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RCPI Launch Manifesto Page 4

Over 700,000 Illegal Medicines Detained Page 8 PHARMACY: The Role of Hospital Pharmacists Page 9 CONFERENCE: 2024 Retina International Congress Page 16 FEATURE: Treating Eczema in Babies Page 22 CPD: Managing Pain Page 33 HONOURS: Hospital Professional Honours 2024 Finalists Page 38

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PRESCRIBING INFORMATION

▼ This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse reactions. Refer to section 4.8 of the SPC for how to report adverse reactions.

Lorviqua®▼25 mg and 100 mg film-coated tablets IE Prescribing Information:

Before prescribing Lorviqua (lorlatinib) please refer to the full Summary of Product Characteristics (SmPC). Presentation: Each 25 mg film-coated tablet contains 25 mg lorlatinib; Each 100 mg film-coated tablet contains 100 mg lorlatinib. Indications: Lorviqua as monotherapy is indicated for the treatment of adult patients with anaplastic lymphoma kinase (ALK) positive advanced non-small cell lung cancer (NSCLC) previously not treated with an ALK inhibitor. Lorviqua as monotherapy is indicated for the treatment of adult patients with ALK positive advanced NSCLC whose disease has progressed after alectinib or ceritinib as the first ALK tyrosine kinase inhibitor (TKI) therapy, or crizotinib and at least one other ALK TKI. Dosage and Administration: Treatment should be initiated and supervised by a physician experienced in the use of anticancer medicinal products. Detection of ALK positive NSCLC is necessary for selection of patients for treatment with lorlatinib because these are the only patients for whom benefit has been shown. Assessment for ALK positive NSCLC should be performed by laboratories with demonstrated proficiency in the specific technology being utilised. Improper assay performance can lead to unreliable test results. The recommended dose is 100 mg lorlatinib taken orally once daily. Treatment should be continued until disease progression or unacceptable toxicity. If a dose is missed, then it should be taken as soon as the patient remembers unless it is less than 4 hours before the next dose. Patients should not take 2 doses at the same time to make up for a missed dose. To manage adverse reaction, dose interruption or dose reduction see SmPC section 4.2. Concurrent use of lorlatinib with medicinal products that are strong CYP3A4/5 inhibitors and grapefruit juice products may increase lorlatinib plasma concentrations, see SmPC section 4.2 for further information. Special populations: Elderly (≥ 65 years): There are limited data on this population, no dose recommendation can be made for patients aged 65 years and older (see section 5.2). Renal impairment : See SmPC section 4.2. No dose adjustment is required for patients with mild or moderate renal impairment. A reduced dose of lorlatinib is recommended in patients with severe renal impairment (absolute eGFR < 30 mL/min), e.g. a once daily starting dose of 75 mg taken orally (see SmPC section 5.2). No information is available for patients on renal dialysis. Hepatic impairment : See SmPC section 4.2. No dose adjustment is required for patients with mild hepatic impairment. No information is available for lorlatinib in patients with moderate or severe hepatic impairment. Therefore, lorlatinib is not recommended in patients with moderate to severe hepatic impairment (see section 5.2). Paediatric population: The safety and efficacy of lorlatinib in children and adolescents < 18 years of age have not been established. Method of administration: Lorlatinib is for oral use. Patients should be encouraged to take their dose of lorlatinib at approximately the same time each day with or without food (see SmPC section 5.2). The tablets should be swallowed whole (tablets should not be chewed, crushed or split prior to swallowing). No tablet should be ingested if it is broken, cracked, or otherwise not intact. Contra-indications: Hypersensitivity to the active substance or to any of the excipients (see SmPC section 6.1). Concomitant use of strong CYP3A4/5 inducers (see SmPC sections 4.4 and 4.5). Special Warnings and Precautions: Hyperlipidaemia: The use of lorlatinib has been associated with increases in serum cholesterol and triglycerides (see SmPC section 4.8). Serum cholesterol and triglycerides should be monitored before initiation of lorlatinib; 2, 4 and 8 weeks after initiating lorlatinib and regularly thereafter. Initiate or increase the dose of lipid lowering medicinal products, if indicated (see SmPC section 4.2). Central nervous system (CNS) effects: CNS effects have been observed in patients receiving lorlatinib, including psychotic effects and changes in cognitive function, mood, mental status or speech (see SmPC section 4.8). Dose modification or discontinuation may be required for those patients

For patients like Bob, EXTRAORDINARY is >5 YEARS OF PFS IN 1L ALK+ aNSCLC1

Start strong against ALK+ aNSCLC with 1L LORVIQUA.1

who develop CNS effects (see SmPC section 4.2). Atrioventricular block : Lorlatinib was studied in a population of patients that excluded those with second degree or third degree AV block (unless paced) or any AV block with PR interval > 220 msec. PR interval prolongation and AV block have been reported in patients receiving lorlatinib (see SmpC section 5.2). Monitor electrocardiogram (ECG) prior to initiating lorlatinib and monthly thereafter, particularly in patients with predisposing conditions to the occurrence of clinically significant cardiac events. Dose modification may be required for those patients who develop AV block (see SmPC section 4.2). Left ventricular ejection fraction decrease : Left ventricular ejection fraction (LVEF) decrease has been reported in patients receiving lorlatinib who had baseline and at least one follow-up LVEF assessment. In patients with cardiac risk factors and those with conditions that can affect LVEF, cardiac monitoring, including LVEF assessment at baseline and during treatment, should be considered. In patients who develop relevant cardiac signs/symptoms during treatment, cardiac monitoring, including LVEF assessment, should be considered. Lipase and amylase increase : Elevations of lipase and/or amylase have occurred in patients receiving lorlatinib (see SmPC section 4.8). Risk of pancreatitis should be considered in patients receiving lorlatinib due to concomitant hypertriglyceridemia and/or a potential intrinsic mechanism. Patients should be monitored for lipase and amylase elevations prior to the start of lorlatinib treatment and regularly thereafter as clinically indicated (see SmPC section 4.2). Interstitial lung disease/Pneumonitis : Severe or life threatening pulmonary adverse reactions consistent with ILD/pneumonitis have occurred with lorlatinib (see SmPC section 4.8). Any patient who presents with worsening of respiratory symptoms indicative of ILD/ pneumonitis (e.g. dyspnoea, cough and fever) should be promptly evaluated for ILD/ pneumonitis. Lorlatinib should be withheld and/or permanently discontinued based on severity (see SmPC section 4.2). Hypertension: Hypertension has been reported in patients receiving lorlatinib (see SmPC section 4.8). Blood pressure should be controlled prior to initiation of lorlatinib. Blood pressure should be monitored after 2 weeks and at least monthly thereafter during treatment with lorlatinib. Lorlatinib should be withheld and resumed at a reduced dose or permanently discontinued based on severity (see SmPC section 4.2). Hyperglycaemia: Hyperglycaemia has occurred in patients receiving lorlatinib (see SmPC section 4.8). Fasting serum glucose should be assessed prior to initiation of lorlatinib and monitored periodically thereafter according to national guidelines. Lorlatinib should be withheld and resumed at a reduced dose or permanently discontinued based on severity (see SmPC section 4.2). Interactions: Concomitant use of a strong CYP3A4/5 inducer is contraindicated (see SmPC sections 4.3 and 4.5). No clinically meaningful changes in liver function tests were seen in healthy subjects after receiving a combination of lorlatinib with the moderate CYP3A4/5 inducer modafinil (see section 4.5). Concurrent administration of lorlatinib with CYP3A4/5 substrates with narrow therapeutic indices, including but not limited to alfentanil, ciclosporin, dihydroergotamine, ergotamine, fentanyl, hormonal contraceptives, pimozide, quinidine, sirolimus and tacrolimus, should be avoided since the concentration of these medicinal products may be reduced by lorlatinib (see SmPC section 4.5). If a strong CYP3A4/5 inhibitor must be concomitantly administered, a dose reduction of lorlatinib is recommended (see SmPC section 4.2). Lorlatinib is a weak inducer of CYP2B6, no dose adjustment is necessary when lorlatinib is used in combination with medicinal products that are mainly metabolised by CYP2B6 (see SmPC section 4.5). Lorlatinib is a weak inducer of CYP2C9, no dose adjustment is required for medicinal products that are mainly metabolised by CYP2C9. Patients should be monitored in case of concomitant treatment with medicinal products with narrow therapeutic indices metabolised by CYP2C9 (e.g. coumarin anticoagulants) (see SmPC section 4.5). Lorlatinib is a weak inducer of UGT, no dose adjustment is required for medicinal products that are mainly metabolised by UGT. Patients should be monitored in case of concomitant treatment with medicinal products with narrow therapeutic indices metabolised by UGT (see SmPC Section 4.5). Lorlatinib is a moderate inducer of P gp. Medicinal products that are P gp substrates with narrow therapeutic indices (e.g. digoxin,

References 1. Solomon BJ et al. Lorlatinib Versus Crizotinib in Patients With Advanced ALK-Positive Non–Small Cell Lung Cancer: 5-Year Outcomes From the Phase III CROWN Study, Journal of Clinical Oncology, MAY2024.

dabigatran etexilate) should be used with caution in combination with lorlatinib due to the likelihood of reduced plasma concentrations of these substrates. Lorlatinib should be used with caution in combination with substrates of BCRP, OATP1B1, OATP1B3, OCT1, MATE1 and OAT3 as clinically relevant changes in the plasma exposure of these substrates cannot be ruled out (see SmPC section 4.5). Fertility, pregnancy and Breast-feeding: Fertility : Male fertility may be compromised during treatment with lorlatinib (see SmPC section 5.3). Men should seek advice on effective fertility preservation before treatment. It is not known whether lorlatinib affects female fertility. Pregnancy : Lorlatinib is not recommended during pregnancy or for women of childbearing potential not using contraception. Women of childbearing potential should be advised to avoid becoming pregnant while receiving lorlatinib. A highly effective non hormonal method of contraception is required for female patients during treatment because lorlatinib can render hormonal contraceptives ineffective (see SmPC sections 4.4 and 4.5). If a hormonal method of contraception is unavoidable, then a condom must be used in combination with the hormonal method. Effective contraception must be continued for at least 35 days after completing therapy (see SmPC section 4.6). During treatment and for at least 14 weeks after the final dose, male patients with female partners of childbearing potential must use effective contraception, including a condom, and male patients with pregnant partners must use condoms (see SmPC section 4.6). Breast-feeding : Lorlatinib should not be used during breast feeding. Breast feeding should be discontinued during treatment and for 7 days after the final dose. Lactose intolerance: This medicinal product contains lactose as an excipient. Patients with rare hereditary problems of galactose intolerance, total lactase deficiency, or glucose galactose malabsorption should not take this medicinal product. Dietary sodium: Patients on low sodium diets should be informed that this product is essentially “sodium-free”. Effects on ability to drive and use machines: Lorlatinib has moderate influence on the ability to drive and use machines. Caution should be exercised when driving or operating machines as patients may experience CNS effects (see SmPC section 4.8). Undesirable Effects: See SmPC section 4.8. The overall safety profile of lorlatinib is presented from data from 476 adults treated with lorlatinib 100 mg once daily with advanced NSCLC from Study A (N=327) and CROWN study (N=149). The most common (≥2%) Grade ≥3 adverse reactions of lorlatinib were Anaemia, Hypercholesterolaemia, Hypertriglyceridaemia, Hyperglycaemia, Cognitive effects, Peripheral neuropathy, Hypertension, Oedema, Weight increased, Lipase increased, Amylase increased. Commonly reported adverse events (≥ 1/100 to < 1/10) were Hyperglycaemia, Psychotic effects, Mental status changes, Speech effects, Pneumonitis, Proteinuria. Dose reductions due to adverse reactions occurred in 20.0% of patients receiving lorlatinib. Very common (≥ 1/10) adverse reactions in patients receiving lorlatinib in this study were Anaemia, Hypertension, Hypercholesterolaemia, Hypertriglyceridaemia, Mood effects, Cognitive effects, Peripheral neuropathy, Headache, Vision disorder, Diarrhoea, Nausea, Constipation, Rash, Arthralgia, Myalgia, Oedema, Fatigue, Weight increased, Lipase increased, Amylase increased. Common (≥ 1/100 to < 1/10) adverse effects were Speech effects, Pneumonitis. Overdose: Treatment of overdose with the medicinal product consists of general supportive measures. Given the dose-dependent effect on PR interval, ECG monitoring is recommended. There is no antidote for lorlatinib. Legal Category: S1A. Package quantities and Marketing Authorisation Numbers: Lorviqua 25 mg film-coated tablets EU/1/19/1355/003, 90 tablets. Lorviqua 100 mg film-coated tablets EU/1/19/1355/002, 30 tablets. For further information on this medicine please contact: Pfizer Medical Information on 1800 633 363 or at EUMEDINFO@pfizer.com For queries regarding product availability please contact: Pfizer Healthcare Ireland, Pfizer Building 9, Riverwalk, National Digital Park, Citywest Business Campus, Dublin 24 + 353 1 4676500. Marketing Authorisation Holder: Pfizer Europe MA EEIG, Boulevard de la Plaine 17, 1050 Bruxelles, Belgium.

Date of Preparation: 01/2024

Ref: LQ 7_2

Contents Foreword

Mahreen Khosa scoops

First Prize in Hospital Pharmacy P4

European Association of Hospital Pharmacists appointment for Roisin P5

Over 700,000 illegal medicines detained HPRA report shows

The Role of Hospital Pharmacists and Hospital Pharmacy Teams in Ireland P9

Enhancing pharmacy-related research P14

Annual Retina Conference held in Dublin P16

A Day in the Life of a Cardiothoracic Theatre Team

Hospital Professional Honors 2024 – The Finalists REGULARS

Editor

In one of our lead news stories this issue, The Irish Hospital Consultants Association (IHCA) has urged the Government to take the necessary actions to follow through on their promises to significantly increase public hospital capacity in order to address waiting lists.

CPD: Managing Pain P33

Feature: Breastfeeding in Women with HIV P63

Feature: Nurse Led Pain Service P66

Intersection of

P72

Hospital Professional News is a publication for Hospital Professionals and Professional educational bodies only. All rights reserved by Hospital Professional News. All material published in Hospital Professional News is copyright and no part of this magazine may be reproduced, stored in a retrieval system or transmitted in any form without written permission. IPN Communications Ltd have taken every care in compiling the magazine to ensure that it is correct at the time of going to press, however the publishers assume no responsibility for any effects from omissions or errors.

PUBLISHER

IPN Communications Ireland Ltd

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GROUP DIRECTOR

Natalie Maginnis n-maginnis@btconnect.com

EDITOR

Kelly Jo Eastwood

EDITORIAL

danielle@hospitalprofessionalnews.ie

ACCOUNTS

Fiona Bothwell cs.ipn@btconnect.com

SALES EXECUTIVE

Avril Boyd avril@hospitalprofessionalnews.ie

SALES & TRAINING MANAGER

Amy Evans | amy@ipn.ie 0872799317

CONTRIBUTORS

Joanne Fahey

Ciara Ni Dhubhlaing

Stephen McMahon

Marie Richardson

Kelly Impey

Dr Cathal O’Connor

Bernie Carter

Conrad Wynne

Kristine V. Lapid

Ann Marie O’Neill

DESIGN DIRECTOR

Ian Stoddart Design

HOSPITALPROFESSIONALNEWS.IE

On page 9, Ciara Ni Dhubhlaing, Chief I Pharmacist, St Patrick’s Mental Health Services gives readers an overview as to where hospital pharmacists and hospital pharmacy teams in Ireland are currently, and where they are headed. She reflects on the vital role played by these professionals within the healthcare landscape and acknowledges some exciting opportunities on the horizon.

In further pharmacy-related news, A newly announced strategic partnership between the Pharmacy Department at St Patrick’s Mental Health Services and the School of Pharmacy at University College Cork (UCC) will see the two organisations come together over the coming five years to advance research and clinical training in mental health pharmacy.

Through a wide range of collaborative activities, the partnership aims to foster innovation and enhance collegiality. Central to this partnership are the facilitation of clinical teaching for pharmacy students at UCC and the advancement of evidence-based research into mental health difficulties, with the goal of improving service user outcomes and informing best practices in mental healthcare.

You can read more about this on page 14.

Elsewhere, this issue features all the Finalists for the 2024 Hospital Professional Honours. The Hospital Professional Honours will represent a celebration of all hospital healthcare teams who were working tirelessly on the frontline.

The Honours are the most influential and respected networking event, lauding excellence, innovation and service development; judged by key influencers including renowned respected experts. Their foundation lies in our collaboration with leading pharmaceutical companies; without whose investment and support, the event would not be possible.

Turn to page 38 for all the details across 15 categories.

I hope you enjoy the issue.

RCPI Launch Manifesto

The Royal College of Physicians of Ireland (RCPI) has developed a manifesto in consultation with its Faculties and Institutes to inform future health policies to be adopted by a new Government after the next General Election. The manifesto has been issued to all political parties and President, Dr Diarmuid O’Shea, is leading these discussions on behalf of RCPI.

In its manifesto, RCPI is calling on all political parties to focus on priorities that safeguard public health, empower medical

education and training and healthcare delivery, and improve patient care.

RCPI and its Faculties and Institutes in recent years have brought attention to issues such as health inequalities, vaping, smoking, and climate and health through development of position papers, educational events for doctors and other healthcare professionals and public engagement events. The College is also a member of Irish alliances of health sector organisations including the Alcohol Health

Alliance, Health Promotion Alliance, the Tobacco 21 Alliance and the Climate and Health Alliance.

This Manifesto outlines the following priority areas:

• Increase capacity and resourcing in both community and hospital settings.

• Prioritise and promote the prevention of illness for a healthier, greener society.

• Introduce public health legislation to reduce harms from tobacco, vaping and alcohol.

Hospital Pharmacist Mahreen Scoops 1st

Mahreen Khosa, Senior Pharmacist at Mater Private Network in Dublin recently won the first prize for her poster at the Hospital Pharmacists Association of Ireland Annual Conference in Dublin for her poster entitled 'Planning the Implementation of a New Oncology Compounding Information System in an Aseptic Compounding Unit: A Mixed Methods Study'.

Her research, which she completed in part fulfilment of her master’s degree in Hospital Pharmacy, stood out among the other 88 entries. As part of the prize, she will have an opportunity to present her research at the European Association of Hospital Pharmacists congress in Copenhagen next spring.

• Review Healthy Ireland Framework and commitment to policy response to address structural and socioeconomic drivers of chronic disease and ill-health.

• Support and fund cross-sectoral actions to tackle root causes of ill-health and health inequalities.

• Examine how health is influenced by corporate entities and how vested interests are handles in health policymaking.

Investment in Spinal Surgery at Mater Private

Mater Private Network has unveiled a new spinal surgical theatre in Dublin, significantly expanding capacity. The culmination of an ¤8 million

investment, places the facilities at the Mater Private at the forefront of spinal care nationally, providing world-class care while also reducing waiting times for patients.

Mr John Hurley, CEO and Mr Ashley Poynton, Clinical Director, Spine and Orthopaedics

The expansion comes at a good time as recent research reveals a growing concern amongst Irish adults regarding their spinal and back health. The research, conducted by Mater Private in partnership with iReach, revealed that almost a third of Irish adults surveyed admitted to suffering from back pain in their daily lives.

Speaking at the opening of Mater Private’s new Spinal Surgery Theatre, Clinical Director for Spine and Orthopaedics at Mater Private Network, Mr. Ashley

Poynton stated, “We are proud to be further expanding our services and building upon our existing spinal surgery programme in Dublin. More adults than ever before are coming to us with back pain and discomfort, and there is no doubt that lifestyle and workplace practices are adding to that number. As the need for robust and effective spinal interventions grow, so too must the ability to treat patients, and we are pleased to be adding five new expert consultants to our team as part of this investment and expansion.”

Mater Private Network will now be able to offer spinal surgery five days a week at its Eccles Street hospital in Dublin 7. This expansion will enable timely care for routine and complex spinal procedures, including those that require on-site ICU services.

Mahreen Khosa, Senior Pharmacist, Mater Private Network, Dublin

Roisin Elected to EAHP Board

At the recent European Association of Hospital Pharmacists (EAHP) General Assembly, a new President and two new Board Members were elected. Furthermore, two new position papers were adopted.

Professor Roisin O'Hare was elected Board Member. Professor O’Hare is the Northern Ireland (NI) Lead Clinical Education Pharmacist, responsible for experiential learning in hospital pharmacy for NI. She is based in Craigavon Hospital in the Southern Health and Social Care Trust and works across both Schools of Pharmacy in NI, Queens University Belfast, where she has recently been made a professor, and Ulster University in Coleraine. Also elected Board Member was Håvard Kirkevold, Leader and Board Member of the Norwegian Association of Hospital Pharmacists for many years whilst Dr Nenad Miljković formally took over his functions as President of EAHP. Dr Miljković is the President of European Council for Pharmacy Education Accreditation (ECPhA) and the Head of the Hospital

Professor Roisin O'Hare

Pharmacy Services at the Institute of Orthopaedics Banjica in Belgrade, Serbia.

The EAHP's General Assembly adopted two new position papers focusing on Shortages of Medicines and Medical Devices and on Procurement. The Position Paper on Shortages focuses on the importance of multistakeholder collaboration and information exchange, with early and timely notification as well as harmonised communication through the creation of a multistakeholder advisory group to address key issues in shortages. In addition, EAHP calls for the implementation of medicines and medical devices procurement models, the evaluation of shortage measures and management systems, the improvement of the measures of quality manufacturing maturity (QMM), and the analysis of domestic manufacturing capacities and capabilities for critical products.

EAHP Boost – Date for your Diary

The European Association of Hospital Pharmacists will hold EAHP BOOST! On 27th-28th September this year in Florence, Italy.

The event is aimed at ‘Humanising the high-tech pharmacy’ and will feature a keynote on the management perspective of automatisation; Automation in Reconstitution and Production of Medicines: Explore cutting-edge technologies like robots in Total Parenteral Nutrition (TPN) production and cytotoxic reconstitution; Bedside Dispensing Services and Pharmaceutical Care: Dive into patient-centered pharmacy services with automated unit-dose production and AI-driven drug information management and Interactive Workshops: Engage in ‘world cafe’ style sessions tailored for beginners, advanced, and expert levels. Visit www.eahp.eu for further details.

Reform Needed to Retain Junior Doctors

The Irish Medical Organisation (IMO) has warned that urgent cultural and systemic change are needed to convince nonconsultant hospital doctors (NCHDs) to stay practising in the Irish health system.

Last month saw Changeover Day, which sees NCHDs rotate to new hospitals for either three, six or 12 months, as well as being the first working day for newly qualified doctors.

The IMO has said that the ongoing recruitment freeze means that NCHDs are being forced to work

even longer hours and additional shifts at very short notice. This pressure is exacerbating an already dismal working environment, which routinely sees NCHDs obliged to work excess hours in contravention of the European Working Time Directive.

Dr Rachel McNamara, Chair of the NCHD Committee of the IMO, said, “Changeover Day sees thousands of NCHDs rotate around the country with few meaningful practical supports, upending family life and causing a huge amount of frustration. In addition, most graduate doctors

are entering the workforce with huge debts which will take years to repay. If we want to retain our doctors and sufficiently recruit for the future, it is imperative that we change the way we treat them.”

Dr McNamara said that a recent survey conducted by the IMO highlighted the poor working conditions facing NCHDs. “The results of our survey were disappointing but not at all surprising. Among the findings were that three-quarters of NCHDs do not feel valued, respected and supported by their employer; over eight in ten say they have routinely

worked over 48 hours a week in the past three months; and threequarters are unsatisfied with the work-life balance their current role offers them.”

She added urgent change was needed. “If nothing is done, we will lose another generation of doctors to other health systems that value their contribution and crucially, offer them the kind of work-life balance that should be a feature of our health system. We need action and unprecedented reform in a number of areas, including working hours, supports, and realistic childcare options.”

Waiting Lists at an ‘All Time High’

The Irish Hospital Consultants Association (IHCA) has urged the Government to take the necessary actions to follow through on their promises to significantly increase public hospital capacity in order to address waiting lists.

The latest figures from the National Treatment Purchase Fund (NTPF) show a significant increase of almost 328,000 in the number of people waiting for care compared with May 2017 at the launch of Sláintecare. This brings the total waiting list figure to a record 911,500 – the highest it has ever been, surpassing the previous record of 910,000 set in August 2022. These record figures come as the Government marks the midpoint of its Waiting List Action Plan for 2024.

The ¤437 million plan set out to reduce waiting lists for outpatient, inpatient and day case appointments and procedures by 6% or around 39,300 by the end of the year, compared with the number waiting at the start of 2024. However, six months into 2024 and instead of an expected reduction of around 19,600, the latest NTPF figures confirm that almost 40,400 additional people have in fact been added to these three main waiting lists – a 60,000 shortfall.

Inpatient and Day Case waiting lists are also up by more than 3,000 (+3%) since the start of January to 88,815 – the highest ever recorded figure for those awaiting hospital treatment.

The waiting list increases come as separate figures confirm

the NTPF was in fact ahead of its activity targets up to the end of April due to increased public hospitals insourcing and private hospitals outsourcing, including arranging 30% more outpatient appointments than anticipated.3 The NTPF was 15% ahead of target in the number of gastrointestinal (GI) scopes arranged, funded an additional 3% of inpatient or day case procedures, and removed an additional 9% of patients from hospital waiting lists without any treatment through its administrative ‘validation’ programme. Despite this increased activity, waiting lists continue to soar.

IHCA Vice President Prof Anne Doherty said, “The NTPF figures released today confirm our fears

that without addressing the very obvious shortages of hospital beds, Consultants, theatres, diagnostic and other facilities the Government will not address the core problems facing our public hospitals.

“It is important to remember that behind every statistic is a person and a family seeking healthcare, often while experiencing pain, suffering and the psychological distress at not knowing when they will be able to receive treatment.

“This is why the IHCA is urging the Government to commit the estimated ¤6 billion in capital funding to build and open all of the essential additional hospital beds, surgical hubs and elective hospitals already announced by the Minister for Health in order to cut waiting lists.”

Professor Colleran Elected New President

The Irish Hospital Consultants Association (IHCA) has appointed Professor Gabrielle Colleran as President. Professor Colleran will shape the IHCA’s agenda by focusing on delivering additional clinical capacity and emphasising the importance of the green transition in healthcare.

Professor Colleran is a distinguished Clinical Associate Professor in Paediatrics at Trinity College Dublin and Assistant Clinical Professor in Women's and Children's Health at the UCD School of Medicine. She leads the Radiology Department at the National Maternity Hospital and

is the Radiology Lead for the National Fetal MRI programme.

A former Vice President of the IHCA, she takes over the presidency from Professor Rob Landers, Consultant Histopathologist at University Hospital Waterford.

With over 16 years of medical experience, including 11 years as a Radiologist and 5 years as a Consultant Paediatric Radiologist, Professor Colleran has published nearly 40 peer-reviewed research works. She is noted for her research on breast cancer predisposition genetics and paediatric imaging techniques.

Professor Gabrielle Colleran, President, IHCA

She is the Co-Chair of the Fetal Taskforce of the European Society of Paediatric Radiology and has received HSE-SPARK grant funding for her research on patient-centred MRIs for autistic children. She is also a member of several key committees and working groups within the Faculty of Radiologists and the Neuroimaging working group within the Neonatal and Children's Brain Consortium Ireland.

Speaking following her appointment Professor Colleran said, “I will seek to advocate for all hospital Consultants in Ireland in a manner which will also aim to deliver profound benefits for Irish patients as a whole. As IHCA President, I will work to advocate for a serious reduction in waiting times for patients, aiming for a six-week maximum. It is simply unacceptable to our membership that in a prosperous, dynamic country, that hundreds of thousands of our citizens are confined to lengthy waiting times which lead to compounded negative outcomes.

“There has been some progress made in recent years, but we also need to take into account the legacy of historic underinvestment in care in this country which presents a series of ongoing challenges to deliver the necessary level of productivity within the system.

“Furthermore, healthcare is one of the leading sources of carbon emission on earth and every health system in the world must work to reduce emissions without compromising patient care. We aim to make the case to government for sensible reductions in energy consumption and a reduction in single-use items where clinically appropriate across the public system.”

Prof Colleran hopes to serve a full two-year term as President, joined by her two Vice Presidents: Prof Anne Doherty, Consultant Liaison Psychiatrist at the Mater Hospital in Dublin, who continues in the role; and newly elected Vice President Mr Colin Peirce, Consultant General and Colorectal Surgeon at the University Hospital Limerick. Also newly elected by the Association’s National Council were Membership Secretary Dr Áine Burke, Consultant Haematologist at Sligo University Hospital, and Treasurer Dr Vincent Wall, Consultant Anaesthesiologist at the South Infirmary Victoria University Hospital, Cork.

New Innovation at Tallaght Hospital

Innovate Health at Tallaght University Hospital (TUH) has been awarded funding of over ¤300,000 from the HSE’s Spark Impact innovation fund. The monies will be split between four separate cutting-edge projects as the Hospital remains committed to introducing the latest innovations in healthcare to benefit patients.

Projects from TUH that have been awarded funding;

1. Advanced Practice

Occupational Therapy (APOT) Led Integrated Hand & Wrist Clinic. This project creates a modernised care pathway providing GP-referred patients with direct access to specialist occupational health care professionals in a primary care setting, the first of its kind in Ireland. Patients with hand and wrist pathologies including carpal tunnel syndrome and

ganglion cysts benefit from reduced waiting times, fewer hospital attendance, and improved overall outcomes.

2. Personalised medicine for patients at risk of stroke. This project called Rapid Pharmacogenetics and Platelet Reactivity Profiling to Facilitate Personalised Antiplatelet Therapy in Patients with Transient Ischemic Attack (TIA) of Ischemic Stroke will be led by Consultant Neurologist Professor Dominick McCabe. Stroke is the leading cause of acquired physical disability in adults, a major risk factor for dementia, and the second most common cause of death worldwide. This innovative solution focuses on the area of precision medicine using pharma genetics, to optimise secondary prevention for patients following TIA/ Ischemic stroke.

3. Evolution of our Smart CP App for patients. Funding has been secured to carry out a digitally enabled Patient Initiated Review (PIR) of our Chronic Pancreatitis App. The funding will be used to further develop our Smart CP app for patients with Chronic Pancreatitis. The Smart CP app enables patients to react more quickly if their health begins to deteriorate. Whether in Donegal or Kerry, they can use the app to immediately communicate any health problems or changes directly with their medical team.

4. Stronger for Surgery. This innovation project will explore how a special “prehabilitation” programme could be introduced to support patients ahead of elective surgery. The team is creating a hybrid prehabilitation service that integrates both acute and already established community care services to

Women in Leadership

educate and empower patients who are waiting for surgery.

Head of Innovation at Tallaght University Hospital Dr. Natalie Cole said, “Projects such as Integrated Hand and Wrist Clinic are a perfect example of collaboration and exemplify our ability to deliver enhanced care in a hospital without walls to better the patient’s experience. This project brings specialists from TUH, St. James’s Hospital and Primary Care together to deliver a modernised care pathway providing patients with direct access to specialist care for hand and wrist pathologies in a primary care setting. This “see and treat” model of care reduces the need for patients to attend the hospital, cuts down on consultant waiting list times, and enables patients to be seen in their communities.”

The Pharmaceutical Managers’ Institute final Women in Leadership event of 2024 takes place on 16th October at Kingswood House Hotel, Dublin. They will host Averil Power, CEO with the Irish Cancer Society as the guest speaker. Averil is currently leads one of the best known patient advocacy groups in the country, having previously held the role of CEO in the Asthma Society. Prior patient advocacy, Averil was heavily involved in politics, having been employed as a political adviser by Minister Mary Hanafin in the Departments of Tourism, Social and Family Affairs and Education.

New co-lead of National Clinical Programme for Surgery

Professor Eamonn Rogers has been appointed co-lead of the National Clinical Programme for Surgery (NCPS).

Professor Rogers is a Consultant Urologist working with the Saolta University Health Care Group and Chairman of the Patient Office of the European Association of Urology. He served as National Clinical Advisor for Urology for the NCPS for the past nine years, leading the development and publication of a model of care for the specialty.

He follows Professor Deborah McNamara who held the role until her election as President of RCSI in June 2024 and will work alongside fellow co-lead Mr Ken Mealy (PastPresident of RCSI).

The aim of the National Clinical Programme for Surgery is to provide a framework for the delivery of safer, timely, accessible, more cost-effective and efficient care for all surgical patients.

NCPS works closely with the other clinical programmes, notably the National Clinical Programme for Anesthesia but also the Acute and Emergency Medicine, and Critical Care programmes. It also works with other clinical programmes, hospitals, hospital groups, specialty bodies, patient advocacy groups and all relevant stakeholders across the health system.

“I am delighted to welcome the appointment of Professor Eamonn Rogers as co-lead of the National Clinical Programme for Surgery.

This clinical programme plays a critical role in our health system, allowing the surgical community to work in collaboration to develop standardised care pathways, clinical guidelines and models of care for the patient journey”, said Professor Deborah McNamara, President of RCSI.

“Eamonn is a very experienced surgeon who brings many years’ experience of policy development and quality improvement to his role as co-lead. I look forward to working with him as he advances the aim of the NCPS to support the delivery of safe, timely, accessible and efficient care for patients.”

Professor Eamonn Rogers NCPS

Over 700,000 Illegal Medicines Detained

HPRA reports continued detentions of substances for likely cosmetic and body image purposes including anabolic steroids and Semaglutide products

The Health Products Regulatory Authority (HPRA) has reported a sharp increase in the volume of illegal medicines detained in the first half of 2024 compared to the same period last year. The HPRA's enforcement section detained 706,881 dosage units of falsified and illegal medicines between January and June 2024, compared to 551,582 units for the same period last year. Announcing its detention figures, the HPRA cautioned the public of the serious health risks posed by prescription medicines being purchased online from unauthorised sources. It states that there is no guarantee as to the safety or quality of illegal prescription medicines purchased outside of the regulated pharmacy setting.

In the first six months of 2024, the most significant categories of illegal products detained included anabolic steroids (23%), analgesics (14%), sedatives (11%) and erectile dysfunction medicines (10%)

The breakdown is as follows:

 Anabolic Steroids –

160,134 units detained.

 Analgesic medicines –96,481 units detained.

 Sedative medicines –80,773 units detained.

 Erectile dysfunction medicines –72,555 units detained.

As part of its enforcement measures, the HPRA continues to monitor online activity promoting

prescription medicines and other substances, and routinely intervenes to disrupt this promotion. In the first six months of this year the key enforcement actions taken include:

 1,603 e-commerce listings and/ or social media pages amended or shutdown.

among some consumers to jeopardize their health for aesthetic, cosmetic and body image purposes by seeking out illegal or unapproved substances.

under certain conditions. While overall the numbers detained are small in comparison to other products, we have already in the first six months of 2024 detained almost triple the volume of illegal units of Semaglutide detained last year.

(*OzempicTM, RybelsusTM and WegovyTM)

In conclusion, Ms Power stated that “when consumers acquire any medicinal substances outside the regulated supply chain, they forego any assurance of safety, quality, or effectiveness. Some of these substances might not be authorised by any global health authority, while others may be counterfeit or falsified despite appearing legitimate. It's crucial not to compromise your health by taking such risks. We strongly advise anyone who has bought prescription medications from unauthorised sources to cease using them immediately and to consult their healthcare provider with any concerns about their well-being."

Additionally, a notable rise is evident in detentions of Semaglutide*, a prescription medication intended for specific medical purposes such as diabetes or weight management under certain conditions. While overall the numbers detained are small in comparison to other products, we have already in the first six months of 2024 detained almost triple the volume of illegal units of Semaglutide detained last year.

(*OzempicTM, RybelsusTM and WegovyTM)

 One prosecution has been initiated and four voluntary formal cautions have been issued.

Gráinne Power, Director of Compliance at the HPRA, noted the significant increase in 2024 data and the apparent willingness of many people to seek access to unregulated products which may pose significant risks to their health. She emphasized the type of units detained also give an insight into a growing tendency

"It's alarming to see consumers willing to take risks by purchasing illegal medicines online and from unregulated sources and this includes products for cosmetic and body image purposes. One such example is the amount of illegal anabolic steroids detained. We believe young men in particular, may be sourcing anabolic steroids for body enhancement while being unaware of the serious health complications posed by these products. Anabolic steroids can cause serious physical and psychological health issues. The potential physical side effects alone include heart failure, liver issues, kidney damage, and infertility.

Additionally, a notable rise is evident in detentions of Semaglutide*, a prescription medication intended for specific medical purposes such as diabetes or weight management

Other products of note detained by the HPRA:

Units Detained

The HPRA works in close cooperation with colleagues from An Garda Síochána and Revenue’s Customs Service with whom there is significant inter-agency collaboration to combat the illegal supply of health products into and within Ireland. It also co-operates and shares intelligence with other regulatory and law enforcement agencies worldwide to prevent the illegal manufacture, importation and distribution of medicines, medical devices, and cosmetics.

Gráinne Power, Director of Compliance at the HPRA

The Role of Hospital Pharmacists and Hospital Pharmacy Teams in Irish Hospitals:

Where we’ve got to

and where we’re going

Hospital Pharmacy Teams have a varied and wide-ranging skillmix with a focus on safe and appropriate use of medicines at the core of each one of those roles.

Initial Education and Training

There are over 1800 people working as part of Hospital Pharmacy Teams, including approximately 18% of the Pharmaceutical Society of Ireland (PSI) registered pharmacists. The hospital pharmacy team-member’s pathway begins with education and training to obtain recognised qualifications and continues in career-long continuing professional development.

Pharmacy Technicians study for a 2 year part-time Level 6 Certificate and may add on a further year for a Level 7 BSc. Some technicians may have undertaken additional accredited training courses, for example in Accuracy Checking or Medicines Management.

Hospital Pharmacy Technicians are represented by The National Association of Hospital Pharmacy Technicians (NAHPT), a voluntary group founded in 1997 dedicated to providing continuous professional development for Hospital Pharmacy Technicians with a mission to increase awareness, enhance professionalism, increase credibility, and build alliances with other members of the health

services sector. Fórsa are currently seeking statutory recognition of the role of pharmacy technician.

Pharmacists studying in Ireland undertake a 5 year integrated full-time MPharm degree including placements and a final pre-registration exam to register with the PSI. Many hospital pharmacists (over 75% in Ireland) go on to complete an additional MSc, for example in Clinical or Hospital Pharmacy, or study for postgraduate diplomas in their specialist areas. Increasing numbers of hospital pharmacists continue on to PhD level contributing to pharmacybased research.

The Hospital Pharmacists Association of Ireland (HPAI) is a vocational professional group within the Fórsa trade union representing this group of highly educated and dedicated healthcare professionals. The mission of the HPAI is to: further the development of hospital pharmacy practices; assist in the provision of continuing pharmaceutical education; represent the views of the hospital pharmacist on issues of relevance to hospital pharmacy; and advance the professional welfare of its members. Under Irish legislation, professional bodies do not have negotiating rights with Government in their own right. By virtue of the

Written by Ciara Ni Dhubhlaing, Chief I Pharmacist, St Patrick’s Mental Health Services

negotiating licence, Fórsa is the representative for hospital pharmacists on issues of pay and conditions of employment. Most recently, HPAI negotiating teams working with Fórsa have secured a long overdue HSE Advanced Specialist Pharmacist Payscale, in recognition of hospital pharmacists working at an advanced level in complex and challenging specialist areas.

On Admission to Hospital

From the point of admission, medication procurement; storage; and supply can be time critical. Hospital Pharmacy Dispensary Teams, including Pharmacy Technicians, and Pharmacy Porters, ensure that systems are

in place for safe and efficient delivery of medications to the patient. This may include sourcing unlicensed medications, ensuring the cold chain is maintained, extemporaneous preparation of medicines, and quality assuring patients’ own medicines for use on the ward, if appropriate. Management of medication shortages is increasingly a high intensity and time-consuming area for pharmacy staff. Sourcing alternative suppliers and products can increase the clinical workload also in cases where treatments need to be switched and additional monitoring and/or patient counselling may be required.

