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Adolescents with type 1 diabetes face barriers that can have a negative influence on self-management behaviors. This study was an analysis of semi-structured interviews with adolescents, parents, and health care providers to better understand these barriers among adolescents in Jordan. Adolescents with type 1 diabetes reported individual-level barriers including feeling labeled, pitied, and stigmatized for having type 1 diabetes. They also discussed the system-level barrier of an education system that does not adapt to meet their needs. Individual- and system-level barriers are interrelated and could influence adolescents’ decisions regarding whether to disclose their condition to others.

Asians believe discussing death-related topics is inauspicious and may bring bad luck. It is critical to explore the end-of-life care preferences of the Asian elderly with less-threatening tools. The study examined older adults’ preferences regarding end-of-life treatments by applying a cartoon version of the Life Support Preferences Questionnaire (LSPQ). A cross-sectional survey was conducted to understand older adults’ preferences for end-of-life treatments. A total of 342 older adults participated in the study, comprising 268 elderly patients from a veterans hospital located in northern Taiwan and 74 elderly family members of the patients. Regardless of scenario, cardiopulmonary resuscitation (CPR) had the lowest score, indicating that older adults considered it a less desirable medical treatment. By contrast, antibiotics and intravenous infusions had the highest scores, indicating that older adults tended to prefer them. End-of-life care preferences were significantly different in genders. CPR and surgical preferences of older adults differed significantly with education level. Different demographic characteristics had different end-of-life treatment preferences, and future research may develop advance care planning programs for different attributes. This cartoon version of the LSPQ can help healthcare professionals to understand older adults’ preferences for end-of-life care and warrants further empirical research.

INTRODUCTION The COVID-19 pandemic led to closure of the 16 UK dental schools and a shift to remote learning. The aim of this study was to explore the impact on the teaching and learning experiences of undergraduate dental students, including their clinical confidence and mental health. METHODS An online survey was distributed to students enrolled at UK dental schools during the time of closure. Paired samples t-tests were employed to analyse the results. RESULTS A total of 312 students responded to the survey. Eighty-five per cent felt that the university closure had a negative impact on their overall learning. Ninety-seven per cent thought their clinical skills would be affected; perceived confidence in treating patients decreased by 27%. The mental health of all respondents was negatively affected although their stress about their studies was not affected. Positive aspects of closure included remote learning and online examinations. CONCLUSIONS The pandemic had both negative and positive impacts on dental students’ education. Universities should adapt their response to future crises and incorporate the positive impacts in future curriculums. Further studies could explore the long-term impact on students’ mental health and clinical skills.

Background: Type 1 diabetes is the most common endocrine condition among adolescents. Diabetes self-management can be challenging during adolescence. Objective: The objective of this study is to understand how adolescents and their parents manage type 1 diabetes in Jordan. Methods: Constructivist grounded theory methodology principles were used to achieve the study aim. A total of 48 participants were recruited using purposive and theoretical sampling techniques, including adolescents and their parents. Data were collected (October 2016 - April 2017) using 38 semi-structured, audio-recorded interviews (one-to-one or joint interviews based on participants’ preferences). Data were collected and analyzed concurrently using different levels of coding, constant comparative analysis, and memo writing. This study was approved by relevant ethics committees from the University of Manchester and Jordan University Hospital. Results: The theme of living with diabetes is presented and discussed in this article. Culture emerged as the central theme; two aspects of culture are presented in this article: collectivism and cultural beliefs. Conclusion: This study identified that diabetes self-management could be influenced by the culture in which Jordanian adolescents live in as well as being shaped by their religious beliefs. These findings are potentially transferable to other Arab and non-Arab countries that share similar cultural aspects and religious beliefs.

