Bronllys Hospital

Barrett’s oesophagus is the only known precursor to oesophageal adenocarcinoma, a cancer with very poor prognosis. The main risk factors for Barrett’s oesophagus are a history of gastro-oesophageal acid reflux symptoms and obesity. Men, smokers and those with a family history are also at increased risk. Progression from Barrett’s oesophagus to cancer occurs via an intermediate stage, known as dysplasia. However, dysplasia and early cancer usually develop without any clinical signs, often in individuals whose symptoms are well controlled by acid suppressant medications; therefore, endoscopic surveillance is recommended to allow for early diagnosis and timely clinical intervention. Individuals with Barrett’s oesophagus need to be fully informed about the implications of this diagnosis and the benefits and risks of monitoring strategies. Pharmacological treatments are recommended for control of symptoms, but not for chemoprevention. Dysplasia and stage 1 oesophageal adenocarcinoma have excellent prognoses, since they can be cured with endoscopic or surgical therapies. Endoscopic resection is the most accurate staging technique for early Barrett’s-related oesophageal adenocarcinoma. Endoscopic ablation is effective and indicated to eradicate Barrett’s oesophagus in patients with dysplasia. Future research should focus on improved accuracy for dysplasia detection via new technologies and providing more robust evidence to support pathways for follow-up and treatment.

Endoscopy is known to be a high generator of waste in healthcare. It also poses an infection risk to patients, both from their own endogenous flora and from exogenous micro-organisms. Increases in infection, as seen during the pandemic, result in increased use of single-use equipment, personal protective equipment, packaging and harmful chemicals. With the significant risk of a further pandemic within the next 5 years, both climate change and the risk of infections should be considered as health emergencies, as they create a revolving door scenario. This article reviews some of the endoscopic and non-endoscopic infection risks and practical ways in which we can improve our environmental footprint while maintaining infection prevention and control.

ABSTRACTIntroductionAntipsychotic medication is increasingly prescribed to patients with serious mental illness. Patients with serious mental illness often have cardiovascular and metabolic comorbidities, and antipsychotics independently increase the risk of cardiometabolic disease. Despite this, many patients prescribed antipsychotics are discharged to primary care without planned psychiatric review. We explore perceptions of healthcare professionals and managers/planners of policy regarding management of antipsychotics in primary care.MethodsQualitative study using semi-structured interviews with 11 general practitioners (GPs), 8 psychiatrists, and 11 managers/planners of policy in the United Kingdom. Interviews were studied using inductive thematic analysis.ResultsRespondents reported competency gaps that impaired ability to manage patients prescribed antipsychotic medications holistically, arising from inadequate postgraduate training and professional development. GPs lacked confidence to manage antipsychotic medications alone; psychiatrists lacked skills to address cardiometabolic risks and did not perceive this as their role. Communication barriers, lack of integrated care records, limited psychology provision, lowered expectation of patients with serious mental illness by professionals, and pressure to discharge from hospital resulted in patients in primary care becoming ‘trapped’ on antipsychotics, inhibiting opportunities to deprescribe. Organisational and contractual barriers between organisations exacerbate this risk, with socioeconomic deprivation and lack of access to non-pharmacological alternatives driving overprescribing. GPs and psychiatrists voiced professional fears of being blamed if an event causing harm occurred after stopping an antipsychotic, which inhibited deprescribing. A range of actions to overcome these barriers were suggested.ConclusionsPeople prescribed antipsychotics experience a fragmented health system and suboptimal care. Many simple steps could be taken to improve quality of care for this population but inadequate availability of non-pharmacological alternatives and socioeconomic factors increasing mental distress need key policy changes to improve the current situation.

The clinical and pharmaceutical interventions of pharmacy professionals are considered impactful inputs towards optimised patient care and safety, by rationalising prescriptions, enhancing therapeutic choices and reducing and preventing medication errors and adverse effects. Pharmacy interventions (PIs), related to the identification, prevention and resolution of drug-related problems, should be recorded for optimal clinical governance and potential health outcomes.Between October 2020 and October 2021, the community hospitals at Powys Teaching Health Board recorded 158 PIs, corresponding to 0.4 interventions per staff per week. Only two members of the team were recording these PIs. Poor indicative PIs can result in lost opportunities for medication optimisation and prescribing rationalisation, increased costs and unidentified training potential.The aims of this project were (1) to record 180 interventions between 22 November 2021 and 8 April 2022 (20 weeks), corresponding to an average threefold increase, compared to the interventions recorded between October 2020 and October 2021 (52 weeks); (2) to have all hospital pharmacy staff recording at least one intervention during the same period.The number of interventions recorded and the number of pharmacy staff recording each intervention were two process measures. The project was completed through two Plan-Do-Study-Act cycles and applied theory on managing change in healthcare.The most successful intervention influencing positively the process measures was the implementation of a new Pharmacy Intervention Record Tool (xPIRT) toolkit that included an online recording tool (xPIRT) and an interactive panel with up-to-date results from all interventions recorded (xPIRT Dashboard). Motivating change was proven to be one of the best determinants of user satisfaction and engagement that contributed to meet the project’s targets. xPIRT Dashboard provided staff the capacity to act on possible personal motivators and the possibility to improving care with medicines on their wards. The implementation of xPIRT toolkit was able to increase the representativity and significance of PIs recorded by the hospital pharmacy team, and it is expected to be used for personal professional development, demonstrating team activity and impact, service planning, prescribing practice optimisation and to identify education/training needs. This toolkit can be easily applied and adapted to other health organisations, settings and services.

