Finance Against Poverty: Volume 2

Over the last decade, the theory that poverty in the world's poorest regions could be alleviated by providing small loans to micro-entrepreneurs has become increasingly popular. This volume examines the effectiveness of this theory when put into practice. The book presents empirical evidence drawn from comparative experiences in seven developing countries and produces some startling conclusions. This work should be essential reading for all those interested in development, poverty-reduction, social welfare and finance. Volume One provides a detailed analysis of this theory and offers policy recommendations for practitioners in the field

Differences in endplate deformation of the adjacent and augmented vertebra following cement augmentation

Vertebral cement augmentation can restore the stiffness and strength of a fractured vertebra and relieve chronic pain. Previous finite element analysis, biomechanical tests and clinical studies have indirectly associated new adjacent vertebral fractures following augmentation to altered loading. The aim of this repeated measures in situ biomechanical study was to determine the changes in the adjacent and augmented endplate deformation following cement augmentation of human cadaveric functional spine units (FSU) using micro-computed tomography (micro-CT). The surrounding soft tissue and posterior elements of 22 cadaveric human FSU were removed. FSU were assigned to two groups, control (n=8) (loaded on day 1 and day 2) and augmented (n=14) (loaded on day 1, augmented 20% cement fill, and loaded on day 2). The augmented group was further subdivided into a prophylactic augmentation group (n=9), and vertebrae which spontaneously fractured during loading on day 1 (n=5). The FSU were axially loaded (200, 1,000, 1,500-2,000N) within a custom made radiolucent, saline filled loading device. At each loading step, FSUs were scanned using the micro-CT. Endplate heights were determined using custom software. No significant increase in endplate deformation following cement augmentation was noted for the adjacent endplate (P>0.05). The deformation of the augmented endplate was significantly reduced following cement augmentation for both the prophylactic and fracture group (P<0.05, P<0.01, respectively). Endplate deformation of the controls showed no statistically significant differences between loading on day 1 and day 2. A linear relationship was noted between the applied compressive load and endplate deflection (R 2=0.58). Evidence of significant endplate deformation differences between unaugmented and augmented FSU, while evident for the augmented endplate, was not present for the adjacent endplate. This non-invasive micro-CT method may also be useful to investigate endplate failure, and parameters that predict vertebral failur

Oral infection with the Salmonella enterica serovar Gallinarum 9R attenuated live vaccine as a model to characterise immunity to fowl typhoid in the chicken

BACKGROUND: Salmonella enterica serovar Gallinarum (S. Gallinarum) is the causative agent of fowl typhoid, a severe systemic disease of chickens that results in high mortality amongst infected flocks. Due to its virulence, the immune response to S. Gallinarum is poorly characterised. In this study we have utilised infection by the live attenuated S. Gallinarum 9R vaccine strain in inbred chickens to characterise humoral, cellular and cytokine responses to systemic salmonellosis. RESULTS: Infection with 9R results in a mild systemic infection. Bacterial clearance at three weeks post infection coincides with increases in circulating anti-Salmonella antibodies, increased T cell proliferation to Salmonella challenge and increased expression of interferon gamma. These responses peak at four weeks post infection, then decline. Only modest increases of expression of the pro-inflammatory cytokine interleukin-1β were detected early in the infection. CONCLUSION: Infection of chickens with the 9R vaccine strain induces a mild form of systemic salmonellosis. This induces both cellular and humoral immune responses, which peak soon after bacterial clearance. Unlike enteric-associated Salmonella infections the immune response is not prolonged, reflecting the absence of persistence of Salmonella in the gastrointestinal tract. The findings here indicate that the use of the S. Gallinarum 9R vaccine strain is an effective model to study immunity to systemic salmonellosis in the chicken and may be employed in further studies to determine which components of the immune response are needed for protection

‘History taught in the pageant way’: Education and historical performace in twentieth-century Britain

Historical pageants were important sites of popular engagement with the past in twentieth-century Britain. They took place in many places and sometimes on a large scale, in settings ranging from small villages to industrial cities. They were staged by schools, churches, professional organisations, women’s groups and political parties, among others. This article draws on contemporary studies of heritage and performance to explore the blend of history, myth and fiction that characterised pageants, and the ways in which they both shaped and reflected the self-image of local communities. Pageants were important channels of popular education as well as entertainment and, although they are sometimes seen as backward-looking and conservative spectacles, this article argues that pageants could be an effective means of enlisting the past in the service of the present and future

