Health visitors’ views on promoting oral health and supporting clients with dental health problems: a qualitative study

Background - Inequalities in dental decay in young children persist, resulting in high admission rates for general anaesthetics for tooth extractions. Health visitors have the potential to improve dental attendance and oral health in families least likely to engage with dental services. There is little evidence on health visitor views on this. Methods - Semi-structured interviews were conducted with a purposive sample of 17 health visitors working in both affluent and deprived areas in a single UK city. Interviews were audio recorded, transcribed, anonymized and analysed following a constructivist grounded theory approach. Results - Knowledge of oral health was high and health visitors requested oral health education specific to the communities they worked in. Health visitors reported effective, formal referral processes to other health services but not to primary NHS dental services even when dealing with infants in pain. Health visitors interviewed were largely unaware of specific NHS dental services which reduce barriers to dental care including interpreting services and dental services for children with additional needs. Conclusions - Health visitors interviewed were knowledgeable and enthusiastic about oral health but not about dental services. Inadequate links with NHS dental services may limit their effectiveness in oral health improvement and this needs to be addressed

Electrical and optical properties of novel phthalocyanine compounds for sensor devices.

UV/visible spectrophotometry measurements, together with measurement of the temperature dependence of ac parameters G (conductance), C (capacitance) and tan (dielectric loss) for 20Hz 162K) relates to the distance of singlet states below the conduction band. The low temperature activation energy indicates hopping conduction between localised states close to the Fermi level. Visible optical absorption and transmission spectra are obtained for 50nm thick sublimed films of heavy fraction rare-earth [HF(pc)(pc*)], gadolinium [Gd(pc)(pc*)] and thulium [Tm(pc)(pc*)] bisphthalocyanine compounds when they have undergone the postdeposition treatments of voltage-cycling to blue, voltage cycling to red and annealing at 393K for one hour; also for untreated fluorochromium phthalocyanine. The different post-deposition treatments produce different effects on the absorption spectra; in the case of annealing, this is attributed to the phase changes occurring in the films. The changes due to the voltage cycling are believed to be a result of oxidation processes taking place in the materials. Absorption data are also analysed in order to obtain information regarding the dispersion of refractive index and dielectric constants withinoptical frequency range. Absorption data are analysed in terms of a well known power law, and a value of 2.3eV is found for the optical gap E[0]. in HF (pc)(pc*)

Streptophage-mediated control of off-flavour taint producing streptomycetes isolated from barramundi ponds

Off-flavour taint of aquaculture products is a global issue reducing consumer confidence in the farmed produce as they are taken up via the gills of fish, and deposited in the lipids of the animal. If the fish are not purged, resulting undesirable muddy earthy flavour taint can be tasted by consumers. These undesirable flavour and odour is caused by the terpenoid compounds namely geosmin and 2-methylisoborneol, produced as secondary metabolites by certain bacteria including the cyanobacteria and actinomycetes. Current strategies to remediate the problem rely on treating the symptoms not the cause and involve the use of time consuming purging methods and costly chemicals. Biological control using bacteriophages, specific to the problem causing bacteria, offers a natural alternative to chemical control, which might reduce further complications of copper based algaecides and its subsequent implications on water quality. In an adaptation of such biological control approach streptomycetes isolated from barramundi ponds were tested for their susceptibility to streptophages to understand whether host destruction via phage lysis would subsequently eliminate off-flavour taint productions by these isolates. Following the determination of the streptophage susceptibility of the isolates one of the most odourous streptomycete species (USC-14510) was selected to be tested further using different pond simulations resembling real-life applications. Geosmin was tested as the indicator of off-flavour taint production and as it has been previously reported that the cyanobacteria-actinomycete interactions occurring in ponds result in even greater levels of geosmin and 2-methylisoborneol, the geosmin levels for the isolate in the presence of cyanobacteria and streptophages were also tested. Findings indicated that the highly odourous Streptomyces species (USC-14510) once infected with streptophages, can lose its capacity to produce off-flavour taints. Pond simulation studies also revealed geosmin production was significantly reduced when streptophages were introduced into the pond water where streptomycete species were grown. The bacteriophage control method developed in the presented study might again confirm significant potential for the bacteriophage-mediated remediation strategy to be adapted by the aquaculture industry

Multidisciplinary team decision-making in cancer and the absent patient: a qualitative study

