"I'll meet you at our bench": adaptation, innovation and resilience among VCSE organisations who supported marginalised and minoritised communities during the Covid-19 pandemic in Northern England - a qualitative focus group study.

BACKGROUND: The Covid-19 pandemic has exacerbated pre-existing inequalities and increased adversity and challenges for vulnerable and marginalised communities worldwide. In the UK, the Voluntary Community and Social Enterprise (VCSE) sector play a vital role in supporting the health and wellbeing of people who are marginalised or experiencing multiple complex needs. However, only a small number of studies have focused on the impact that Covid-19 had on the VCSE sector. METHODS: As part of a Health Inequalities Impact Assessment (HIIA), we conducted qualitative focus groups with staff and volunteers from five organisations to examine short, medium and longer-term impacts of Covid-19 upon the VCSE sector in Northern England. Nine online focus groups were conducted between March and July 2021. FINDINGS: Focus group transcripts were analysed using Framework Analysis and yielded three central themes: (1) exacerbation of pre-existing inequalities, adversity and challenges for vulnerable and marginalised populations; (2) the 'price' of being flexible, innovative and agile for VCSE staff and volunteers; and (3) the voluntary sector as a 'lifeline' - organisational pride and resilience. CONCLUSIONS: While the voluntary sector 'adapted at pace' to provide support during Covid-19 and in its continued aftermath, this resilience has potentially come at the cost of workforce and volunteer wellbeing, compounded by political obstacles and chronic shortage in funding and support. The VCSE sector has a vital role to play in the post-lockdown 'levelling up' agenda. The expertise, capacity and resilience of VCSE organisations, and their ability to respond to Covid-19, should be celebrated, recognised and supported adequately to maintain its resilience. To not do so threatens the sector's sustainability and risks jeopardising attempts to involve the sector in addressing the social determinants of health.

Resource Allocation in a National Dental Service Using Program Budgeting Marginal Analysis.

INTRODUCTION: In any health system, choices must be made about the allocation of resources (budget), which are often scarce. Economics has defined frameworks to aid resource allocation, and program budgeting marginal analysis (PBMA) is one such framework. In principle, patient and public values can be incorporated into these frameworks, using techniques such as willingness to pay (WTP). However, this has not been done before, and few formal resource allocation processes have been undertaken in dentistry. This study aimed to undertake a PBMA with embedded WTP values in a national dental setting. METHODS: The PBMA process was undertaken by a panel of participant-researchers representing commissioners, dentists, dental public health staff, and academics. The panel reviewed current allocations and generated a set of weighted criteria to evaluate services against. Services to be considered for removal and investment were determined by the panel and wider discussion and then scored against the criteria. Values from a nationally representative WTP survey of the public contributed to the scores for interventions. Final decisions on removal and investment were taken after panel discussion using individual anonymous electronic voting. RESULTS: The PBMA process resulted in recommendations to invest in new program components to improve access to general dentists, care home dentistry, and extra support for dental public health input into local government decisions. Disinvestments were recommended in orthodontics and to remove routine scaling and polishing of teeth. DISCUSSION: The PBMA process was successful in raising awareness of resource allocation issues. Implementation of findings will depend on the ability of decision makers to find ways of operationalizing the decisions. The process illustrates practical aspects of the process that future dental PBMAs could learn from. KNOWLEDGE TRANSFER STATEMENT: This study illustrates a framework for resource allocation in dental health services and will aid decision makers in implementing their own resource allocation systems.

The Interplay between socioeconomic inequalities and clinical oral health.

