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Research into the gut microbiota of human infants is necessary in order to better understand how inter-species interactions and ecological succession shape the diversity of the gut microbiota, and in turn, how the specific composition of the gut microbiota impacts on host health both during infancy and in later years. Blastocystis is a ubiquitous intestinal protist that has been linked to a number of intestinal and extra-intestinal diseases. However, emerging data show that asymptomatic carriage is common and that Blastocystis is prevalent in the healthy adult gut microbiota. Nonetheless, little is known about the prevalence and diversity of this microorganism in the healthy infant gut, including when and how individuals become colonized by Blastocystis. Here, we surveyed the prevalence and diversity of Blastocystis in an infant population (n = 59) from an industrialized country (Ireland) using Blastocystis-specific primers at three or more time-points up to 24 months old. Only three infants were positive for Blastocystis (prevalence = 5%) and this was only noted for samples collected at month 24. This rate is comparatively low relative to previously reported prevalence rates in the contemporaneous adult population. These data suggest that infants in Westernized countries that are successfully colonized by Blastocystis most likely acquire this microorganism via horizontal transfer.

Introduction: Cerebral oxygenation (rcSO 2 ) monitoring in preterm infants may identify periods of cerebral hypoxia or hyperoxia. We hypothesised that there was a relationship between rcSO 2 values and short term outcome in infants of GA < 32weeks., Methods: RcSO 2 values were recorded for the first 48 h of life using an INVOS monitor with a neonatal sensor. The association between cranial ultrasound scan measured brain injury and rcSO 2 was assessed., Results: 120 infants were included. Sixty-nine percent (83) of infants had a normal outcome (no IVH, no PVL, and survival at 1 month); less than one-quarter, 22% (26), had low grade IVH 1 or 2 (moderate outcome); and 9% (11) of infants had a severe outcome (IVH ≥ 3, PVL or died before 1 month age). rcSO 2 values were lower for infants GA < 28weeks when compared with those GA 28-32, p < 0.001. There was no difference in absolute rcSO 2 values between the three outcome groups but a greater degree of cerebral hypoxia was associated with preterm infants who had low grade 1 or 2 IVH., Conclusion: Infants of GA < 28 weeks have lower cerebral oxygenation in the first 2 days of life. A greater degree of hypoxia was seen in infants with grade 1 or 2 haemorrhage. Normative ranges need to be gestation specific.

The Irish National Consent Policy (NCP) proposes that the legal requirement for consent extends to all forms of interventions, investigations and treatment, carried out on or behalf of the Health Service Executive (HSE). This study employs a quantitative descriptive approach to investigate the practices for obtaining consent for an identified group of routine neonatal procedures in neonatal facilities throughout Ireland. The BAPM (British Association of Perinatal Medicine) guidelines were identified as 'gold standard' for the purposes of this study. The results indicated a lack of consistency between participating units pertaining to the modes of consent utilised and notable variances from 'gold standard' guidelines. Unanimity was evident for 3 procedures only (administering BCG, 6-in-1, and donor breast milk to infant). Significant findings related to EEG with video recordings, MRI/CT and gastro intestinal imaging, screening of an infant with suspected substance abuse or retinopathy of prematurity screening (ROP), administration of Vitamin K, and the carrying out of a lumbar puncture.

Neonatal abstinence syndrome (NAS) is the clinical picture of infants withdrawing from in-utero substance exposure. The incidence of NAS rose in Dublin maternity hospitals in the 1970's and '80's in parallel with increasing in opiate abuse in that city. The purpose of this study was to determine if a similar pattern was emerging in Cork University Maternity Hospital. Data from the Erinville Hospital (2000-2007) and CUMH (2008-2011) were compared. Sixteen cases of NAS were identified, two at Erinville Hospital (22,987 deliveries; incidence = 0.09/1000 deliveries) and 14 at CUMH (37,414 deliveries; incidence = 0.38/1000 deliveries; p < 0.01). Five of the 16 mothers were using heroin, while ten were on methadone maintenance. All were multi-drug abusers. Newborns requiring pharmacotherapy for NAS (5/16) had prolonged hospitalisations compared to those requiring supportive care. NAS in Cork is increasing. Primary, secondary and tertiary preventative measures are warranted to prevent further escalation.

