Barriers to Accessing Primary Dental Care in Adults with Alcohol Dependence: A Qualitative Study.

BACKGROUND: People with alcohol dependence (AD) frequently experience oral health problems, but their dental attendance is poor, with limited evidence to the reasons why from their perspective. OBJECTIVE: To explore perceived barriers, motivators, and facilitators to accessing primary dental care in people with AD. METHODS: Qualitative study consisting of remote one-to-one and group semistructured interviews with a convenience sample of adults with lived experience of AD in northern England. Data were audio-recorded, transcribed, and coded. A reflexive thematic analysis method was used; use of COM-B model informed data interpretation. RESULTS: Twenty adults with lived experience of AD participated in 18 one-to-one interviews and 1 group interview (of 3 participants). Barriers to access were fear and physical, social, and environmental factors (physical effects of AD, financial barriers, nonprioritization of oral health). Motivators to access were pain and prioritization of oral health. Facilitators to access were patterns of alcohol use (i.e., sobriety) and dental service provision within recovery services. CONCLUSIONS: Fear of "the dentist" is a major barrier to accessing dental care, and pain is the primary motivator, among people with AD, although neither are unique to this population. Fear and physical, social, and environmental barriers to access contribute to problem-oriented attendance, which negatively affect oral health outcomes. Opportunity to facilitate attendance increases when a person is in remission from AD through their physical capabilities improving. Increasing capability and opportunity can influence attendance beyond the automatic motivation of pain. Provision of dental care within recovery services could facilitate access to care. Understanding the "web of causation" is key to developing any intervention to improve dental access in people with AD. Further research is needed from the perspective of other adult populations with lived experience of AD, as well as of dental professionals, to gain deeper insight into barriers, facilitators, and possible solutions. KNOWLEDGE TRANSFER STATEMENT: The results of this study can help dental professionals understand factors affecting access to primary care in people with alcohol dependence to provide knowledge that may reduce stigma surrounding the disease. Results also demonstrate areas for intervention development for public policy.

Customised vestibular rehabilitation with the addition of virtual reality based therapy in the management of persistent postural-perceptual dizziness.

OBJECTIVE: Visual-vestibular mismatch patients experience persistent postural and perceptual dizziness. Previous studies have shown the benefit of vestibular rehabilitation for visual desensitisation using gaze stabilisation exercises and optokinetic stimulation. This study assessed the benefit of customised vestibular rehabilitation with visual desensitisation and virtual reality based therapy rehabilitation in the management of patients with persistent postural-perceptual dizziness. METHODS: This retrospective study included 100 patients with Situational Characteristic Questionnaire scores of more than 0.9. All patients received virtual reality based therapy along with usual vestibular rehabilitation using gaze stabilisation exercises with a plain background followed by graded visual stimulation and optokinetic digital video disc stimulation. Patients' symptoms were assessed before and after vestibular rehabilitation using the Situational Characteristic Questionnaire, Generalised Anxiety Disorder Assessment-7, Nijmegen Questionnaire and Dizziness Handicap Inventory. RESULTS: There were statistically significant improvements in Situational Characteristic Questionnaire scores, Nijmegen Questionnaire scores and Dizziness Handicap Inventory total score. However, there was a statistically insignificant difference in Generalised Anxiety Disorder Assessment-7 scores. There was a significant positive correlation between post-rehabilitation Situational Characteristic Questionnaire scores and other questionnaire results. CONCLUSION: Incorporating virtual reality based therapy with customised vestibular rehabilitation exercises results in significant improvement in persistent postural-perceptual dizziness related symptoms.

White matter lesions in magnetic resonance imaging of the brain in 56 patients with visual vertigo.

BACKGROUND: Visual vertigo is defined as a condition in which there is worsening or triggering of vestibular symptoms in certain visual environments. Previous studies have associated visual vertigo with an increased prevalence of underlying white matter lesions on brain imaging. METHOD: This study evaluated the magnetic resonance imaging scans of the brain from a cohort of patients with visual vertigo, and compared the outcomes to an age- and gender-matched group of healthy volunteers.Results and conclusionWhite matter lesions were observed in 17.9 per cent of the patient group and in 16.3 per cent of the control group. The prevalence of white matter lesions in the patient group was not too different to that expected based on age.