This study aimed to explore the factors affecting the behavioral intentions of older adults toward advance care planning (ACP). A questionnaire survey was conducted at 2 medical wards and a senior activity center in northern Taiwan. Four hundred one participants were older adults aged over 65 years, comprising hospitalized patients, their caregivers, and members of a senior activity center. The regression model revealed that participant type (patient, caregiver, or community resident); financial support; discussion of ACP with family; and knowledge, attitudes, and subjective norms accounted for 46.3% of the variance in behavioral intentions. The behavioral intention of caregivers was higher than that of patients. The behavioral intention of participants who were financially dependent on the family was lower than that of pensioners. Regarding discussing ACP with family, older adults in the contemplation and preparation stages score higher on behavioral intention than those in the precontemplation stage. This study supports the theory of reasoned action. Older adults' ACP knowledge and attitudes need to be enhanced through education. Caregivers' behavioral intentions tend to perform ACP. Sharing their caring experiences may be a strategy for promoting ACP. Older adults' financial status affects their behavioral intentions. Therefore, financial planning should be performed early and should incorporate ACP.

Objective: Cleft palate (CP) can affect breathing, leading to sleep-disordered breathing (SDB). Sleep position can affect SDB, but the optimum sleep position for infants with CP is unknown. We aimed to determine the design of a pragmatic study to investigate the effect of the 2 routinely advised sleep positions in infants with CP on oxygen saturations. Design: A multicentered observational cohort. Setting: Four UK-based cleft centers, 2 advising supine- and 2 side-lying sleep positions for infants with CP. Participants: Infants with isolated CP born July 1, 2015, and December 31, 2016. Of 48 eligible infants, 30 consented (17 side-lying; 13 supine). Interventions: Oxygen saturation (SpO2) and end-tidal carbon dioxide (ETCO2) home monitoring at age 1 and 3 months. Qualitative interviews of parents. Outcome Measures: Willingness to participate, recruitment, retention, and acceptability/success (>90 minutes recording) of SpO2 and ETCO2 monitoring. Results: SpO2 recordings were obtained during 50 sleep sessions on 24 babies (13 side-lying) at 1 month (34 sessions >90 minutes) and 50 sessions on 19 babies (10 side-lying) at 3 months (27 sessions >90 minutes). The ETCO2 monitoring was only achieved in 12 sessions at 1 month and 6 at 3 months; only 1 was >90 minutes long. The ETCO2 monitoring was reported by the majority as unacceptable. Parents consistently reported the topic of sleep position in CP to be of importance. Conclusions: This study has demonstrated that it is feasible to perform domiciliary oxygen saturation studies in a research setting and has suggested that there may be a difference in the effects of sleep position that requires further investigation. We propose a study with randomization is indicated, comparing side-lying with supine-lying sleep position, representing an important step toward better understanding of SDB in infants with CP.

IntroductionThe craniofacial abnormalities found in infants with cleft palate (CP) decrease their airway patency and increase their risk of obstructive sleep apnoea (OSA). We hypothesise that optimising sleep position in infants with CP may improve airway patency and offer a ‘low-cost, high-impact’ intervention to prevent the negative impacts of OSA. Because cleft centres give inconsistent advice about sleep position: some recommend back-lying and others side-lying, we will compare these in a randomised controlled trial.Methods and analysisThe aim is to determine the clinical effectiveness of side-lying as compared with back-lying sleep positioning in terms of reducing oxygen desaturation resulting from OSA in 244 infants aged 3–5 weeks of age, diagnosed with an isolated CP in/by UK cleft centres. Primary outcome is the 4% Oxygen Desaturation Index measured using pulse oximetry during sleep.Research plan1. Multicentre randomised controlled trial of side-lying compared with back-lying sleep positioning in reducing oxygen desaturation resulting from OSA in infants with CP at one month of age. 2. Internal pilot questionnaire-based study to support parents and clinicians regarding study participation, seeking to identify and address any barriers to recruitment. Monitoring data from the internal pilot will be used in the final analysis. 3. Co-development of new UK recommendations with Cleft Lip and Palate Association (CLAPA) regarding sleep position for infants with CP.Ethics and disseminationThe study protocol has received the favourable opinion of the West Midlands-South Birmingham Research Ethics Committee. Study results will be published on affiliated webpages and in peer-reviewed publications and conference contributions.Trial registration numberNCT04478201.

