Neath Port Talbot Hospital

The availability of good medical care tends to vary inversely with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced. The market distribution of medical care is a primitive and historically outdated social form, and any return to it would further exaggerate the maldistribution of medical resources.

Primary biliary cirrhosis (PBC) is a classical autoimmune liver disease for which effective immunomodulatory therapy is lacking. Here we perform meta-analyses of discovery data sets from genome-wide association studies of European subjects (n=2,764 cases and 10,475 controls) followed by validation genotyping in an independent cohort (n=3,716 cases and 4,261 controls). We discover and validate six previously unknown risk loci for PBC (Pcombined<5 × 10(-8)) and used pathway analysis to identify JAK-STAT/IL12/IL27 signalling and cytokine-cytokine pathways, for which relevant therapies exist.

OBJECTIVE: To measure the incidence of childhood fractures in a defined population. SETTING: Accident and emergency (A&E) departments covering the Swansea and Neath Port Talbot areas of South Wales in 1996. METHODS: Linkage of data from A&E departments with population data to produce fracture incidence rates by anatomical site and cause in children aged 0-14 years. RESULTS: During 1996, 2463 new fractures occurred in 2399 residents yielding a fracture rate of 36.1/1000 children. Fractures were more common in boys than girls and increased with age in both groups. Sports and leisure activities accounted for 36% of fractures, assaults for 3.5%, and road traffic accidents 1.4%. Fractures of the radius/ulna were most frequent (36%). CONCLUSIONS: The fracture rate in South Wales children is twice the rate reported in previous studies. Further research is required to elucidate the reasons behind this high rate. Many fractures could be prevented by the use of safer surfaces in school playgrounds, and wrist protection in in-line skaters and possibly in soccer players.

BACKGROUND: Patients with diabetes mellitus are at an increased risk of thyroid disease. The frequency of thyroid dysfunction in diabetic patients is higher than that of the general population and up to a third of patients with type-1 diabetes (T1DM) ultimately develop thyroid dysfunction. Unrecognised thyroid dysfunction may impair metabolic control and add to cardiovascular disease risk in diabetic patients. AIMS: Our aims were to review the current literature on the association between thyroid dysfunction and diabetes mellitus, to highlight relevant clinical implications, and to examine present thyroid disease screening strategies in routine diabetes care. RESULTS: The pleiotropic effects of thyroid hormones on various metabolic processes are now better understood. Uncontrolled hyperthyroidism in diabetic patients may trigger hyperglycaemic emergencies while recurrent hypoglycaemic episodes have been reported in diabetic patients with hypothyroidism. Furthermore, thyroid dysfunction may amplify cardiovascular disease risk in diabetic patients through inter-relationships with dyslipidaemia, insulin resistance and vascular endothelial dysfunction. However, the significance of subclinical degrees of thyroid dysfunction remains to be clarified. While these developments have implications for diabetic patients a consensus is yet to be reached on optimal thyroid screening strategies in diabetes management. CONCLUSIONS: The increased frequency of thyroid dysfunction in diabetic patients and its likely deleterious effects on cardiovascular and metabolic function calls for a systematic approach to thyroid disease screening in diabetes. Routine annual thyroid testing should be targeted at diabetic patients at risk of thyroid dysfunction such as patients with T1DM, positive thyroid autoantibodies or high-normal TSH concentrations.

Fibromyalgia syndrome (FMS) is a chronic condition with unknown aetiology. The pathophysiology of the disease is incompletely understood; despite advances in our knowledge with regards to abnormal central and peripheral pain processing, and hypothalamo-pituitary-adrenal dysfunction, there is no clear specific pathophysiological therapeutic target. The management of this complex condition has thus perplexed the medical community for many years, and several national and international guidelines have aimed to address this complexity. The most recent guidelines from European League Against Rheumatism (EULAR) (2016), Canadian Pain Society (2012), and The Association of the Scientific Medical Societies in Germany (AWMF) (2012) highlight the change in attitudes regarding the overall approach to FMS, but offer varying advice with regards to the use of pharmacological agents. Amitriptyline, Pregabalin and Duloxetine are used most commonly in FMS and though modestly effective, are useful adjunctive treatment to non-pharmaceutical measures.