Telemedicine diagnosis for fetal alcohol syndrome - The Manitoba experience.

The diagnosis of fetal alcohol syndrome has been possible, with increasing precision, since the original descriptions in the 1970s. Multidisciplinary diagnostic approaches have been recognized as most appropriate, although they are often not available. Telemedicine has been used in Canada over the same time period for a variety of diagnositc applications.Since 1999, funding by the Manitoba government has allowed the consolidation of services for children with prenatal alcohol exposure in Manitoba, and has allowed the development of a format for diagnosis using telemedicine.This paper describes the authors' experience with the above and offers observations that may be helpful to other programs that are focused on developing this format for the diagnosis of fetal alcohol syndrome.

Telematics and protocols of care in critical care environments.

The paper discusses the potential roles for protocols of care within critical care environments from the perspective of providing real-time support for their application. The discussion is based around a conceptual model of care in critical care environments. This model has been developed in the wider context of developing information technology systems to support clinical care in critical care environments. The conceptual model of care is a three layer model which demonstrates both the hierarchical and temporal aspects of the care delivered to patients. It is proposed that if the value of protocols of care is to be realised in critical care environments then they must be seamlessly integrated into the routine data management associated with the care of patients. In order to demonstrate this and to evaluate the utility of this concept in the clinical environment, the systems from the AIM TANIT (Telematics in Anaesthesia and Intensive Therapy) project have been used as prototype platforms. The application of the concepts developed are described in two critical care environments: the anaesthesia department and the intensive care unit. Problems in using protocols of care in intensive care units suggest that integrating these with a problem solving methodology to create an integrated care plan may be a more appropriate approach to patient management.

TANIT AIM project (A2036): Telematics for ANaesthesia and Intensive Therapy.

On-going work relating to the development of advanced telematics systems for Critical Care environments is described. This work is in part sponsored by the Commission of European Communities under the AIM TANIT project. Two example departments have been selected for piloting in the project: Intensive Care and Anaesthesia. The objective of this paper is to outline the complex issues that need to be addressed when developing such systems.

Information management systems for intensive care.

On-going work relating to the development of advanced information management systems for intensive care is described. The objective of this paper is to outline the complex issues that need to be addressed when developing such systems. This work is in part sponsored by the Commission of the European Communities under the AIM TANIT project, and an overview of its approach is given. Data protection, security and confidentiality aspects are emphasised, together with the need to balance data availability with the need for security.

Postural control in sitting the SAM system: evaluation of use over three years.

The most appropriate posture in which to support the person with severe disability and diverse symptoms as a result of complex pathology remains more a matter of opinion than the result of research. This work reviews some of the studies which have attempted to identify definitive criteria for seating in such cases. Factors relating to measurement and conditions which threaten to invalidate the results of research in this field are highlighted. A description of the Seating and Mobility (SAM) system is given, together with a report of the monitoring of nine children with cerebral palsy using the system for a period of three years. The difficulties inherent in this work are noted and questions for future considerations are raised.

Localization of a retroviral element within the rd gene coding for the beta subunit of cGMP phosphodiesterase.

Retinal degeneration in the rd mouse is inherited as an autosomal recessive trait and is caused by a defect in the gene encoding the beta subunit of cGMP phosphodiesterase. Recently, a close genetic association of the rd gene with an endogenous xenotropic murine leukemia virus (Xmv-28) was established by linkage analysis using recombinant inbred strains of mice. In this study, genomic DNA mapping and sequence analyses clarify the position of the proviral sequences in relation to the rd gene. We find that the Xmv-28 provirus is integrated into intron I of the rd gene 1511 bp downstream of the exon-intron boundary. The transcriptional orientation of the provirus is opposite to that of the gene for the beta subunit of cGMP phosphodiesterase. Reverse transcription-PCR demonstrates that the integrated Xmv-28 sequences are transcribed in the retina. The provirus is present in every strain of rd mouse tested.