Underscoring these processes are national and local policies and procedures, including those required by regulatory bodies such as the Health Information and Quality Authority (HIQA), the Mental Health Commission (MHC), and the Pharmaceutical Society of Ireland (PSI).

Pharmacy staff have a significant governance role in supporting compliance with regulations and good practice guideline. This includes designing, undertaking, and supporting audits on e.g. the use of medicines, adherence to prescribing and monitoring guidelines, and compliance with statutory regulations.

Hospital Pharmacy teams also work to ensure that the best value is obtained from the considerable investment made in medicines. These teams are tasked with

Cavan & Monaghan Hospital Pharmacy Team

Hospital Pharmacy

stewardship of the largest nonpay expense in the Irish health system. Medicines rationalisation and optimum management reduces both direct and indirect costs in healthcare.

During a Hospital Admission

Pharmacy Porters are often the ’face’ of Pharmacy on the wards. Their communication and organisational skills are critical to optimise secure and timely delivery of medications, particularly where storage requirements such as refrigeration are important. They therefore facilitate space and time for clinical interventions by other team members.

Pharmacists and pharmacy technicians routinely build positive therapeutic relationships with the patients under their care, as well as family members or those who support patients prescribed medications. The process of building therapeutic relationships is facilitated by pharmacy team members during:

• Medicines reconciliation

• Documentation of adverse reactions and allergies to medications

• Obtaining medication histories to inform future treatment choice

These relationships mean that pharmacists can be in a position to advocate for patients’ wishes around medication treatment, particularly where the patient may struggle to communicate this otherwise e.g. in some mental health conditions or cognitive impairment.

During an admission, pharmacists

undertake regular reviews of medication records to check for accuracy, completeness, and adherence to local and national prescribing policies. Clinical pharmacists will also screen for opportunities to optimise medication regimens and for potential risks that may be presented by pharmacological or physiological interactions, for example, therapeutic duplications and medication, formulation, or dose choices. Pharmacists and pharmacy technicians can provide practical information to patients such as inhaler technique and management of medicationrelated adverse effects thereby supporting adherence to medication and reducing overall costs to the health service.

Pharmacists being part of a multi-disciplinary team (MDT) and contributing to the development of individual treatment plans at the point of prescribing improves quality of care and can support appropriate medication-related monitoring, thereby improving patient safety. Comprehensive knowledge of medications, including the impact of different biological processes and disease states on medicines absorption, distribution, metabolism, and excretion, is an essential skill of MDT pharmacists. The ability to communicate this information clearly and tailor medication choices, doses, and treatment durations are also fundamental skills of pharmacists who work on an MDT.

Pharmacy teams members working with our youngest and oldest patients in Paediatrics

Members of the HPAI Executive Committee at the HPAI Conference 2023

or Child and Adolescent Mental Health (CAMHS), and in Older Adult or Geriatrics Teams may spend a lot of time liaising with family members to ensure the patient is adequately supported in their medication needs both during and after an admission.

On Discharge from Hospital

Ensuring continuity of supply of medicines after discharge is often the remit of pharmacy team members, particularly in the case of uncommon or higherrisk medications.

When preparing for discharge, hospital pharmacy team members can check the patient’s understanding of their medication regimen, ensure they know how to use newly prescribed devices such as inhalers, and facilitate seamless transition of care to the community. In some cases that may involve liaising with primary care colleagues on medicines follow up to ensure that care is not compromised by organisational boundaries. Communication with Community Pharmacy colleagues, District Nurses, and GPs can be an important step in maintaining treatment pathways and patient safety.

A large part of many hospital pharmacists’ roles is teaching and training of pharmacy team members such as more junior pharmacists or pharmacy technicians and medical and nursing colleagues on pharmaceutical care issues, including new developments in medicines. Formal training and informal exchange of knowledge

and information throughout hospital teams ensures continued professional development and optimised quality of care for inpatients. Pharmacists and pharmacy technicians in education roles can supervise and facilitate learning for pharmacist and technician students and provide learning opportunities to students of other professions such as medicine and nursing. This leads to improvements in the knowledge and skills of the multidisciplinary workforce overall and better interprofessional communication.

Expansion of Pharmacist Roles

Many pharmacists lead on highimpact medication safety initiatives within their areas, for example on falls risk reduction or antibiotic stewardship. Some hospital pharmacists may additionally have roles in outpatient clinics, e.g. anticoagulant clinics; and in other countries pharmacist prescribing has facilitated the development of these services where expertise in medicines is highly advantageous. In recognition of the proven benefits of pharmacist prescribing, the Minister for Health established an Expert Taskforce in July 2023, to support the expansion of the role of pharmacists in Ireland. Legislation and guidance are gradually being introduced with ongoing stakeholder consultation.

In addition to their expertise in broad specialisms, for example, Medication Safety, Antimicrobial Stewardship, Medicines Information, and Research; many pharmacists have specialist knowledge in particular therapeutic areas such as, but not limited to: Oncology/

Haematology, Maternity Care, Respiratory/Cystic Fibrosis(CF), Cardiology, Transplant Medicine, ITU, and Palliative Care. A small selection of these roles are examined in more detail below and reflected in the existence of HPAI Special Interest Groups (SIGs) for Aseptics, Care of the Older Person, Cardiology, Critical Care, Mental Health, and Renal.

• Aseptic Services Pharmacy Teams With thanks to: Olivia Flynn, Chief II Pharmacist, University Hospital Limerick; Fiona Begley, Chief II Pharmacist, St. Vincent’s University Hospital Dublin; Eamonn Henry, Chief II Pharmacist Oncology, Haematology & Aseptic Services, Letterkenny University Hospital; and Aisleen Haughey, Senior Pharmacist, Letterkenny General Hospital.

Aseptic Services Pharmacy is a specialised area of Hospital Pharmacy concerned with the safe preparation of sterile medicines for injection, predominantly for the treatment of cancer i.e. Systemic Anti-Cancer Therapy (SACT). 26 Hospital Pharmacy Teams in Ireland currently deliver SACT.

Medicines are prepared in an aseptic compounding unit (ACU) which is a clean room facility supplied with sterile HEPAfiltered air. An ACU contains pharmaceutical isolators to protect staff from exposure to hazardous drugs and to protect sterile drugs from contamination by staff and the environment. Each ACU has its own programme of quality assurance (QA) in place to ensure drugs that are reconstituted are of the quality required and are safe and effective. QA can consist of environmental (agar settle plates) and physical (pressures/ temperature) monitoring. The benefit of QA is to allow the ACU the possibility of extending the shelf-life of the reconstituted drug to allow for the advance preparation of certain drugs.

Once validated to work in an ACU, following intensive 3-6month training programmes, pharmacy staff may undertake some of the following roles in aseptic services:

Pharmacists

• Supervising the aseptic compounding of SACT including pre and in-process checking and final product release

• Overseeing and maintaining facilities to prepare sterile medicines

• Interpretation of QA results

• Overall responsibility for the Quality Management Plan for the ACU

Naas General Hospital Pharmacy Staff celebrating World Hospital Pharmacy Day on the 27th of March 2024

• Education and training of new staff-members

• Writing up and approving standard operating procedures

Pharmacy Technicians

• Performing aseptic compounding duties

• Performing daily QA functions

• Writing up standard operating procedures

• Ordering and stock management

Having an on-site ACU in a hospital means that hospital will have greater flexibility in relation to the supply of SACT, allowing for accommodation of urgent treatments and dose changes in a timely manner and reducing the need to outsource. It also increases the potential for participation in Clinical Trials through preparation of drugs that are not commercially available but offer innovative treatments for patients.

Of particular concern to members of the Aseptics Services Special Interest Group (ASSIG) is the lack of regulation of Hospital Pharmacy ACUs. The H-PICs document published in 2013 was endorsed by the HPAI as standards that ACUs should aspire to, however this document needs updating and, ideally, a governance framework to support pharmacists and pharmacy technicians working in aseptic services.

• Paediatric Pharmacy Teams With thanks to: Diarmaid Semple, Senior Pharmacist PICU, CHI Crumlin; Emma O’Grady, Senior Pharmacist Cystic Fibrosis, CHI Temple Street; and Sara O'Connell, Parental Nutrition Pharmaceutical Technician, CHI Crumlin.

In paediatrics, pharmacists are essential sources of information particularly due to the higher off label and unlicensed use of medicine. The Paediatric Pharmacy Department, unlike most Irish Adult hospitals, supplies

patients with discharge medicines to ensure continuity of supply whilst Community Pharmacies order in unlicensed medicines. A parent remarked that it was fitting the last person they had seen after their child’s heart surgery was the pharmacist as they had also been one of the first people they met having to obtain specialist medication directly from hospital.

Paediatrics itself as a speciality is further sub-divided into other specialities such as Paediatric Intensive Care (PICU), Cardiology, Nephrology, Metabolic, Renal, CF, and Parental Nutrition.

For example, the Paediatric Parental Nutrition Pharmacy Team involves a Chief II and Senior Pharmacist with a Senior Pharmacy Technician working together to ensure that there is good communication between the prescribers and dieticians in determining both a child’s nutritional and electrolyte needs. Linking with suppliers, maintaining stock levels, and quality control are key roles for the pharmacy technician on the team.

Some of the sickest patients in hospitals are in intensive care, where pharmacists’ drug information and pharmacokinetic knowledge is in high demand by Intensivists. Paediatric Intensive care is no different and pharmacists in the PICU provide specialist knowledge in the treatment and use of drugs in patients from hours old to 16years and from 600g to 120kg.

Paediatric Cystic Fibrosis (CF) Pharmacists are at the forefront of optimising personalised medication regimens, providing expert pharmaceutical care tailored to children, and ensuring the safe and cost-effective use of some of our highest cost therapies. Specialist knowledge and expertise in the area of CF offers significant advantages by ensuring personalised, high quality care and fostering a collaborative,

informed approach to managing CF. For patients and their families, this means having a dedicated professional who can address their unique medication needs, answer questions, and provide continuous support and education. This role helps to reduce medication related issues, improve adherence to treatment regimens, and offer peace of mind knowing they have a trusted expert as part of their healthcare team. Overall, a specialist CF pharmacist plays a crucial role in improving the wellbeing and health outcomes of patients with CF, while also providing invaluable support to their families.

As a specialist, the pharmacist is ideally positioned to provide education to members of the CF multidisciplinary team (MDT), and contribute to the literature through research and publication, improving the care of CF patients at a local, national, and international level.

• Pharmacy Informatics Teams With thanks to: Moninne Howlett, Chief Pharmacy Information Officer, Children’s Health Ireland.

Pharmacy informaticists are amongst some of the newer specialist roles for in hospital pharmacy. This is a rapidly growing area in response to the long-awaited digitisation and increasing complexity of medication management in Irish hospitals. Specialist Informatics Pharmacists are critical to support the procurement, implementation, and optimisation of health information technology systems. These include both local and national level systems such as pharmacy information systems, electronic health records (EHRs), automated dispensing systems, and smart-infusion pumps; ideally these systems are integrated to allow data to flow freely between them. Achieving this 'closed loop’ medication management brings significant increases in safety and efficiency but significantly changes how medications are distributed,

Hospital Pharmacy

prescribed, and administered. The day-to-day management of these systems, including staff training, database management, system configuration, and data analysis requires a highly specialised workforce, including specifically trained pharmacists and pharmacy technicians.

• Mental Health Pharmacy

Teams With thanks to: Ciara Ni Dhubhlaing, Chief I Pharmacist, St Patrick’s Mental Health Services and Ita Fitzgerald, Senior Pharmacist St Patrick’s Mental Health Services.

Similarly to paediatrics, there are many sub-specialties within Mental Heath (MH) including Dementia, Child and Adolescent Mental Health (CAMHS), Psychiatric Intensive Care, Eating Disorders, and Substance Misuse. Mental Health Pharmacists will usually have some knowledge of all of these conditions and more.

Physical co-morbidities are common in many MH conditions therefore the pharmacist’s generalist knowledge e.g. regarding COPD or blood pressure management is a valuable addition

WEBINAR Transforming Clinical Pharmacy Processes Using MEG

to the holistic care of the patient. Pharmacists are particularly attuned to patient safety around the evidence-based use and monitoring of medications and MH Pharmacy Teams manage some critical and high-risk medications such as Clozapine, Lithium, and Sodium Valproate to ensure safe and effective use.

Additional complexities within MH include legal considerations around capacity or detention under the Mental Health Act (MHA) that may need to be factored into treatment decisions.

Wednesday 2nd October 12:30 pm

Some of the HPAI negotiating committee: Deirdre Lynch, Richard Sykes, Elaine Conyard

This includes cases of acute illness that can negatively impact a person’s decision-making capacity or where a patient is detained under the Mental Health Act. For example medicines administration via injectable formulation may be supported by MHA legislation and clinically appropriate where it is in the best interests of the person.

MH professionals work within bio-psycho-social models where the medicines; psychological therapies; and social support, including family support, are all important in recovery. Specialist MH Pharmacists must therefore have a good knowledge of their MDT colleague’s roles in addition to their own, and treatment pathways are highly individualised and collaborative according to the patient’s needs, experiences, and preferences. It is a privilege for pharmacy teams to be able to walk the path to recovery with our patients.

The first World Hospital Pharmacy Day was held on the 27th of March 2024 to recognise the importance of, and to celebrate the work done by hospital pharmacies. Like the event, it is clear that we are only getting started on what can be achieved by Hospital Pharmacy Teams to optimise medicines use and to deliver excellence in patient care.

BLUEFISH PHARMACEUTICALS LAUNCHES

Meladura 2 mg Melatonin prolonged-release tablets

Product Information: Meladura 2mg prolonged-release tablets (melatonin) |Marketing Authorisation Holder (MAH): Bluefish Pharmaceuticals AB, P O Box 49013 100 28 Stockholm, Sweden | Marketing Authorisation Number(s): PA1436/047/001 | Legal Category: Medicinal product subject to medical prescription | Date of Last Review of API : 25/06/2024 | Further information including the SPC is available on request from Bluefish Pharmaceuticals AB Adverse event details should be reported to: HPRA Pharmacovigilance, Website: www hpra ie

Enhancing Pharmacy-Related Research

St Patrick’s Mental Health Services and University College Cork announce strategic partnership to enhance pharmacy-related research and clinical collaborations

A newly announced strategic partnership between the Pharmacy Department at St Patrick’s Mental Health Services and the School of Pharmacy at University College Cork (UCC) will see the two organisations come together over the coming five years to advance research and clinical training in mental health pharmacy.

Speaking about the partnership, Ciara Ni Dhubhlaing, Chief Pharmacist at St Patrick’s Mental Health Services, said: "In our most recent organisational strategy, The Future in Mind 2023 – 2027, St Patrick’s Mental Health Services reaffirmed its commitment to enhancing evidence-based understandings of mental health difficulties through research, and to supporting individuals and organisations committing to work in mental healthcare in their training and education. This partnership with UCC signifies a significant step forward in a shared vision of improving education, training and research.

“By working together, we will leverage our collective strengths to drive innovation in clinical training and to pioneer new research as we strive to improve outcomes for service users

Head of the College of Medicine and Health, UCC

and inform best practice in mental health services. We look forward to the opportunities this partnership brings and the positive impact we envisage it will have on advancing pharmacy practices in mental health.”

The partnership between St Patrick’s Mental Health Services and University College Cork will enable a wide range of activities including:

• Research: The partnership will support research into mental health and enhance evidencebased knowledge.

• Clinical teaching: Dedicated administrative links will be established to oversee integrated clinical teaching and research between both organisations.

• Professional development: Both organisations will facilitate mutual professional development, ensuring continuous learning opportunities and growth for staff members within St Patrick’s

Mental Health Services and UCC, and pharmacy students.

• Sharing expertise: There will be active exchange of information and consultation on matters of mutual interest, fostering informed decision-making and collaboration. Staff from both organisations will establish and strengthen collaborative links, sharing expertise and resources to enhance capabilities.

Professor Helen Whelton, Head of the College of Medicine and Health, UCC said: “This new partnership with the innovative St Patrick’s Mental Health Services perfectly aligns with our UCC strategy to strengthen our collaboration with the health sector through an academic health sciences model. It embodies the vision of University College Cork by connecting and empowering individuals across academia and healthcare services to create and share knowledge. By focusing on those facing mental health difficulties, we are confident that this strategic alliance will significantly enhance pharmacyrelated research and clinical collaborations. This endeavour will yield substantial benefits, improving patient care and health outcomes across hospitals,

primary care and the community, while contributing to the creation of a more inclusive and compassionate world.”

Professor Laura Sahm, Vice Dean of School of Pharmacy, UCC said: “I am thrilled to be part of this exciting new partnership, which will form part of the transformation of UCC’s research culture. This will be achieved through the implementation of engaged research and open research with clinicians at St Patrick’s Mental Health Services. I would welcome other UCC colleagues to join in this collaboration and see how we can effect positive change with person-centred research and learning.”

This partnership announcement comes as St Patrick’s Mental Health Services continues to progress its Academic Institute, which, established in 2022, will be progressed into an international research centre, pioneering research in the field of mental health. The Academic Institute of St Patrick’s Mental Health Services will play a crucial role in investigating and enhancing mental health treatments and evidence-based practices by collaborating with key partner organisations.

L/R Ciara Ni Dhubhlaing, Chief Pharmacist, St Patrick’s Mental Health Services; Ita Fitzgerald, Senior Pharmacist, St Patrick’s Mental Health Services; Prof Brendan Griffin, Head of School and Professor in Pharmaceutics at the School of Pharmacy, University College Cork; Prof Laura Sahm, Vice Dean of the School of Pharmacy, University College Cork; and Gráinne Donohue, Academic Institute Programme Manager, St Patrick’s Mental Health Services

Professor Helen Whelton,

Start Strong Go Long

Deep and durable relief across psoriatic disease

Tremfya 100 mg solution for injection in pre-filled pen PRESCRIBING INFORMATION. ACTIVE INGREDIENT(S): Guselkumab. Please refer to Summary of Product Characteristics (SmPC) before prescribing. INDICATION(S): Treatment of moderate to severe plaque psoriasis in adults who are candidates for systemic therapy. Treatment of active psoriatic arthritis in adult patients, alone or in combination with methotrexate, who have had an inadequate response or have been intolerant to a prior disease-modifying antirheumatic drug (DMARD) therapy. DOSAGE & ADMINISTRATION: For use under guidance/supervision of physician experienced in diagnosis and treatment of conditions for which Tremfya is indicated. Subcutaneous injection. Avoid areas showing psoriasis. Adults: For both indications, 100 mg at weeks 0 and 4, followed by maintenance dose every 8 weeks. In the case of psoriatic arthritis, for patients at high risk for joint damage according to clinical judgement, consider a dose of 100 mg every 4 weeks. Consider discontinuation if no response after 16 weeks of treatment for plaque psoriasis and 24 weeks for psoriatic arthritis. Children: No data available in children/adolescents <18 years. Elderly: No dose adjustment required, limited information in subjects aged ≥ 65 years, very limited information > 75 years. Renal & Hepatic impairment: Not studied. CONTRAINDICATIONS: Serious hypersensitivity to active substance or excipients; clinically important, active infection. SPECIAL WARNINGS & PRECAUTIONS: Infections: Potential to increase risk. If signs/ symptoms of clinically important chronic/acute infection occur, monitor closely and discontinue Tremfya until resolved. Tuberculosis: Evaluate patients for TB pre-treatment; monitor for signs/ symptoms of active TB during and after treatment. Consider anti-TB therapy prior to Tremfya if past history of latent/active TB and adequate treatment course not confirmed. Serious hypersensitivity reaction: Includes anaphylaxis. Some serious hypersensitivity reactions occurred several days after treatment and included urticaria and dyspnoea. If occurs, discontinue Tremfya immediately and initiate appropriate therapy. Hepatic Transaminase Elevations: An increased incidence of liver enzyme elevations has been observed in patients treated with Tremfya q4w compared to patients treated with Tremfya q8w or placebo. When prescribing Tremfya q4w in psoriatic arthritis, consider evaluating liver enzymes at baseline and thereafter according to routine patient management. If increases in ALT or AST are observed and drug-induced liver injury is suspected, Tremfya should be temporarily interrupted until this diagnosis is excluded. Immunisations: Consider completing all appropriate immunisations prior to Tremfya. Do not use live vaccines concurrently with Tremfya; no data available; before live vaccination, withhold Tremfya for at least 12 weeks and resume at least 2 weeks after vaccination. SIDE EFFECTS: Very common: Respiratory tract infection. Common: headache, diarrhoea, arthralgia, injection site reactions, transaminases increased. Other side effects: hypersensitivity, anaphylaxis, rash, herpes simplex infections, neutrophil count decreased. Refer to

SmPC for other side effects. LEGAL CATEGORY: Prescription Only Medicine (POM). PRESENTATIONS, PACK SIZES, MARKETING AUTHORISATION NUMBER(S): Pre-filled pen, X1, EU/1/17/1234/002. MARKETING AUTHORISATION HOLDER: Janssen-Cilag International NV, Turnhoutseweg 30, B-2340 Beerse, Belgium. FURTHER INFORMATION IS AVAILABLE FROM: Janssen Sciences Ireland UC, Barnahely, Ringaskiddy, IRL - Co. Cork, P43 FA46. Prescribing information last revised: July 2022. Adverse events should be reported. Healthcare professionals are asked to report any suspected adverse events via: HPRA Pharmacovigilance Website: www.hpra.ie. Adverse events should also be reported to Janssen Sciences Ireland UC on 1800 709 122 or at dsafety@its.jnj.com.

References: 1. Reich K. et al., Five-year maintenance of clinical response and improvements in healthrelated quality of life in patients with moderate-to-severe psoriasis treated with guselkumab: results from VOYAGE 1 and VOYAGE 2. British Journal of Dermatology, 2021, June. https://doi.org/10.1111/ bjd.20568. 2. Blauvelt A, Papp KA, Griffiths CEM, et al. Efficacy and safety of guselkumab, an antiinterleukin-23 monoclonal antibody, compared with adalimumab for the continuous treatment of patients with moderate to severe psoriasis: Results from the phase III, double-blinded, placeboand active comparator-controlled VOYAGE 1 trial. J Am Acad Dermatol 2017;76:405-17. 3. Reich K, Armstrong AW, Foley P, et al. Efficacy and safety of guselkumab, an antiinterleukin-23 monoclonal antibody, compared with adalimumab for the treatment of patients with moderate to severe psoriasis with randomized withdrawal and retreatment: Results from the phase III, double-blind, placebo and active comparator-controlled VOYAGE 2 trial. J Am Acad Dermatol. 2017;76:418-31. 4. McInnes IB, et al. Long-Term Efficacy and Safety of Guselkumab, a Monoclonal Antibody Specific to the p19 Subunit of Interleukin-23, Through Two Years: Results From a Phase III, Randomized, DoubleBlind, Placebo-Controlled Study Conducted in Biologic-Naive Patients With Active Psoriatic Arthritis. Arthritis Rheumatol. 2022 Mar;74(3):475-485. 5. Mease PJ, et al. Guselkumab in biologic-naïve patients with actives psoriatic arthritis (DISCOVER-2): a double-blind, randomised, placebo-controlled phase 3 trial. Lancet 2020;395:1126-1136. 6. Ritchlin CT, et al. Guselkumab, an inhibitor of the IL-23p19 subunit, provides sustained improvements in signs and symptoms if active psoriatic arthritis: 1 year results of a phase III randomised study of patients who were biologic-naïve or TNFα inhibitor-experienced. RMD Open. 2021;7:e001457. 7. Deodhar A et al. Guselkumab in patients with active psoriatic arthritis who were biologic-naive or had a previously received TNFα inhibitor treatment (DISCOVER-1): a double-blind, randomised, placebo-controlled phase 3 trial. Lancet 2020; 395:1115-1125. 8. TREMFYA® Summary of Product Characteristics, available at medicines.ie.

CP-430955 | Date of Preparation: February 2024

2024 Retina International Congress Held in Dublin

Highlights from the Retina International World Congress 2024 - Targeting the Cure: the Future of Vision Research - Friday 07 June

Vision loss to a person with inherited retinal degeneration (IRD) is “an unbidden guest”, someone who comes into your life uninvited, that you cannot “kick out”.

This powerful depiction of life with an IRD was presented at the 2024 Retina International World Congress (RIWC 24) in Dublin recently, by Mr Franz Badura, Chair of Retina International.

Together with Professor Jane Farrar, Head of the School of Genetics and Microbiology at Trinity College Dublin (TCD) and Chair of the Scientific Committee, RIWC, Mr Badura opened the third day of the conference (Friday, 7 June) entitled “Targeting the Cure; the Future of Vision Research”.

Keynote Address

The keynote address was given by Professor Jean Bennett, F. M. Kirby Professor of Ophthalmology in the Perelman School of Medicine at the University of Pennsylvania in the USA.

Entitled “Shared Vision: Academic Partnerships in Gene Therapy Research”, Prof Bennett explained that, at the beginning, research in this area had no genes, no animal models, no surgical methods to deliver genes, no outcomes and no funding. However, today she said that more than 300 genes that

cause IRDs have been identified, and thanks to patient advocates and organisations such as Retina International and Fighting Blindness, there are research groups currently working on IRDs.

Prof Bennett explained that at the outset there were many challenges and unknowns with the delivery of gene therapy for IRDs and she described the initiation of gene therapy trials as a “scary time”.

“There were many, many issues that had to be de-risked,” she said.

Outlining the advancements in IRD gene therapy, Prof Bennett said that today there are 37 different gene therapies approved for use, 15 of which target different genetic diseases and just one of which is for blindness - Luxturna.

Prof Bennett said that, to date, more than 120 clinical trials have been initiated using gene therapy, many of which are in the late stages. The majority of these trials, she explained, use adenoassociated virus (AAV) and enrol participants from the age of one to 90 years’ old. The trials are targeting more than 24 different diseases.

Today gene therapy trials are taking place in numerous countries around the world targeting multiple

different diseases including very rare conditions such as Usher syndrome and some very common diseases such as Age-related Macular Degeneration (AMD).

Prof Bennett explained that there were also trials currently underway using antisense CRISPR gene therapy or gene editing. The first direct delivery of CRISPR-Cas gene therapy was administered to the retina, and the first results of those studies were recently published in the New England Journal of Medicine, she added.

“So the eye has it for gene therapy. We have made great progress,” Prof Bennett said.

After outlining several different gene therapy clinical trials that she has been involved in, Prof Bennett said, in summary, that she was very excited about the potential of treatments for different forms of IRDs.

“It's been 34 years since that first gene was identified. We all thought it would go much more quickly, but it has happened for some diseases, and we think that now we can speed things up and move things forward using the technology that is now available and the de-risking that has happened. There are great opportunities for progress and great possibilities of collaboration

between not only academia and patients, but small biotech and Big Pharma,” Prof Bennett concluded. The subject of gene therapy was central to several talks that followed with experts speaking on topics such as trials in gene editing therapies for IRDs.

Patient Pathways

Professor David Keegan, consultant ophthalmologist at the Mater Misericordiae University Hospital in Dublin, addressed the conference on the Target 5000 project which was established by Fighting Blindness.

Target 5000 aims to provide a genetic and clinical diagnosis for people with IRD, to allow them to get a better understanding of their condition and improved access to potential new therapies.

There are three sites as part of Target 5000; two in Dublin and one in Belfast. Prof Keegan at the Mater is the coordinator, with colleagues Mr Tomas Burke and Prof Ian Flitcroft working closely with Prof Julie Silvestri at Belfast Health and Social Care Trust, in Northern Ireland, and Dr Paul Kenna and Dr Emma Duignan at the Eye and Ear Hospital, Dublin.

Prof Keegan explained that patients with IRDs face significant challenges in receiving a diagnosis with many having to visit multiple specialists over several years before they get an answer. He added that the psychological impact of vision loss can also have a major negative impact on patients’ mental health.

“It is not just that physical limitation of vision impairment and blindness, but it's also that impact on well-being. So it's a public health issue because rare diseases are not rare. They are individually rare, but they are not rare. They are quite common in society.”

Left to right Professor Jean Bennett and Professor Julie Silvestri

Concentrating on patients and their needs from a service, Prof Keegan explained that they wanted a diagnosis, a prognosis, information on the inherited pattern of their disease that would inform future family planning, access to new clinical trials, practical supports and improved treatments.

Prof Keegan introduced the clinical patient pathway for Target 5000 which involves referred patients undergoing clinical assessment, research-grade genetic testing, genetic counselling and multidisciplinary care. All patients are referred and then put on the register, which Prof Keegan said was due to be upgraded shortly to allow seamless ERN integration.

Prof Keegan explained that 2,500 patients of an estimated 3,000 IRD patients in Ireland are now registered with Target 5000. Approximately 1,200 of these have been seen at the Mater Hospital in Dublin. All patients have had accredited genetic testing with an 82 per cent resolution rate.

He said that Target 5000 is now linked into the HSE National Rare Disease Office and a care pathway has been developed for retinitis pigmentosa already. Work is also currently underway to develop national care pathways for Usher syndrome, Bardet Biedl syndrome and Stickler syndrome.

Gene Therapy

The congress heard from several international experts on the topics of genetic research, clinical trials and the exploration of potential new gene therapies for IRDs.

Speakers included Dr Sophia MillingtonWard, Research Fellow, Genetics, at the School of Genetics and Microbiology, TCD, who spoke on “Retinal degenerations

– elucidating genetics architecture and exploring gene therapies”; Professor Robin Ali, Professor of Human Molecular Genetics at University College London (UCL) Institute of Ophthalmology who spoke on “Gene therapy in children with severe retinal dystrophy associated with AIPL1 gene defects”; and Dr Daniel C. Chung, Chief Medical Officer at SparingVision, a genomic medicine company specialising in gene therapies for vision loss, who addressed the conference on “Gene Agnostic Therapeutic Approaches”.

The Immune System and IRDs

In the afternoon session, the conference heard from Professor Sarah Doyle, Associate Professor in Immunology, Department of Clinical Medicine at the School of Medicine, TCD and Head of the Immunobiology Research Group. Professor Doyle is also a member of the RIWC24 Scientific Committee.

Prof Doyle addressed the conference on “Therapeutic target identification for degenerative eye disease”.

Discussing the immune system and its role in retinal degeneration, Prof Doyle explained that the innate immune system responds to damage-associated molecular patterns or DAMPS. These DAMPs are generated in a gene-agnostic manner due to tissue injury from genetic mutations. They can also be generated as a result of acquired injury from cigarette smoke or from excess glucose in diabetes for example.

“We are looking at this overarching geneagnostic approach to understanding how retinal degenerations might progress in a geneagnostic way,” she explained.

The immune system usually repairs and restores the damage done through the activation of pattern recognition receptors. She explained that a lot can be learned from examining non-ocular disease and chronic inflammatory diseases that do not affect the eye but are also driven by pattern recognition receptors.

Prof Doyle explained that when it comes to identifying therapeutic targets for IRDs, these

Left to right Mr. Franz Badura and Professor Jane Farrar

Left to Right Avril Daly, Retina International, Alena Reznichenko and Adrianna Montague, Johnson & Johnson Innovative Medicine and Finbarr Roche, Fighting Blindness

pattern recognition receptors of the innate immune system can be examined to see if inhibiting them or reducing their ability to signal would reduce the chronic inflammation that occurs in the retina.

Prof Doyle’s work focuses on SARM1 (Selective Androgen Receptor Modulator 1) which is known to be associated with cell death in the brain and nervous system. SARM1 is also highly expressed in the photoreceptor cells of the retina.

Prof Doyle’s work examines a potential link between SARM1 and IRDs which may offer a new potential target for a therapeutic approach to retinal disease.

According to Prof Doyle, the potential for therapeutic inhibition of SARM1 is “really strong” and research has already shown that this type of gene therapy works well for peripheral neuropathy.

“There is hope that SARM1 might act as an adjunct therapy or another option for slowing progression of retinal degeneration,” she said.

Artificial Intelligence and AMD

The RIWC 24 conference also heard that artificial intelligence (AI) has the potential to support clinicians in diagnosing and screening retinal disease by performing more laborious tasks previously carried out by ophthalmologists.

Dr Tiarnán Keenan, staff clinician in retinal disease with the Division of Epidemiology and Clinical Applications at the National Eye Institute (NEI) in the USA spoke on AMD and AI.

Dr Keenan said we are currently facing “a global burden of eye disease”, and postpandemic there are a lot of challenges to the traditional models of ophthalmology care.

Currently in Europe, one in four or a quarter of all those over 60, have some degree of AMD –approximately 70 million people. Therefore it is a real challenge to not only provide consultant care to all of those affected but also to carry out screening for people who are currently undiagnosed, he explained.

In this context, he said AI has the potential to help change the paradigm of care by making it more convenient for patients and less taskintensive for healthcare professionals.

Dr Keenan is a member of the Collaborative Community on Ophthalmic Imaging Working Group for AI in AMD. Established in conjunction with the FDA, the group examines the potential of AI to make a significant positive impact on the diagnosis and management of AMD while also being aware of regulatory requirements.

He set out several examples of AI projects in ophthalmology including the first-ever AI device

to receive FDA approval in medicine which is used today to screen for diabetic retinopathy.

Dr Keenan introduced an example called DeepSeeNet which uses AI to detect and classify AMD. Trained on a total of 58,400 images, DeepSeeNet simulates the grading process which before was done by humans and can detect individual AMD risk factors for each eye and then calculate a patient-based AMD severity score using the AREDs Simplified Severity Scale.

In another example, he outlined a project called Notal Vision Home OCT which is now FDAapproved. This is a personal OCT device which the AMD patient takes home. It allows patients to take daily scans of their retinas. The OCT reading goes to the Notal Health Cloud and is analysed by the Notal AI algorithm which can detect and quantify the fluid and plot it on the patient record. It is also made available to the patient’s doctor for remote review and can trigger an alert if needed.

“In some cases, it's about accuracy. We can get even higher accuracy than the retinal specialist. I think a much more interesting second point is the ability of AI technology to really expand potential access to care, including difficult-to-reach populations. And thirdly, these are sometimes tasks that humans just can't do, that AI is able to do,” Dr Keenan said.

The Retina International World Congress 2024 took place in Dublin from the 5th to the 8th of June. The four-day event, which was hosted by Fighting Blindness, brought together clinical experts, researchers, advocates and people living with IRDs from all over the world.

Left to right Finbarr Roche and Professor David Keegan

Left to right Professor Matt Campbell and Professor Sarah Doyle

Over ¤300,000 for Innovating Health News

Projects from TUH that have been awarded funding;

1. Advanced Practice Occupational Therapy (APOT) Led Integrated Hand & Wrist Clinic. This project creates a modernised care pathway providing GP-referred patients with direct access to specialist occupational health care professionals in a primary care setting, the first of its kind in Ireland. Patients with hand and wrist pathologies including carpal tunnel syndrome and ganglion cysts benefit from reduced waiting times, fewer hospital attendance, and improved overall outcomes.

Caption: Front Row left to right: Sinéad Gill – Clinical Innovation Specialist, Dr Natalie Cole – Head of Innovation, Olga Hill – Clinical Specialist Occupational Therapist, Siobhan Power - Clinical Specialist Dietician for Perioperative Services.

Back Row: John Kelly – Deputy CEO, Alexander Fives – Designer in Residence, Professor Dominick McCabe - Consultant Neurologist. (Missing Prof Paul Ridgeway, Niamh Wilke, and Consultant Surgeon Maria Whelan)

of acquired physical disability in adults, a major risk factor for dementia, and the second most common cause of death worldwide. This innovative solution focuses on the area of precision medicine using pharma genetics, to optimise secondary prevention for patients following TIA/Ischemic stroke.

Marking World Sjögren’s Day

Marking World Sjögren’s Day (23 July), the SYNERG-IE Programme, based at RCSI University of Medicine and Health Sciences, has launched its website, social media, and has opened a call for patients and the public to join an advisory panel. The research programme aims to address longstanding challenges in the recognition, diagnosis, and management of the condition.

Sjögren’s (pronounced 'SHOWgrins') is a chronic debilitating autoimmune disease which affects approximately up to 1 in 200 people worldwide, predominantly women aged between 40-50 years at time of diagnosis.

The ambitious ¤2.5 million study, funded by the Health Research Board, is known as SYNERG-IE. It is co-designed with patient-group Sjögren’s Ireland and combines the skills of multidisciplinary researchers, the insights of patients, and the needs of healthcare professionals and policymakers to bring about transformative change in Sjögren's care and research. Academic collaborators include experts from University College Cork, National College of Art and Design, and Technological University Dublin.

The five-year programme, funded by the Health Research Board APRO-2023-28, aims to make a

to immediately communicate any health problems or changes directly with their medical team.

With the support of the Spark Impact funding and our own Innovate Health team at THU, staff involved in these four projects will successfully design, develop, and deploy novel solutions to complex challenges for their patients,

their colleagues and the health service at large.

difference to the lives of people affected by Sjögren's across several areas:

• By optimising prescribing practices and medicines use, people will experience more personalised and effective treatments.

• Co-design approaches will be used to develop improved care pathways to enhance care experiences.

• National guidance and policies will provide a clearer framework for primary carebases healthcare professionals, reducing the current delays in diagnosis and treatment.

• The increased knowledge stemming from undergraduate and postgraduate education initiatives will improve awareness and understanding.

Dr Michelle Flood, Senior Lecturer, RCSI School of Pharmacy and Biomolecular Sciences and SYNERG-IE Principal Investigator said, “With the launch of the call for patients and the public to join the SYNERG-IE Advisory Board on World Sjögren's Day 2024, we are excited to embark on a much-needed research programme to transform care experiences for people living with Sjögren’s. Together, we aim to make impactful advancements through collaboration.”

Wound Care

Hidradenitis Suppurativa: wound care and management

Hidradenitis Suppurative (HS) is a chronic inflammatory skin condition. Disease severity is classified and assessed by clinicians using the Hurley Staging system from I- III. This ranges from a solitary nodule like in Hurley stage I to the deeprooted nodules, abscesses, skin tunnels or fibrotic scar tissue found in Hurley stage III. This condition primarily affects intertriginous areas such as axillary, groin, perianal, perineal and inframammary regions, with women affected more than men. The age of onset is around puberty.

According to British Association of Dermatologists (2018) guidelines on HS, initial management involves providing dressings for pus producing lesions. However, there are no guidelines for HS wound management. The impact of this condition on patient’s quality of life makes even the simplest of tasks much more challenging. This reiterates what research has stated about the negative psychological effect on a patient’s life with HS. Wound management should be tailored to each patient individually. As with HS there is no such thing as “one size fits all”. Every opportunity should be taken in the clinical setting to discuss wound care options. My clinical experience has given me an indepth insight into living with the condition and the impact it has on a person and their family such as psychosocial and financial burden. An example of the financial impact on one patient was devastating as she missed working days due to her HS flares in axilla. This affected her driving to work, resulting in

Written by Kelly Impey, Dermatology Advance Nurse Practitioner, Tallaght University Hospital

financial loss. The dressings she was using would not stay in place while driving the manual car. An opportunity arose to change her car to an automatic and this had a positive impact for her as it meant the dressings stayed in place on her work commute and resulted in less time off work.

Despite the improved availability of dressings in HS wound management, patients can still find choosing the right dressing for them confusing. Often wounds can be at different stages of flaring and not all dressing carry out the same function. Wounds with heavy exudate require more absorbent dressing while less absorbent dressings can be used with less exudate.

Nurses, pharmacists and doctors play a vital role in discussing wound care options available to patients on both the GMS (medical card scheme) or PCRS (primary care reimbursement scheme). The aim of wound care for HS patients is to improve quality of life, minimise the pain, absorb the exudate from the wound, reduce odour and reduce staining on clothing. They should also be comfortable to wear.

Persistent pus like discharge from wounds can become malodorous. This odour can be a major source of embarrassment in HS especially at dressing changes. Patients report that spraying deodorant directly on to open wound areas can irritate and sting the affected areas. Some patients describe applying dressings on

their wounds in order to spray deodorant to the axilla to mask the odour of exudate from wounds.