<div> <p>Peatland restoration efforts are accelerating globally with a primary aim of restoring the carbon balance of these ecosystems. Degraded peatlands export carbon to the atmosphere but also to freshwater environments as dissolved organic compounds. Whilst hydrological restoration measures can effectively reduce emissions of CO2 from upland peatlands, the impact on carbon export to the aquatic environment is less apparent. In some cases, dissolved organic concentrations can even increase after restoration, without clear mechanisms that could drive such a response. We aim to determine whether the response of the peat microbial community to restoration measures can explain poorly understood trends in dissolved organics. </p> </div><div> <p>We investigated a severely degraded peatland in South Wales that has experienced historic drying to considerable depth, almost complete loss of surface vegetation, and a lowering of the peat surface. Restoration measures implemented over the past 16 years have involved hydrological intervention through gulley-blocking as well as efforts to stabilize the peat surface and re-establish plant communities.  Porewater collected over the first 6 months of our investigation indicates, contrary to expectation, that DOC concentrations were lowest in the most severely degraded region of the bog and highest in the least disturbed regions. We will discuss the potential drivers behind this observed trend, focusing on the role played by the peatland microbiome in the processing of dissolved organics in the peatland. In addition, we draw on water-table monitoring and sampling results to consider how environmental and geochemical conditions moderate biotic processing of dissolved organics. Improvement of our understanding of the microbial community response to rewetting measures is required as this underpins the function and carbon balance of these systems and will ultimately inform management approaches. </p> </div>

Torjesen says that Scotland was successful in reducing knife crime by adopting a public health approach and not by an increase in enforcement activity and resources.1 The debate about the …

Subcutaneous apomorphine injections provide prompt relief of OFF periods, but are considered an underused therapy. One reason for this might be the perception of difficulty in initiating apomorphine therapy. Over the past 30 years of use, Parkinson’s nurses have built a wealth of experience in how to initiate apomorphine in patients with motor fluctuations. The authors present here a case series of 24 Parkinson’s patients whose apomorphine dose was rapidly titrated according to the practice of the Parkinson’s nurse overseeing the titration. Most patients were successfully and safely titrated within 2 hours, indicating that this rapid schedule may be useful in reducing patient distress and making better use of available resources, compared to the slower schedule than is suggested in the UK apomorphine prescribing information. Patients were successfully initiated in a wide variety of settings, including day hospitals and within their own homes.

BackgroundIn healthcare, many service evaluation questionnaires use free-text boxes without formal mechanisms for analysis. Patients and carers spend time documenting concerns that are often ignored or managed locally in an ad hoc manner. Currently, palliative care experiences of patients and carers in Wales are measured using a service evaluation questionnaire, comprising both closed and open-ended questions. Previous research, exploring free-text responses from this questionnaire, suggests that questionnaire refinement should accommodate service users’ expressed priorities and concerns, and highlights the need to incorporate free-text data analysis strategies during study design.MethodsResults from a previous analysis of 596 free-text responses provided the basis for an expert consensus day, where the current service evaluation questionnaire was refined. The refined version was tested during cognitive interviews with patients (n=10) and carers (n=7) receiving palliative care from 1 of 2 UK hospices. Data were analysed thematically.ResultsInterviews highlighted minor areas for change within the questionnaire and provided broader insight into patients’ experiences of palliative care services. Patients and carers place an emphasis on simplifying language, decreasing the numeric response range and reducing written instructions; relying instead on visual cues, including formatting and layout. Findings highlighted the importance patients attached to providing meaningful free-text contributions.ConclusionsQuestionnaire refinement should use the patient perspective to effectively facilitate respondent understanding, pertinence and usability. The importance of employing data analysis strategies during questionnaire design may reduce research waste, thus enabling a better interrogation of service provision.

The section on preparing a plan for access and recreation should be regarded as an integral component of a full management plan and not as an independent document. There may be occasions when there is a need to present the section as a stand-alone document, but its relationship with the remainder of the site plan must not be forgotten. One of the key components of the access section is the identification of the carrying capacity of the site. This is the level of access that can be accommodated without detracting from the quality of the experience that visitors enjoy on the site. There will be two main areas of impact: Visitors can have a direct impact on the infrastructure, landscape and wilderness qualities of a site, for example, paths may become over-wide and unsightly. People can also visit sites in such large numbers that they become a distraction to others. This is particularly important in areas of high landscape or wilderness value. An access objective with performance indicators is required for most sites. Performance indicators for access must be measurable and quantified (i.e. so that they can be monitored), and the data should be easy to collect. The number of indicators should be kept to a minimum, but there should be sufficient to provide the evidence necessary to ensure that the quality of the access provisions can be measured.