NiPI Jan-Feb 2026 by GreenX Publishing

IAANMP SUPPLEMENT

✽ The year in review

✽ Poster competition winners

✽ Journal article review

✽ Meet the members

IN FOCUS

Antimicrobial stewardship

Diabetes

Skin and soft tissue infections

Paediatric pain

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Time to update the professional development checklist

Welcome to the latest edition of Nursing in Practice Ireland (NiPI)

A very Happy New Year to all our readers, we hope you had a peaceful Christmas and enjoyed a little downtime with family and loved ones. Finding those precious snippets of time to recharge can be difficult in the demanding and dynamic world of nursing care provision – where Christmas isn’t necessarily a holiday for many of us. In fact, the festive period is often a time for working long, busy shifts, eating reheated Brussel sprouts in a staffroom, and missing out on those treasured moments with family and friends. A lot of sacrifices have to be made, year on year, by many nurses and their fellow healthcare workers – the true and unsung heroes of Christmas.

While there are no awards for working over the festive season, there are some prizes to be won in healthcare. Trinity College Dublin’s School of Nursing and Midwifery recently awarded several honours in recognition of exceptional academic results and the highest end-of-year marks in its undergraduate and postgraduate nursing and midwifery programmes. In this edition of NiPI , our regular contributor Theresa Lowry Lehnen summarises highlights from the recent ceremony. Although unmentioned in the article, Theresa also received an award at the event for her own outstanding academic achievements, and we would like to take this opportunity to congratulate her. We are very proud to have Theresa as part of the team. We are kicking off 2026 with

another bumper edition of NiPI which includes tips from Marie Cantwell, Professional Development Coordinator for General Practice Nursing, on how to create a new year professional development checklist. As the NMBI Professional Competence Scheme approaches, this article also has relevance for practitioners beyond the general practice setting.

To help you add a few CPD points to your competency portfolio, this edition of NiPI features a comprehensive CPD module looking at menopause. Expert practitioner Cats Keye, ANP, describes the physiology, burden, and management strategies to help nurses in general practice, and beyond, to provide evidence-based, supportive care to this patient group.

In conference coverage, this edition includes a summary of highlights from the Irish Thoracic Society 2025 Annual Scientific Meeting. Primary ciliary dyskinesia, asthma, and bronchiectasis are just some of the topics covered in the report.

In clinical articles, we have a mixed bag of endocrinology, dermatology, microbiology, and more. ANP in Diabetes Olivia Mc Cabe discusses the bidirectional relationship between obstructive sleep apnoea and diabetes in her article, while Dr Anne Griffin, Associate Professor in Human Nutrition and Dietetics, and Senior Dietitian Tonya O’Neill, explore the challenges and barriers to implementing structured diabetes self-management education –specifically the DESMOND programme – in the Midwest of Ireland.

In skin care, Dr Johnny Loughnane, retired GP with a specialist interest in dermatology, presents the most common forms of skin and soft tissue infections, looking at the causative bacteria, correct diagnosis, and optimal management approaches. Staying with microorganisms, ANP Theresa Lowry Lehnen discusses antimicrobial stewardship and ways in which nurses can lead and engage in antimicrobial stewardship activities.

Finally in clinical content, MPSI Donna Cosgrove presents the best practice guidance for the assessment and management of pain in children. She describes the FLACC Assessment Scale as well as pharmacological and non-pharmacological approaches to pain relief.

We hope you enjoy another nurseled, diverse, and packed edition of NiPI . Thank you to the IAANMP, PDCGPNs, and to all our contributors for sharing their knowledge and expertise to promote clinical excellence, evidence-based practice, and optimal patient outcomes in general practice. As always, we welcome feedback, suggestions, and new contributors from our nursing and midwifery community.

New authors and contributors are very welcome to get in touch If you would like to write an article for NiPI, contact denise@greenx.ie

To contribute to the IAANMP supplement, contact iaanmp@gmail.com

] A message from Denise and the team at NiPI

All the latest healthcare and nursing news from around Ireland

NMBI NEWS

Updates from the Nursing and Midwifery Board of Ireland

43 Skin and soft tissue infections

Exploring the wide spectrum of severity from low-risk to lifethreatening cases

48 The assessment and management of pain in children

An update on the effects of untreated pain and best practice guidance

CPD module: Menopause management for general practice nurses

A comprehensive overview of the physiology, burden, and optimal management strategies

20 ITS 2025

Coverage of the Irish Thoracic Society Annual Scientific Meeting

Empowering diabetes care in primary practice: Lessons from the Midwest DESMOND Programme

Looking at the challenges and barriers to diabetes education 27 IAANMP OFFICIAL SUPPLEMENT

Updates from the Irish Association of Advanced Nurse Midwife Practitioners

54 Sleep apnoea and diabetes: Partners in risk

A bidirectional relationship that has significant implications for patient outcomes

58 Antimicrobial stewardship: A nursing imperative across all healthcare settings How nurses can lead, support, and sustain antimicrobial stewardship activities

EDITOR

Denise Doherty denise@greenx.ie

SUB-EDITORS

Emer Keogh emer@greenx.ie

Elaine Walsh elaine@greenx.ie

CREATIVE DIRECTOR

Laura Kenny laura@greenx.ie

Celebrating 50 years of nursing and midwifery at RCSI

A new sculpture has been unveiled at the Royal College of Surgeons in Ireland (RCSI) to celebrate the 50th anniversary of the Faculty of Nursing and Midwifery. The abstract work by Northern Irish artist John Rainey features nursing and midwifery leaders ascending a staircase, and was commissioned by the faculty to celebrate nursing and midwifery leadership in the 21st Century.

Mr Rainey was commissioned to create a total of four sculptures in honour of inspiring nurses and midwives. The previous three feature Florence Nightingale, Elizabeth O’Farrell, and Dame Peta Taaffe – the first Chief Nursing Officer for Ireland. This fourth and final piece represents the morphing of the sickness model with a modern wellness model from hospital teaching to university education.

The RCSI Faculty of Nursing and Midwifery Fellowship is the highest nursing and midwifery award in Ireland. This final abstract piece reflects the procession, led by the Dean, to the platform in RCSI at the Fellowship and Membership awarding ceremony each year.

Commenting, Ms Mary Godfrey, Dean

of the Faculty of Nursing and Midwifery, said: “The purpose of this commission is to celebrate and raise the profile of key leaders in nursing and midwifery in the 21st Century. It honours individuals who have made a monumental contribution

to the development of the professions. They have built on the core values of nursing and midwifery in Ireland – compassion, care, and commitment –and have accelerated progress over the last decade.”

Urgent need for future supply of health and social care workers in Ireland

Minister for Health Jennifer Carroll MacNeill has published a paper on Ireland’s future health and social care workforce, which demonstrates an urgent need to build a future supply of healthcare workers. The document is part of the Department’s long-term health and social care workforce planning projections in the context of Ireland’s dependence on healthcare workers that were educated abroad, its

ageing population, and rising prevalence of chronic diseases. The document sets out “an evidence-based strategic direction” for the health and social care workforce for the next 15 years.

The Economic and Social Research Institute Capacity Reviews commissioned by the Department of Health inform the demand projections within the paper and provide a crucial evidence-base. Projections and gap analysis show an

expectation of a shortfall across health and social care staff categories modelled. The analysis also demonstrates that with the implementation of planned health policies and workforce reforms, there will be an average annual growth rate required of approximately 1.4-2 per cent from 2023 to 2040 for the professions modelled. Population demographics are the major driver for this increased demand.

Pictured L-to-R: Prof Mark White, Executive Dean, Faculty of Nursing and Midwifery, RCSI; Aíne Gibbons, RCSI Director of Development and Alumni Relations; and Northern Ireland sculptor John Rainey

According to the paper, a whole of government response is required to support the higher education institutions to significantly expand student capacity to meet the future needs of the health, disability, and education sectors.

Minister Carroll MacNeill said the paper is “an important step” in ensuring an adequate workforce to deliver care. She added that Sláintecare reform “is transforming how healthcare is delivered in Ireland”, and described the health and social care workforce as “our strongest asset”.

“Every day, across a wide range of settings, they go to extraordinary lengths to deliver care to thousands of people. However, our modelling projections are showing that if we continue on our current trajectory, we will not have a sufficient number of health and social

care workers in the future. In recent years, significant investment has been made in the workforce.

“Substantial progress has been made to build capacity and improve the availability of health professionals to support integrated care across the entire health service and to deliver on modernised care pathways. Developing a dynamic, agile workforce and increasing the domestic supply of health and social care professionals will be essential to ensuring an economically sustainable workforce that can meet the health needs of our growing and ageing population.”

Minister for Further and Higher Education, Research, Innovation, and Science, James Lawless welcomed the paper, saying: “My department strongly supports this long-term approach and

HSE urges nurses to consider a career in public health nursing

The HSE is encouraging nurses to consider a career as a public health nurse (PHN). Applications for the HSE Public Health Sponsorship Programme are now open. The programme will equip nurses with the necessary skills to progress their career in public health nursing and make a difference in the community.

The programme is open to nurses registered with the Nursing and Midwifery Board of Ireland (NMBI) who have a minimum of two years’ post-registration experience. It runs for one academic year, commencing each September.

Postgraduate Public Health Nursing programmes are delivered by three higher education institutions: University College Cork (UCC), University College Dublin, and the University of Galway. Upon successful completion of the course, participants are offered a permanent contract.

Clodagh Brackett, a UCC student PHN based in Blackrock, Cork city, completed the Student PHN Sponsorship Postgraduate Programme after joining in September 2024. She gained experience working in both the hospital environment and in the community while completing a graduate nurse rotation programme.

Ms Brackett said: “I am so happy that I have completed the PHN course. It was a year full of learning and dedication, which has allowed me to be competent in my role as a PHN. My job is so diverse, from visiting newborn babies that have just been discharged from the maternity services to caring for people at the final stages of their lives.

“The support I have from my ADPHN and my colleagues is outstanding. Although PHNs are lone workers, the sense of community in public health

the shared ambition to expand domestic education and training capacity. Since 2022, more than 1,300 additional training places have been delivered across priority health and social care disciplines, with a further 600 places on track for 2026.

“Delivering this vision will require continued cross-government collaboration and sustained investment. Significant funding has been secured for 2025-2026 and beyond, and my officials and the HEA [Higher Education Authority] are progressing further expressions of interest to the sector to expand training capacity where it is most needed. I remain committed to working with the Minister for Health to ensure we have the skilled workforce required to deliver high-quality health and social care services into the future.”

nursing is astounding, and the support I have received really encourages my further learning. It’s a great course to have done and will stand to me throughout my nursing career.”

Grainne Ryan, National Lead for Public Health Nursing, HSE Office of the Nursing and Midwifery Services, added: “Public health nursing services aim to deliver safe, quality, and person-centred community nursing care across a person’s life. The service is committed to promoting health and wellbeing and enabling people to live healthy, fulfilled lives. The recruitment and retention of PHNs is a significant priority for us. I’d encourage nurses to consider the sponsorship programme. It is a blended academic programme, which will equip nurses with the necessary skills and experience to take the next step in their career.”

Groundbreaking common conditions service launched at boots

Boots Ireland has announced the launch of the pioneering Common Conditions Service, a significant healthcare initiative that will empower community pharmacists to provide advice, treatment, and for the first time in Ireland, prescribe prescription-only medication, when appropriate, for eight common conditions.

This innovative service marks a pivotal moment for primary care in Ireland. The required legal changes have been made for expanding the clinical role of community pharmacists and enhancing patient access to timely, professional healthcare. Historically, pharmacists have offered advice and over-the-counter solutions; now, under established clinical protocols, they will, in addition, be able to prescribe, where appropriate, and supply certain prescription-only medicines directly.

The initial eight common conditions

covered by the service include:

✽ Allergic rhinitis

✽ Cold sores

✽ Conjunctivitis

✽ Impetigo

✽ Oral thrush

✽ Shingles

✽ Uncomplicated urinary tract infections

✽ Vulvovaginal thrush.

“We are incredibly proud to be at the forefront of this transformative healthcare initiative in Ireland,” said Caoimhe McAuley, Director of Pharmacy and Superintendent Pharmacist at Boots. “The Common Conditions Service underscores Boots’ unwavering commitment to expanding patient care within the community. By enabling our highly trained pharmacists to diagnose and prescribe for these common ailments, we are improving access to primary care for everyone

and significantly reducing pressure on GP services.”

Patients can access the Common Conditions Service by booking an appointment through www.boots.ie/ common-conditions, where they will complete a brief pre-consultation form and select a convenient time and pharmacy. Additionally, patients can walk into a Boots pharmacy and speak to a pharmacist or be referred by a healthcare assistant for a consultation. The consultation is priced at €35, and while the consultation itself is not covered by government schemes, any prescribed and dispensed medicines may be eligible for reimbursement under existing schemes.

Following a consultation, the pharmacist may:

✽ Where appropriate, provide a prescription for medication.

✽ Offer lifestyle and healthcare advice.

✽ Recommend an over-the-counter medication.

✽ Refer the patient to a doctor or other healthcare professional.

First national report on cancer awareness and attitudes among the Traveller community in Ireland

The first national study of its kind in Ireland has been conducted to assess cancer awareness, attitudes, screening participation, and access to healthcare among the Traveller community. Social determinants of health have a significant impact on Traveller health, while stigma and discrimination can significantly hinder Travellers’ ability to adopt risk-reducing lifestyle behaviours, participate in screening, and access healthcare. Findings reveal a high level of awareness of cancer risks among the Traveller community, while the development of the role of the Traveller healthcare worker was viewed

positively and identified as a means to improve Traveller health.

The HSE’s National Cancer Control Programme commissioned the codesigned study led by University College Dublin (UCD) in partnership with Pavee Point Traveller and Roma Centre on Cancer Awareness and Attitudes among the Traveller Community in Ireland.

The research aimed to understand Travellers’ awareness of cancer risk factors and signs and symptoms; identify barriers and enablers to cancer risk reduction and early diagnosis of cancer – including access to health services and engagement with cancer

prevention/risk-reducing behaviours; and assess the impact of the social determinants of health on health-related behaviours. The study also looked at healthcare professionals’ views regarding the barriers and enablers for Travellers concerning healthy lifestyle behaviours, cancer screening participation, and timely reporting of cancer symptoms.

Traveller community health workers across Ireland coordinated and collected data from 483 surveys and assisted in recruitment for the qualitative interviews with Travellers and health professionals.

Dr Una Kennedy, GP Advisor to

the HSE’s National Cancer Control Programme, said, “We are delighted to publish this research report on cancer awareness and attitudes amongst the Traveller community in Ireland. The research provides an understanding of cancer awareness and attitudes among the Traveller community in Ireland as well as barriers and enablers for Travellers engaging with the health system. This is the first study of its kind to be undertaken in Ireland. The research provides baseline data to inform the development and delivery of effective cancer prevention and early diagnosis initiatives, monitor the impact of these initiatives, and support better understanding of policy priorities.”

The majority of respondents agreed that there are actions they can take to reduce their cancer risk, particularly smoking, with a total of 88 per cent of respondents spontaneously citing it

as a risk factor. There was also strong recognition of ultraviolet radiation from the sun and sunbeds as a risk factor, with 92 per cent identifying sunbed use and 78 per cent citing sunburn as a risk factor. Most Travellers knew that a lump or a bump, or a changing mole, could be a sign of cancer. Other common signs and symptoms of cancer such as an ongoing cough or losing weight were less well recognised.

The key enablers for accessing cancer screening were speaking with the local Traveller primary healthcare worker (28%), and receiving an invitation to attend screening helps to improve screening uptake (27%). Barriers to acting on a potential sign or symptom of cancer include not wishing to discuss their symptoms with a doctor’s receptionist (37%), fearing the potential diagnosis (32%), and the possibility of needing additional tests (31%).

Dr Patricia Fox, principal investigator on the project and Assistant Professor, UCD School of Nursing, Midwifery, and Health Systems, said: “Our findings reveal a ‘whole of government’ approach is required to address the underlying social determinants of health, which negatively impact Travellers in the context of cancer prevention, screening, and early detection. There needs to be continued partnership with Traveller organisations and primary healthcare for Travellers projects on all initiatives related to the Traveller community and particularly with reference to increasing knowledge of cancer risk factors and targeted and mainstreaming support for cancer prevention, screening, and early detection. Trusted relationships with culturally sensitive, well-resourced healthcare professionals and health services are also key, as is employing flexible, innovative approaches in this context.”

Iron deficiency in mothers during early pregnancy linked to lower language and motor skills in offspring

It is well known that iron is essential for brain development throughout pregnancy; however, the critical window appears to be much earlier than previously understood, according to recent findings. University College Cork (UCC) researchers have called for routine screening for iron deficiency in pregnant women in the wake of new research demonstrating that iron deficiency in early pregnancy may be associated with lower language and motor development scores in children at two years of age – even in the absence of anaemia. The study was published in The Journal of Nutrition and builds on earlier data showing that four-in-five pregnant women in Ireland are iron deficient by

Image: iStock.com/dragana991

the third trimester.

The latest research was conducted by the Irish Centre for Maternal and Child Health Research (INFANT), UCC, and partners at the University of

Minnesota and the Masonic Institute of the Developing Brain. The study included 189 mother-child pairs who participated in the IMPROvED and COMBINE cohort studies at the INFANT Research Centre, UCC.

Key findings:

✽ Over 40 per cent of healthy, lowrisk women had low iron stores by mid-pregnancy.

✽ Babies born to mothers who were iron deficient early in pregnancy had lower iron stores at birth.

✽ Iron deficiency in early pregnancy may be associated with lower motor and language developmental scores at age two.

Lead researcher Dr Elaine McCarthy,

Lecturer in Nutrition at UCC’s School of Food and Nutritional Sciences and Lead Investigator at the INFANT Research Centre, said: “We have previously shown that iron deficiency is very common in pregnancy, even in high-resource, low-risk settings like Ireland. This new research provides an early indication of the lasting consequences of iron deficiency without anaemia in pregnancy, further emphasising the importance

of adequate iron nutrition during pregnancy to protect the developing infant brain. These findings highlight the need for screening for iron deficiency in women during pregnancy, and trials to look at the benefit of targeted supplementation in women with low iron stores; not just focusing on anaemia in pregnancy. Our aim is to support women. With the right information, dietary guidance, and early screening, iron deficiency is

something we can address effectively.”

Following last year’s findings, the researchers at UCC and the Ireland South Women and Infants Directorate have developed a free, practical resource, titled ‘A guide on iron during pregnancy’, for expectant parents. It is available to download at: www.infantcentre.ie/wp-content/ uploads/2025/05/UCC-ISWID-AGuide-on-Iron-During-PregnancyFinal-PDF.pdf

A family affair as TUH welcomes latest nursing graduates

Tallaght University Hospital (TUH) recently celebrated its newest nursing graduates as well as a notable family milestone, as two sisters from Co Kildare advanced their healthcare careers at the hospital. Ms Kate Cribbin from Leixlip, Co Kildare, was among 64 new nurses who graduated from the four-year degree programme, delivered jointly between Trinity College Dublin and TUH. Adding to the poignancy of the occasion, Kate’s sister Eve was settling into the hospital as she began her onsite training as a medical intern. For the Cribbin family, the moment was particularly meaningful.

Kate’s path into nursing began at just 16, inspired by the time she spent caring for her grandfather, who lived with Alzheimer’s disease. That experience, she said, shaped her determination to work in healthcare and support families going through challenging moments.

Eve’s decision to pursue medicine was sparked during her Transition Year, when she undertook a placement at TUH. The exposure to patient care, teamwork, and the hospital’s fast-moving clinical environment

left a lasting impression and set her on course to return years later as a medical intern.

Throughout their studies, Kate and her fellow nursing students divided their time between university

lectures and clinical placements across the hospital’s wards and specialist departments. In their final year, students spent one semester on campus – aside from a six-week supernumerary placement – before transitioning to a nine-month internship at TUH.

The graduates were formally conferred with a Bachelor of Science degree in General Nursing by Trinity College Dublin in November 2025 and returned to TUH to mark the completion of their clinical nurse training.

Speaking ahead of that ceremony, TUH Director of Nursing Ms Áine Lynch commended the dedication shown by this cohort:

“It is wonderful to stand alongside our new nursing graduates who have worked extremely hard to reach this moment. This is an important and proud milestone, not just for the graduates themselves, but for their families and the colleagues who supported them along the way. I am especially delighted that 87 per cent of our new graduates will begin their professional careers here at TUH. Their commitment to our hospital and our patients is deeply valued.”

Dr Eve Cribbin and her sister Nurse Kate Cribbin

Highest number of registered nurses and midwives on record in Ireland

The Nursing and Midwifery Board of Ireland (NMBI) has published its State of the Register 2025 Report. Now in its fourth edition, the annual statement provides an overview of the configuration and trends within both the nursing and midwifery professions in Ireland. The data is based on the information collected by NMBI as part of the annual renewal process, which is compared annually in June each year.

This year’s document shows that as of 1 June 2025, there were 92,385 nurses and midwives on the NMBI Register. This figure reflects a 3 per cent increase since 2024 and is the largest number of registered nurses and midwives on record. The number of practising and patient-facing registrants has also increased, with 86,948 nurses and midwives stating that they are currently practising (a 3% increase) and 79,194 are patient-facing (a 4% increase). However, the number of registered midwives decreased by 3 per cent.

Chief Nursing Officer Rachel Kenna said the latest report “provides clear, reliable data and important insights that can inform policy development and decisionmaking”. She also described the data provided by the document as “central in helping to shape better policies to support and empower nurses and midwives, and advance their practice, while ensuring the highest standards of public safety”.

A total of 5,136 new registrants joined the NMBI Register, including Irish and internationally educated nurses and midwives. Compared to previous years, there has been a decrease in the number of new registrants who were educated

abroad, and an increase in the number of Irish graduates joining the Register. In 2025, 1,649 new Irish-educated nurses and midwives were added to the NMBI Register, an increase of 5 per cent (1,569) since the 2024 figures were released.