Objective: To examine the composition of the evolving microbiota of preterm infants at weeks 2 and 4 of life., Settings: The paediatric intensive care unit of the Cork University Maternity Hospital., Methods: The microbial diversity of faecal samples from 10 preterm infants was determined using 16S rRNA amplicon pyrosequencing technology., Results: In total, 452 863 sequences were obtained from 20 faecal samples collected from 10 preterm infants, allowing a level of analysis not previously reported. The preterm infant microbiota samples were dominated by Proteobacteria (46%), followed by Firmicutes (45%), while the phyla Actinobacteria (2%) and Bacteroidetes (7%) were detected at much lower levels at week 2 of life. This colonisation pattern was similar at week 4 of life. At the family level, Enterobacteriaceae were detected at 50% and 58% at weeks 2 and 4, respectively. The preterm infants were characterised by a lack of detectable Bifidobacterium and Lactobacillus genera commonly associated with the infant gut. In addition to the dominance of the Proteobacteria, a high level of interindividual variation was observed, indeed the relative proportions of different phyla, families and genera in different infants ranged from <1% to >90%., Conclusions: The results indicate that in addition to an uncharacteristic microbiota relative to that reported for healthy term infants, there was a large interindividual variation in the faecal microbiota diversity of preterm infants suggesting that the preterm microbiota is individual-specific and does not display a uniformity among infants.

Over-The-Counter Analgesics (OTCA) account for over a fifth of Irish pharmacy sales. Little is known about patterns of use, specifically in children. This study investigated parents' use of OTCAs in children. A questionnaire exploring use of OTCAs and knowledge of side-effects was distributed to guardians of children attending three GP surgeries in South of Ireland from June-September 2010. The questionnaire was completed by 183 parents (response rate 95%). Many respondents (n = 121, 66.1%) were using analgesics when not required or using an inappropriate analgesic for a child's symptom. Private patients demonstrated better use (n = 31, 40%) than those with Medical Cards (n = 18, 22.5%) (p = 0.016). Identification of potential side-effects was poor, with drowsiness (n = 88, 49%), rash (n = 39, 22%) and nausea (n =3 2, 18%) listed as potential side-effects. Inappropriate use of OTCAs is prevalent in Irish children. Parents need more information and guidance on their use.

Objective: To present 50 years of hospital-based maternal and perinatal outcomes in Sudan, and the role of an international collaboration with an Irish maternity hospital, over the period 2002-2009, in recent health-indicator improvements., Design: Retrospective descriptive study., Setting: Omdurman Maternity Hospital, Sudan., Population: All women who delivered at Omdurman Maternity Hospital, and their newborn infants, from July 1957 to October 2007, comprising 339 448 births., Methods: The original logbook data was extracted. Infant and maternal health indicators were calculated according to World Health Organization definitions., Main Outcomes Measures: Total annual births, maternal mortality ratio and maternal complications, neonatal mortality and stillbirth rates, and rates of delivery methods., Results: Total births increased 50-fold from 499 in 1958 to 24 913 in 2007. Significant reductions in morbidity and mortality began in the mid-1990s. From 2001 to 2007, maternal mortality fell from 329 to 36 per 100 000 live births: an 85% reduction. Stillbirth rates almost halved, from 35 to 19 per 1000 births in 2001 and 2007, respectively. Neonatal mortality rates remained largely static, at 24 per 1000 live births in 2007, but there is recent evidence of a decline., Conclusion: This hospital-based data offers a unique historical portrait of health outcomes in one of the largest maternity hospitals in Africa, and shows steady, sustained improvements in maternal, stillbirth and neonatal mortality rates since the 1990s. The partnership was associated with a number of positive infrastructural, educational, and staffing achievements. Whether it directly contributed to improved health outcomes has not been established., (© 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2011 RCOG.)

