Irish Medical Journal[JOURNAL]

PRESENTATION: A 14-year-old female presented to the emergency department with a five-day history of abdominal pain and vomiting. Amylase was raised on admission and she was managed conservatively for presumed acute pancr... PRESENTATION: A 14-year-old female presented to the emergency department with a five-day history of abdominal pain and vomiting. Amylase was raised on admission and she was managed conservatively for presumed acute pancreatitis. Her condition did not improve and she deteriorated a number of days into admission and developed bilious vomiting. DIAGNOSIS: CT abdomen-pelvis showed trichobezoars in the stomach and duodenum. TREATMENT: She underwent emergent laparotomy and manual removal of bezoars in a tertiary centre followed by multi-disciplinary input post-operatively. DISCUSSION: Atypical abdominal pain in the paediatric population not responding to initial treatment warrants review of diagnosis and further investigation with consideration for early tertiary service input.

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When Sepsis Kills: A Fatal Cascade of Invasive Group A Streptococcal Sepsis.

Brulinska NK, Harb M, Kiely P

Ir Med J · 2026 Jun · PMID 42348317

PRESENTATION: A previously healthy 22-year-old woman presented with right groin pain, unilateral leg swelling, and dyspnoea following recent infection and minor trauma. She was hypotensive and tachycardic with a painful,... PRESENTATION: A previously healthy 22-year-old woman presented with right groin pain, unilateral leg swelling, and dyspnoea following recent infection and minor trauma. She was hypotensive and tachycardic with a painful, mottled limb and oxygen saturations of 91%. DIAGNOSIS: Investigations demonstrated lactic acidosis, coagulopathy, pulmonary emboli, visceral infarcts, and necrotising soft-tissue infection. Cultures confirmed Streptococcus pyogenes. TREATMENT: Despite antibiotics, emergency surgery, and advanced life support, the patient died of multiorgan failure. DISCUSSION: iGAS infection can mimic thromboembolic disease and requires urgent recognition.

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Fulminant Thrombotic Thrombocytopenic Purpura presenting through the FAST Stroke Pathway.

Maroof A, Huang HYR, Elsadig H … +7 more , Maharaj S, Elderderi D, Ibrahim NAB, Ayeni T, Murray L, Kiely P, Malik F

Ir Med J · 2026 Jun · PMID 42348316

PRESENTATION: A previously healthy woman in her mid-40s of African ancestry presented with sudden-onset left-sided weakness, aphasia, and collapse. On arrival, she was disoriented with a fluctuating GCS of 9-11. Neurolog... PRESENTATION: A previously healthy woman in her mid-40s of African ancestry presented with sudden-onset left-sided weakness, aphasia, and collapse. On arrival, she was disoriented with a fluctuating GCS of 9-11. Neurological assessment revealed speech impairment and limb weakness. DIAGNOSIS: CT brain showed multifocal parietal and cerebellar infarctions. Laboratory tests revealed severe thrombocytopenia (20 × 10³/mm³), anaemia (Hb 9 g/dL), elevated creatinine (180 μmol/L), and high troponins (1139 ng/L). Peripheral smear confirmed red cell fragmentation, and ADAMTS13 activity was <10%, confirming fulminant Thrombotic Thrombocytopenic Purpura (TTP). TREATMENT: Thrombolysis was contraindicated due to profound thrombocytopenia, and intensive supportive care was initiated, including vasopressors, transfusions, and planned plasma exchange. Despite aggressive management, she developed hemodynamic collapse and died within 24 hours. DISCUSSION: This case highlights fulminant TTP mimicking acute stroke, emphasizing the importance of early recognition in patients with severe thrombocytopenia. Prompt multidisciplinary intervention and TTP-specific therapy are essential to improve survival outcomes.

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Regional Anaesthesia for Tibial Fracture Surgery in the Third Trimester of Pregnancy.