The human gut is a complex ecosystem occupied by a diverse microbial community. Modulation of this microbiota impacts health and disease. The definitive way to investigate the impact of dietary intervention on the gut microbiota is a human trial. However, human trials are expensive and can be difficult to control; thus, initial screening is desirable. Utilization of a range of in vitro and in vivo models means that useful information can be gathered prior to the necessity for human intervention. This review discusses the benefits and limitations of these approaches.

A real-time analysis by STA-FTIR of changes occurring and volatiles evolved during processing of perovskites for PV technology. Solvent retention, presence of chemical species and decomposition of materials can be evaluated to gain insight into material composition.

We compared two management strategies for the perfused but pulseless hand after stabilisation of a Gartland type III supracondylar fracture. We identified 19 patients, of whom 11 were treated conservatively after closed reduction (group 1). Four required secondary exploration, of whom three had median and/or anterior interosseus nerve palsy at presentation. All four were found to have tethering or entrapment of both nerve and vessel at the fracture site. Only two regained patency of the brachial artery, and one patient has a persistent neurological deficit. In six of the eight patients who were explored early (group 2) the vessel was tethered at the fracture site. In group 2 four patients also had a nerve palsy at presentation and were similarly found to have tethering or entrapment of both the nerve and the vessel. The patency of the brachial artery was restored in all six cases and their neurological deficits recovered completely. We would recommend early exploration of a Gartland type III supracondylar fracture in patients who present with a coexisting anterior interosseous or median nerve palsy, as these appear to be strongly predictive of nerve and vessel entrapment.

31.12.13). Chi squared analysis was used to compare the rate between the two groups and the rate of false negative (FN) and minimal signs (MS) categories considered together.

BACKGROUND: Transcranial ultrasound stimulation can acutely modulate brain activity, but the lasting effects on neurons are unknown. OBJECTIVE: To assess the excitability profile of neurons in the hours following transient ultrasound stimulation. METHODS: Primary rat cortical neurons were stimulated with a 40 s, 200 kHz pulsed ultrasound stimulation or sham-stimulation. Intrinsic firing properties were investigated through whole-cell patch-clamp recording by evoking action potentials in response to somatic current injection. Recordings were taken at set timepoints following ultrasound stimulation: 0-2 h, 6-8 h, 12-14 h and 24-26 h. Transmission electron microscopy was used to assess synaptic ultrastructure at the same timepoints. RESULTS: In the 0-2 h window, neurons stimulated with ultrasound displayed an increase in the mean frequency of evoked action potentials of 32% above control cell levels (p = 0.023). After 4-6 h this increase was measured as 44% (p = 0.0043). By 12-14 h this effect was eliminated and remained absent 24-26 h post-stimulation. These changes to action potential firing occurred in conjunction with statistically significant differences between control and ultrasound-stimulated neurons in action potential half-width, depolarisation rate, and repolarisation rate, that were similarly eliminated by 24 h following stimulation. These effects occurred in the absence of alterations to intrinsic membrane properties or synaptic ultrastructure. CONCLUSION: We report that stimulating neurons with 40 s of ultrasound enhances their excitability for up to 8 h in conjunction with modifications to action potential kinetics. This occurs in the absence of major ultrastructural change or modification of intrinsic membrane properties. These results can inform the application of transcranial ultrasound in experimental and therapeutic settings.

BACKGROUND: Despite many studies on the action of yellow light in acne, its efficacy and mechanisms of action are still unclear. OBJECTIVES: To determine if IPL can cause a clinical improvement in acne and whether it modifies TLR2 and TNFα expression. METHODS: Twenty-one patients with mild to moderate acne involving their backs received 530 nm IPL treatments once every 2 weeks. Assessments at baseline and after the fourth treatment included lesion counts, Leeds grading and SER. Biopsies from the treatment area were taken at three time points. TLR2 expression was determined using immunohistochemistry, and TaqMan Low Density Arrays were used to measure TNFα, IL-8 and IL-10. RESULTS: Inflamed lesion counts fell significantly by 28.0% (p = 0.002) but not the Leeds score, SER or non-inflamed lesions. A reduction in TNFα expression of 17.6% (p = 0.031) weakly correlated with the change in lesion counts. TLR2 expression fell by 2.6% (p < 0.001) but did not correlate with lesion counts. Neither IL-10 nor IL-8 expression was significantly altered. CONCLUSIONS: 530 nm IPL significantly reduces inflammatory lesions, where its efficacy will need optimising to make it a viable treatment option. Its mechanism seems to include a novel anti-TNFα effect, independent of IL-10 up-regulation.