Historical pageants and the Medieval past in twentieth-century England

This article examines the representation of the medieval past in historical pageants in twentieth-century England. Pageants were an important aspect of popular engagement with the past, and often focused heavily on the medieval period. Different episodes and characters both historical and legendary—Alfred the Great, King John and Robin Hood, for example—featured at different times and in different ways during the twentieth century. Many communities saw their origins as being medieval, and almost all found important stories to tell from this period. However, the emphasis shifted over time, with the lessons of the ‘constitutional Middle Ages’ featuring prominently in Edwardian pageants, whereas by the 1950s elements of the romantic and grotesque were increasingly prominent. Throughout the twentieth century, aspects of civic medievalism were an important feature in pageants, particularly those staged in urban locations, but the style of representation of the medieval period changed over time, partly under the influence of new media—notably the cinema, radio and television. In the second half of the twentieth century, historical pageantry declined significantly, though it never disappeared; and although popular interest in the medieval past was undiminished, it increasingly took different forms

Prescribing trends over time by non-medical independent prescribers (NMIPs) in primary care settings across Wales (2011-2018): a secondary database analysis

Introduction: As of 2015, as part of the implementation of the Welsh Government primary care plan and primary care clusters, the Welsh Government has encouraged non-medical healthcare professionals working in primary care to train as independent prescribers (IPs). Objectives: This research aimed to identify the number of NMIPs in primary care in Wales and describe their prescribing trend of items between 2011 and 2018, in order to compare their prescribing pattern before and after the implementation of primary care clusters for Wales. Design: Retrospective secondary data analysis and interrupted time series analysis in order to compare prescribing by non-medical independent prescribers (NMIPs) preimplementation and postimplementation of primary care clusters across Wales. Results: Over the study period, 600 NMIPs (nurses n=474 and pharmacists n=104) had prescribed at least one item. The number of nurse IPs increased by 108% and pharmacists by 325% (pharmacists had the largest increase between July 2015 and March 2018). The number of items prescribed by NMIPs increased over time by an average of 1380 per month (95% CI 904 to 1855, p<0.001) after the implementation of primary care clusters compared with 496 (95% CI 445 to 548, p<0.001) prior its implementation. Approximately one-third of the items prescribed by NMIPs was within Betsi Cadwaladr University Health Board (HB) with only 4% in Powys Teaching HB. Conclusion: The number of NMIPs and their volume of prescribing in primary care in Wales has increased following the implementation of primary care clusters in 2015. This suggests that the Government’s recommendations of using NMIPs in primary care have been implemented. Future studies should focus on efficiency and quality of prescribing by NMIPs in primary care

The INCENTIVE Study: a mixed methods evaluation of an innovation in commissioning and delivery of primary dental care compared to traditional dental contracting

Background Over the past decade, commissioning of primary care dentistry has seen contract currency evolving from payment for units of dental activity (UDAs) towards blended contracts that include key performance indicators such as access, quality and improved health outcome. Objectives The aim of this study was to evaluate a blended/incentive-driven model of dental service provision. To (1) explore stakeholder perspectives of the new service delivery model; (2) assess the effectiveness of the new service delivery model in reducing the risk of and amount of dental disease and enhancing oral health-related quality of life (OHQoL) in patients; and (3) assess cost-effectiveness of the new service delivery model. Methods Using a mixed-methods approach, the study included three dental practices working under the blended/incentive-driven (incentive) contract and three working under the UDAs (traditional) contract. All were based in West Yorkshire. The qualitative study reports on the meaning of key aspects of the model for three stakeholder groups [lay people (patients and individuals without a dentist), commissioners and the primary care dental teams], with framework analysis of focus group and semistructured interview data. A non-randomised study compared clinical effectiveness and cost-effectiveness of treatment under the two contracts. The primary outcome was gingivitis, measured using bleeding on probing. Secondary outcomes included OHQoL and cost-effectiveness. Results Participants in the qualitative study associated the incentive contract with more access, greater use of skill mix and improved health outcomes. In the quantitative analyses, of 550 participants recruited, 291 attended baseline and follow-up. Given missing data and following quality assurance, 188 were included in the bleeding on probing analysis, 187 in the caries assessment and 210 in the economic analysis. The results were mixed. The primary outcome favoured the incentive practices, whereas the assessment of caries favoured the traditional practices. Incentive practices attracted a higher cost for the service commissioner, but were financially attractive for the dental provider at the practice level. Differences in generic health-related quality of life were negligible. Positive changes over time in OHQoL in both groups were statistically significant. Limitations The results of the quantitative analysis should be treated with caution given small sample numbers, reservations about the validity of pooling, differential dropout results and data quality issues. Conclusions A large proportion of people in this study who had access to a dentist did not follow up on oral care. These individuals are more likely to be younger males and have poorer oral health. Although access to dental services was increased, this did not appear to facilitate continued use of services. Future work Further research is required to understand how best to promote and encourage appropriate dental service attendance, especially among those with a high level of need, to avoid increasing health inequalities, and to assess the financial impact of the contract. For dental practitioners, there are challenges around perceptions about preventative dentistry and use of the risk assessments and care pathways. Changes in skill mix pose further challenges. Funding The National Institute for Health Research Health Services and Delivery Research programme