HS commonly occurs in areas of skin-to-skin contact leading to skin friction. Minimizing skin trauma is vital in HS patients. It is important to discuss clothing modification such as avoiding tight fitting clothing instead wear loose fitting under wear or wear wireless bras with wide straps. Patients should be advised not to scrub aggressively or use harsh skin products. Instead use a nonfragranced gentle wash.

Patients should be made aware that some areas affected by HS may have chronic drainage from their wounds. This can lead to problems for surrounding skin. Peri-wound skin can be an issue for patients as mismanagement of exudate can result in maceration and irritation of the skin surrounding the wound. Repeated dressing changes during the day can result in skin trauma as adhesive dressings sticking to the skin can cause adhesive related skin injury and limit the patient in dressing choices. Patients should be informed before reapplying any dressings the area should be clean and dry.

Often there are indicators that will occur hours prior to appearance of a lesion, these include redness, burning, pruritus or stinging in an area a lesion may be flaring. Patients usually present afebrile and well despite exudate. Therefore, it is important to inform patients that not all exudate is a sign of infection but to be mindful of the signs and symptoms to watch out for and seek medical attention if required. Some hydrofiber dressings contain anti-

microbial properties that can help if infection is present. These may need a secondary dressing to keep them in place.

Unfortunately flares in HS can be unpredictable. Over the counter dressings can be expensive. Patients often resort to using cheaper alternatives such as hygiene products, kitchen towel, breast pads or cotton pads if leakage occurs and no dressings are available. Inform patients that these may dry, stick to the wound, and cause pain on removal. Advise patients that wetting the dressing before removal or using adhesive remover sprays can minimise the pain.

Thankfully, patients with a GMS or PCRS have better access to a wide selection of dressings. Some dressings available on PCRS include Polymen, aquacel, adaptic and wound pads. Ensure the dressings prescribed do not need an extra secondary dressing to secure them in place. If a second dressing is required, advise patient how to use them. This list of dressings can be found on the on PCRS website.

A welcomed advancement in wound management of HS is the introduction of Hidrawear. This is available on GMS and Private prescription. This HS specific wound dressing system uses underwear style garments to hold dressings in areas that would otherwise be difficult to secure, such as axilla or groin.

My knowledge of dressings is limited to my clinical experience. I have not received any financial benefits from wound dressing suppliers.

“The aim of wound care for HS patients is to improve quality of life, minimise the pain, absorb the exudate from the wound, reduce odour and reduce staining on clothing. They should also be comfortable to wear”

Munster Technological University Hosts Rare Diseases Symposium

Munster Technological University (MTU) hosted the All-Ireland Rare Disease Interdisciplinary Research Network (RAiN) symposium recently at its Kerry campus. This symposium was open to anyone living with or interested in rare diseases.

Rare diseases, though individually rare, collectively present a formidable challenge to the global population, impacting approximately 350 million people worldwide. In Ireland, the situation is particularly alarming, with an estimated 410,000 individuals grappling with rare diseases, a staggering 70% of whom are children and young people. RAiN, in direct response to this urgent research gap, provides a platform for the voices of individuals and families to be heard and actively contribute to research that directly affects them.

RAiN is funded by the Department of the Taoiseach’s office through the Shared Island New Foundations Awards and University College Dublin (UCD) Strategy funding. This network promotes and extends excellent North-South connections to increase knowledge, influence practice, develop policy, and improve patient outcomes on the island of Ireland.

RAiN, a testament to the power of collaboration, represents a united effort to address the unique needs of families affected by rare diseases. By amplifying their voices, we are driving meaningful change and making a real difference in their lives.

Speakers and attendees at the Rare Disease Interdisciplinary Research Symposium at MTU earlier this month

The network involves University College Dublin (UCD), Queen’s University Belfast (QUB) and 33 partner organisations across the Republic and Northern Ireland, including Munster Technological University. RAiN is co-led by Associate Professor Suja Somanadhan (UCD) and Professor Amy Jane McKnight (QUB).

The symposium brought together approximately 50 attendees, including researchers, health and social care professionals, academics, policymakers, and advocates in the rare disease field. It showcased the power of collective action in promoting equality, diversity, and inclusion for rare diseases.

The symposium was opened by Associate Professor Suja Somanadhan (UCD), and Professor Maggie Cusack (President of MTU) welcomed everyone to the symposium and highlighted the challenges faced by those living with a rare disease across Ireland and the role of RAiN.

of the ‘hot school meals programme’ for those adhering to lifelong low-protein dietary therapy. As part of Bernadette’s presentation, attendees heard from a young man living with tyrosinemia, from the parent of a child with homocystinuria and the perspective of the Irish PKU (Phenylketonuria) community through research Bernadette conducted in collaboration with Associate Professor Somanadhan in the RAiN network.

CRAG member Lucy Gallagher shared a powerful message, virtually, reminding other young people living with rare diseases to “Be the voice, not the Echo”.

After lunch, the symposium heard from Ian Fallon, who presented on the work of BUMBLEance, the first non-governmental funded child ambulance service in Ireland. Catherine Carty (UNESCO Chair MTU) spoke about rare diseases

Associate Professor Suja Somanadhan opening the Rare Disease Research Symposium at MTU

in relation to Principle Two of the United Nations Sustainable Developmental Goals Declaration to “Leaving No One Behind”. Rosie Dempsey (MTU) described the process of designing a cartoon video which raises awareness of haemophilia. This video was developed in collaboration with Children’s Health Ireland (CHI). Professor Josephine Hegarty and Maria Caples University College Cork (UCC) presented their work on developing a competency framework on genomic education. The day concluded with a panel conversation led by Associate Professor Somanadhan. The panelists included Anne Lawlor (22q11), Mary Vasseghi (TSC Ireland), Cassandra Dinius and Daniel Mikula (Rare Disease Clinical Trial Network), and Triona Seery (Patient Advocate). The discussion was highly engaging, focusing on the importance of partnership through patient and public involvement and engagement (PPIE) in rare disease research. The key message was that it is imperative to place the voices of people living with rare diseases and their families at the very core of research. The day was an immense success, and RAiN and MTU would like to thank all who attended, participated or supported the day. Stay tuned for many more RAiN events in the future.

For more information on RAiN, see the network’s website - https:// www.rainrareresearch.org/

Eczema in Children

Treating Eczema in Babies

Atopic dermatitis (AD), also known as eczema, is the most common skin condition in children, affecting 30% of Irish babies in the first 2 years of life. AD has a significant impact on quality of life (QOL) for infants and their parents. The main burdensome symptoms are itch and sleep disruption (Image 1). AD is associated with other atopic conditions such as food allergy, asthma, and allergic rhinitis. These associations often lead to babies with AD being treated with ineffective and inappropriate treatments, such as dietary restriction, which have no role in AD. AD is also associated with neuropsychiatric diseases such as anxiety, depression, and attentiondeficit hyperactivity disorder. There is growing evidence that developing eczema in early life might increase the risk of autism. Immunologically, there may be a window of opportunity to intervene in early life to prevent progression to more chronic and severe AD. For all these reasons, effective is the treatment of eczema in babies is extremely important.

Cause of AD

The cause of AD relates to a combination of the triad of skin barrier dysfunction, skin dysbiosis, and dysfunctional inflammation. Skin barrier dysfunction is genetically inherited, with filaggrin mutations significantly increasing the risk of developing AD. Filaggrin plays an important role in the skin’s barrier function. It brings together structural proteins in the outermost skin cells to form tight bundles, flattening and strengthening the cells to create a strong barrier. In AD, skin is heavily colonised with Staphylococcus aureus (S. aureus) in lesional and non-lesional skin. A rising proportion of S.

Written by Dr Cathal O’Connor, Clinical Research Fellow in Paediatric Dermatology, Irish Clinical Academic Training Programme, Royal College of Physicians of Ireland

aureus in skin microbiome samples predicts a flare, and diversity of non-staphylococcal species returns once a flare has been treated. A hallmark of AD is Th2-mediated inflammation, with high levels of IL-4 and IL-13 that promote dysfunctional allergic inflammation. With chronic or untreated AD, other immune pathways can become activated. Each component of the triad interacts with the others in a vicious cycle, for example filaggrin deficiency allows antigens to penetrate the stratum corneum and stimulate inflammation, and subsequently IL-4 and IL-13 production leads to reduced filaggrin production. It has recently been shown that dupilumab (a biologic targeting IL-4 and IL-13) not only reduces inflammation but enhances skin barrier function, highlighting the importance of adequately treating inflammation in AD. It is essential to treat each

component of the causes of AD adequately to optimise outcomes.

Treatment of AD

To deal with the three intertwining causes of AD, a three-pronged approach is necessary: emollients to replenish the skin barrier, topical steroids or calcineurin inhibitors to reduce inflammation, and antiseptic bleach baths to reduce cutaneous dysbiosis. In special scenarios oral antibacterial or antiviral agents may be required.

Parents of babies with AD should NOT be told to use topical steroids ‘sparingly’ or ‘thinly’ and should be advised to treat for an adequate duration. Babies with AD should NOT be treated with oral steroids (outside of expert centres with a therapeutic exit strategy in place) due to the severe side effects and lack of disease modification. Parents of babies with AD should NOT be told to change their washing powder or reduce/ eliminate foods from their diet, as AD is not caused by detergents or food allergy, and this can lead to nutritional deficiencies.

Anti-inflammation

The use of anti-inflammatory steroid creams/ointments is

essential to reduce inflammation in AD. Early and aggressive use of topical steroids can reduce the duration of disease, and may also reduce the risk of developing associated problems. The dermatology team in Crumlin have recently shown that reducing inflammation in the skin using steroid creams also reduces systemic inflammation, suggesting that topical steroids can correct the systemic immune dysregulation in AD. For mild AD, hydrocortisone 1% can be dispensed over the counter. However, hydrocortisone 1% is a very weak anti-inflammatory agent, and is not sufficient to treat more severe eczema. For moderate AD, agents such as clobetasone butyrate (Eumovate) or betamethasone valerate 0.025% (Betnovate RD) can be used. For severe AD, potent agents such as betamethasone valerate 0.1% (Betnovate 0.1%) or mometasone furoate (Elocon) should be used. In general it is better to use a more potent topical steroid less frequently than a weaker topical steroid more frequently, for two reasons: systemic absorption is related to the frequency of application, and the burden of treatment with daily topical steroid

application is much higher than twice weekly. Topical steroids should be applied liberally (not sparingly!) so that the affected skin is left glistening afterwards. Ointments are preferable to creams as the higher lipid content makes the vehicle more effective. There is no benefit to using topical steroids more than once dailymore frequent use increases the risk of systemic absorption and reduces adherence. In general, therapy should be continued once daily for two weeks, then weaned to alternate days for two weeks, then maintained twice weekly (weekend therapy on Saturdays and Sundays is a good option for busy parents) until the skin has been clear for several months.

Myth 1 Topical steroids should be applied sparingly/thinly and only for short bursts

Topical steroids are a very elegant way to deliver local antiinflammatory therapy, without the potential side effects that systemic therapy can produce. Skin that is inflamed with AD is on fire immunologically. This immune dysregulation needs to be extinguished appropriately to prevent worsening or chronic AD. If topical steroids are stopped too quickly the inflammation can return rapidly. Parents are almost always counselled by pharmacists and non-dermatology doctors about the risk of skin thinning, but this is generally limited to prolonged use of extremely potent topical steroids such as Dermovate (which should only be prescribed for palmoplantar AD). We have recently performed qualitative research interviewing parents of children with severe eczema, and the ‘mixed messages’ about the safety of topical steroids can cause significant upset.

Myth 2 Topical steroids can never be used on broken skin in AD

When skin inflammation is so severe that it has caused skin breakdown, either directly or indirectly from scratching, it is essential to reduce inflammation to avoid further damage. It is safe to apply topical steroids to broken skin.

Topical tacrolimus, a calcineurin inhibitor, is an alternative to topical steroids. It is a useful antiinflammatory adjunct, particularly in the maintenance phase of AD (rather than the treatment of flares, when it is less effective than potent topical steroids). The only side effect is mild stinging with the first few applications, which usually settles down with ongoing use. Given the lack of steroid, it is particularly useful for sensitive areas such as the eyelids.

Topical tacrolimus is much more expensive than topical steroids. Myth 3 Topical tacrolimus can never be used in babies and only 0.03% can be used in older children

Topical tacrolimus (Protopic) has been used in dermatology for decades, with an overwhelming volume of reassuring safety data. Protopic 0.1% is licensed for patients over 16 years, and Protopic 0.03% is licensed from two to 16 years. Dermatologists usually prescribe the 0.1% formulation for all ages, because of the extensive safety data and the enhanced efficacy. There is extensive anecdotal evidence of safety of Protopic in younger infants, so Protopic 0.1% is often prescribed off-license for infants under two years.

Skin barrier replenishment

Moisturisers (also known as emollients) should be used twice daily or more, and moisturising after a bath (‘soak and seal’) is an excellent way to hydrate the skin. Moisturisers should be applied downwards to avoid blocking or irritating hair follicles. A pump dispenser is useful for preventing bacterial colonisation of the moisturiser container. Alternatively, a large spoon can be sterilised (using boiling water) and dipped into a tub to avoid transfer of bugs from the parent’s hand to the container. Appropriate bathing advice for babies with AD is to avoid soaps or irritant products that produce bubbles, use an emollient (that does not contain sodium laureth sulfate) as a wash, keep the temperature of the bath tepid, and limit the duration of the bath/shower to 10 minutes or less. The skin should be gently patted dry afterwards.

Myth 4 There is a number one brand of emollient for treating AD

There is no particular brand of emollient that is significantly superior than any other for treating AD. One of the key causes of AD is an impaired skin barrier, and every individual has differing levels of various proteins in their skin that retain moisture and protect us from external threats. Every moisturiser has a different mixture of ingredients, so it best for parents to try several brands to see which leaves the skin most hydrated.

Antimicrobial strategies

For infection-driven flares, the addition of sodium hypochlorite (eg Milton) bleach baths is an effective strategy for reducing microbial colonisation, without causing antibiotic resistance. Two capfuls (60mL) can be added to a baby bath (50L) and four capfuls

(120mL) can be added to a full bath (100L) once or twice weekly. Topical fusidic acid (Fucidin) is frequently prescribed by non-dermatologists for AD and other skin infections. S. aureus resistance to fusidic acid has reached crisis point, driven by inappropriate use of topical antibiotics, and topical fusidic acid should no longer be routinely prescribed for AD. Moreover, the selection for fusidic acid resistant strains also selects for methicillin resistance, creating even more problems with MRSA. If antibiotics are required for infected AD, then oral antibiotics should usually be prescribed, in conjunction with topical antiseptics (eg Milton).

Myth 5 Topical antibiotics are better than oral antibiotics because they do not cause antimicrobial resistance

Topical antibiotics are known to cause localised antimicrobial resistance in the area being treated, but also in cutaneous sites distant to application. One recent study even showed antimicrobial resistance on the skin of close contacts. While oral antibiotics have scope to cause more antimicrobial resistance in an individual patient due to exposure to other flora such as in the gastrointestinal tract, topical antibiotics are usually washed off ‘as is’, compared to oral antibiotics which are excreted in urine or egested in faeces as less active or inactive by-products. The introduction of topical antibiotics directly to waste water is a major contributor to antimicrobial resistance globally.

Special scenarios

Bacterial superinfection

As mentioned, S. Aureus is a major contributor to pathogenesis and flares of AD. While patients with AD are almost always colonised with S. aureus, some babies will develop bacterial superinfection. This manifests as weeping of clear or purulent fluid, honey-coloured crust, folliculitis, abscess, or cellulitis. If there is evidence of bacterial superinfection then oral antibiotics should be prescribed, guided by microbiological cultures (predominantly for resistance information) and local antimicrobial practices. These should be prescribed in conjunction with topical antiseptic measures, which should be instituted as a preventative measure.

Eczema herpeticum

Eczema herpeticum occurs due to infection with herpes simplex virus, and is more common in children. It manifests as clusters of painful and itchy blisters which

evolve into punched-out erosions, sometimes associated with fever. Children can have inactive AD, so it does not represent a sign of treatment failure. It is helpful to take viral PCR swabs to confirm the diagnosis. Treatment should be immediately started with oral acyclovir/valaciclovir. Intravenous therapy may be required if there is concern for ophthalmic or central nervous involvement, or if the patient is unwell. Children with recurrent eczema herpeticum should consider prophylactic antiviral treatment.

Eczema coxsackium

Eczema coxsackium is a recently described entity caused by coxsackie A6 or A16 in babies with AD. Clusters usually occur in springtime. It looks very similar to eczema herpeticum but it is not itchy and there is a slightly purpuric hue to the background skin. Respiratory viral panels can be sent to confirm enterovirus infection as the PCR testing is difficult to access. Given the similarities to eczema herpeticum it is very reasonable to start treatment with acyclovir or valaciclovir but enteroviruses do not express viral thymidine kinase and therefore do not respond to antiviral treatment.

When to refer

Babies with persistent or severe AD despite the use of appropriate potent topical therapy should be referred to dermatology for consideration of advanced therapies. Use of 1% hydrocortisone for a few days does not represent a trial of topical steroids: an adequately potent steroid should be prescribed for at least two weeks to assess response. Dermatologists now have access to dupilumab, a biologic drug targeting IL-4 and IL-13 which is now licensed from 6 months and can be life-changing. In addition, other biologic drugs and oral janus kinase (JAK) inhibitors are also available. JAK inhibitors have a more rapid onset of action and quickly reduce itch, but there are still some concerns about longterm use, based on studies in other conditions such as rheumatoid arthritis, with patients who represent a very different population to babies with AD. Topical JAK inhibitors have been licensed in some countries with significant benefit seen in AD, although cost is currently prohibitive.

Overall it is a very positive time for dermatologists and patients with AD, with effective treatments already available and many more in the pipeline.

Ovarian Cancer

An Overview of Ovarian Cancer

What is ovarian cancer?

Ovarian cancer is an umbrella term for a multitude of different types of cancer that affect the ovaries, fallopian tubes, and the primary peritoneal cavity. The peritoneal cavity, also known as the peritoneum, is a thin membrane that lines the abdominal cavity and covers many of the organs inside that cavity.

There are different types of ovarian cancer. The type of ovarian cancer you have depends on the type of cell it starts in.

• Epithelial ovarian cancer is cancer of the surface of the ovary (the epithelium), and is the most common ovarian cancer. Fallopian tube cancer and primary peritoneal cancer are also included in this type of ovarian cancer.

• Germ cell ovarian cancer derives from the reproductive cells of the ovaries. Germ cell ovarian cancer is rare.

• Stromal cells ovarian cancer derives from connective tissue cell. Stromal cells ovarian cancer is also very rare.

• Small cell carcinoma (SCCO) of the ovary is an extremely rare ovarian cancer and it is not certain whether the cells in SCCO are from ovarian epithelial cells, sex-cord stromal cells or germ cells.3

Ovarian cancer in Ireland

Ireland has one of the highest rates of ovarian cancer in Europe

Ireland also has the 2nd lowest survival rates for ovarian cancer out of 24 EU countries

On average 387 women are diagnosed and 307 women die each year in Ireland from ovarian cancer.2

Written by Bernie Carter, Assistant Director of Nursing, Marie Keating Foundation

It is the 6th most common cancer in Irish women after nonmelanoma skin cancer and the 4th most common cause of death from cancer.

Poor prognosis cancers have in common vague symptoms, late diagnosis, usually at an advanced stage, and a lack of effective treatment options.

Ovarian cancer mainly affects women who have been through the menopause (usually over the age of 50).

It can also affect younger women. Lack of screening for ovarian cancer

There is no reliable screening test for ovarian cancer and every person assigned female at birth is at risk. Delays in diagnoses is common due to this lack of screening and also because symptoms of ovarian cancer are often confused with other conditions. Most people are diagnosed once the cancer has already spread, making it more difficult to treat. While every woman is at risk, ovarian cancer is often overlooked and underfunded.3

Risk factors for ovarian cancer

• Getting older - most cases of ovarian cancer occur between the ages of 50 – 79 but younger people can also get ovarian cancer.

• Family history - risk is higher for women with a family history of ovarian, breast, endometrial or colorectal cancer.

• Faulty inherited genes - 5 to 15% are caused by inherited faulty genes, such as faults in the BRCA1 & BRCA2 gene and Lynch syndrome.

• Ethnicity - women of Ashkenazi Jewish descent are at a higher risk of carrying BRCA1 and BRCA2 mutations and hence have an increased risk of ovarian cancer.

• Pregnancy & Breast feedingyour risk is higher if you have not delivered children. A decreased number of ovulatory cycles (for example during pregnancy and lactation) reduces the risk of ovarian cancer.

• The contraceptive pill - for every five years it is taken, hormonal contraception is known to reduce the risk of developing ovarian cancer by 20%.

• Smoking - an increase the risk of certain types of ovarian cancer such as mucinous ovarian cancer.

• HRT - slight increased risk. Discuss with your G.P.

• Medical conditionendometriosis or diabetes.

• Being overweight or obesehaving excess body fat is linked to an increase in risk of ovarian cancer.

Having one or more risk factors does not mean that you will definitely get ovarian cancer.3,6,7

Symptoms of ovarian cancer

Let’s B.E.A.T. Ovarian Cancer:

• Bloating or an increase in the size of your abdomen.

• Eating less and feeling full more quickly.

• Abdominal and pelvic pain you feel most days.

• Talk to your GP about your symptoms.

Other possible symptoms may include:

• Needing to pass urine more often.

• Tiredness that is unexplained.

• Weight loss that is unexplained.

• Changes in your bowel habit or symptoms of irritable bowel syndrome, especially if this starts after the age of 50.

• Abnormal bleeding – Any post-menopausal bleeding should always be checked by your primary health care provider or doctor.3,4

Diagnosis

of ovarian cancer

As mentioned, there is no routine screening test to diagnose ovarian cancer. A HPV cervical screening test (previously known as the Smear) does not check the ovaries and hence it will not detect ovarian cancer. While cervical screening is effective in early detection of cervical cancer, it is not a test for ovarian cancer.

It is very important to speak to your G.P. if you have any of the symptoms listed and if they persist for more than 3 weeks. Particularly if you have family

history of ovarian or breast cancer or if you have a family history of the BRCA gene alteration (BRCA1 or BRCA2).

Your GP may do the following tests

• Pelvic exam.

• Transvaginal or pelvic ultrasound.

• CA-125 blood test.

Your GP may refer you to a specialist (Gynaecologist) who may request further tests to diagnose or rule out ovarian cancer. Tests that may be done include the following:

• CT scan - several x-rays are taken from different angles to create a detailed image of your ovaries.

• Needle biopsy - a needle is passed through your tummy, under anaesthetic, to retrieve a sample of ovary cells or fluid from around the ovaries, so it can be checked for cancer.

• Laparoscopy - a small opening is made in your tummy under anaesthetic and a tube with a camera is inserted to look at your ovaries, a small tissue sample may also be removed for testing.

If ovarian cancer is diagnosed, these tests can help find check if the cancer has spread.5

Treatment for ovarian cancer

A multidisciplinary team (MDT) will discuss the best treatment option for each individual.

Your treatment depends on several factors

• Type of ovarian cancer.

• Stage of the cancer (Size and Spread).

• Grade of the cancer – tells us how the cancer cells look in comparison to normal healthy cells.

• Your general health. The main treatments for ovarian cancer are

• Surgery.

• Chemotherapy.

• Radiotherapy.

• Targeted Therapies (e.g. PARP inhibitors).

• Clinical trials.

• A combination of treatments may be required.5,6

References available on request

New Approaches in Overcoming Obesity and Cancer

Cancer patients with the condition of obesity could see more positive outcomes from immunotherapy treatment

Principal Investigator Dr Melissa Conroy, alongside Dr Eimear Mylod and Professor Joanne Lysaght

Scientists, funded by Breakthrough Cancer Research, have discovered revolutionary new approaches to overcome key challenges presented by obesity in the treatment of Oesophageal cancer through the redirection of Natural Killer Cells.

There is no one-size-fitsall treatment for cancer and some forms of the disease, like the ones linked to obesity such as Oesophagogastric adenocarcinomas (a type of oesophageal cancer which affects the lower part of the food pipe), can be especially difficult to treat and currently have very low survival rates.

In a ground-breaking development, a team of scientists in Trinity College Dublin, funded by Ireland’s leading cancer research charity Breakthrough Cancer Research, have discovered an innovative approach to making immunotherapy treatment more effective for these cancer patients. The findings, published recently in Nature-Scientific Reports show how a category of cancer-killing immune cells are profoundly and negatively impacted by ‘abdominal fat’ but can be redirected to the tumour by a new drug called E6130.

Oesophageal cancer has long posed a significant challenge in the medical field, with only one in four patients surviving past the critical five-year mark post-diagnosis.

Recognising the urgent need for transformative therapies, Principal Investigator Dr. Melissa Conroy, alongside Dr. Eimear Mylod and Professor Joanne Lysaght, have identified vast potential for novel immunotherapeutic approaches. Their research explores innovative strategies targeting the immune system, particularly Natural Killer (NK) cells. NK cells are the body’s own first-line defence against cancer and play a crucial role in directly recognising and eliminating cancer cells.

One of the key findings of the research, conducted by Dr. Eimear Mylod under Dr. Conroy and Prof. Lysaght’s mentorship, is the profound impact of obesity on oesophageal cancer progression. Notably, individuals with higher levels of visceral fat characterised by excessive abdominal fat, exhibit lower levels of NK cells within their tumours. Through rigorous investigation, the team identified a molecule known as Fractalkine, responsible for drawing NK cells into fat deposits, thus diverting them away from the tumour site where they are needed most.

Building upon this initial discovery, the team introduced an innovative intervention. By utilising a drug named E6130, they successfully redirected NK cells from fat deposits towards the tumour, marking a significant breakthrough in cancer immunotherapy. However, the journey towards effective treatment doesn’t end there.

Dr. Conroy and her collaborators encountered a subsequent challenge: upon reaching the tumour site, NK cells were suppressed in patients with the condition of obesity, hindering their anti-cancer activity. Undeterred, the researchers are now focused

on overcoming the suppression of NK cells within such tumours. Whether through the introduction of fortified NK cells from healthy donors or through innovative strategies to counteract suppression within the tumour microenvironment, the team believes that they can enhance efficacy of immunotherapies for oesophageal cancer patients.

“This research not only offers hope for oesophageal cancer patients but also holds promise for advancing immunotherapy across various cancer types,” stated Dr. Conroy. “By addressing the intricate interplay between the immune system, obesity and cancer, we are paving the way for more effective and personalised treatment approaches.”

The findings from this study represent a significant milestone in cancer research, with farreaching implications beyond oesophageal cancer. As many as 13 cancers are currently strongly linked to obesity. As the medical community continues to unravel the complexities of cancer immunity, Dr. Conroy’s team stands at the forefront, driving innovation and delivering hope to patients worldwide.

The research is being funded by Breakthrough Cancer Research through their award-winning partnership with Qualtrics through their campaign called five for the Fight. Orla Dolan CEO of Breakthrough Cancer Research said, “We are thrilled to see the publication of these powerful new findings. This team have not only unlocked how visceral or belly fat can impede a patient’s immune system reaching their tumour but they have gone a step further and found a way to overcome that. The immune system is a powerful tool in treating cancer but its complexity is still being unravelled. This research is a huge step in unleashing that tool for more patients.”

Breakthrough Cancer Research is Ireland’s leading cancer research charity. They work with researchers and scientists throughout Ireland and fund exceptional patent focused translational research throughout Ireland and beyond. They particularly focus on poor prognosis or low survival cancers which are often diagnosed at an advanced stage and are poorly served by current treatments.

Breakthroughcancerresearch.ie

Ask yourself, where is your nearest AED?

When I first started working in the medical device industry almost 30 years ago in 1995, it was a time before AEDs as we know them really existed in Ireland. The small medical company I worked for then provided a wide range of equipment mostly in the area of resuscitation with the salesperson at that time selling defibrillators to Ambulance Services around the country. In many cases, this was the first time ambulances were getting to carry and use defibrillators, thanks to the ECG analysis programme within which it could determine whether the patient needed a shock or not. Even hospitals only had defibrillators in acute areas such as theatres, coronary care and the accident and emergency departments, but not on the wards. I was fascinated with the machines and what they could do and soon I started learning that the ones we were supplying were saving lives in the hands of the Ambulance personnel. This was a first and especially important step towards improving outcomes from heart attacks and cardiac arrest.

What ambulance personnel see when they arrive on scene today has greatly evolved from what they saw even as recently as in the midnineties. When a person suffered a cardiac arrest, 999 was called and people waited for the ambulance to arrive. Nowadays, CPR is given by a by-stander and sometimes an AED is used, often just grabbed from the nearest hotel or shop, which is something we have come to expect them to have.

Working in the industry I knew that early CPR was important and

Written by Conrad Wynne, Senior Product Specialist, OxygenCare

that defibrillators could save lives. AEDs could be used by anyone but little knowledge of how they worked or how safe they were was known, even amongst medical professionals. Along with this lack of understanding of how safe this new technology was, there were many barriers to their introduction of these lifesaving devices. There was limited choice for those wishing to buy an AED, which was uncommon and expensive. In 1996 one of the earlier AEDs introduced was priced at almost ¤5000. People were also afraid of being sued if they attempted to save someone’s life. Organisations such as Croí (The West of Ireland Heart and Stroke Charity), the Irish Heart Foundation, and more recently, PHECC (The Pre-Hospital Emergency Care Council), worked diligently over the years to raise awareness about the importance of CPR, early defibrillation, and appropriate responses in cardiac emergencies. In the past, even when an ambulance arrived, it might not have been equipped

with a defibrillator, so people were coached to specifically request a ‘Cardiac Ambulance’.

One day in 1997 a small box arrived at my workplace which changed things. In the box was a new style AED but it was not immediately clear to me what it was and who would use it. This device was so much smaller and simpler than previous models, it did not have a printer like the ambulance model and its battery was not rechargeable. I wondered what could you do with that data card? This was in fact the dawning of the modern AED.

When it comes to treating cardiac arrest there simply is not enough time to rely on even the quickest ambulance responses or time to travel to a hospital and then find the right people with the right equipment and training – we know this now. Every minute that passes is a 10% reduction in the possibility of saving a cardiac arrest victims life. But what is acceptable? Is a 5-minute delay ok so we only save half of the people?

Back then so much awareness was needed. It was not just AEDs that were needed, in order to save more lives, the symptoms of cardiac arrest needed to be recognised more quickly, help needed to be called for more

Pictured left to right: Maurice Moran, Managing Director, OxygenCare; Etáin Moran, Corporate Affairs & Brand, OxygenCare; Conrad Wynne, Senior Product Specialist, OxygenCare with the Defibtech LifeLine AED and LifeLine View AED

quickly and CPR needed to be given more quickly.

Fast forward to the early 2000s and I am now working directly for a large manufacturer. Having sold just four AEDs in the year 2000 and 25% growth to five AEDs in 2001, the opportunity arose to develop a plan to support charities helping to create awareness.

In 2002 Croí reported that of some 6000 victims of cardiac arrest in Ireland in that year 99% would in fact die. This was announced at a breakfast meeting and press launch for the Community First Responder (CFR) Schemes in Connemara, amongst the very first CFR groups in the country. With heavy rains forecast and in anticipation of a potential bog slide, the country’s media who were waiting for this event had fortuitously booked into the same hotel. They took the initiative of attending the CFR launch and filled the room to hear presentations from the local Ambulance Chief, a Cardiologist and also the Chief of the Fire Service at Dublin Airport, one of the country’s most successful Public Access Defibrillator schemes – even at that stage of development of AED programmes. In modern terms, the press launch went ‘viral’ with hourly references on most radio news programmes, TV news and print media followed the next day. It did not take long before I started getting calls and orders for AEDs from Government Departments.

The interest from Government was key to the success of driving sales and growth of AEDs. The first National Conference in 2004 run by the Irish Heart Foundation in the Helix followed, with over 1000 delegates present. At this event, the Department of Health sent a delegation which formed the Sudden Cardiac Death Task force. This led to important statistical and supporting work to encourage growth of placement of AED programmes. Again, this received extensive positive media coverage.

In 2011, Government enacted The Good Samaritan Act to protect providers from being sued for attempting to assist another human being, which removed a further barrier to CFR programmes being created.

In 2016 the Health and Safety Act advised large and medium sized employers that they should protect their employees by providing and maintaining AEDs at the workplace. Fortunately, many organisations are motivated by social conscience i.e. having an AED is the right thing to do, they are maintained properly, accessible and there is staff training about how easy they are to use. These AED programmes at workplaces are saving lives. Workplaces take fire prevention and protection seriously, but how often do companies conduct Fire Drills for example vs CPR and AED training? We test our fire alarms every week and even do fire drills and evacuations – but how often do we do cardiac

Richard Smith, engineer at OxygenCare, calibrating a Corpuls AED

arrest emergency scenario training, so we are ready when the unthinkable happens.

It has happened to me on more than one occasion where an AED I have provided has been used successfully within weeks. It always gives me a chill to think what if they had delayed their purchase. Thankfully, it is becoming more common to hear of cardiac arrest survival but there is still a long way to go. Every year sees improvements with more AEDs being placed in more industries and in more public places. The numbers of voluntary Cardiac First Responder schemes are growing annually with support from the CFR Ireland Charity and the National Ambulance Services CFR engagement officers.

And it has delivered results. Today when the Ambulance turns up to a cardiac event CPR is very likely to be ongoing. The latest statistics from the Republic of Ireland’s Out of Hospital Cardiac Arrest Registrar showed that in 2022, CPR was in progress more than 84% of the time and an AED was in use 31% of the time. 1Survival rates to hospital discharge is 7.3%, which is a massive step forward from of 1% in 2003 and every life counts, but we can still do better. Our rural landscape and distances to advanced care present a challenge too.

To do better we need more AEDs placed, more awareness and more CPR being taught across all walks of life. It is encouraging to see

the Irish Heart Foundation’s ‘CPR 4 Schools’ Programme teaching transition year students these important lifesaving skills. Dental Guidelines state that dentists now need to have an AED on-site.

In the 2023 Budget, the Irish Government reclassified AEDs to remove them from the 23% VAT rate band, meaning 0% VAT is now applicable on all AEDs, cabinets, and training equipment, which is a huge step forward in making AEDs more affordable.

The importance of checking and maintaining AEDs was highlighted by HIQA (Health Information and Quality Authority) in 2014 who reported that more than 20% of AEDs were not rescue ready. A single AED is often considered sufficient, but for many large workplaces, schools and buildings, realistically it is not enough. The gold standard employed by Airports for example is a oneminute fast walk in either direction from the nearest AED. Remember the 10% per minute rule? Let us surmise, it takes a minute to realise what has happened to that person who has slumped in their chair, one more minute to get to the AED and another minute back, another minute to power it on, open the pads packet and attach them to the patient before a lifesaving shock is delivered. So now we are at 4 minutes, maybe 5 and already half the opportunity to save that person’s life is gone. What if the AED is located a five-minute fast walk away? That is a 10-minute round trip, and the clock does not stop.

So, ask yourself, where is your nearest AED?

Reference 1Out of Hospital Cardiac Arrest Register Annual Report publishedNational Ambulance Service

Cardiothoracic

A Day in the Life of a Cardiothoracic Theatre Team

Written by Kristine V. Lapid, Clinical Nurse Manager II of Cardiothoracic Theatre Department, University Hospital Galway

At the Cardiothoracic Department, Theatre 11 in Galway University Hospital there is a dedicated Cardiothoracic Theatre Team consisting of 13 staff members led by Kristine Lapid, the acting Clinical Nurse Manager II, working alongside her 12 highly specialised theatre staff nurses.

Covering a wide variety of Cardiothoracic surgeries the likes of which include Coronary Artery Bypass Grafting, Mitral and Aortic Valve Replacement, Aortic Root Replacement, Minimally Invasive Valve Repair and Replacement, Septal Myectomy, Pericardiectomy, Video Assisted Thoracic Surgery and Open Thoracotomy , all but to name a few ensures that for the staff operating within the Cardiothoracic Department, no two days are the same with each day presenting its own unique challenge for all of those involved. With patient safety and surgical success at the heart of what they do 'Literally'.

Elective cases start off with the routine morning briefing with the Perioperative Surgical Team, Anaesthetic Team, Perfusionists and Cardiothoracic Staff Nurses all in attendance. It is of vital importance as it enables the sharing and clear communication of the Operative Plan, promoting the need for Teamwork, mitigating

any potential hazards for the patient, reducing preventable harm and ensuring that all equipment required will be available and at hand.

Lending itself to a broader knowledge base for the upcoming planned procedure with a clear pathway and clear communication ensures that each Team Member has a clear understanding of the tasks at hand and can anticipate future events pre planning accordingly.

Once the patient has been sent for and has been brought into the Theatre, prior to the induction of anaesthesia WHO sign in is carried out the confirm that the patients identify and align with the correct site and the procedure type written in the consent form, any anticipated blood loss, allergies and any other possible future complications.

The surgical equipment and instruments are prepared and Cardiothoracic Nurses anticipate the needs of the Perioperative Team from the very start. Always ensuring the highest integrity and sterility of any possible implant for each Cardiothoracic Case, remaining calm, alert and focused, at all times has become the dayto-day routine for this Team of Nurses. Advocates for the patient from the moment he or she enters

the Theatre until they are ready to be transferred safely to another department, safety, privacy and dignity is at the forefront of this Teams culture during their stay in the Cardiac Theatre.

The majority of patients will be anaesthetised for Cardiothoracic Cases so providing them with the best care when it comes to sterility ensuring that there will be no postoperative infection from the initial thorough skin and site preparation to the application of the dressings on the wound site.

An utmost standard of care is maintained at all times from making sure that the surgical count is correct, maintaining infection control, ensuring patient skin integrity all throughout the surgery, safe placement and positioning of the patient right down to maintaining the Cardiothoracic theatre Temperature based on the needs and requirements of the patient.

Double checking patient input and output, making sure regularly that all blood and blood products are available should they be required, with clear and concise communication and engagement with the Perioperative Team, multidisciplinary Team members such as the Blood Bank, Wards, Porters, Purchasing Department and the Intensive Care Unit this

Cardiothoracic Theatre nurses from left Richelle Acorin, Rizalyn Manguiat, Sunu Radha, Bernadette Folan, and Clinical Nurse Manager II Kristine V. Lapid

Cardiothoracic Team of Nurses ensures that no stone is left unturned.

Covering elective day to day cases forms the vast majority of the Cardiothoracic Teams duties and responsibilities but it doesn't just stop there. Emergency situations occur regularly where quick thinking and action is required at a moment’s notice. Forming part of the equipment required for such an event is the Cardiac Tamponade Trolley.

Cardiothoracic Staff Nurses are on call at all times to respond instantly if and when required. Through ongoing training and development the Cardiothoracic Theatre Nurses called in to respond immediately delegate and take on the role of a scrub nurse whilst also requiring the need to circulate at all times attending to the needs of the patient in a high pressure high stress emergency environment.

With the scrub role comprising of surgical assistance alongside the surgical team, setting up the sterile instruments and equipment required at a moment’s notice. With the patient on the verge of Cardiac Tamponade defined by a fluid accumulation in the pericardial sac requires early diagnosis and immediate intervention. This condition is known to have multiple causes

Cardiothoracic Theatre nurses from left Sunu Radha, Varsha Vishwanathan, Anjaly Jose, Clinical Nurse Manager II Kristine V. Lapid, Cardiothoracic theatre nurses Biji Baby, Devi Arackal

including but not limited to postoperative bleeding after Cardiac Surgery.

Cardiac Tamponade an increase of the intrapericardial pressure, a compression of the heart with Cardiac inflow restriction, eventually leading to organ failure, shock and Cardiac Arrest in extreme cases. For this unique Team of Nurses and their broad range of specialities they have learned to take each day in their stride irrespective of what may present itself to them, ready to jump into action when called to do so.