Oral health inequalities associated with socioeconomic status are widely observed but may depend on the way that both oral health and socioeconomic status are measured. Our aim was to investigate inequalities using diverse indicators of oral health and 4 socioeconomic determinants, in the context of age and cohort. Multiple linear or logistic regressions were estimated for 7 oral health measures representing very different outcomes (2 caries prevalence measures, decayed/missing/filled teeth, 6-mm pockets, number of teeth, anterior spaces, and excellent oral health) against 4 socioeconomic measures (income, education, Index of Multiple Deprivation, and occupational social class) for adults aged ≥21 y in the 2009 UK Adult Dental Health Survey data set. Confounders were adjusted and marginal effects calculated. The results showed highly variable relationships for the different combinations of variables and that age group was critical, with different relationships at different ages. There were significant income inequalities in caries prevalence in the youngest age group, marginal effects of 0.10 to 0.18, representing a 10- to 18-percentage point increase in the probability of caries between the wealthiest and every other quintile, but there was not a clear gradient across the quintiles. With number of teeth as an outcome, there were significant income gradients after adjustment in older groups, up to 4.5 teeth (95% confidence interval, 2.2-6.8) between richest and poorest but none for the younger groups. For periodontal disease, income inequalities were mediated by other socioeconomic variables and smoking, while for anterior spaces, the relationships were age dependent and complex. In conclusion, oral health inequalities manifest in different ways in different age groups, representing age and cohort effects. Income sometimes has an independent relationship, but education and area of residence are also contributory. Appropriate choices of measures in relation to age are fundamental if we are to understand and address inequalities.

Factors affecting direction and strength of patient preferences for treatment of molar teeth with nonvital pulps.

AIM: To elicit the factors affecting willingness to pay (WTP) values for the preferred options of participants for dealing with a molar tooth with a nonvital pulp, a common but difficult problem. METHODOLOGY: A total of 503 patients were recruited from dental practices in the North East of England and interviewed. Their preferred treatment option for a molar tooth with a nonvital pulp (endodontics, extraction and various prosthetic restorative options) and WTP for this preferred option were elicited. Factors affecting preferred option and WTP were analysed using econometric modelling. RESULTS: Overall, 53% of the sample wished to save the tooth with a mean WTP of £373. The variance in WTP was high. Of those opting for extraction, the majority chose to leave a gap or have an implant. The preferred option was influenced by previous treatment experience. WTP was only influenced by having a low income. CONCLUSIONS: The high level of variance in WTP and its relatively unpredictable nature pose difficult questions for policy makers trying to ensure the delivery of an equitable service. For dentists, it is important not to make assumptions about patient preference and strength of preference when making decisions. Ideally, WTP values should be considered alongside effectiveness data, and those on costs, in policy making.

Weighting and valuing quality-adjusted life-years using stated preference methods: preliminary results from the Social Value of a QALY Project.

OBJECTIVES: To identify characteristics of beneficiaries of health care over which relative weights should be derived and to estimate relative weights to be attached to health gains according to characteristics of recipients of these gains (relativities study); and to assess the feasibility of estimating a willingness-to-pay (WTP)-based value of a quality-adjusted life-year (QALY) (valuation study). DESIGN: Two interview-based surveys were administered - one (for the relativities study) to a nationally representative sample of the population in England and the other (for the valuation study) to a smaller convenience sample. SETTING: The two surveys were administered by the National Centre for Social Research (NatCen) in respondents' homes. PARTICIPANTS: 587 members of the public were interviewed for the relativities study and 409 for the valuation study. METHODS: In the relativities study, in-depth qualitative work and considerations of policy relevance resulted in the identification of age and severity of illness as relevant characteristics. Scenarios reflecting these, along with additional components reflecting gains in QALYs, were presented to respondents in a series of pairwise choices using two types of question: discrete choice and matching. These questions were part of a longer questionnaire (including attitudinal and sociodemographic questions), which was administered face to face using a computer-assisted personal interview. In the valuation study, respondents were asked about their WTP to avoid/prevent different durations of headache or stomach illness and to value these states on a scale (death = 0; full health = 1) using standard gamble (SG) questions. RESULTS: Discrete choice results showed that age and severity variables did not have a strong impact on respondents' choices over and above the health (QALY) gains presented. In contrast, matching showed age and severity impacts to be strong: depending on method of aggregation, gains to some groups were weighted three to four times more highly than gains to others. Results from the WTP and SG questions were combined in different ways to arrive at values of a QALY. These vary from values which are in the vicinity of the current National Institute for Health and Clinical Excellence (NICE) threshold to extremely high values. CONCLUSIONS: With respect to relative weights, more research is required to explore methodological differences with respect to age and severity weighting. On valuation, there are particular issues concerning the extent to which 'noise' and 'error' in people's responses might generate extreme and unreliable figures. Methods of aggregation and measures of central tendency were issues in both weighting and valuation procedures and require further exploration.