Inhibited Production of iNOS by Murine J774 Macrophages Occurs via a phoP

Background. There are no reported data to explain how Salmonella suppress nitrite ion production in macrophages or whether this phenomenon is unique to typhoidal or non-typhoidal serovars. The aims of this study were, therefore, to investigate these phenomena. Methods. We measured survival of S. typhimurium 14028 and its phoP mutant in murine J774 macrophages, cultured with or without interferon gamma. We compared expression of inducible nitric oxide synthase (iNOS) mRNA and protein, and nitrite ion production and also examined binding of nuclear factor B (NFB) and activator protein 1 (AP-1) to macrophage DNA. Results. S. typhimurium 14028 inhibited binding of NFB and AP-1 to DNA in murine J774. A macrophages via an intact phoP regulon. This correlated with increased survival and reduced iNOS expression. Suppression of NFB activity was ameliorated in macrophages cultured with IFN-γ and this correlated with increased expression of iNOS mRNA and nitrite ion production, although IFN-γ had no effect on AP-1/DNA interaction. We show, that with one exception, suppression of iNOS is unique to typhoidal serovars. Conclusion. S. typhimurium inhibit NFB and AP-1 interaction with macrophage DNA via the PhoP regulon, this reduces nitrite ion production and is principally associated with typhoidal serovars

A qualitative exploration of oral health care among stroke survivors living in the community.

Background: Dental disease is highly prevalent in people with stroke. Stroke survivors regard oral hygiene as an important, yet neglected, area. The aim was to explore experiences of and barriers to oral care, particularly in relation to oral hygiene practice and dental attendance, among stroke survivors in the community. Methods: This was a qualitative study incorporating a critical realist approach. Interviews were conducted with community-dwelling stroke survivors requiring assistance with activities of daily living, and focus groups were held with health and care professionals. Interviews and focus groups were recorded and transcribed verbatim. Thematic analysis was conducted. Results: Twenty-three stroke survivors were interviewed, and 19 professionals took part in 3 focus groups. Professionals included nurses, speech and language therapists, occupational therapists, dieticians, professional carers and dental staff. Interviews revealed difficulties in carrying out oral hygiene self-care due to fatigue, forgetfulness and limb function and dexterity problems. Routine was considered important for oral hygiene self-care and was disrupted by hospitalization resulting from stroke. Professionals highlighted gaps in staff training and confidence in supporting patients with oral care. Access to dental services appeared particularly problematic for those who were not registered with a dentist pre-stroke. Conclusion: Oral hygiene routines may be disrupted by stroke, and resulting disabilities may make regular oral self-care more difficult. This study has identified specific barriers to oral hygiene self-care and dental service access. Findings from this study are feeding into the development of an intervention to support stroke survivors with oral care

Shaping dental contract reform – a clinical and cost effectiveness analysis of incentive-driven commissioning for improved oral health in primary dental care

Objective: To evaluate the clinical and cost-effectiveness of a new blended dental contract incentivising improved oral health compared with a traditional dental contract based on units of dental activity (UDAs). Design: Non-randomised controlled study. Setting: Six UK primary care dental practices, three working under a new blended dental contract; three matched practices under a traditional contract. Participants: 550 new adult patients. Interventions: A new blended/incentive-driven primary care dentistry contract and service delivery model versus the traditional contract based on UDAs. Main Outcomes Measures: Primary outcome was as follows: percentage of sites with gingival bleeding on probing. Secondary outcomes were as follows: extracted and filled teeth (%), caries (International Caries Detection and Assessment System (ICDAS)), oral health-related quality of life (Oral Health Impact Profile-14 (OHIP-14)). Incremental cost-effective ratios used OHIP-14 and quality adjusted life years (QALYs) derived from the EQ-5D-3L. Results: At 24 months, 291/550 (53%) patients returned for final assessment; those lost to follow-up attended 6.46 appointments on average (SD 4.80). The primary outcome favoured patients in the blended contract group. Extractions and fillings were more frequent in this group. Blended contracts were financially attractive for the dental provider but carried a higher cost for the service commissioner. Differences in generic health-related quality of life were negligible. Positive changes over time in oral health-related quality of life in both groups were statistically significant. Conclusions: This is the first UK study to assess the clinical and cost-effectiveness of a blended contract in primary care dentistry. Although the primary outcome favoured the blended contract, the results are limited because 47% patients did not attend at 24?months. This is consistent with 39% of adults not being regular attenders and 27% only visiting their dentist when they have a problem. Promotion of appropriate attendance, especially among those with high need, necessitates being factored into recruitment strategies of future studies