Duncan A, O'Donnel B

Ir Med J · 2026 Jun · PMID 42348315

PRESENTATION: A 27-year-old woman at 33 weeks' gestation presented with severe pain and swelling in her lower leg following a fall from a standing height at home. DIAGNOSIS: Imaging confirmed a severely comminuted tibial... PRESENTATION: A 27-year-old woman at 33 weeks' gestation presented with severe pain and swelling in her lower leg following a fall from a standing height at home. DIAGNOSIS: Imaging confirmed a severely comminuted tibial fracture. Given pregnancy-related concerns and historical debate regarding peripheral nerve blockade masking acute compartment syndrome (ACS), careful perioperative planning was undertaken with multidisciplinary input. TREATMENT: The patient elected for regional anaesthesia following shared decision-making. Intraoperative anaesthesia was achieved with a single-shot spinal and popliteal sciatic nerve block. Postoperative analgesia included a continuous low-concentration sciatic catheter infusion, intravenous paracetamol, and PRN oxycodone, alongside structured neurovascular monitoring. DISCUSSION: This case demonstrates that regional anaesthesia with low-dose continuous peripheral nerve blockade can provide effective analgesia in tibial trauma during pregnancy without delaying ACS recognition when rigorous monitoring is employed, while also minimizing foetal exposure to systemic anaesthesia and opioids.

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A National Experience in Paediatric Achalasia: Symptom Recurrence, Reintervention, and Transition Challenges.

Elifranji M, Fadel W, Ahmed MEA … +1 more , Gillick J

Ir Med J · 2026 Jun · PMID 42348282

AIMS: To assess the long-term outcomes and quality of life (QOL) of patients who underwent intervention for esophageal achalasia in a national Paediatric centre over an 18-year period. METHODS: All patients who underwent... AIMS: To assess the long-term outcomes and quality of life (QOL) of patients who underwent intervention for esophageal achalasia in a national Paediatric centre over an 18-year period. METHODS: All patients who underwent surgical or radiological intervention after a diagnosis of achalasia between 2006 and 2024 were identified. A retrospective review of patient demographics, operative technique and Eckardt score before intervention was undertaken. Patients were contacted via telephone to re-assess QOL using Eckardt and Achalasia Scoring Questionnaire (ASQ) scoring systems. RESULTS: In total, 31 patients were identified and 28 were included in the analysis (15 female and 13 male). The majority 21(75%) underwent laparoscopic Heller Myotomy. The mean age at intervention was 11.6 years. The mean duration of follow-up was 7.6 years. The mean pre-operative Eckardt score was 6.9. The mean post-operative Eckardt score was 2.9. Twenty-one patients (75%) were initially symptom free for an average of 17.4 months and 7 (25%) remain symptom free to this day. Eleven (39%) required further interventions. In terms of quality of life, the current mean ASQ score is 19.4 (scoring system 10-31, with 10 representing symptom free). Of the patients who are now adults, 12 (57%) had a formal transition of care to adult services. CONCLUSION: Although surgery may initially improve achalasia symptoms, it is not curative. Patients require lifelong follow-up and support to manage this challenging chronic condition. Ensuring patients are transitioned from Paediatric to adult services could help improve future QOL and tools such as ASQ could help monitor this in an outpatient setting.

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Reducing Anaesthesia's Carbon Footprint: A Survey of Awareness and Attitudes.

Anderson H, Goodings A, Nordrum O … +1 more , Iohom G

Ir Med J · 2026 Jun · PMID 42348256

AIMS: This study aimed to explore Irish anaesthesiologists' attitudes toward environmentally sustainable anaesthesia, including perceptions of safety, efficacy, and policy influences on anaesthetic choice. METHODS: A cro... AIMS: This study aimed to explore Irish anaesthesiologists' attitudes toward environmentally sustainable anaesthesia, including perceptions of safety, efficacy, and policy influences on anaesthetic choice. METHODS: A cross-sectional online survey was distributed to anaesthesiologists across Ireland between March and June 2025. The questionnaire assessed demographic factors, preferences for intravenous versus inhalational anaesthesia, environmental awareness, and institutional support. Descriptive and comparative statistical analyses were performed. RESULTS: A total of 98 responses were received. Patient factors and ease of administration were the primary determinants of anaesthetic choice, while cost was less influential. Environmental considerations were common, with 71 (72%) reporting they consider environmental impact when selecting an anaesthetic technique. Most respondents (n=86, 88%) were willing to modify their practice to reduce environmental harm, yet 55 (56%) felt their institution did not provide adequate environmental education or guidance. DISCUSSION: Irish anaesthesiologists demonstrate strong awareness and willingness to engage in sustainable practice, but institutional training and policy support remain limited. Targeted education and system-level initiatives may enhance environmentally responsible anaesthetic care.

