–2011). A Comprehensive Textbook of Postpartum Hemorrhage; An Essential Clinical Reference for Ef ective Management 4 2nd Edition, Sapiens Publishing. 5 WHO Recommendations for the Prevention and Treatment of Postpartum Haemorrhage 2012 Blue Pill, Pink Pill: another updateDr Jane Flint, Chair of the BCS Joint working women over 55 years with more atypical symptoms.
Group Recommendations for Women's Heart Health recently advised us that ‘evidence Fol owing up on whether there had been any of increasing cardiovascular risks in women progress on our request for more pre- and post- in the <55 age group (smoking, gestational marketing safety analyses by gender I have diabetes and STEMI) continues to emerge'.
learned that due to changes in pharmacovigilance legislation last year, the MHRA have had to focus Myocardial infarction (STEMI) is increasing in women on the implementation of the new procedures. The aged over 55 years and a MINAP (Myocardial former Pharmacovigilance Working Party has been Ischaemia National Audit Project) audit has shown replaced by a Pharmacovigilance Risk Assessment smoking to be increasing in this patient group. Committee with increased powers to request and A study in the Journal of the American Medical review safety data. Currently there are two significant Association (JAMA) in 2012 found that the highest safety referrals relating to women's health products mortality rate from myocardial infarction was in on-going within Europe: these are for combined Medicines Optimisation ‘Helping patients to make the most of medicines', the on May 2nd. A copy of the Guidance and further good practice guidance for healthcare professionals information is available on http://www.rpharms.com/ in England has been endorsed by NHS England, RCGP, RCN, AoMRCs and ABPI, and was published The Self-selection of P medicines Discussions between the GPhC and various members and to col ect their views as a prelude to organisations, including the RPS and PDA, earlier further action.
this year have not resulted in any change in their decision to go ahead with the proposed ruling We also understand that the RPS is planning to that will permit the self-selection of P medicines.
consult with its members on this issue.
What are your views? Don't let this issue pass you by The PDA have recently held a series of meetings without having your say.
across the country to discuss the proposal with The Women's LibraryWe reported last year that The Women's Library relocation to the new premises. It will then operate was under threat of closure unless it could find a from the LSE archives Reading Room until work on new home. Fortunately the LSE has come to the a new Reading Room (which will house the open rescue and has been running the Women's Library access printed material) and Exhibition area has since January this year when from January until been completed. During this transition period archive 23rd of March the Reading Room and Exhibition and museum col ections will be available from areas were open, albeit for reduced hours.
August and books, periodicals, pamphlets and other printed materials from September.
The Library is now closed until 1st August to al ow staff to prepare the col ections for removal and Iodine in Pregnancy Iodine tablets are given routinely classified as iodine deficient, as to pregnant women in Germany defined by the WHO guidelines stated Antonie Marqwardt on recommended concentrations during her presentation of iodine during pregnancy. on ‘Health Promotion for Cognitive development in the Mothers and Babies' at our women's children as assessed by Brighouse Conference. This IQ measurements at age 8 and came as a surprise to many the reading ability at age 9 was of us and led to discussion on found to be significantly lower in the possible rationale for the those born to women who were different approaches adopted classified as iodine deficient.
by the UK and Germany.
The paper concludes that even Therefore, it was with some though severe iodine deficiency interest that I watched a report is not an issue in developed on the local BBC TV news one countries, nonetheless iodine day last week. A paper has deficiency should be treated as been published in The Lancet an important health issue to be reporting that iodine deficiency addressed in the UK. in pregnancy may have an effect A number of the national papers on the mental development of the reported on these new findings baby1. Analysing urine samples last week, but if you want to read from over 1,000 women during more the full paper can be the first trimester of pregnancy revealed that over two thirds were Lancet website. 1 Bath, SC, Steer,CD, Golding J, Emmett P, Rayner MP. Ef ect of inadequate iodine status in UK pregnant women on cognitive outcome in their children: results from the Avon Longitudinal Study of Parents and Children (ALSPAC). The Lancet. Early online publication 22 May 2013. 2013 Annual Subscriptions
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