Other notable figures include:

✽ 3 per cent increase in registered general nurses

✽ 2 per cent increase in registered psychiatric nurses

✽ 24 per cent increase in registered advanced nurse practitioners (total of 1,204 on the register)

✽ 8 per cent increase in registered advanced midwife practitioners (total of 40 on the register)

✽ 15 per cent increase in registered nurse prescribers (total of 2,963 on the register)

✽ 26 per cent increase in registered midwife prescribers (total of 132 on the register)

✽ No change in the number of registered

intellectual disability nurses

✽ A marginal 1 per cent increase in registered public health nurses.

Since June 2023, the NMBI states it has observed a steady decrease in the number of registered nurses and midwives requesting a Certificate of Current Professional Status (CCPS) –also commonly known as a Certificate of Good Standing or Verification of Registration – which is required to practise abroad. According to the Board, this downhill trend in CCPS applications suggests that fewer nurses and midwives are choosing to register in other jurisdictions.

Minister for Health Jennifer Carroll MacNeill said: “The number of Irisheducated graduate nurses and midwives coming onto the NMBI register is increasing year on year. In addition, Irish-educated and registered nurses and midwives are opting to stay and practise in Ireland. This is positive news and is important for workforce planning and long-term stability in our health services.”

NMBI Chief Executive Officer Carolyn Donohoe added: “The comprehensive data provided in the NMBI State of the Register supports our collective efforts to ensure the Irish healthcare system is equipped to meet future needs. It is heartening to note that there are now 92,385 nurses and midwives on the NMBI Register, which is a 3 per cent increase on the previous year, and the highest number recorded to date.”

The full report is available to download on the NMBI website.

NMBI announces new board president

The Nursing and Midwifery Board of Ireland (NMBI) has announced the election of Ms Áine Lynch as its new Board President following a board meeting on 24 November 2025. Ms Lynch succeeds Dr Louise Kavanagh McBride, who was Board President from January 2023 to January 2026.

Acknowledging the efforts and contributions of both women, Ms Carolyn Donohoe, NMBI Chief Executive Officer, said: “Áine Lynch’s proven leadership and deep commitment to the professions of nursing and midwifery puts NMBI in a strong position for the years ahead. As we congratulate our new President on her appointment, I would also like to recognise our outgoing President, Dr Louise Kavanagh McBride, whose leadership has made a lasting impact on our organisation.”

Ms Lynch was appointed a board member of the NMBI by the Minister of Health in 2021 and was elected VicePresident in 2023. With more than four decades of experience, Ms Lynch has worked in Ireland, the UK, and the Middle East. She has spent several years at Tallaght University Hospital (TUH) in

Ms Áine Lynch

roles such as ward manager, clinical facilitator, and assistant director of nursing, nurse practice development, and has been Director of Nursing and Integrated Care at TUH since 2017 –where she leads a team of over 1,600 registered general nurses and 250 healthcare assistants. Other areas of responsibility include the integrated care brief, patient advice and liaison service, pastoral care team, and the arts and health department. Ms Lynch is also the executive lead for the Patient Community Advisory Council.

Previously, Ms Lynch worked at regional level from 2016-2017 as Interim Director of the Nursing and Midwifery

Planning and Development Unit, Dublin South Kildare and Wicklow, Office of the Nursing and Midwifery Services Director, HSE. In 2022-2023, she undertook the role of interim Chief Director of Nursing and Midwifery, Dublin Midlands Hospital Group. Ms Lynch is also an Adjunct Associate Professor, School of Nursing and Midwifery, Trinity College Dublin, awarded in 2018. In 2023, she was awarded Fellow by Examination, Nursing and Midwifery, Royal College Surgeons in Ireland.

Speaking about her appointment, Ms Lynch said: “It is an honour and privilege to have been elected President of NMBI and l would like to thank my Board colleagues for their trust in electing me. I would also like to pay special tribute to our outgoing President, Dr Louise Kavanagh McBride, for her guidance and leadership over the last three years.

“As I move from Vice-President into this new role, I am acutely aware of the opportunities and challenges ahead for nursing and midwifery. I look forward to working collaboratively with the Board, the executive team, and our key partners as we continue our important work to support and empower the professions of nursing and midwifery.”

NMBI publishes gender pay gap report 2025

The Nursing and Midwifery Board of Ireland (NMBI) has published its report outlining gender pay figures for 2025. The NMBI Gender Pay Gap Report 2025 demonstrates that approximately 76 per cent of NMBI employees are women and 24 per cent are men – consistent with the profession’s long-standing female dominance. It shows a minimal gender pay gap, whereby the mean hourly gender

pay gap was 1 per cent and the median hourly gender pay gap was 5 per cent.

The report emphasises that the gender pay gap does not indicate an illegal, unequal pay for equal work, but instead reflects the distribution of roles, grades, and seniority within the organisation. The NMBI also reaffirms its commitment to ensuring that it “promote fairness, transparency, and inclusion by continuing to monitor pay outcomes and reviewing

recruitment and progression practices to support equity”.

“It [the report] provides a clear picture of our current position and supports our ongoing work to strengthen equality, foster balanced opportunities, and ensure that our resourcing and organisational practices continue to evolve in line with best practice.”

The full report is available on the NMBI website.

✽ AUTHOR : Catriona Keye, PhD candidate, RANP MSc, RGN, Dip PN, H Dip NS, RNP MFTM RCPS (Glas) DiGP, Advanced Nurse Practitioner, General Practice (Menopause)

CPD Module: Menopause management for general practice nurses

Nurses play a crucial role in the management of menopause and its symptoms

To earn free CPD points, go to www.nurseCPD.ie and complete the quizzes based on this article.

Menopause is a natural life stage, marking the end of a woman’s reproductive cycle. Postmenopause is defined as the absence of menstruation for 12 consecutive months, typically occurring at 51 years of age.¹

The transitional period preceding menopause, known as perimenopause, may begin several years earlier and is characterised by hormonal fluctuations that lead to physical, emotional, and psychological symptoms.²

General practice nurses (GPNs) play a crucial role in supporting women during this transition, providing education, symptom management, and guidance on lifestyle and pharmacological interventions.³ This module is designed to support GPNs fulfil this role.

Epidemiology

In Ireland, approximately 652,000 women aged 45-65 are considered within the menopausal age bracket.⁴ Among them, 420,000 are in paid employment, indicating the socioeconomic relevance

of menopause.4 Surveys reveal that up to 80 per cent of women feel unprepared for menopause, exposing critical gaps in education and support.5

A recent Irish survey (2025) highlighted that 67 per cent of women felt Ireland lacked adequate workplace support during menopause, with 83 per cent stating menopause education should be mandatory in the workplace.5

Even with all the media attention around menopause, 66 per cent of Irish women remain unprepared for the impact of menopause, and 57 per cent still feel the topic is taboo.5 Globally, women now spend one-third of their lives postmenopause, highlighting the need for long-term health management strategies.6

Physiology of the menstrual cycle and changes in perimenopause and menopause

The menstrual cycle is a complex hormonal process involving the hypothalamus, pituitary gland, ovaries, and uterus. A typical cycle lasts 28 ± four days and comprises three primary phases:7

✽ Menstrual phase (days one to five): The menstrual phase marks the beginning of the menstrual cycle, starting on day one, which is the first day of bleeding. This phase occurs when no fertilisation or implantation has taken place in the previous cycle. As a result, the levels of oestrogen and progesterone drop sharply, signalling the uterus to shed its lining (the endometrium). The average duration of menstruation is three to seven days, though this can vary. During this time, hormone levels are at their lowest,

and the body is essentially resetting for a new cycle.7

✽ Follicular phase (days one to 14): The follicular phase begins at the same time as menstruation (day one), but continues until ovulation, which is around day 14 in a typical 28-day cycle. The hypothalamicpituitary-ovarian axis regulates this phase. The hypothalamus releases gonadotropin-releasing hormone (GnRH), which stimulates the anterior pituitary gland to secrete follicle-stimulating hormone (FSH). FSH acts on the ovaries, encouraging a group of follicles to develop. Each follicle hosts an immature egg and, typically, one dominant follicle is selected to mature fully. As it grows, this follicle produces increasing levels of oestrogen.7 Oestrogen has several important functions during this phase:

● It stimulates the regeneration of the endometrium, which had been shed during menstruation.

● It triggers the production of cervical mucus, which facilitates sperm survival.

● It sends feedback to the brain, leading to a surge in luteinising hormone (LH) when oestrogen peaks. This LH surge occurs just before ovulation and signals the release of the mature egg from the dominant follicle. This release, ovulation, is the end of the follicular phase and is the most fertile time in the cycle. This process is controlled by feedback mechanisms between oestrogen, GnRH, FSH, and LH, and marks the onset of the luteal phase.8

✽ Luteal phase (days 15-28): The luteal phase follows ovulation, typically on days 15 to 28 in a standard 28-day cycle. Once

the egg is released, the empty follicle becomes the corpus luteum. The corpus luteum begins to secrete progesterone and some oestrogen. The main role of progesterone during this phase is to maintain and stabilise the endometrial lining, making it thick and nutrient-rich to support potential implantation of a fertilised egg. Progesterone also reduces uterine contractions to help protect a possible early pregnancy. If fertilisation and implantation occur, the embryo begins to produce human chorionic gonadotropin (HCG), which keeps the corpus luteum active, so it continues to produce progesterone until the placenta takes over hormone production. If pregnancy does not occur, the corpus luteum degenerates after about 10-14 days, leading to a drop in progesterone and oestrogen. This hormone withdrawal causes the endometrial lining to break down and shed, leading to menstruation and the start of a new cycle.8

Hormonal changes in perimenopause

Perimenopause usually begins between 45 and 55 years of age, marked by declining follicular reserve and irregular hormone production:9

✽ Follicular phase: Delays in early

follicular development due to elevated FSH levels, leading to menstrual cycles becoming erratic.

✽ Ovulation: Becomes irregular or absent (anovulatory cycles).10

✽ Luteal phase: Progesterone deficiency is common, causing endometrial instability and irregular bleeding.

✽ FSH and LH: FSH rises due to reduced ovarian feedback, and LH fluctuates.¹¹ These hormonal shifts can cause menopausal symptoms.

Hormonal changes in menopause

Menopause is the last day of the last menstrual cycle, with postmenopause being 12 months without menstruation; both are diagnosed retrospectively.12

✽ Ovarian function ceases, oestradiol and progesterone decline.

✽ FSH and LH rise due to loss of negative feedback.

✽ Oestrogen deficiency causes widespread atrophy of oestrogen-

FIGURE 1: Female sexual cycle

FIGURE 2: Changes in sex hormones due to ageing

responsive tissues. This results in endometrial atrophy (leading to amenorrhoea) and genitourinary symptoms of menopause; ie, vaginal atrophy, dryness, and dyspareunia.¹²

✽ Testosterone, produced by the ovaries and adrenal glands, also declines but at a much slower rate than oestrogen, and may be a contributing factor to symptoms of low libido.¹³

Causes of menopause

✽ Natural (physiological) menopause: This is the expected outcome of ovarian follicular depletion.12 A woman is born with a finite number of follicles, which are depleted over her lifetime until ovulation and menstruation cease.12

✽ Surgical menopause: Results from the removal of both ovaries (bilateral oophorectomy). This causes an abrupt, immediate menopause due to the sudden loss of ovarian hormone production, often leading to more severe symptoms.13

✽ Premature ovarian insufficiency (POI): Loss of normal ovarian function before the age of 40.14,15 It affects approximately 1 per cent of women and can be idiopathic or due to genetic, autoimmune, or metabolic factors.14,15

✽ Iatrogenic (medical) menopause: Induced by medical treatments that damage ovarian function, such as chemotherapy or pelvic radiotherapy.¹⁶ This can be temporary or permanent, depending on the treatment and the woman's age.

Signs and symptoms

✽ Vasomotor: Changes to the regulation of body temperature, including hot flushes, night sweats, cold sweats, chills.¹⁷

✽ Genitourinary: Vaginal dryness, dyspareunia, urinary tract infections, urinary frequency, and/or urgency.¹²

✽ Psychological : Mood swings, anxiety, cognitive decline, brain fog,

imposter syndrome, becoming easily overwhelmed.¹⁸

✽ Sleep: Insomnia, fatigue.19

✽ Musculoskeletal: Reduced bone density, joint stiffness, muscle aches, back pain.20

✽ Sexual: Low libido is a common and often distressing symptom, influenced by hormonal changes, psychological factors, and physical symptoms like vaginal dryness. 12,21

Menopause-related health risks

✽ Cardiovascular disease (CVD): Loss of oestrogen increases low density lipoprotein, reduces high density lipoprotein, and promotes vascular inflammation, raising the risk of hypertension and atherosclerosis.22,23

✽ Osteoporosis: Oestrogen regulates bone turnover. Its deficiency accelerates bone loss, increasing fracture risk.20,24

✽ Metabolic syndrome: Oestrogen reduction can lead to visceral fat gain, insulin resistance, and type 2 diabetes.25,26

✽ Genitourinary syndrome: Includes vaginal atrophy, urinary symptoms, pelvic floor dysfunction, and dyspareunia.¹²

✽ Cognitive and mood disorders: Oestrogen influences the production, metabolism, and function of serotonin and dopamine, affecting memory, attention, and mood.18,27

✽ Sexual dysfunction: Oestrogen and testosterone deficiency can lead to persistent sexual problems beyond low libido, including reduced arousal and orgasmic difficulties, impacting relationships and quality of life.28

✽ Skin and hair: Oestrogen supports collagen synthesis its reduction causes dryness, thinning skin, and hair loss.29

✽ GPN implications: Education, risk screening, preventative strategies, and timely interventions are of great importance.30,31 Non-pharmacological management strategies are outlined in Table 1

Pharmacological management strategies

Pharmacological interventions are a cornerstone of menopause management, particularly for moderate to severe symptoms. Understanding their mechanisms of action is vital for GPNs to provide effective patient education and support safe usage.

Hormone replacement therapy (HRT) is the most effective treatment for vasomotor and genitourinary symptoms.37 Systemic HRT works by replenishing the body's declining oestrogen levels. Oestradiol binds to oestrogen receptors located throughout the body, including the thermoregulatory centre in the hypothalamus, blood

Lifestyle modifications Daily exercise. Diet (Mediterranean) and weight management 32

Cognitive behavioural therapy (CBT) and mindfulness

Support

For mood/sleep disturbances.33 CBT can also be effective in addressing negative thoughts and relationship dynamics contributing to low libido34

Advocacy and support groups. Peer support and counselling, including relationship counselling for issues related to intimacy35

Complementary therapies, eg, yoga36 May improve symptoms

TABLE 1: Non-pharmacological management strategies

CPD MODULE

vessels, skin, bones, and brain. This binding stabilises the hypothalamic thermostat, reducing the frequency and severity of hot flushes. For women with an intact uterus, a progestogen is co-prescribed to oppose oestrogen's proliferative effect on the endometrium, thereby preventing hyperplasia and carcinoma.38 Systemic oestrogen can also improve libido indirectly by relieving vasomotor symptoms and improving overall wellbeing.

Vaginal oestrogen provides local relief for genitourinary symptoms of menopause.39 Low-dose topical oestrogen (creams, tablets, rings) acts locally on the vaginal and vulvar epithelium. It binds to oestrogen receptors, stimulating glycogen production in vaginal cells, which supports the growth of protective lactobacilli. This restores the normal acidic pH, increases blood flow, and promotes thickening and elasticity of the vaginal tissues, thereby alleviating dryness, dyspareunia, and urinary frequency/urgency.⁴⁰ This can also improve sexual function by alleviating physical discomfort, which may secondarily help libido.41

Testosterone therapy can be considered for women with low libido that does not improve with firstline treatments like HRT.42,43 Testosterone, either directly or via conversion to oestradiol by the enzyme aromatase, acts on androgen receptors in the brain and other tissues. It is believed to modulate central nervous system pathways involved in sexual desire and motivation. Its use can increase libido, sexual arousal, and overall sexual function in some women.43 It is licensed in some countries for this purpose, although use in Ireland may be off-label, requiring specialist consultation.42

Non-hormonal alternatives are used when HRT is contraindicated or declined by the patient.44 Commonly used preparations include:

✽ Selective serotonin reuptake inhibitors/

serotonin and norepinephrine reuptake inhibitors (SNRIs) (eg, citalopram, venlafaxine): These antidepressants increase the availability of serotonin and, in the case of SNRIs, norepinephrine in the synaptic cleft. The exact mechanism for reducing hot flushes is not fully understood, but is thought to involve the modulation of central neurotransmitters in the hypothalamus, particularly serotonin, which plays a role in thermoregulation.45

✽ Gabapentin: A drug that stabilises nerve activity in the central nervous system. Its mechanism is thought to involve reducing the release of neurotransmitters that play a role in pain and the body’s thermoregulation, thereby helping to control hot flushes.46

✽ Neurokinin 3 (NK3) receptor antagonist (eg, fezolinetant): This newer class of drug works by blocking NK3 receptors in the hypothalamus. Neurokinin B, which acts on these receptors, is a key player in the thermoregulatory dysfunction that causes hot flushes. By antagonising these receptors, the drug helps to stabilise the body’s temperature control centre. 47

Pharmacological management of bone health may include bisphosphonates (eg, alendronate). These drugs adsorb to bone mineral and are ingested by osteoclasts during bone resorption. Once inside the osteoclast, they induce cell death, thereby inhibiting bone breakdown and reducing bone turnover.48

Selective oestrogen receptor modulators (SERMs) act like oestrogen in some tissues of the body, while blocking oestrogen’s effects in others. SERMs are medical multitaskers. In bone, they act like oestrogen, strengthening bones49 (raloxifene), whereas in the breast, they act as an anti-oestrogen to reduce oestrogen stimulation (tamoxifen).50

Ospemifene is a SERM that has an

oestrogen-like effect on the vaginal and genital tissues and is taken as an oral tablet rather than a vaginal pessary for genitourinary symptoms of menopause.51

HRT contraindications and risk factors

✽ Contraindications:3,38

● Active/recent/history of breast, ovarian, or endometrial cancer

● Active thromboembolic disease

● Pregnancy

● Active liver disease.

✽ Relative contraindications:3,38

● Hypertension: Ensure controlled before initiating treatment.

● Endometriosis: Ensure adequate progesterone protection, start with lowdose oestrogen and monitor symptoms.

● Abnormal vaginal bleeding: HRT should not be commenced in women with undiagnosed abnormal vaginal bleeding. Combined HRT itself may cause unscheduled bleeding in the first six months of use, but if it is persistent or new onset (after six months), pelvic disease should be excluded.

● Migraine: Although not a contraindication for HRT, low-dose transdermal preparations are favoured.

● High risk of gall bladder disease: The risk may be increased further with HRT (the risk may be lower with transdermal therapy).

Irish referral pathways for complex menopause cases

The complex clinic will see patients with a history of CVD, cerebrovascular disease, and hormone-sensitive cancers. The menopause specialists, in conjunction with specialist consultants, may make different decisions regarding suitability for treatment.

✽ National Maternity Hospital, Dublin52

✽ The Coombe Hospital53

✽ Rotunda Hospital54

✽ Cork University Maternity Hospital56

✽ Nenagh General Hospital Women's Health Hub.

GPN role: Early recognition, referral, collaborative care, and documentation. Referral is important for the management of complex cases.

Irish free HRT scheme (Since June 2025)

Free oral, transdermal, and vaginal HRT, including testosterone and the Mirena intra-uterine device, are available under the Drugs Payment Scheme.56

GPN role: Inform patients, assess eligibility, monitor outcomes, counsel on lifestyle, and support follow-up.

Monitoring strategies

Standardised assessment tools are very useful for objectively evaluating the severity of menopausal symptoms, guiding treatment decisions, and monitoring the effectiveness of interventions. The Greene Climacteric Scale (GCS) is one of the most widely used and researched tools. It is a 20-item self-report questionnaire that measures the presence and severity of symptoms across three domains: Psychological, somatic, and vasomotor. 57 Its utility in both clinical practice and research is underpinned by its strong psychometric properties.

Validity refers to how well an instrument assesses what it is intended to measure. The GCS has demonstrated good construct validity, meaning its domain structure accurately reflects the symptom clusters experienced during menopause. It also shows good convergent validity, correlating well with other established measures of

menopausal symptoms and quality of life.58,59 This indicates that a high score on the GCS is a true indicator of significant menopausal symptom burden.

Reliability refers to the consistency of the tool’s results. The GCS has shown high test-retest reliability, meaning it produces stable scores when administered to the same individual on two separate occasions (assuming no change in clinical status).60

Application in clinical practice for GPNs:

1. Baseline assessment: The GCS provides an objective baseline score before initiating HRT or other treatments. A total score of >15 or high subscale scores can help quantify symptom burden and justify the need for treatment, particularly when symptoms are subjective. 57

2. Monitoring treatment efficacy: At follow-up, re-administering the GCS allows for a direct comparison of scores. A reduction in the total or subscale scores provides objective evidence that the treatment (eg, HRT) is having a therapeutic benefit. This can also be useful in identifying issues that are not a result of menopause, eg, if musculoskeletal scores are not reducing, it may be valuable to carry out inflammatory marker bloods or refer for a specific scan.

3. Identifying persistent issues: If psychological scores remain high despite adequate oestrogen therapy,

it may indicate the need for additional support, such as CBT or a review of contributing factors.