Objective To critically examine the process of multidisciplinary team (MDT) decision-making with a particular focus on patient involvement. Design Ethnographic study using direct non-participant observation of 35 MDT meetings and 37 MDT clinics, informal interviews and formal, semistructured interviews with 20 patients and 9 MDT staff members. Setting Three head and neck cancer centres in the north of England. Participants Patients with a diagnosis of new or recurrent head and neck cancer and staff members who attend the head and neck cancer MDT. Results Individual members of the MDT often have a clear view of which treatment they consider to be ‘best’ in any clinical situation. When disagreement occurs, the MDT has to manage how it presents this difference of opinion to the patient. First, this is because the MDT members recognise that the clinician selected to present the treatment choice to the patient may ‘frame’ their description of the treatment options to fit their own view of best. Second, many MDT members feel that any disagreement and difference of opinion in the MDT meeting should be concealed from the patient. This leads to much of the work of decision-making occurring in the MDT meeting, thus excluding the patient. MDT members seek to counteract this by introducing increasing amounts of information about the patient into the MDT meeting, thus creating an ‘evidential patient’. Often, only highly selected or very limited information of this type can be available or known and it can easily be selectively reported in order to steer the discussion in a particular direction

How does priority setting for resource allocation happen in commissioning dental services in a nationally led, regionally delivered system: a qualitative study using semistructured interviews with NHS England dental commissioners

Objectives: To understand approaches to priority setting for healthcare service resource allocation at an operational level in a nationally commissioned but regionally delivered service. Design: Qualitative study using semistructured interviews and a Framework analysis. Setting: National Health Service dentistry commissioning teams within subregional offices in England. Participants: All 31 individuals holding the relevant role (dental lead commissioner in subregional offices) were approached directly and from this 14 participants were recruited, with 12 interviews completed. Both male and female genders and all regions were represented in the final sample. Results: Three major themes arose. First, 'Methods of priority setting and barriers to explicit approaches' was a common theme, specifically identifying the main methods as: perpetuating historical allocations, pressure from politicians and clinicians and use of needs assessments while barriers were time and skill deficits, a lack of national guidance and an inflexible contracting arrangements stopping resource allocation. Second, 'Relationships with key stakeholders and advisors' were discussed, showing the important nature of relationships with clinical advisors but variation in the quality of these relationships was noted. Finally, 'Tensions between national and local responsibilities' were illustrated, where there was confusion about where power and autonomy lay. Conclusions: Commissioners recognised a need for resource allocation but relied on clinical advice and needs assessment in order to set priorities. More explicit priority setting was prevented by structure of the commissioning system and standard national contracts with providers. Further research is required to embed and simplify adoption of tools to aid priority setting

Impaired natural killer cell phenotype and function in idiopathic and heritable pulmonary arterial hypertension

BACKGROUND: Beyond their role as innate immune effectors, natural killer (NK) cells are emerging as important regulators of angiogenesis and vascular remodeling. Pulmonary arterial hypertension (PAH) is characterized by severe pulmonary vascular remodeling and has long been associated with immune dysfunction. Despite this association, a role for NK cells in disease pathology has not yet been described. METHODS AND RESULTS: Analysis of whole blood lymphocytes and isolated NK cells from PAH patients revealed an expansion of the functionally defective CD56(-)/CD16(+) NK subset that was not observed in patients with chronic thromboembolic pulmonary hypertension. NK cells from PAH patients also displayed decreased levels of the activating receptor NKp46 and the killer immunoglobulin-like receptors 2DL1/S1 and 3DL1, reduced secretion of the cytokine macrophage inflammatory protein-1β, and a significant impairment in cytolytic function associated with decreased killer immunoglobulin-like receptor 3DL1 expression. Genotyping patients (n=222) and controls (n=191) for killer immunoglobulin-like receptor gene polymorphisms did not explain these observations. Rather, we show that NK cells from PAH patients exhibit increased responsiveness to transforming growth factor-β, which specifically downregulates disease-associated killer immunoglobulin-like receptors. NK cell number and cytotoxicity were similarly decreased in the monocrotaline rat and chronic hypoxia mouse models of PAH, accompanied by reduced production of interferon-γ in NK cells from hypoxic mice. NK cells from PAH patients also produced elevated quantities of matrix metalloproteinase 9, consistent with a capacity to influence vascular remodeling. CONCLUSIONS: Our work is the first to identify an impairment of NK cells in PAH and suggests a novel and substantive role for innate immunity in the pathobiology of this disease

‘You can’t start a car when there’s no petrol left’: a qualitative study of patient, family and clinician perspectives on implantable cardioverter defibrillator deactivation

