Periradicular tissue fluid-derived biomarkers for apical periodontitis: An in vitro methodological and in vivo cross-sectional study.

BACKGROUND: Periradicular tissue fluid (PTF) offers a source of diagnostic, prognostic and predictive biomarkers for endodontic disease. AIMS: (1) To optimize basic parameters for PTF paper point sampling in vitro for subsequent in vivo application. (2) To compare proteomes of PTF from teeth with normal apical tissues (NAT) and asymptomatic apical periodontitis (AAP) using high-throughput panels. METHODOLOGY: (1) To assess volume absorbance, paper points (n = 20) of multiple brands, sizes and sampling durations were inserted into PBS/1%BSA at several depths. Wetted lengths (mm) were measured against standard curves to determine volume absorbance (µL). To assess analyte recovery, paper points (n = 6) loaded with 2 µL recombinant IL-1ß (15.6 ng/mL) were eluted into 250 µL: (i) PBS; (ii) PBS/1% BSA; (iii) PBS/0.1% Tween20; (iv) PBS/0.25 M NaCl. These then underwent: (i) vortexing; (ii) vortexing/centrifugation; (iii) centrifugation; (iv) incubation/vortexing/centrifugation. Sandwich-ELISAs determined analyte recovery (%) against positive controls. (2) Using optimized protocols, PTF was retrieved from permanent teeth with NAT or AAP after accessing root canals. Samples, normalized to total fluid volume (TFV), were analysed to determine proteomic profiles (pg/TFV) of NAT and AAP via O-link Target-48 panel. Correlations between AAP and diagnostic accuracy were explored using principal-component analysis (PCA) and area under receive-operating-characteristic curves (AUC [95% CI]), respectively. Statistical comparisons were made using Mann-Whitney U, anova and post hoc Bonferonni tests (α < .01). RESULTS: (1) UnoDent's 'Classic' points facilitated maximum volume absorbance (p < .05), with no significant differences after 60 s (1.6 µL [1.30-1.73]), 1 mm depth and up to 40/0.02 (2.2 µL [1.98-2.20]). For elution, vortexing (89.3%) and PBS/1% BSA (86.9%) yielded the largest IL-1ß recovery (p < .05). (2) 41 (NAT: 13; AAP: 31) PTF samples proceeded to analysis. The panel detected 18 analytes (CCL-2, -3, -4; CSF-1; CXCL-8, -9; HGF; IL-1ß, -6, -17A, -18; MMP-1, -12; OLR-1; OSM; TNFSF-10, -12; VEGF-A) in ≥75% of AAP samples at statistically higher concentrations (p < .01). CXCL-8, IL-1ß, OLR-1, OSM and TNFSF-12 were strongly correlated to AAP. 'Excellent' diagnostic performance was observed for TNFSF-12 (AUC: 0.94 [95% CI: 0.86-1.00]) and the PCA-derived cluster (AUC: 0.96 [95% CI: 0.89-1.00]). CONCLUSIONS: Optimized PTF sampling parameters were identified in this study. When applied clinically, high-throughput proteomic analyses revealed complex interconnected networks of potential biomarkers. TNFSF-12 discriminated periradicular disease from health the greatest; however, clustering analytes further improved diagnostic accuracy. Additional independent investigations are required to validate these findings.

Indocyanine green-mediated antimicrobial photodynamic therapy as an adjunct to periodontal therapy: a systematic review and meta-analysis.

OBJECTIVES: The aim of this systematic review and meta-analysis was to evaluate the efficacy of indocyanine green-mediated photodynamic therapy (ICG-PDT) as an adjunct to non-surgical periodontal therapy (NSPT), in the management of chronic periodontitis. MATERIALS AND METHODS: Four electronic databases (PubMed, Cochrane Central Register of Controlled Trials, Embase via OVID, Web of Science) were searched for randomised controlled trials comparing NSPT with ICG-PDT to NSPT without laser therapy. Primary outcome measures were changes in probing pocket depth (PPD) and clinical attachment level (CAL). Clinical outcomes were extracted and pooled from 7 eligible trials and meta-analyses conducted using mean difference with standard deviations. RESULTS: For PPD, adjunctive ICG-PDT resulted in a mean additional reduction of 1.17 mm (95% CI: 0.67-1.66 mm) at 3 months and a mean additional reduction of 1.06 mm (95% CI: 0.54-1.57 mm) at 6 months. For CAL, adjunctive ICG-PDT resulted in a mean additional gain of 0.70 mm (95% CI: 0.17-1.23 mm) at 3 months and a mean additional gain of 1.03 mm (95% CI: 0.83-1.24 mm) at 6 months. No adverse events were reported in any studies. CONCLUSIONS: The adjunctive use of ICG-PDT in NSPT results in improved treatment outcomes at 3 and 6 months post-therapy. Further investigation is needed to evaluate variables such as different photosensitiser concentrations and adjusting parameters associated with the light source. CLINICAL RELEVANCE: Indocyanine green-based photosensitisers may be a novel, clinically efficacious agent for use in the management of periodontitis.