Other monitoring strategies include:

✽ Regular blood pressure (BP) checks25

✽ Lifestyle and dietary assessment31

✽ Bone health: FRAX tool, calcium, and vitamin D intake61

✽ Cardiovascular health: BP, lipids, glucose Q3 risk score 37,62

✽ Sexual health: Routinely and sensitively enquire about sexual function, including libido, as part of a holistic review21

✽ Follow-up: Schedule reviews at three months after initiation and six to 12 months thereafter for stable patients.37

Conclusion

Menopause is a complex, multidimensional life stage. GPNs play a pivotal role in education, symptom management, monitoring, and referrals. The use of validated tools like the GCS enhances the objectivity of assessments, ensuring treatment decisions are data-driven and effectiveness is accurately evaluated. Awareness of Irish referral pathways and the free HRT scheme, combined with practical monitoring strategies, ensures the delivery of safe, effective, and equitable care. Understanding hormonal changes, oestrogenrelated health risks, and the detailed mechanisms of pharmacological treatments, including the multifactorial nature of symptoms, allows nurses to optimise outcomes and improve quality of life for menopausal women. ✽

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Q3 Risk score calculator. Available at: www.qrisk.org/lifetime/

✽

AUTHOR : James Fogarty

Irish Thoracic Society, Annual Scientific Meeting

Brensocatib ‘a game changer’ in treatment of bronchiectasis

The Irish Thoracic Society Annual Scientific Meeting took place from 20-22 November 2025 at the Galway Bay Hotel. Throughout the meeting, attendees heard from international and national experts in respiratory medicine about the latest developments and advances in the field.

The first guest lecture was delivered by Prof James Chalmers from the University of Dundee, Scotland, and chief editor of the European Respiratory Journal

Prof Chalmers, a renowned consultant respiratory physician, runs a specialist clinic for patients with complex respiratory infections, particularly bronchiectasis, at Ninewells Hospital, Dundee.

In his talk, ‘Big news for bronchiectasis’, he highlighted bronchiectasis research as a rapidly advancing and dynamic field, encouraging early-career attendees to consider it as a focus within the specialty.

The meeting heard that patients with bronchiectasis face a significant symptom burden and frequent exacerbations, with around 25 per cent requiring hospitalisation for an exacerbation each year across Europe.

“This is not a mild disease,” Prof Chalmers said, adding the condition was “incredibly heterogeneous”.

He said that the condition is his passion, having worked in the area for the last 20 years, and, for him, a “major driver” of clinical trials has been to discover improved treatment options. “There is a lot happening in bronchiectasis. But this was a field

where historically there hasn’t been a lot going on,” he said.

“In the last one to two years, it really has been transformed.”

Previously, Prof Chalmers noted that bronchiectasis had long been neglected and viewed as a condition of limited significance.

“It was [believed to be] rare. It was predominantly caused by tuberculosis (TB), and in places like western Europe, where TB rates were going down, bronchiectasis [was thought to] disappear,” he said. “[But] we now know that bronchiectasis rates have been rocketing in the last 20 to 30 years, as we recognised these cases with the advances in CT.”

This recent surge in activity has led to a dramatic rise in bronchiectasis clinical trials, increasing from a single study in the early 2000s to more than 10 randomised controlled trials completed or reported last year.

Regarding treatments, he noted that long-term macrolides are highly effective, yet only 17 per cent of patients across Europe currently receive them.

“We know they reduce exacerbations, but for some reason they don’t get used as a preventative therapy for most of those frequent exacerbators,” he said.

He added that significant work was required to provide a common, high standard of care for people with bronchiectasis, and “a lot of that starts with trials”.

Prof Chalmers said that earlier this year, the US Food and Drug Administration approved 10mg and 25mg doses of brensocatib, while the European Medicines Agency (EMA) approved the 25mg dose in November, marking the first ever licensed therapy for bronchiectasis. He added that clinical trial data showed brensocatib reduced exacerbations by 20 per cent at both doses.

He noted that the 25mg dose offers the same efficacy in reducing exacerbations, while also providing additional benefits for lung function and symptoms. “I think the EMA has made the right decision,” he said. “And there is much more to come – there are trials opening up everywhere because of the success of brensocatib and the availability of data.”

Prof Chalmers concluded that the new guidelines encourage clinicians to take a proactive approach in managing bronchiectasis patients.

He reiterated that macrolides are often the first-line treatment and, while not suitable for everyone, they are very effective, adding that “brensocatib is going to be a game changer”.

Prof Chalmers urged the meeting to also address other treatable aspects of bronchiectasis, including exercise, bronchodilators, and additional supportive therapies.

“There is a lot we can do for these patients, and we should be aiming to improve everyone’s outcomes.”

More robust diagnostic strategy for asthma needed

A more robust diagnostic strategy for confirming asthma in patients would be valuable for clinicians, the recent Irish Thoracic Society (ITS) 2025 Annual Scientific Meeting heard.

Dr Cara Gill, a respiratory specialist registrar and research fellow at Beaumont Hospital, Dublin, presented a talk titled ‘Asthma untangled: Standardising expert clinician judgement with a structured multi-modal approach’.

Dr Gill and colleagues recently completed a prospective cohort study, with the primary objective of demonstrating the efficacy of the AZTEC score.

She explained that the study aimed to answer the question: ‘Do patients in clinic actually have asthma to begin with?’

“The first question we had to ask is how do we actually decide what was asthma and what wasn’t asthma,” she said.

Dr Gill added that a cohort of patients referred from primary care, or other clinics

in the hospital, had symptoms suggestive of asthma or the label of asthma.

“They were already on inhaled corticosteroid therapy and they remained symptomatic,” she said.

“We know that the guidelines don’t really tell us what to do with these patients to confirm that they have asthma,” she said.

The team assigned a score to features that suggested that patients had asthma or another condition. Patients attended the clinic five times over six months, and investigations, including questionnaires and home FEV1 (forced expiratory volume in one second) monitors, were performed.

“After the end of that [period], we were able to provide a template that assigned up to 16 features that suggested someone had asthma or did not have asthma,” she said.

A total of 222 people completed the

study, with asthma confirmed in 60 per cent of participants. Among the 40 per cent who did not have asthma, other conditions included allergic rhinitis, gastrooesophageal reflux disease, and chronic obstructive pulmonary disease (COPD).

She said that the study highlighted the need for a more robust diagnostic strategy in confirming asthma.

The ITS meeting also heard from Prof Breda Cushen, HSE National Respiratory Clinical Lead, who delivered a guest lecture on the changing face of COPD care in Ireland.

Prof Cushen said that clinical outcomes are better when comprehensive multidimensional approaches are used to inform clinical decision-making in complex conditions like COPD.

Although she admitted there were regional disparities, Prof Cushen said Ireland has taken a “visionary approach” to COPD care.

PCD more common than currently recognised

Primary ciliary dyskinesia (PCD) is much more common than currently recognised, the Irish Thoracic Society 2025 Annual Scientific Meeting heard.

An inherited disorder, PCD is a clinically and genetically heterogeneous condition, caused by pathogenic variants in at least 50 genes, but likely many more.

The variants result in the congenital impairment of mucociliary clearance due to a defect in the cilia. Clinically, PCD is variably characterised by bronchiectasis, chronic rhinosinusitis, recurrent otitis media, laterality defects, and infertility.

Dr James O’Hanlon, University Hospital Galway (UHG), gave a presentation on ‘A view of PCD in a tertiary referral centre in Ireland’ to the meeting.

Dr O’Hanlon told attendees that

PCD prevalence “is likely grossly underestimated”, with only 1,236 people with genetically-diagnosed PCD known to the European Reference Network (ERN)-LUNG registry and 698 included in the US registry.

He added that a 2022 Lancet study looked at the frequency of diseasecausing variants in 29 PCD genes in 182,000 individuals worldwide.

The study estimated the global prevalence of PCD to be one in 7,500.

“We know that at least 50 genes are associated with PCD, with 37 deemed definitely associated,” he said.

Another 2022 study from the European Respiratory Journal found that motile ciliopathy associated genes were identified in 12 per cent of the 142 patients

recruited for whole-genome sequencing who had a diagnosis of idiopathic bronchiectasis.

“The bottom line is that most people with PCD remain undiagnosed,” Dr O’Hanlon said. He added that different mutations can affect different parts of the axoneme, resulting in variable clinical manifestations.

“The resultant lung disease is heterogeneous across all ultrastructural and genotype groups and some are more severe than others,” he said. They are worse in those with inner dynein arm, central apparatus, and microtubular disorganisation ultrastructural defects, Dr O'Hanlon noted.

“When we compare this to [cystic fibrosis], which is a monogenic disease,

we can see that comparatively there is a huge variety in what can go wrong in PCD and how that can present.”

Traditionally, guidelines have recommended using a combination of tests to diagnose PCD.

In Ireland, however, the requirement for patients to travel abroad for these investigations has likely led to their underutilisation, resulting in a greater reliance on clinical features for diagnosis.

This year, the European Respiratory Society and American Thoracic Society published consensus guidelines for the diagnosis of PCD for the first time. The diagnosis can be confirmed either by genetic testing or by transmission electron microscopy (TEM), but other methods can support a diagnosis in the correct clinical context.

High-speed video microscopy is the only diagnostic test that allows direct visualisation of ciliary dyskinesia. It can identify abnormalities in cilia affected by pathogenic mutations in DNAH5, the most common gene associated with PCD. Immunofluorescence is another valuable tool, particularly for clarifying genetic uncertainty related to variants of unknown significance, such as HYDIN.

“The guidelines recommend that PCD patients would have all of these investigations performed, but a more practical approach is possible where access is limited,” he said. “Immunofluorescence is much easier to analyse and perform than TEM, so we will likely see a more prominent role in diagnosis going forward.”

He emphasised the importance of obtaining a clear diagnosis, noting that patients with confirmed PCD gain access to specialised, multidisciplinary care provided through dedicated PCD referral centres. Following diagnosis and the initiation of appropriate management, stabilisation of the condition and improvements in lung function can also be achieved.

He noted that delayed diagnosis in adults with PCD is associated with

reduced ‘forced expiratory volume’ at the time of diagnosis, as well as an increased likelihood of Pseudomonas aeruginosa colonisation.

“Now there are specific therapies in development targeting known pathogenic mutations, which will hopefully be a future therapy option for our patients,” he said.

While genetic diagnosis is strongly encouraged whenever possible, it is negative in about 30 per cent of cases, so often further testing is needed, the meeting heard. TEM is the only way to confirm a diagnosis where there is no pathogenetic phenotype identified. TEM is 99 per cent specific in confirming a PCD diagnosis when performed within specialist centres.

Nasal nitric oxide (nNO) testing can also support a diagnosis and is easily performed in clinic. It can be measured during velum closure or tidal breathing, with velum closure providing greater accuracy and less variability.

Dr O’Hanlon explained that in UHG, a search was carried out on a clinic letter database for mention of PCD or related terms. Patients who had been given PCD as a primary diagnosis were identified. Patients were further analysed with regard to previous diagnostic evaluation, clinical features, co-morbidities, and sputum microbiology. The aim of the study was to identify patients with suspected PCD, and assess their previous diagnostic evaluation. A diagnosis would then be made and formal multidisciplinary care would be instituted.

A total of 25 patients were identified, 60 per cent of whom were female, with a median age of 38. Four of these patients had a diagnosis confirmed by genetic testing or TEM.

“So, despite having typical clinical features, the vast majority of patients with suspected PCD had not had the required diagnostic work-up to confirm the diagnosis.”

Following these findings, clinicians continued to actively case-find while

also identifying cases opportunistically. Once identified, these patients were referred to the specialist bronchiectasis clinic for comprehensive evaluation and management.

“Now we have five new confirmed diagnoses of PCD by genetic analysis,” he said. nNO has been performed in 12 patients and was positive in nine. One patient was referred to the UK for TEM.

Regarding the most common causative genes, five were identified, with HYDIN being by far the most frequent. The HYDIN gene encodes a protein essential for ciliary motility, but it does not affect the overall ciliary ultrastructure, meaning that TEM results appear normal.

“These patients often have preserved lung function,” he said. He also highlighted that the majority of these patients are within the Traveller community.

In terms of take-home messages, Dr O’Hanlon emphasised that clinicians should maintain a high index of suspicion for PCD in patients with typical features, as a confirmed diagnosis has important implications for care. Certain causative genetic mutations, such as HYDIN, may be more prevalent in Ireland than in other populations.

When asked why HYDIN may be more common here than elsewhere, Dr O’Hanlon said it was known to be more common in closed ethnic groups, with consanguinity a big risk factor.

“But we would still not expect to see it as prevalent in Ireland as compared to the rest of Europe. Most of the people we have seen are members of the Traveller community, but some are not, and don’t have any risk factors. So there is more to it than that as well.”

He stated that UHG, along with other sites in Ireland, will be designated as a PCD centre as part of the ERN-LUNG International PCD Registry.

“We then will be able to centralise care and establish a nationwide diagnostic pathway for adult and paediatric medicine, which will hopefully have important implications for these patients.”

Pricing on obesity medications must be addressed

The dominant intervention for patients presenting with severe and complicated obesity remains surgery, the Irish Thoracic Society 2025 Annual Scientific Meeting was told by a leading expert in the field.

“There’s no equivocation about that,” Prof Francis Finucane, Consultant Endocrinologist, University Hospital Galway, and Professor of Medicine, University of Galway, informed attendees.

During a talk entitled, ‘A two-pronged approach to obesity’, Prof Finucane explained that surgery was safe and more effective “than even the best drugs still”.

“And importantly, it is very costeffective, especially against drug therapy,” he said.

However, Prof Finucane added that new medications have “totally changed our thresholds for certain interventions, the ambitions we have for patients, and their expectations”.

Regarding drug therapy, Prof Finucane explained that progress had been slow for many years, until the recent development of glucagon-like peptide (GLP)-1 receptor agonists, which have significantly changed treatment options and patient outcomes.

“GLP-1 is a ubiquitous molecule in the sense that it is produced all along the gastrointestinal tract,” he said.

“It has numerous actions on lots of different tissues.”

However, Prof Finucane added that these medications’ actions are predominantly felt in the centres in the brain that influence appetite, satiety, and reward centres associated with eating.

“That’s how these drugs work. We talk about ‘weight loss’ drugs, but really we want to reframe that,” he said. “These aren’t so much ‘weight loss’ drugs as ‘eat less’ drugs.”

He added that the medications can have side effects, including pancreatitis, which occurs in approximately one in 500

patients, gallbladder disease in nearly 4 per cent, and more common issues such as constipation, vomiting, and nausea. “There are a lot of things we need to think about when we prescribe them.”

While they can be very effective, Prof Finucane stressed that there is a variation in the response of patients to the medication in terms of weight loss.

“It is not a reflection of their intelligence or motivation – it’s a reflection of their biology,” he said.

“We don’t know and the big challenge is trying to figure out the variation in response to these drugs.”

Answering this question would save patients from “futile treatment” and the health service considerable funds.

“There are a significant minority, even with the best drugs, who don’t lose any weight,” he said.

Prof Finucane said people with obesity who need treatment “ought to be getting the drugs provided by the healthcare system, according to the same rules we provide drugs for other conditions”.

“Why is that not happening in Ireland? The biggest challenge we face is that our patients can’t afford these drugs. I might see 20 patients on a morning, and we

might offer 10 of those patients obesity medications, and half of them will say ‘I can’t afford them’. It is heartbreaking. And I think it is unique in medicine, where you have a situation where you’d like to offer a patient a safe, efficacious treatment and you can’t because they can’t pay for it.

That is a huge challenge.”

He said that these medications are too expensive and this was “a nettle that needed to be grasped” by society. “We’re aligned with drug companies 99 per cent of the time, but when it comes to the cost of medications, our interests and our patients’ interests are diametrically opposed to the commercial interests of drug companies, which by law have to make a profit and have to maximise the return for their shareholders.”

He said that companies need to be encouraged to “do the right thing by society” in terms of pricing.

Prof Finucane also urged Ireland to adopt a similar approach to unhealthy, ultra-processed foods as it did with smoking, describing the recent series of Lancet articles on obesity as a “blueprint for government action”.

“We have to emulate what you have done over the last 30 years in respiratory public health. We are way behind,” he said. “Voluntary codes around the marketing and advertising of unhealthy food to children are toothless, unenforceable, and tend to go around in circles… There is complete policy inertia when it comes to obesity and yet we think we are doing great.”

Prof Finucane highlighted the work of the new HSE National Clinical Programme for Obesity in providing a positive framework of care for patients with severe and complicated obesity. He also praised the 2013 Healthy Ireland strategy.

“Then by 2015/2016, they had the obesity policy and action plan, and it was clear that industry had time to get its ducks in a row and influence that very strongly.”

Image: iStock.com/Munro

✽ AUTHORS

: Dr Anne Griffin, Associate Professor in Human Nutrition and Dietetics, University of Limerick; and Tonya O’Neill, Senior Dietitian – Diabetes, Limerick

Empowering diabetes care in primary practice: Lessons from the Midwest DESMOND Programme

With prevalence rates rising, the need for scalable, evidence-based interventions is urgent

Type 2 diabetes mellitus (T2DM) is a growing public health challenge in Ireland, particularly among older adults.1 With prevalence rates rising and complications increasing, the need for scalable, evidence-based interventions is urgent. Structured diabetes selfmanagement education (DSME) has emerged as a cornerstone of diabetes care, equipping patients with the knowledge, skills, and confidence to manage their condition effectively. 2,3

One such programme – Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND) – has been implemented in the Midwest of Ireland since 2010. Facilitated by trained dietitians and diabetes nurse specialists in primary care, DESMOND is an evidence-based group education programme for people with T2DM that focuses on long-term self-management through behaviour change.4,5 Participants complete six hours of education (either one full day or two half days) in groups of up to 12 people, with the opportunity to be accompanied by a support person if desired.6 In the HSE Midwest service, local policy is to offer a follow-up session after six months. Despite the programme’s proven benefits, uptake of DSME remained inconsistent in the midwest.

To better understand this, we conducted two complimentary studies between 2019 and 2021:

1. A retrospective evaluation of clinical outcomes among DESMOND participants.7

2. A qualitative study exploring healthcare

professionals’ experiences, barriers, and enablers related to DSME referral and delivery (unpublished).

Together, these studies provide a comprehensive view of both the clinical impact and the practical realities of implementing DSME in routine primary care.

Clinical effectiveness: What the data show

The retrospective study evaluated adults with T2DM who attended both the DESMOND programme and a locally developed six-month follow-up session.6 Participants had a mean age of 63 years, with a wide range in time since diagnosis (three months to 11 years). Clinical outcomes were measured at baseline and follow-up, focusing on HbA1c (glycated haemoglobin), weight, and body mass index (BMI).

Among the 66 participants who completed both the DESMOND programme and the locally developed six-month follow-up, the data revealed encouraging improvements in clinical outcomes. Glycaemic control improved significantly, with average HbA1c levels dropping from 58mmol/mol to 52mmol/ mol, a reduction that brought more participants below the recommended target threshold.7 At baseline, just over half of the group met the target of less than 53mmol/mol, but by follow-up, this had increased to 71 per cent.

Changes in body weight were more modest overall, with an average reduction of 1.4kg. However, a closer

look showed that 13 per cent of participants achieved a weight loss of more than 5 per cent, a clinically meaningful change associated with improved metabolic health. 8 Shifts in BMI categories also reflected positive trends: The proportion of individuals in the normal weight range increased, while those classified as overweight decreased. Although the percentage of participants in the obese category remained unchanged, more than half of those individuals recorded meaningful weight loss, suggesting that even small changes may be achievable and beneficial within this cohort.

These results reinforce the value of structured education in improving metabolic outcomes, particularly when delivered by trained professionals in a supportive group setting. Importantly, the study also highlighted the potential for sustained benefits when education is followed by targeted follow-up.

Implementation challenges: What providers say

In parallel, our qualitative study explored the attitudes, knowledge, and referral practices of eight healthcare professionals across the midwest. Participants included nurses, podiatrists, physiotherapists, and occupational therapists, some of whom were active referrers to DESMOND, while others were not.

Despite broad support for patient education, several barriers to DSME uptake were identified:

✽ Unclear referral pathway: Many professionals were unsure whether they could refer directly or lacked clarity on eligibility criteria. Even among those familiar with the DSME, uncertainty about the referral process and lack of feedback on patient attendance were common frustrations.

✽ External barriers: Issues such as frailty, transport, rural location, and digital literacy were cited as obstacles, particularly for older adults. While the DSME moved online during the Covid-19 pandemic, participants noted that many older patients struggled with technology or lacked access to devices.

✽ Internal barriers: Patient-related factors such as denial, stigma, and low self-efficacy were recurring themes. Our professionals observed that some patients resisted the diagnosis or preferred to manage their condition independently, while others were reluctant to attend group sessions due to embarrassment or fear of judgment.

✽ Low programme visibility: Several providers had never heard of DSME before being contacted for the study. Others expressed a desire for more information, including printed materials, opportunities to observe sessions, and updates via webinars or team meetings.

Why this matters for clinical practice

Our findings highlight that DSME’s clinical benefits can only be fully realised when supported by clear systems and processes. Integration into routine care depends on several key factors:

1. Streamlined referral pathways

Many healthcare professionals, particularly those outside of general practice, were unsure whether they could refer patients directly or were unfamiliar with the process. This uncertainty can lead to missed opportunities for patient engagement, especially in the critical early months following diagnosis. 9 Addressing this gap by streamlining referral protocols and ensuring all members of the multidisciplinary team are informed and empowered to refer could significantly improve uptake.