Welcome to the Cardiothoracic Team, welcome to Theatre 11.

Enhancing Care for Patients with Lower Urinary Tract Symptoms

The introduction of a Nurse-Led Urology Clinic at Roscommon University Hospital for Lower Urinary Tract Symptoms (LUTS) has significantly enhanced patient care, reduced wait times, while also reducing the number of patients who require consultant urologist review.

The clinic was established to provide a focused targeted urological assessment of symptoms, as well as treatment, support, and education to enable patients to manage their urological condition without surgery and to reduce wait times for LUTS assessment and management.

Prior to the commencement of the Advanced Nurse Practitioner (ANP) LUTS clinic in February, patients requiring ongoing nursing management or intervention were referred to University Hospital Galway. Wait times from referral to review have decreased from 1-2 years to 6-8 weeks at present, with 156 new patients assessed between February and June.

LUTS and specifically male LUTS is one of the most prevalent complaints presenting to urology outpatients. Research conducted by the National Clinical Programme in Surgery (NCPS) revealed that male LUTS is one of the more common causes for

Michelle Healy, Advanced Nurse Practitioner and Clinic Lead for the Lower Urinary Tract Symptoms (LUTS) Clinic at Roscommon University Hospital

referral to a urologist in the Saolta University Health Care Group.

Professor Eamonn Rogers, Consultant Urologist at Saolta University Health Care Group and Co-Lead National Clinical Programme in Surgery said, “The Nurse-Led Urology Clinic is one of the strategies of the Model of Care in Urology developed by the NCPS to improve access for urological care and to reduce waiting times to be seen in clinics.”

Michelle Healy, Advanced Nurse Practitioner and Clinic Lead, stated, "We have an excellent urology service here at

Roscommon University Hospital, between the Rapid Access Haematuria service and the LUTS service, and to have two visiting Consultant Urologists from University Hospital Galway aligned to service and supporting us, is fantastic.”

“We are providing care to patients as close to home as possible and our patients always comment on how easy it is to travel to Roscommon, and how tremendous the service is. So it's wonderful to see that the clinic is already making a significant difference in the lives of our patients.

“As ANP, my role involves the evaluation of urinary flow rates, catheterisation, teaching and education on intermittent self-catheterisation and selfintermittent dilatation, benign bladder instillations and endoscopic guidance of guidewire to facilitate catheterisation. The referral pathway to the clinic for patients experiencing LUTs is via their GP to the Consultant Urologist who triages the referral to the ANP-LUTS clinic. Patients with any red flags, such as haematuria, are referred to the consultant Urologist for further investigation.

Thrombosis

Thrombosis Ireland Recognise outstanding efforts by Health Care Professionals

Venous thromboembolism (VTE) compromising deep vein thrombosis (DVT) and Pulmonary embolism (PE) is the leading cause of death and disability worldwide. In Ireland, VTE remains the leading cause of maternal mortality. Globally, two thirds of all cases of VTE are hospital acquired, meaning that they occur either during a patient’s hospital stay or within 90 days of discharge. In majority of patients, such events are preventable through timeous risk assessment, initiation of appropriate prophylaxis and patient education. In many cases, VTE is treatable, but if left undetected, can be potentially fatal.

In recent years, significant advances have been made in the field of VTE prevention and Thrombosis Ireland have been proud to support the efforts being made by many of our healthcare providers & Research Scientists, to improve the quality of blood clot prevention, treatment & recovery in our hospitals.

Every year, Thrombosis Ireland, on behalf of Thrombosis Patients and their families, launch their VTE Exemplar Awards and invite you to nominate an individual, a hospital, a hospital group or a researcher or research group, in recognition of their outstanding efforts in the area of VTE prevention, treatment & recovery.

Examples of previous Thrombosis Ireland Exemplar Award Winners:

Carol Walsh, ANP, Acute Medicine & Emer O’Sullivan, Quality & Patient Safety Manager – Bantry Hospital – Won Best Hospital Award 2023. Carol & Emer, took on a quality improvement project (QIP) to reduce the rates of hospital associated venous

Written by Ann Marie O’Neill, CEO, Thrombosis Ireland

thromboembolism (HA-VTE) in Bantry General Hospital. Following risk cause analysis the QIP focused on improving the identification of patients who were at risk for developing HA-VTE thus ensuring they could receive the appropriate prophylactic therapy within 14hrs of admission. They also ensured that they Educated patients and HCP on hospital associated VTE. Weekly audits show completion of VTE Risk Assessments improved from an average of 17% to 83%

Alana Dineen, Senior Clinical Pharmacist & Consultant Gynecologist, Dr. Zibi Marchocki from Cork University Hospital won Best Maternity Hospital 2023 for their work on a Recent guideline which they developed for Postoperative VTE Prophylaxis for Gynaecologic Oncology Patients post Major Abdominal Surgery at Cork University Maternity Hospital. This Guideline was developed due to the criticality of VTE prophylaxis for this patient cohort, an evidencebased local policy reflecting current national and international best practice, was an important tool in managing this risk safely and appropriately for these patients. The aim was to reduce the incidence of postoperative VTE in patients following major abdominal surgery for gynaecologic malignancy, an extended course of 28 days, of LMWH prophylaxis is recommended and is an accepted practice worldwide. However, there are some limitations to the use of LMWH.

The use of an oral preparation for VTE prophylaxis instead of a LMWH on discharge for eligible patients represents a change in current practice in CUMH, but offers greater convenience for the patient, while reducing the time and resources required for predischarge counselling and training, reducing the risk of sharps injuries, and eliminating the requirement to store and dispose of a sharp at home. The introduction of this alternative management option therefore, has the potential to improve medication adherence and patient satisfaction, while easing post discharge transition of care and preserving patient safety.

Joanna Desmond ADM, Limerick University Maternity Hospital was awarded the Quality Improvement Award for 2024.

In University Maternity Hospital Limerick, they recognised that they had suboptimal compliance with our VTE scores at 4 key contact points in pregnancy. They undertook a robust quality improvement project. A multidisciplinary team worked on the project which encompassed audit, staff survey, root cause analysis and the implementation of a QIP. Staff education and training was undertaken along with the development of current and future state process maps. The Clinical Midwife Manger in the antenatal ward was instrumental in her commitment and leadership at ward level to embed the practice. They were able to achieve a 100% compliance with VTE assessment across 4 key contact points and sustain this compliance for over 6 months.

Niamh O’Hanlon, Chief Pharmacist II, St. Vincent’s University Hospital won a VTE Warrior Award in 2021. These special ‘Warrior’ awards go to individuals who go above and beyond for their Patients. Niamh is a major force in driving quality improvement in the field of Thromboprophylaxis and is dedicated to patient safety in the setting of anticoagulation. She ensures that patients in the SVUH are managed and educated appropriately and is she is always mindful of the Patient Perspective. Who do you know that deserves to be recognised? Lodge your nomination now!

Application Form: https://thrombosis.ie/wp-content/ uploads/2024/06/Final-ApplicationForm-2024.docx

The closing date for receipt of nominations is 5pm, Thursday, September 5th. Awards will be presented on Friday 4th October at VTEDUB24 International Conference in the Mater Hospital, Dublin.

Variation in the practice of wide local excision for melanoma in Ireland and the UK: a questionnaire survey

Written by Eileen O’Connor1, Cathal O’Connor1,2, Garret O’Connell1, Howard Peach3 and Sally O’Shea1

1Dermatology, South Infirmary Victoria University Hospital, Cork

2Medicine, University College Cork, College Road, Cork

3Leeds Teaching Hospitals NHS Trust, Leeds, UK

Melanoma is the fifth most common cancer in Ireland and the UK.1,2 In Ireland, between 1995 and 2015, the age-standardized rates of melanoma have increased by 5.1% per annum for men and 2.6% per annum in women.3 Wide local excision (WLE) is a surgical procedure in which an additional margin of tissue is removed from around the scar of a primary excision, and is a standard treatment for melanoma.4,5 WLE has been shown to improve overall and melanoma-specific survival.6

National Institute for Health and Care Excellence (NICE) guidelines recommend the margins for WLE based on the stage of the primary melanoma: melanoma in situ (MIS) requires at least a 5 mm margin; clinical stage I requires at least 1 cm; and stage II or above requires at least 2 cm, unless this would result in ‘unacceptable disfigurement or morbidity’.7 These guidelines also recommend that when determining the margins of WLE one should consider the margins that have already been achieved during the primary excision. The Melanoma Margins Trial II (MelmarT-II) is currently underway to clarify whether 1 cm or 2 cm WLE margins are more effective in decreasing local recurrence and increasing survival in intermediate and highrisk melanomas [primary tumour (pT)2b–pT4b].8

There is currently a dearth of information and clinical guidelines on the technical aspects of the WLE procedure. The Practical Manual for Dermatologic and Surgical Melanoma Management recommends measuring margins from the edge of the biopsy scar or the periphery of any residual disease.5 Excisions should be oriented longitudinally to minimize interference with lymphatics.9 MelMarT-II specified that surgeons should mark the central half of a linear scar and measure the radial margin perpendicularly along its length.10 At each end of the central half, a semicircle should be marked with a radius equal to the predetermined excision

margin.10 In Melanoma in Clinical Practice, authors recommend an elliptical excision down to but not including deep fascia, with primary closure, using a 3 : 1 ratio (length to width), with orientation along Langer’s lines.4 Other sources suggest orientating excisions along relaxed skin tension lines (RSTL) to optimize scar formation and minimize wound contraction.11 With limited resources describing the technical aspects of WLE it is unclear how clinicians learn to perform this procedure.

The aims of this study were to determine if there is variation in the performance of the technical

Figure 1 Baseline characteristics of the questionnaire respondents (n = 128). SpR, specialist registrar

aspects of WLE among clinicians in Ireland and the UK and to clarify how clinicians learned the technique.

Materials and methods

This was an international, crosssectional study conducted using an online questionnaire over a 9-month period from 29 April 2021 to 10 March 2022. Invitations to the survey were distributed through national and international professional associations that specialize in plastic surgery, dermatology and melanoma research in Ireland and the UK, including the British Association

of Reconstructive and Aesthetic Plastic Surgeons, Irish Association of Dermatologists, British Association of Dermatologists, Melanoma Focus and the BioGenoMel Consortium. Only doctors who perform WLE were included in the study.

Data were collected on demographics and WLE practice through an online questionnaire hosted by Google forms (Appendix S1; see the Supporting Information). Questionnaires were distributed by the professional associations to their members. Analysis was performed using coded data

Melanoma

transferred from Microsoft Excel to SPSS. The STROBE statement is included in Appendix S2; see Supporting Information.

Results

There were 134 responses to the questionnaire. Six responses were excluded because the respondents did not perform WLE. Regarding specialty, 73 participants (57%) were dermatologists, 49 (38%) were plastic surgeons and 6 (5%) were in other fields such as maxillofacial, general and breast surgery. Most (80%, n = 102) respondents were consultants, and 20% (n = 26) were registrars or specialist registrars. Fifty-six (44%) clinicians worked in their position for 3–10 years, 49 (38%) for over 10 years and 23 (18%) for less than 3 years (Figure 1).

Almost all respondents (99%, n = 127) reported learning their WLE technique from a consultant: dermatologists (52%, n = 67), plastic surgeons (49%, n = 63) or other consultants (14%, n = 18). Over half (56%, n = 72) of respondents learned WLE solely from consultant plastic surgeons or dermatologists. Textbooks (16%, n = 20), internet videos (3%, n = 4), internet photos (3%, n = 4) and ‘other’ sources (15%, n = 19) were also reported (some respondents used more than one resource).

Variation was seen in specific aspects of WLE technique. Most (81%) oriented WLE incisions longitudinally or obliquely, 2% oriented them transversely and 17% specified ‘other’. ‘Other’ orientation answers included orientation of WLE scars along the RSTL, adjusting according to skin or soft tissue laxity, the location on the limb, the planned margin, the orientation of the narrow excision scar, or the need for reconstruction. Most (87%) made allowances for orientation along RSTL.

Respondents were split on whether or not to consider the margins achieved on the initial narrow margin excision; 59% included the initial margin and 41% did not include the initial margin. In terms of depth, 79% excised to deep fascia, 18% to the next biological margin and 3% to include deep fascia. Most (71%) respondents marked the skin with the skin relaxed, as opposed to stretched (29%). After drawing skin markings, 70% of respondents incised through the line, 27% outside the line and 3% inside the line.

Almost all (95%) respondents infiltrated with local anaesthetic after drawing the skin margins. Most (84%) measured the margin arc from the edge of the scar; however, 16% measured from the central 50% of the scar. A greater proportion of plastic surgeons measured the arc from the centre of the scar (29%, 14/49 of plastic surgeons vs. 8%, 6/73 dermatologists), whereas a greater proportion of dermatologists measured the arc from the edge of the scar (92%, 67/73 of dermatologists vs. 71%, 35/49 of plastic surgeons) (P = 0.003). If dog ear repair was performed, 60% did not send the tissue for histology.

Discussion

Variance was seen in the planning and performing of WLE in this cohort of respondents. Most clinicians learn how to perform WLE exclusively from other clinicians, without other resources such as textbooks or videos. The only statistically significant difference between dermatologists and plastic surgeons was the calculation of the margin arc from the edge of the scar (more common in dermatology) vs. the central 50% of the scar (more common in plastic surgery).

Significant variation was seen in whether clinicians consider

NEWS - Mental Health Bill 2024

the peripheral and deep margins already achieved on initial narrow margin excision. The 2022 NICE guidelines recommend taking these into account, although these guidelines were published after this study was completed, highlighting the need for guidelines and standardization of the procedure.7 Almost a third (29%) of respondents stretched the skin when measuring margins, potentially decreasing the margin achieved. Few (5%) respondents infiltrated with local anaesthetic before creating skin markings, which could also decrease the margin achieved.

There was marked divergence in terms of incising through, outside or inside skin markings, which may also affect the margin. There was significant contrast in terms of depth of the margin, with most clinicians excising to deep fascia, but some excising to the next biological margin or to include the deep fascia. Excising down to but not including deep fascia has been suggested.4 Operative Standards for Cancer Surgery states that WLE for MIS should only include skin and subcutaneous fat.12 Body site and skin thickness are factors to be considered, as these may affect a clinician’s approach. Practically, excising to deep fascia may be difficult, especially in areas like the abdomen, where there is increased subcutaneous fat, and could result in unnecessarily deep incision margins.

There was consensus that WLE scars on the limbs should be oriented longitudinally or obliquely. This is important because lymphatics of the upper and lower limbs have a vertical or longitudinal distribution. Therefore, transverse incisions could damage lymphatics, impair drainage and precipitate problems such as lymphoedema.

Strengths of this research included the use of a detailed survey, the wide distribution to professional

organizations in Ireland and the UK, and the lack of previous research in the area. To our knowledge this is the first study examining variation in WLE for melanoma. Limitations included the small sample size; under-representation of plastic surgeons and other surgical specialties, such as maxillofacial surgeons, who carry out a considerable volume of WLE; and under-representation of doctors in training, which limited insights into current training practices and limits the ability to detect difference in practices between consultants and doctors in training. Survey studies with small sample sizes are susceptible to responder bias, and it was not possible to calculate a response rate for this survey as it was impossible to assess how many doctors had received the email link or seen the link on association websites.

WLE is a major component of melanoma management. Variations or inconsistencies in its practice may lead to discrepancies in outcomes. Although numerous studies are underway to determine the preferred margins for WLE, it is essential that a standard practice of WLE and margin calculation is developed to optimize outcomes. Although most WLE in the UK are performed by plastic surgeons,13 it is important that a uniform approach to technique is adopted by all specialists undertaking WLE. This study highlights the need for guidelines to clarify the technique of WLE and to ensure a more uniform approach to the procedure. Future work in the area should include the development of a Delphi consensus process for the procedure of WLE for melanoma among the key stakeholders involved in Ireland and the UK, such as dermatologists, plastic surgeons and other speciality surgeons who perform WLE.

References available on request

Minister for Mental Health and Older People, Mary Butler, has announced the publication of the Mental Health Bill 2024 , which was approved by Government on 24 July. The development of the new Mental Health Bill, which will replace the existing Mental Health Acts 2001 – 2022, is a longstanding priority of the Department of Health and features in the current Programme for Government.

Minister Butler said, “I am delighted to publish this important piece of legislation today. The publication of the Bill is an important milestone, and I am happy to deliver on my commitment to ready the Bill for the next steps in the legislative process. Today’s publication means that the Bill will be ready for introduction to the Oireachtas as soon as possible on the return of the Dáil in September. The Bill will replace the 2001 Act, introducing a more modern, person-centred approach to mental health legislation and will put in place a more robust framework in which our mental health services will be delivered and regulated. Importantly, the Bill introduces the regulation of community mental health services, including CAMHS, for the first time.”

Minister Butler added, “The Bill contains numerous important measures, which will have a tangible beneficial impact on individuals accessing mental health services, empowering them to play a more active role in making decisions about their care and treatment. The Bill is lengthy and complex, containing 202 sections, and I look forward to guiding it through the legislative process and to bringing it to Committee Stage in the Autumn.”

The Bill was subject to extensive consultation during the current drafting process and prior to the publication of the General Scheme in July 2021, including ongoing consultation with the Mental Health Commission, the Health Service Executive (HSE) and other Government Departments and stakeholders.

60 Second Summary

Post-operative analgesia is crucial in enabling patients to mobilise promptly, commence early rehabilitation, have a greater chance of returning to their pre-operative baseline and therefore better long-term prognosis.

Short-acting opioids are preferable to long-acting opioids in opioid naïve patients due to superior effectiveness in managing acute pain, reduced risk of respiratory impairment, and reduced risk of dependence, misuse and diversion. Short acting opioids should be charted both regularly and as required in the immediate aftermath of surgery. As acute pain subsides, the regular opioid should be weaned down and ceased followed by as required opioids.

Analgesia should be patient specific considering: age, weight, injuries, hepatic function, renal function and titrated to patient functionality and pain.

Post-operative nausea and vomiting, and constipation are very common post-operative side-effects. Patients should have at least one regular laxative prescribed if they are prescribed opioids, except in gastrointestinal surgery where the consultant general surgeon will determine if and when laxatives are needed. Anti-emetics should be prescribed considering the QTc interval, patient’s other regular medicines and if the patient has Parkinson’s disease.

NSAID’s are best avoided in older patients due to the increased risk of bleeding and acute kidney injuries.

multidisciplinary team alongside consultant

orthogeriatrician Dr Helen O’Brien and pain management CNS leading to the development and use of post- operative analgesia

AUTHOR: Marie Richardson

Marie Richardson is a Senior Pharmacist at Our Lady of Lourdes Hospital (OLOLH) in Drogheda. Marie holds an MPharm from the University of Strathclyde, has over 6 years hospital pharmacy experience, 15 years’ experience working in community pharmacy, has completed an MSc in Clinical Pharmacy from UCC and is currently undertaking an employment-based PhD with UCC, RCSI and OLOLH examining hospital pharmacist prescribing. She has collaborated with a multidisciplinary team alongside consultant anaesthetist Dr Fauzia Bano, consultant orthogeriatrician Dr Helen O’Brien and pain management CNS Gwyneth Mahoko in OLOLH leading to the development and use of post-operative analgesia prescribing guidelines.

200 Word Summary:

1. REFLECT - Before reading this module, consider the following: Will this clinical area be relevant to my practice?

2. IDENTIFY - If the answer is no, I may still be interested in the area but the article may not contribute towards my continuing professional development (CPD). If the answer is yes, I should identify any knowledge gaps in the clinical area.

knowledge gap - will this article satisfy those needs - or will more reading be required?

Post- operative analgesia is crucial in enabling patients to mobilise rehabilitation, have a greater chance of returning to their pre- operative better long-term prognosis.

4. EVALUATE - Did this article meet my learning needs - and how has my practise changed as a result? Have I identified further learning needs?

5. WHAT NEXT - At this time you may like to record your learning for future use or assessment. Follow the

3. PLAN - If I have identified a

Short-acting opioids are preferable to long-acting opioids in opioid effectiveness in managing acute pain, reduced risk of respiratory of dependence, misuse and diversion. Short acting opioids should as required in the immediate aftermath of surgery. As acute pain should be weaned down and ceased followed by as required opioids

Managing pain and associated issues in the post-operative setting

Analgesia should be patient speciﬁc considering: age, weight, function and titrated to patient functionality and pain.

Most of us will undergo a surgical procedure at some point in our lifetime. These can be elective or acute procedures. However, with all surgical procedures, there can be some associated pain and other side-effects in the aftermath which needs to be carefully monitored and managed.

Managing pain and associated issues in the post-operative setting

on patient recovery and their long-term prognosis. Inadequate post-operative pain management can result in numerous avoidable consequences that can have a catastrophic impact on patients and their recovery as indicated in Figure 1.

Most of us will undergo a surgical procedure at some point in our lifetime. These can be elective or acute procedures However, with all surgical procedures, there can be some associated pain and other side-effects in the aftermath which needs to be carefully monitored and managed.

Post-Operative Pain:

Management of post-operative pain can have a significant impact

Management of post-operative pain can have a signiﬁcant impact on patient recovery and their long-term prognosis. Inadequate post-operative pain management can result in numerous avoidable consequences that can have a catastrophic impact on patients and their recovery as indicated in Figure 1 below.

Psychological Impact

• Depression

• Delirium

Post- operative nausea and vomiting, and constipation are very effects. Patients should have at least one regular laxative prescribed opioids, except in gastrointestinal surgery where the consultant general and when laxatives are needed. Anti- emetics should be prescribed patient’s other regular medicines and if the patient has Parkinson’s

Delays to early patient postoperative mobilisation has potentially the single greatest impact on the long term prognosis of the patient. Where the patient

NSAID’s are best avoided in older patients due to the increased risk injuries.

• Chronic Pain

Economic Cost

• Increased readmission incidence

• Increased length of stay

• Additional supports

resides can also be affected: can they be discharged home or do they require additional rehabilitation or are they unable to reside at home independently in the future? All of this can understandably be very traumatic for patients and their families. A further consideration is that it is predominantly older patients who present to our acute hospitals with orthopaedic injuries such as hip fractures which are generally the most prevalent acute orthopaedic presentation. Every single day a patient is immobile, approximately 4% muscle mass is lost. Most of our acute hip fracture patients tend to be older and frailer, therefore they cannot afford to lose any further muscle mass. To further emphasise the importance of early postoperative mobilisation of hip fracture patients, it has also been associated with reduced mortality.

• Cannot commence physiotherapy

• Increased risk of thromboembolism and pneumonia

• Falls & Pressure Ulcers Reduced

Figure 1: Risks of inadequate management of post-operative pain

Figure 1: Risks of inadequate management of post-operative pain

34 CPD 110: PAIN

If patients were to be immobilised unnecessarily, this will have a significant impact on their long term prognosis and their ability to actively engage with and undertake their rehabilitation program. In turn, this can reduce the likelihood of patients returning home or to their baseline mobility and living as active and as fulfilled a life as they did before their presentation to hospital.

In the elective surgical setting, it is now quite common for patients to undertake a prehabilitation programme i.e. they will be given exercises and advice before their surgical procedure to ensure good muscle tone. This has been shown to have a positive impact on patient mobilisation, recovery and prognosis. However, this is not an option for acute presentations.

Pain is cited as the main reason noted by physiotherapists for patients being unable to mobilise post-operatively. Therefore, if we can control and manage postoperative patient pain, we can have a significant positive impact on their prognosis and quality of life.

Work in OLOLH:

A multidisciplinary team in OLOLH including a consultant Anaesthetist Dr Fauzua Bano, consultant Orthogeriatrician Dr Helen O’Brien, Pain Management CNS Gwyneth Mahoko and Senior Pharmacist Marie Richardson worked to develop a post-operative prescribing guideline for the orthopaedic setting.

It is predominantly Non Consultant Hospital Doctors (NCHDs) who prescribe in the post-operative setting. The goal was that a comprehensive guideline was available for NCHDs to consult, in order to safely and appropriately prescribe analgesia and associated medicines to manage pain and common post-operative side-effects.

Contra-indications to use, cautions in use, dosing guidance, agents in order of preference, dosage adjustments for older patients, and items that needed to be reviewed before prescribing were laid out under 6 distinct headings. The areas on the guideline included: paracetamol, NSAIDs, opioids, laxatives, gabapentenoids and anti-emetics.

Patient Specific:

In line with best practice and optimal patient care, analgesia

prescribing should always be patient specific. Analgesia should consider the patient age, weight, renal function, hepatic function, subjective pain analysis, patient functionality, the type of procedure the patient has undergone, the nature of their injuries, if several pain inducing injuries are noted and any other medication the patient is prescribed.

To put this in context, the postoperative opioid needs of a 93 year old female patient, weighing 50kg, with mild renal impairment presenting with a hip fracture will be markedly different to 45 year old male patient weighting 110kg presenting with polytrauma from a traffic collision who has normal hepatic and renal function, no co-morbidities and no regular medication.

All analgesia prescribed should be carefully monitored, reviewed regularly and titrated to the individual patient requirements and functionality.

What is new in post-operative pain management:

The recommended management of post-operative pain has undergone significant changes in the last decade. Prior to this, it was acceptable to prescribe long-acting opioids in the post-operative setting. However, significant issues were

arising globally due to misuse, dependence and diversion of long acting opioids.

In addressing this challenge, Hah et al published a paper in 2017 Levy et al published an editorial in 2018 indicating that long-acting opioids should be avoided in opioid naïve patients in the post-operative setting.1,2 An opioid naïve patient is a patient not routinely prescribed or taking opioids.

In 2020, it was followed by the publication of a multidisciplinary international general consensus guideline reinforcing earlier publications, offering clear, concise guidance on how to target the issues of opioid abuse as detailed above.3 Avoidance of long-acting opioids, setting realistic patient pain expectations, regular review and down titration of opioids to cessation,3 utilising only shortacting opioids and short-duration discharge prescriptions were offered as guidance on how to deal with the challenges.

The HSE issued a guidance document in January 2022 “GUIDANCE FOR OPIOID PRESCRIBING FOR ACUTE NONCANCER PAIN, POSTOPERATIVE PAIN AND POST-PROCEDURE PAIN” which sets out clear goals for opioid prescribing in this setting.4 The overall objective of the document is to avoid misuse, diversion

and misappropriation of opioids. Furthermore, it indicated patient information and education should be provided about opioids and that unneeded opioids and medicine should be safely disposed of at their community pharmacy. It also recommends short-acting opioids are to be prescribed regularly and as required for opioid naïve patients, with a maximum 4 days’ supply of opioids on discharge prescriptions, patients should be down titrated as soon as possible and doses reviewed regularly.

Opioid analgesia is predominantly initiated in acute hospitals and discharge prescriptions are generally prepared by the most junior doctors for patient return to the community setting. It is important that prescribers are aware of this and prescribe safely and appropriately in order to help manage the issues of inappropriate opioid use.

Plan for management:

The WHO pain ladder has been the mainstay for a rational stepwise approach to pain management. The original ladder had 3 steps and solely focused on upward management of pain as it was originally formulated for the management of cancer pain. However, it was subsequently adopted as a tool for all pain management.

Opioids:

Opioids are routinely required to manage acute post- operative pain. As detailed above, only short-acting opioids should be used in opioid naïve patients. However, age, renal function, other prescribed medicine and co -morbidities are also a signiﬁcant consideration, especially for older patients. As we age, our ability to metabolise and excrete medicines naturally declines resulting

Figure 2: New WHO analgesia ladder indicating bi-directional pain management including a new step 4 ref: Mestdagh et al 20236

Figure 2: New WHO analgesia ladder indicating bidirectional pain management including a new step 4 ref: Mestdagh et al 2023(6)

The latest version as detailed in Figure 2 has the addition of a fourth step for interventional treatments and is also bidirectional. This is particularly relevant for the management of acute post-operative pain where treatment starts higher up the pain ladder and is then titrated down as the patient recovers and pain levels reduce alongside their analgesia needs.5

Opioids:

Opioids are routinely required to manage acute post-operative pain. As detailed above, only short-acting opioids should be used in opioid naïve patients. However, age, renal function, other prescribed medicine and co-morbidities are also a significant consideration, especially for older patients. As we age, our ability to metabolise and excrete medicines naturally declines resulting in accumulation of medicines. This is more likely with long-acting opioids and can result in drowsiness, delirium, respiratory depression, confusion and hallucinations.

Short-acting opioids should be prescribed regularly and as required in the immediate aftermath of surgery. Doses should be as per individual patient requirements. Both the regular and as required doses should be reviewed regularly in the context of patient functionality and pain, and titrated to the individual patient needs.

In accordance with Figure 2 above,6 the analgesia prescribed should be reduced, and titrated down as the patients pain reduces and correspondingly their need for opioid analgesia. Patient’s in the acute post-operative setting would usually commence on strong opioids or step 3 of the WHO pain ladder.5,6

Oxycodone:

OxyNorm® should be prescribed for regular administration four times per day with additional as required doses charted. The as required doses are crucial for administration approximately 30 minutes before physiotherapists approach the patient and enhance mobilisation and rehabilitation and ultimately ensure optimal pain management and therapeutic outcomes. They can also be administered if needed in between regularly prescribed doses.

When stepping down to step 2 of the WHO pain ladder and utilizing weak opioids such as tramadol and codeine(5), it is necessary to exercise caution and consider their relative potencies compared to morphine as indicated in Figure3 below

Buprenorphine and Fentanyl (100 times more potent than oral Morphine)

Morphine:

Although patients can be reduced to tramadol or codeine products caution should be exercised with older patients. Tramadol can interact with other medicines such as SSRI’s and SNRI’s to increase the risk of serotonin syndrome and seizures. It can also cause drowsiness, mood changes and dizziness.

Paracetamol:

It can be administered either as Sevredol® 10mg tablets or Oramorph® liquid and should be prescribed as four times a day for regular administration with additional as required doses if needed.

exacerbated by the common prescribing anti-platelets and anti-coagulants in this patient group.

o Additionally, non-selective NSAID’s increase the risk of bleeding 4 fold, while selective NSAID’s increase the risk of bleeding 3 fold.

Paracetamol is the most commonly prescribed analgesic and is on the ﬁrst step of the WHO pain ladder(5). It is very well tolerated and can be prescribed for oral, intravenous or rectal administration. However, consideration of patient weight and hepatic function must be made prior to prescribing. If a patient is <50 kg, the dose should be reduced to 15mg/kg

Tapentadol:

Paracetamol:

Palexia® FC tablets can be prescribed three times a day for regular administration with additional as required doses charted.

Opioid metabolism and excretion:

Due to the predominant renal metabolism of opioids, dose reduction may be necessary for patients with renal impairment who are prescribed morphine or oxycodone. However, tapentadol should avoided in patients with severe renal impairment.

Opioid weaning and tapering:

To ensure the safe and effective management of opioids, it is recommended to gradually reduce the regular dose before discontinuing it when appropriate. Additionally, it is important to reduce as-needed doses along with regular short-acting opioid doses and keep them charted for possible future use.

When stepping down to step 2 of the WHO pain ladder and utilizing weak opioids such as tramadol and codeine,5 it is necessary to exercise caution and consider their relative potencies compared to morphine as indicated in Figure3 below.

Paracetamol is the most commonly prescribed analgesic and is on the first step of the WHO pain ladder.5 It is very well tolerated and can be prescribed for oral, intravenous or rectal administration. However, consideration of patient weight and hepatic function must be made prior to prescribing. If a patient is <50 kg, the dose should be reduced to 15mg/kg.

Hepatic function should always be reviewed by prescribers. If the patient exhibits elevated liver function tests (LFTs) indicating impaired ability to metabolise medicines hepatically; paracetamol dosing should either be reduced or alternatively not prescribed to avoid further deterioration of hepatic functionality.

Non-Steroidal Antiinflammatories (NSAIDs):

NSAID’s would be a rational choice for use in patients post-surgery to reduce pain and inflammation in accordance with the WHO pain ladder. However, they should not be routinely be prescribed to older patients for long periods of time due to:7

• Older patients are at naturally higher risk of bleeding due to their age, but this risk is

o Regular use of NSAIDs has been found to increase the mortality rate for gastrointestinal bleeds to 21%, in contrast to the 7% mortality rate observed in patients who do not take NSAIDs.

Hepatic function should always be reviewed by prescribers. If the patient exhibits elevated liver function tests (LFTs) indicating impaired ability to metabolise medicines hepatically;

• Risk of acute kidney injury is doubled within 30 days of commencement of an NSAID

• All NSAIDs double the risk of hospitalisation due to heart failure

• Increased blood pressure, fluid retention and increased risk of fatal cardiovascular events

If NSAID’s are required for older patients in the post-operative setting, they should be prescribed for a short period of time and always prescribed with a proton pump inhibitor. Low dose as opposed to maximum doses is also preferable.7 In community pharmacy, regular OTC purchases of NSAID’s should be borne in mind.

For younger patients, NSAID’s can be routinely used. However, consideration should be given to their co-morbidities, medical history and other medications prescribed. As with older patients

Figure 3: Potencies of opioids relative to morphine

36 CPD 110: PAIN

short-term NSAID use with coprescribing of a proton pump inhibitor is preferable.

Laxatives:

Reduced mobility relative to presurgery mobility is normal. This can increase the risk of constipation in its own right. However, in the post-operative setting, patients are routinely prescribed opioids to manage post-operative pain which commonly cause constipation. This can be uncomfortable and potentially debilitating for patients and reduce their ability to mobilise thereby impeding rehabilitation. Bowel motion is routinely monitored on surgical wards.8

With this in mind, patients should be prescribed at a minimum one regular laxative if they are prescribed an opioid. The only exception is patients who have undergone gastrointestinal surgery. In this instance laxatives should only be prescribed on and in accordance with the explicit instructions of the consultant general surgeon.

Lactulose should always be prescribed and administered regularly to ensure effectiveness. Movicol® and senna are also commonly used in this setting. Phosphate or Microlax® enema’s can be prescribed for as required use.

Gabapentenoids:

Post-surgery, certain patients may encounter neurological pain, based on the complexity of the procedure. Gabapentin and pregabalin are potential treatment options that can help manage this type of pain. It is important to note that these medications, like opioids have a high likelihood of being misused leading to misappropriation and dependence. Careful monitoring of their use is essential to prevent any adverse consequences.

When they are prescribed, they should be initiated and used at the lowest effective dose for the shortest period of time necessary. For instance, gabapentin 100mg three times a day or pregabalin 25mg three times a day prescribed regularly only.

They should be reviewed regularly and ceased when appropriate. It is also prudent to exercise caution when prescribing these agents to older patients, as they may be

more susceptible to orthostatic hypotension symptoms.

Anti-emetics:

Post-Operative Nausea and Vomiting (PONV) is a common issue for patients. It can be a side-effect of anaesthesia used during the surgical procedure and can be very prevalent in the first 24 hours post-surgery. PONV is also a common side-effect of opioids which are routinely prescribed in this setting.9,10

PONV is very unpleasant and uncomfortable for patients. It is especially important patients are prescribed an anti-emetic at a minimum on as required basis for the first 24 hours post-surgery to ensure they can rest and recover from the procedure. They should be prescribed separately for oral and/ or intravenous administration. It is often advisable that post-operative anti-emetics remain charted as required for the duration of their hospital admission.

However, the choice of anti-emetic must consider the patient’s comorbidities, other medications prescribed and QTc interval.

Parkinson’s Disease:

Parkinson’s disease is a neurodegenerative condition leading to motor symptoms such as tremors, bradykinesia, rigidity, and postural instability due to depletion of dopamine in the substantia nigra of the brain. 15,000 people are currently affected by Parkinson’s disease in Ireland, however as it is the fastest growing neurodegenerative condition, we can anticipate seeing more patients with this condition.

It is treated by administration of medicines that act on the dopaminergic neurological system to aid stimulation of the dopamine receptors in diverse ways:

a) levodopa a precursor of dopamine.

b) dopamine receptor agonists e.g. pramipexole and rotigotine.

c) monoamine oxidase B inhibitors e.g. rasagiline.

Nausea and vomiting are mediated in part by the release of dopamine and the activation of dopaminergic pathways in the gastrointestinal tract and chemoreceptor trigger zone. This in turns stimulates the vomiting

centre. Several anti-emetics exert their effects by antagonising the dopaminergic pathway.

However, given the aetiology and treatment of Parkinson’s disease as detailed above, anti-emetics whose pharmacological actions are mediated via the dopaminergic pathway should be avoided in patient with Parkinson’s disease due to drug-drug interactions which may lead to impaired control of Parkinson’s symptoms.11

The anti-emetics of choice in Parkinson’s disease are:

a) domperidone

b) ondansetron

c) cyclizine

Heart Failure:

Cyclizine should be avoided in heart failure or acute myocardial infarction as it can cause a reduction in cardiac output.9)

QTc interval:

Many anti-emetics can prolong the QTc interval. Furthermore, patients are commonly prescribed other regular medication, which they may have been taking pre-admission, which can also cause QTc prolongation. There is an additive effective of adding an additional QTc prolonging medicine to a patient’s medication regimen.12

Common medicines which can prolong the QTc interval includes* citalopram, escitalopram, amitriptyline, amiodarone, clarithromycin, lithium, haloperidol, ivabradine, ranolazine, venlafaxine, tolterodine and sotalol.

*Note this is not an exhaustive list of QTc prolonging medicines; check

QUESTIONS

medicine SPC’s and interaction resources for information.

When we examine commonly prescribed anti-emetics; domperidone, ondansetron, prochlorperazine and metoclopramide, they can all potentially cause QTc prolongation.9 They should therefore not be prescribed to patients who have a prolonged QTc on ECG or if a patient is already prescribed another agent which could prolong the QTc interval. Cyclizine prescribed intravenously and/ or orally is preferred in this instance.

Conclusion:

Acute post-operative pain management plays a pivotal role in promoting patient mobilisation. This in turn has a significant impact on the patient’s longterm prognosis, quality of life and their ability to return to their pre-operative baseline. Short-term use of short-acting opioids as regular and as required analgesia is preferred to avoid dependence, misuse and misappropriation.

The orthopaedic post-operative prescribing guideline in OLOLH, has led to a notable 30% improvement in post-operative mobilisation of patients as noted by our orthopaedic physiotherapists.

Whilst prescribing analgesia correctly and safely is a significant part of post-operative care, other common side effects must also be managed to ensure patient comfort and expedite recovery.

References available on requst

a) Long-acting opioid analgesia is preferable in opioid naïve patients in the post-operative setting.

True or False

b) Patient weight and LFT’s must be reviewed before prescribing paracetamol.

True or False

c) Opioid prescribing should always be patient specific.

True or False

d) What is the order of preference for anti-emetics for patients who have Parkinson’s Disease?

e) What opioid should not be prescribed in severe renal impairment?

New Research into Parkinson’s Disease

A new project led by researchers at RCSI University of Medicine and Health Sciences aims to uncover critical insights into the progression and potential treatment of Parkinson’s disease.

 Articles

Department of Physiology and Medical Physics is also a partner on the project.

 Research Papers

 Reviews

The ambitious ¤1.8 million study known as the 4DPDOmics project is coordinated by Professor Jochen Prehn, Chair of the RCSI Department of Physiology and Medical Physics Principal Investigator at the SFI FutureNeuro Research Centre. It hopes to enhance understanding of the neurodegenerative disorder Parkinson’s disease through advanced analysis techniques. Dr Niamh Connolly, Lecturer, RCSI

The project will explore how specific genes and proteins behave across different cell types and disease stages. Focusing on the abnormal protein deposits known as α-synuclein that are characteristic of Parkinson’s, the researchers are aiming to find new targets for future treatments.

 Programme Descriptions

 Reports

Case Reports

 Letters to editor

Professor Jochen Prehn highlighted the innovative nature of the research, "This project represents a significant step forward in Parkinson’s disease research. By examining how

Top Honours for Rasha

Rasha Alshaikh was named a joint winner of the Postgraduate Researcher of the Year Award at the 2024 College of Medicine and Health Postgraduate Research Student Awards Ceremony held recently.