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Long-term impact of haemorrhoidal artery ligation on anal function and continence.

Anwar A, Abushara S, Naseem M … +3 more , Rampersad C, Casey S, Arif A

Ir Med J · 2026 Jun · PMID 42348182

AIMS: Haemorrhoidal artery ligation (HALO) and variants including Doppler-guided HAL (DG-HAL), HAL with rectoanal repair (HAL-RAR), and transanal haemorrhoidal dearterialisation (THD) serve as minimally invasive alternat... AIMS: Haemorrhoidal artery ligation (HALO) and variants including Doppler-guided HAL (DG-HAL), HAL with rectoanal repair (HAL-RAR), and transanal haemorrhoidal dearterialisation (THD) serve as minimally invasive alternatives to excisional haemorrhoidectomy, reducing pain while preserving sphincter function. Long-term faecal incontinence remains a concern due to its quality-of-life impact. This systematic review assessed prevalence, severity, and patterns of incontinence beyond six months post-procedure across HAL techniques. METHODS: PRISMA 2020 guidelines directed searches of PROSPERO, MEDLINE, PubMed, Scopus, Cochrane Library, and ScienceDirect for 2015-2024 studies reporting continence >6 months after HAL-based procedures. Six studies (3 RCTs, 1 prospective, 2 retrospective cohorts; total n=671 patients) met PICOS criteria, with Wexner Incontinence Scores reported or retrospectively mapped. Quality appraisal used CASP Cohort Checklist. RESULTS: Seventeen (2.5%) of 671 patients developed postoperative faecal incontinence. Of these, 14 (82%) cases were mild (Wexner 1-4) and transient, resolving within 3-6 months; 3 (18%) were moderate (Wexner 5-8), primarily in HAL-RAR (9/158 [5.7%]). Standard HAL showed 0/76 (0%) cases; THD had 1/104 (1.0%); DG-HAL had 7/293 (2.4%). No severe incontinence occurred. DISCUSSION: HALO techniques demonstrate excellent long-term continence safety (overall 2.5% low-grade incontinence). HAL-RAR's higher risk (5.7%) warrants counselling. Standardised scoring and multicentre trials are recommended.

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An evaluation of a revised analgesia protocol for elective joint arthroplasty.

Di Lucia L, O'Neill R, Fahey J … +1 more , Duggan M

Ir Med J · 2026 Jun · PMID 42348181

AIMS: Mayo University Hospital performs approximately 350 joint arthroplasty surgeries per annum. We revised our analgesia protocol in 2024 based on best current practice. METHODS: We conducted this evaluation from Janua... AIMS: Mayo University Hospital performs approximately 350 joint arthroplasty surgeries per annum. We revised our analgesia protocol in 2024 based on best current practice. METHODS: We conducted this evaluation from January to July 2025. All patients presenting for joint arthroplasty surgeries were invited to be included. RESULTS: Our evaluation included 147 patients; 94 patients had a total hip arthroplasty and 53 had a total knee arthroplasty. The average age was 69 years, and 142 (96.5%) of patients were living at home independently before surgery. 53 (36%) were on prescribed analgesics pre-operatively. The average pain score on day 1 (day after surgery) was 4.8 for the hip arthroplasty patients and 5.5 for the knee arthroplasty patients. The total oral morphine equivalent requirements for the first 2 days were 48 mgs for the hip surgery patients and 65 mgs for the knee surgery patients. The median length of stay for all patients was 4 days. On follow up at 6 weeks, 135 (91%) of patients were mobilising independently. Overall satisfaction of the patient's experience (0-10) was 8.7 for the knee arthroplasty patients and 8.8 for the hip arthroplasty patients. DISCUSSION: Overall, we were satisfied with our analgesic protocol, but we want to improve the day 1 and 2 pain scores particularly in the knee arthroplasty patients. We are discussing the introduction of adductor canal blocks pre-operatively.

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A review of a perinatal genetics and genomics service's role in prenatal diagnosis.