2. Improved access and flexibility

Patients living in rural areas, those with mobility challenges, or those reliant on carers often face logistical difficulties in attending in-person sessions. While the shift to online delivery during the Covid-19 pandemic offered some flexibility, digital literacy and technology access remain limiting factors for many older adults.10 Expanding the programme through community-based venues, telehealth options, and flexible scheduling could help reach those who are currently underserved. In addition, the inclusion of family members or carers at DSME sessions not only improves accessibility but also strengthens the support network around the individual.11

3. Feedback loops for referrers

Clinicians who refer patients to DSME often receive no confirmation of attendance or outcomes, making it difficult to reinforce learning or tailor

Issues such as frailty, transport, rural location, and digital literacy were cited as obstacles, particularly for older adults

follow-up care. Establishing a feedback loop would support continuity of care and help clinicians better understand the programme’s impact on their patients.12,13

4. Enhanced programme visibilit y

Finally, visibility of the programme within the healthcare system is essential. Several participants had never heard of the DSME prior to the study, and others expressed a desire for more information, such as printed materials, webinars, or opportunities to observe sessions. Raising awareness through team meetings, professional development events, and targeted outreach to underrepresented professions could help embed DSME more firmly within the culture of diabetes care.13,14

Conclusion

Within the Midwest, DESMOND offers a proven DSME model for empowering patients with T2DM to manage their condition effectively. Its success depends not only on programme quality but also on system-level support for implementation. By addressing barriers to referral and attendance, and by centring the programme within integrated care pathways, clinicians can help ensure that structured education becomes a routine and impactful part of diabetes care in Ireland.

In recent years, diabetes care in Ireland has evolved significantly, supported by national strategies and local service developments. The HSE Integrated Model of Care for People with T2DM (2024) provides a clear, standardised framework for where and how individuals with diabetes should receive care across the spectrum, from prevention and diagnosis to complex management. 6 Locally, the establishment of integrated care hubs and the expansion of multidisciplinary teams have further enhanced access to care. Increased staffing, including

additional diabetes nurse specialists and dietitians, has enabled the delivery of DSME programmes like DESMOND in more community-based venues, bringing care closer to where people live. These developments have not only improved accessibility but also reinforced the integration of education and self-management support within routine care.

Together, these national and regional

References

1. Balanda K, Barron S, Fahy L, McLaughlin A. Making chronic conditions count: Hypertension, stroke, coronary heart disease, diabetes. A systematic approach to estimating and forecasting population prevalence on the island of Ireland. 2010. Available at: https://pure. ulster.ac.uk/en/publications/makingchronic-conditions-count-hypertensionstroke-coronary-hear/

2. Powers MA, Bardsley JK, Cypress M, et al. Diabetes self-management education and support in adults with type 2 diabetes: A Consensus Report of the American Diabetes Association, the Association of Diabetes Care and Education Specialists, the Academy of Nutrition and Dietetics, the American Academy of Family Physicians, the American Academy of PAs, the American Association of Nurse Practitioners, and the American Pharmacists Association. Diabetes Care . 2020;43(7):1636-1649. doi:10.2337/dci20-0023.

3. Davis J, Fischl AH, Beck J, et al. 2022 National Standards for Diabetes SelfManagement Education and Support. Sci Diabetes Self Manag Care . 2022;48(1):4459. doi:10.1177/26350106211072203.

4. Skinner TC, Carey ME, Cradock S, et al. Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND): Process modelling of pilot study. Patient Educ Couns 2006;64(1-3):369-377. doi:10.1016/j. pec.2006.04.007.

initiatives create a strong foundation for embedding DSME as a standard component of diabetes management in Ireland.

By addressing remaining barriers to referral and engagement, and by leveraging the new integrated care infrastructure, clinicians can help ensure that structured education becomes a truly universal and impactful element to diabetes care.

As the burden of diabetes continues to grow, particularly among older adults, the need for accessible, evidencebased education is more urgent than ever. The experience from the Midwest demonstrates that when supported by system-level innovation and local collaboration, DSME can empower people with diabetes to take an active role in their health and improve outcomes across the continuum of care. ✽

5. Chatterjee S, Davies MJ, Stribling B, et al. Real-world evaluation of the DESMOND type 2 diabetes education and self-management programme. Practical Diabetes . 2018;35(1):19-22a.

6. Scannell C, O’Neill T, Griffin A. The effectiveness of a primary care diabetes education and self-management programme in Ireland: A six-month follow-up study. Endocrinol Diabetes Metab . 2025;8(2):e70036. doi:10.1002/ edm2.70036.

7. American Diabetes Association Professional Practice Committee. 13. Older adults: Standards of care in diabetes-2025. Diabetes Care . 2025;48(1 Suppl 1):S266-S282. doi:10.2337/ dc25-S013.

8. American Diabetes Association Professional Practice Committee. 6. Glycaemic goals and hypoglycaemia: Standards of care in diabetes-2025. Diabetes Care . 2025;48(1 Suppl 1):S128-S145. doi:10.2337/dc25-S006.

9. Public Health England. A systematic review and meta-analysis assessing the effectiveness of pragmatic lifestyle interventions for the prevention of type 2 diabetes mellitus in routine practice. London: Public Health England; 2015. Available at: https:// assets.publishing.service.gov.uk/ media/5b6c484ae5274a2967e4cfc0/ PHE_Evidence_Review_of_diabetes_ prevention_programmes-_FINAL.pdf

10. Choudhary P, Bellido V, Graner

M, et al. The challenge of sustainable access to telemonitoring tools for people with diabetes in Europe: Lessons from Covid 19 and beyond. Diabetes Ther 2021;12(9):2311-2327. doi:10.1007/ s13300-021-01132-9.

11. Busebaia TJA, Thompson J, Fairbrother H, Ali P. The role of family in supporting adherence to diabetes self-care management practices: An umbrella review. J Adv Nurs . 2023;79(10):36523677. doi:10.1111/jan.15689.

12. Ljungholm L, Edin-Liljegren A, Ekstedt M, Klinga C. What is needed for continuity of care and how can we achieve it? Perceptions among multiprofessionals on the chronic care trajectory. BMC Health Serv Res . 2022;22(1):686. doi:10.1186/ s12913-022-08023-0.

13. Huber C, Montreuil C, Christie D, Forbes A. Integrating self-management education and support in routine care of people with type 2 diabetes mellitus: A conceptional model based on critical interpretive synthesis and a consensusbuilding participatory consultation. Front Clin Diabetes Health . 2022;3:845547. doi:10.3389/fcdhc.2022.845547.

14. Davies MJ, Bodicoat DH, Brennan A, et al. Uptake of self-management education programmes for people with type 2 diabetes in primary care through the embedding package: A cluster randomised control trial and ethnographic study. BMC Prim Care . 2024;25(1):136. doi:10.1186/ s12875-024-02372-x.

✽

THIS ISSUE:

Committee news ] The year in review ] Poster winners: 2025 National Conference ] Journal article review ] Meet the members ]

WELCOME FROM MELISSA AND THE TEAM

IAANMP committee update: A heartfelt thank you and a warm welcome

] Author: IAANMP Editorial Officer

The IAANMP extends its deepest gratitude to our outgoing committee officers for their dedication, leadership, and commitment to the Association and advanced practice in Ireland.

We sincerely thank Dona Cromar, Roisin Lennon, Vincent Melvin, and Gemma Smyth for their invaluable contributions to the Association and their tireless work in promoting

excellence, collaboration, and innovation within ANP and AMP practice. Their time, expertise, and dedication have played a vital role in strengthening the IAANMP’s vision and supporting the professional growth of advanced practitioners nationally. We wish them every success in their continued professional journeys and future endeavours.

We are delighted to welcome new officers to the IAANMP committee in 2026 and look forward to their contribution to the ongoing activities

and development of the organisation.

Our new officers are Louise Moore, RANP in Rheumatology; Sara Daly, RANP in Respiratory; Claire Kearney, RANP in Obesity; Luke Sheehan, RANP in Urgent Care; and Anne Mc Guire, RANP in Cardiothoracics.

IAANMP Committee 2026:

✽ Chair: Melissa Hammond

✽ Vice-Chair: Caroline Fraser

✽ Treasurer: Louise Moore

✽ Secretary (Membership): Sarah Daly

✽ Secretary (Education): Anne Mc Guire

Melissa Hammond, Chairperson Caroline Fraser, Vice-Chair

Theresa Lowry Lehnen, Editorial Officer IAANMP Supplement & website

EDITORIAL DIRECTOR: Theresa Lowry Lehnen

Louise Moore, Treasurer

Claire Kearney, PRO & GDPR Officer

Sarah Daly, Membership Secretary

Anne McGuire, Education Secretary Luke Sheehan, Committee Officer

Leena Rodrigues, Committee Officer

Fiona Colbert, Committee Officer

Kathleen Canavan, Committee Officer

✽ Editorial (Advanced Practice supplement and website):

Theresa Lowry Lehnen

✽ PRO: Claire Kearney

✽ Committee Officers: Fiona Colbert, Kathleen Canavan, Leena Rodrigues, and Luke Sheehan.

The IAANMP remains committed to supporting and empowering ANMPs across Ireland through continued collaboration, dissemination of best practice, and the advancement of excellence in advanced practice nursing and midwifery. Working

together, we will continue to uphold high professional standards and represent the voice of advanced practice across the healthcare sectors. For more details, please visit the committee section on our website: https://iaanmp.com/the-committee/.

IAANMP 2025 YEAR IN REVIEW

✽ Authors: Theresa Lowry Lehnen, RANP, IAANMP Editorial Officer; and Melissa Hammond, RANP and Chair IAANMP

Ayear of growth, leadership, and national impact

Last year, 2025, was a landmark for the IAANMP, defined by innovation, collaboration, and substantial progress in amplifying the voice and visibility of ANMPs across Ireland. As a national representative body for ANMPs, the IAANMP continued to lead with purpose and vision, championing advanced practice, supporting professional development, and promoting excellence in patient-centred care.

Throughout the year, the Association demonstrated its commitment to ensuring that advanced practitioners are recognised as key clinical leaders driving innovation, improving access to services, and shaping the evolving landscape of Irish healthcare.

Representation, growth, and advocacy

Membership of the IAANMP grew exponentially in 2025, reflecting the expansion of ANMP posts across primary, secondary, and tertiary care. The Association now proudly

represents 572 members. This growth mirrored the ongoing national recognition of advanced practice roles as essential components of Ireland’s integrated and multidisciplinary model of healthcare delivery.

In 2025, the IAANMP took a leading role in shaping national workforce and policy decisions, engaging directly with government, the Department of Health, the HSE, the Nursing and Midwifery Board of Ireland, the Irish Nurses and Midwives Organisation, and academic experts. These strategic collaborations ensured that ANPs and AMPs had a strong, influential voice, advancing the expansion of advanced practice, professional recognition, and driving sustained investment in role development across Ireland.

The Association collaborated with Tile Media on their TG4 production Altraí na hÉireann, further promoting

the visibility and impact of ANMPs at a national level. In addition, IAANMP committee officers were involved in the E-STAR online survey project, a national research initiative evaluating the standards and requirements for advanced practice in Ireland, contributing valuable insights to inform future policy and workforce planning. Through its strategic partnerships and national presence, the IAANMP continued to influence health policy and promote the role of advanced practitioners in delivering safe, effective, and accessible care aligned with national healthcare reform.

The

IAANMP

Advanced Practice Supplement

A defining achievement of 2025 was the introduction and continued success of the IAANMP Advanced Practice Supplement, published within the Nursing in Practice Ireland (NiPI) journal. In collaboration with GreenCross Publications, NiPI editor Denise Doherty, IAANMP Chair Melissa Hammond, and the IAANMP Committee, Theresa Lowry Lehnen (RANP) initiated the concept that led to the establishment of the supplement and also continues to play an editorial role in its ongoing development and publication.

The IAANMP Advanced Practice

Supplement provides a professional forum for ANMPs to share evidencebased practice, research findings, clinical innovations, and reflective professional insights, and highlights the influence and impact of advanced practitioners across the healthcare sectors.

The supplement has significantly enhanced the visibility of advanced practice in Ireland and has become a cornerstone of professional communication and engagement for IAANMP ANMPs. Its success reflects the collective strength of Ireland’s advanced practice community.

Professional development and education:

IAANMP webinars via MedCafe

Education and professional growth remained a priority for the IAANMP in 2025. In collaboration with MedCafe, the Association delivered a series of live and recorded webinars that reached and engaged advanced practitioners across Ireland, providing high-quality, evidence-based continuing professional development (CPD).

The MedCafe platform provides flexible and accessible learning opportunities that support the educational needs of ANMPs across diverse clinical settings. These webinars reflect members’ strong commitment to lifelong learning and reinforce the IAANMP’s reputation as a leading provider of high-quality professional education for advanced practitioners.

Digital transformation:

The Siilo platform

2025 saw the introduction of the Siilo platform, a secure and interactive digital space developed to strengthen communication, engagement, and resource sharing across the IAANMP membership. The initiative was set up for members by Dona Cromar, RANP and IAANMP Committee Officer.

Siilo serves as a modern, digital

hub where members can access Association news, policy updates, educational materials, and event information. The platform also facilitates real-time collaboration and networking through discussion forums and professional communities.

The launch of Siilo represented a major step forward in the Association’s digital strategy, fostering connectivity and engagement across Ireland’s advanced practice network. It reflects the IAANMP’s commitment to digital innovation and to creating inclusive, interactive environments that support professional dialogue and peer collaboration.

IAANMP updated website

The IAANMP updated its website in 2025 to provide a more streamlined, informative, and engaging experience for members and visitors. The refreshed site reflects IAANMP’s ongoing commitment to supporting the professional development, collaboration, and visibility of ANMPs across Ireland.

The updated website features improved navigation and expanded content, including sections on membership, the IAANMP Supplement in NiPI, webinars, a national repository, education updates, news and events, and professional resources. These enhancements ensure members have easy access to key information, clinical guidance, and updates relevant to advanced practice.

Showcasing the growth of advanced practice in Ireland, IAANMP now represents 572 advanced practitioners across more than 30 specialist areas. The updated website serves as a central hub for communication, research, and innovation, promoting excellence in advanced nursing and midwifery practice nationwide.

IAANMP social media influence

In 2025, the IAANMP strengthened its digital presence and influence through its active LinkedIn and X (Twitter) platforms, highlighting the achievements of advanced practitioners, and fostering professional collaboration. Throughout the year, IAANMP’s social media networks engaged a growing audience of practitioners, educators, and healthcare leaders, amplifying the voice of advanced practice in Ireland. Regular posts showcased clinical insights, policy developments, and member achievements – fostering leadership, innovation, and advocacy across the profession.

GDPR

The IAANMP updated its general data protection regulation (GDPR) policy in 2025 to reflect current data protection standards and best practices. The updated policy ensures full compliance with the GDPR and Irish data protection laws, reinforcing the Association’s commitment to transparency, accountability, and the secure handling of personal data. The IAANMP collects and processes only the information necessary for membership, communication, and organisational purposes, safeguarding all data through secure systems and limited authorised access. Personal information is never shared with third parties without explicit consent, and members retain the right to access, correct, or request deletion of their data at any time.

The 2025 IAANMP National Conference

The 2025 IAANMP National Conference was a standout highlight of the year, marking one of the Association’s most successful events to date. It attracted record attendance from across the advanced practice community, academia, and healthcare leadership,

showcasing the growing impact and reach of advanced practice in Ireland.

The 21st annual conference provided an important forum for knowledge exchange, showcasing advanced practice innovation, Irish research, and service development projects that demonstrated the measurable impact of ANPs and AMPs on healthcare delivery.

Key themes included strengthening and evolving the Advanced Practice Model of Care, clinical competence, leadership, innovation, education, and wellbeing. Delegates engaged in panel discussions, interactive sessions, and keynote presentations that reinforced the leadership role of ANPs and AMPs in shaping the future of Irish healthcare. The conference also celebrated professional achievement through the presentation of the IAANMP Bernie Carpenter Bursary Awards to Ms Sarah Daly (Respiratory RANP) and Ms Hannah Walsh (Emergency RANP), recognising their outstanding contributions to clinical excellence and research.

The poster competition awards further highlighted the innovation,

scholarship, and clinical leadership demonstrated by practitioners across a range of specialties. First prize was awarded to Gemma Finegan, cANP Paediatric Emergency Medicine, Our Lady of Lourdes Hospital, Drogheda, for her poster titled ‘What is the current level of nurses’ knowledge regarding paediatric fever, and how do nurses in a general hospital paediatric setting approach its management in clinical practice?’. Second prize was presented to Avril Gannon, cANP Respiratory, Midland Regional Hospital, Tullamore, for her poster on ‘COPD admission avoidance winter initiative’. Third prize was awarded to Niamh Orla Finan, RANP, Brothers of Charity Services Ireland West Region, for her poster ‘ANP – transforming care for adults with intellectual disabilities’. Together, these awards and presentations showcased the depth of expertise, innovation, and dedication within Ireland’s advanced practice community. The 2025 IAANMP National Conference reflected the Association’s ongoing commitment to professional

excellence, leadership, and the advancement of clinical innovation and healthcare reform nationwide.

Overall, the 2025 IAANMP National Conference reflected the Association’s unwavering commitment to professional excellence, leadership, and advancement. It highlighted the IAANMP’s pivotal role in driving the national conversation on clinical innovation, healthcare reform, and the ongoing evolution of the advanced practice model of care in Ireland.

Advanced Practice Week (10th-16th November 2025)

We had an excellent response to Advanced Practice Week 2025, during which we showcased powerful testimonials from IAANMP members, patients, and colleagues who work alongside them. These testimonials highlighted the outstanding, highquality work being carried out by ANPs and AMPs across the country, reflecting the depth, impact, and professionalism of advanced practice in Ireland. Caroline Fraser, RANP IAANMP committee officer, played a key role in coordinating the initiative, using IAANMP digital and social media platforms to highlight the campaign and enhance its visibility.

Policy engagement: Submission on recommendation 28

Thank you to the Chief Nursing Officer at the Department of Health for inviting the IAANMP to submit our vision in response to Recommendation 28 of the Report of the Expert Review Body on Nursing and Midwifery. We also extend our sincere thanks to all who contributed to the recent survey on education pathways for advanced practice and senior nursing leadership roles.

Recommendation 28:

To inform continued strategic implementation and development of

Panel discussion at the 2025 IAANMP National Conference

advanced nursing and midwifery practice, a further evaluation of the impact of advanced practice across the system should be commissioned by the Department of Health and HSE within two years (four years postimplementation of the Policy on the Development of Graduate to Advanced Nursing and Midwifery Practice).

The IAANMP welcomed the opportunity to make the submission to the Department of Health on recommendation 28 of the Expert Review Body on Nursing and Midwifery report as this aligns with the future development, integration, and sustainability of advanced practice roles within Ireland’s health and social care system. Since its establishment, IAANMP has been dedicated to advancing the role of ANMPs as pivotal leaders in delivering high-quality, evidencebased, and person-centred care.

This submission was delivered in December 2025 to the Department of Health, and is available on the IAANMP website for our members to read.

Purpose of the IAANMP submission:

To align existing legislation and policy with the recommendations of the Expert Review Body (ERB) on Nursing and Midwifery (2022) by formally recognising that all registered nurses and midwives can act as independent practitioners within their defined scope of practice under the Nurses and Midwives Act 2011 and the Health Act 1970.

Irish context from the view of IAANMP members practising on the ground: Ireland’s nursing and midwifery workforce is the largest and most widely distributed professional group in health service delivery. The ERB Report (2022) and Sláintecare (2019-2023) both

call for a rebalanced model of care, moving from hospital to community and from dependence to professional autonomy. Current legislation and policy already enable independent practice but have yet to be activated at scale.

ANMPs have consistently demonstrated their capacity to improve patient outcomes, enhance service efficiency, and contribute to workforce innovation across both acute and community care settings.

This submission outlines key recommendations to strengthen the advanced practice framework in Ireland, including strategies to:

✽ Support the continued growth and equitable distribution of ANMP posts across all healthcare settings.

✽ Ensure sustainable pathways for education, mentorship, and clinical supervision.

✽ Recognise and expand the leadership and research contributions of ANMPs in shaping national healthcare policy.

✽ Promote the integration of advanced practice roles in addressing system pressures, such as waiting lists, chronic disease management, and access to care.

IAANMP believes that fully realising the potential of advanced practice will not only improve access to care and patient outcomes but will also support a more resilient, responsive, and modern health system, aligned with Sláintecare goals and the Department’s vision for highquality, person-centred, and integrated healthcare.

We look forward to continued collaboration with the Department of Health and other stakeholders to advance this critical agenda and ensure that advanced practice continues to thrive as a cornerstone of healthcare delivery in Ireland.

Innovation and clinical excellence

2025 was a year defined by innovation, with ANMPs leading transformative initiatives across multiple healthcare settings.

From chronic disease prevention and management to respiratory, cardiovascular, women’s and men’s health, emergency department and mental health services, cancer care, and beyond, ANMPs continued to pioneer service improvements that enhanced access, improved quality, and enriched the patient experience.

The IAANMP proudly celebrated these achievements, recognising that ANMPs embody the principles of evidence-based, autonomous, and patient-centred care. Many practitioners contributed to audit, quality improvement, and research initiatives that informed national standards and clinical policy.

Through its national conference, policy engagement, advanced practice supplement, and digital channels, the IAANMP amplified these successes, ensuring that the contributions of advanced practitioners were acknowledged and valued within Ireland’s healthcare system.

Looking forward to 2026

As 2025 drew to a close, the IAANMP celebrated a year of remarkable growth, innovation, and professional achievement. Looking ahead to 2026, the Association is committed to consolidating these successes and further strengthening the foundations laid over the past year, driving continued advancement in advanced practice across Ireland. Plans for 2026 include the continued publication of the IAANMP Advanced Practice Supplement within NiPI, increased collaboration

via the Siilo platform, and the expansion of educational initiatives via MedCafe webinars and digital resources. The IAANMP is committed to deepening partnerships with government bodies, nursing and midwifery leaders, and academic experts to drive policy development, champion research, and support the sustained growth and advancement of advanced practice roles across Ireland. The IAANMP reaffirms its commitment to representing and

supporting advanced practitioners, advocating for continued investment in advanced practice roles, and ensuring that ANMPs remain central to the delivery of safe, effective, and person-centred healthcare in Ireland.