 In-depth review articles critique fundamental field of research or practice and support early-year pharmacists.

Rasha's project, supervised by Dr Katie Ryan and Professor Christian Waeber, aims to test the effects of the S1P1 receptor modulator Siponimod in In vitro and In vivo models of retinal neovascularization and to develop controlled release intravitreal drug delivery systems for the management of diabetic retinopathy or macular degeneration. Her research has the potential to significantly improve the treatment of patients with these prevalent disorders.

different cell types respond to the disease and identifying key changes occurring in genes and proteins, we hope to discover important targets for therapy. We will also confirm our findings in clinical samples and combine them with patient data to contribute to the development of more personalised treatment strategies."

Funded by the EU Joint Programme for Neurodegenerative Diseases Research (JPND) through the Health Research Board (HRB), 4DPD-Omics is a collaboration with expert researchers in Ireland, Germany, France, The Netherlands, Sweden, Hungary and the Czech Republic.

The project is further supported by the advanced single-cell and spatial analysis platforms funded through the Science Foundation Ireland (SFI) Research Infrastructure Programme.

Dr Niamh Connolly emphasised the collaborative effort involved: "The 4DPD-Omics project brings together a diverse team of researchers and clinicians, united by a common goal to better understand and ultimately combat Parkinson’s disease. Our multidisciplinary approach, combined with cutting-edge technology, will enable us to delve deeper into the disease mechanisms."

 Practice reports share innovations on any area of practice, including delivering clinical services, pharmacy administration, or new approaches to inform and engage with patients with the aim to improving pharmacy practice.

 Perspective articles focus on a specific future directions, and may include original data as well as expert insight and opinions.

Congratulations to Rasha on her outstanding work and well-deserved recognition.

Contact: Kelly Jo Eastwood at: kelly-jo@ipn.ie or Aoife Hunter at: aoife@ipn.ie

Major Trauma Doubles in Galway

A study carried out by doctors at University Hospital Galway (UHG) has revealed the changing presentation of trauma patients, with a doubling of cases and older patient profile emerging over the course of a decade.

Based on critical care data from UHG, the study looked at the characteristics of trauma patients, the nature of their injuries and trends in mortality rates over a 10 year period.

709 major trauma patient admissions between 2010 and 2021 were reviewed as part of the study (major trauma is defined as serious injury with the potential of causing death and disability).

Dr Ciara Hanley, UHG Consultant Anaesthesiologist and lead author of the study said; “Trauma remains one of the commonest causes of death and disability worldwide. Over the last decade, we have seen a significant change in the pattern and demographic of major trauma presenting to our centre, and in those requiring critical care input.”

In the 10 year period, trauma cases doubled and patients aged 65 and older accounted for 45.7% of all admissions. Within this older cohort, 47.5% of patients are aged 80 and over. The study found that the majority of these older patients had good outcomes overall; most of them underwent surgical intervention and were discharged from critical care within 48 hours.

• 97.6% of cases had blunt force trauma injuries caused by either a fall (45.4%) or road traffic accident (29.2%)

• Orthopaedic, thoracic and spinal trauma were the most frequent organ systems injured (53%, 37% and 32.5% respectively)

• Admissions are predominately male, with an overall mean of 68.4%

• Frailty has a significant adverse impact in older patients including increased 30-day mortality, increased incidence of complications, delayed discharge, and increased readmission rates

The study highlights the high quality specialist care delivered by the critical care team in UHG which is a designated TUSS (Trauma Unit with Specialist Services). A total of 400 patients underwent surgical treatment at our regional site and only 51 patients required an inter-hospital transfer for specialist management not provided in UHG.

Dr Alan Hussey, Clinical Director of Saolta’s Perioperative Directorate stated; “This data shows the volume and complexity of trauma work that University Hospital Galway manages. Our clinical teams are providing an essential, life-saving service for the entire region while managing an increasing caseload.”

ONOURS Hospital Professional 2024

Hospital Professional Honours 2024

IPN Communications are delighted to launch the 2024 Hospital Professional Honours, which will be held this year on Saturday, September 14th, 2025.

The Honours are hosted by Hospital Professional News to promote excellence, dedication and innovation within the hospital sector. Hospitals across Ireland have faced an especially challenging few years. They have risen to the occasion with aplomb. That’s why we want this year’s Honours to be the biggest yet – not only in recognition of excellence, but as applause to the teams around Ireland who helped keep the country going under severe and sometimes unrelenting pressure.

The Hospital Professional Honours will represent a celebration of all hospital healthcare teams who were working tirelessly on the frontline.

The Honours are the most influential and respected networking event, lauding excellence, innovation and

service development; judged by key influencers including renowned respected experts.

Their foundation lies in our collaboration with leading pharmaceutical companies; without whose investment and support, the event would not be possible.

This year, 15 Honour Categories have been launched:

 Fresenius Kabi Innovation in Aseptic Compounding

 Medisource Hospital Pharmacy Technician of the Year

 Haematology Project of the Year

 Young Hospital Pharmacist of the Year

 Galapagos Biotech Ltd, an Alfasigma company, Multidisciplinary Team of the Year

 Grunenthal Advancing the

Standard of Care in Pain Management

 Athlone Pharmaceuticals Hospital Pharmacy Team of the Year

 Excellence in Respiratory

 Viatris Excellence in Cardiovascular Initiative

 Pharmasource Hospital Pharmacist of the Year

 MSD Excellence in Oncology Initiative

 MedFind Innovation and Service Development

 Excellence in Patient Safety

 GSK ViiV Infectious Diseases Project of the Year

We were overwhelmed with both the quantity and quality of the entries this year, making it an extremely difficult task for our esteemed judging panel.

On the next few pages we feature the incredibly worthy finalists across all 15 Honour Categories.

For further information on sponsorship opportunities or to attend on the evening, please contact Danielle Norton at: Danielle@hospitalprofessionalnews.ie

Call for papers: make your contribution to Hospital

 Articles

 Research Papers

 Reviews

 Programme Descriptions

 Reports

Case Reports

 Letters to Editor

 Support fellow hospital professionals as well as aspiring junior professionals and early-year hospital pharmacists

 Practice reports share innovations on any area of practice, including delivering clinical services, pharmacy administration, or new approaches to inform and engage with patients

 Perspective articles focus on a specific field or discipline and discuss current advances or future directions, and may include original data as well as expert insight and opinions

Pharmasource Hospital Pharmacist of the Year 2024 ONOURS Hospital Professional 2024

Gráinne Johnston - Mater Misericordiae University Hospital

Gráinne Johnston is the definition of a team player. She not only thrives to support and progress her own area of the pharmacy department, but makes a conscious effort to aid other areas and colleagues whenever she sees an opportunity, regardless of the increased workload it may place on her plate. Gráinne has truly integrated herself in all the different areas of the pharmacy department and aims to ensure the MMUH is a progressive department, responsive to the ever-changing Hospital Pharmacy landscape.

Darren Walsh - University Hospital Waterford Darren’s role is a unique one within oncology in Ireland, breaking barriers for pharmacy practice. His versatility as a pharmacist has been shown by him stepping in to cover roster gaps in a care of the elderly and acute stroke ward for a number of months this year. He has shown leadership in advancing pharmacy practice, teamwork as an integral member of a diverse MDT and a commitment to pharmacy as a profession mentoring and teaching students, pharmacists, and pharmacy technicians.

Louise O'Brien - St James's Hospital

Louise is the Senior Cardiothoracic Pharmacist in St. James’s Hospital, where we carry out over 300 cardiac operations a year and over 500 thoracic surgeries, primarily for lung cancer.

Louise is involved in the care of the patient throughout their journey, she reviews their medications in the Pre Assessment Clinic, ensures appropriate medications are stopped, then during their hospital stay she continues to communicate with the patients and explains medications they are prescribed.

Louise Byrne - Tallaght University Hospital

Louise Byrne is the pharmacy aseptic unit manager and a pharmacy management team member in Tallaght University Hospital (TUH) since 2001. Over the last 26 years she has presented and supported the development of over 30 posters which have been submitted to Irish and International Conferences such as HPAI, NAHPT, EAHP, IPHOS, QAPs annual conferences since 2000. Her commitment to the evolvement of aseptic unit services in Ireland and the advancement of the profession has been unparalleled.

Katie Cooke - Cork University Hospital

Chief 2 Pharmacist and Cancer Services Clinical Pharmacy Lead at Cork University Hospital, Katie’s exceptionally leadership skills, patient-centred focus and commitment and devotion to her role and the hospital cancer Directorate are exemplar. She continues to be involved in almost every initiative ongoing in the hospital that involved SACT and the Aseptic Compounding Unit – she is always in the thick of it, being innovative, and out-of-the-box thinker and ultimately impossibly thoughtful, kind and empathetic. She has been described as a credit and a blessing to the CUH hospital and the Hospital Pharmacy Service nationally and internationally.

Hospital Professional 2024

Young Hospital Pharmacist of the Year 2024

Jayne Tuthill - Mater Misericordiae University Hospital

Jayne is currently working in a Chief II project manager post, leading implementation of the National Cancer Information System (NCIS) at MMUH. She has managed the Drug Safety Service for over a year and consistently delivered an excellent service output. Jayne has provided crucial support to the Clinical Pharmacy Service and has progressed a number of pharmacy services including the psychiatry ward service and the drug safety service. She has implemented a number of high-risk drug audits and risk management initiatives throughout the hospital.

Emer Cronin - University Hospital Waterford

Emer Cronin is a Hospital Pharmacist in University Hospital Waterford (UHW). UHW is a model 4 hospital and the regional cancer centre for the HSE South East Cancer group. Emer graduated from University College Cork with a masters in pharmacy in 2019 and completed her MSc in Clinical Pharmacy in University College Cork in 2023. She has worked in a number of areas but has worked as an acting senior pharmacist in the area of oncology/haematology for the past year and a half. Emer has been an excellent addition to the hospital pharmacy department in UHW, excelling in every area, and rapidly showing competency befitting an early ascension into an acting senior role.

Bernadette Hayes - UL Hospitals Group

Bernadette is a Senior Pharmacist at University Hospital Limerick and has worked as a valued member of the Aseptic Compounding Unit team within the Pharmacy Department for the past two years. Bernadette is highly motivated and demonstrates a true passion for her work, embodying dedication and expertise in her role. Bernadette was one of the primary drivers of the recent innovation project of semi-automated compounding which has been implemented successfully into work practices within the Aseptic Compounding Unit, thereby increasing capacity within the unit for chemotherapy compounding all the while ensuring both patient and staff safety were at the forefront.

Cillian O’Donovan is currently Chief II Pharmacist in Informatics at Tallaght University Hospital (TUH). He has been a valued member of the pharmacy team since joining as a pre-registration pharmacist in 2018. Since then, Cillian has held a variety of roles in the department, including as a surgical pharmacist (gastrointestinal, vascular, orthopaedics) and a critical care pharmacist (intensive care and post-anaesthetic critical care). These roles have allowed Cillian to develop as a well-rounded and experienced clinical pharmacist, who regularly supports and mentors junior members of the department and who is highly regarded among his peers.

Cillian O’Donovan - Tallaght University Hospital

Fresenius Kabi Innovation in Aseptic Compounding ONOURS Hospital Professional 2024

Pharmacy Aseptic Compounding Unit TeamSt James’s Hospital

With projected increases in demand in future years, the pharmacy department at St James’s Hospital undertook a scoping exercise to investigate the potential impact of Robotic Compounding would have on services. After completing thorough research and on procurement of a Compounding Robot the team have observed huge benefits including an improved patient experience, service resilience and improved quality assurance.

They are the first hospital in Ireland to successfully introduce this innovative technology to their Aseptic Compounding Unit. The benefits to patients, pharmacy staff and healthcare colleagues have been immense.

University Hospital Waterford Aseptic Services Team

At University Hospital Waterford (UHW), the team recognised an opportunity to advance the role of their senior pharmacy technicians in the Aseptic Compounding Unit (ACU). By upskilling a senior pharmacy technician to perform Pre- and InProcess Checking (PIPC) of SACT, they sought to optimise their pharmacy workforce, enhance patient safety, and improve the efficiency of the compounding processes.

The project aligns with recommendations in the literature advocating for the advancement of pharmacy technician practice to enhance patient care and optimise the healthcare workforce. Importantly, this innovation was not merely a costsaving measure but a genuine investment in patient safety and the professional development of a key staff member.

Department

of Pharmacy, Aseptic Compounding Unit at University Hospital Limerick - UL Hospitals Group

As a result of the increasing development of new anticancer therapies and novel approaches to providing healthcare, this team looked to technology to improve the process of chemotherapy preparation in their aseptic compounding unit, in the hope of improving service provision for both patients and pharmacy staff. The semi-automated compounding of intravenous chemotherapy is an evolving technology with previously identified benefits to patients and operator safety. The introduction of a Gri-fill® 4 semi-automated unit to University Hospital Limerick (UHL) in 2022 marked the first use of semi-automated chemotherapy compounding in Ireland. The implementation and comparative analysis carried out by the team at UHL, was the first of its kind in the Irish hospital setting.

Hospital Professional 2024

Excellence in Patient Safety 2024

VTE Prevention team - Bantry General Hospital

HA-VTE is a preventable complication of a hospital admission and is one of the leading causes of hospital related death. It is proposed that 70% of HA-VTE is preventable with appropriate thromboprophylaxis. A quality improvement project (QIP) was undertaken to reduce the rates of hospital associated venous thromboembolism (HA-VTE) in BGH. The QIP focused on improving the identification of patients who were at risk for developing HA-VTE thus ensuring they could receive the appropriate prophylactic therapy. The overall aim of the project was to reduce the rate of HA-VTE to zero for patients admitted to Bantry General Hospital.

MMUH Drug Safety Service & the MMUH Insulin Sub-group - Mater Misericordiae University Hospital

The Drug Safety Committee Insulin Subgroup was established in 2019 to review insulin-related incidents and to implement quality improvement initiatives. The subgroup is multidisciplinary in nature with medical, nursing and pharmacy representatives including diabetes nurse specialists, Endocrinology NCHDs and a Consultant Endocrinologist.

The MMUH Insulin subgroup has supported a patient safety focus on insulin, has motivated subgroup members and hospital staff to prioritise insulin safety initiatives in the busy clinical environment and has impacted all clinical areas of the hospital through the multidisciplinary nature of the group. The subgroup delivers an excellent output and have addressed multiple insulin safety issues since their establishment to ensure patient safety.

Senior Antimicrobial Stewardship Pharmacists - Mayo University Hospital

The Antimicrobial Stewardship (AMS) pharmacists in MUH in collaboration with the microbiologists and immunologists in GUH have developed a penicillin allergy-delabelling programme. Education on this programme was provided to pharmacists in MUH and to medics and nursing within the hospital. The penicillin allergy delabelling process is crucial for reassessing the accuracy of a penicillin allergy label. These steps provide valuable insights into the nature, severity, and appropriateness of the reported allergy.

Medication Safety Team - Blackrock Health Hermitage Clinic

The Medication Safety team at Blackrock Health Hermitage Clinic led by the Medication Safety Pharmacist is one of the most comprehensive in the country. Based on publicly available HIQA inspection data, they record more data than the majority of hospitals in Ireland regardless of size or bed capacity. The medication safety programme itself is comprised of doctors, nurses and pharmacists within the hospital. The improvements to the medication safety processes at the Hermitage now mean they have one of the most comprehensive systems in the country. One of the most impressive components of the process was the introduction of Qlik App software for analysis of the data. In tandem with the IT department, they have built a dedicated piece of software that extracts data so that it can be presented in an extremely user-friendly manner.

Grunenthal Advancing the Standard of Care in Pain Management ONOURS Hospital Professional 2024

Pain Management Centre - Croom Orthopaedic Hospital, ULHG

Lack of timely access to services was impacting on University Hospital Limerick Pain Management services. A business case was formulated identifying the potential reconfiguration of services within the proposed areas. The aim of approach was to create a leaner process flow while encompassing the quadruple aim. Set objectives were only attainable through the reconfiguration of space potentially available.

Since opening in December, 2021, the Pain Management Centre has improved efficiency and waiting lists have reduced from 49 months to 12 weeks from referral to review for routine patients. Time to pain intervention has also reduced from 60 weeks to 12 weeks from review time with the ability to facilitate larger lists. Emergency procedures can now be facilitated in day-theatre immediately following assessment in outpatient clinics. The Pain Management centre continues to work towards a hub and spoke model of care. With the strengthening of services onsite and the development of the unit towards a centre of Excellence, support of community based care is imperative. It is the goal of the centre to support education in the acute and community setting.

Mater Misericordiae University Hospital Drug Safety Service, Dr C. Hearty & R. Lynch

The number of prescribed opioids is increasing each year in Ireland. Surgeons play a pivotal role in opioid stewardship efforts. Excessive prescribing of opioids on discharge has been identified as a focal point for intervention. This study aimed to audit hospital prescriber adherence to local guidelines on opioid discharge prescribing for acute post-operative pain and to intervene as necessary, using a clinician-mediated multifaceted intervention to improve post-operative opioid discharge prescribing.

The study highlighted the volume of opioids prescribed on discharge for post-operative patients across 3 different surgical specialities in a single teaching hospital. It demonstrated that there is potential for inappropriate or overprescribing in the absence of active opioid stewardship.

MOVE-Online Trial - Mater and UCD

This team undertook a research endeavour to address a significant gap in Ireland's chronic pain management landscape. Their focus on investigating online chronic pain management programmes was driven by the pressing need to extend care access to those facing barriers to tradiditonal in-person interventions.

Through this initiative, they aimed to investigate the feasibility and acceptability of delivering the MOVE-Online programme; a novel online, interactive pain management programme combining Mindfulness-Based Stress Reduction (MBSR) and exercise from both a pragmatic perspective in addition to investigating the opinions and perspectives of the individuals with chronic pain regarding availing of pain management interventions online. Through this invesitagtion the team desired to demonstrate insight into advancing pain management delivery in Ireland by exhibiting how innovation and technology can be integrated in the field of pain management, through utilisation of accessible online communication technology delivery methods that facilitate interactive group-based pain management and allow individuals with chronic pain to engage actively with online learning material.

ONOURS Hospital Professional 2024

Grunenthal Advancing the Standard of Care in Pain Management

deploGet Ready® Chronic Pain Management Solution - Mater Private Cork

Spinal Cord Stimulation (SCS) is an advanced neuromodulation solution to assist in the management of chronic pain. The clinical evidence supports SCS as a cost-effective life-long technology centred solution to improve several quality-of-life metrics. To ensure the optimal outcome individuals need to be followed up systematically. This is not always possible because providing quality aftercare can consume hours of valuable clinical and administrative resources resulting in, we believe, an unnecessary higher healthcare resource utilisation.

The team’s post-implant pathway was based on the traditional principal of “face-to-face” clinical interactions. Several steps of the pathway were labour intensive, time restricted and an expensive use of clinical resources. The Mater Private Hospital, Cork and Medtronic collaborated on a pilot programme to deploGet Ready®, a digital remote patient management solution for truly connected care that aims to optimise the entire care pathway. This platform has shown to have a potential and significant role in providing quality the aftercare without impacting negatively on the patient outcome.

The Department of Pain Medicine - St. James’s Hospital

The Department of Pain Medicine in St. James’s Hospital was established in 2004 and offers a variety of services for the management of acute, chronic, and cancer pain conditions. It is an extremely busy and ever-evolving service and in recent years has expanded to include 2 Pain Consultants, 1 Pain fellow, 1 Advanced Nurse Practitioner (ANP), 4 Clinical Nurse Specialists (CNS) and 2 secretaries. In recent years, the quantity and complexity of input required by the pain team has expanded in line with the increasing acuity of patients and therapies offered.

The aim of this project was to establish a completely Nurse led Qutenza Clinic in St James Hospital. Therefore, enabling rapid access for patients undergoing Qutenza Therapy and prompt re treatment for patients if necessary and seamless integration to Consultant OPD / Multidisciplinary Team following discharge from the Qutenza Clinic.

Beaumont Hospital iPainCentre

Beaumont Hospital is the only Pain Service in the RCSI Hospital Group and with a catchment area of nearly 1 million people, the largest catchment area of the 17 public funded Pain Services in the country.

The team recognised that the model of care for patients with lower back pain (LBP) was not optimal, and a new approach to managing patients with low back pain was required. Based on the teams experience, they applied to Sláintcare for funding to reform the way low back pain is managed by their hospital pain service and to explore if the multidisciplinary hospital pain team can work with the community based services to improve access to care and patient outcomes.

The team aim to reduce the burden of pain and disability by supporting patients to remain in employment, continue with social interactions, and every day activities. They are the first Pain Service in Ireland to reach out into the community to integrate services for the benefit of the patient and have called this new service the iPainCentre at Beaumont Hospital.

Excellence in Respiratory Care 2024

Galway University Hospitals & Galway City Integrated Care Respiratory Team - Saolta University Health Care Group

This new respiratory team was implemented under the Enhanced Community Care (ECC) programme. A significant aspect of the ECC rollout is the establishment of the Integrated Care Programme for the Prevention and Management of Chronic Disease (ICPCD).

Under this programme, the newly formed team created the ‘One-StopShop’ Respiratory Clinic for patients with suspected or confirmed asthma or COPD.

This ‘one-stop-shop’ model of respiratory specialist care is in line with Slaintecare, providing holistic specialist care close to the patient’s home in a manner that is most convenient to them i.e. one place, on the one day where they get everything from the diagnosis right through to treatment, management and an ongoing care plan.

COPD Virtual Care at Home Programme at Tullamore Midland Regional Hospital

The COPD Virtual Ward launched in the Midlands Regional Hospital Tullamore (MRHT) in March 2024 with the aim of transforming the care of patients with Chronic Obstructive Pulmonary Disease (COPD) by using digital technology.

Upon presentation to the Emergency Department in MRHT, COPD patients identified as suitable for the service are enrolled in the COPD Virtual Ward. At the heart of this new service lies the integration of digital health technology through the PatientMPower App. Through this user-friendly application, patients can report daily symptoms, and are equipped with a pulse oximeter to monitor vital health metrics including oxygen levels and heart rate on a daily basis.

This initiative represents a positive shift in COPD management. By harnessing digital health technology, the team are empowering patients to take an active role in monitoring their health, while facilitating timely intervention by healthcare professionals.

Thoracic service for Lung Cancer - St James's Hospital

The Consultant led team recently implemented ERATS (Enhanced Recovery After Thoracic Surgery) Guidelines, and the reason for this initiative was to improve patient flow and allow improved access for patients. There were many reasons for implementation including that the European Society of Thoracic Surgery published Enhanced Recovery Guidelines for patients post Lung resection in 2019. The team wanted to implement these guidelines that ensured their care was in line with best practice internationally.

In December 2023, the department was Accredited by the ESTS (European Society of Thoracic Surgery), the first in Ireland and only 11 departments in Europe accredited to date.

ONOURS Hospital Professional 2024

Haematology Project of the Year

Pharmacy, Gynaecology and Haematology Multidisciplinary Team - Cork University Maternity Hospital

The aim of this project was to determine patients discharged with extended VTE prophylaxis post major abdominal surgery for a gynaecological malignancy in CUMH: (1) Are eligible for a DOAC post-discharge for VTE prophylaxis and receive counselling from a clinical pharmacist (2) Apixaban efficacy (postoperative VTE events) and safety (postoperative major bleeding) compared to tinzaparin. (3) Patient adherence and satisfaction to apixaban. A recent guideline was developed for Postoperative VTE Prophylaxis for Gynaecologic Oncology Patients post Major Abdominal Surgery at Cork University Maternity Hospital. This was an important tool in managing this risk safely and appropriately for these patients.

VTE quality Improvement team at University Maternity Hospital Limerick

The objective of the project was to reduce the risk of VTE in the high risk pregnant patient population by fully achieving compliance with mandatory VTE assessments at 4 key stages in the woman care journey. By ensure VTE assessments were complete, the recommended treatment options could be utilised to reduce the risk of VTEs in the team’s service users. The team recognised that they had sub optimal compliance with their VTE scores at 4 key contact points in pregnancy. They undertook a robust QIP utilising an A3 problem solving tool. A multidisciplinary team worked on the project which encompassed audit, staff survey, root cause analysis and the implementation of a QIP. Staff education and training was undertaken along with the development of current and future state process maps.

VTE Prevention team at Bantry General Hospital

Local rates of hospital acquired VTE had exceeded the national rates. National HA-VTE rates were approximately 8 per 1000 while local HA-VTE rates are at an average of 32.2 per 1000 for 2022. The hospital group introduced VTE risk assessments on the medication charts but this failed to reduce rates. Emer O’Sullivan and Carol Walsh undertook a Postgraduate Certificate in Quality Improvement Leadership in Healthcare in the RCPI with the goal of using the skills gained during the course to find a solution to this problem and improve care for patients attending Bantry General Hospital. The overall aim of the project was to reduce the rate of HA-VTE to zero for patients admitted to Bantry General Hospital.

SVUH Thrombosis Committee - St Vincent's University Hospital

St Vincent’s University Hospital (SVUH) has a long-standing focus on venous thromboembolism (VTE) prevention and its management. This project outlined their commitment to VTE prevention and treatment culminating with their goal – the establishment of an anticoagulation stewardship team. The objective was to minimise the risk of venous thromboembolism for all patients attending SVUH through; Risk assessment of all inpatients for risk of VTE with appropriate action; Multidisciplinary approach to management and responsibility – medical, nursing, pharmacy; Ongoing audit & education of both staff and patients.

GSK ViiV Infectious Diseases Project of the Year

Hospital Professional 2024

Dr Liam Townsend & the PRECISE study teamSt James's Hospital / University Hospital Galway

Healthcare workers (HCWs) are at increased risk of SARS-CoV-2 infection compared to the general population. Accurate estimates of COVID-19 seroprevalence in HCWs and the factors associated with HCW infection were necessary to understand infection transmission and dynamics of immunity within healthcare settings.

As the pandemic progressed, there was an increasing need to understand the durability of immunity within HCWs, especially with the introduction of COVID-19 vaccination and emerging variants of concern. COVID-19 continues to cause ill-health amongst HCWs, and the team here aimed to further explore the ongoing impact this has on HCW workplace attendance, the associated costs of HCW illness, and the mitigating role that vaccination may play. The principles employed in the PRECISE study can also be applied to other infections associated with HCW ill-health, most notably Influenza and Respiratory Syncytial Virus.

Dr. Peter Barrett and the Health Protection Team in the Department of Public Health, Cork & KerrySt. Finbarr’s Hospital

The team recognised that their internal and external communication mechanisms needed to become more robust and streamlined; most new cases and outbreaks of infectious diseases were being notified electronically to the Department, rather than via the more traditional mechanisms of paper/postage. More clinical staff were required to respond to the additional volume and complexity of notifications across the region, yet they needed a clear structure to ensure that high-priority strategic/prevention work could continue to progress in Cork & Kerry, rather than allocating all of limited clinical resources to the acute ‘reactive’ response.

An Acute Health Protection Duty Room was developed at the end of 2022 to provide a more robust model of delivering the acute public health response to new cases and outbreaks of infectious disease. This new model of service delivery was informed by international health protection experience obtained by Dr. Barrett during Higher Specialist Training in Public Health Medicine, as well as by evidence reviews of alternative models of service delivery undertaken by the MDT in HSE South West.

The objectives of this initiative align with the HSE Health Protection Strategy 2022-2027.

Professor John Lambert, Consultant in Infectious Diseases, Medicine and Sexual Health (GUM). Mater, Rotunda and UCD School of Medicine

When Covid struck Ireland in March 2020, it was clear there would be long-term complications.

The objective of this project was to continue to follow the Irish patients, both and adults and children, with long Covid, to better characterise these conditions, to look at long-term outcome and to develop protocols to assist GPs with the support and management of patients in their practice with this condition.

The Mater Hospital was the first to establish a long Covid clinic, with funding obtained through a HRB Competitive Grant. The team widely published on Covid and Long Covid and piloted a study on the use of low dose Naltrexone (LDN) for the management of Long Covid symptoms.

ONOURS Hospital Professional 2024

MedFind Solutions Innovation and Service Development

Acute Medicine and Transitions of Care Clinical Pharmacy TeamSt James’s Hospital

International standards, including guidance from the National Institute for Health and Care Excellence, advises that each patient should have their medicines reconciled within 24 hours of hospital admission.

The ability to achieve this target is impacted by staffing shortages against a background of a demand for more intensive clinical intervention for an ageing and more medically complex patient population

There is a growing body of evidence that has demonstrated the benefits of involving pharmacy technicians in the medication reconciliation process. A decision was therefore made to incorporate a clinical support technician (CST) in to the acute medicine and transitions of care pharmacy team. This study demonstrated that significant time savings are achievable by CST involvement in the clinical pharmacy team. This facilitated the completion of additional medicines reconciliations and enabled the pharmacist to undertake additional clinical activities such as clinical reviews, medicines optimisation, training of staff and completion of clinical guidelines.

Galway University Hospitals & Galway City Integrated Care Respiratory Team - Saolta University Health Care Group

The team developed a ‘one-stop-shop’ clinic was developed in the community, for patients with suspected asthma or COPD. The establishment and roll-out of the ‘One-stop-shop’ respiratory clinic in Galway City Integrated Hub catchment area has demonstrated remarkable success since its inception in April 2023. Almost 300 patients have availed of the service.

Future plans are to continue providing the ‘one-stop-shop’ model for patients in the community and to initiate a similar model for patients who need to attend the acute respiratory services. This simple but highly effective concept is directly transferable across other sectors.

SVUH Thrombosis Committee - St Vincent's University Hospital

The outline of this project set about establishing a anticoagulation stewardship team for St Vincent’s University Hospital. St Vincent’s University Hospital (SVUH) has a long standing focus on venous thromboembolism (VTE) prevention and its management. Over the past 2 decades they have built on a body of work on VTE prevention, diagnosis and treatment culminating in establishment of an anticoagulation stewardship team.

They began with an audit in 2007, and now use IEHG funded VTE MEG App to facilitate easier auditing of VTE prophylaxis prescribing and compliance with guidelines. Then came the introduction of risk assessment in 2010, with its review, update and incorporation into their inpatient record.

Their change to clinical pharmacy practice is an additional focus on VTE prevention – this has a critical impact on prevention of avoidable harm – multiple interventions across clinical areas of the hospital on a daily basis to prevent VTE related harm. 2024 saw the appointment of dedicated anticoagulation personnel – a clinical lead, and anticoagulation stewardship pharmacist role will facilitate them to further enhance their focus on VTE prevention and treatment.

ONOURS Hospital Professional 2024

MedFind Solutions Innovation and Service Development

Joseph

Egan Podiatrist - MyFeet.ie - Merrion Foot Clinic

Over the past ten years, the team here have seen a huge demand for the treatment of podiatric warts and verruca’s. On a day to day basis they have noted that the current treatment for verruca through salicylic acid or silver Nitrate was providing a very low and disappointment efficacy for patients.

After 3 years of in house reviews and audits of our patients they found that the efficacy of salicylic acid was less than 35% on 5-6 treatments in the clinic over a two month period. This was often painful, inconvenient and meant patients had to stop activity such as running, swimming and general sports for the duration of their treatment.

Following investigation Joe and his team discovered a swift laser machine that is used a standard treatment for the treatment of warts and verruca’s in many countries such as Australia, Germany and around the world. After training and the purchase of the swift laser machine along with training of staff on the protocol of this treatment it was launched it into the clinic in 2022.

Since then, the team have transformed the treatment of Verruca’s and warts. It has been a revolution to the practice, saved the team and their patients time, money, pain and is having incredible results.

St Patrick’s Mental Health Services Pharmacy Technicians - St. Patrick’s University Hospital

St. Patrick’s Mental Health Services (SPMHS) is the largest independent provider of acute mental health services in Ireland. The relatively small team of 20 staff including pharmacists, technicians and support staff provides pharmacy services to inpatients, homecare patients, and outpatients. The team works together to deliver high quality, effective, patient-centred care; and to ensure the safe and appropriate use of medication to support our service users (SUs) in their recovery. There was a change in practice in SPMHS whereby the day on which SUs were admitted for planned maintenance Electroconvulsive Therapy (mECT) changed from a Tuesday to a Monday. SUs were now being admitted on a Sunday when the SPMHS pharmacy is closed. This meant that a supply of medication was not readily available and there was potential for a patient safety risk due to missed doses of medication.

Pharmacy Technicians identified this potential risk and looked at how best to supply medication to ensure it was available on the ward for SU’s admitted for mECT on a Sunday. The mECT medication supply project has had a positive impact in reducing errors of omission measured as reducing from 0.9 omissions per SU to 0.2 omissions per SU over the same time period before and after implementation.

The Impact of Affirmations Cards during Pregnancy, Birth and Postnatal: A Research StudyThe National Maternity Hospital

A Community Midwife in The National Maternity Hospital (NMH), upon recognising the impact of spoken affirmations for women during labour, designed a set of positive affirmation cards for pregnancy, labour and the postnatal period. She successfully pitched for funding from The NMH foundation who award small grants twice a year.

Over 800 sets of cards were distributed nationally over a six-month period in 2023. This demonstrates the transfer ability of this project not only nationally but internationally.

This project was largely successfully through the deep commitment and passion for women centred midwifery care by the team. A collective leadership style was adopted. Each team member is driven by a mutual purpose and shared vision namely to provide maternity service users with support tools to assist in a positive journey into parenthood.

ONOURS Hospital Professional 2024

Consultant-Led Team of the Year

Bantry General Hospital Diabetes Team

The Diabetes team at Bantry General Hospital have implemented a large number of service improvements such as; IT improvements – The team were early adopters of flash glucose monitoring and rtCGM, meaning that almost all of patients with type 1 diabetes, and most of those with type 2 diabetes on insulin, have access to continuous glucose monitoring; Access improvements – The team have created shared generic emails for both the Nursing and Podiatry services, ensuring continuous patient access to the service. The inpatient referral pathway has also upgraded to a streamlined online process; Team education – The team have established monthly MDT meetings to collaboratively discuss interesting or difficult cases and Staff education – The diabetes team have run two successful Diabetes Multidisciplinary Team Education training days for nursing staff to enhance their knowledge and thereby enable them to provide better inpatient care.

Pain Management Service, Croom Orthopaedic Hospital, ULHG

Each team member here is recognised and appreciated for the individual contribution as well as the team based contribution to patient care and treatment outcome. There is a shared team goal and mission which fosters a sense of purpose and encompasses unity among team members. Monthly MDT meetings, multidisciplinary patient feedback and open-door policy among the team facilitates open and transparent communication. Team members are encouraged and empowered to share views and ideas to care as well as being supported in shared decision making for the benefit of staff, the patients, the service and the community as a whole.

Thoracic Surgery Department - St James's Hospital

The Consultant led team here recently implemented ERATS (Enhanced Recovery After Thoracic Surgery) Guidelines. The reason for this initiative was to improve patient flow and allow improved access for patients. St. James’s perform over 50% of the countries lung resections for primary lung cancer. In 2022, they performed 352 thoracic surgeries, and in 2023 they performed 459. The demand continues to grow and they have no increased access to beds.

The European Society of Thoracic Surgery published Enhanced Recovery Guidelines for patients post Lung resection in 2019. The team wanted to implement these guidelines that ensured their care was in line with best practice internationally.

Cardiology Department - Beacon Hospital

Beacon Cardiology Department is in a phase of rapid expansion. With improved optimisation of Cath Lab operating hours and both increased patient and staff numbers they were outgrowing their facilities. With the higher volume in cases they needed to expand the Admissions and Recovery areas to improve patient safety, patient outcomes, Patient flow and over all patient and staff experience.

With this in mind they opened the third Cath lab in January 2024. The main focus for the third Cath Lab was to invest on the Structural Heart Programme and give more time to an expanding hospital programme. This additional lab enables the team to allocate the remaining labs to the expanding Arrhythmia and Coronary services.

Viatris Excellence in Cardiovascular Initiative ONOURS Hospital Professional 2024

Mr. Sadiq Siddiqui and the Cardiothoracic Surgery Team at University Hospital Galway

The objective of this project was to provide excellent state-of-the-art care in the HSE. Minimally invasive vessel harvesting dramatically, almost eradicates the risk of leg wound infections following coronary artery surgery. This complication has always been a challenge for the team’s patient group who following successful major surgery and burden with a difficult to heal wound that is costly to patient’s health and time and financially a large burden on the HSE at 15000 euros per infection.

They have reduced the wound infection rate from 7% to 0% with the introduction of minimally invasive vessel harvesting while maintaining excellent clinical outcomes and improving patient satisfaction from the cosmesis of their wound and the avoidance of post-operative complications.

Beaumont Hospital Cardiac Rehabilitation Team

Beaumont Hospital’s Cardiology Department provides cardiac patients with the most comprehensive Cardiac Rehabilitation (CR) programme in Ireland. As well as delivering the largest annual throughput of patients, the department is internationally recognised as a centre of excellence for CR. Beaumont Hospital is the first and only CR centre in Ireland and the UK to achieve international accreditation in CR and secondary prevention.

Patients are provided with an exceptionally high concentration of multi-disciplinary expertise overseen by an actively involved Medical Director (Consultant Cardiologist), and each member of the multi-disciplinary team (MDT) has recognised expertise in their respective field. This seamless CR service benefits from close cooperation and communication between MDT members, allowing patients to achieve optimal health.

Cardiology Department at Beacon Hospital

In conjunction with Professor Jonathan Lyne’s extensive clinical expertise, the team noticed a gap in their Cardiology services for a more technological approach to treatment of Atrial arrhythmias within Beacon Hospital.

After collaboration with Medtronic they realised they could introduce this high-tech process in a safe and efficient way by benefitting patient’s overall outcome by providing 85 per cent one-year freedom from recurrence of atrial arrhythmias.

Professor Lyne travelled to Germany to undertake the training programme returning with a high level of knowledge in this field. The team carried out a controlled ‘first day study’ and undertook 4 cases successfully. Since then they are the first hospital globally to carry out 100 of these cases.

Empowering people worldwide to live healthier at every stage of life

With 1,600 people working across ﬁve sites in Ireland, Viatris provides access to medicines, develops innovative solutions and improves healthcare for patients.

Job Code: CC-2023-001 Date of Preparation: July 2023 www.viatris.ie

Viatris

Newenham Court, Malahide Road, Dublin 17, Dublin, Ireland.

Viatris.ie

Galapagos Biotech Ltd, an Alfasigma Company, Multidisciplinary Team of the Year 2024 ONOURS Hospital Professional 2024

St Patrick’s University Hospital Mental Health Services, Centre for Obesity Management, St Columcille’s Hospital Loughlinstown, & UCC School of Pharmacy

This team represent a group of clinical and academic professionals working together to address the complex and international problem of high rates of obesity (2-3 times higher than the general population) and associated suboptimal management practices in psychiatry.

They wanted to address the problem of suboptimal obesity management in psychiatric settings, with a particular focus on increasing patient access to evidence-based treatments in the management of antipsychotic-induced weight gain (AIWG). Within psychiatry, as pharmacy and medical professionals, they recognised that this challenging task was not possible without collaboration with those specialised in obesity management.

Furthermore, given the problem they wanted to address is a transdiagnostic and global problem, they wanted the work produced through the collaboration between psychiatry and endocrinology professions to have a wider-reaching impact beyond local settings.

SAFE Team Blackrock Health Hermitage Clinic

The Situational Awareness for Everyone (SAFE) Team Project Lead Ms AnnMarie Mulligan approached the Chief Executive Officer (CEO) Mr Gordon Dunne and Director of Nursing (DON) Ms Melanie Mc Donnell BHHC in May 2023 to share the aims and objectives of the QIP and get financial support and approval to collaborate with Royal College Physicians Ireland (RCPI) to participate in the SAFE Programme.

Once approval was granted the SAFE Team Project Lead set about establishing a Quality Initiative Project (QIP) Team to lead the QI. Understanding and acknowledging the difficult process of developing an effective team and acknowledging the potential barriers allowed the team work more effectively together from the start.