The role of the GP in managing suspected transient ischaemic attack: a qualitative study.

BACKGROUND: National guidelines recommend patients with suspected transient ischaemic attack (TIA) should be seen by a specialist within 24 h. However, people with suspected TIA often present to non-specialised services, particularly primary care. Therefore, general practitioners (GPs) have a crucial role in recognition and urgent referral of people with suspected TIA. This study aims to explore the role of GPs in the initial management of suspected TIA in the United Kingdom (UK). METHODS: One-to-one, semi-structured interviews with GPs, TIA clinic staff and patients with suspected TIA from two sites in the UK: Cambridge and Birmingham. Thematic analysis was undertaken to explore views on the role of the GP in managing suspected TIA. Thirty semi-structured interviews were conducted with stroke patients (n = 12), GPs (n = 9) and TIA clinic hospital staff (n = 9) from two hospitals and nine GP practices in surrounding areas. RESULTS: Three overarching themes were identified: (1) multiple management pathways for suspected TIA; (2) uncertainty regarding suspected TIA as an emergency or routine situation; and (3) influences on the urgency of GP management. CONCLUSIONS: Guidelines on the primary care management of TIA describe only a small proportion of the factors which influence GP management and referral of suspected TIA. Efforts to improve treatment, appropriate referral and patient experience should use a real rather than idealised model of the GP role in managing suspected TIA.

Postoperative Complications Following LeFort 1 Maxillary Advancement Surgery in Cleft Palate Patients: A 5-Year Retrospective Study.

OBJECTIVE: To investigate the postoperative complication rates of LeFort 1 maxillary advancement surgery in cleft patients when performed by a single surgeon over a 5-year period. DESIGN: A retrospective case note review of 79 cleft palate patients. SETTING: All surgery was performed by a single oral and maxillofacial surgeon in a tertiary care center. PARTICIPANTS: All cleft palate patients over 17 years of age who opted for surgical correction of maxillary hypoplasia with a LeFort 1 between 2010 and 2015. Patients required full surgical and clinical records. INTERVENTIONS: Complete surgical advancement of the maxilla ranging from 2.0 to 18.0 mm performed by conventional osteotomies (87%) or distraction osteogenesis (13%). MAIN OUTCOME MEASURE(S): Postoperative patient- and clinician-reported complications at set-interval follow-up appointments. RESULTS: Twenty-one patients (26.58%) reported no complications; 11 postoperative complications were identified in the remaining cohort. Temporary paresthesia of the infraorbital nerve was the most common complication (53.16%) followed by infection (13.92%). Other complications included relapse (11.39%), maxillary instability (6.33%), velopharyngeal impairment (6.33%), nasal obstruction (5.06%), chronic sinusitis (3.80%), bony dehiscence (1.27%), gingival necrosis (1.27%), partial necrosis of the maxilla (1.27%), and loss of tooth vitality (1.27%). CONCLUSIONS: LeFort 1 maxillary advancement surgery in cleft palate patients is associated with a wide range of postoperative complications, most commonly temporary paresthesia of the infraorbital nerve. Detailed, informed consent is essential prior to surgery.

Effective Pain Management Strategies in Endodontic Therapy.

Pain management is the key to providing successful root canal therapy. All patients hope for a painless procedure and look forward to being free of their symptoms when treatment is complete. However, managing pain throughout endodontic therapy can be challenging and improving awareness of various analgesic techniques can make a significant difference to both patient and practitioner. This article should provide some insight into these methods and use current literature to discuss how they can be delivered in a clinical setting. By doing so, practitioners can utilize these techniques to make endodontic treatment a more comfortable procedure. Clinical relevance: This article aims to improve the reader's awareness of the various clinical, pharmacological and behavioural analgesic techniques that can be used to help control presenting symptoms, reduce iatrogenic-induced pain and manage post-operative discomfort in the endodontically compromised patient.