Background Children with cleft lip and/or palate (CLP) are prone to poorer oral health outcomes than their peers, with serious implications for treatment. Little is known of the knowledge and practice of children with CLP in caring for teeth and how these contribute to oral health. Aim To investigate (i) parents’ and children's knowledge of oral health, (ii) how knowledge is acquired, and (iii) how knowledge is implemented. Design A qualitative design was used to investigate knowledge, beliefs, and practices reported by parents and children, age 5–11 years with CLP. Data were collected from 22 parents and 16 children and analysed using thematic analysis. Results Four themes were derived as follows: (i) implicit knowledge: children express simple knowledge underpinned by basic rationales, (ii) situated knowledge: children gain skills as part of everyday childhood routines, (iii) maintaining good practice in oral health: parents take a lead role in motivating, monitoring, and maintaining children's toothbrushing, and (iv) learning opportunities: pivotal moments provide opportunities for children to extend their knowledge. Conclusion Developers of oral health education interventions should take account of children's implicit knowledge and the transmission of beliefs between generations that influence toothbrushing behaviours. This could enhance interventions to support parents and children's practice.

The term ‘boundary-work’ is used to refer to the constant effort to draw and re-draw the boundary of science; it has long been portrayed as constructed by the stakeholders of science to demarcate science from non-science to establish the authority of science. Twenty-nine semi-structured interviews were carried out with students from one university in England, originally to explore their views about genetically modified (GM) food. However, the distinctive repertoires adopted by students of natural science as opposed to humanities and social sciences were striking. As a result, the focus of this study shifted to examine the discourse students adopted to talk about a controversial scientific topic, using GM food as a case study. This paper shows that the boundary between scientific and non-scientific academic disciplines is heavily ingrained in university students' discourse and it is collectively constructed by both actors that are included in, and excluded from, the institution of science. The innate authority assigned to the institution of science is found to have deepened the gap between scientific and non-scientific disciplines. In this study, science disciplines were portrayed as coherent and consistent, following similar scientific methods and philosophy whereas humanities and social sciences disciplines were merely considered as ‘non-science’ disciplines. Hence, this paper suggests the wide scope of science should be better recognised and acknowledged in the education system. Finally, this paper demonstrates that people's role in relation to the institution of science has an impact on their discourse about and, perhaps subsequently, their views towards, science and technology.

Objective:To identify outcomes relating to sleep-disordered breathing (SDB) that are relevant to parents, during the early weeks of caring for infants with cleft palate (CP), and compare these with clinical outcomes identified in a systematic search of research literature.Design:A qualitative study using telephone/face-to-face interviews with parents explored their understanding of breathing and respiratory effort in infants with CP.Setting:Care provided by 3 specialist cleft centers in the United Kingdom, with study conducted in parents’ homes.Participants:Criteria for participation were parents of infants with isolated CP aged 12 to 16 weeks. Thirty-one parents of infants with CP (over 12 weeks) were invited to participate in the interview. Interviews were completed with 27 parents; 4 parents could not be contacted after completing the sleep monitoring.Results:Parents’ description of infants’ sleep suggests that breathing is not considered as a separate priority from their principal concerns of feeding and sleeping. They observe indicators of infants’ breathing, but these are not perceived as signs of SDB. Parents’ decision to use lateral or supine sleep positioning reflects their response to advice from specialists, observation of their infants’ comfort, ease of breathing, and personal experience. Outcomes, identified in published research of SDB, coincide with parents’ concerns but are expressed in medical language and fit into distinct domains of “snoring,” “sleep,” “gas exchange,” and “apnea.”Conclusions:Parents’ description of sleeping and respiration in infants with CP reflect their everyday experience, offering insight into their understanding, priorities, and language used to describe respiration. Understanding parents’ individual priorities and how these are expressed could be fundamental to selecting meaningful outcomes for future studies of airway interventions.