Due to the success of the QI the QIP Team have already commenced negotiations to roll out this project to the wider Blackrock Healthcare Group i.e. Blackrock Clinic, Galway Clinic and Limerick Clinic.

LIAM Mc team at Cork University Hospital

The LIAM Mc (Linking In with Advice and support for Men with Metastatic Cancer) team is a prime example of how a group of hospital professionals and researchers are working together to enhance care for men with advanced cancers. The team have developed a 12-week intervention programme run over 2 years with funding support from the Irish Cancer Society with a goal of providing participants with the tools and supports they need to live their best lives after a cancer diagnosis.

The cross-disciplinary nature of the programme, the array of expertise involved and helping to support each other by bringing their own strengths to the table, has made communication essential.

Their selfless hard work, boundless enthusiasm, knowledge sharing, communication skills and patient-centred focus really deserves to be highlighted, recognised and applauded on this scale.

St Frances Clinic Mental Health team, CHI at Temple St.Childrens Health Ireland

The team here is a busy one, involving nursing, psychiatry, psychology, and with some supports from OT and SLT. On a daily basis they work with young people in the emergency department to acutely assess and support their needs and work closely with paediatric colleagues to support young people admitted with physical and mental health needs.

In addition to providing acute support to young people and families daily, they recognise the ever increasing needs in this arena and contribute to national working groups striving to improve care, contributing for example to national model of care groups for liaison psychiatry, eating disorders and paediatrics.

Rapid Access Frailty Team at Midland Regional Hospital MRHT

The RAFT (Rapid Access Frailty Team) at MRHT is a team of healthcare professionals specialising in the care of older people in the Emergency Dept (ED). The team focus on people with frailty over the age of 75 years attending the ED.

The RAFT initiative was set up in 2016 as a joint initiative with ED and the Geriatric department at MRHT to address the increasing presentations of frail patients to the ED. The primary goal was enhanced frailty assessments in ED with discharge to Community Reablement teams. Following a success pilot in 2016, a business application followed and the team has evolved since then.

Stronger for Surgery, Tallaght University Hospital

While most people are familiar with the term “rehabilitation,” most are not familiar with the concept of “prehabilitation.” Prehabilitation means mitigating modifiable risk factors (frailty, malnutrition, cigarette smoking, and anxiety) in advance of surgery to reduce the likelihood of severe postoperative complications and reduce length of stay. Access to prehabilitation programs is now recommended for all patients awaiting scheduled surgery. However information for patients about prehabilitation is lacking.

In Jan 2023, Ms. Siobhán Power, Clinical Specialist Dietitian for Perioperative Services and Ms. Maria Whelan, Consultant Surgeon in Tallaght University Hospital (TUH) recognised the need to address this lack of information. They aspired to provide patients awaiting surgery with the information they needed to get themselves ready. They wanted a patient-centred, sustainable and accessible solution. It is from here that the idea for a series of animated videos, scripted by experts from the wider multidisciplinary team was born

ONOURS Hospital Professional 2024

Medisource Hospital Pharmacy Technician of the Year 2024

Amy Plunkett - Mater Misericordiae University Hospital

Some of the attributes that demonstrate Amy’s professionalism include her problem solving, organisation, communication and team work skills.

Amy manages supply of all drugs in the MMUH. She prioritises the most important issues and adapts her working day to ensure these circumstances are dealt with calmly and efficiently. Since Amy stepped into her current role, she has helped the pharmacy navigate logistical difficulties presented by drug shortages and experienced a significant challenge in obtaining stocks of various drugs. She is described as a positive influence on all of her colleagues.

Anne O'Flynn - UL Hospitals Group

Anne O’Flynn is a Senior Pharmacy Technician at University Hospital Limerick and has worked in the Aseptic Unit for 10 years. She is highly motivated and has demonstrated a true passion for her work, embodying dedication and expertise in her role. Anne is highly experienced and plays a pivotal role in ensuring the smooth running of the Aseptic Unit

Anne’s journey to becoming a valued Hospital Pharmacy Technician in University Hospital Limerick is a testament to her unwavering dedication, exceptional skill set, and profound commitment to patient care.

Caroline Monahan - Tallaght University Hospital

Caroline Monahan is a hard-working, reliable and enthusiastic team player who strives for excellence in all her endeavours. As a Senior Pharmaceutical Technician and Medicine Management Technician Supervisor, Caroline has spent the last 20 years championing the expanding role of the hospital technician and has demonstrated exceptional leadership in rolling out innovative technician services in Tallaght University Hospital (TUH).

Tara Hayden - St Luke’s Hospital

Tara Hayden is a senior pharmacy technician in St Luke’s Hospital, Kilkenny. This is an acute general hospital serving the people of counties Carlow and Kilkenny. Tara is an integral member of the pharmacy team. She is professional in her approach to patient safety and patient centred-care.

Her versatility and adaptability allow her to tackle any challenge that comes her way. She serves as a role model for her colleagues, embodying the highest standards of ethical conduct and excellence in pharmacy practice.

Aoife Mulcahy - Blackrock Clinic

Aoife Mulcahy is an outstanding Pharmacy Technician who has the strongest work ethic. Every day she cannot do enough to support her colleagues, her patients and her friends both in work and in community. She is a quick learner and came from community with no prior experience in chemotherapy or aseptic compounding. Aoife quickly adapted in a period of extreme staff shortages and took on the role of compounding chemotherapy with enthusiasm.

She is also described as someone who brings ‘great positivity’ to her department.

Hospital Professional 2024

MSD Excellence in Oncology Initiative

Investigation of Homologous Recombination Deficiency in DNA Damage Repair in Breast Cancer Brain Metastases - RCSI & Beaumont Hospital

Dr Jason McGrath and his team undertook this initiative to improve treatment for Breast Cancer Brain Metastases (BCBM), a challenging area in oncology due to its complexity and poor prognosis. His focus is on Homologous Recombination Deficiency (HRD), which significantly impacts cancer's aggressiveness and response to treatments like PARP inhibitors. This project aligns with his commitment to advancing personalised medicine by developing non-invasive models for predicting HRD status, enabling tailored treatments, and potentially broadening the eligibility for PARP inhibitor therapy. Through this work, he aims to enhance patient care by integrating cutting-edge genomic insights into practical, clinical applications, significantly impacting patient outcomes in oncology.

Testicular Survivorship Clinic and Register, Oncology Day Unit/Cancer Clinical Trials, Tallaght University Hospital

Registry based studies in US and Northern Europe have highlighted a dismal picture of testicular cancer survivors. While the life expectancy of general population has increased in the last five decades, an opposite trend has been observed for this cohort. The survivors of testicular cancer experience early incidence of other cancers, cardiovascular diseases, low testosterone and metabolic syndrome which in turn affects their life expectance as well as socio-economic and sexual health. For early diagnosis, prevention and treatment of these complications, we set up an ANP-led clinic in TUH. The objective of this clinic is to improve the quality and longevity of testicular cancer survivors.

COMPASS study - Blackrock Health Hermitage Clinic

The COMPASS study was a prospective observational study examining Community Oncology use of Molecular Profiling to personalise the Approach to Specialised cancer treatment at Sanford and was open to Irish patients with advanced cancer in Hermitage Clinic.

With increasing interest in personalised medicine, genomic testing is becoming more widely utilised in the community. The primary objective of this study was to observe the impact that tumour genomic testing has on treatment options for patients with advanced cancer. Each of the BHHC patients genomic test results were presented at the Sanford Health MTB and outcomes were documented.

UHL Lymphoedema Early Detection TeamUniversity Hospital Limerick

Breast cancer Related Lymphoedema (BCLR) is a well-known side effect of breast cancer treatments including surgery, chemotherapy, radiation therapy and endocrine therapies. Damage or overload to the lymphatics predisposes high-risk cohorts to the development of arm lymphoedema.

The aim of this project is “to introduce a lymphoedema early detection service in UHL oncology unit for all breast and gynae patients who have had surgery and/or radiation to reduce the incidence and impact of lymphoedema in Ireland. The findings from the pilot will be used to support future funding for similar services in all oncology centres.”

Athlone Pharmaceuticals Hospital Pharmacy Team of the Year ONOURS Hospital Professional 2024

Pharmacy department at Blackrock Health Hermitage Clinic

The pharmacy department at the Hermitage Clinic are constantly striving to improve practices to drive the patient safety and medication management agendas. The team at the Hermitage has in the last 5-year’s embraced countless changes which have improved patient experience while also improving efficiencies within the department.

The pharmacy technicians keep motivation high through their engaged work style. The department offers pharmacy technicians the ability to work across a number of areas in any given which not only include traditional dispensary and ward top-up services but also monoclonal antibody preparation, and MMPT (drug history, patient counselling) duties.

The pharmacists maintain their motivation through their contribution to a tremendous clinical pharmacy service that sees them at the point of prescribing throughout the day.

St Patrick’s University Hospital Mental Health Services Pharmacy Team

St. Patrick’s Mental Health Services (SPMHS) is the largest independent provider of acute mental health services in Ireland. This relatively small team of 20 staff including pharmacists, technicians and support staff provides pharmacy services to inpatient, homecare and outpatients. The team works together to deliver the highest quality, effective patient centred care to ensure the safe and appropriate use of medication to support a Service User in their recovery in SPMHS.

The team is supported through committed leadership to develop a culture of open collaboration to keep unified as they develop their hybrid remote working practices. They are motivated to act as a collective unit, ensuring everyone is involved and aware of their own responsibilities and what the team's goals are whilst co-operating together to support the overall objectives of the department.

Hospital Pharmacy Team at The National Maternity Hospital

The National Maternity Hospital pharmacy team provide pharmaceutical care for some of the most vulnerable patients in the healthcare system - mothers and newborns. Maintaining motivation within the team is essential for ensuring high-quality patient care and fostering a positive work environment. They have a very high staff retention rate, having maintained a full staff quota for the past ten years.

Each team member has clearly defined roles and responsibilities based on individual expertise and scope of practice. Each pharmacy technician is individually assigned to ward-based drug histories, top-ups, or dispensary/ invoice processing. The specialist skills of clinical pharmacists are utilised in a variety of MDTs as pharmacists are individually assigned to neonatology, antimicrobial stewardship, maternal medicine, and informatics/medication safety, with the pharmacist executive manager (PEM) responsible for overall service and strategic direction.

Pharmacy Team at Midland Regional Hospital Portlaoise

The pharmacy team here come together daily to achieve pharmacy service delivery with differing challenges by the day and the hour, but all the while seeking to be better, more consistent, more patient focussed than the previous day.

As a relatively small team deployed over multiple sites, one of the biggest challenges is operational communications. The team have created a multi-faceted communication plan that serves to maintain a consistent work approach irrespective of the challenge. The team communicates outwards to the wider hospital team using the MRHP Medicines App and carefully curated push notifications.

The pharmacy team is strongly motivated by patient welfare and has repeatedly innovated and shown versatility and responsiveness to further patient care.

Mater Misericordiae University Hospital Pharmacy Department

The Mater Misericordiae University Hospital (MMUH) pharmacy team is a dynamic, ambitious and supportive team who strive to deliver the hospital’s mission to care for the sick with compassion and professionalism at all times, respect the dignity of human life, and to promote excellence, quality and accountability through their activities. The MMUH Pharmacy delivers a number of critical clinical services to hospital patients including dispensary, clinical pharmacy, aseptic compounding, medicines information, infectious diseases, antimicrobial stewardship, heart lung transplantation, pulmonary hypertension and drug safety services.

The large pharmacy team support each other to perform to the highest standards while ensuring staff are ongoing development and motivation in all aspects of their role. This is achieved from their first day of service in the MMUH Pharmacy with the dedicated on-boarding process that includes an assigned mentors and dedicated training programmes for all new staff.

Pharmacy Department at St James’s Hospital

The staff working in St James’s Hospital Pharmacy department bring dynamism, energy, collegiality, and respect to their everyday activities. The result is a department that is vibrant, curious, willing to challenge the status quo whilst caring for their patients and supporting and respecting colleagues.

Daily the technicians and pharmacists, within each of their specialist area strive for excellence during their routine duties. Pharmacists, technicians and support staff work together to ensure the correct medications are prescribed and available for use, that patients understand their medicines and that all clinical staff are up to date with the relevant medicines information.

Their goal is to work with, encourage and upskill all staff so that each member of the team works to their fullest potential.

Urgent Need for Tailored Guidelines

A qualitative study from researchers within the Pharmacy Department of St Patrick’s Mental Health Services and the School of Pharmacy in University College Cork has revealed the urgent need for tailored guidelines in managing antipsychotic-induced weight gain, as findings highlight the gaps between current guidelines and practices and the needs of those taking antipsychotics.

The study, Informing the development of antipsychoticinduced weight gain management guidance: patient experiences and preferences - a qualitative descriptive study, which was published in BJPsych Open on 1 August 2024, explores how patients with lived experiences of antipsychotic-induced weight gain (AIWG) perceive and manage this challenging side-effect.

Clinically significant weight gain1 has been linked to almost all antipsychotic medications, prescribing of which extends to many mental health difficulties beyond psychosis, and is usually seen within weeks of starting treatment.

Managing weight gain effectively in patients with mental health difficulties who are taking antipsychotics is crucial to

ensuring their physical health is maintained. However, while limited international guidance exists, management recommendations for clinicians largely replicates recommendations for population level weight management practices, with self-led ‘lifestyle changes’ given prominence, and the use of additional medications to reduce antipsychotic-induced appetite increases considered only when other options have proven ineffective.

Development of available management recommendations has largely been informed by the expert opinion of guideline development groups, with no or minimal representation of the voice of lived experience. This study was the first of its kind to explore the management preferences of patients with experience of managing weight gain from antipsychotics and to compare this with current management algorithms informing clinicians’ practice.

A diverse range of people (n = 17) with experiences of mild to severe antipsychotic-induced weight gain and mental health difficulties including schizophrenia, bipolar affective disorder and major depressive disorder were interviewed regarding:

Professor Laura Saham, Co-author, Head of Clinical Pharmacy Practice, UCC

• Their experiences of managing AIWG

• The acceptability, feasibility, and transferability of current management algorithms and the interventions contained within (both pharmacological and non-pharmacological)

• How patient-centred management practices can be realised within Irish healthcare settings.

Speaking about the study, Lead Researcher and Senior Pharmacist at St Patrick’s Mental Health Services, Ita Fitzgerald said: “Findings have shown that the lack of available management guidance for antipsychotic-induced weight gain remains a challenge for clinicians, with currently endorsed approaches neither being fitfor-purpose or aligned with the experiences and needs of those prescribed antipsychotics and who experience unwanted weight gain. This study provides guidance and recommendations for ways in which a proactive, individualised, holistic, and collaborative approach to AIWG management can be practically realised both within guidelines and services. It is hoped that the publication of this study will mark a significant step towards empowering and supporting clinicians to manage the complex side effect of antipsychotic-induced weight gain in a way that is most responsive to the needs of the individual patient.”

Key Findings showed:

1. Patient preferences for management differ significantly from that advocated for in management guidelines: Patients with AIWG describe current management guidelines as overly simplistic and lacking flexibility required for management to be tailored towards their needs. The standardised, stepwise approach, universally recommended and focusing primarily on use of lifestyle changes, does not reflect the realities of managing overweight or obesity caused by antipsychotics.

2. Behavioural changes are often insufficient: Many participants reported that lifestyle changes alone were insufficient to manage AIWG. Continued recommendations from clinicians to implement lifestyle changes could worsen feelings of isolation and internalised stigma, while also reducing the likelihood of seeking help in future due to fear of stigma.

3. Individualised approaches are key: Participants emphasised that AIWG is a unique cause of weight gain and as such, requires an equally distinctive approach to management. Recommendations for management of AIWG must recognise diversity among individuals and allow for interventions to be tailored towards risk of living with overweight or obesity, individual physical and mental health capabilities and patients’ treatment preferences.

4. Need for early use of pharmacological interventions: Study participants advocated for the earlier use of pharmacological interventions, such as metformin, especially for those who are severely ill at the onset of antipsychotic treatment, have a personal or family history of living with obesity, or where appetite increases following starting an antipsychotic are severe.

Professor Laura Sahm, co-author of the study and Head of Clinical Pharmacy Practice at UCC, said: “This study represents a crucial step in recognising the importance of a patient-centred and patient-informed approach to combat antipsychoticinduced weight gain. By working collaboratively, patients and prescribers can adopt a strategy that aligns best with their shared and agreed goals of therapy.”

Based on the experiences of participants, the study recommends that current guidelines are expanded to include preventive measures and early interventions tailored to individual patient needs and risks. The study recommendations also put forward ways in which the four tenets of patient-centred management (proactive, individualised, holistic and collaborative approaches) can be enacted both within guidelines and psychiatric services.

Guidelines and practice of breastfeeding in women living with HIV—Results from the European INSURE survey

Written by A. Keane1, F. Lyons1, K. Aebi-Popp2,

C. Feiterna-Sperling3, H. Lyall4, A. Martínez Hoffart5, H. Scherpbier6, C. Thorne7, H. Albayrak Ucak8, A. Haberl9

1Department of Infectious Disease and Genitourinary Medicine, St James Hospital Dublin

2Department of Infectious Diseases, University Hospital Bern, University of Bern, Switzerland

3Charité Universitätsmedizin Berlin, Klinik für Pädiatrie m. S. Pneumologie, Immunologie und Intensivmedizin, Berlin, Germany

4Department of Paediatric Infectious Diseases, Imperial College Healthcare NHS Trust, London, UK

5Posithiva Gruppen, Knowledge Network for Women Living with HIV, Stockholm, Sweden

6Department of Paediatrics, Amsterdam University Medical Centre, Amsterdam, The Netherlands

7University College London, Great Ormond Street Institute of Child Health, London, UK

8CPL Life Science, Vaccine Research and Development, Reading, UK

9Department of Internal Medicine, Infectious Diseases, HIVCENTER, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany

The high effectiveness of antiretroviral therapy (ART) has transformed the lives of people living with HIV. In addition, ART is the most important measure of HIV prevention, including prevention of vertical HIV transmission. However, there is still controversy regarding the small risk of HIV transmission in the setting of effective maternal ART, where there is access to safe, affordable alternatives to breast milk.1

The World Health Organization (WHO) reports the rate of vertical transmission without ART, or other specific interventions, as ranging from 15% to 25% in Europe and the USA, and from 25% to 45% in low-resource settings, where breastfeeding is the norm.2,3 In low-resource settings, the estimated risk of HIV transmission attributable to breastfeeding, in the absence of maternal or infant ART, is 25%–48%.4

Rates of vertical transmission in high-resource settings, where mothers living with HIV are advised not to breastfeed, are reported as less than 0.5%.5,6 There is increasing data, primarily from low-resource settings, on breastfeeding-associated transmission in the setting of maternal ART.7 A large randomized controlled trial comparing the efficacy of maternal ART and prolonged infant ART (PROMISE IMPACT), conducted in SubSaharan Africa and India, reported a breastfeeding-associated HIV transmission rate of 0.3% and 0.7% at 6 and 12 months of breastfeeding, respectively, in 1 219 mother–infant pairs where

mothers were taking combination ART. There was no increased risk of toxicity reported in these infants.8 Of note, in the maternal ART group, only 41% of women had a viral load below the limit of detection at delivery or at their study entry visit 1 week post-partum.

The WHO recommends that women living with HIV breastfeed for at least 12 months but may continue breastfeeding up to 24 months or longer (similar to the general population) while being supported with adherence to ART.9 The WHO recommends exclusive breastfeeding but states that mixed feeding is not an indication to stop breastfeeding in the presence of ART. These guidelines are recommended as global guidance regardless of HIV prevalence.1

We know that, in high-resource settings, most guidelines recommend against breastfeeding for women living with HIV, and there is a paucity of data on breastfeedingassociated transmission in areas where there is continuous access to maternal ART and maternal and infant monitoring. In addition, there are reports of increased intention to breastfeed or actual breastfeeding in women living with HIV5, 10 and documented wish to breastfeed and fear of stigma in women living with HIV who do not breastfeed.11 Research and collaboration is needed to inform guidance and best practice in

INSURE Study

these settings to provide best medical care during this period.

Women Against Viruses in Europe (WAVE), part of the European AIDS Clinical Society (EACS), is an initiative established in 2014 to promote the welfare of women living with HIV in Europe. WAVE sought to gather information on breastfeeding recommendations and practices for women living with HIV across Europe and to develop a collaborative network to share experience, bridge data gaps, and provide research opportunities to improve our understanding and to inform guidelines for healthcare providers.

This survey, conducted by the WAVE breastfeeding group, aims to review similarities and

differences in breastfeeding recommendations for women living with HIV in Europe and create a conversation and supportive network for providers caring for women living with HIV who wish to breastfeed.

Methods

A steering group consisting of healthcare providers, nongovernmental organization representatives and researchers was established to develop a survey (Appendix A1) to review national guideline recommendations and country practices in relation to breastfeeding for women living with HIV. In addition, each country was asked about the trends in breastfeeding, current breastfeeding-related research, and willingness to participate in a network for collaboration and research. The survey, INSURE (HIV

aNd BreaStfeeding in EURopE), consisted of 38 questions, including multiple choice and free text for descriptive answers. Not all of the questions were mandatory. The survey was developed and distributed via Jotform, which was also used to collate results. The steering group identified a contact person in each country across Europe to whom the survey link was sent. These contacts were mostly identified through EACS and WAVE networks. Thus, 31 contacts were emailed a link to the survey on 30 March 2022, requesting one response per country. Contacts were asked to link in with colleagues as needed to provide the most appropriate response for their country. The survey was closed on 9 May 2022, after a series of reminders were sent alerting respondents of the closing date.

Results

In total, 25 responses were included in the final analysis. Some respondents omitted some questions, leading to different denominators throughout the results. The survey took a minimum of 12 min and a maximum of 43 min to complete, as recorded by Jotform. Respondents were encouraged to attach links to or files of referenced guidelines.

A flowchart of country responses in relation to HIV and pregnancy guidelines is shown in Figure 1. Where countries did not have national guidelines, responses were provided around country practices, which are included in the results. This is clearly indicated in Table 1.

Of the 23 countries with national guidelines, 12/23 (52%) reported

Guidelines and practice of breastfeeding in women living with HIV Results from the European INSURE survey

Figure 1: Country responses: HIV and pregnancy guidelines Guidelines and practice of breastfeeding in women living with HIV

survey

that their guidelines recommend against breastfeeding, 11/23 (48%) offer an option to breastfeed if certain clinical criteria are met, and no countries offer an option to all women to breastfeed.

Although not specifically asked in the survey, three countries independently advised that, although their guidelines recommended against breastfeeding, if a woman wishes to breastfeed, she would be supported to do so where medically appropriate.

In total, 12/25 (48%) respondents reported that the number of women living with HIV who breastfeed in their country is increasing, 12/25 (48%) felt it was stable, and 1/25 (4%) felt it was decreasing.

Maternal viral load, duration/type of breastfeeding, and neonatal post-exposure prophylaxis

The survey asked a range of questions around conditions for breastfeeding:

Seventeen respondents (17/17 [100%]) reported that a suppressed maternal HIV viral load (within 4 weeks of estimated delivery date) was required to support breastfeeding.

Ten respondents (10/11 [91%]) reported that a suppressed viral load needs to be maintained for a minimum period of time during pregnancy.

One respondent (1/11 [9%]) reported that a suppressed viral load prior to conception is required for breastfeeding.

Five respondents (5/12 [42%]) reported that their guidelines include a recommendation on duration of breastfeeding.

Eleven respondents (11/20 [55%]) have a recommendation on the minimum age of introduction of solids.

Sixteen respondents (16/19 [84%]) reported that all infants born to women living with HIV (including breastfed and non-breastfed infants) receive post-exposure prophylaxis (PEP).

Twelve respondents (12/16 [75%]) reported that PEP is not extended in infants who are breastfed.

Three respondents (3/16 [19%]) reported that PEP is extended in some breastfed infants.

One respondent (1/16 [6%]) reported that PEP is extended in all breastfed infants.

Information on breastfeeding

Six respondents (6/20 [30%]) have dedicated healthcare workers to educate women living with HIV on breastfeeding.

Thirteen respondents (13/20 [65%]) have a multidisciplinary approach for management of women living with HIV who wish to breastfeed.

Countries reported a variety of different healthcare workers in their multidisciplinary team, including midwives, paediatricians, gynaecologists, infectious disease specialists, clinical nurse specialists, social workers, and case manager/peer workers from an non-governmental organization.

Laws surrounding HIV and breastfeeding

Twenty-two respondents (22/25 [88%]) reported that there were no known cases of women living with HIV breastfeeding who had been reported to the police or social services or been prosecuted or convicted due to breastfeeding. Three respondents (3/25 [12%]) reported that this has occurred in their country, and two respondents stated that social services had been informed.

Ten respondents (10/25 [40%]) said breastfeeding is exempt from laws concerning HIV exposure and/or transmission, and 15 respondents (15/25 [60%]) reported that breastfeeding is not exempt from laws concerning HIV exposure and/or transmission.

Research on HIV and breastfeeding

Eight countries (8/25 [32%]) have research studies on breastfeeding in women living with HIV, and some reported multiple studies. At a national level, five research studies (5/9 [56%]) are ongoing, two (2/9 [22%]) have been published [10-13], and two research studies (2/9 [22%]) have been completed. At the local level, three research studies (3/4 [75%]) are ongoing, and one respondent reported that their research studies (1/4 [25%]) have been published.14, 15

One respondent (1/6 [17%]) reported having a breastmilk biobank.

Twenty-four (24/25 [96%]) respondents would like to collaborate in data collection around breastfeeding in women living with HIV coordinated by WAVE.

Discussion

Through this survey, we sought to better understand the current

situation and transition of guidelines and practice in Europe in regard to breastfeeding in women living with HIV. Our results demonstrate that countries report an increasing number of women who decide to breastfeed and heterogeneity in guidelines and practice across respondents. There is adequate data in HIV serodifferent sexual couples to support the statement ‘undetectable = untransmissible’ (U = U) regarding the ability of effective ART to prevent sexual transmission of HIV.16, 17 We do not have the same level of evidence to apply U = U to the breastfeeding situation. The risk is lower when the mother’s viral load is not detectable, but breastfeedingassociated transmissions in the setting of effective maternal ART have been reported.13, 18, 19

Despite many guidelines recommending against breastfeeding, some women will choose to breastfeed. Comments in the survey revealed that clinical practice differs from what is recommended in guidelines. To minimize risk in a supported way, many countries offer support to women who choose to breastfeed despite their national guidelines recommending against breastfeeding. Freeman-Romilly et al. describe providing a ‘managed risk’ plan for women living with HIV who want to breastfeed their infants, including ‘Ten safer breastfeeding rules’ and ‘The Safer Triangle’.13

We need to recognize the complexities of breastfeeding in women living with HIV who wish to breastfeed. It must be noted that formula feeding is the only method of feeding that has zero risk of HIV transmission to the infant, and this needs to be discussed with the mother. However, taking a hard-line approach to counselling against breastfeeding may result in a mother breastfeeding in secret and a lost opportunity for education, adherence support, and close monitoring. Open conversation leading to shared decision making is important in understanding a mother’s and parents’ values, discussing risks and benefits, and providing education to ensure the best outcome for the infant [20]. We believe it is our duty to encourage and support an open discussion around breastfeeding in women living with HIV.

NOURISH-UK, an ongoing study exploring how new mothers/ birthing parents living with HIV

make decisions around feeding their babies in the UK, will help better inform guidelines and supports for parents by sharing experiences and offering peer support.21

One-third of countries are already conducting research on breastfeeding in women living with HIV in their country. The vast majority of respondents would like to join a European network to bring together expertise in this area. Since the total number of breastfeeding women living with HIV is increasing but still small in most European countries, collaboration to increase our understanding is essential.

This survey is the first to review practices and guidelines in relation to breastfeeding in women living with HIV in Europe. Although guidelines themselves were not independently reviewed, the survey was sent to an informed group of clinicians, non-governmental organization representatives, and researchers, and—where national guidelines were available— verbatim fragments of the guidelines were gathered. This article has led to the development of a working group to review and translate guidelines across Europe. We received a broad range of responses but did not reach every country in Europe.

The establishment of the INSURE WAVE breastfeeding network will help fill the data gap and start a discussion in Europe around breastfeeding in women living with HIV.

Conclusions

Breastfeeding recommendations for women living with HIV vary across Europe. Many national guidelines recommend against breastfeeding, but some include management recommendations if women choose to breastfeed. Around half of the countries report an increase in the number of women living with HIV who are breastfeeding. Almost all of the respondents express a keen interest in joining a network supported by EACS/WAVE to expand our knowledge and research opportunities. This survey and the differences and similarities across countries will help bring respondents together to create a European platform for discussion and collaboration so that more data can be collected and a consensus reached on how best to support women living with HIV who want to breastfeed to do so safely.

Pain Management

Nurse Led Pain Service at Mayo University Hospital

Written by Joanna Fahey Clinical Nurse Specialist CNS p, RGN, RM, RNP, MSc In Pain Management

The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage,” Chronic pain is a major health issue for our patients, their families and us as healthcare professionals who care for them. Inadequately managed pain can lead to adverse physical and psychological patient’s outcomes for individual’s patients and families. Effective management of acute pain is key to prevent chronic pain.

According to a study (PRIME 2011) which looked at the prevalence, impact and cost of chronic pain, it is a significant health problem in Ireland with up 1 in 3 people experiencing chronic pain, at some point in their life. The cost of chronic pain per patient was ¤5,665 per year extrapolated to ¤5.34 billion or 2.86% of GDP per year. The current/ post COVID-19 pandemic also poses a challenge as an increase in demand for chronic pain services may occur with patients potentially developing post viral pain syndromes.

Acute Pain Service was developed in Mayo General Hospital (MGH) in 2007 to address the needs of patients with acute pain, including postoperative pain. Currently in Mayo University Hospital (MUH) a Clinical Nurse Specialist Ms Joanna Fahey, leads a Consultant anaesthetic supervised acute pain service. Nurse-led rounds have emerged as a promising strategy to foster patient engagement, improve communication among healthcare team members, and optimize patient care delivery. Nurse led pain rounds at Mayo university Hospital has given me significant experience working in the acute setting and recognises the patients always comes first. I am passionate about ensuring patients receive the best high quality care that meets their needs in a timely manner, I have the expertise and experience to deal with patients who are suffering in acute pain in the acute setting. I can assess, reassess and manage patient care to ensure the highest standard using evidence based practice, care planning approach.

I can plan, Implement and coordinate and evaluate care in collaboration with the patient, the family and the Multidisciplinary

team. As a Clinical Nurse Specialist I have a unique role in that I always get to have bedsides conversations with the patients and optimise their pain relief reducing their stay in hospital.

I began my nursing career in Beaumont hospital in 1999 in participation with RCSI and DCU, I moved to MUH in 2004 and has been at MUH for 20 years. I worked in theatre for over 10 years and this is where I found the labour of love for pain managements and completed my Masters in Pain Management in UCD under the late Professor Laserina O’ Connor. I was luckily enough to have had Laserina as my lecturer in UCD, she was an engaging and inspiring educator who was a bright light in advancement of pain nursing profession.

Laserina O'Connor was a registered advanced nurse practitioner (RANP) and registered nurse prescriber (RNP) in pain management. She led an MSc Advanced Pain Management / Prescriptive Authority Program, a Professional Certificate in Pain Management, a CPD ‘Developing Acute Pain Champions’ and a Diploma in Diabetes Nursing. She was also President of the Irish Pain Society, the first registered nurse appointed to this position. Laserina's lasting influence on the pain nursing discipline has affected many of her students and colleagues alike.

Mayo University Hospital is a 362bed hospital, with 5 directorates, including the Peri-operative division and a maternity service and then orthopaedic dept. The Maternity ward within MUH has one of highest acuity level with on average 50 women undergoing a Lower Segment Caesar Section (LSCS) in a month. Irish caesarean section rates currently averaging 1 in 3 births (a combined rate for

first and subsequent mothers of 36.6%), and much higher in some units, and climbing rapidly (AIMS Ireland 2024).

Surgical birth is major abdominal surgery which poses immediate short and long term health consequences for mother, infant and all future pregnancies. Caesarean section pain is associated with moderate to severe post-operative pain which can influence post-operative recovery and patient satisfaction as well as breast-feeding success and mother-child bonding.

Pain after caesarean section can be related to at least two components, somatic pain from the wound incision and visceral pain from uterine contractions. Relief of acute pain after LSCS represents a major therapeutic challenge as postoperative pain hinders early mobilization and rehabilitation with consequences on duration of hospital stay and overall recovery. Utilizing our proposed analgesia fast track regime for women have proved successful showing reduction in post-operative length of stay (LOS), shorter convalescence and rapid functional recovery with subsequent economic savings. Our data suggests the practice of a multimodal approach to post-operative analgesia and that the use of Diclofenac 100mg PR/ PO 50mg in conjunction with

paracetamol (Oxynorm/ Tapentadol if required) provides effective postoperative analgesia.

A recent audit carried out on the use of rectal diclofenac for postop lower segment caesarean section pain: An audit examining compliance, complications and efficacy, 43 participants, with a mean age of 34.5, were recruited: with 32 participants prescribed as per FAST-TRACK. Non-adherence to prescribed post-op analgesia was reported in 11 participants. The anaesthesia team were responsible for 2 cases of nonadherence - 1 (0.43%) patient had an allergic reaction to paracetamol, 5 (2.15%) patients refused diclofenac per rectum and took oral diclofenac, 2 (0.86%) women had a post-partum haemorrhage (>1000mls) and did not receive diclofenac on the day of delivery but once bloods were checked the next day and bleeding had resolved received PR diclofenac. Side effects were reported by 2 (0.86%) women, 1 reported angio-oedema and a rash on day 2 (however this lady stay was extended due to ongoing rash secondary to an antibiotic allergy) and 1 (0.43%) reporting diarrhoea.

A median pain score of 1 (0-10) and median pain satisfaction of ‘very satisfied’ (satisfied – very satisfied) was reported. The audit was carried out by Professor Michelle Duggan consultant anaesthetist and Joanna Fahey. Mayo University Hospital has achieved significant standardization in post-operative

Professor Laserina O’Connor

Staff on Maternity ward

pain management. Anesthetists have initiated evidenced based management strategies improving outcomes. These strategies are based on the PROSPECT guideline for elective caesarean section.

The occurrence of pain symptoms is one of the primary reasons to seek healthcare in the general population especially in the Orthopaedic department. Over 90 patients per month attend an injection clinic under the Orthopaedics service.

Currently the Orthopaedics service access and delivers most of the interventions for chronic back pain with some input from anaesthetics and radiology. The orthopaedic service offers epidural injections and Steroid Injection an adjuvant pain modality. The significant burden of chronic pain highlights the need for cost effective interventions to reduce long-term disability. The injection service had a high satisfaction rate among patients allowing them to return to functionality and return to work/ sport and reducing the socioeconomic burden.

However, the waiting lists are long and repeated injections are not often conducted in a timely manner, going against the HSE strategy of providing safe effective care in a timely manner. One of the main issues the Orthopaedics department within in Mayo University Hospital (MUH) was the lack of an integrated treatment space and/or adequate time slots for clinics. As part of the

reconfiguration of services in the hospital the development and integration of St Johns unit was used a potential solution to this lack of room availability service in the MUH area allowing the orthopaedic access to twelve beds for injection service.

waiting list for joint injections Waiting list for joint injections

helpful (the patients always know the name of the office staff)

 St Johns unit is easily accessible especially for those with a physical adversity.

 Minimal wait times

 Consequently, this has yielded positive feedback being acknowledged by the office staff.

 Finally, utilisation St Johns has reduced the waiting list appendix 1.

The patient who is in pain is central to every decision I make or propose to make in relation to their care.

Utilization of St Johns on Saturdays have been phenomenally successful for the following reasons.

 All appointments are confirmed to validate appointments.

 The wait room is clean and comfortable.

The patient who is in pain is central to every decision I make or propose to make in relation to their care. - Consequently,

 Instructions from the orthopaedic office staff are friendly and

 Offering appointments on a Saturday offers more flexibility for patients who require a lift, do not need to take a day of work / college, and not an early appointment.

NCCP Cancer Alliance Activity Report

The HSE National Cancer Control Programme (NCCP) and Minister of State at the Department of Health, Colm Burke TD presented cancer groups with plaques in recognition of the work they do for people affected by cancer at an event in Farmleigh recently.

Each member of the Alliance of Community Cancer Support Centres & Services (the Alliance) were presented with a plaque to reward them for the valuable role these community cancer support centres and services have in supporting cancer patients and their families across the country. Additionally, the Annual Activity Report for 2023 was published and the inaugural steering group was announced.

Speaking following the event, Professor Risteárd Ó Laoide, National Director, HSE National

Cancer Control Programme (NCCP) said, "Today marks a significant milestone in our collective efforts to support cancer patients and their families throughout Ireland. The presentation of plaques to each member organisation of the NCCP Alliance and the introduction of our inaugural steering group underscore the vital role community cancer support centres play in our healthcare system. These centres provide invaluable psychosocial support and survivorship programmes, ensuring comprehensive care for those living with and beyond cancer.

“The launch of our Annual Activity Report for 2023 highlights the impact of our work. The ¤3 million funding allocated through Budget 2024 will further empower these organisations to continue their essential services, reinforcing

our commitment to integrated care pathways and the principles of Sláintecare. We are grateful to the Department of Health for their support. We thank all our community partners for their dedication and engagement with our Best Practice Guidance. Together, we are creating a more supportive, responsive, and effective cancer care network across the country."

The Alliance is an NCCP initiative, set up in 2022, made up of voluntary and charity organisations delivering support services directly to cancer patients and their families. The Alliance advocates for and supports the development of integrated pathways between the cancer centres, acute hospitals, community cancer support services and primary care. It is very much in line with the values of Sláintecare and

I am immensely proud to have been part of such successful project which has led to delivering safe and effective patient care.

seeks to provide assurances to healthcare professionals that these organisations are working to an agreed standard as set out in Best Practice Guidance published by the NCCP. They have an important role in delivering psychosocial services and survivorship programmes for those living with and beyond cancer. Services include counselling, provision of information, physical activity opportunities, financial advice and return to work support. They offer peer support and both individual and group services.

The Minister for Health allocated ¤3m in funding to NCCP’s Alliance of Community Cancer Support Centres & Services through Budget 2024. NCCP is currently in the process of distributing those funds. These funds will directly impact the delivery of services for patients and families nationally.

Nutrition & GI

Nutrient Intakes and Gastrointestinal Symptoms Among Esophagogastric Cancer Survivors up to 5 Years Post-Surgery

Written by A. E. Bennett1, L. O’Neill2, S. L. Doyle3, E. M. Guinan4, J. O’Sullivan5, J. V. Reynolds6 and J. Hussey6

1Unit of Nutrition and Dietetics, Department of Clinical Medicine, School of Medicine, Trinity Centre for Health Sciences, Dublin

2Discipline of Physiotherapy, School of Medicine, Trinity Centre for Health Sciences, Dublin, Ireland;c Trinity St James’ Cancer Institute, St James’ Healthcare Campus, Dublin

3School of Biological, Health, and Sport Sciences, Technological University Dublin, Dublin

4Trinity St James’ Cancer Institute, St James’ Healthcare Campus, Dublin, Ireland;e Faculty of Health Sciences, Trinity College Dublin

5Department of Surgery, School of Medicine, Trinity Centre for Health Sciences, Dublin

6Trinity St James’ Cancer Institute, St James’ Healthcare Campus, Dublin; Department of Surgery, School of Medicine, Trinity Centre for Health Sciences, Dublin

Ireland has the second-highest incidence of recorded cancer cases globally, with 326.6 cases per 100,000 of the population compared to the global average of 190.0 cases per 100,000 (Citation1). Gastric and esophageal cancers are the 8th (Citation2) and 14th (Citation3) most common cancers in Ireland, respectively. The 5-year survival rates for all cases of gastric or esophageal cancer are 27% and 23%, respectively, partly due to a significant proportion of cases being diagnosed at advanced stages (Citation2, Citation4, Citation5). However, significant improvements in the surveillance, detection, treatment, and management of these diseases in recent decades are evident (Citation4, Citation6), with, for example, the survival rate for those presenting with locally advanced esophageal cancer now approaching 50% (Citation4, Citation5).