McMahon G, Rigney T, Doyle S

Ir Med J · 2026 Jun · PMID 42348180

AIMS: The aim of this study was to review prenatal anomaly cases referred to the Department of Perinatal Genetics and Genomics at the National Maternity Hospital. METHODS: We conducted a retrospective review of all patie... AIMS: The aim of this study was to review prenatal anomaly cases referred to the Department of Perinatal Genetics and Genomics at the National Maternity Hospital. METHODS: We conducted a retrospective review of all patients who were referred to the Department between August 2021 to April 2025. We included cases referred for consideration of further genetic testing because of a fetal anomaly where initial QF-PCR and chromosomal microarray studies did not reveal a genetic diagnosis. RESULTS: There were 109 patients who met our inclusion criteria. A molecular diagnosis was made in 56 (51.4%) of this cohort. These diagnoses were apparently de novo in 35 cases (62.5%) and inherited in 21 (37.5%). Pregnancy outcomes showed 31 cases (28.4 %) had a livebirth surviving the neonatal period. DISCUSSION: Our findings demonstrate the high diagnostic yield and clinical value of a dedicated Perinatal Genetics and Genomics service as part of the multi-disciplinary team for prenatal diagnosis. These cases all have a higher rate of recurrence in subsequent pregnancies compared to the empiric risk, indicating a need for ongoing genetics counselling in subsequent pregnancies. This data also indicates a high proportion of these patients experience a fetal or neonatal loss and that appropriate psychological input is needed.

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Intensive Care Consultants and their obligation from the Assisted Decision Making (Capacity) Act 2015.

Bourke J, Keane S

Ir Med J · 2026 Jun · PMID 42346317

AIMS: The purpose of this paper was to explore the level of knowledge and preparedness that Intensive Care Consultants have of their obligations under the Assisted Decision Making (Capacity) Act 2015 as it pertained to p... AIMS: The purpose of this paper was to explore the level of knowledge and preparedness that Intensive Care Consultants have of their obligations under the Assisted Decision Making (Capacity) Act 2015 as it pertained to patients requiring decisions to be made on their behalf within the Intensive Care Environment. METHODS: The 2015 Act was reviewed and a questionnaire was developed assessing key provisions of the Act necessary for lawful decision making. The questions were formatted with binary responses to confirm that respondents were operating within the meaning of the law; subject to the legal principle of ignorantia legis neminem excusat. This questionnaire was circulated amongst Intensive Care Consultants working in Model 4 Hospitals approved for Joint Facility of Intensive Care training. A third-party online survey platform was used to anonymously collect and process responses from those who consented to participate. Qualitative analysis of the responses was performed. RESULTS: 22/63 (35%) ICU physicians completed the questionnaire. 19/22 (86%) were aware of the introduction of the 2015 Act. 14/22 (64%) were able to identify a "relevant person" under the meaning of the Act. 9/22 (41%) had received training in relation to the act. 7/22 (32%) of respondents were aware of the scope of decisions covered by the Act. 6/22 (27%) were aware of the legal obligations placed upon them by the Act. When challenged, 0/6 (0%) of those were able to successfully identify all statutory criteria for decision making capacity. 5/22 (26%) of respondents stated they had changed their approach to patient decision making since the introduction of the Act. DISCUSSION: Deficits in preparedness, knowledge of and familiarity with the Act were evident amongst all respondents. The legislation does not allow for physician interpretation and requires full compliance at all times. Training was either not provided to or not sought out by the majority of respondents. Of those who reported that they were aware of their obligation no one was able to fully demonstrate the minimum expected statutory criteria for decision making capacity. Failure to comply with the legislation leaves practitioners subject to liability. More worryingly physicians have reported little change in their approach to decision making. More training in the area is likely needed.

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Children Admitted with Pertussis Over a One-Year Period.