The impact of income inequality on individual and societal health: absolute income, relative income and statistical artefacts.

The relative income hypothesis, that relative income has a direct effect on individual health, has become an important part of the literature on health inequalities. This paper presents a four-quadrant diagram, which shows the effect of income, relative income and aggregation bias on individual and societal health. The model predicts that increased income inequality reduces average health regardless of whether relative income affects individual health. If relative income does have a direct effect then societal health will decrease further.

Presence of lorazepam in the blood plasma of drug free rats.

Lorazepam has been identified in the blood plasma of non-medicated rats by means of HPLC and gas chromatography combined with mass spectrometry. It was found to be present in about 1 ng per ml blood plasma. This pharmacologically highly active compound is the first dichlorinated benzodiazepine described to occur naturally in a tissue of mammals, not treated with benzodiazepines.

Single gene inheritance of occurrence of head spots in mice.

Results from earlier selection studies indicated that while the size of head spots in mice descended from the Goodale head-spot strain was a quantitative, polygenic trait, head-spot occurrence was probably a qualitative trait inherited by one or two genes. The present study was undertaken to examine this possibility by crossing a head-spot stock with three inbred strains and with two noninbred stocks carrying mutant genes. Observed segregation ratios in the F2 and backcross generations of these crosses were compared to results expected under various models of qualitative inheritance. Evidence of linkage between known loci and a putative head-spot gene also was sought. Results indicated that head spotting was inherited primarily by the action of a recessive autosomal gene, head spot (hs). The action of this gene was subject to modification, in some crosses, by other genes or by environmental factors. Attempts to demonstrate linkage between the head spots and known single-locus traits were unsuccessful.

Benzene inhibition of in vitro rabbit reticulocyte haem synthesis at delta aminolaevulinic acid synthetase: reversal of benzene toxicity by pyridoxine.

Benzene (0.113 M) inhibited haem and protein synthesis in rabbit reticulocytes. This inhibition of haem synthesis was found when L-2-[14C]-glycine was used as the radioactive precursor. However, when 4-[14C]delta-aminolaevulinic acid (ALA) was used, there was no significant inhibition. Since ALA measures the haem synthetic pathway beyond the enzyme delta-aminolaevulinic acid synthetase (ALA synthetase), these results suggest that benzene inhibits haem synthesis at or before ALA synthetase. This was confirmed by demonstrating that 1 mM ALA both protected against and reversed the benzene inhibition of reticulocyte protein synthesis. In addition, 1 mM pyridoxine both protected against and reversed the benzene inhibition of reticulocyte protein synthesis. In addition, ImM pyridoxine both protected against and reversed the benzene inhibition of reticulocyte haem and protein synthesis. These results indicate that benzene (or a metabolite) either competes with pyridoxal phosphate at ALA synthetase or competes with pyridoxine for pyridoxal phosphokinase. These results are discussed in terms of their implications for the possible roles of ALA synthetase and the haemin-controlled repressor in benzene-induced aplastic anaemia.

Benzene and lead inhibition of rabbit reticulocyte heme and protein synthesis: evidence for additive toxicity of these two components of commercial gasoline.

Both benzene and lead are known hematopoietic toxins. These compounds are components of commercial gasoline, and therefore pose an environmental risk. The present study demonstrates that benzene and lead individually inhibit both intact reticulocyte heme and protein synthesis in the presence or absence of iron-transferrin. When these two compounds are present in the same incubation, their effects are additive. These in vitro results suggest that further evaluation of the combined risks of benzene and lead is indicated. Furthermore, the data shows the potential for additive interaction by chemically unrelated environmental compounds.

Unilateral clubbing of the fingernails in patients with hemiplegia.

A survey based on an analysis of photographs compared the angle at the base of the fingernail in paralysed hands with controls. The significance of the changes in the nail bed angle in relation to clubbing and atrophy of the finger is discussed.