Despite these improvements in survival, the development and treatment of esophagogastric cancer often results in decrements in function, to include muscle loss (Citation7–9), fatigue (Citation10, Citation11), social limitations (Citation9, Citation12), and swallowing and other foodrelated difficulties (Citation11, Citation13). Malnutrition is common, ranging from 22% to 62%, depending on the stage of diagnosis, treatment, or recovery (Citation14, Citation15). Longterm consequences of disease management can affect a significant proportion of survivors, with over a third experiencing

symptoms associated with their treatment, more than a year after surgery (Citation16). In the Lasting Symptoms After Esophageal Resection (LASER) Study, for example, approximately threequarters of participants who were at least 12 months postsurgery reported experiencing ongoing early satiety, reduced energy levels, and/or heartburn (Citation16).

As the number of survivors increases, healthcare services must be coordinated to manage the consequences of treatment and to ensure that survivors are supported to implement behaviors that reduce the risk of new and recurrent cancers (Citation17, Citation18). The World Cancer Research Fund (WCRF) includes among its recommendations for primary and secondary cancer prevention and cancer survival (Citation19) that persons maintain a healthy weight, be physically active, eat a diet rich in wholegrains, vegetables, and fruits, avoid high-calorie foodstuffs, and limit red and processed meats and sugar-sweetened drinks. However, the capacity of survivors to adhere to recommendations may be impacted by symptoms experienced after treatment, such as difficulty consuming a diet rich in wholegrains, vegetables, and fruits when an individual is prone to early satiety (Citation16), diarrhea (Citation10, Citation11), or weight loss (Citation14, Citation20, Citation21).

Research on the long-term nutritional intakes and GI symptoms of survivors of

esophagogastric cancer is limited. To better understand the shortand long- term opportunities to optimize nutritional status and secondary cancer prevention, this study aimed to explore nutritional intakes and GI symptoms among esophagogastric cancer survivors up to 12 months, 13–36 months, and 37+ months post-surgery.

Methods

Participants were identified from the Upper Gastrointestinal (UGI) Cancer Registry at St James’ Hospital, Dublin, Ireland. Persons that had completed treatment with curative intent for esophageal, esophagogastric, or gastric cancer in the 5 years prior, and who were in remission, were eligible to participate. Persons with evidence of metastatic or recurrent disease and/or a lack of medical approval to participate, were ineligible for recruitment. Eligible persons were invited to participate by letter and provided written informed consent in advance of data collection.

Demographic Data

Data were collected from medical records on age, smoking status, relevant medical history (gastroesophageal reflux disease (GERD) and Barrett’s Esophagus), and treatment history (neoadjuvant and adjuvant therapy).

Anthropometric Measures and Activity Levels

Anthropometric measures were taken in the Wellcome TrustHealth Research Board Clinical Research Facility (CRF) at St James’ Hospital.

Weight (kg) was obtained using a calibrated SECA digital medical scale. Height (cm) was measured, without shoes, using a SECA stadiometer. Body mass index (BMI) was calculated as (weight (kg))/(height (m2)). Waist circumference (cm) was measured to the nearest millimeter with a flexible measuring tape at the midpoint between the iliac crest and the 12th rib following gentle expiration. Waist circumference was measured in duplicate and averaged for data entry.

Activity levels were monitored by an Actigraph GT3X+ (Actigraph, Pensacola, Florida), a triaxial accelerometer. Participants wore the monitor during waking hours for one week prior to attending the CRF for anthropometric measurements. Monitor wear and non-wear time was logged in an activity diary.

Nutritional intake, Malnutrition, and Secondary Cancer Prevention

Habitual nutritional intake was assessed using the 131item European Prospective Investigation of Cancer (EPIC) Food Frequency Questionnaire (FFQ) (Citation22, Citation23). Data were converted to nutrient intakes using the FETA FFQ EPIC Tool for Analysis (version 6.0). The adequacy of total energy, macronutrient and micronutrient intakes, and the contribution of each macronutrient to total energy intake, was assessed in line with relevant national (Citation24, Citation25) and international (Citation19, Citation26, Citation27) guidelines.

Malnutrition risk was assessed using the 4-item Short Nutritional Assessment Questionnaire (SNAQ) (Citation28). Items are cumulatively tallied to a maximum score of 19 points. Scores <14 points indicate a risk of undernutrition.

The WCRF and American Institute for Cancer Research (AICR) Score (Citation29, Citation30) is a standardized scoring system used to assess adherence to the WCRF/AICR Cancer Prevention Recommendations. The score is based on adherence to 7 core recommendations and one optional recommendation (related to breastfeeding). Adherence to the 7 core recommendations was examined in this study (Citation31). A recommendation is scored as 1, 0.5, or 0 points for meeting, partially meeting, or not meeting the recommendation, respectively. Two recommendations (have a healthy weight and eat a diet rich in wholegrains, vegetables, fruits, and beans) have two subrecommendations, with the subrecommendations each scored as 0.5, 0.25, or 0 points for meeting, partially meeting, or not meeting the sub-recommendation, respectively. The final score ranges from 0-7, with a higher score indicating greater

adherence to recommendations. Anthropometric measurements, Actigraph data, and data from the EPIC FFQ were used to determine the score for relevant recommendations.

Two components of the WCRF/ AICR score were modified: % calories consumed from ultraprocessed foods (aUPFs) and weekly consumption of red and processed meat. The output of the EPIC FFQ did not permit the creation of tertiles using % calories consumed from aUPFs, so the data were categorized into tertiles based on grams (g) of snacks and jams consumed. The same scoring applied, with 1, 0.5, and 0 points assigned to the lowest, middle, and highest tertiles, respectively. The output of the EPIC FFQ also did not permit grams of white, red, and processed meats to be analyzed separately, so meat (chicken, turkey, beef, pork, lamb) and meat products (e.g. bacon, corned beef, sausages, and beef burgers) were analyzed as a composite weight. The WCRF/AICR cutoffs were amended to reflect national recommendations (Citation24) on grams of cooked white (50–75 g per day up to 3 days a week), red (50–75 g per day up to 3 days a week), and processed

(limited) meat consumed weekly. Scores of 1, 0.5, and 0 were assigned to daily intakes of ≤43 g (≤150 g red meat + ≤150 g white meat divided by 7 days), 44–64 g (151–225 g red meat + 151–225 g white meat divided by 7 days), and ≥65 g (≥225 g red meat + ≥225 g white meat divided by 7 days), respectively.

Gastrointestinal Symptoms

The 15-item Gastrointestinal Symptoms Rating Scale (GSRS) (Citation32) provided ratings for five gastrointestinal symptom clusters: abdominal pain, diarrhea, constipation, reflux, and indigestion. Each item was rated on a 7-point Likert scale, ranging from no discomfort to very severe discomfort over the past 7 days. The mean score of 3 items determined the score for the overall cluster to which those 3 items belong. The composite scores of items on stomach pain, hunger, and nausea contribute to the overall score for Abdominal Pain. The composite scores of items on diarrhea, loose stools, and the urgent need to have a bowel movement contribute to the overall score for Diarrhea. The composite scores of items on constipation, hard stools, and the sensation of not emptying bowels upon defecating contribute to the

overall score for Constipation. The composite scores of items on heartburn and acid reflux contribute to the overall score for Reflux. The composite scores of items on borborygmus, bloating, burping, and flatus contribute to the overall score for Indigestion. Higher scores indicate more severe GI symptoms.

Analysis

Data were entered into SPSS (version 27) and assessed for normality. Data were presented descriptively using counts and percentages. Normally distributed data were presented using the mean and standard deviation and non-normally distributed data were presented using the median and interquartile range (IQR). Participant characteristics, nutritional intakes, and GI symptoms were summarized numerically for the full cohort. Participants were also categorized based on time post-surgery, that is, up to 12 months post-surgery, 13–36 months post-surgery, and 37+ months post-surgery. Comparisons of nutritional intakes, WCRF/AICR scores, and GI symptoms between the three subgroups were made using a one-way between-groups ANOVA with post-hoc tests. Actigraph data were analyzed using Actilife

Nutrition & GI

6 software. Moderate-to-vigorous physical activity (MVPA) levels were assessed using Freedson (1998) cut-points (Citation33).

Statistical significance was taken at p < 0.05.

Results

Demographics

Most (82.5%, n33) of the 40 participants were male and almost one in five (17.5%, n7) were female. The mean age of the total group was 65.5 ± 9.3 years and mean time post-surgery was 28.8 ± 18.4 months (range 6–62 months). A majority (80.0%, n32) of participants had been diagnosed with esophageal cancer and 20.0% (n8) had been diagnosed with gastric cancer. Most (82.5%, n33) participants were ex-smokers, with the highest proportion (39.4%, n13) of exsmokers being in the 37+ months post-surgery category. Only 12.5% (n5) of the total group had never smoked and 5.0% (n2) were smoking at the time of the study.

Anthropometric Measures and Activity Levels

Half (50.0%, n20) of the total group and of each subgroup had a BMI in the healthy range, with 30.0% (n12) and 20.0% (n8) of the total group having a BMI in the overweight and obese categories, respectively. The subgroup that was 6–12 months post-surgery had the highest proportion (41.7%, n5) of persons with a BMI in the overweight category. The subgroup that was 13–36 months post-surgery had the highest proportion (28.6%, n4) of persons with a BMI in the obese category. No participant had an underweight BMI.

In terms of waist circumference and associated elevated cardiac

risk, 42.4% (n14) of male participants and 42.9% (n3) of female participants had a waist circumference in the low-risk category, while all remaining participants presented with waist circumferences categorized as high or very high risk.

MVPA levels were lowest among those who were 6–12 months post-surgery and highest among those who were 37+ months postsurgery, with more than two in five (45.0%, n18) of the total group meeting the activity guidelines.

Nutritional intakes, Malnutrition, and Secondary Cancer Prevention

Participants within 12 months of surgery had statistically significantly higher fat (129 ± 46 g), fiber (21 ± 9 g), folate (385 ± 154 µg), copper (0.8 ± 0.6 mg), and iron (15 ± 4 mg) intakes when compared to participants that were 13–36 months post-surgery (86 ± 28 g, 13 ± 3 g, 264 ± 42 µg, 0.7 ± 0.4 mg, and 10 ± 2 mg respectively). There were no significant differences between the intakes of those who were 13–36 months postsurgery and those who were 37+ months post-surgery.

Among the full cohort, mean protein intake (105 ± 46 g) accounted for 17.5% of total energy intake. Mean total fat (109 ± 45 g) and saturated fat intakes (45 ± 20 g) represented 40.9% and 16.9% of total energy intake, respectively. Mean carbohydrate intake (260 ± 98 g) accounted for 43.4% of total energy intake.

Mean intakes of fiber, Vitamin D, copper, iodine, and potassium were below recommended intakes (Citation34, Citation35), whereas mean sodium intakes exceeded public health recommendations

(Citation36) across all three subgroups. The proportions that always or usually added salt during cooking were 41.6% (n5), 50.0% (n7), and 42.8% (n6) of those that were 6–12 months, 13–36 months, and 37+ months post-surgery, respectively. The proportions that always or usually added salt at the table were 16.7% (n2), 57.1% (n8), and 64.2% (n9) of those that were 6-12 months, 13–36 months, and 37+ months post-surgery, respectively.

Vegetables were eaten daily by 50.5% (n6), 35.7% (n5), and 50.0% (n7) of those that were 6–12 months, 13–36 months, and 37+ months post-surgery, respectively. Fruits were eaten daily by 50.5% (n6), 35.7% (n5), and 57.1% (n8) of those that were 6–12 months, 13–36 months, and 37+ months post-surgery, respectively. The total group consumed a median of 287 g (approx. 3.7 portions) fruits and vegetables daily. The median weight of fruits and vegetables consumed were 392 g (approx. 5 portions), 233 g (approx. 3 portions), and 343 g (approx. 4.5

portions) among those who were 6–12 months, 13–36 months, and 37+ months post-surgery, respectively. There were no statistically significant (p = 0.484) between-group differences in fruit and vegetable intakes.

Meat (red and white meat) and meat products were consumed by almost all (97.5%, n39) participants. A median of 120 g (IQR 95) cooked meat and meat products per day was consumed by the total group, with those that were 6–12 months, 13–36 months, and 37+ months post-surgery consuming a median of 136 g (IQR 112), 112 g (IQR 75), and 136 g (IQR 173) per day, respectively. There were no statistically significant (p = 0.313) betweengroup differences in meat and meat product consumption.

The range for SNAQ scores was widest for those that were 6–12 months post-surgery, ranging from 4 to 18. SNAQ scores for those 13–36 months and 37+ months post-surgery ranged from 11–18 and 10–18, respectively. Of the total group, 27.5% (n11) scored <14 on

the SNAQ, indicating a risk of malnutrition. The proportion of each subgroup that scored <14 on the SNAQ was 33.3% (n4), 28.6% (n4), and 21.4% (n3) for 6–12 months, 13–36 months, and 37+ months post-surgery, respectively.

The mean WCRF/AICR score for the total group was 3.6 ± 1.1 (range 0.75–5.5), indicating adherence to an average of 3.6 of the 7 cancer prevention recommendations included. Mean scores for each subgroup were 3.3, 3.4, and 3.9 for those that were 6–12 months, 13–36 months, and 37+ months post-surgery, respectively. There were no statistically significant betweengroup differences (p = 0.432).

Gastrointestinal Symptoms

There were no significant between-group differences in gastrointestinal symptoms. Average scores indicated that discomfort levels ranged from minor (score on scale = 2) to mild (score on scale = 3) discomfort. Abdominal pain, constipation, and reflux were more commonly reported as minor symptoms, while indigestion and constipation were more commonly reported as mild symptoms.

Discussion

It is well-established that as an upper GI cancer, esophagogastric cancer has profound short- and medium- (Citation8, Citation11, Citation14, Citation21, Citation37, Citation38) term effects on the nutritional status of those diagnosed. As the 5-year survival rate continues to improve (Citation4), there is greater exploration of the long-term impacts of GI symptoms and nutritional changes on health outcomes (Citation16), and on factors that play a role in secondary cancer prevention. This analysis explored cross-sectional nutrient intakes and GI symptoms at 3 timepoints across a 5-year period after curative treatment for esophagogastric cancer. At all timepoints, a risk of malnutrition was evident, discomfiting GI symptoms were reported, overweight and obesity were present in half of participants, and adherence to nutritional guidance for secondary cancer prevention (Citation19) was limited.

The proportion of participants at risk of malnutrition in the present study ranged from a fifth to a third, with scores highest among those who were 13–36 months post-surgery. Nutritional challenges are common, with findings in the current study

reflecting several findings in the LASER study (Citation16), a multicenter European study of over 800 disease-free patients that underwent esophageal cancer resection. The LASER study reported that over 40% of participants struggled to maintain their weight or continued to lose weight, more than one year post completion of treatment. In the current study, caloric intakes were lowest among individuals who were 13–36 months post-surgery. Although their intakes were not statistically significantly lower relative to the intakes of those who were 6–12 and 37+ months post-surgery, this finding may highlight the value of nutrition support from dietitians which was provided throughout the first 12 months post-surgery, and possibly indicate that challenges to nutritional intake persist for several years post-surgery before becoming more stable after 36 months.

The LASER study (Citation16) reported that common long-term GI symptoms associated with treatment included early satiety, heartburn, and bloating/cramping; all of which have the potential to negatively impact on food intake (Citation11, Citation39) and subsequent nutritional status. There were no significant between-group differences in GI symptoms in this study, with all subgroups experiencing similar levels of minor/mild GI discomfort, regardless of the time since treatment. Somewhat similarly, the presentation of these symptoms in the LASER study was persistent across timepoints (1–2 years, 3–4 years, and >5 years), but at least 15% of participants in the LASER study reported experiencing severe GI symptoms. The development of the ES4 (Esophagus and Stomach Surgery Symptom Scale) scale (Citation40) included 344 persons with esophagogastic cancer who were 6 months to 5 years postsurgery, of which 107 persons had undergone surgery for esophageal cancer. Most participants in the ES4 study reported no symptoms or mild symptoms in terms of abdominal distension, abdominal hypersensitivity, cervico-thoracic symptoms, and diet-induced systemic symptoms (Citation40). The likely presentation of even mild GI symptoms for a prolonged period post-surgery highlights the need to monitor nutritional status over time (Citation41, Citation42) and manage survivors’ expectations of their recovery.

Malnutrition is associated with involuntary losses of fat and lean tissue (Citation38) and an

increased risk of sarcopenia, a multifactorial syndrome linked with compromised functional performance (Citation8). Although no participant in this study had underweight, half of participants had overweight or obesity, and it is known that excess adiposity can mask lean tissue losses (Citation8, Citation43). The incidence of sarcopenic obesity in this patient group is potentially as high as 75% (Citation44) and it has been implicated in adverse health outcomes such as Type 2 Diabetes Mellitus and nonalcoholic fatty liver disease (Citation45). Elevated cardiometabolic risk is also typically present, and this was potentially indicated in this study due to most participants having waist circumferences categorized as either high or very high risk. Exercise and nutrition interventions (Citation41, Citation46, Citation47) have the potential to improve longterm markers of cardiovascular and metabolic health, with in-person (Citation9, Citation47) and telehealth (Citation41) approaches deemed acceptable in the literature. Telehealth approaches may be particularly valuable in providing long-term rehabilitative support across a wider geographic area, and their long-term feasibility warrants further exploration.

Nutrition-related recommendations for secondary cancer prevention include adequate amounts of wholegrains, vegetables, and fruits, limited amounts of red and processed meats, and limited amounts of refined and convenience foods (Citation19). International recommendations for fiber range between 25 and 30 g per day (Citation26), and at 17 g/d in this study, intakes were lower than recommendations and the national average of 19 g (Citation48). Relatedly, suboptimal intakes of fruits and vegetables were also evident, with a median of 3.7 portions/d consumed, compared to the national recommendation of 5–7 portions/d (Citation24). That said, average intakes of fruits and vegetables were higher in this study compared to the average national intake of 2.9 portions/d (Citation49). Meat and meat products were consumed regularly by almost all participants. A median of 120 g/d cooked meat and meat products was consumed, exceeding national recommendations (Citation24) and the average national intake of approximately 70 g/d (Citation50). With discomfiting GI symptoms, meeting requirements

for fiber, vegetables, and fruits is challenging, and when appetites are poor, displacing these with nutritionally dense alternatives such as meat and dairy is common. However, given the importance of fiber, vegetables, and fruits in reducing the risk of cardiovascular disease and cancer (Citation51), and improving day-to-day function (Citation52), it is important that survivors are supported by qualified professionals, such as dietitians, to adopt health-promoting eating behaviors that optimize their longterm wellbeing.

The strengths and limitations of this work are acknowledged. Participants were identified through a high-volume national center for esophagogastric cancer treatment and include only those with no evidence of disease progression at the time of data collection. The modest sample size reflects the challenges of long-term diseasefree follow-up in this cohort and is comparable to other studies in this area (Citation8, Citation9, Citation37, Citation39). The measures of physical function and dietary habits may be confounded by the overall and sub-group sample sizes, and as such, results must be interpreted with caution. Causal inferences cannot be made due to the observational study design. Validated instruments were used to collect data on nutritional intakes (Citation22, Citation23), malnutrition status (Citation28), and GI symptoms (Citation32), and this is a strength of the study. Obtaining accurate assessments of nutritional intake is challenging, particularly in smaller cohorts where measurement error is more difficult to overcome (Citation53), and this must be considered in interpreting the data. Future research should employ validated instruments to assess dietary intake on a larger cohort at regular intervals to provide more nuanced insights into the trajectory of dietary change post-surgery.

As rates of long-term survivorship continue to increase, it is essential that those recovering from esophagogastric cancer are supported to implement and maintain behaviors that enhance the quality of their survival and reduce secondary cancer risk. This study indicates that many opportunities remain for the development of health-promoting interventions in the rehabilitation of this cohort, and that further research on the long-term health needs of this group is warranted.

The Intersection of Conduct and Care

Written by Stephen A McMahon Co-Founder Irish Patients Association

The Irish Patients Association, founded as Ireland’s first independent, cross-disease patient advocacy group, operates on a non-political basis with a focus on patient safety and rights protection. Since 2013, the association has been reliant on voluntary work without public funding from the Health Service Executive (HSE) or paid staff.

Patient safety in Ireland's healthcare system remains fraught with issues, including problems within Emergency Departments, prolonged waiting times for consultant appointments and surgeries, restricted access to GP panels in various regions, and persistent funding overruns. While some issues are due to resource limitations, others require cultural and operational changes rather than just financial input. A critical area for improvement is the corporate conduct towards patients, which often lacks the expected standards of respect and professionalism. Corporate conduct encompasses how healthcare organizations interact with patients, manage medical errors, allocate resources, and ensure transparency and responsiveness in addressing patient concerns and complaints.

Financial Concerns Amid Workforce Issues

The HSE has secured a ¤1.5 billion supplemental budget to manage this year's overspending, aiming to mitigate any adverse impacts on patients. However, there is concern regarding the HSE’s workforce cap of 130,000 by the end of 2024, which is significantly lower than the current annual turnover rate of 145,985 WTE or 163,792 personnel. Clarity on this cap is necessary to ensure adequate staffing levels to meet patient needs. Furthermore, the unresolved Internal Audit investigation into the ¤19 million intended for children's spinal operations raises additional concerns. The HSE's approach needs to transition from a reactive to a proactive stance, identifying and addressing issues before they escalate.

Patient User Experience

The HSE own Patient Experience Survey conducted by HIQA for 2022 reports high satisfaction levels however Patients were also less positive about the availability of emotional support, time to discuss care and treatment with a Doctor, information on how to manage a condition after leaving

hospital, and opportunities for family members to talk to a Doctor. 22% of participants said that they did not find a member of staff to talk to about their worries and fears.

On the other hand, benchmarking against other industries presents a different insight.

In May 2024, the strategic communications firm, The Reputations Agency, published its Ireland RepTrak® 2024 report which studies public perceptions of 100 of the largest, most important and most familiar organisations in Ireland. This year the HSE, with an annual budget of ¤23Billion, was positioned in the weak reputation tier and ranked in 95th place. The challenge for the HSE is to understand why they have performed in this way compared to for example the Mater Private Network and the Blackrock Healthcare Group who ranked in 7th and 10th position respectively in the same study.

[See table 3.]

Patient Experiences Reflect Systemic Issues

Several patient experiences in 2024 highlight systemic failures requiring urgent attention. Issues

include poor communication and unprofessional behavior from healthcare providers. For instance, patients have reported being told that there are "sicker people" who need attention or that management prioritizes other issues over their concerns, which is disrespectful and unprofessional.

Examples of Problematic Conduct Include:

Handling Phone Calls: One patient’s calls to Hospital A were redirected to Hospital B, resulting in a curt response and a disconnected line when attempting to proceed with a transfer request.

Mixed Wards: An elderly patient was repeatedly placed in mixed wards against her will and preferences, allegedly due to discriminatory practices favoring certain patients for private or female-only wards.

Long Waits and Communication: The extended wait for ADHD assessments has left patients in limbo for over a year without clear timelines, significantly impacting their well-being.

Surgical and Equipment Failures: Last-minute cancellations of surgeries due to overlooked health issues and denial of necessary

Figure 1: Half Year Review - Health Systems Performance January - June 2024 vs Year End 2023

medical equipment for home discharge demonstrate a lack of thoroughness and disregard for patient needs.

Challenges in Care Transfer and Delayed Diagnoses

Patients also face difficulties in transferring care closer to home. One patient, who had traveled extensively for 20 years, struggled to switch to a more conveniently located hospital due to new waiting lists, despite serious conditions. This highlights systemic issues in patient management and accessibility. Additionally, delayed diagnoses and dismissive responses to patient complaints further tarnish the healthcare experience. For instance, a patient's injury was ignored for months, and when accountability was sought, the response from the Doctor was irritated and dismissive.

"Change and Reform in our healthcare systems should not be preceded by preventable funerals and injury to patients"

Waiting Lists and Cancellations

Waiting lists for operations are growing, with adult lists increasing by 4.4% by Q2 2024 compared to the previous year. The number of patients waiting 6-12 months, 12-18 months, and over 18 months has also risen. For children aged 0-15 years,

waiting lists grew by 28,000 in the first 16 weeks of 2024, despite a minor overall drop. Misallocation of ¤19 million intended to reduce waiting times and improve spinal and orthopaedic services for children underscores the need for accountability and effective fund management. The Department of Health has requested an audit of children's orthopaedic care to examine the use of this funding.

Cancelled Operations and Overcrowded Emergency Departments

Overcrowding in emergency departments led to 50,000 operation cancellations in the first quarter of 2024, which could have reduced the waiting list by 55%. This overcrowding significantly impacts patient safety and highlights issues in capacity and processing efficiency within the HSE. The HSE should adopt best practices, including detailed reporting on rescheduled operations post-cancellation, similar to the NHS in England.

Disparities in Consultant Waiting Times

As of mid-2024, 20.5% of the population without private health insurance is waiting for their first consultation with a hospital

consultant, whereas those with private insurance face minimal waiting times. This disparity raises concerns about the effectiveness of Sláintecare, especially if unsafe waiting times are not reduced significantly. While there has been a 5% decrease in patients waiting over 18 months, the number waiting between 12 and 18 months has surged by 17.7%. Alarmingly, children are now experiencing longer waits than adults, with 16.1% of children waiting over 12 months by June 2024 compared to 14.2% at the end of the previous year.

Conclusion: The Importance of Conduct

The Importance of ConductThe Reputations Agency Ireland RepTrak® 2024 report highlights that conduct is as crucial as products and services in building and protecting reputations. Healthcare organisations must prioritise fairness, transparency, and ethical behaviour to uphold patient rights and improve care quality. A commitment to respectful and compassionate interactions with patients and their carers is essential. This commitment is vital in a financially constrained yet hungry industry and starts with genuinely listening to patients and their families.

Figure 2: Disparities in Consultant Waiting Times

Figure 3: Table 3 HSE scores over the past seven years

Women’s experiences of seeking healthcare for abdominal pain in Ireland: a qualitative study

Written by Eibhlín B. Windrim1, Brian E. McGuire1,2 and Hannah Durand3

1School of Psychology, University of Galway, Galway

2Centre for Pain Research, University of Galway, Galway, Ireland

3Division of Psychology, University of Stirling, Stirling, Scotland

Abdominal pain refers to pain that occurs between the chest and the pelvic area. It can present as cramping, dull, aching, sharp, or stabbing pain that may be either constant or intermittent. Abdominal pain can be acute or chronic. Acute abdominal pain typically presents suddenly and may be associated with nausea or vomiting, and is often attributable to infection, inflammation, perforation, or obstruction.1

Chronic abdominal pain lasts for greater than three months’ duration,2 and may be indicative of underlying pathology;3 however, the underlying cause of abdominal pain cannot be specified in about one third of patients.4 Abdominal pain often affects functional capacity and quality of life and is a leading cause of healthcare utilisation internationally.3

Abdominal pain affects between 22% and 25% of the population, with a higher prevalence among women (24%) than men (17%).5,6

Gastrointestinal issues such as irritable bowel syndrome (IBS) and

inflammatory bowel disease (IBD) account for much of the abdominal pain experienced by both men and women, with sex-based differences in pathogenesis and presentation being well established.7, 8 However, abdominal pain is also a common symptom of a wide variety of gynaecological conditions, such as endometriosis, fibroids, ovarian syndromes, and pelvic inflammatory disease.3, 9 Pain in the abdomen during menstruation (i.e., dysmenorrhea) secondary to various gynaecological disorders and/or as a primary form of disease is also common and debilitating.10, 11

Healthcare and the gender pain gap

The Gender Pain Gap refers to the phenomenon in which women’s pain is more poorly understood and undertreated compared to pain in men due to systemic gaps and biases. Clinical trials and other types of health research have traditionally adopted a ‘male as default’ or andronormative approach,12 which limits our

understanding of pain conditions that predominantly affect women or how certain conditions affect men and women differently. This phenomenon has also contributed to the normalisation of women’s pain and gender biases within healthcare,13 which may result in women not seeking help for debilitating symptoms and impact the nature and quality of healthcare interactions for those who do. In their systematic review on gender bias in healthcare, Samulowitz and colleagues12 identified a distinct pattern of gendered norms in the chronic pain literature. Women were presented as having greater bodily awareness and therefore heightened sensitivity to pain relative to men. It was also commonly suggested that pain without an identifiable cause is a natural characteristic of the female body. Additionally, women’s pain is more likely to be considered hysterical or psychological in origin, and as such is more likely to be described as ‘medically unexplained.’

Sex and gender influence the presentation of pain, which in turn influences patient care. In general, pain is underestimated by healthcare professionals (HCPs); however, evidence suggests male patients’ pain is overestimated relative to female patients’ pain.14 The ability of HCPs to accurately assess patient pain is often compromised by pre-existing gender biases, which determine how pain is addressed and treated in healthcare settings.15 Gender variations in healthcare experiences have been observed for abdominal pain, specifically. In their study on gender disparity in the analgesic treatment of acute abdominal pain in emergency departments, Chen et al.16 reported that, although women were more likely to present with abdominal pain than men, they were less likely to receive pain relief than men reporting similar pain scores. Women’s abdominal pain is often considered less serious than men’s, oftentimes being dismissed as ‘just’ dysmenorrhea17 without due regard for severity or impact of the pain.18 Due to the normalisation of dysmenorrhea, both socially and medically, perceived dismissal of women’s abdominal pain symptoms in healthcare contexts is common.16, 17, 19, 20 Experiences of dismissal by HCPs can lead to feelings of guilt, inadequacy, and helplessness, which can impact self-efficacy and resilience as well as future help-seeking behaviour. In Ireland, women have been demonstrated to delay seeking necessary healthcare assistance for a month or more on average.21 Delay was influenced by women’s knowledge, beliefs, and social factors; in particular, women were more likely to delay when they anticipated that they would not be heard by HCPs. Validation from HCPs is important to ensure patients feel comfortable in seeking help.22,23 Anticipated or experienced invalidation by HCPs may explain the greater tendency for women to self-advocate and utilise more self-advocacy strategies than men.24 Women may develop these skills and strategies, particularly health informationseeking,25 in an attempt to

overcome the challenges they face in accessing care.

The Gender Pain Gap is a systemic issue; therefore, it is useful to consider the various contextual determinants that may influence the experiences of women with pain within specific healthcare systems and distinct socio-political and cultural landscapes. Ireland has a two-tier healthcare system, consisting of both private and public healthcare services.26, 27 This type of system can exacerbate healthcare disparities and result in fragmentation of care and strain on public service resources.27 This two-tier system has its origins in the early 1900s and is in large part a consequence of the Catholic church’s historical alliance with the medical profession in Ireland.28 Although modern Ireland may be described as socially liberal, some would argue its conservative history can still be seen in the church’s continued influence over Irish healthcare

policy and delivery,28 which may disproportionately impact female patients. Repeated women’s healthcare-related scandals, both historical29, 30 and contemporary,31, 32 have demonstrated Ireland’s poor track record in providing adequate care to women. Although there have been substantive changes to women’s health policy in response to public outcry in recent years, the extent to which these have impacted women’s healthcare experiences to date is unclear. Cumulatively these factors are likely to influence women’s pain-related help-seeking behaviour, as well as the quality of care they receive. However, there is a dearth of research on the experiences of women seeking healthcare for abdominal pain in the Irish context to date.

Cumulatively the literature suggests that there are clear gender-based disparities present in healthcare systems, which can negatively impact the experiences of women with pain. In particular, women who present with abdominal pain are likely to have their pain experiences dismissed

or invalidated, and to have their conditions misdiagnosed and undertreated. However, there is a dearth of research on the experiences of women with abdominal pain accessing healthcare in the Irish context, specifically. Given the unique interplay of healthcare systemrelated factors, social and cultural factors, and recent changes in women’s health policies and practice,33, 34 understanding women’s experiences of seeking help for abdominal pain in Ireland can provide important insights to help optimise healthcare delivery nationally, while contributing to the broader global discourse on sex- and gender-based disparities in healthcare. The current study aimed to explore women’s experiences of accessing healthcare for abdominal pain in Ireland using a qualitative approach.

Method

Participants and recruitment

Women over the age of 18 years who were resident in Ireland and had attended Irish healthcare

services for abdominal pain were invited to take part in the study. No restrictions were placed on the type, severity, or duration of abdominal pain. A convenience sampling approach was taken. Study information was disseminated via social media platforms (Reddit, LinkedIn, Facebook, and Twitter) and flyers were posted on the university campus and at healthrelated conferences. Snowball sampling was also used, whereby participants were encouraged to share the study information with others who may have been eligible to take part. Recruitment took place over a period of four months (March–June 2023).

A total of 14 women took part in the study. Data collection ceased once data adequacy (i.e., data sufficient to answer the research question in both amount and variety35) was achieved according to evaluation by all members of the research team. Participant information is presented in Table 1. Only age groups are reported to better protect participant anonymity. Table

Pain

Study design and procedure

A qualitative interpretative approach to the research was employed. One-to-one interviews were used to explore participants’ experiences of the healthcare system in Ireland when presenting with abdominal pain. Interviews were conducted by the lead author (EBW) via video-conferencing platforms Zoom and Microsoft Teams, where participants were invited to remain on- or offcamera, as desired. Interviews were semi-structured and followed a previously prepared interview guide (see Additional file 1). Time was allocated at the start of each interview to inform the participant of the study’s purpose and content, to obtain informed consent, and to build rapport with the participant. Participants were encouraged to ask any questions they had concerning the research and their participation and were reminded that they were not obligated to share any information with which they were uncomfortable. The interviews lasted an average of 31 min (range: 15–55 min). Interviews were audio-recorded and transcribed verbatim by the lead author (EBW) for analysis. Transcripts were validated by a senior author (HD) to ensure they accurately captured participants’ verbal and non-verbal communication (e.g., pauses,

laughter). After transcription, audio recordings were destroyed. Ethical approval was obtained from the School of Psychology Research Ethics Committee at the University of Galway (Ref: SREC-17-Feb-23). Ethical standards of the institutional research committee were upheld throughout the research process. Data was handled and stored in accordance with requirements set out by General Data Protection Regulation (GDPR).

Data analysis

Reflexive thematic analysis according to Braun and Clarke36,37,38 was used to analyse the data. An inductive approach was taken, whereby themes were entirely derived from the data. This analysis approach comprised the following six stages:

1. Familiarising yourself with the data: Interview recordings were transcribed verbatim by the lead author, facilitating familiarisation with the data.

2. Generating initial codes: A semantic approach was taken to generate codes, by extracting relevant phrases and sentences from the data, establishing recurrences throughout the data.

3. Searching for themes: Relationships between codes were considered using visual

representations. Codes were then divided based on similarity, creating themes.

4. Reviewing themes: The coded data extracts were reviewed for each theme. The validity of each theme was reviewed in relation to the dataset and the research topic, to ensure the analysis provided an accurate representation of the data and addressed the research aim.

5. Defining and naming themes: Each theme was given an operational name and definition. Each theme was defined by identifying its context and depth in relation to the research question.

6. Producing the report: A detailed account of each theme supported with extracts from the transcripts was established within the final report.

The analysis was undertaken by the lead author, with support from a senior author (HD) with extensive experience in qualitative health research. The lead author transcribed the interviews, developed the codes, and generated an initial set of themes. The research team had frequent meetings to discuss the data and analysis throughout this phase. Codes, categories, and initial themes were reviewed

by a senior author (HD) for comprehensiveness, coherence, and grounding in the data. Any proposed refinements to the themes were agreed among all authors.

The credibility of the findings was ensured through prolonged engagement with the data and frequent in-depth discussions among the research team during the data collection, analysis, and writing processes. Peer debriefing, whereby findings and interpretations were discussed with colleagues not directly involved in the research to help identify any potential biases, challenge assumptions, and gain additional relevant insights, was practiced during the analysis stage to enhance the credibility of the findings.39

Reflexivity

Reflexivity was practiced throughout the research process. Reflexivity involves researchers acknowledging and critically reflecting their role in shaping the research and its findings, including how personal beliefs, values, and experiences may impact data collection, analysis, and interpretation.40 The lead author and interviewer (EBW) was a young cisgender female living in Ireland with experience of the Irish healthcare system. This may

Fig. 1

From: Women’s experiences of seeking healthcare for abdominal pain in Ireland: a qualitative study

Figure 1

have facilitated rapport-building with participants, who largely shared similar characteristics. Reflexive writing was employed to record the researchers’ viewpoints and decisions throughout the research process, establishing a reference log for later stages of the research. This also enhanced the dependability and confirmability of the findings.41 The research team also met frequently to practice collaborative reflexivity, questioning each other’s assumptions and decisions from their individual perspectives across all stages of the research. Peer debriefing, as described above, also facilitated reflexivity.

Results

Four themes were constructed from the data. Themes are outlined below (see Fig. 1) and illustrated using supporting quotations.

Theme 1 – “Just Get on with It” –Normalisation and Invalidation

All participants described instances of not feeling listened to by HCPs in the past. For the majority, this was explicitly linked to dismissal and invalidation of their symptoms and the normalisation of abdominal pain in women. Participants felt that their doctors saw their pain as an inherent part of their womanhood and therefore not needing treatment, “like having a uterus can discredit other ailments,” (P07).

“‘Oh, it’s normal, and a lot of people have really painful periods, it’s just part of being a woman, blah blah blah…’” (P01, quoting HCP)

“‘Oh, you’ve a sore tummy? Welcome to womanhood.’” (P05, quoting HCP)

“I usually leave the doctor just feeling really confused and kind of, like, dismissed.” (P02)

Some participants internalised the normalisation of their pain, which influenced the ways in which they understood and described their experiences. These participants minimised their own symptoms during the interviews. Many regarded their pain as normal and described themselves as simply “unlucky” (P01) or as having a “low pain tolerance” (P01) relative to others. For most, this internalised normalisation of pain resulted from having their abdominal pain invalidated in their initial interactions with HCPs.

“I was like, ‘oh, it’ll pass.’” (P05)

“We might be feeling really bad, but you will try to minimise it yourself.” (P11)

The invisible nature of abdominal pain was discussed, with several participants relaying experiences of pain with a ‘visible’ cause being taken more seriously by their doctors. One participant (P07) described a comparatively positive experience of attending their hospital’s emergency department with a dislocated hip, versus the negative experience she had had in the same department when presenting with abdominal pain.

“Luckily, recently my hip dislocated, and everybody believed me, […] because it was a very visible, physical ailment. I was so shocked and almost gassing myself again, I’m like, ‘all these people seem to really believe you this time, maybe that means it’s not real.’ (laughs)” (P07)

Participants struggled to negotiate pain management solutions with their HCPs. These conversations typically centred on the type, effectiveness, and tolerability of medications for pain management. Some participants felt that the over-the-counter analgesics they were advised to use were ineffective for managing their pain. Others struggled to tolerate certain kinds of medications due to unique sensitivities or side-effects. Some participants were no longer able to tolerate certain medications they had used to manage their pain over many years. Experiences of contraceptive prescribing were mixed; some participants were told “to just go on the pill and that’ll sort everything,” (P08), while another participant was denied contraception for pain management. Participants with unspecified and/or gynaecological abdominal pain were particularly unsatisfied with their treatment.

“The pain killers they give you are nowhere near as strong as what you actually need.” (P13)

“I’m very sensitive to medication and I don’t agree with a lot of medication, and I had in the past the experience that they were not listening to [me about] certain pain killers or anti-inflammatories I can’t take.” (P12)

“I had to beg to be given anything.” (P06)

“In the same way I can’t ignore an email from a client, I don’t think they should be able to ignore my pain.” (P10)

Theme 2 – “Bad Enough”? Costs of (Not) Seeking Help

Participants described the significant impact of abdominal pain on their daily lives. For most, pain was associated with

adverse impacts on academic, social, and working life. Several participants reported that their symptoms interfered with even basic functions such as eating and sleeping.