Striking back against racist violence in the East End of London, 1968-1970.

This article tells the hitherto untold story of how different Pakistani organisations mobilised in response to racist violence and harassment in the east London Borough of Tower Hamlets (1968-1970). In telling this story, the authors analyse the problematic nature of official and public understandings of, and responses to, racist violence, and how it distorted the lives of racialised minorities. Drawing on original archival research carried out in 2014, this piece identifies the emergence of two distinct political repertoires from within the Pakistani community: the integrationist approach and the autonomous approach. The integrationist approach involving the Pakistani Welfare Association (PWA) and the National Federation of Pakistani Associations (NFPA) tried to address the problem through existing local state 'race relations' apparatuses and mainstream political channels, while at the same time re-establishing consent for the police as the agents of law and order. In contrast, a network of Black Power groups, anti-imperialists and socialists led by the Pakistani Progressive Party (PPP) and the Pakistani Workers' Union (PWU) challenged both the local political leadership and the authority of the police in Tower Hamlets, while also undermining the stereotype of Asian people as 'weak' and 'passive'. In recovering this lost episode of resistance to 'Paki-bashing', unleashed in the aftermath of Enoch Powell's inflammatory speeches, this essay makes a contribution to the history of autonomous anti-racist collective action undertaken by racialised minorities in Britain.

Exploiting Dentine Matrix Proteins in Cell-Free Approaches for Periradicular Tissue Engineering.

The recent discovery of mesenchymal stem cells within periapical lesions (PL-MSC) has presented novel opportunities for managing periradicular diseases in adult teeth by way of enhancing tissue regeneration. This discovery coincides with the current paradigm shift toward biologically driven treatment strategies in endodontics, which have typically been reserved for non-vital immature permanent teeth. One such approach that shows promise is utilizing local endogenous non-collagenous dentine extracellular matrix components (dECM) to recruit and upregulate the intrinsic regenerative capacity of PL-MSCs in situ. At picogram levels, these morphogens have demonstrated tremendous ability to enhance the cellular activities in in vitro and in vivo animal studies that would otherwise be necessary for periradicular regeneration. Briefly, these include proliferation, viability, migration, differentiation, and mineralization. Therefore, topical application of dECMs during ortho- or retrograde root canal treatment could potentially enhance and sustain the regenerative mechanisms within diseased periapical tissues that are responsible for attaining favorable clinical and radiographic outcomes. This would provide many advantages when compared with conventional antimicrobial-only therapies for apical periodontitis (AP), which do not directly stimulate healing and have had stagnant success rates over the past five decades despite significant advances in operative techniques. The aim of this narrative review was to present the novel concept of exploiting endogenous dECMs as clinical tools for treating AP in mature permanent teeth. A large scope of literature was summarized to discuss the issues associated with conventional treatment modalities; current knowledge surrounding PL-MSCs; composition of the dECM; inductive potentials of dECM morphogens in other odontogenic stem cell niches; how treatment protocols can be adapted to take advantage of dECMs and PL-MSCs; and finally, the challenges currently impeding successful clinical translation alongside directions for future research. Impact statement Apical periodontitis (AP) is an inflammatory condition that is associated with a great degree of morbidity and ultimately leads to tooth loss. The purpose of this review was to summarize the current evidence pertaining to stem cell therapy in endodontics and present a novel clinical methodology through which they may be utilized to address AP. A comprehensive overview of the basic science, clinical translation, and potential challenges are presented in this review.

Protocol for Past BP: a randomised controlled trial of different blood pressure targets for people with a history of stroke of transient ischaemic attack (TIA) in primary care.