Studies have shown that domestic knowledge and practices relating to the prevention of food-borne disease may be inadequate and that family outbreaks of food poisoning are numerically very important. The use of the mass media can be beneficial in health education and it could provide “cues to action” helping to improve domestic food hygiene. Members of the public were questioned about their desire for information on food hygiene and what sources of information they would use. Different components of the mass media were analysed for the information they provided on food safety and the results indicated they were an underutilized resource for food hygiene education. Provides recommendations that are inexpensive but could prove successful, and gives sources of appropriate advice

AIMS: Artificial intelligence has the potential to transform the radiotherapy workflow, resulting in improved quality, safety, accuracy and timeliness of radiotherapy delivery. Several commercially available artificial intelligence-based auto-contouring tools have emerged in recent years. Their clinical deployment raises important considerations for clinical oncologists, including quality assurance and validation, education, training and job planning. Despite this, there is little in the literature capturing the views of clinical oncologists with respect to these factors. MATERIALS AND METHODS: The Royal College of Radiologists realises the transformational impact artificial intelligence is set to have on our specialty and has appointed the Artificial Intelligence for Clinical Oncology working group. The aim of this work was to survey clinical oncologists with regards to perceptions, current use of and barriers to using artificial intelligence-based auto-contouring for radiotherapy. Here we share our findings with the wider clinical and radiation oncology communities. We hope to use these insights in developing support, guidance and educational resources for the deployment of auto-contouring for clinical use, to help develop the case for wider access to artificial intelligence-based auto-contouring across the UK and to share practice from early-adopters. RESULTS: In total, 78% of clinical oncologists surveyed felt that artificial intelligence would have a positive impact on radiotherapy. Attitudes to risk were more varied, but 49% felt that artificial intelligence will decrease risk for patients. There is a marked appetite for urgent guidance, education and training on the safe use of such tools in clinical practice. Furthermore, there is a concern that the adoption and implementation of such tools is not equitable, which risks exacerbating existing inequalities across the country. CONCLUSION: Careful coordination is required to ensure that all radiotherapy departments, and the patients they serve, may enjoy the benefits of artificial intelligence in radiotherapy. Professional organisations, such as the Royal College of Radiologists, have a key role to play in delivering this.

This article presents a qualitative descriptive study of the impact of being prohibited from working by the asylum seeking processes within the United Kingdom and the subsequent effects of gaining refugee status. In‐depth unstructured and semi‐structured interviews were used to explore one individual's experience, with grounded theory methods employed to guide the data analysis and identify themes. The resultant themes were; the lack of control resulting in change of identity and roles, changes in motivation and the impact of stigma. The findings provide insider insights into the impact of legislatively imposed occupational injustice, the need to establish safety needs and the desire to have a sense of belonging. It challenges readers to examine their own beliefs on asylum seeking and explore ways in which communities can integrate refugees, providing opportunities to regain a meaningful role within society and re‐establishing their lost sense of identity. Key Words: Asylum seekersOccupational changeMotivational changeWorker identityQualitative research

Doctors increasingly rely on medical apps running on smart phones or tablet computers to support their work. However, these apps vary hugely in the quality of their data input screens, internal data processing, the methods used to handle sensitive patient data and how they communicate their output to the user. Inspired by Donabedian's approach to assessing quality and the principles of good user interface design, the Royal College of Physicians' Health Informatics Unit has developed and piloted an 18-item checklist to help clinicians assess the structure, functions and impact of medical apps. Use of this checklist should help clinicians to feel more confident about using medical apps themselves, about recommending them to their staff or prescribing them for patients.

PURPOSE: Virtual glaucoma clinics allow rapid, reliable patient assessment but the service should be acceptable to patients and concordance with treatment needs to be maintained with adequate patient education. This study compares experiences and understanding of patients reviewed via the virtual clinic versus the standard clinic by way of an extended patient satisfaction questionnaire (PSQ). PATIENTS AND METHODS: One hundred PSQs were given to consecutive patients attending glaucoma clinics in October 2013. All 135 patients reviewed via the virtual clinic from April 2013 until August 2013 were sent postal PSQs in September 2013. Data were obtained for demographics, understanding of glaucoma, their condition, satisfaction with their experience, and quality of information. Responses were analyzed in conjunction with the clinical records. RESULTS: Eighty-five percent of clinic patients and 63% of virtual clinic patients responded to the PSQ. The mean satisfaction score was over 4.3/5 in all areas surveyed. Virtual clinic patients' understanding of their condition was very good, with 95% correctly identifying their diagnosis as glaucoma, 83% as ocular hypertension and 78% as suspects. There was no evidence to support inferior knowledge or self-perceived understanding compared to standard clinic patients. Follow-up patients knew more about glaucoma than new patients. Over 95% of patients found our information leaflet useful. Forty percent of patients sought additional information but less than 20% used the internet for this. CONCLUSION: A substantial proportion of glaucoma pathway patients may be seen by non-medical staff supervised by glaucoma specialists via virtual clinics. Patients are accepting of this format, reporting high levels of satisfaction and non-inferior knowledge to those seen in standard clinics.