Dore A, Valla P, Scanlan B … +6 more , Kitt E, Cunney R, Habington A, O'Reilly M, Kelleher S, Harty S

Ir Med J · 2026 Jun · PMID 42345838

AIMS: This study examines cases of Bordetella pertussis admitted to a tertiary hospital in Dublin, Ireland over a one-year period. Described are the demographics, clinical features, severity, morbidity, clinical course a... AIMS: This study examines cases of Bordetella pertussis admitted to a tertiary hospital in Dublin, Ireland over a one-year period. Described are the demographics, clinical features, severity, morbidity, clinical course and vaccination status of patients. METHODS: This retrospective cohort study included all children admitted with pertussis from January 2024 to December 2024 inclusive. Data were collected from patient records and analysed with descriptive statistics. RESULTS: Of the 26 children admitted, 20 (76.9%) were <6 months of age. Median length of stay was 7 days and 3 (11.5%) required readmission. Oxygen supplementation was required in 10 (38.4%) cases and intravenous hydration for >48 hours in 11 (42.3%). The pertussis severity score (PSS) was >5 (severe) in 18 (69.2%). Vaccine eligible children comprised 16 of 26 cases (61.5%). Vaccination status was documented in 24 children; 13 (54.1%) were unvaccinated against pertussis, with 10 (76.9%) ineligible due to age. Vaccination was completed in 4 (16.7%), and 7 (29.1%) were partially vaccinated. Maternal vaccination status was documented in 15 cases, 3 (20.0%) received antenatal vaccination. CONCLUSION: Pertussis is associated with significant morbidity particularly in infants. Many children are admitted before full vaccination highlighting the importance of maternal antenatal pertussis vaccination.

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Sepsis in General Practice: experience and attitudes regarding Early Warning Scores.

Murphy S, McCarthy D, O'Dwyer MJ … +1 more , Smiddy MP

Ir Med J · 2026 Jun · PMID 42345383

AIMS: To explore General Practitioner (GP) knowledge and experience of sepsis and their attitudes toward the implementation of Early Warning Score (EWS) tools in general practice. Early Warning Scores are clinical scorin... AIMS: To explore General Practitioner (GP) knowledge and experience of sepsis and their attitudes toward the implementation of Early Warning Score (EWS) tools in general practice. Early Warning Scores are clinical scoring systems that combine vital signs to detect early signs of patient deterioration and prompt timely medical intervention. As General Practitioners (GP) are usually the first point of contact for unwell patients, the use of EWSs in General Practice requires exploration. METHODS: A qualitative study design based on the Theoretical Domains Framework using semi-structured interviews with GPs in the Republic of Ireland was used. RESULTS: Interviews were facilitated with eight GPs. Four dominant domains were identified: Knowledge, Skills, Beliefs about Consequences and Environmental Context and Resources. All participants had knowledge of sepsis and EWSs, and those who used it found it beneficial in supporting clinical decision-making. CONCLUSION: GPs in this study demonstrated knowledge and experience related to sepsis. Attitudes towards the potential for use of EWSs in primary care were mixed however some participants were already using informal systems to identify risk of sepsis. Currently no EWs is validated for use in primary care. Research into the use of EWSs for primary care is needed.

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Clinical and Quality-of-Life Outcomes of Omalizumab Treatment in Chronic Spontaneous Urticaria.

Hynes J, Basheer O'Dwyer S, Lynch M

Ir Med J · 2026 Jun · PMID 42345364

AIMS: To evaluate response to omalizumab in chronic spontaneous urticaria (CSU), assess concordance between symptom and quality-of-life scores, and identify predictors of response. METHODS: Single-centre retrospective re... AIMS: To evaluate response to omalizumab in chronic spontaneous urticaria (CSU), assess concordance between symptom and quality-of-life scores, and identify predictors of response. METHODS: Single-centre retrospective review of adults with CSU treated with omalizumab in a dermatology department in the Midwest of Ireland. Data included demographics, disease duration, and baseline and latest Urticaria Severity Score (USS), Dermatology Life Quality Index (DLQI), and itch and rash scores. Responders were defined as ≥50% USS improvement. Associations were analysed using Spearman's correlation and Cohen's κ. RESULTS: Thirty-six patients were included; 22 (61%) responded, including 11 complete responders. Complete responders had lower baseline USS and DLQI. Correlations between USS and other measures were moderate, with slight-moderate agreement. DISCUSSION: Omalizumab improved CSU outcomes. Lower baseline severity predicted complete response, while symptom and quality-of-life improvements showed limited individual concordance.