BACKGROUND: Blood pressure (BP) lowering in people who have had a stroke or transient ischaemic attack (TIA) leads to reduced risk of further stroke. However, it is not clear what the target BP should be, since intensification of therapy may lead to additional adverse effects. PAST BP will determine whether more intensive BP targets can be achieved in a primary care setting, and whether more intensive therapy is associated with adverse effects on quality of life. METHODS/DESIGN: This is a randomised controlled trial (RCT) in patients with a past history of stroke or TIA. Patients will be randomised to two groups and will either have their blood pressure (BP) lowered intensively to a target of 130 mmHg systolic, (or by 10 mmHg if the baseline systolic pressure is between 125 and 140 mmHg) compared to a standard group where the BP will be reduced to a target of 140 mmHg systolic. Patients will be managed by their practice at 1-3 month intervals depending on level of BP and followed-up by the research team at six monthly intervals for 12 months.610 patients will be recruited from approximately 50 general practices. The following exclusion criteria will be applied: systolic BP <125 mmHg at baseline, 3 or more anti-hypertensive agents, orthostatic hypotension, diabetes mellitus with microalbuminuria or other condition requiring a lower treatment target or terminal illness.The primary outcome will be change in systolic BP over twelve months. Secondary outcomes include quality of life, adverse events and cardiovascular events.In-depth interviews with 30 patients and 20 health care practitioners will be undertaken to investigate patient and healthcare professionals understanding and views of BP management. DISCUSSION: The results of this trial will inform whether intensive blood pressure targets can be achieved in people who have had a stroke or TIA in primary care, and help determine whether or not further research is required before recommending such targets for this population. TRIAL REGISTRATION: ISRCTN29062286.

Current trends in endodontic irrigation amongst general dental practitioners and dental schools within the United Kingdom and Ireland: a cross-sectional survey.

Aims To investigate current trends in endodontic irrigation amongst general dental practitioners (GDPs) and dental schools within UK and Ireland. Secondly, to evaluate if significant differences exist between the irrigant practices of National Health Service (NHS) and private GDPs.Methodology In 2019, an online questionnaire was distributed to the 18 dental schools within the UK and Ireland and 8,568 GDPs. These surveys explored current trends in teaching and usage of endodontic irrigants. Chi-squared tests were performed to make comparisons between NHS and private GDPs (α <0.01).Results All 18 dental schools (100%) and 495 GDPs (6%) returned valid questionnaires. Three hundred and thirty (66.7%) practitioners were NHS and 165 (33.3%) were private. There was strong consensus on irrigation teaching amongst dental schools. These results aligned with GDP responses in terms of irrigant selection (sodium hypochlorite [NaOCl]); NaOCl concentration (≤3%); ethylenediaminetetraacetic acid (EDTA) contact time (>0-5 minutes); final rinse protocols (penultimate EDTA rinse); irrigant temperature (room); and agitation techniques (manual dynamic activation; >0-60 seconds). There was, however, considerable variation in NaOCl contact time and GDPs infrequently used chelating agents or agitation techniques. Compared with private practitioners, NHS GDPs used significantly lower NaOCl contact times and concentrations, less EDTA and activation techniques, and more chlorhexidine (P <0.01).Conclusions Overall, irrigation teaching within the UK and Ireland is consistent and evidence-based. Furthermore, trends in irrigant usage amongst UK GDPs are now more aligned with these teaching practices. Significant differences were, however, observed between NHS and private practitioners.

Racism and the sociological imagination.

Our chief purpose in this article is to argue for a restoration of a strong notion of agency to sociological accounts of social relations, and particularly those concerned with group formation and conflict. We contend that much contemporary sociological writing on this topic continues to rely on the concepts of race and ethnicity as primary explanatory or descriptive devices. This has two important consequences: on the one hand it reproduces the powerful theoretical obfuscation associated with these concepts, whilst on the other it prompts the notion that human agency has only an illusory role as an intentional agent. Drawing on the intellectual resources of a Hegelian-inflected historical materialism and realism, we challenge both claims by arguing for a post-race, post-ethnicity sociology of group formation, one which allows a greater scope for agency in the determination of social life.

"And now for the good news..." the impact of negative and positive messages in self-management education for people with Type 2 diabetes: A qualitative study in an ethnically diverse population.

OBJECTIVES: To explore the impact of Diabetes Education and Self Management for Ongoing and Newly Diagnosed (DESMOND) Foundation education, particularly from interviewees' narratives regarding recall of good and bad news messages and behaviour changes. METHODS: In-depth, semi-structured interviews were conducted with a purposive sample (n=19) of people who had attended education sessions as part of a randomised controlled trial in two UK sites with ethnically diverse populations. Data collection and analysis were informed by the constant comparative approach and facilitated through charting. RESULTS: Findings were similar in people from different ethnic backgrounds. Exploration of levels of recall of the sessions suggested that this was variable and sometimes very limited, but that interviewees had all assimilated some relevant learning. Key themes emerged relating to the way in which interviewees recalled and had been influenced by positive (good news) and negative (bad news) messages within the education sessions, including biomedical explanations. Both types of message appeared to have an important role in terms of motivation to change behaviour, but a notable observation was that none of the interviewees recalled receiving bad news messages when diagnosed. DISCUSSION: Our findings have highlighted the importance of providing and combining both negative and positive messages within education designed to promote self-management behaviour change.