Aims: To determine whether healthcare providers apply the best interest principle equally to different resuscitation decisions., Methods: An anonymous questionnaire was distributed to consultants, trainees in neonatology, paediatrics, obstetrics and 4th medical students. It examined resuscitation scenarios of critically ill patients all needing immediate resuscitation. Outcomes were described including survival and potential long-term sequelae. Respondents were asked whether they would intubate, whether resuscitation was in the patients best interest, would they accept surrogate refusal to initiate resuscitation and in what order they would resuscitate., Results: The response rate was 74%. The majority would wish resuscitation for all except the 80-year-old. It was in the best interest of the 2-month-old and the 7-year-old to be resuscitated compared to the remaining scenarios (p value <0.05 for each comparison). Approximately one quarter who believed it was in a patient best interests to be resuscitated would nonetheless accept the family refusing resuscitation. Medical students were statistically more likely to advocate resuscitation in each category., Conclusion: These results suggest resuscitation is not solely related to survival or long-term outcome and the best interest principle is applied differently, more so at the beginning of life., (© 2010 The Author(s)/Acta Paediatrica © 2010 Foundation Acta Paediatrica.)

Background: With the increasing complexities in medicine and the reduction in working hours, shift work patterns are emerging for hospital doctors and with them the possibility for discontinuity of patient care and negative outcomes for patient safety., Aims: The purpose of this study was to evaluate the prevalence, format and structure of formal handover rounds in Irish hospitals in four different specialties., Methods: A 26-item questionnaire was sent to 61 participants in 26 hospitals., Results: Just over a quarter of respondents (28%) reported formal handover rounds. Respondents from Obstetrics and Gynaecology were more likely to report handover rounds (80%). Prominent features of handover include frequent consultant (100%) and post-call staff (73%) attendance., Conclusion: This study confirms that handover rounds are not universal in Irish hospitals. While this does not imply that patient safety is compromised, the need for effective and comprehensive handover is a critical aspect of patient care.

Universal neonatal BCG vaccination was discontinued in Cork in 1972. Following an outbreak of TB in 2 creches in the HSE South, a universal BCG vaccination program was re-introduced in October 2008. The aim of this study was to determine the vaccination process (in-hospital and community) and the in-hospital uptake of the vaccine. Following informed parental consent, babies of birth weight > 2.5 Kg were eligible for in-hospital vaccination if they were not: febrile, jaundiced on phototherapy, on antibiotics and if not born to HIV- positive mothers. Parents of babies not vaccinated in-hospital were asked to book an appointment in either of the 2 Cork community clinics. The immunisation nurse collected data on BCG vaccination, prospectively. This study examined vaccination uptakes in-hospital and community over a 6 month period (October 2008 to March 2009). There were 4018 deliveries during the study period. In-hospital consent was declined in only 16 babies (<1%) while the in-hospital vaccination uptake was 80% of total liv births. Although 635 newborns were admitted to the NICU, only 46 (8%) were vaccinated while in the NICU. At least 48% of planned community vaccination has been achieved to date. In conclusion, in-hospital consent was almost universal and vaccination uptake was satisfactory. NICU exclusion criteria accounted for a significant proportion of non-vaccination in-hospital. These criteria need to be readdressed considering that all premature babies are given other routine newborn vaccines at 2 months of age, regardless of weight.

Background: A number of recent developments in medical and nursing education have highlighted the importance of communication and consultation skills (CCS). Although such skills are taught in all medical and nursing undergraduate curriculums, there is no comprehensive screening or assessment programme of CCS using professionally trained Standardized Patients Educators (SPE's) in Ireland. This study was designed to test the content, process and acceptability of a screening programme in CCS with Irish medical and nursing students using trained SPE's and a previously validated global rating scale for CCS., Methods: Eight tutors from the Schools of Nursing and Medicine at University College Cork were trained in the use of a validated communication skills and attitudes holistic assessment tool. A total of forty six medical students (Year 2 of 5) and sixty four nursing students (Year 2/3 of 4) were selected to under go individual CCS assessment by the tutors via an SPE led scenario. Immediate formative feedback was provided by the SPE's for the students. Students who did not pass the assessment were referred for remediation CCS learning., Results: Almost three quarters of medical students (33/46; 72%) and 81% of nursing students (56/64) passed the CCS assessment in both communication and attitudes categories. All nursing students had English as their first language. Nine of thirteen medical students referred for enhanced learning in CCS did not have English as their first language., Conclusions: A significant proportion of both medical and nursing students required referral for enhanced training in CCS. Medical students requiring enhanced training were more likely not to have English as a first language.