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Podcasting as an adjunct learning strategy in paediatric teaching for medical students.

Conlon N, McCallion N, Hourihane J

Ir Med J · 2026 Jun · PMID 42345363

AIMS: Determine patterns of undergraduate student use and general user experience of a ten-part custom-designed Paediatric podcast series. METHODS: Patterns of use and learning styles were determined by anonymous student... AIMS: Determine patterns of undergraduate student use and general user experience of a ten-part custom-designed Paediatric podcast series. METHODS: Patterns of use and learning styles were determined by anonymous student survey. RESULTS: Of 75 students, 66 (88%) completed the survey; 38 (58%) being non-native English speakers. 49 (74%) listened to at least one episode (median 5 episodes). Users reported high levels of satisfaction with audio quality and ease of use. 37 (76%) agreed the podcast helped them to learn core topics. 9 (18%) students listened solely during "dedicated study time", with the majority (n=39; 80%) using a mobile-learning approach. 19 (39%) used closed captioning with 14 (74%) rating it "useful". Time constraint was the most frequently cited reason for non-engagement. CONCLUSION: Podcasts are a welcome learning resource for a diverse cohort of medical students.

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Increased public and clinician awareness of rabies after UK death.

Phair E, de Paor M, Gaughan L … +2 more , McKeown P, Jessop L

Ir Med J · 2026 Jun · PMID 42345362

AIMS: To identify trends within rabies Post Exposure Treatment (PET) product use for 2025 compared with previous years and highlight potential underlying causes. METHODS: Data from the National Immunisation Office (NIO)... AIMS: To identify trends within rabies Post Exposure Treatment (PET) product use for 2025 compared with previous years and highlight potential underlying causes. METHODS: Data from the National Immunisation Office (NIO) was analysed retrospectively. The years 2020-2022 had low ordering due to COVID-19 so the years 2019, 2023 and 2024 were averaged in a 'baseline year'. Statistical analyses calculated absolute and percentage increases of rabies PET product use in 2025 compared to previous years. RESULTS: Ireland saw a sharp increase of 643 units (249%) in rabies vaccine and 103 units (368%) Human Rabies Immunoglobulin (HRIG) use in 2025 compared to the baseline year. CONCLUSION: This trend may be associated with heightened clinician and public awareness of rabies prone exposure (RPE) and recent changes to service delivery. External factors including resurgence of travel following COVID-19, a UK rabies related death in June 2025 and global rabies product shortage may compound this.

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Bridging the Gap: Implementing the 2024 National Cancer Control Programme (NCCP) Melanoma Imaging Guidelines in Real-World Practice.

Foo A, O'Regan A, Mahon L … +2 more , O'Neill BL, Goodman D

Ir Med J · 2026 Jun · PMID 42345358

Malignant Melanoma is the fourth most common cancer in Ireland, known for rapid progression and metastasis. Targeted immunotherapy has significantly improved 5-year survival. In May 2024, the National Cancer Control Prog... Malignant Melanoma is the fourth most common cancer in Ireland, known for rapid progression and metastasis. Targeted immunotherapy has significantly improved 5-year survival. In May 2024, the National Cancer Control Programme issued guidelines for radiological staging and surveillance, helping clinicians in determining the appropriate radiological modality and timeline for staging and surveillance. This audit revealed gaps in follow-up imaging due to organizational constraints and health service pressures. Compliance with staging imaging was high at 92% (11/12), improving to 100% (12/12) following re-audit. In contrast, compliance with surveillance imaging was lower, with 55% (6/11) for PET-CT and 27% (3/11) for MRI/CT brain, improving to 87.5% (7/8) and 50% (4/8), respectively, in the second cycle. Continued audit and multidisciplinary education are vital for consistent, guideline-based melanoma follow-up.

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Establishing Ireland's Healthcare Greenhouse Gas Baseline: Key Findings, Implications, and Future Directions.

Nordrum OL, O'Dowd TM, Brennan MM … +6 more , Bond B, Breen R, McCarthy ND, Chersich MF, O'Donovan D, Kavanagh P

Ir Med J · 2026 Jun · PMID 42345352

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Irish Medical Journal[JOURNAL]

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