Different systolic blood pressure targets for people with history of stroke or transient ischaemic attack: PAST-BP (Prevention After Stroke--Blood Pressure) randomised controlled trial.

OBJECTIVE: To assess whether using intensive blood pressure targets leads to lower blood pressure in a community population of people with prevalent cerebrovascular disease. DESIGN: Open label randomised controlled trial. SETTING: 99 general practices in England, with participants recruited in 2009-11. PARTICIPANTS: People with a history of stroke or transient ischaemic attack whose systolic blood pressure was 125 mm Hg or above. INTERVENTIONS: Intensive systolic blood pressure target (<130 mm Hg or 10 mm Hg reduction from baseline if this was <140 mm Hg) or standard target (<140 mm Hg). Apart from the different target, patients in both arms were actively managed in the same way with regular reviews by the primary care team. MAIN OUTCOME MEASURE: Change in systolic blood pressure between baseline and 12 months. RESULTS: 529 patients (mean age 72) were enrolled, 266 to the intensive target arm and 263 to the standard target arm, of whom 379 were included in the primary analysis (182 (68%) intensive arm; 197 (75%) standard arm). 84 patients withdrew from the study during the follow-up period (52 intensive arm; 32 standard arm). Mean systolic blood pressure dropped by 16.1 mm Hg to 127.4 mm Hg in the intensive target arm and by 12.8 mm Hg to 129.4 mm Hg in the standard arm (difference between groups 2.9 (95% confidence interval 0.2 to 5.7) mm Hg; P=0.03). CONCLUSIONS: Aiming for target below 130 mm Hg rather than 140 mm Hg for systolic blood pressure in people with cerebrovascular disease in primary care led to a small additional reduction in blood pressure. Active management of systolic blood pressure in this population using a <140 mm Hg target led to a clinically important reduction in blood pressure.Trial registration Current Controlled Trials ISRCTN29062286.

Patients' views about taking a polypill to manage cardiovascular risk: a qualitative study in primary care.

BACKGROUND: A 'polypill' containing a combination of antihypertensives and statins could prevent up to 80% of cardiovascular disease (CVD) events. AIM: To investigate patients' opinions about the use of a polypill for CVD prevention. DESIGN AND SETTING: Qualitative study of 17 patients from seven primary care practices in Birmingham, UK. METHOD: Patients were recruited through purposive sampling to maximise variation of characteristics. Semi-structured interviews were conducted with responders. Results were analysed and reported using a qualitative description approach. RESULTS: Patients expressed concerns that polypill prescription for primary prevention simply on the basis of age was unnecessary and would lead to side effects, despite recognising potential benefits. For high-risk patients, or for secondary prevention, a polypill was deemed more acceptable, but was still felt to require regular monitoring of blood pressure and cholesterol. CONCLUSION: Patients were sceptical about the role of a polypill as a 'blanket' approach. If a population strategy offering a polypill to all people over a certain age was to be implemented, it would need to be supported by patient education.

Would primary healthcare professionals prescribe a polypill to manage cardiovascular risk? A qualitative interview study.

OBJECTIVES: A 'polypill' containing both blood pressure-lowering and cholesterol-lowering drugs could prevent up to 80% of cardiovascular disease events. Since little is known about the attitudes of primary healthcare professionals to use of such a pill for cardiovascular disease prevention, this study aimed to investigate opinions. DESIGN: Semistructured interviews were conducted with participants. A qualitative description approach was used to analyse and report the results. SETTING: Participants were recruited from nine primary care practices in Birmingham. PARTICIPANTS: Sixteen healthcare professionals (11 primary care physicians and 5 practice nurses) were selected through purposive sampling to maximise variation of characteristics. OUTCOME MEASURES: Outcome measures for this study were: the attitude of healthcare professionals towards the use of a polypill for primary and secondary cardiovascular disease prevention; their views on monitoring the drug; and the factors influencing their willingness to prescribe the medication. RESULTS: Healthcare professionals expressed considerable concern over using a polypill for primary prevention for all people over a specific age, although there was greater acceptance of its use for secondary prevention. Regularly monitoring patients taking the polypill was deemed essential. Evidence of effectiveness, patient risk level and potential medicalisation were key determinants in willingness to prescribe such a pill. CONCLUSIONS: Primary healthcare professionals have significant concerns about the use of a polypill, particularly in the prevention of cardiovascular disease in people who are not regarded as being at 'high risk'. If a population-based polypill strategy is to be successfully implemented, healthcare professionals will need to be convinced of the potential benefits of a drug-based population approach to prevention.