Objective: To explore the attitudes towards implantable cardioverter defibrillator (ICD) deactivation and initiation of deactivation discussions among patients, relatives and clinicians. Design: A multiphase qualitative study consisting of in situ hospital ICD clinic observations, and semistructured interviews of clinicians, patients and relatives. Data were analysed using a constant comparative approach. Setting: One tertiary and two district general hospitals in England. Participants: We completed 38 observations of hospital consultations prior to ICD implantation, and 80 interviews with patients, family members and clinicians between 2013 and 2015. Patients were recruited from preimplantation to postdeactivation. Clinicians included cardiologists, cardiac physiologists, heart failure nurses and palliative care professionals. Results: Four key themes were identified from the data: the current status of deactivation discussions; patients’ perceptions of deactivation; who should take responsibility for deactivation discussions and decisions; and timing of deactivation discussions. We found that although patients and doctors recognised the importance of advance care planning, including ICD deactivation at an early stage in the patient journey, this was often not reflected in practice. The most appropriate clinician to take the lead was thought to be dependent on the context, but could include any appropriately trained member of the healthcare team. It was suggested that deactivation should be raised preimplantation and regularly reviewed. Identification of trigger points postimplantation for deactivation discussions may help ensure that these are timely and inappropriate shocks are avoided. Conclusions: There is a need for early, ongoing and evolving discussion between ICD recipients and clinicians regarding the eventual need for ICD deactivation. The most appropriate clinician to instigate deactivation discussions is likely to vary between patients and models of care. Reminders at key trigger points, and routine discussion of deactivation at implantation and during advance care planning could prevent distressing experiences for both the patient and their family at the end of life

Microsomal triglyceride transfer protein lipidation and control of CD1d on antigen-presenting cells

Microsomal triglyceride transfer protein (MTP), an endoplasmic reticulum (ER) chaperone that loads lipids onto apolipoprotein B, also regulates CD1d presentation of glycolipid antigens in the liver and intestine. We show MTP RNA and protein in antigen-presenting cells (APCs) by reverse transcription–polymerase chain reaction and by immunoblotting of mouse liver mononuclear cells and mouse and human B cell lines. Functional MTP, demonstrated by specific triglyceride transfer activity, is present in both mouse splenocytes and a CD1d-positive mouse NKT hybridoma. In a novel in vitro transfer assay, purified MTP directly transfers phospholipids, but not triglycerides, to recombinant CD1d. Chemical inhibition of MTP lipid transfer does not affect major histocompatibility complex class II presentation of ovalbumin, but considerably reduces CD1d-mediated presentation of α-galactosylceramide (α-galcer) and endogenous antigens in mouse splenic and bone marrow–derived dendritic cells (DCs), as well as in human APC lines and monocyte-derived DCs. Silencing MTP expression in the human monocyte line U937 affects CD1d function, as shown by diminished presentation of α-galcer. We propose that MTP acts upstream of the saposins and functions as an ER chaperone by loading endogenous lipids onto nascent CD1d. Furthermore, our studies suggest that a small molecule inhibitor could be used to modulate the activity of NKT cells

End of life care:A qualitative study comparing the views of people with dementia and family carers

Background: In recent years, UK policy has increasingly recognised the importance of end-of-life care in dementia. While professional consensus on optimal palliative care in dementia has been reported, little is known about the perspectives of people with dementia and family carers. Aim: To compare the views of people with dementia and family carers of people with dementia (current and recently bereaved) on optimal end-of-life care. Design: Qualitative interviews (32) and a focus group were conducted. Data were thematically analysed. Setting/participants: Participants comprised people with early stage dementia, living at home in the north-east of England (n = 11); and current and bereaved carers (n = 25) from six services providing end-of-life care in England. Findings: Seven areas were identified as important to end-of-life care for people with dementia and/or family carers. People with dementia and carers expressed the need for receiving care in place, ensuring comfort and a skilled care team. However, they disagreed about the importance of planning for the future and the role of families in organising care and future decision-making. Conclusion: Further comparison of our findings with expert consensus views highlighted key areas of divergence and agreement. Discordant views concerning perceptions of dementia as a palliative condition, responsibility for future decision-making and the practical co-ordination of end-of-life care may undermine the provision of optimal palliative care. Professionals must explore and recognise the individual perspectives of people with dementia and family carers

Learning from contract change in primary care dentistry: a qualitative study of stakeholders in the north of England

The aim of this research was to explore and synthesise learning from stakeholders (NHS dentists, commissioners and patients) approximately five years on from the introduction of a new NHS dental contract in England. The case study involved a purposive sample of stakeholders associated with a former NHS Primary Care Trust (PCT) in the north of England. Semi-structured interviews were conducted with 8 commissioners of NHS dental services and 5 NHS general dental practitioners. Three focus group meetings were held with 14 NHS dental patients. All focus groups and interviews were audio recorded and transcribed verbatim. The data were analysed using a framework approach. Four themes were identified: ‘commissioners’ views of managing local NHS dental services’; ‘the risks of commissioning for patient access’; ‘costs, contract currency and commissioning constraints’; and ‘local decision-making and future priorities’. Commissioners reported that much of their time was spent managing existing contracts rather than commissioning services. Patients were unclear about the NHS dental charge bands and dentists strongly criticised the contract's target-driven approach which was centred upon them generating ‘units of dental activity’. NHS commissioners remained relatively constrained in their abilities to reallocate dental resources amongst contracts. The national focus upon practitioners achieving their units of dental activity appeared to outweigh interest in the quality of dental care provided