Assignment of the beta-subunit of rod photoreceptor cGMP phosphodiesterase gene PDEB (homolog of the mouse rd gene) to human chromosome 4p16.

The gene encoding the beta-subunit of rod photoreceptor cGMP phosphodiesterase (gene symbol PDEB, homolog of the mouse rd gene) is mapped to human chromosome 4 using somatic cell hybrids and further localized to the chromosome band 4p16 using in situ hybridization. A mutation in the mouse gene underlies the recessive trait of retinal degeneration in the rd mouse. Thus, the human homolog is a candidate for lesions causing retinal degeneration.

INFORM: European survey of computers in intensive care units.

The aims of this study were (a) to survey and evaluate the impact of information technology applications in High Dependency Environments (HDEs) on organizational, psychological and cost-effectiveness factors, (b) to contribute information and design requirements to the other workpackages in the INFORM Project, and (c) to develop useful evaluation methodologies. The evaluation methodologies used were: questionnaires, case studies, objective findings (keystroke) and literature search and review. Six questionnaires were devised covering organizational impact, cost-benefit impact and perceived advantages and disadvantages of computerized systems in HDE (psychological impact). The general conclusion was that while existing systems have been generally well received, they are not yet designed in such a developed and integrated way as to yield their full potential. Greater user involvement in design and implementation and more emphasis on training emerged as strong requirements. Lack of reliability leading to parallel charting was a major problem with the existing systems. It proved difficult to assess cost effectiveness due to a lack of detailed accounting costs; however, it appeared that in the short term, computerisation in HDEs tended to increase costs. It is felt that through a better stock control and better decision making, costs may be reduced in the longer run and effectiveness increased; more detailed longitudinal studies appear to be needed on this subject.

The potassium channel MBK1 (Kv1.1) is expressed in the mouse retina.

1. The neurons of the retina have electrical properties that are different from those of most of the other neurons of the central nervous system. To identify the voltage-gated ion channels found in the retina, we screened mouse retinal cDNA libraries with oligonucleotide probes homologous to the mammalian K+ channel MBK1 (Kv1.1) and ligated two partial clones to produce a full-length clone with no significant differences from MBK1. 2. Expression of MBK1 mRNA was determined by RNAse protection. MBK1 mRNA was detected in retinal RNA and was also detected in brain, liver, and heart RNAs. 3. We transcribed the full-length clone, injected it into oocytes of Xenopus laevis, and measured the membrane currents 2 to 6 days later. Depolarization from a holding voltage of -90mV induced a slowly activated outward current with a peak value as large as 20 microA. The current inactivated very slowly with a single exponential time course [mean time constant, 6.5 +/- 0.4 sec (SEM) for activation voltage of -10mV]. 4. The outward current was reduced to half-maximal by 0.42 mM tetraethylammonium, 1.1 mM 4-aminopyridine, and 3.2 mM Ba2+ but was not significantly attenuated by Co2+ (1 mM). 5. The reversal potential (measured with tail currents) changed by 53mV per decade change of [K+] from 1 to 77 mM. 6. The voltage for half-maximal activation of the conductance was -26.6mV (+/- 1.7mV), and the voltage required for an e-fold increase in conductance was 6.9mV (+/- 0.5mV). 7. Thus, the mRNA for MBK1 found in the mouse retina causes the expression of a voltage-dependent K+ current which has properties suitable for may retinal neurons.

INFORM: development of information management and decision support systems for High Dependency Environments.

The long-term aim in the INFORM Project is to develop, evaluate and implement a new generation of Information Systems for hospital High Dependency Environments (HDE-Intensive Care Units, Neonatal Units, Burns Units. Operating and Recovery Rooms, and other specialised areas). The distinguishing feature of the HDE is the very large amount of data that is collected through monitors and paper records about the state of critically ill patients; this has made the role of the staff a technical one in addition to a caring one. The INFORM System will integrate Decision Support with on-line, off-line and observed patient data and, in addition, will incorporate and integrate unit management features. In the Exploratory Phase of the Project, functional requirements have been set out. These are based on four components: conceptual model of the HDE; evaluation of existing HDE Information Systems; development of a novel software architecture using a Knowledge-Based Systems (KBS) methodology, and based on a critical review of KBS applied to the HDE: monitoring of appropriate leading-edge technological developments. The conceptual model has two components: a patient-related information model, and a department-related cost model. The patient-related model is identifying key and difficult areas of decision making. A key aspect of INFORM is integration of clinical Decision Support for these areas into the Information System through a layered software architecture. The lower layers are concerned with monitoring and alarming and the higher levels with patient assessment and therapy planning. The functionality and interconnection of these layers are being determined.