Acknowledgement: The IAANMP Committee extends its heartfelt appreciation to all members for their professionalism, dedication, and leadership throughout 2025. Your expertise, innovation, and

commitment to excellence continue to define the strength of the advanced practice community and to inspire progress across the Irish healthcare system.

Together, we advance practice, empower leadership, and strengthen our collective voice. Together, we shape the future of healthcare in Ireland.

#StrongerTogether

POSTER COMPETITION WINNERS: IAANMP NATIONAL CONFERENCE 2025

✽ Author: Theresa Lowry Lehnen, IAANMP Editorial Officer

The IAANMP is committed to promoting excellence, innovation, and leadership in advanced practice across Ireland. Each year, the IAANMP National Conference provides a unique platform for ANMPs to share clinical expertise, research, and evidence-based innovations that advance patient care and professional practice. A highlight of the annual conference is the national poster competition, which showcases the outstanding scholarly and clinical work of ANPs and AMPs nationwide. The competition celebrates original research, quality improvement initiatives, and innovative models of advanced practice that demonstrate the impact and evolving scope of advanced practitioners in Irish healthcare.

This section features the winning abstracts from the IAANMP National Conference 2025 poster competition. These exemplary submissions reflect the depth of clinical inquiry, leadership, and commitment to excellence that define advanced nursing and midwifery practice in Ireland. Through their work, these advanced practitioners continue

to influence policy, enhance patient outcomes, and contribute to the advancement of healthcare delivery across all settings.

Poster competition winners: 1st place

Abstract

Research question: What is the current level of nurses’ knowledge regarding paediatric fever, and how do nurses in a general hospital paediatric setting approach its management in clinical practice?

Background: Fever is a leading cause of paediatric healthcare visits globally. Despite extensive research demonstrating the benefits of mild to moderate fever in children, and the availability of updated clinical guidelines, misconceptions portraying fever as harmful persist, contributing to significant fear and anxiety among both parents and healthcare professionals. Nurses caring for

Melissa Hammond, IAANMP Chair; and 1st place winner Gemma Finegan, cANP, Paediatric Emergency Medicine, Our Lady of Lourdes Hospital, Drogheda, Co Louth

children play a critical role in assessing febrile patients, implementing interventions, and educating caregivers. Comprehensive knowledge of fever and its management is therefore essential to ensure safe, evidence-based practice and effective caregiver education.

Aim: To examine the knowledge and attitudes of nurses caring for children in an acute general hospital setting regarding fever and its management.

Design: An anonymous, cross-sectional, descriptive, quantitative study.

Methods: The study was undertaken in a mixed tertiary general hospital. Participants were nurses working in paediatric settings within this hospital. Data were collected using an anonymous, pre-validated questionnaire, distributed via QR code. Of 81 nurses invited, 63 responded (78 per cent response rate). Responses were gathered through Smart Survey and analysed using the Statistical Package for Social Sciences (SPSS) version 28. Data were coded, transformed, and statistically analysed to explore knowledge levels and attitudes.

Findings: The study identified significant gaps in knowledge, particularly concerning febrile seizures, antipyretic use, and adherence to best practice guidelines. Inconsistencies were evident between reported beliefs and actual practices. Strengths were noted in understanding fever pathophysiology and the pharmacology of antipyretics.

Recommendations: These findings highlight the need for ongoing, targeted education for nurses in acute paediatric care. Enhancing professional knowledge and addressing misconceptions may improve clinical

practice and strengthen caregiver education, thereby increasing parental confidence and competence in managing childhood fever.

Poster Competition

Winners: 2nd place

Project lead: Avril Gannon, Candidate Respiratory ANP

Other team members: Claire Connor, Senior Respiratory Physiotherapist; Chithra Varghese, Respiratory Consultant, patientMpower

Project title: COPD admission avoidance winter initiative

Organisation: HSE, Respiratory Department, Midland Regional Hospital Tullamore

Abstract

Aims: To reduce winter pressures and prevent avoidable hospital admissions, a targeted initiative was launched for high-risk chronic obstructive pulmonary disease (COPD) patients with a history of frequent exacerbations. A total of 10 patients were selected for the programme based on having three or more hospital admissions for acute exacerbation of COPD (AECOPD) in the previous 12 months. The aim was to provide early intervention, enhanced selfmanagement, and continuous monitoring to support patients at home and avoid further admissions.

Methods/approach: All selected patients consented to participate and were provided with a pulse oximeter linked to a digital portal. This portal transmitted real-time oxygen saturation and heart rate data to a dedicated respiratory team who monitored the readings twice daily. The system enabled early identification of clinical deterioration, allowing prompt clinical review and intervention.

Melissa Hammond, IAANMP Chair; and 2nd placed Avril Gannon, c ANP Respiratory, Midland Regional Hospital, Tullamore

In addition, each patient received a personalised COPD selfmanagement plan and a rescue prescription containing antibiotics and oral corticosteroids. The action plan guided patients on recognising symptom changes, when to use rescue medication, and when to seek further medical support. Respiratory clinicians maintained regular virtual contact, offering advice, support, and timely adjustments to care as needed.

Results/outcomes: This initiative empowered patients to manage their condition more confidently during the high-risk winter period. It promoted early treatment of exacerbations and improved continuity of care, while significantly reducing reliance on emergency services.

Discussion: A total of 9 patients (66.67% female, n=6), aged between 59 and 86 years, were enrolled in the remote monitoring programme. Five patients were on long-term oxygen therapy, and one was on ambulatory oxygen therapy. Prior to the intervention, from December 2023 to November 2024, this cohort

had a combined total of 50 hospital admissions and 15 emergency department (ED) attendances, all related to COPD exacerbations. During the 12-week remote monitoring period, these outcomes were reduced to one hospital admission (due to an unresolved chest infection) and one ED attendance which did not require admission. Notably, none of the participants required GP visits during this period. The results strongly suggest the initiative is a promising, scalable model for managing highrisk COPD patients during seasonal pressure periods.

Implications for practice:

✽ Remote monitoring + personalised care reduced admissions and ED use

✽ Digital tools empower patients in self-management

✽ Early intervention prevents exacerbation escalation

✽ Winter pressure relief on acute services

✽ Scalable model for chronic disease management in the community.

Poster competition winner: 3rd place

Abstract

Author: Niamh Orla Finan

Organisation: Brothers of Charity Services Ireland – West Region

Role: Advanced Nurse Practitioner

Clinical innovation abstract title: Advanced nurse practitioner: Transforming care for adults with intellectual disabilities

Aims and objectives:

1. Minimise unnecessary primary and secondary care visits.

2. Improve access to timely, personcentred care by reducing delays and enhancing service capacity.

3. Enhance staff knowledge to support compliance with prescribed clinical interventions.

Background: Adults with intellectual disabilities (ID) face multiple health challenges requiring frequent care. Access barriers often lead to preventable hospital visits, increasing strain on healthcare systems. 1,2 The ANP role offers timely, person-centred care through reasonable adjustments. This approach supports the Sláintecare Action Plan (2023) 3 by promoting community-based, integrated services. ANPs also upskill frontline staff with condition-specific training, improving early intervention, treatment compliance, and service efficiency.

Methodology: In 2024, the ANP role was introduced in Brothers of Charity Services Ireland – West Region (BOCSIWR), serving over 1,900 individuals. Inclusion criteria: Adults using BOCSIWR services with conditions within ANP scope (eg, diabetes, asthma, hypertension, gastrointestinal disorders, weight management, infections, and wounds). Exclusion criteria: Individuals under 18, non-BOCSI-WR users, and emergency/surgical cases. The ANP delivered training in epilepsy, diabetes, constipation, enema use, and clinical skills. A retrospective quantitative analysis was completed for all interventions and training from January-December 2024.

Results:

✽ 276 assessments conducted for 82 individuals, replacing GP/ hospital visits

✽ 30 per cent reduction in external healthcare usage

✽ Average wait time reduced to 9.7 days (vs 14+ days for GP)

✽ Service capacity increased by 85 per cent

✽ 26 training sessions were delivered to 322 BOCSI-WR staff and four with local CNME

✽ Feedback showed increased clinical confidence and reduced healthcare anxiety.

Discussion: The ANP model improved access, reduced wait times, and strengthened frontline care. Service users benefited from quicker, more personalised care. Staff confidence and clinical outcomes improved. Plans include expanding the ANP service, enhancing training, and building partnerships with external providers for broader impact.

References:

1. Doody O, McMahon J, Lyons R, et al. Presenting problem/conditions which result in people with an intellectual disability being admitted to acute hospitals in the Republic of Ireland: An analysis of NQAIS clinical data from 2016-2020. Limerick, Ireland: University of Limerick and Office of the Nursing and Midwifery Service Director, Health Service Executive; 2021.

2. Department of Health. Sláintecare Action Plan. Dublin, Ireland: Department of Health; 2023.

3. Grunwald M, Nadolny S, Groendahl A, et al. Advanced nursing practice as a preventive approach for adults with intellectual disabilities. Eur J Public Health. 2024;34(Suppl 3):ckae144.1613. doi:10.1093/eurpub/ckae144.1613.

Melissa Hammond, IAANMP Chair; and 3rd placed Niamh Orla Finan, ANP, Brothers of Charity Services Ireland –West Region

JOURNAL ARTICLE REVIEW

Research article reviews featured in the IAANMP advanced practice supplement highlight the important role of evidence-based practice in advancing clinical excellence and improving patient outcomes. These reviews provide insightful analysis and appraisal of contemporary research across diverse healthcare

specialties, translating scientific findings into practical knowledge for advanced clinical decisionmaking. By engaging with current literature and evaluating emerging evidence, ANMPs contribute to the continuous development of advanced practice in Ireland, fostering a culture of research-informed care and

professional leadership within the IAANMP community.

In this edition, the journal article ‘The development and implementation of a digital platform in a fracture liaison service’ is reviewed by Leena Rodrigues, RANP (fracture liaison service) at St Vincent’s University Hospital.

‘The development and implementation of a digital platform in a fracture liaison service’

AUTHORS: Conlon B, O’Brien H, Clarke V.

REFERENCE: Conlon B, O'Brien H, Clarke V. The development and implementation of a digital platform in a fracture liaison service. Arch Osteoporos . 2025 Jan 8;20(1):7. doi: 10.1007/s11657-024-01491-3. PMID: 39775166.

PUBLISHED DATE: 8 January 2025. Published in Achieves of Osteoporosis , Volume 20, January 2025. Available at: https://pubmed.ncbi.nlm.nih. gov/39775166/

JOURNAL ARTICLE REVIEW

AUTHOR: Leena Rodrigues, RANP (fracture liaison service), MSc (advanced practice nursing), MSc (clinical practice), RNP, Grad dip (critical care nursing), RGN.

Introduction and study rationale:

In their article, Conlon et al (2025) highlight that fragility fractures, caused by low-impact trauma due to weakened bones in people over the age of 50, are a serious but often underrecognised health problem. Around 23 per cent of women worldwide

are affected, yet many fractures go undiagnosed or un-noticed. Nearly one-in-five people who experience a fragility fracture will suffer another within two years, highlighting the importance of identifying at-risk individuals early and providing timely treatment to prevent future fractures. Barriers to effective management include poor symptom awareness, lack of physician referral, and the absence of a dedicated specialty to manage this patient cohort.

The authors highlight that care following a first fragility fracture is often inadequate. Many healthcare systems struggle to identify fractures promptly and coordinate treatment effectively, leaving patients at risk of breaking another bone. They point to fracture liaison services (FLS) as the internationally recognised model for addressing this issue. These services offer a structured approach, including patient identification, bone health assessment, starting treatment, and ongoing follow-up. Early identification, they note, is key to creating an efficient, effective, and fair service. Additionally, the key performance indicators (KPIs)

developed by Javaid and colleagues provide a useful framework for monitoring and improving secondary fracture prevention services, helping ensure care is more consistent and effective worldwide.

In Ireland, the authors highlight several major challenges in managing fragility fractures. A national survey in 2021 found that the country’s 10 FLS sites were under-resourced and lacked standardised procedures. In 2022, nine sites contributed data to the National FLS Database (FLS-DB), yet identification rates remained low, with only about a third of expected fragility fractures being captured. At their own hospital, fewer than 10 per cent of patients with potential fragility fractures were identified, largely due to limited time and the absence of a consistent approach. Much of the work depended on manual record reviews and referrals, and the lack of electronic patient records made it difficult to confirm diagnosis and enter data efficiently. In addition, manually anonymising data for the national database was time-consuming and prone to errors. These issues highlight the urgent

need for better digital systems and more efficient, streamlined ways to identify and monitor patients at risk.

The authors point out that digital technology has emerged to be a powerful and innovative solution internationally for identifying, treating, and monitoring patients within FLS. They note that this approach fits well with Ireland’s Digital Health Strategic Implementation Plan 20232027, which aims to use data-driven, digitally connected services to improve care and empower patients to take a more active role in their treatment.

To address gaps in patient identification and data management, the authors developed a digital platform designed to streamline the FLS workflow. The system supports patient identification, documentation of clinical care episodes, monitoring of treatment adherence, and secure integration with the National FLS-DB, while ensuring compliance with data protection regulations. Support from organisations was secured through a business case and committee approval, providing the funding and infrastructure needed to implement the digital solution effectively.

Methods

Conlan et al ensured transparency, efficiency, and compliance with national financial regulations and followed a competitive tender process in line with HSE guidelines. The contract was awarded to Openmedical, a digital healthcare company, to develop a platform that met the requirements of FLS.

Identification and patient data capture

The authors adapted the hospital’s existing eTrauma digital platform to include an FLS module. To ensure all patients with fragility fractures

were identified – age, mechanism of injury, and fracture site were set as mandatory fields. Once a patient was identified, their information was automatically transferred to the FLS platform, giving staff real-time visibility of new cases and greatly reducing the manual work previously needed for patient identification. The authors note that this time-saving feature allows clinicians to focus more on patient care rather than case finding.

The platform also includes a colourcoded dashboard to show patient status at a glance – purple for those awaiting assessment, yellow for patients currently under treatment, and green for those who have been discharged. This visual system makes it easier to prioritise workflow and get an overview of all cases.

A shared electronic health record was introduced that was both user-friendly and comprehensive. It captured a wide range of information, including patient demographics, clinical history, medication use, osteoporosis risk factors, previous treatments, FRAX (fracture risk assessment tool) scores, mobility status, and diagnostic results. This system made it easier to carry out bone health and falls assessments while also ensuring that all data requirements for the National FLS-DB were met.

KPIs and compliance monitoring: Conlon et al explain that the digital platform was upgraded to automatically identify, extract, and anonymise data for the National FLSDB. This improvement made it possible to transfer data securely while reducing the errors that often occur with manual entry. Since the system is cloud-based and uses two-factor authentication, it also provides safe and compliant remote access in line with both European and national data protection standards.

The system also allowed for continuous monitoring of patients’ progress against the 11 national KPIs. Automatic alerts were triggered if key targets, such as completing a bone health assessment within 90 days, were not met. To monitor treatment adherence, digital questionnaires were sent to patients via SMS at four and 12 months after their assessment, and clinicians were notified if follow-up action was required.

Results

Within five months of implementation, the platform identified 545 patients who likely had fragility fractures, capturing around 87 per cent of the estimated cases based on the internationally accepted 5:1 non-hip ratio. The smooth integration between the eTrauma and FLS systems made patient identification and data transfer much more efficient. During the same period, nearly 200 patients (37 per cent of those identified) were assessed and treated through the FLS platform in this single RANP-led service, representing a significant increase in service capacity.

The authors developed a digital platform designed to streamline the FLS workflow

The platform’s real-time monitoring, colour-coded tracking, KPI alerts, and automated adherence reminders all helped enhance patient safety, improve clinical oversight, and maintain continuity of care. In

addition, anonymised data from 162 patients were successfully uploaded to the National FLS Database, demonstrating the platform’s ability to support compliant data integration and national reporting.

Implications

for practice, policy, and research

This work highlights the clear benefits of digital innovation in FLS, particularly in overcoming case finding and manual data handling. In practice, digitalisation can free up clinicians to spend more time on patient care, while also supporting audit and quality improvement

processes locally and nationally.

For policymakers, Conlon et al offer a proof of concept that could guide national strategies for integrating digital solutions into secondary fracture prevention. Standardisation and interoperability across hospital systems are essential for such platforms to be expanded at regional and national level.

From a research perspective, future studies should focus on linking digital FLS platforms with patient outcomes and cost-effectiveness analysis. Also, evaluating the role of digital tools in supporting patient engagement and treatment adherence would be beneficial.

Conclusion

Conlon et al provide a strong example of how digital health innovation can improve fracture liaison services. Their digital platform significantly increased patient identification rates (from 10 to 87 per cent) and reduced the burden of manual administrative work, leading to more efficient service delivery and better-quality data. Although wider adoption and long-term outcomes still need to be explored, this study offers a practical model for integrating digital tools into FLS systems and represents an important step in improving service efficiency and secondary fracture prevention.

MEET THE MEMBERS

Reflections on working as a RANP in urgent care

Working as a Registered Advanced Nurse Practitioner (RANP) in urgent care brings together everything I value about clinical practice – autonomy, complexity, teamwork, and variety. No two shifts are the same: One hour may involve rapid assessment and decisionmaking for an acutely unwell patient, the next might focus on providing reassurance and safety netting for someone managing a long-term condition. The role combines advanced clinical expertise with leadership, education, and research.

My journey to advanced practice

My career began in the high-pressure environment of the emergency department, where I trained and worked as an emergency nurse

practitioner. That grounding in accident and emergency taught me how to assess quickly, communicate clearly, and lead calmly. I learned the value of critical thinking, teamwork, and compassionate care under pressure – skills that continue to shape my practice today.

Over time, I developed a particular interest in frailty and the complex

needs of older adults presenting to emergency services. I saw firsthand how earlier intervention and communitybased support could prevent avoidable admissions and improve quality of life. This interest led me to pursue advanced practice, completing my MSc in Advanced Clinical Practice at St George’s University. The programme strengthened my diagnostic reasoning and clinical confidence while embedding the four pillars of advanced practice: Clinical, leadership, education, and research.

From emergency to community and back again

After several rewarding years in emergency care, I joined an urgent community response team focused on admission avoidance. This role allowed me to apply advanced clinical skills in patients’ homes, providing rapid assessment, treatment, and support to help remain safely in the community. Working alongside paramedics,

Luke Sheehan, RANP, Urgent Care

therapists, and GPs, I gained a deeper understanding of frailty, system flow, and the importance of integrated care pathways. That experience profoundly shaped my perspective on how urgent and emergency care can be delivered beyond the hospital walls. Yet, when I later returned to frontline urgent care, I brought with me a broader, more holistic approach, one that values prevention as much as rapid response.

Transition to Ireland and registration as a RANP

My move from the UK to Ireland marked a significant professional milestone. Becoming registered with the Nursing and Midwifery Board of Ireland as a registered advanced nurse practitioner validated my previous experience and underscored the international recognition of advanced practice. The process involved demonstrating competence, education, and scope of practice, reflecting on how advanced roles are evolving.

Now practising as a RANP in urgent care, I draw on both my emergency and community backgrounds to provide patient centred, evidence-based care. The transition has reinforced how adaptable advanced practice can be, bridging services and ensuring patients receive the right care, in the right place, at the right time.

Research, audit, and education

Research and education continue to underpin my practice. I have contributed to service audits on frailty and remain actively involved in teaching and supervising advanced practice trainees. Ongoing professional learning is a priority, and I am currently pursuing postgraduate study in clinical geriatrics to deepen my expertise in the care of older people.

Leadership and professional involvement

Leadership within advanced practice extends beyond direct clinical care. I

am engaged in service development, quality improvement, and professional networks which advocate for the RANP role. Promoting visibility, consistency, and understanding of advanced practice. Collaborative leadership and reflective practice are key to sustaining the growth and credibility of the role.

Closing reflections

My journey, from emergency nursing in the UK, through community-based ACP work, to becoming a RANP in Ireland, has been one of growth, reflection, and rediscovery. Returning to urgent care feels like coming full circle, but with greater depth and perspective. The combination of rapid decision making, holistic thinking, and evidence-based care makes advanced practice both challenging and deeply rewarding. I am proud to contribute to a profession that continues to evolve while keeping compassion and patient safety at its core.

SPOT THE DIFFERENCE

In Memory of Trisha McKeown RANP, Esteemed IAANMP Member and Former Committee Officer

We are deeply saddened by the loss of our colleague and friend, Trisha McKeown, Registered Advanced Nurse Practitioner (RANP), long-standing IAANMP member, and former Association Secretary, who passed away recently. Trisha was a remarkable clinician, an inspiring leader, and a dedicated advocate for advanced practice. Her commitment, compassion, and contributions have left a lasting impact on our profession, and her legacy will continue to resonate for many years to come.

Trisha began her nursing career in 1993 as a staff nurse at Whipps Cross University Hospital in London, where she first discovered her passion for emergency care, a field she remained dedicated to throughout her life. For the past 20 years, she served patients, families, and colleagues within the UL Hospitals Group, earning deep respect for her expertise, compassion, and unwavering professionalism.

A registered children’s nurse and nurse prescriber of both ionising radiation and medications, Trisha achieved her MSc in Advanced Practice at NUIG in 2011 and became a RANP in 2013. Her clinical knowledge, commitment to excellence, and drive to improve patient care set a

standard to which many aspire.

Trisha played an active and valued role in multiple national forums, including the HSE West Forum, EMP ANP & LIU Forums, and was a key contributor to the EMP LIU Forum, where she led the design of the new National IU document, an achievement that reflects her leadership, innovation, and dedication to advancing practice at a national level.

A committed IAANMP member since 2012, Trisha served as Association Secretary and longstanding Committee Officer, bringing clarity, organisation, warmth, and an unwavering sense of purpose to her role. Her contribution to the Association has been immense, and her legacy will remain embedded in the continued

development and recognition of advanced practice in Ireland.