“Yeah, I couldn’t really function. (laugh)” (P01)

Some participants spoke of how their symptoms and resulting hospital stays impacted their ability to attend lectures and required them to seek extensions for assignments while attending university. One discussed how, later, the same symptoms also interfered with her work.

“I had to [get] a doctor’s note because I wasn’t able to hand in an assignment on time. I could barely… I had no energy. […] So, it was awful, and I could barely get out of bed for a lecture. If I had a two-hour lecture, I’d make it to the second hour. Even if it was at twelve o’clock in the day, if it was a twelve to two lecture, I’d make it in for one o’clock. It was really, really not fun.” (P09)

“Multiple assignments had to get pushed back, and email multiple tutors to say I’m in hospital.” (P06)

“How am I supposed to be fully functioning in work if I’m constantly battling?” (P06)

Despite significant and wideranging impacts of pain on the lives of participants, many reported not wanting to go to their doctor until their symptoms were “bad enough” (P05). For many, this was due to the expectation that their concerns would be dismissed. For others, there was concern that there would not be any treatment options available to them. Those who had experienced medical trauma previously were particularly reluctant to seek care.

“To be like, ‘actually, this is bad enough for me to go to my GP and pay like 80 quid,’ I don’t want to be told that I’m due my period, y’know? If I’ve hit this point where I’m coming seeking medical attention for it, I know myself that it’s worse than a f***ing period.” (P05)

“[I wouldn’t go to the doctor] because knowing there’s nothing really they can do about it.” (P01)

“In the end they just gave me painkillers [that] I think I had at home. So, if it’s just that next time, y’know, for sure I might not go as soon.” (P04)

This idea that pain needed to be severe in order to warrant care was reinforced for some participants by their doctors.

One participant described being denied a referral for specialist care because her symptoms did not meet a certain threshold of severity, despite the impact they were having on her wellbeing.

Theme 3 – “Fight Your Case,” Fight For Care

This theme describes the experience of having to fight to be heard and to receive care from HCPs, as well as the ways in which participants accessed information and support from others to facilitate this fight. The perceived importance of self-advocacy when engaging with HCPs was evident throughout the interviews. Participants felt there is an onus of self-care to be borne by patients who are unable to rely on HCPs for care and support. Despite feeling that “there’s something wrong” (P02) and that their abdominal pain is “out of the ordinary” (P01), participants struggled to have their needs addressed by HCPs, who they felt did not take their concerns seriously.

“[Doctor said patient was stressed] It was like, yes, I’m stressed. Of course, I’m stressed, there’s sh*t going on. But then also, I have been stressed before. I know this is not my body’s immediate reaction to stress.” (P09)

“There’s something wrong, because, like, I have changed my diet and stuff. I have changed my diet and it’s still… it’s still happening no matter what I eat.” (P02)

“Respectfully, I have been having my period for over ten years now and I – this is not, like, this is not the normal pains.” (P10)

Social support facilitated participants in their fight for care, particularly support and encouragement from other women. Mothers assisted participants in advocating for themselves and were sometimes described as being the driving force behind their care. Many participants also received informational and emotional support from friends. Other women, including strangers, were described as playing pivotal roles in participants’ self-advocacy journeys.

“My Mam, my hero.” (P09)

“I would discuss […] with my friends, y’know, I’m always saying, ‘oh my, y’know, my stomach is sore,’ and they’re always saying, like, ‘go to get it sorted.’” (P02)

“Never met her before or nothing and she was so helpful and only

Pain

for her I probably would still be in so much pain.” (P08, referring to an endometriosis advocate she heard on the radio and contacted for advice)

In contrast, some participants highlighted that societal perceptions of women’s pain acted as an impediment to them accessing care. For example, one participant described how the absence of discussion around menstruation when she was growing up impacted how she sought healthcare assistance for her pain.

“I found similarly to what I found at home, it was very much, ‘just get on with it, it’ll be grand.’ It’s like its period cramps essentially is what I – it was minimised to that, but it absolutely was not. So, that went on for years. […] Now, I did eventually find a really, really lovely healthcare practitioner, […] but I didn’t find her until I was almost in my late twenties.” (P11)

Social support provided some participants with the validation they needed to take the first step in seeking healthcare. Participants who had normalised their pain described how peers influenced their decision to seek help by affirming that their pain was debilitating. Having someone else confirm that their pain was severe and warranted investigation gave impetus to help-seeking.

Theme 4 – “Out of the Loop” –Systemic Barriers to Care

Many participants discussed structural issues within the Irish healthcare system as barriers to receiving effective care. There was a particular focus on issues of communication. Participants discussed how communication within and between healthcare departments and services was

lacking, with one participant commenting that, when she was admitted to the emergency department for abdominal pain, “at no point in time had they gotten on to gynaecology to take a look, despite the fact that I attend there for gynaecology,” (P06). Some participants expressed desire for a more “community based,” (P12), “collaborative,” (P11), and “holistic” (P12) healthcare approach, which they believed might improve the situation for both patients and HCPs.

“I don’t even know if [my GP has] been told about the endometriosis. I’m very out of the loop.” (P05)

“A lot of people are not getting the treatment they need, and they deserve, because the communication just isn’t there.” (P09)

Discussion

The current study aimed to explore the help-seeking experiences of women with abdominal pain in Ireland. Participants’ experiences were largely negative, characterised by feelings of dismissal and invalidation, struggle to have symptoms taken seriously, and frustration with systemic barriers to diagnosis and treatment. Internalised normalisation of pain was apparent in this sample, with many participants describing a perceived need for their pain to reach a certain (high) threshold of severity, as evaluated by themselves or others, before seeking medical attention. Participants felt that they were primarily responsible for making sure they received the care that they needed. Despite feeling frustrated with their healthcare experiences, participants acknowledged that many of the barriers they faced were systemic

and expressed empathy for HCPs operating within a flawed system.

Past experiences of perceived dismissal by HCPs affected participants’ willingness to seek healthcare. Participants emphasised the importance of feeling heard by HCPs, with some stating that their doctor’s ability to make them feel heard was more important to them then their medical expertise. This is consistent with previous literature, which highlights that listening is essential for building a trusting patient-doctor relationship that facilitates open communication.22,42 Resource limitations within the healthcare system, particularly in public healthcare, place extreme pressures on HCPs’ time, which may exacerbate patients’ feelings of dismissal. Participants suggested that a more collaborative approach to healthcare could be beneficial not only for their own health, but also for HCPs. This could alleviate some of the pressures faced by HCPs, and GPs in particular, to be “expert in everything.”

All women in this study emphasised the importance of self-advocating in order to be taken seriously by HCPs. Although women have been shown to have greater self-advocacy intentions, these do not appear to be associated with less negative clinical experiences regarding pain,24 suggesting that disparities in care cannot be attributed to women failing to self-advocate. It is likely that these disparities are in part due to the normalisation of women’s abdominal pain. Both women and doctors may assume that their abdominal pain is normal, even when that pain is severe.17, 20, 43 This is also a systemic issue, whereby pressures on the healthcare system result

NEWS - New Clinical Trials Oversight Group

in the de-prioritisation of “nonurgent” or “non-malignant” issues, without due consideration for the impact on functioning or quality of life. Clearer conceptualisation of health and illness according to the International Classification of Functioning, Disability and Health (ICF)44 in the healthcare system, whereby activity limitations and participation restrictions are central, could help alleviate some of these issues.

Conclusions

Participants described mostly negative experiences of seeking healthcare for abdominal pain. Previous experience of dismissal of symptoms and social perceptions influenced participants’ willingness to engage with healthcare services. Women may internalise the idea that severe pain is normal and attempt to tolerate it without effective support, potentially to their long-term detriment. Participants’ experiences with healthcare reinforced their view that self-advocacy is essential to allow them the chance to receive care for their pain. There are systemic issues at play within the Irish healthcare system that limit women’s ability to access abdominal pain management support. Public health campaigns that challenge normative views of women’s abdominal pain as not warranting healthcare intervention and promote appropriate helpseeking for disabling pain are needed. Education and training for HCPs on the Gender Pain Gap and its implications for patient care, as well as clear referral pathways for women presenting with abdominal pain, are needed to ensure more equitable healthcare delivery for individuals with pain in Ireland.

References available on request

Minister for Health, Stephen Donnelly has announced the establishment of a National Clinical Trials Oversight Group which is tasked with developing recommendations to increase the number of trials taking place in Ireland.

Clinical trials are a fundamental component in enabling high-quality care and improving patient outcomes.

The National Clinical Trials Oversight Group will propose sustainable solutions, with a view to creating more efficiencies in the clinical trials system. This will ensure Ireland can build on its excellent reputation across the clinical trials landscape and further position the State as a key strategic host in attracting international clinical trials.

At present, Ireland is not attracting as many clinical trials as some other European countries. National initiatives have been implemented and additional steps are being taken to address this and improve the clinical trial landscape in Ireland. Solutions are required to address challenges that remain, including, the excessive administrative burdens, workforce, and operational resources, as well as slow start-up speeds.

Establishing the new oversight group, Minister for Health, Stephen Donnelly TD said, "We need to do better for patients. I want to double the number of clinical trials taking place in Ireland. A strong clinical trial infrastructure can give patients access to treatments that deliver improved outcomes and, in some cases, can be lifesaving. I want to see Ireland aim for best in class globally in terms hosting more clinical trials, thereby increasing the number of people who can access and participate in clinical trials with the ultimate objective of achieving better patient outcomes.

“I have established the National Clinical Trials Oversight Group to propose tangible, innovative solutions. Improvements have the potential to make an enormous difference to patients. I would like to thank the Chair, Professor Donal Brennan, and all the members of the group, for their commitment in progressing the important work of this Group. The work of the Oversight Group will be a vital contribution to the improvement of Ireland’s clinical trials landscape.”

The MA2VER2ICK Tool Study

Evaluation of a novel clinical pharmacy tool in identifying and categorising drug-related problems in hospitalised patients

Written by C O’Donovan1,2, M Henman2, C McManamly1, A Seoighe1, E Deasy1,2

1Pharmacy Department, Tallaght University Hospital, Dublin, Ireland,

2School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Ireland

Abstract

Introduction

Literature searching has revealed a lack of high-quality research outlining the use of tools or checklists in hospitalised patients. Additionally, few tools identified relate directly to clinical pharmacy practice. The tools identified focus on specific disciplines (e.g. critical care) or specific tasks (e.g. handover).

The MA2VER2ICK Tool is a novel clinical pharmacy tool which has recently undergone review and adaptation.1 The tool is unique as it is comprehensive and applicable to all hospitalised patients, regardless of clinical discipline. The intended purpose of the tool is to assist clinical pharmacists in comprehensive pharmaceutical care planning.

Aim

Demonstrate the utility of the MA2VER2ICK tool in

Roche’s

pharmaceutical care planning, by outlining the type and frequency of drug-related problems occurring in hospitalised patients.

Methods

A prospective, observational, cross-sectional study was conducted in a 560-bed acute university teaching hospital. Clinical pharmacists adopted the tool in their daily practice, in a mixed medical-surgical inpatient population, over four weeks. All drug-related problems identified were recorded and assigned to the applicable category within the tool, by the clinical pharmacist. Additionally, all drug-related problems were retrospectively assigned to applicable categories of the Pharmaceutical Care Network Europe Classification for Drug Related Problems Version 9.1,2 for comparison, by two independent researchers.

Results

All identified drug-related problems identified were successfully categorised using the MA2VER2ICK Tool. In total, 753 drug-related problems were identified in 180 patients over four weeks, with 233 patient-pharmacist encounters occurring. The mean age of patients was 68.9±16 years, while 51.7% (93/180) were

female and 48.3% (87/180) were male. The mean number of drugrelated problems identified per patient was 4.2±3.6. The highest number of drug-related problems experienced by an individual was 20, while 17 patients experienced no drug-related problem.

The majority of drug-related problems identified using the tool related to medication reconciliation (52.7%; 397/753), followed by prescription endorsement and administration (17.3%; 130/753) and pharmacotherapy optimisation (9.3%; 70/753).

In comparison with the MA2VER2ICK Tool, the Pharmaceutical Care Network Europe classification system has a much larger range of categories for assigning drug-related problems. Despite this, a proportion of identified drug-related problems 1.6% (12/753) could not be categorised using this tool, while there were also several categories within the tool 43.2% (19/44) whereby no drug-related problems were assigned.

Conclusion

This study demonstrates that the MA2VER2ICK Tool is a robust clinical pharmacy tool, that is effective and practical in assisting clinical pharmacists with the identification of drug-related

problems and thus is a useful guide to facilitate pharmaceutical care planning at the patient’s bedside. This is in comparison with the Pharmaceutical Care Network Europe classification system, which has less utility as a clinical pharmacy tool, but is better placed as a research instrument.

Despite demonstrating the usefulness of the MA2VER2ICK Tool in identifying drugrelated problems, the clinical significance of those identified was not assessed during this study. However, data collection occurred in real time, facilitating the identification of actual and potential problems, thus reducing the likelihood of underestimating the incidence rate.

References

1. O’Donovan C, Henman M, McManamly C et al. A mixedmethods review and adaptation of a novel clinical pharmacy tool: The MA2VER2ICK Tool Study. 2024. International Journal of Pharmacy Practice. 2024;32(S1):i45.

2. PCNE Classification for Drug-Related Problems V9.1: Pharmaceutical Care Network Europe; 2020 [cited 06 December 2023]. Available from: https://www. pcne.org/upload/files/417_PCNE_ classification_V9-1_final.pdf

Alecensa (alectinib) receives licence in the EU as the first and only targeted adjuvant

treatment for people with ALK-positive early-stage lung cancer

Roche Products (Ireland) Limited (RPIL) is pleased to announce that Alecensa® (alectinib) monotherapy, as adjuvant treatment following tumour resection for adult patients with anaplastic lymphoma kinase (ALK)-positive non-small cell lung cancer (NSCLC) at high risk of recurrence (Stage IB [≥4 cm]–IIIA ALK +NSCLC [7th edition UICC/ AJCC]7 has received a licence in the European Union. Data from the Phase III ALINA trial, where Alectinib demonstrated a 76% reduction in the risk of disease recurrence or death in people with resected ALK-positive

NSCLC, supported the marketing authorisation application.

“For the first time, patients who have undergone surgical resection of ALK-positive NSCLC can be treated with an ALK inhibitor, which can reduce the risk of disease recurrence or death,” said Maitiú Ó Nualláin, Lung Oncology Patient Journey Partner at Roche Products Ireland.

“This is an important approval for people who have historically faced a high risk of their cancer returning after surgery. The use of early ALK testing will help to identify all

patients that could benefit from this new treatment option.”

In the ALINA study, Alectinib reduced the risk of disease recurrence or death by 76% (hazard ratio [HR]=0.24, 95% CI: 0.13-0.45, p<0.0001) compared with platinum-based chemotherapy in people with completely resected IB (tumour ≥ 4 cm) to IIIA (UICC/AJCC 7th edition)7 ALK-positive NSCLC. In an exploratory analysis, an improvement of central nervous system disease-free survival was observed (HR=0.22; 95% CI: 0.08-0.58). This is of particular importance for people with ALK-

positive NSCLC, who are at greater risk of developing brain metastases than those with other types of NSCLC. The safety and tolerability of Alectinib in the ALINA trial were generally consistent with previous trials in the metastatic setting and no unexpected safety findings were observed.

The recommended dose of Alectinib is 600 mg (four 150 mg capsules) taken twice daily with food (total daily dose of 1200 mg). Patients with underlying severe hepatic impairment (Child-Pugh C) should receive a starting dose of 450 mg taken twice daily with food (total daily dose of 900 mg).

Clinical R&D

NATIONAL ROLLOUT OF HEALTHY AGE FRIENDLY HOMES PROGRAMME

Healthy Age Friendly Homes (HAFH), a first-of-its-kind programme to enable older adults to continue living independently, launches nationwide today (10 July). This joint Health and Local Government programme, recognised globally as a best practice example of coordinated support services, will assist up to 10,500 older adults each year through timely interventions. It is estimated that the programme will result in an annual saving of ¤41.5 million to the State through the prevention of hospitalisation and early or unnecessary admission to long-term residential care.

The programme’s key partners include the Department of Health; Health Service Executive (HSE); Department of Housing, Local Government and Heritage; Age Friendly Ireland, and the Sustainable Energy Authority of Ireland (SEAI).

Following a two-year pilot across nine sites, the programme is now expanding to all 31 local authorities. Local Healthy Age Friendly Homes Coordinators will manage support packages — across Housing, Health, Technology, Finance, Energy Efficiency and Social/Community — for each person referred. Home-based assessments will identify a diverse range of supports to enable the older person to continue living independently –whether in their own home or in more suitable housing. These supports could include housing adaptations, rightsizing to a more appropriate home, and assistive technology such as age-friendly tablets or wearable PanPan. It will also provide connections to services such as occupational therapists, social and community groups like Meals on Wheels and transportation to hospital appointments.

An evaluation conducted by Maynooth University involving over 2,130 participants during the pilot phase revealed significant improvements in self-reported health status, quality of life, social support, and functional ability. The Healthy Age Friendly Homes - Pilot Evaluation released today, underscores the programme’s success in enhancing the wellbeing of older adults. In total there were 6,908 supports delivered between May 2021 and December 2023. Of the participants surveyed, over 3,270 people received home visits; over 1,400 participants live in urban areas; 963 participants indicated housing adaptations were required in their home, with 347 having been assisted in

making a housing adaptation grant application and 376 were provided information on housing adaptation grants for consideration and followup. The report also found that 74% of programme participants own their home; 51% live alone; 37% live with a significant other; and 11% live in their own home with a family member.

More than 50% of research participants now feel they have strong levels of social support, a 9% increase, with almost 4 out of 5 research participants reporting having greater self-belief in their ability to respond to new or difficult situations.

Mark Harrington, National Manager of Healthy Age Friendly Homes added: “International evidence shows that the environment — Housing, Health, Technology, Finance, Energy Efficiency and Social/Community— greatly influences how older adults manage at home. The HAFH initiative is poised to support up to 10,500 older adults across Ireland each year, ensuring they receive the right support, at the right time, in the right place. There are currently 44 Local Healthy Age Friendly Homes Coordinators across Ireland, meaning from Dublin to Limerick; from Galway to Waterford, there is a coordinator — or even in some regions two coordinators — in your local authority.”

“Residential care homes are essential when needed, but this service aims to prevent early admission by ensuring timely interventions. While there is an estimated annual saving of ¤41.5 million to the State, HAFH focuses on enhancing quality of life and supporting independent living, rather than solely on cost-effectiveness. Our goal is to provide alternatives to older people, reducing the risk of hospitalisation, premature entry into long-term care, and social isolation through a well-rounded model of care. This person-centred approach ensures that the older person is at all times the decision maker in the supports required.”

STUDENTS EMBARK ON CANCER JOURNEY

This summer, seven promising third-level students will embark on a significant journey to help advance Ireland’s understanding and treatment of cancer. Their innovative research into poor prognosis cancer is being funded by Breakthrough Cancer Research’s Summer Scholarship Programme. This year’s scholarships are kindly supported by the annual AIB Community Fund.

This initiative connects students with top research teams to cultivate the next generation of

leaders in cancer research. The charity is dedicated to ensuring that patients have access to the best possible cancer treatments and never have to hear that there is ‘no hope’. Each student has been awarded a scholarship of ¤3,000 to conduct their research over a 6-10 week period this summer.

The funded projects include:

1. Assessing the impact of palliative and ablative radiotherapy on poor prognosis cancers.

2. Improving the treatment of seizures associated with brain tumours

3. Exploring the information and communication needs of lung cancer patients.

4. Examining drug treatments that could improve survival rates and minimise side effects in ovarian cancer patients.

5. Studying the effects of physical activity and nutritional health on ovarian cancer patients before and after surgery.

6. Identifying how certain proteins and molecules affect drug resistance and cell behaviour in ovarian cancer.

7. Investigating potential new treatments for pancreatic cancer. Amongst the students awarded scholarships is Kimya Ghaffarian from University College Cork, who is exploring the impact of qualityof-life palliative radiotherapy may have in patients with poor prognosis cancers. Kimya says “Unfortunately, many patients with incurable cancer don’t know the potential benefits of radiotherapy. It is a safe and effective treatment option for pain and other debilitating symptoms. There is currently no quality-of-life data on Irish patients with incurable disease receiving radiotherapy as it is difficult to ask patients who are often near the end of life to return to hospital for additional appointments to complete questionnaires.” This study will use easy-to-access mobile phone electronic applications to collect the important information which will help healthcare practitioners identify patients who may benefit most from treatment. It is hoped that the electronic application will encourage more patients to be assessed in a cost-effective and less disruptive way.

Meanwhile, medical student Nazia Rafiq from Trinity College Dublin is looking at whether treatments for seizures associated with brain tumours can be improved. Around the tumour is an area of brain tissue called the peritumoral region. Using cell lines from

donated brain tissue, in-vivo models and novel clinically relevant drugs, this project will assess if the AMPA receptors contribute to generating seizures and the growth of the tumour. The project aims to improve treatment options for patients using drugs that target the AMPA receptor. Speaking about the importance of the Breakthrough Cancer Research’s Summer Scholarship Programme, Nazia added “This scholarship really highlights the importance of facilitating research opportunities for students at my stage. It helps us decide whether an academicclinician pathway is really for us. It allows us to make connections with researchers and clinicians at later stages of their career who can provide us with valuable guidance and advice.”

Breakthrough Cancer Research is Ireland’s leading cancer research charity. They work with researchers and scientists throughout Ireland and fund exceptional patient-focused translational research throughout Ireland and beyond. They particularly focus on poor prognosis or low survival cancers which are often diagnosed at an advanced stage and are poorly served by current treatments.

Over the past 20 years, Breakthrough has helped bring 9 new treatments to the clinic and delivered over 300 novel discoveries in cancer prevention, diagnosis and treatment.

Now in its fourth year the Summer Scholarship Programme promotes and drives more patient-focused cancer research within Ireland, through the education of the next generation of cancer researchers. For more on the Summer Scholarship Programme, see breakthroughcancerresearch.ie or email research@breakcancer.ie

GOVERNMENT URGED TO INVEST ¤5.5 MILLION IN DEMENTIA SERVICES TO TACKLE INEQUITY ACROSS IRELAND

The Alzheimer Society of Ireland (The ASI) is calling on the Government to invest ¤5.5 million in dementia supports and services to address inequity of access across the country.

The organisation is highlighting the vital need for increased care services, social protection, research resources and workforce planning to meet the growing needs of thousands of people across the country.

The recommendations are contained in The ASI’s Pre-Budget Submission 2025; Equal Dementia Supports, Building on Momentum

in 2025, which was launched today at Buswell’s Hotel in Dublin – and calls for additional State investment to address a rising demand for dementia services.

The submission asks Government to build on the momentum of the past four years with an investment of ¤5.5m, alongside tangible policy solutions to address:

• Ongoing geographical inequity in dementia services and supports (including Day Care, Day Care at Home, Weekend Activity Clubs, Dementia Advisers, Clinical Nurse Specialists in Dementia)

• Financial struggles of family carers

• Mental health needs of people living with dementia and those who care and support them

• A sustainable dementia workforce

• Support for Irish dementia research.

The ASI’s Head of Advocacy, Research and Public Affairs, Cormac Cahill said there are 29 Dementia Advisers working across Ireland who are consistently in demand.

“In 2023, the service worked with 4,607 new clients, a 12% increase on 2022. In 2024, demand for the first four months of the year for the service is already 6% ahead of 2023 – showing an 18% increase since the start of 2023.

“Providing greater access to the Dementia Adviser Service will support more people living with dementia and their families to navigate services and supports and receive personalised and timely information about dementia, which has been identified as a significant challenge.

“Our services throughout the country such as Day Care and Day Care at home have waiting lists and ongoing capacity challenges. We are ambitious for the lives of people with dementia, and those who care for, and support them. The actions in this submission have the power to be lifeenhancing and life-changing.

“We appreciate the support from this Government, particularly Minister Mary Butler and her continued understanding and funding of much-needed dementia services. This support has led to considerable improvement in the level of dementia supports in Ireland. Given the rising need and the immense challenges faced by people impacted by dementia, what we are proposing in Budget 2025 can build on the investment in recent years and help to address these challenges.”

This inequity in services was highlighted by Kathleen Farrell, who lives with Lewy Body Dementia, and said: “We should be able to stay in our own homes if that is what we want. Everybody should be entitled to the same support no matter where they live in the country. Time is not our friend; we cannot wait for a service sometime in the future”.

The ASI has highlighted the urgent need for a Dementia Registry to quantify the number of people diagnosed with dementia in Ireland and where they live.

Dr Laura O’Philbin, Research and Policy Manager with The Alzheimer Society of Ireland said: “The lack of hard data on the number of people living with dementia in Ireland and where they live makes our estimations just that, estimations on prevalence rather than evidence-based facts. A Dementia Registry is essential for planning equitable and responsive service provision, ensuring that limited resources are used in the most optimal was possible.”

The organisation has also outlined the need for investment in Dementia Research. Quality research and innovation lead to better outcomes for people with dementia and their families. Ireland has developed a solid foundation in dementia research. Continued investment is vital to capitalise on expertise and knowledge while facilitating a more cohesive research focus across all disciplines.

INVACARE UNVEILS LATEST INNOVATIONS AND RE-BRAND OF MATRX AT DUBLIN ESS CONFERENCE

Leading healthcare manufacturer Invacare unveils its latest innovations and fresh new concepts under its Matrx brand at the prestigious European Seating Symposium in Dublin this week.

Matrx is an award-winning range of clinician-led seating and

positioning solutions specifically designed for the health and wellbeing of wheelchair users around the world.

This week’s symposium brings therapists and clinicians from all over the world together for threedays of research, insights and education within the field.

Invacare’s Matrx range has seen significant global growth over the last number of years and is fast becoming a respected name in the industry.

Sofie Vercaemer, Occupational Therapist and Head of Seating and Mobility at Invacare, expressed her excitement about the European Seating Symposium 2024. She shared, “We are thrilled to be here for this year’s ESS and unveil our latest developments from our Matrx brand. There is a science behind our seating and a truly unique concept that we want to share with delegates during the event.

Over 600 delegates are gathering at the symposium and Invacare welcomed them into their Matrx M-Lab, a space dedicated to expert insight, and seating innovation. Sofie added: “At Invacare, we believe in the power of collaboration and knowledgesharing to drive positive change. Our clinical education team from Motion Concepts in Canada are also joining us to lead on several speaker presentations at the symposium.

“By supporting these events, we aim to enhance education for clinicians, and improve the well-being of individuals with disabilities worldwide.”

Invacare’s Global Head of Communications, Leisa Evans, added, “We continue to strengthen relationships and meet with clinicians, customers and industry colleagues. Our gold sponsorship of the symposium reflects our ongoing commitment to advancing in the field of seating and mobility in Europe and beyond.”

ST PATRICK’S MENTAL HEALTH SERVICES’ ANNUAL REPORT

The recently published 2023 Annual Report for Ireland’s largest independent, not-for-profit mental healthcare provider, St Patrick’s Mental Health Services, has revealed consistent demand for remote care, with approximately 20% of its service users accessing comprehensive, multidisciplinary team-led care through online channels during 2023.

Grounded in a human rights-based ethos, St Patrick’s Mental Health Services introduced homecare and remote services in 2020, which offers choice and empowerment by removing barriers and providing care within the person’s home environment.

A human rights-based approach to care seeks to ensure that the rights of people using services are protected, promoted and supported by the services they’re engaged with. Through the provision of rights-based care, St Patrick’s Mental Health Services strives to ensure that its practices and policies uphold and safeguard the dignity, autonomy and fundamental rights of each service user.

Remote care services are now a core part of St Patrick’s Mental Health Services’ overall service delivery model, with 881 people receiving treatment through this service in 2023 alone. Since its introduction, the Homecare service, which offers inpatient level care to both adults and adolescents in their own home via online channels, has represented an average of 23% of all admissions to the service over the last four years.

The report also showed that during 2023, inpatient care was delivered to 2,341 service users while there were 15,466 Dean Clinic appointments and 18,769 attendances at day programmes.

Speaking about remote care and its role in enhancing human rights-based approaches to mental health treatment, Paul Gilligan, CEO at St Patrick’s Mental Health Services said: “The world is evolving at a rapid pace and how we respond to mental health difficulties must evolve with it. What we are witnessing is not only a shift in technology available, but also a new level of ease and comfort in implementing and using digital healthcare for both mental healthcare professionals and service users.

Nearly one-quarter of service users now choose to access care remotely and the provision of technology-enabled care has become integral to ensuring

Clinical R&D

a sustainable and adaptable mental healthcare service. While inpatient services remain at the heart of St Patrick’s Mental Health Services’ operations, remote care has the potential to become a cornerstone of our human rightsbased ethos by providing choice and empowerment and removing barriers to mental healthcare.”

St Patrick’s Mental Health Services’ 2023 Annual Report also showed significant digital growth in other areas, including the development of a new Digital Transformation Strategy and significantly increased usage of its service user online portal, Your Portal.

By the end of 2023, there were over 2,500 service users registered to use Your Portal, an online portal that empowers service users to play a more active role in their recovery by providing them with greater access to their healthcare records and enabling them to contribute to and monitor their care plans.

Since its launch in 2020, Your Portal, which is Ireland’s first service user portal, has seen a 51% increase in the number of service users using the portal, with 490 additional users recorded in 2023.

The publication of the 2023 Annual Report comes after, earlier this year, St Patrick’s Mental Health Services also published its first Digital Health Transformation Strategy. This strategy outlines how, over the next five years, St Patrick’s Mental Health Services will use digital technologies to promote positive mental health; to educate people in managing their own mental health; to provide service users with recovery and self-management tools; to enable the delivery of the highest quality care and treatment to more people; and to further empower service users as partners in their care.

The 2023 Annual Report, which is available to view here, also outlined significant progress and achievements in a number of other key pillars of activity that are central to St Patrick’s Mental Health Services’ mission and vision, including service user partnership, advocacy and education and research and training.

MUNSTER TECHNOLOGICAL UNIVERSITY HOSTS RARE DISEASES SYMPOSIUM

Munster Technological University (MTU) hosted the All-Ireland Rare Disease Interdisciplinary Research Network (RAiN) symposium on the 10th of June 2024 at its Kerry campus. This symposium was open to anyone living with or interested in rare diseases.

Catherine Carty (UNESCO Chair Manager), Daniel Mikula (Rare Disease Research Catalyst Consortium) Bernadette Sheehan Gilroy (MTU)

Associate Professor Suja Somanadhan (UCD) Dr Maria Caple (UCC) and Professor Josephine Hegarty (UCC)

The symposium brought together approximately 50 attendees, including researchers, health

and social care professionals, academics, policymakers, and advocates in the rare disease field. It showcased the power of collective action in promoting equality, diversity, and inclusion for rare diseases.

Bernadette Sheehan Gilroy from the Dept of Health and Leisure Studies (MTU) spoke about low-protein dietary therapy in the context of inborn errors of metabolism expressing concerns including the lack of research to support the recent implementation of the ‘hot school meals programme’ for those adhering to lifelong low-protein dietary therapy. As part of Bernadette’s presentation, attendees heard from a young man living with tyrosinemia, from the parent of a child with homocystinuria and the perspective of the Irish PKU (Phenylketonuria) community through research Bernadette conducted in collaboration with Associate Professor Somanadhan in the RAiN network.

Thereafter, the work of RAiN’s Children’s Research Advisory Group (CRAG) was presented by two members of the CRAG - Ethan Gilroy and Aaryan Mahesh. The two young members emphasised the importance of amplifying the voices of young people in rare disease research. CRAG member Lucy Gallagher shared a powerful message, virtually, reminding other young people living with rare diseases to “Be the voice, not the Echo”.

After lunch, the symposium heard from Ian Fallon, who presented on the work of BUMBLEance, the first non-governmental funded child ambulance service in Ireland. Catherine Carty (UNESCO Chair

MTU) spoke about rare diseases in relation to Principle Two of the United Nations Sustainable Developmental Goals Declaration to “Leaving No One Behind”. Rosie Dempsey (MTU) described the process of designing a cartoon video which raises awareness of haemophilia. This video was developed in collaboration with Children’s Health Ireland (CHI). Professor Josephine Hegarty and Maria Caples University College Cork (UCC) presented their work on developing a competency framework on genomic education. The day concluded with a panel conversation led by Associate Professor Somanadhan. The panelists included Anne Lawlor (22q11), Mary Vasseghi (TSC Ireland), Cassandra Dinius and Daniel Mikula (Rare Disease Clinical Trial Network), and Triona Seery (Patient Advocate). The discussion was highly engaging, focusing on the importance of partnership through patient and public involvement and engagement (PPIE) in rare disease research. The key message was that it is imperative to place the voices of people living with rare diseases and their families at the very core of research. The day was an immense success, and RAiN and MTU would like to thank all who attended, participated or supported the day. Stay tuned for many more RAiN events in the future.

For more information on RAiN, see the network’s website - https:// www.rainrareresearch.org/

SPINAL INJURIES IRELAND (SII) MARKS 30TH ANNIVERSARY

Ireland’s only spinal cord injury charity reflects on milestone anniversary to urge public to continue supporting 2400 people across Ireland living with spinal cord injury

Spinal Injuries Ireland (SII) is celebrating their 30th anniversary this year and have called on businesses across the country to help them make their annual flagship fundraiser – A Day in My Wheels - their most successful fundraising and awareness event to date.

SII is Ireland’s only support agency dedicated to providing a nationwide person-centred service to assist people to engage fully in society following spinal cord injury which is described by the World Health Organisation and one of the move devastating & life changing injuries a person can sustain. During this time, the charity has provided services and support to over 5000 people with a spinal cord injury and over 20,000 family members and carers. On average,

three people a week sustain a SCI every week in Ireland.

In conjunction with celebrating their 30th anniversary as a charity, SII is calling on businesses across Ireland to declare their expressions of interest for their biggest fundraising and awareness campaign of the year, ‘A Day In My Wheels 2024.’

‘A Day in my Wheels’ provides companies with the chance to engage in an interactive educational experience and provides a holistic understanding of the challenges wheelchair users face when it comes to inclusivity, diversity and employability in the workplace.

SII CEO Fiona Bolger said the annual fundraiser was a key part of SII’s mission in Ireland to create a more accessible and supportive environment for wheelchair users and people with spinal cord injury. She said: “Inclusivity and accessibility is crucial in aiding people with SCI to return to the workplace, and companies need to ensure they are doing all they can to help wheelchair users thrive and feel accepted in the workplace.

“I would urge CEOs across Ireland to sign up to our expression of interest for A Day in my Wheels and join us in raising awareness of the issues faced by those with SCI and be part of the solution.”

The most recent ‘A Day In My Wheels’ workshops raised over ¤30,000 for the charity last year, with the charity hoping to better that for 2024.

To date since the fundraiser began, A Day in My Wheels has raised almost ¤200,000 over the last 3 years. SII has to fundraise over a ¤1 million annually to cover their costs.

Founded in 1994, SII has grown from a small community initiative set up by a group of former patients to a nationally recognized organisation based in a state-ofthe-art resource centre beside the National Rehabilitation Hospital in Dún Laoghaire.

With a mission to empower individuals with spinal cord injuries to live full and independent lives, the charity has made significant strides in raising awareness, funding research, and delivering critical services.

Reflecting on how far the charity has come since its inception 30 years ago, SII Events Manager Philip Quinlan said: “I remember starting in SII in a tiny, cold portacabin just beside the entrance to the old hospital. We only had four full-time permanent staff then – now, we have 17 staff working for our charity.

“We had no fundraising staff, so I initiated that role – the main aim was to get one outreach officer on the road visiting our service users because that’s where they indicated to us that they had the biggest challenge, having left the hospital and all its support. We’re immensely proud to now have a full Services team of 8 people providing a fantastic service for our service users and families.”

Ms Bolger added: “It is amazing to reflect on how far the organisation has come since then, beginning as a small group with the common purpose of supporting people with a spinal cord injury in Ireland

“It is thanks to our incredibly generous donors, supporters and dedicated volunteers that we are still here today, continuing to provide people living with spinal cord injury with much-needed care and support.

Express your interest for ‘A Day In My Wheels’ by emailing info@spinalinjuries.ie or by phoning 01 653 2180.

For more on Spinal Injuries Ireland and the services it provides, see www.spinalinjuries.ie

THE VISION VAN - COMBATTING PREVENTABLE BLINDNESS ACROSS IRELAND

Every day in Ireland, 18 people begin to lose their eyesight, yet 70% of blindness is preventable

Elaine Crossan, Vision Ireland; Fundraiser and Former Paralympian Peter Ryan, Campion Insurance; Denise Harris, CEO of the Harris Group; Jim Campion, CEO of Campion Insurance with the Vision Van

through early detection and treatment. To tackle this worrying trend and raise awareness about the importance of good eye health, Vision Ireland has proudly launched the Vision Van service.

In order to facilitate early screening for various eye conditions, Harris Group, Ireland’s pre-eminent distributor of commercial vehicles, generously donated a state-of-theart mobile unit, which provides vital public education and awareness.

A staple vehicle from Harris Group’s range of electric vehicles, the Maxus eDeliver 9 is equipped with screens and tools for detecting eye conditions, including an Amsler grid for recognising the early stages of AMD (Age-related Macular Degeneration), the most common cause of blindness in Ireland in people over the age of 50. The Vision Van will also provide simulation services through virtual reality and information to the public on various other eye conditions.

Former Irish Paralympian Peter Ryan officially launched the Vision Van today along with sponsor Denise Harris, CEO of the Harris Group, at their headquarters on the Naas Road in Dublin. The donation was also significantly helped by Peter Ryan’s fundraising run from Malin to Mizen Head, along with the support of partners such as Campion Insurance, Bayer and Abbvie, with Circle K covering EV charging costs.

Speaking at today’s launch, Denise Harris commented “We are delighted to support Vision Ireland as they travel across the country promoting good eye health to the public, to safeguard against avoidable vision impairment and blindness. It is important that we

mind our eyes. Of all the faculties that people depend on, I consider that eyesight is one of the most important; education, awareness, and screening are critical for independent living.

Vision Ireland’s Vision Van will benefit many communities across Ireland, and I hope that everyone will appreciate the foresight and effort of Vision Ireland in pioneering this service. It will, I am sure, support many people to better manage their vision and ensure they can live the fullest possible life.”

Former Paralympian Peter Ryan said, “I’m delighted to see the Vision Van get on the road. I feel that people underestimate how many people in Ireland are affected by eye conditions. It is essential that people have access to services like those offered on the Vision Van. I know it will have a massive impact in communities around Ireland.”

Vision Ireland Chief Services Officer Aaron Mullaniff said, “With our Vision Van setting off around the country, we hope to start important conversations about eye health. Our team will be travelling around Ireland informing the public about various sight-loss conditions that can often be difficult to pick up or can be age related. Our aim is to make the public aware of these conditions and equip everyone with the lifestyle information required to manage their eye health. Be sure to pay the Vision Van a visit to learn about how you can look out for your eye health.”

The Vision Van will be coming soon to locations around the country to start much-needed conversations about eye health.

Legal Category: Product subject to prescription which may not be renewed (A).

Marketing Authorisation Number: EU/1/18/1345/001 4 vials; EU/1/18/1345/002 5 vials

Marketing Authorisation Holder: AstraZeneca AB, SE-151 85, Södertälje, Sweden.

Further product information available on request from: AstraZeneca Pharmaceuticals (Ireland) DAC, College Business and Technology Park, Blanchardstown Road North, Dublin 15, Ireland. Freephone 1800 800 899.

ONDEXXYA® is a trademark(s) of the AstraZeneca group of companies. This medicinal product is subject to additional monitoring.

Date of Preparation: January 2024

Veeva ID: IE-5804