Background Implementation intentions enable individuals to translate good intentions into action. Parents and children can find maintaining oral health difficult, as evidenced by the presence of tooth decay. This is a common condition in children in spite of being preventable through the use of regular tooth brushing, fluoride protection and avoiding sugar intake. Even when parents and children are positive about looking after the teeth, they can face challenges in maintaining consistent habits. The aim of this paper is to describe the design of a video animation to teach parents and children how to use implementation intentions to establish new habits to improve oral health, applied in this case, to parents and children with cleft lip and/or palate (CLP). Methods Evidence from a qualitative study of parents’ and children’s knowledge, beliefs and behaviour informed the design of an animation forming part of an intervention for children and parents using implementation intentions. The user views generated a set of guiding principles to determine the style and content of a teaching video, whilst an animation designer translated the key messages of implementation intention into images and characters appealing and meaningful to the target audience of children and parents. Results A team of researchers, an animation designer and a script writer designed a 2-min video as a teaching tool for children and parents. The team drafted and iteratively refined the content and visuals, with guidance from an advisory group and informal discussions with children in the target age group and their parents. Planning, consulting, designing and production of the animation spanned a total of 20 weeks. The video explains how to formulate ‘if-then’ plans using the voices of a boy and his mother in a conversation, with examples from oral health to illustrate how to enact intentions. It is available via digital media and designed to be delivered by dental care practitioners. The effectiveness of the intervention will be evaluated as part of a feasibility study. Conclusion The current study describes the development of an intervention mediated through an animation tutorial that enables children and parents to devise ‘if-then’ plans to improve oral health as a collaborative endeavour between parents and children. The animation uses examples from oral health, but we believe there is scope for exploring application of the intervention to other areas of behaviour.

This paper investigates university students' discourse about their food practices at home to address two technical issues in the existing literature about family and food: first, the lack of scholarly attention to adult children's accounts about family food practices, and second, that existing studies about family food too often treat what is reported by respondents as what actually happens. The paper is based on an analysis of twenty-nine semi-structured interviews conducted with university students. Two types of images constructed in the students' discourse are noted: the institutional image and the individual image. This paper finds that students' discourse about family food practices tends to focus on highlighting the institutional image of the student's family rather than on constructing the individual image of the respective student. This paper suggests that adult children's accounts about family food practices can provide a different perspective to the accounts of women, and that the intera...

In the March 2011 edition of this journal, there appeared an overview of the regulation of health and nutrition claims ( Gilsenan, 2011 ) with particular reference to the Regulation on Nutrition and Health Claims made on Foods ( EC, 1924/2006 ). From the issue of regulation arises the equally important next question of how such regulation might be enforced. This article examines the role played by enforcement in the control of nutrition and health claims. The article examines the prospects for enforcement of the regulation with reference to enforcement theory and practice and previous decisions concerning health and nutrition claims, with particular emphasis on the UK. The use of nutrition and health claims is common ( Caswell et al. 2003 ). An illustration of the extent of the part played by health and nutrition claims is provided by a survey of the Irish food market in 2007. The survey found that some 47% of foods featured a nutrition claim and some 18% a health claim ( Lalor et al., 2010 ). Nutrition and health claims for food can help consumers make well informed choices in relation to their diet ( Leathwood et al. 2007 ). Prior to the regulation there was no harmonised legislation explicitly governing the use of health and nutrition claims in the EU. Member states of the EU were left to control such claims at national level. In the UK there was no regulation specific to health and nutrition claims relating to food; only general control of misleading advertising applicable to all goods and services (see Table 1 below). In some member states the control of health and nutrition claims was the subject of self-regulatory initiatives such as the Joint Health Claims Initiative in the UK and the Swedish Food Sector's Code of Practice on health claims in the labelling and marketing of food products. Experience with the national codes has informed the implementation of the regulation ( Asp & Bryngelsson, 2007 ). Whereas the regulation has provided a comprehensive approach to the control of health and nutrition claims, the same cannot be said for enforcement which remains a matter for member states. The lack of effective enforcement or the differences in the approaches of the member states may jeopardise the aims of the regulation of facilitating cross border trade and providing a high level of consumer protection.