Even during her short illness, Trisha continued to ask about the Association and the upcoming conference, an enduring testament to her dedication, her sense of responsibility, and her deep commitment to the advancement of the profession.

Trisha was deeply passionate about education and nurturing the next generation of nurses and advanced practitioners. She devoted herself to empowering staff, strengthening knowledge, and enhancing the quality of care delivered to patients and families. She firmly believed in the potential and progression of advanced practice and championed it at every opportunity.

The IAANMP extends its heartfelt condolences to Trisha’s family, friends, colleagues, and all who had the privilege of working with her. Her loss is deeply felt across the advanced practice community. Trisha will be remembered with immense respect and affection for her leadership, dedication, and the kindness she showed to all.

May she rest in peace.

Ar dheis Dé go raibh a hanam dílis.

✽ AUTHOR : Marie Cantwell, Professional Development Coordinator for General Practice Nurses

A message from your PDCs

Some tips and guidance for your 2026 professional development checklist

Avery Happy New Year to all our general practice nursing colleagues across the country.

We want to start 2026 by acknowledging the incredible work you are doing daily at the heart of community-based healthcare. We understand the demand on general practice to manage additional winter surges, along with the continuous need to maintain services in screening, immunisations, and chronic disease management; all the while meeting sundry patient care needs as they present.

During New Year, most of us aim to reset, renew, or recharge, and it can also be an opportune time for a review of our professional lives. In general practice we can sometimes be removed from nursing leadership and management, leaving general practice nurses (GPNs) individually responsible for developing and maintaining competence to ensure our skills match the evolving needs of our patients. Being a ‘competent’ nurse is not a static achievement; it is a continuous journey throughout our professional lives – no matter how familiar the practice setting,

This can also be a great time of year to review the standards, guidelines, and legislation that underpin a nurse’s professional practice, accountability, and commitment to compassionate patient care. When logging on to the Nursing and Midwifery Board of Ireland (NMBI) website www.nmbi.ie to renew your registrations, it can be a good time to check out the standards and guidance pages, including the new Code of Professional Conduct and Ethics, and remind ourselves of what good practice by registered nurses and registered midwives looks like.

The Code is substantially different to the previous edition, and all registered nurses and midwives must commit to upholding the six principles of respect, accountability, competence, trust, collaboration, and leadership.

Here are some suggestions for your 2026 professional checklist

Before the January rush sets in, take 20 minutes to look at your basic requirements: Is your BLS (basic life support) certification up to date or due to expire soon? Have you a plan to access training? The same applies to anaphylaxis management – do you need your two-yearly online update? What about CervicalCheck – have you completed your required updates? Have you looked at HSELanD recently? Have you updated your profile so that you can access the catalogues appropriate to general practice?

If you need instructions, contact your nearest professional development coordinator (PDC) for GPNs. Have a wander through all the catalogues and the hubs; you may be surprised what programmes are available online that will be useful in updating your knowledge.

The Enhanced Community Care hub, in particular, hosts a huge amount of information in relation to integrated care and the support of your patients living with chronic disease.

Sign up for the PDC monthly webinar series that take place at lunchtimes on the second-last Friday of each month. These hour-long webinars are delivered by a diverse range of notable experts and feature topics of huge interest and value to GPNs.

Start the portfolio process:

Developing a continuing professional development (CPD) portfolio helps nurses to track and document their learning and accomplishments over time, effectively providing evidence of achievements, competencies, and areas of expertise. In advance of the NMBI professional competence scheme, its website includes information on the current pilot scheme, which will be evaluated this year before being rolled out further in 2027. Beginning the process of planning and recording professional development activities will mean being a step ahead when the process begins formally.

Let’s make 2026 a year of clinical excellence, professional pride, and, most importantly, supported learning

Other CPD options include clinical workshops (especially with improved access to the centres for nurse and midwifery education), conferences, study days, research, journal subscriptions, and reflective practice. Examine service need: There is little point in upskilling in a specific area such as dermatology if, for example, there are other practitioners in your service who already provide those services for patients. Sit down with colleagues and talk about where there are gaps or opportunities in the practice. Would your patient population benefit from you having additional proficiency in women’s healthcare? Is there a demand for sexual

health clinics? Do you have an interest in chronic disease management and have an interest in upskilling to manage more of that in practice?

Your PDCs are here to help you navigate your educational path. Whether you are looking for a specific course, want help developing a portfolio, or just want to discuss your career trajectory, your PDCs will be glad to advise. Let’s make 2026 a year of clinical excellence, professional pride, and, most importantly, supported learning.

Wishing you a healthy, happy, and fulfilling year ahead. ✽

CONTACT DETAILS FOR PDC s

Marie Courtney marie.courtney@hse.ie

086 787 2408

CHO 4 Cork/Kerry

Marie Cantwell marie.cantwell@hse.ie

087 607 8925

CHO 9 Dublin North City and County

Kathy Taaffe kathy.taaffe@hse.ie 087 132 1424

CHO 1 Sligo, Leitrim, Cavan, Monaghan, Donegal

Elizabeth Carroll elizabeth.carroll2@hse.ie 087 491 2159

CHO 5 Carlow, Kilkenny, Wexford, Waterford, South Tipperary

Mairead Murphy mairead.murphy11@hse.ie 087 120 6184

CHO 2 Galway, Roscommon, and Mayo

✽ AUTHOR : Dr Johnny Loughnane, retired GP with a specialist interest in dermatology, Newcastlewest, Co Limerick

Skin and soft tissue infections

SSTIs are common bacterial infections that present with a wide spectrum of severity from low-risk impetigo to life-threatening necrotising fasciitis

Acute skin and soft tissue infections (SSTIs) are common bacterial infections. They are especially common in children. SSTIs present with a wide spectrum of severity from low-risk impetigo to life-threatening necrotising fasciitis. Staphylococcus aureus (Staph aureus) is the most common pathogen in non-bullous and bullous impetigo. Purulent lesions (folliculitis, furuncles, and carbuncles) are usually caused by Staph aureus. Non-purulent infections (most cellulitis, erysipelas) are usually caused by Streptococcus pyogenes (Strep pyogenes)

SSTIs are classified according to the tissues involved – the superficial epidermis, (impetigo, ecthyma); the hair follicles (folliculitis, furuncle, carbuncle); and the deep fascia (fasciitis).

Staph aureus

Up to 40 per cent of the population are colonised with Staph aureus. Many patients presenting with a communityacquired SSTI do not, in fact, have pre-existing colonisation. Staph aureus

has the potential to cause a broad spectrum of infection, ranging in severity from asymptomatic colonisation, to bacteraemia, osteomyelitis, pneumonia, or endocarditis.

When faced with an undifferentiated skin infection, the initial task is to check for the presence or absence of purulence, as pus usually indicates a Staph aureus infection. The prevalence of purulent SSTIs has increased since the emergence of community-acquired methicillin-resistant Staph aureus (CAMRSA). Staph aureus SSTIs have a high rate of recurrence.

Strep pyogenes

Group A β -haemolytic strep (Strep pyogenes) causes some cases of non-bullous impetigo. It is particularly unusual in children less than two years of age. Strep pyogenes may cause the rare but potentially fatal necrotising fasciitis. Nephritogenic strains of Strep pyogenes very rarely cause poststreptococcal glomerulonephritis.

Minor skin injury provides the portal

The prevalence of purulent skin and soft tissue infections has increased since the emergence of community-acquired methicillin-resistant Staph aureus

of skin entry for Staph aureus. Trauma, lacerations, bites, scratches (eczema), burns, ulceration, chickenpox, and fungal infections may cause such injury.

Impetigo involves the superficial skin. The great majority of impetigo cases involve children. Exposed body areas such as the face and extremities are the most frequently involved sites. It is very contagious.

Non-bullous impetigo is the most common SSTI in primary care. While Strep pyogenes causes some cases of non-bullous impetigo, the majority are caused by Staph aureus. There is no conclusive evidence that treatment prevents nephritis. Acute rheumatic fever is not a sequela. Impetigo is not painful, but may cause a mild itch.

Non-bullous impetigo is characterised by 2-4mm erythematous macules that rapidly evolve to short-lived papules that, in turn, evolve to form thin-walled vesicle or pustules. These rupture, leaving a superficial erosion covered with a honey-coloured crust.

Bullous impetigo is characterised by vesicles and bullae (1-2cm in diameter), which are filled with clear yellow fluid that can become turbid or purulent. It tends to develop on clinically intact skin and intertriginous areas. Bullae rupture, leaving a thin, brownish crust. As lesions spread centrifugally, central clearing may give them an annular appearance. Lesions may coalesce to form large, reddish, superficial, round-to-oval erosions. A peripheral collarette of skin may be found at the edge of ruptured bullae.

A: NON BULLOUS IMPETIGO

Characterised by 2-4mm erythematous macules that rapidly evolve to thin-walled vesicles (just under the patient’s nose) or pustules. Pustules rupture, leaving superficial erosions covered with a ‘honeycoloured’ crust

B: NON BULLOUS IMPETIGO

By the time patients present, the ‘honeycoloured’ crust may be the only finding. Note the area immediately adjacent to the upper lip demonstrating spontaneous clearing without treatment

C: BULLOUS IMPETIGO

The fast-advancing ‘honey-coloured’ crust periphery with central clearing. Vesicles and early bullae can be seen

D: BULLOUS IMPETIGO

Is more likely to develop on clinically intact skin and intertriginous areas such as the axilla. Bullae rupture to give a brownish crust. Lesions may coalesce to form large, reddish, superficial, round to oval erosions. Some regard bullous impetigo as a localised form of staphylococcal scalded skin syndrome (SSSS), as both are caused by similar toxinproducing strains of Staph aureus that cause severe blistering and exfoliation

Management

Untreated impetigo resolves slowly, without scaring (two weeks for nonbullous impetigo, four to six weeks for bullous impetigo). Crusts can be gently removed by applying Vaseline, followed by cleaning with a warm, damp facecloth. As it is highly infectious, children should stay home from school until lesions have crusted over, or until two days after starting treatment. The National Institute for Health and Care Excellence recommends hydrogen peroxide 1 per cent cream eight-hourly for five days for localised, non-bullous impetigo in patients who are not systemically unwell or at high risk of complications.

Advice on using a topical antibiotic is confusing, with some recommending a five-day course of fucidic acid. Because the risk of developing antibiotic resistance with topical antibiotics is higher than with the oral route, others advise a five-day course of oral flucloxacillin, if an antibiotic is indicated (eg, greater than three lesions). Oral flucloxacillin is recommended for ecthyma, although there is a lack of convincing evidence this reduces scarring.

E: ECTHYMA

This may arise from impetigo, folliculitis, a scratch, an insect bite, or scabies. Initially puss accumulates under a grayyellow scab. Progression into the dermis gives rise to a shallow ulcer, surrounded by erythema. If the scab is lifted, the sharply demarcated, evenly punched-out borders and the necrotic purulent base of the ulcer are seen. Crusts are frequently haemorrhagic. There is a significant risk of scarring

SSSS

Like bullous impetigo, staphylococcal scalded skin syndrome (SSSS) is caused by exfoliative toxins that target desmoglein-1 in the skin. In infants, who have not yet formed antibodies to Staph aureus , these toxins disseminate throughout the body from the primary focus of infection, causing widespread erythema, flaccid blistering, desquamation, and erosions. Nikolsky’s sign is positive, with shearing of the epidermis from the dermis on lateral pressure. SSSS favours intertriginous areas. It usually starts around the eye or the nasopharynx, so always check these sites for signs of blistering or crusting if SSSS is suspected. In slightly older children and adults, acquired immunity protects against SSSS, and bullous impetigo is a more likely presentation. SSSS can be lifethreatening. Therefore, young children and immunocompromised patients require urgent admission.

Adex Gel has been shown to improve atopic eczema from moderate to mild in 2 weeks without corticosteroids1

Adex Gel also improved:

Quality of life1

Total eczema area2

Redness2

Dryness2

Sleeplessness2

Itch2

Specially formulated with a high level of oils (30%) and an ancillary anti-inflammatory, nicotinamide (4%) which is a form of vitamin B3, to help reduce inflammation.

Recommended for use as long as necessary, all over the body including on the face, hands and flexures.

Available at your local pharmacy. For patients aged 1 year+

Scan the QR code for more trial information

Product name: Adex™ Gel. Key ingredients: Isopropyl myristate 15%, liquid paraffin 15%, nicotinamide 4%. Uses: Highly moisturising and protective emollient with an ancillary anti-inflammatory medicinal substance for the treatment and routine management of dry and inflamed skin conditions such as mild to moderate atopic dermatitis, various forms of eczema, contact dermatitis and psoriasis. Package sizes: 100g tube and 500g pump pack. Further information is available from: Dermal Laboratories Ltd, Tatmore Place, Gosmore, Hitchin, Herts, SG4 7QR, UK. ‘Adex’ is a trademark. SCORAD, SCORing Atopic Dermatitis. CDLQI, Children’s Dermatology Life Quality Index.

References: 1. Gallagher J. et al. Evaluation of an Emollient with Nicotinamide in Managing Moderate Atopic Eczema in Paediatric Patients: A RealWorld GP Study. Data presented at the European Academy of Dermatology and Venereology (EADV) Spring Symposium, May 2025, Prague, Czech Republic. 2. Gallagher J. et al. Impact of an Emollient Containing Nicotinamide on Moderate Atopic Eczema and Quality of Life in Paediatric Patients. Data presented at the European Academy of Dermatology and Venereology (EADV) Spring Symposium, May 2025, Prague, Czech Republic.

Adverse Events/Incidents should be reported. Reporting forms and information can be found at www.hpra.ie. Adverse Events/Incidents should also be reported to Dermal.

Scan for Adex Gel essential information and adverse event/ incident reporting.

Adex Gel does not contain corticosteroids

Purulent SSTIs

Purulent SSTIs – folliculitis, furuncle, and carbuncle – present as localised collections of pus in cavities formed by necrosis and breakdown of the wall of the hair follicle. Folliculitis is an infection of the superficial portion of the hair follicle. Clinically, it presents as clusters of papules and pustules on an erythematous base. The scalp, extremities, paranasal area, axilla, and beard (sycosis barbae) are most frequently involved. With folliculitis, the inflammatory process is confined within the hair follicle whereas with a furuncle or carbuncle, the entire follicle and surrounding tissue is involved.

Between the dermis and underlying muscle and fascia, the hypodermis forms a layer of adipose tissue. Furuncles (also known as boils) develop from folliculitis, with infection spreading deeper into the hair follicle, producing a localised subcutaneous collection of pus within the hypodermis. A fibrinoid wall forms around the accumulated puss, separating it from the dermis and subcutaneous tissue.

A carbuncle is formed when several adjacent furuncles coalesce to form a cluster of involved hair follicles, connected by a sinus tract extending deeper into the hypodermis.

Clinical signs of furuncles and carbuncles include erythema, swelling, and induration, topped with necrotic skin or points of spontaneous drainage. Fluctuance is a classic finding, but may not be evident in early infection.

Cellulitis may surround the lesions, spreading radially. Pus drains from multiple drainage points on a carbuncle, representing the many adjoining hair

F: FURUNCLE

Multiple, recurrent furuncles in the axilla

G: CARBUNCLE

This lesion from the chest wall of the same patient as slide F shows several adjacent furuncles coalescing to form a carbuncle with puss draining from three hair follicles

H: CARBUNCLE

A carbuncle on the lower chest wall, with surrounding erythema

Clindamycin or doxycycline are recommended if methicillin-resistant Staph aureus is suspected

follicles involved. Carbuncles are found most often on areas of thickened skin, such as the back, neck, and thigh.

Abscess denotes either a furuncle or a carbuncle. Not every abscess develops from a hair follicle infection, eg, breast abscess, perianal abscess. As it may be difficult to distinguish between folliculitis, furunclem, and carbuncle, the term ‘purulent skin infection’ is increasingly used for any skin infection with pus.

The diagnosis is clinical, and swabbing for culture is rarely helpful. Applying moist heat promotes pus formation and drainage. Incision and drainage are recommended when fluctuance can be demonstrated.

Packing the drained cavity with gauze, following incision and drainage, is thought to be of no benefit.

Should an antibiotic be added to incision and drainage? Many large, placebo-controlled, randomised trials show benefit when an antibiotic is added, with an increase in clinical cure rates and reduced rates of recurrence. Many feel antibiotics are often unnecessary, especially when managing an uncomplicated furuncle or carbuncle. Some experts question the modest benefits in the above studies, as they may not outweigh the consequent increased risk of community antibiotic resistance. If an antibiotic is prescribed, choice is empiric and based on the clinical diagnosis.

There is no compelling evidence supporting superiority of any one antibiotic above another. As Staph aureus is the most likely pathogen, flucloxacillin is generally the first choice. Clindamycin is an alternative if the patient is allergic to penicillin. Clindamycin or doxycycline are recommended if MRSA is suspected.

Cellulitis

Cellulitis presents as an acute, spreading infection of the skin and subcutaneous tissues. The advancing borders are poorly defined (unlike erysipelas). Spread is sometimes patch-like. It is characterised by erythema, pain, and oedema, with local

Note the non-distinct upper borde r

THE

The patient had a history of axillary clearance. She recently suffered a minor prod of a thorn to her hand

tenderness and warmth. Any break in the skin integrity is a risk factor (leg ulcer, trauma, tinea pedis).

Other conditions causing a red leg, such as lipodermatosclerosis and irritant contact dermatitis, are frequently misdiagnosed as cellulitis. Most cases of non-purulent cellulitis are caused by Strep pyogenes, with only a minority caused by Staph aureus. If pus is seen, the most likely cause is Staph aureus. It can be very difficult to find pus in cellulitis.

Erysipelas

Presents as a painful, slightly raised, erythematous rash. Onset is acute, with a high temperature and vivid red colour. Unlike cellulitis, in erysipelas the inflammation is situated more superficially in the dermis. Many consider erysipelas to be a non-purulent form of cellulitis limited to the epidermis, and the terms are sometimes used interchangeably.

In erysipelas, borders are more sharply defined. It most commonly affects the face and the lower extremities. It spreads rapidly. Lymphoedema is a risk factor for erysipelas. The most common

The intense inflammation has caused the development of

The rash is raised and has developed within the past 24 hours

pathogen is Strep pyogenes. In more severe inflammation, serous, fluid-filled bullae may develop and should not be confused with pus.

Management of cellulitis and erysipelas

Patients with cellulitis and erysipelas who show signs of systemic toxicity (fever, hypotension, tachycardia), are immunosuppressed, or have comorbidities (diabetes mellitus, heart failure, renal failure) should be admitted. Admission is advised for patients not responding promptly to oral therapy at home or if there is clinical deterioration at any time. Most of these infections are caused by Strep pyogenes. Therefore, β-lactam antibiotics are the first-choice antibiotic treatment. If Staph aureus is suspected, oral flucloxacillin 500mg QID should be taken for at least five days. MRSA coverage may be added if there is thought to be a risk. Patients treated in the community should

Infectious Disease Society of America recommends incision and drainage of a furuncle or carbuncle should be followed by systemic antibiotic therapy in the following circumstances:

 Severe or extensive disease

 Rapid disease progression

 Associated cellulitis

 Signs and symptoms of systemic illness

 Associated coexisting conditions or immunosuppression

 Very young or very advanced age

 Abscess in an area difficult to drain (eg, face, hands, or genitalia)

 Associated septic phlebitis

 Inadequate response to incision and drainage alone

be followed up after 48 hours to check on the response to antibiotic therapy.

Necrotising fasciitis

Necrotising fasciitis is an infection of the fascia, a layer of connective tissue that lies below the hypodermis. Necrotising fasciitis often begins at the site of minor skin trauma, leading to rapid bacterial spread and necrosis of subcutaneous fat, muscle, and fascia. Fluid-filled bullae may develop. It spreads rapidly along fascial planes under the subcutaneous fat.

This is a life-threating infection and urgent admission for prompt debridement is indicated. Watch out for signs of systemic toxicity (fever, chills, hypotension). Other signs include tenderness out of proportion to what you see, bullae or cutaneous necrosis with oedema, oozing a greyish fluid, crepitus, numbness, and rapid progression of symptoms and signs. Classic clinical features are frequently absent at the time of presentation to primary care. Always keep the diagnosis in mind if a patient being treated for SSTI fails to respond to therapy, especially if their condition deteriorates. It is rare, but late diagnosis and delayed surgical debridement can be fatal. ✽

I: CELLULITIS OF THE LOWER LIMB

J: CELLULITIS OF

UPPER LIMB

L: ERYSIPELAS OF THE RIGHT SIDE OF THE FACE

K: ERYSIPELAS OF THE LOWER LIMB

bullae

✽ AUTHOR : Donna Cosgrove, MPSI

The assessment and management of pain in children

Due to a variety of factors, a child’s pain is different to that experienced by adults

Pain is an unpleasant sensory and emotional experience that can be associated with, or resembles that associated with, real or potential tissue damage. It is detected by nociceptors, which are present in most body tissues and are responsive to thermal, chemical, and mechanical stimuli.1 Noxious stimuli cause tissue injury and activate nociceptors indirectly when chemical substances (ie, potassium, serotonin, bradykinin, histamine, prostaglandins, leukotrienes, substance P) are released.

The mechanical or chemical stimuli are then converted into action potentials, which travel to the dorsal horn at the posterior of the spinal cord. From there, the stimulus goes to the thalamus through the anterolateral system, and also to the somatosensory cortex. Emotional and cognitive components, in conjunction with nociceptive impulses, lead to the sensation of pain.

Pain in children

Historically, children’s pain has been under-recognised and undertreated. Minimal or no anaesthesia was used in infant surgery, even into the 1980s. 2,3 We now know that the nociceptive system starts functioning at the 20th week of gestation.