Recent controlled studies have supported the effectiveness of anger management training for people with intellectual disabilities (IDs). This report describes an evaluation instrument designed to assess their usage of specific anger coping skills. The Profile of Anger Coping Skills (PACS) is designed for completion by a staff member or carer. Three situations are first elicited in which a client frequently displays anger. The respondent then rates each situation for the extent to which the client deploys each of eight behavioural and cognitive coping skills. In a preliminary reliability study, 20 users of a day service for people with IDs were rated independently by two staff members, with one of them completing the assessment on two separate occasions: the PACS showed good test-retest reliability and lower, but still acceptable, interrater reliability. The PACS was subsequently used, in a different day service, as part of the assessment pack administered before and after a 12-week anger management group, with a parallel assessment of an untreated control group. The treated group showed substantial decreases in measures of anger, which were maintained at 6-month follow-up. Increases in PACS-rated anger coping skills were also seen in all participants in the anger management group, but not in the control group. There were differences in the extent to which different coping skills were acquired by the treated group, and there were also individual differences in the profile of specific skills acquired. It is concluded that the PACS is a reliable instrument for assessing anger coping skills, particularly when used repeatedly with the same informant. It provides information that is useful for both individual care planning and the design of future anger management programmes.

Unitary explanations of mental illness symptoms appear to be inadequate when faced with everyday experiences of living with these conditions. In particular, the experience of voice hearing is not sufficiently accounted for by biomedical explanations. This paper revisits data collected from a sample of people who hear voices to perform a secondary analysis with the aim of examining the explanatory devices deployed by individuals in their accounts of voice hearing. Secondary analysis is the use of existing data, collected for a previous study, in order to explore a research question distinct from the original inquiry. In this study, we subjected these data to a thematic analysis. People who hear voices make use of standard psychiatric explanations about the experience in their accounts. However, the accounts paint a more complex picture and show that people also impute personal meaning to the experience. This in turn implicates both personal and social identity; that is, how the person is known to themselves and to others. We suggest that this knowledge can inform a more thoughtful engagement with the experiences of voice hearing by mental health nurses.

Some of the factors influencing the isolation rate of Bordetella pertussis during a whooping cough epidemic in West Glamorgan, Wales, are reported. The organism was isolated from 39% of patients with clinical whooping cough, pernasal swabbing being much more successful than cough plates. Isolation rates were increased in the non-immunized, particularly in the first year of life. Erythromycin and co-trimoxazole significantly reduced the isolation rate of B. pertussis but this did not occur with penicillin. In this study 20% of patients were culture positive 6 weeks after the onset of their infection. It is suggested that the Department of Health and Social Security recommendation of a minimum period of three weeks exclusion of children from school is inadequate. During the epidemic, the proportion of strains of B. pertussis containing antigen 2 more than doubled.

Pre-surgical studies allow study of the relationship between mutations and response of oestrogen receptor-positive (ER+) breast cancer to aromatase inhibitors (AIs) but have been limited to small biopsies. Here in phase I of this study, we perform exome sequencing on baseline, surgical core-cuts and blood from 60 patients (40 AI treated, 20 controls). In poor responders (based on Ki67 change), we find significantly more somatic mutations than good responders. Subclones exclusive to baseline or surgical cores occur in ∼30% of tumours. In phase II, we combine targeted sequencing on another 28 treated patients with phase I. We find six genes frequently mutated: PIK3CA, TP53, CDH1, MLL3, ABCA13 and FLG with 71% concordance between paired cores. TP53 mutations are associated with poor response. We conclude that multiple biopsies are essential for confident mutational profiling of ER+ breast cancer and TP53 mutations are associated with resistance to oestrogen deprivation therapy.