Background: Benchmarking is that process through which best practice is identified and continuous quality improvement pursued through comparison and sharing. The Vermont Oxford Neonatal Network (VON) is the largest international external reference centre for very low birth weight (VLBW) infants. This report from 2004-7 compares survival and morbidity throughout Ireland and benchmarks these results against VON., Methods: A standardised VON database for VLBW infants was created in 14 participating centres across Ireland and Northern Ireland., Results: Data on 716 babies were submitted in 2004, increasing to 796 babies in 2007, with centres caring for from 10 to 120 VLBW infants per year. In 2007, mortality rates in VLBW infants varied from 4% to 19%. Standardised mortality ratios indicate that the number of deaths observed was not significantly different from the number expected, based on the characteristics of infants treated. There was no difference in the incidence of severe intraventricular haemorrhage between all-Ireland and VON groups (5% vs 6%, respectively). All-Ireland rates for chronic lung disease (CLD; 15-21%) remained lower than rates seen in the VON group (24-28%). The rates of late onset nosocomial infection in the all-Ireland group (25-26%) remained double those in the VON group (12-13%)., Discussion: This is the first all-Ireland international benchmarking report in any medical specialty. Survival, severe intraventricular haemorrhage and CLD compare favourably with international standards, but rates of nosocomial infection in neonatal units are concerning. Benchmarking clinical outcomes is critical for quality improvement and informing decisions concerning neonatal intensive care service provision.

Unlabelled: Swimming pool sanitation has largely been concerned with the microbiological quality of pool water, which is normally treated using a number of chlorine products. Recent studies have pointed to the potential hazards of chlorine by-products to the respiratory epithelium, particularly in indoor, poorly ventilated, pools. The aim of our study was to elucidate whether chronic exposure to indoor chlorinated swimming pools was associated with an increased likelihood of the development of asthma in boys., Methods: The subjects were boys aged between 6 and 12 years. Data was collected by means of parental responses to a standardized asthma questionnaire (ISAAC: International Study of Asthma and Allergies in Childhood), supplemented with additional questions regarding frequency of attendance, number of years attendance, whether the child is a swimming team member. The questionnaire return rate was 71/% (n = 121). 23 boys were excluded on the basis that they had asthma before they started swimming (n = 97). There was a significant association between number of years a boy had been swimming and the likelihood of wheezing in the last 12 months (p = 0.009; OR = 1.351; 95% CI = 1.077-1.693) and diagnosed asthma (p = 0.046; OR = 1.299; 95% CI = 1.004-1.506). The greater the number the number of years a boy had been attending an indoor, chlorinated pool, the greater the likelihood of wheezing in the last 12 months or "had asthma". Age, parental smoking habits and being a swimming team member had no association with any of the asthma variables examined. Swimming pool attendance may be a risk factor in asthma in boys.

Objective: To explore the clinical staff attitudes towards ethical decision making in neonatal intensive care units (NICUs) in Ireland, to establish differences between doctors and nurses and to compare attitudes in Ireland with those in Europe., Design: Cross-sectional study by means of an anonymous questionnaire. 64 doctors and 228 nurses in seven NICUs participated (response rates 74% and 81%, respectively). Through factor analysis the staff answers to 12 attitude statements were used to build a score whose range varied from 0 (preservation of life in any case) to 10, indicating a more individualised approach according to the patient's best interests., Main Outcome Measure: Staff attitudes to ethical decision making in NICU., Results: Mean values of attitude scores were 5.8 (95% CI 5.3 to 6.2) for doctors, and 6.0 (95% CI 5.5 to 6.5) for nurses. Respondents with experience in follow-up of NICU graduates had significantly higher scores (6.7 vs 5.4, p = 0.018), while the opposite was true among more religious staff (5.8 vs 6.9, p = 0.026) and particularly for minority religions such as Muslim (4.1, 95% CI 3.1 to 5.2). Scores were higher after age 30 for nurses, and after age 40 for doctors, suggesting the adoption of a less vitalistic viewpoint as respondents grow older and more experienced. Among doctors, a relationship was found between the attitude score and their self-reported non-treatment practices., Conclusions: In Ireland, NICU doctors and nurses hold similar attitudes towards ethical decision making. Personal and professional factors have a statistically significant impact on attitude score. Compared with the rest of Europe, attitudes in Ireland appear more similar to those of southern rather than northern European countries.