Studies looking at the activity around pain pathway nerve terminals have observed that nociceptive neurons do not form a specific structure in the spinal cord in preterm neonates, meaning that the premature newborn brain is actually more sensitive to pain

than the adult brain, and is not always able to distinguish between noxious and innocuous stimulation.1

Children have a higher concentration of nociceptors per square metre of body surface compared to adults, and a higher level of neuromediators – meaning a higher sensitivity level. The plasticity and specific features of a child’s nervous system means that prolonged or repeated pain at a young age can increase pain

sensitivity in adulthood. 3

A child’s pain is different to pain that is experienced by an adult, not only due to brain development, but also due to the different emotional and psychological factors that affect comprehension and response. Healthcare settings can feel unfamiliar and overwhelming for babies, children, and young people, especially when meeting multiple healthcare workers. 3,4 At times, children may be viewed as

Face No expression or smile

Legs Normal position or relaxed; usual muscle tone and motion to arms and legs

Activity Lying quietly, normal position, moves easily; regular rhythmic breaths

Occasional grimace or frown, withdrawn, disinterested; appears sad or worried

Uneasy, restless, tense; occasional tremors

Squirming, shifting back and forth, tense or guarded movements; mildly agitated (head back and forth, aggression); shallow, splinting breaths; occasional sighs

Cry No cry (awake or asleep) Moans or whimpers, occasional complaint; occasional verbal outburst or grunt

Consolability Content, relaxed

passive recipients of care, which can lead to poor communication, with the child not being fully heard, or not given sufficient information. A positive healthcare experience builds confidence, supports decisionmaking, and improves how a child understands and manages their condition. Healthcare workers can foster this by introducing themselves, encouraging active involvement in treatment discussions, and treating patients and carers with kindness, compassion, and respect.

Reassured by occasional touching, hugging, or ‘talking to’; can be distracted

Young people aged 16 or over are generally presumed to have capacity to make their own healthcare decisions, with parents and carers playing less and less of a role as children grow more independent. Clear, honest information –particularly about pain and how it will be managed – helps reduce anxiety. Creating a calm environment, using distraction and therapeutic play, and validating a child’s pain experience all contribute to better, more supportive care.

Clear, honest information – particularly about pain and how it will be managed – helps reduce anxiety

Frequent to constant frown, clenched jaw, quivering chin; distressed-looking face; expression of fright or panic

Kicking, or legs drawn up; marked increase in spasticity; constant tremors or jerking

Arches, rigid, or jerking; severe agitation; head banging; shivering (not rigors); breath holding, gasping, or sharp intake of breaths; severe splinting

Crying steadily, screams or sobs, frequent complaints; repeated outbursts; constant grunting

Difficult to console or comfort; pushing away caregiver; resisting care or comfort measures

Paediatric pain assessment

The updated World Health Organisation analgesic ladder advocates five principles in terms of the correct use of analgesics, which is relevant to adults and children: 5

✽ Use oral forms where possible

✽ Give at regular intervals

✽ Administer based on pain severity, where severity is assessed by a pain intensity scale

✽ Tailor the dose to the individual patient

✽ Maintain attention to detail throughout the prescription of pain medications. For optimal pain management, frequent and appropriate assessment of pain should be performed – ie, in severe pain, a pain assessment should be performed every two to four hours. The specifics of pain location, quality, duration, and intensity should all be assessed and recorded, and assessments repeated as necessary.1 Due to the subjective nature of pain, self-reporting by the child is preferred;

TABLE 1: The FLACC Scale for children aged two months to seven years 6

however, in pre-verbal or non-verbal children, monitoring behavioural signs (facial expression, cry, irritability, feeding, sleep disturbance, and activity levels), physiological parameters (heart rate, respiratory rate, blood pressure, skin colour, oxygen saturation), and reports from caregivers are also useful to indicate discomfort levels.1,5 Importantly, the absence of change in physiological parameters does not mean absence of pain.

More than 60 assessment tools are available for the paediatric population, with no evidence to recommend one over any other, although it is vital that a developmentally appropriate assessment tool should be used.

One of the most commonly used tools for young children, due to its ease of use, is the Face, Legs, Activity, Cry and Consolability Scale (FLACC) ( Table 1). The FLACC scale is an observational tool to assess pain, validated for children from the age of two months to seven years, in many different pain conditions. A revised version (r-FLACC) is also available, which includes additional behavioural measures for improved pain assessment in children with cognitive impairment.7

To use the scale, paediatric patients who are awake should be observed for one to five minutes or longer. If asleep, they should be observed for five minutes or longer. Based on observations during this time, each category is scored on the 0-2 scale, which results in a total score of 0-10: 6

✽ 0: Relaxed and comfortable

✽ 1-3: Mild discomfort

✽ 4-6: Moderate pain

✽ 7-10: Severe discomfort or pain or both.

This score can then be used to guide pain management decisions.

Pain management

Acute pain

Pain relief can make examination and testing of the patient easier, meaning

that a diagnosis may be more easily made. There is evidence that early treatment of pain does not affect diagnostic accuracy.1

In infants and young children, the following evidence-based methods to prevent or treat pain can be offered, especially for acute needle pain: 8

✽ Topical anaesthesia, ie, lidocaine and prilocaine (Emla cream).

✽ Sucrose or breastfeeding for infants aged 0-12 months.

✽ Comfort positioning, such as swaddling or skin-to-skin for infants; sitting upright on a parent or carer’s lap for those aged six months and older.

✽ Age-appropriate distraction, ie, toys, books, blowing bubbles, apps, games, electronic devices.

First-line pain medications, paracetamol and ibuprofen, can be used as monotherapy or together for more severe pain, with or without additional physical and psychological approaches.1 Ibuprofen is more effective than paracetamol for treatment of acute pain like musculoskeletal trauma, headache, and dental pain, and has a similar safety profile. In fact, ibuprofen has comparable efficacy to oral morphine for treatment of sprains, fractures, and post-orthopaedic procedures and tonsillectomy, with a superior safety profile.

For dental pain and pain posttonsillectomy, the combination of

paracetamol and ibuprofen is more effective than paracetamol alone. Where first-line options are not working for children in acute severe pain, opioids can be used. Intranasal fentanyl is a common choice due to its effectiveness and minimal distress at administration. Morphine is the most common intravenous agent. Any patient being treated with opioids must be monitored and have the medication titrated as appropriate.

Multimodal analgesia, which combines different classes of pain-relieving drugs and nonpharmacological approaches, acts synergistically for more effective pain control – and has fewer side effects –than a single analgesic or modality. 8 When used successfully, nonpharmacological measures are able not only to reduce pain and anxiety, but also reduce the amount of medication required.1,3

Effective multimodal analgesia approaches include: 8

✽ Medications: Basic analgesia, ie, paracetamol, non-steroidal anti-inflammatory drugs, COX-2 inhibitors; and opioids, ie, tramadol, morphine, methadone; adjuvant analgesics, ie, gabapentin, clonidine, amitriptyline.

✽ Rehabilitation: Physical therapy, graded motor imagery, occupational therapy, psychology (ie, cognitive behavioural therapy).

Paracetamol and ibuprofen can be used as monotherapy or together for more severe pain

✽ Additional non-pharmacological modalities: Diaphragmatic breathing, bubble blowing, hypnosis, progressive muscle relaxation, biofeedback, aromatherapy, acupressure, acupuncture; physical treatments such as massage, heat compresses, ice packs, repositioning.

Anxiety and mood can also impact pain experience. By offering patients a chance to express any fears or concerns, this gives an opportunity to

provide reassurance, using methods like reviewing their pain plan. 2

Chronic pain

Chronic pain (lasting for more than three months) is reported in 11-38 per cent of children. 1 As in adults, lower socioeconomic status, anxiety, depression, and low self-esteem are associated with chronic pain occurrence. The most common types of chronic pain in children are headaches, abdominal pain, and musculoskeletal pain. The best way to manage chronic pain is by using multiple approaches: Psychological, physical, occupational, and pharmacological – and individualised to the patient, with the primary aim being functional improvement rather than strictly pain reduction. These strategies are likely to be more successful with the involvement of the parents/caregivers. Involving parents and caregivers in the clinical discussion around pain management of their child informs and empowers them to help in providing optimal pain management at home. Psychological strategies like distraction, and physical strategies like appropriate

wound dressing or encouraging physical activity, are useful, teachable skills to take home. Adequate analgesics should also be prescribed.

Untreated pain

Accurate assessment of paediatric pain can be extremely difficult. In paediatric patients admitted to hospital, pain may not be assessed adequately or regularly. There are myriad reasons for this, including:1,2,3

✽ Limited experience and training in acute pain management in children.

✽ Crowded emergency rooms in the hospital environment.

✽ Individual clinical condition.

✽ Variations in children’s age, development, communication levels, personalities, and temperaments.

✽ Lack of clinical standards.

✽ Underuse of pain scoring tools.

✽ Old misconceptions (ie, ‘children do not feel as much pain as adults’).

Untreated acute pain (due to issues like disease, trauma, surgery, interventions, or diseasedirected therapy) can lead to fear or avoidance of future engagement with the healthcare system; therefore adequate pain management is vital. 8

Even untreated needle pain (from experiences like vaccinations, blood draws, cannulations) can result in needle phobia, hyperalgesia, and anxiety about procedures, resulting in avoidance of healthcare.

Exposure to severe pain without sufficient pain management is ultimately linked with increased risk of chronic pain, anxiety, and depressive disorders in adulthood, increased morbidity and mortality, and increased burden on healthcare resources.1

Conclusion

Pain in children is a complex sensory and emotional experience, influenced by developing neurological pathways, making early and repeated pain particularly impactful across the lifespan. Accurate and developmentally appropriate assessment is essential to guide management choices that may include pharmacological and/ or non-pharmacological strategies. Effective, compassionate pain management not only reduces suffering but also prevents long-term consequences such as chronic pain, anxiety, needle phobia, and avoidance of healthcare. ✽

References

1. Trottier ED, Ali S, Doré-Bergeron MJ, Chauvin-Kimoff L. Best practices in pain assessment and management for children. Paediatr Child Health. 2022;27(7):429-448. doi:10.1093/pch/pxac048.

2. Rodkey EN, Pillai Riddell R. The infancy of infant pain research: The experimental origins of infant pain denial. J Pain. 2013;14(4):338-350. doi:10.1016/j. jpain.2012.12.017.

3. Pancekauskaitė G, Jankauskaitė L. Paediatric pain medicine: Pain differences, recognition, and coping acute procedural pain in paediatric emergency room.

Medicina (Kaunas). 2018;54(6):94. Published 2018 Nov 27. doi:10.3390/ medicina54060094.

4. National Institute for Health and Care Excellence. Babies, children, and young people’s experience of healthcare. NG204. 2021. Available at: www.nice.org.uk/ guidance/ng204

5. Gai N, Naser B, Hanley J, et al. A practical guide to acute pain management in children. J Anesth. 2020;34(3):421-433. doi:10.1007/ s00540-020-02767-x.

6. Children’s Health Ireland. FLACC Behavioural Pain Assessment Scale. Dublin:

CHI; 2017. Available at: https://media. childrenshealthireland.ie/documents/PainFLACC-Revised-June-2017.pdf

7. Malviya S, Voepel-Lewis T, Burke C, et al. The revised FLACC observational pain tool: Improved reliability and validity for pain assessment in children with cognitive impairment. Paediatr Anaesth 2006;16(3):258-265. doi:10.1111/j.14609592.2005.01773.x.

8. International Association for the Study of Pain. Fact Sheets. Pain in children: Management. 2021. Available at: www. iasp-pain.org/resources/fact-sheets/painin-children-management/

This information is intended for healthcare professionals only

WHY MEDICATE?

TRY NUTRITIO N FIRST

EAACI 2022 recognises that medications are often inappropriately used in the treatment of GER and GERD in infants1

APTAMIL ANTI-REFLUX

is a unique formulation for the dietary management of reﬂux and regurgitation in formula-fed infants

Thickened with carob bean gum

Signiﬁcant reduction in episodes and severity of regurgitation in 83% of formula-fed infants within 1 month2

Helps to normalise oesophageal pH3

Greater viscosity in the stomach compared to starch-based feeds4

EAACI: European Academy of Allergy & Clinical Immunology; GER: Gastroesophageal Reﬂux; GERD: Gastroesophageal Reﬂux Disease

References: 1. Meyer R et al., Pediatr Allergy Immunol. 2022 Oct;33(10):e13856. doi: 10.1111/pai.13856. PMID: 36282131. 2. Bellaiche, et al. Pediatr Gastroenterol Hepatol Nutr. 2023;26(5):249-265 3. Vandenplas Y et al. Eur J Pediatr 1994;153:419–23. 4. Nutricia Research. Artiﬁcial digestion model. Data on ﬁle.

IMPORTANT NOTICE: Breastfeeding is best. Aptamil Anti-Reﬂux is a food for special medical purposes for the dietary management of frequent reﬂux and regurgitation. It should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. Suitable for use as the sole source of nutrition for infants from birth and as part of a weaning diet from 6-12 months. This product should not be used in combination with antacids or other thickeners and is not suitable for premature infants. Refer to label for details.

Date of Publication: July 2025. Nutricia Ireland, Deansgrange Business Park, Deansgrange, Co. Dublin.

✽ AUTHOR : Olivia McCabe, Advanced Nurse Practitioner in Diabetes, Our Lady’s Hospital, Navan

Sleep apnoea and diabetes: Partners in risk

Bidirectional relationship has significant implications for patient care and long-term outcomes

Sleep apnoea, particularly obstructive sleep apnoea (OSA), is a common yet underdiagnosed condition in individuals with diabetes. Characterised by repeated episodes of upper airway obstruction during sleep, OSA causes intermittent hypoxia and interrupted sleep, further contributing to poor metabolic control. The bidirectional relationship between sleep apnoea and diabetes is becoming better understood, with significant implications for patient care and long-term outcomes.

Pathophysiological link

The repeated drops in oxygen saturation in OSA trigger sympathetic nervous system activation, systemic inflammation, and cortisol release –factors that promote insulin resistance and impair glucose metabolism.1,2 This sequence worsens glycaemic control in people with type 2 diabetes and increases glycaemic variability in those with type 1 diabetes. In type 1, OSA is also associated with autonomic neuropathy and an increased risk of nocturnal hypoglycaemia. 3

Why is sleep apnoea more common in type 2 diabetes?

A bidirectional relationship has been observed between sleep apnoea and type 2 diabetes, with each condition aggravating the other, particularly when undiagnosed or untreated.

The hypoxia, and subsequent sympathetic activation, inflammation, and insulin resistance, can be profound, disrupting glucose

metabolism to the extent that OSA is now associated with the onset and progression of type 2 diabetes.

Obesity, a well-recognised comorbidity of type 2 diabetes, further increases the risk of OSA. Fat deposits around the neck narrow the airway, while abdominal fat places pressure on the chest wall – both of which affect breathing during sleep.

Shared risk factors

OSA and diabetes share several overlapping risk factors, including:

 Central obesity

 Hypertension and dyslipidaemia

 Sedentary lifestyle

 Increasing age

 Postmenopausal status in women

 Autonomic dysfunction in type 1 diabetes.

Healthcare providers should be alert to the possibility of OSA in diabetic patients who present or report with symptoms such as loud snoring, persistent fatigue, or disrupted sleep.

Screening recommendations

People with diabetes – especially those who are overweight or hypertensive –should be screened for OSA using tools such as the STOP-BANG Questionnaire or Epworth Sleepiness Scale.

Indicators include:

 Loud snoring

 Excessive daytime tiredness

 Morning headaches

 Witnessed apnoea events

 High neck circumference or body mass index (BMI) >35.

Those with high-risk scores should be referred for overnight oximetry or polysomnography through a sleep clinic or respiratory team.

Clinical consequences

Unrecognised and untreated OSA can lead to:

 Elevated HbA1c and insulin resistance

 Impaired diabetes self-management due to fatigue and cognitive dysfunction

 Increased cardiovascular risk (hypertension, stroke, arrhythmias, myocardial infarction)

 Poor quality of life.

The combination of OSA and diabetes is associated with a further increased risk of cardiovascular morbidity and all-cause mortality. 2,4

Making every contact count

Education remains a cornerstone of integrated care. Despite the welldocumented bidirectional relationship between type 2 diabetes and OSA, awareness among patients, and sometimes clinicians, is limited. OSA offers a unique ‘teachable moment’ within the clinical encounter, where education can support individuals to appreciate the impact of fragmented sleep and nocturnal hypoxia on glycaemic variability, insulin resistance, and cardiovascular risk. Early

recognition of hallmark symptoms such as loud snoring, excessive daytime fatigue, and morning headaches provides an opportunity for timely referral, diagnosis, and intervention.

This approach is closely aligned with the ‘Make every contact count’ (MECC) 8,9 initiative, which emphasises the value of routine clinical interactions as opportunities to influence health behaviours. Embedding OSA screening and education into diabetes care pathways therefore supports dual benefits: Optimising metabolic outcomes and easing the broader cardiometabolic burden.

The ‘Every move counts’ campaign reinforces the importance of reducing sedentary behaviour and recognising that ‘all movement matters’ – whether through structured exercise or everyday activities such as walking, gardening, or household chores.11 While the campaign does not specify exact figures, international evidence indicates that achieving at least 150 minutes of moderate-intensity physical activity per week is associated with significant improvements in insulin sensitivity, glycaemic control, and weight management.

In Ireland, however, the Healthy Ireland Survey 2024 found that only 41 per cent of adults meet these recommended activity levels, while the average adult spends over five hours per day sitting.11 For individuals with type 2 diabetes and OSA, promoting even

For individuals with type 2 diabetes and OSA, promoting even small, achievable increases in activity has the dual benefit of improving metabolic health and reducing OSA severity

small, achievable increases in activity has the dual benefit of improving metabolic health and reducing OSA severity. Embedding these messages within routine diabetes and sleep care empowers patients to adopt sustainable lifestyle changes that improve outcomes across both conditions.

CPAP therapy:

Clinical impact

Continuous positive airway pressure (CPAP) therapy is the mainstay treatment for moderate to severe OSA. It improves oxygenation during sleep and reduces apnoea episodes, with several metabolic and cardiovascular benefits:

 Improved insulin sensitivity and glycaemic control (particularly in adherent users)

 Reduction in blood pressure

 Improved daytime alertness and energy

 Better engagement with lifestyle modification and diabetes self-care. 5

GLP-1 receptor agonists: Dual impact on metabolic health and sleep apnoea

New therapies such as semaglutide and tirzepatide have significantly advanced the management of type 2 diabetes and obesity. Glucagon-like peptide (GLP)-1 receptor agonists promote weight loss by delaying gastric emptying and reducing appetite. 6

Given that obesity is a key risk factor for OSA, GLP-1 therapies may indirectly improve OSA severity by decreasing body mass and alleviating upper airway obstruction. These agents should be considered as part of a comprehensive strategy for cardio-metabolic risk reduction in patients with types 2 diabetes and co existing OSA.7

Practical management of sleep apnoea in diabetes

Optimal diabetes self-management – maintaining glucose within target range, making healthy

food choices, staying physically active, and adhering to prescribed medications – forms the cornerstone of care. However, additional targeted strategies can significantly improve outcomes, including:

 Medical interventions: Timely diagnosis and initiation of evidencebased treatment for OSA is essential. CPAP therapy remains the gold standard, with demonstrated benefits for glycaemic control, blood pressure, and cardiovascular outcomes.

Adjunctive interventions such as mandibular advancement devices or, in selected cases, bariatric or upper airway surgery may also be appropriate.

 Medication optimisation: In people with type 2 diabetes and OSA, ensuring appropriate glucose-lowering therapy is vital, particularly agents with proven cardiovascular benefit (eg, GLP-1 receptor agonists, sodium-glucose co-transporter-2 (SGLT2) inhibitors).

Optimising antihypertensive and lipidlowering therapies further reduces cardiometabolic risk, and medication adherence should be reinforced at every clinic appointment.

 Lifestyle modification: Lifestyle change is a cornerstone of management for both conditions. Priorities include achieving and sustaining a healthy BMI, promoting regular physical activity, improving sleep hygiene, moderating alcohol consumption, and supporting smoking cessation. Even modest weight reduction has been shown to improve OSA severity and enhance insulin sensitivity, underscoring the shared benefit of integrated interventions.

 Education and awareness: Many individuals remain unaware of the strong bidirectional link between type 2 diabetes and OSA. Structured education creates a ‘teachable moment’ where patients can recognise

the impact of poor sleep on glucose control and cardiovascular health. Embedding education within diabetes reviews – aligned with the MECC framework – empowers patients to identify symptoms, engage in screening, and adopt sustainable lifestyle changes that improve both metabolic and sleep outcomes.

Conclusion

Sleep apnoea is a common, but often unrecognised contributor to poor glycaemic control and cardiovascular risk in people with diabetes. Screening for OSA in high-risk individuals, combined with interventions such as CPAP and GLP-1 therapy, can significantly improve clinical outcomes. A holistic, team-based approach, including respiratory, sleep, and diabetes services, is essential to improving quality of life and long-term health in this population. ✽

References:

1. Reutrakul S, Mokhlesi B. Obstructive sleep apnoea and diabetes: A state-of-theart review. Chest. 2017;152(5):1070-1086. doi:10.1016/j.chest.2017.05.009.

2. Foster GD, Sanders MH, Millman R, et al. Obstructive sleep apnoea among obese patients with type 2 diabetes. Diabetes Care. 2009;32(6):1017-1019. doi:10.2337/ dc08-1776

3. Kent BD, Grote L, Ryan S, et al. Diabetes mellitus prevalence and control in sleepdisordered breathing: The European Sleep Apnoea Cohort (ESADA) study. Chest. 2014;146(4):982-990. doi:10.1378/ chest.13-2403.

4. Pamidi S, Tasali E. Obstructive sleep apnoea and type 2 diabetes: Is there a link? Front Neurol. 2012;3:126. doi:10.3389/ fneur.2012.00126.