Varying uses of the ABCD2 scoring system in primary and secondary care: a qualitative study.

OBJECTIVES: To explore the usage of the ABCD2 risk stratification score by general practitioners (GPs) and hospital staff during the referral of patients with suspected transient ischaemic attack (TIA) or minor stroke. DESIGN: Qualitative study using semistructured interviews. SETTING: Nine general practices and two hospital sites in England (Birmingham and Cambridge). PARTICIPANTS: Nine GPs and nine hospital staff (two consultants, four nurses, two ultrasonographers and one administrator). RESULTS: In both sites, clinicians used a referral proforma based around the ABCD2 scoring system for a range of purposes including self-education, to assist emphasising urgency to the patient, as a referral pathway facilitator and as a diagnostic tool. Negative views of its role included potential medicolegal threats, that it was a barrier to appropriate care, and led to misdiagnoses. Despite having differing uses by different clinicians, the ABCD2 proforma was the central means of interprofessional communication in TIA referrals across both sites. CONCLUSIONS: Understanding how prediction rules are used in practice is key to determining their impact on processes of care and clinical outcomes. In practice, GPs and their colleagues use the ABCD2 score in subtly different ways and it functions as a 'boundary object' by both accommodating these multiple purposes, yet still successfully aiding communication between them.

Patients' experiences of self-monitoring blood pressure and self-titration of medication: the TASMINH2 trial qualitative study.

BACKGROUND: Self-management of hypertension, comprising self-monitoring of blood pressure with self-titration of medication, improves blood pressure control, but little is known regarding the views of patients undertaking it. AIM: To explore patients' views of self-monitoring blood pressure and self-titration of antihypertensive medication. DESIGN AND SETTING: Qualitative study embedded within the randomised controlled trial TASMINH2 (Telemonitoirng and Self Management in the Control of Hypertension) trial of patient self-management of hypertension from 24 general practices in the West Midlands. METHOD: Taped and transcribed semi-structured interviews with 23 intervention patients were used. Six family members were also interviewed. Analysis was by a constant comparative method. RESULTS: Patients were confident about self-monitoring and many felt their multiple home readings were more valid than single office readings taken by their GP. Although many patients self-titrated medication when required, others lacked the confidence to increase medication without reconsulting with their GP. Patients were more comfortable with titrating medication if their blood pressure readings were substantially above target, but were reluctant to implement such a change if readings were borderline. Many planned to continue self-monitoring after the study finished and report home readings to their GP, but few wished to continue with a self-management plan. CONCLUSION: Participants valued the additional information and many felt confident in both self-monitoring blood pressure and self-titrating medication. The reluctance to change medication for borderline readings suggests behaviour similar to the clinical inertia seen for physicians in analogous circumstances. Additional support for those lacking in confidence to implement prearranged medication changes may allow more patients to undertake self-management.

Migrant labour, racism and the British National Health Service.

This study explores the dynamics of racism, specifically its generation and reproduction as an ideology, and its role in affecting the reception and occupational location of migrant medical labour in Britain. It is argued that the treatment of 'overseas doctors' in Britain draws on a complex interplay between racism and nationalism underpinned by the historical construction of 'welfarism' as a moral legitimator of 'Britishness'. Through an exploration of internal and external immigration controls introduced with the aim of regulating migrant labour, we demonstrate how British social policy and elite discourses of 'race' combine to construct moral prescriptions of threat such that migrants and British-born 'non-whites' entering the British medical profession are forced to negotiate 'saviour/pariah' ascriptions indicative of discriminatory but contradictory processes specific to the operation of the British National Health Service as a normative institution.