Background: Neonatal seizures are often subclinical, making accurate diagnosis difficult., Objective: To describe the clinical manifestations of electrographic seizures recorded on continuous video-EEG, and to compare this description with the recognition of clinical seizures by experienced neonatal staff., Methods: Term infants, at risk of seizures, were monitored by continuous 12-channel video-EEG from <6 hours of birth for up to 72 hours. All clinical seizures were recorded by experienced neonatal staff on individual seizure charts. Video-EEG recordings were subsequently analysed. The number, duration and clinical expression of electrographic seizures were calculated (in seconds), and compared with the seizures clinically suspected by the neonatal staff., Results: Of 51 infants enrolled, nine had electrographic seizures. A further three had clinically suspected seizures, without associated electrographic abnormality. Of the total 526 electrographic seizures, 179 (34%) had clinical manifestations evident on the simultaneous video recording. The clinical seizure activity corresponded to 18.8% of the total electrographic seizure burden. Overdiagnosis also occurred frequently. Of the 177 clinically suspected seizure episodes documented by staff, 48 (27%) had corresponding electrographic evidence of seizure activity Thus, only 9% (48/526) of electrographic seizures were accompanied by clinical manifestations, which were identified and documented by neonatal staff., Conclusion: Only one-third of neonatal EEG seizures displays clinical signs on simultaneous video recordings. Moreover, two-thirds of these clinical manifestations are unrecognised, or misinterpreted by experienced neonatal staff. In the recognition and management of neonatal seizures clinical diagnosis alone is not enough.

Unlabelled: New evidence-based guidelines have been launched with recommendations that may impact how resuscitations, particularly of LBW infants, are enacted., Aim: to determine current resuscitation practices in Maternity units in Ireland and benchmarked these results to a recent study in the United States., Methods: A 20-question survey was developed and mailed to a lead neonatologist/paediatrician in each of 19 maternity units in Ireland in May 2006., Results: There was 84% response rate to the surveys mailed which included 10 level II and 6 level III units. NRP qualification was considered obligatory for all paediatrics doctors in all units, with 14/16 units running at least one NRP course per year (range 1-9). Self inflating bags were more commonly used (44%), followed by T-piece resuscitators (31%) and flow inflating bags (25%). Pulse oximeters to alter the fraction of inspired oxygen were used by (25%) of units during the management of very low birth weigh infants, with a useful signal being achieved in one minute in most cases. Air/oxygen blenders were available for (44%) of units; however, all units use 100% O2 for initial resuscitation. CO2 detectors for ETT position were used in only 2 units (12%). A third of units (31%) used plastic wrap to prevent heat loss in VLBW infants. CPAP/PEEP were used by 44% of the surveyed units, generally with initiating pressure of 5 cm H2O., Conclusions: NRP is now an obligatory feature in all NICU's in Ireland compared to the 1990s when resuscitation training was disorganized and inconsistent. Variations in resuscitation practices still exist among different units. Many units may not be able to apply 2006 NRP guidelines especially for VLBW infants unless there is a significant investment in air/oxygen blenders, pulse oximeters, CO2 detectors and resuscitators that control peak pressures and CPAP/PEEP.

Background: Population-based studies of childhood cancer incidence, survival and mortality make an important contribution to monitoring the successful implementation of new treatment guidelines and to understanding the epidemiology of these diseases., Methods: We analysed incidence and survival data for cancers diagnosed in children under 15 years of age in the Republic of Ireland during 1994-2000 (the first 7 years of National Cancer Registry coverage), and longer term mortality trends., Results: World age-standardised incidence rates in Ireland averaged 142 cases per million children per year, slightly higher than the European average and slightly lower than the US average, although differences varied by diagnostic group. Observed 5-year survival in Ireland (79% overall) was slightly higher than European and US averages, and was significantly higher for acute non-lymphocytic leukaemia (67%) and (compared with the USA) significantly lower for Hodgkin lymphoma (83%). No significant increases in incidence rates were evident from the available 7 years' data, either overall or for particular diagnostic groups. Rates of childhood cancer mortality have declined markedly since the 1950s., Conclusions: Data presented here are in line with other developed countries and suggest major improvements in treatment and consequent survival.