5. Aronsohn RS, Whitmore H, Van Cauter

E, Tasali E. Impact of untreated obstructive sleep apnoea on glucose control in type 2 diabetes. Am J Respir Crit Care Med. 2010;181(5):507-513. doi:10.1164/ rccm.200909-1423OC.

6. Wilding JP, Batterham RL, Calanna S, et al. Once-weekly semaglutide in adults with overweight or obesity. N Engl J Med. 2021;384(11):989-1002. doi:10.1056/ NEJMoa2032183.

7. Blackman A, Foster GD, Zammit G, et al. Effects of weight loss on obstructive sleep apnoea severity. Ten-year results of the Sleep AHEAD Study. Am J Respir Crit Care Med. 2021;203(2):221-229. doi:10.1164/ rccm.201912-2511OC.

8. American Diabetes Association Professional Practice Committee. Diagnosis and classification of diabetes: Standards of care in Diabetes – 2024. Diabetes Care. 2024;47(Suppl 1):S20-S42. doi:10.2337/ dc24-S002.

9. Health Service Executive. Making every contact count: A health behaviour change framework and implementation plan for health professionals in the Irish Health Service. Dublin: HSE; 2017.

10. Health Service Executive. Healthy Ireland Survey 2024: Summary Report. Dublin: Department of Health; 2024. Available at: www.drugsandalcohol. ie/42364/.

11. Department of Health. Every Move Counts: National Physical Activity and Sedentary Behaviour Guidelines for Ireland. Dublin: DoH; 2021. Available at: www.gov. ie/en/healthy-ireland/publications/everymove-counts-national-physical-activityand-sedentary-behaviour-guidelines-forireland/.

12. Healthy Ireland Survey 2024. Government of Ireland. Available at: www. gov.ie/en/healthy-ireland/publications/ healthy-ireland-survey-2024/.

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✽ AUTHOR : Theresa Lowry Lehnen RGN, PG Dip Coronary Care, BSc, MSc, RNP, PG. Dip Ed (QTS), M Ed, PhD FFNMRSCI, Advanced Nurse Practitioner General Practice

Antimicrobial stewardship: A nursing imperative across all healthcare settings

Nurses are ideally positioned to lead, support, and sustain antimicrobial stewardship activities

Antimicrobial resistance (AMR) is widely recognised as one of the most serious threats to global health. As once-reliable anti-microbial treatments become less effective, the management of common infections becomes more complex, and vulnerable patients face increased risks of prolonged illness, complications, and poorer outcomes. The misuse and overuse of antimicrobials in hospitals, community care, long-term care, and outpatient settings are major contributors to this crisis.1 More than 35,000 people die each year due to antibiotic resistance across Europe. 2

According to the World Health Organisation 2025 Global Antibiotic Resistance Surveillance Report, onein-six laboratory confirmed bacterial infections worldwide in 2023 were resistant to standard antibiotic treatments, highlighting the urgent global need for robust antimicrobial stewardship (AMS) practices in all care settings. 1

Nurses are ideally positioned to lead, support, and sustain AMS activities. Their engagement is important in safeguarding the effectiveness of antimicrobial therapy, optimising patient outcomes, and contributing to the reduction of AMR. 2,3

In recognition of the urgent need to curb AMR, the HSE in Ireland developed the Antimicrobial Resistance and Infection Control (AMRIC) 2022-2025 guidance, which sets out a national framework for

Image: iStock.com/MJ_Prototype

strengthening AMS across all areas of healthcare. This guidance highlights the scale of the challenge and reinforces that effective stewardship must extend beyond prescribing decisions alone. It calls for a whole system, coordinated approach that integrates clinical, organisational, and public health strategies to reduce inappropriate antimicrobial use and improve infection prevention and control. 3,4

AMRIC emphasises that AMS is not solely the responsibility of prescribers.

Instead, it requires active engagement from the entire healthcare workforce, including pharmacy, microbiology, infection prevention specialists, healthcare assistants, and organisational leadership. Within this multidisciplinary model, nurses are positioned as central contributors given their continuous patient contact, pivotal role in assessment and monitoring, and capacity to influence prescribing decisions through early recognition of infection, advocacy for

timely review of antimicrobial therapy, and adherence to evidence-based care pathways. As frontline clinicians, nurses are uniquely placed to support safe prescribing practices, promote patient education, and ensure that stewardship principles are embedded into everyday care. 3,4

AMS is defined as a coordinated set of interventions designed to optimise the use of antimicrobial medications, ensuring that patients receive the appropriate agent, dose, route, and duration of therapy while minimising unnecessary use, toxicity, and resistance. 3,4 In practice, AMS encompasses activities that span patient assessment, appropriate prescribing, administration, monitoring, infection prevention, education, and evaluation of antimicrobial use.

In Ireland, the majority of antibiotic use occurs outside hospital settings, in community care, residential facilities, and outpatient clinics. These environments often lack the robust AMS oversight found in hospitals, making them particularly important targets for stewardship initiatives. 5 Nurses, who routinely engage in triage, assessment, specimen collection, administration, patient education, monitoring, and care coordination, are uniquely positioned to influence antimicrobial use positively. Across acute, community, and long-term care settings, nurses are often the first and most frequent point of contact for patients, giving them the opportunity to implement evidence-based stewardship interventions effectively. 4,5

Nursing-led AMS: Challenges and solutions

Despite their central role, nurses encounter several barriers to effective stewardship. These include lack of formal AMS education, unclear role definition, time pressures, high workload, and limited access to diagnostic resources. In some cases, cultural expectations from patients or colleagues may create pressure to prescribe antimicrobials, even when not clinically indicated. Resource limitations are particularly pronounced in long-term care and community settings, where staffing constraints, high patient turnover, and limited laboratory access can impede evidence-based decisionmaking. Overcoming these challenges requires institutional commitment, multidisciplinary collaboration, and inclusion of nurses in policy and governance structures.1,4

Approximately 80 per cent of antibiotic prescribing in Ireland is conducted in general practice. 6 Patient demands, expectation, familiarity with the clinician, and time restraints have been documented as key factors for overprescribing antibiotic therapy in general practice, despite clinical evidence suggesting when it is not necessary. 7

Efforts to reduce unnecessary antibiotic prescribing in Ireland include education and training for prescribing healthcare professionals; implementing decision support tools; using point of-care testing including C-reactive protein; and supporting evidence-based

Across acute, community, and long-term care settings, nurses are often the first and most frequent point of contact for patients...

practice through audit and evaluation. Initiatives also promote delayed prescribing where possible, evaluating its effectiveness, identifying barriers, and enhanced adoption through behavioural science approaches.7

All prescribing healthcare professionals have an ethical responsibility to prescribe antibiotics judiciously to reduce the risk of resistance. 8 This requires a comprehensive understanding of the core principles of antibiotic selection, including the underlying pathology, and the therapeutic characteristics of the prescribed agents, ensuring that treatment is evidence-based, safe, and cost-efficient. 9 Ethical practice also includes a commitment to AMS and the responsibility to effectively communicate with and educate patients when antibiotics are not indicated.7 Practice standards, decision-making frameworks, clinical governance structures, and the regulatory body outline the criteria for safe and effective nurse prescribing practice. Good prescribing practice should optimise patient outcomes, support patient care, and encourage treatment concordance and adherence, while considering clinical response, tolerability, and lifestyle factors. Patients should be included in clinical decisionmaking processes, informing them of available options, while ensuring that prescriptive practice is safe, evidencebased, appropriate and in the patient’s best interest. 9,10

Multiple studies have demonstrated that nurses contribute meaningfully to AMS outcomes. A scoping review examining nurse-led AMS activities in hospitals found that nurses are central to identifying patients with infections, administering and monitoring antimicrobial therapy, collecting highquality specimens, educating patients and families, and participating in policy development and quality improvement initiatives.11 These interventions have been associated with reduced inappropriate antimicrobial use,

lower rates of adverse drug events, and improved adherence to local and national guidelines.

In addition to hospital settings, nurses in long-term care, community services, and primary care are key stewards. A recent survey highlighted that nurses perceive themselves as advocates for appropriate antimicrobial use, educating patients and carers, monitoring therapy, and communicating critical clinical information to prescribers. However, many nurses report feeling underutilised in stewardship decision-making, despite their frontline role in patient care.11,12 International literature supports this view, indicating that AMS programmes that incorporate nursing leadership or structured nursing input achieve better adherence to guidelines, more appropriate antimicrobial use, and improved patient outcomes.12

The HSE Medicines Management Programme, working in partnership with the AMRIC team, introduced a national preferred antibiotics initiative, commonly referred to as the green/ red antibiotic list. This initiative forms a key component of Ireland’s national AMS strategy and aims to standardise antimicrobial prescribing across primary and community care. By clearly identifying preferred first-line ‘green’ antibiotics, the system guides clinicians toward agents that are effective for common infections, have favourable safety profiles, and present a lower selective pressure for the development of antimicrobial resistance. This approach not only supports safer, evidence-based prescribing, but also reduces unwarranted variation in clinical practice. 5,13

The initiative is strengthened by the HSE AMRIC community antimicrobial prescribing guidelines, available at: www.hse.ie/eng/services/list/2/ gp/antibiotic-prescribing/, which provide detailed, condition-specific recommendations to support prescribers in choosing the most appropriate

antimicrobial therapy. These guidelines outline when preferred ‘green’ antibiotics should be used, the clinical indications they cover, optimal duration of therapy, and when alternative agents may be required. Equally important, the guidance highlights circumstances in which ‘red’ antibiotics should be avoided unless there is a clear, evidence-based rationale for their use, typically due to their broader spectrum, higher risk of adverse events, or greater potential to drive resistance. Together, the preferred antibiotics list and accompanying guidelines promote consistency, improve patient safety, and help ensure that antimicrobial use in the community is appropriate, targeted, and aligned with national stewardship priorities. 5,13

ANPs and RNPs

Advanced nurse practitioners (ANPs) and registered nurse prescribers (RNPs) play a leading role in AMS, not only through their prescriptive authority, but also through their influence on patient understanding and expectations. 9,10 They are strategically positioned to reduce unnecessary antibiotic prescriptions by applying evidencebased assessment, diagnostic reasoning, and therapeutic decisionmaking. A key component of this role involves challenging the common misconception that antibiotics provide a ‘quick fix’ for all infections. By fostering realistic treatment expectations, ANPs and RNPs encourage patients to consider nonantibiotic management strategies for self-limiting conditions, thereby reducing inappropriate antimicrobial use and limiting the selection pressure that drives resistance. 8,14

The issue of antibiotic resistance continues to escalate globally, representing a major threat to public health and healthcare systems.1 The careful selection of empirical therapy guided by up-to-date local resistance

patterns is essential to ensure both treatment efficacy and the preservation of antimicrobial effectiveness for future patients. 9,10 ANPs and RNPs contribute to this process by integrating local epidemiological data, guideline recommendations, and individual patient factors into their prescribing decisions. 5 Their consistent application of stewardship principles across settings, from primary care and community clinics to acute care hospitals, ensures a coordinated approach to responsible antibiotic use.

In addition to their clinical responsibilities, ANPs and RNPs play a central role as educators and advocates for AMS within the community. They deliver patientcentred guidance on the risks of inappropriate antimicrobial use, including adverse drug reactions, the emergence of resistant pathogens, and the increased likelihood of treatment failure. By providing clear, accessible information, ANPs and RNPs help patients understand the importance of completing prescribed courses, adhering to recommended dosing, and recognising when antibiotics are not indicated, such as for viral infections.14

Education initiatives led by nursing professionals may take multiple forms, ranging from one-on-one consultations and personalised advice during clinical encounters to broader public health campaigns aimed at raising community awareness. Nurses also engage in collaborative efforts with other healthcare providers, including general practitioners, pharmacists, and allied health staff, to standardise messaging, reinforce consistent stewardship principles, and ensure that communication around antibiotic use is evidence-based and culturally appropriate. Through these multifaceted educational roles, ANPs and RNPs not only enhance patient knowledge and empowerment, but also directly contribute to reducing inappropriate

antimicrobial use and slowing the progression of resistance at the community level.14

There are significant opportunities for research and innovation in nursingled stewardship. Future studies could explore strategies aimed at addressing patient expectations for antibiotics in cases where they are clinically unnecessary. This research may include evaluating the effectiveness of structured communication frameworks, shared decision-making models, and behavioural interventions designed to reduce inappropriate prescribing. It is equally important to consider the psychological, cultural, and social factors that influence both patient demand and clinician prescribing behaviours. Understanding these influences can inform the development

of tailored interventions that support ANPs and RNPs in making judicious prescribing decisions while maintaining patient satisfaction and trust. By combining clinical expertise with a focus on education, communication, and behaviour change, ANPs and RNPs are integral to the ongoing effort to curb antimicrobial resistance and promote sustainable prescribing practices.

Conclusion

AMS is a shared responsibility that extends across all healthcare disciplines and settings. Nurses, by virtue of their central and continuous involvement in patient care, are uniquely positioned to lead, support, and embed stewardship initiatives. In Ireland, the HSE AMRIC guidance recognises this potential and

advocates for comprehensive, multisetting implementation of AMS practices. Through active engagement in patient assessment, specimen management, administration and monitoring, patient education, infection prevention, audit, and multidisciplinary collaboration, nurses can ensure that antimicrobial therapy is safe, effective, and appropriate. Formalising nursing roles in stewardship, providing education, and embedding AMS into daily practice will enhance patient outcomes, preserve antimicrobial efficacy, and contribute to the national and global fight against antimicrobial resistance. Nurses are not only caregivers, they are stewards of one of medicine’s most precious resources, and their leadership is critical for sustainable antimicrobial use. ✽

References

1. World Health Organisation. WHO warns of widespread resistance to common antibiotics worldwide. Geneva: WHO; 2025.Availalble at: www.who.int/news/item/13-10-2025-whowarns-of-widespread-resistance-to-commonantibiotics-worldwide

2. Brannigan E. RESIST newsletter. Edition 22. Health Service Executive Antimicrobial Resistance and Infection Control Programme (AMRIC). Dublin: HSE; 2024.

3. Health Service Executive. Antimicrobial Stewardship. HSE; 2025. Available at: www. hse.ie/eng/about/who/healthwellbeing/ our-priority-programmes/hcai/antimicrobialresistance/antimicrobial-stewardship/.

4. Health Service Executive AMRIC. Antimicrobial Stewardship Guidance for All Healthcare Settings. HSE; 2022. Available at: www.hse.ie/eng/services/list/2/gp/antibioticprescribing/antibicrobial-stewardship-audittools/amric-ams-event-and-workshoppresentation-slides.pdf.

5. Health Service Executive. Community Infection Prevention and Control and Antimicrobial Stewardship Resource Guide.

HSE; 2025. Available at: www.hse.ie/eng/ about/who/healthwellbeing/our-priorityprogrammes/hcai/resources/general/ community-infection-prevention-and-controland-antimicrobial-stewardship-resourceguide.pdf.

6. Devine P, O’Kane M, Bucholc M. Trends, variation, and factors influencing antibiotic prescribing: A longitudinal study in primary care using a multilevel modelling approach. Antibiotics (Basel). 2022;11(1):17.

7. Murphy R, Ahern E, Deegan A, et al. Changing behaviour: Reducing unnecessary antibiotic prescribing. A systematic review and meta-analysis. Dublin: Department of Health (Ireland); 2024.

8. Parzen-Johnson S, Toia J, Sun S, Patel S. Antimicrobial stewardship for nurse practitioners and physician assistants: Enhancing patient safety through education. Antimicrobial Stewardship and Healthcare Epidemiology. 2023;3(1): e165. doi:10.1017/ ash.2023.434.

9. Nursing and Midwifery Board of Ireland. Practice standards and guidelines for nurses and midwives with prescriptive authority. 4th ed. Dublin: Nursing and Midwifery Board of

Ireland; 2019.

10. Health Service Executive. National nurse and midwife medicinal product prescribing guidelines. Dublin: Office of the Nursing and Midwifery Services Director. Health Service Executive; 2020.

11. Nampoothiri V, Bonaconsa C, Surendran S, et al. What does antimicrobial stewardship look like where you are? Global narratives from participants in a massive open online course. JAC Antimicrob Resist. 2021;4(1): dlab186. doi:10.1093/jacamr/dlab186.

12. Gotterson F, Buising K, Manias E. Nurse role and contribution to antimicrobial stewardship: An integrative review. Int J Nurs Stud. 2021; 117:103787. doi: 10.1016/j. ijnurstu.2020.103787.

13. Health Service Executive. HSE AMRIC community antimicrobial prescribing guidelines. Dublin: HSE. Available at: www. hse.ie/eng/services/list/2/gp/antibioticprescribing/

14. Bankar N, Ugemuge S, Ambad R, et al. Implementation of antimicrobial stewardship in the healthcare setting. Cureus. 2022;14(7): e26664. doi:10.7759/cureus.26664.

✽ AUTHOR : Theresa Lowry Lehnen RANP

TCD School of Nursing and Midwifery Awards 2025

Celebrating outstanding achievements and performance in nursing and midwifery

On Wednesday 3 December 2025, the Trinity College Dublin (TCD) Annual School of Nursing and Midwifery Awards Ceremony took place, celebrating students who achieved exceptional academic results and the highest end-of-year distinction marks in each programme.

The undergraduate awards recognised exceptional achievement across all Bachelor-level programmes, including general nursing, children’s and general nursing, intellectual disability nursing, mental health nursing, and midwifery. Each award celebrated the student who attained the highest end-of-year distinction mark within their cohort.

The postgraduate awards honoured

excellence across an extensive suite of programmes, ranging from areas such as advanced practice nursing and midwifery, specialist nursing, mental health, ageing and intellectual disability, and clinical health sciences education. These awards also acknowledged the outstanding academic performance of students who achieved the highest distinction marks in their respective postgraduate courses.

The ceremony also featured special honours recognising excellence in clinical education and professional practice. The Preceptor of the Year Award was presented to Emma May Condon from St James’s Hospital in recognition of her outstanding commitment to

supporting and mentoring students in clinical learning environments.

The prestigious Lorraine Andrews Medal and Prize was awarded to Erica Ridge, recognising her compassion, integrity, and positive impact on her peers in the midwifery programme.

Head of the School of Nursing and Midwifery Dr Damien Brennan congratulated the awardees, describing them as the “outstanding top achievers of their programmes”, and noted that TCD is the leading school of nursing and midwifery in Ireland. The school ranks first in Ireland and the European Union, and 20th in the world for nursing in the QS World University Subject Rankings 2025. ✽

Across

1 Bring into action (6) 4 S pectator (6)

Movement of vehicles en masse (7) 10 Useful (7) 11 O pposite of outer (5)

- Useful (7)

- Opposite of outer (5)

12 Put into service (5)

- Put into service (5)

Number of deadly sins (5)

15 St andpoint (5)

17 C olour of snow (5)

Proposal (5)

Eg, a resident of Rome (7)

Predatory canine mammal (4)

Actually (6)

- Number of deadly sins (5)

18 O utline; silhouette (7)

- Standpoint (5)

20 Person proposed for office (7) 21 O ppose (6)

- Colour of snow (5)

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Over half of adults disregard expiry dates on cosmetics

New Health Products Regulatory Authority (HPRA) research reveals that the majority of Irish adults continue to use cosmetic products beyond their expiry date or recommended shelf life. According to its national survey, six-in-10 (60%) people are willing to disregard expiry dates or the ‘open jar’ symbol – an oversight that may pose health risks.

The findings also highlight a significant gap in consumer understanding of cosmetic product labelling, with just four-in-10 (41%) aware of the ‘open jar’ symbol. This symbol indicates the timeframe after opening during which the product remains safe to use. After this time, it may begin to degrade and pose a risk to consumers.

The HPRA warns that using expired cosmetics can reduce their effectiveness and, in some cases, increase the risk of irritation or other adverse reactions.

"Cosmetics are a staple in many people’s daily routines with half of adults (49%) using four or more products each day. When used as intended, cosmetics are generally very safe,” said Ms Lisa Byrne, Cosmetic Product Manager at HPRA. “However, our research reveals a clear gap in consumer understanding and awareness on product shelf-life – and a tendency to overlook expiry guidance.”

The research also found:

✽ More than a quarter (28%) of respondents have purchased what

they suspected were counterfeit cosmetics. Of these, four-in-10 made their purchase online.

✽ Over one-third (35%) of Irish adults reported experiencing a side effect from cosmetic products, most commonly skin irritation or rashes.

✽ Reports of side effects increased to 41 per cent among those willing to use cosmetic products beyond expiry and use by dates, and to 54 per cent among those who may have purchased counterfeit products.

✽ Consumers were far more likely to ‘always’ review instructions (37%) and ingredients (30%) on labels than to check period after opening/best-before dates (23%).

✽ When deciding which cosmetic products to purchase, value for money was the most important factor (32%), followed by the product’s benefits (15%) and brand (15%).

Ms Byrne emphasised that using products beyond their recommended use period can compromise both quality and safety.

“Ingredients can degrade or become contaminated, especially if exposed to light, air, and bacteria. This can lead to chemical changes or the growth of harmful microbes, which may make the product unsafe for use. For example, over time the active ingredients in sunscreen – ultraviolet filters may lose potency or efficacy, reducing its effectiveness to protect our skin from sun damage. We urge consumers to pay close attention to expiry dates and the ‘open jar’ symbol on all cosmetic labels, and to responsibly discard products that have exceeded their safe-use period.

“While one-in-three respondents say they have experienced a suspected side effect when using a cosmetic, our research shows this is more likely to happen among those who purchased cosmetics from unverified or unreputable sources and among those who do not engage with the expiry or use by date. By following a few simple steps – such as checking expiry dates, noting the ‘open jar’ symbol, and sourcing products responsibly – consumers can reduce the risk of undesirable effects, safeguard their health, and ensure their cosmetics perform as intended.”