Retinal degeneration in the rd mouse is caused by a defect in the beta subunit of rod cGMP-phosphodiesterase.

Mice homozygous for the rd mutation display hereditary retinal degeneration and the classic rd lines serve as a model for human retinitis pigmentosa. In affected animals the retinal rod photoreceptor cells begin degenerating at about postnatal day 8, and by four weeks no photoreceptors are left. Degeneration is preceded by accumulation of cyclic GMP in the retina and is correlated with deficient activity of the rod photoreceptor cGMP-phosphodiesterase. We have recently isolated a candidate complementary DNA for the rd gene from a mouse retinal library and completed the characterization of cDNAs encoding all subunits of bovine photoreceptor phosphodiesterase. The candidate cDNA shows strong homology with a cDNA encoding the bovine phosphodiesterase beta subunit. Here we present evidence that the candidate cDNA is the murine homologue of bovine phosphodiesterase beta cDNA. We conclude that the mouse rd locus encodes the rod photoreceptor cGMP-phosphodiesterase beta subunit.

Fine mapping of a putative rd cDNA and its co-segregation with rd expression.

Retinal degeneration is inherited in an autosomal recessive pattern in the retinal degeneration (rd) mouse. The defective gene for this disease has been mapped to mouse chromosome 5 between the well-defined (anchor) genes Afp and Gus. We recently cloned a putative rd cDNA, zr.408, using a strategy based on subtractive and differential hybridization. zr.408 was shown to hybridize to a larger message from rd/rd mice than from normal mice in Northern blots; was mapped to mouse chromosome 5; and was used to detect restriction fragment length polymorphisms (RFLPs) between rd/rd and +/+ DNA in genomic Southern blots. In order to obtain further evidence that zr.408 does in fact correspond to the rd gene, we used two methods to position zr.408 on chromosome 5. Analysis of an intersubspecific backcross localized the sequences corresponding to zr.408 between the genes Afp and Gus, as expected for rd. The second approach involved an interspecific backcross using C57BL/6J-rd/rd mice congenic for the normal allele of rd, which was derived from the wild mouse, Mus spretus; the results of this study showed that zr.408 is at or near the rd locus. These two studies add evidence to the existing data, which suggest that zr.408 is the correspondent of the rd gene.

Isolation of a candidate cDNA for the gene causing retinal degeneration in the rd mouse.

The inherited retinal degeneration of the rd mouse results in the exclusive loss of one cell type, the photoreceptors. We took advantage of this visual-cell loss to devise a strategy for the isolation of photoreceptor-specific cDNAs based on the use of subtractive and differential hybridizations. The resulting pool of photoreceptor-specific cDNAs was screened for a candidate cDNA for the rd gene, and a putative rd cDNA that maps to mouse chromosome 5, the chromosome to which the rd gene has been assigned, was identified. On Northern blots the candidate rd cDNA hybridizes a 3.3-kilobase RNA species from 9- to 11-day-old developing normal retina and, much more faintly, a 3.6-kb RNA species from age-matched rd retina. The 0.3-kilobase difference in the size of the mRNAs hybridized suggests that a structural alteration in the gene corresponding to the candidate rd cDNA has occurred in the rd mouse. This was further supported by the detection of polymorphisms between rd/rd and +/+ mouse genomic DNA after digestion with restriction endonucleases and probing with the candidate rd cDNA. Expression of mRNAs hybridized by the candidate rd cDNA is detected in normal and diseased retinas at postnatal day 1 but the signal intensity is considerably lower in the rd retina. To our knowledge, this is the earliest molecular defect reported in the rd retina that is observed prior to any phenotypic signs of photoreceptor degeneration.