Unlabelled: The Royal College of Physicians & Surgeons of Canada developed a competency framework to assist future specialists in responding to challenges as health care providers. The CANMEDs project described 7 essential roles of Specialist Physicians include Health Advocate, Manager, Scholar, Medical Expert, Professional, Communicator and Collaborator (HMSEPC(2)). The object of the current study was to investigate whether medical students and dental students in Ireland recognised these responsibilities as essential to a qualified doctor/dentist., Methods: Ninety-eight medical and forty-six dental students (year 1 and year 4) were asked to mind map the responsibilities of qualified doctors/dentists. The comments on the mind map were applied to one of the 7 CANMED roles. There were 484 comments from 128 students. Students had the greatest number of responses referring to the Medical and Dental Expert (257, 30.4%) and Professional (227, 26.9%) roles. This was followed by Communicator (130, 15.4%), Scholar (107, 12.7%) and Health Advocate (82, 9.7%) roles. There were relatively few responses relating to Manager (12, 1.4%) and Collaborator (i.e. teamwork) roles (30, 3.6%). There were no differences in responses between Dental Students and Medical Students and between 1 st year and 4th year students. Similarly there were no differences between the responses of Irish students (n =95; 68%) and International students (n =45; 32%) Students are aware of their responsibilities as Medical or Dental experts (diagnostic and therapeutic skills) for ethical and effective patient care (professional role). They are somewhat aware of the Communicator (therapeutic relationships and effective listening), Scholar (personal continuing education strategies) and Health Advocate (contribute to improved community health) roles. In general they have little concept of the importance of Management skills (utilising resources effectively), and of Collaboration (teamwork and consulting effectively with other physicians and health care professionals). Medical and Dental Educators and Curriculum Committees should address these important deficiencies.

The objective of this paper is to examine trends in infant mortality (IMR) and low-birth weight (LBW) in the Southern Health Board (SHB) area and to investigate the relationship between IMR and social and economic factors. IMR data were obtained from the Central Statistics Office (CSO) over a 10-year period (1988-1997). Social deprivation was measured using the Small Area Health Research Unit (SAHRU) Deprivation Index, which consists of five census-based indicators; unemployment, low social class, car ownership, rented accommodation and overcrowding. During the 10 years, 556 infants died, 380 deaths (68%) occurring in the neonatal period and 176 (32%) in the post-neonatal period. There was a downward trend in IMR throughout the study period, from 11.3 in 1988 to 4.0 in 1997 (p < 0.001). The IMR in Cork City was higher than the rate in the SHB area as a whole (p = 0.0001). Congenital anomalies accounted for 34% of neonatal deaths. Sudden infant death syndrome (SIDS) and congenital anomalies accounted for 45% (79/176) and 22% (39/176) of postnatal deaths, respectively. Only 7% of all district electoral division (DED's) in the SHB were classed in the most deprived SAHRU Deprivation Index category (level 5). Yet, almost half (43%) of the DED's in Cork City were level 5 compared to only 1% in Cork County and 2% in Kerry. Despite significant overall improvements in infant mortality in the SHB, infants born into the lower socio-economic area (Cork City) continue to experience higher relative risks of mortality in comparison with those born in the higher socio-economic areas. Further investigation into the apparently divergent socio-economic patterns of infant mortality within the SHB is necessary.

We evaluated the need for a structured Neonatal Resuscitation Programme (NRP) by means of a questionnaire sent to 25 Irish maternity hospitals inquiring about staff availability and current teaching structures. Having taught NRP to almost 1000 health care providers, we present a descriptive evaluation of the programme by a sample of 429 NRP participants, exploring their opinions of NRP. Our results show that midwives were responsible for newborn resuscitation at all low risk deliveries. Only 5 units (23%) had a registrar available on-site 24 hours a day, while the remaining units (77%) had to summon additional medical help from outside, in emergency situations occurring outside of normal working hours. Resuscitation equipment was checked by nurses alone (52%), or by a nurse and physician (48%), on a daily (45%), alternate days (41%) or weekly basis (14%). Although 19 units had some form of neonatal resuscitation training available, only 35% of respondents were happy with the current training structures. Almost half of the 429 providers (45%) replied to the survey. Most (85%) indicated that NRP improved their skills and confidence. Two thirds of participants found the lesson on medications the most difficult theory lesson, while 45% found endotracheal intubation the most difficult skills station. Because of the wide geographical distribution of deliveries in this country, we conclude that all perinatal professionals should be trained to perform newborn resuscitation in a coordinated, team-approach manner. NRP provides such training with a high degree of approval from Irish health care providers.