Broad, multispecific CD4 + and CD8 + T-cell responses to the hepatitis C virus (HCV), as well as virus-cross-neutralizing antibodies, are associated with recovery from acute infection and may also be associated in chronic HCV patients with a favorable response to antiviral treatment. In order to recapitulate all of these responses in an ideal vaccine regimen, we have explored the use of recombinant HCV polypeptides combined with various Th1-type adjuvants and replication-defective alphaviral particles encoding HCV proteins in various prime/boost modalities in BALB/c mice. Defective chimeric alphaviral particles derived from the Sindbis and Venezuelan equine encephalitis viruses encoding either the HCV envelope glycoprotein gpE1/gpE2 heterodimer (E1E2) or nonstructural proteins 3, 4, and 5 (NS345) elicited strong CD8 + T-cell responses but low CD4 + T helper responses to these HCV gene products. In contrast, recombinant E1E2 glycoproteins adjuvanted with MF59 containing a CpG oligonucleotide elicited strong CD4 + T helper responses but no CD8 + T-cell responses. A recombinant NS345 polyprotein also stimulated strong CD4 + T helper responses but no CD8 + T-cell responses when adjuvanted with Iscomatrix containing CpG. Optimal elicitation of broad CD4 + and CD8 + T-cell responses to E1E2 and NS345 was obtained by first priming with Th1-adjuvanted proteins and then boosting with chimeric, defective alphaviruses expressing these HCV genes. In addition, this prime/boost regimen resulted in the induction of anti-E1E2 antibodies capable of cross-neutralizing heterologous HCV isolates in vitro. This vaccine formulation and regimen may therefore be optimal in humans for protection against this highly heterogeneous global pathogen.

Although approximately 3 % of the world's population is infected withHepatitis C virus(HCV), there is no prophylactic vaccine available. This study reports the design, cloning and purification of a single polyprotein comprising the HCV core protein and non-structural proteins NS3, NS4a, NS4b, NS5a and NS5b. The immunogenicity of this polyprotein, which was formulated in alum, oil-in-water emulsion MF59 or poly(dl-lactide co-glycolide) in the presence or absence of CpG adjuvant, was then determined in a murine model for induction of B- and T-cell responses. The addition of adjuvants or a delivery system to the HCV polyprotein enhanced serum antibody and T-cell proliferative responses, as well as IFN-γresponses, by CD4+T cells. The antibody responses were mainly against the NS3 and NS5 components of the polyprotein and relatively poor responses were elicited against NS4 and the core components. IFN-γresponses, however, were induced against all of the individual components of the polyprotein. These data suggest that the HCV polyprotein delivered with adjuvants induces broad B- and T-cell responses and could be a vaccine candidate against HCV.

Carboxyfullerene (C60) is known as a photosensitizer for virus inactivation. Its regioisomer with C3 symmetry, named the C3 isomer, could also inactivate the dengue-2 virus without light when the dose of C3 isomer was increased to 40 μM, indicating the possible involvement of a light-independent mechanism. Further analysis showed that the C3 isomer blocked viral replication at the attachment and penetration stages, suggesting that a direct interaction between the C3 isomer and the virion is required for inactivation. The C3 isomer with a bipolar structure showed better lipid interaction and dengue-2 virus suppression than D3, another isomer that contains evenly distributed hydrophilic side chains. Moreover, the C3 isomer selectively inactivated enveloped viruses (viz., dengue-2 virus and Japanese encephalitis virus) instead of nonenveloped viruses (viz., enterovirus 71 and coxsackievirus B3). Collectively, these findings support the hypothesis that C3 isomer suppression of enveloped viruses is effected through its hydrophobic interaction with the viral lipid envelope. Our report, which demonstrates the light-dependent and -independent mechanisms of C60 on viral inactivation, will aid in the development of novel anti-viral agents for use against enveloped viruses.

Elevated serum transaminase levels of dengue patients indicate the possible impact of dengue virus infection on liver function. To elucidate the action of dengue virus infection in liver cells, an in vitro cell line system was established that mimicked the liver status of diverse clinical patients. Briefly, four hepatoma cell lines (HA22T, Huh7, Hep3B, and PLC) and one nonmalignant hepatocyte cell line (Chang liver) were included, representing various levels of tumorigenicity and differentiation. Our data showed that in these five cell lines, dengue-2 virus attached to each cell type equally well; however, this virus had higher replication rates and levels of virion production in differentiated Huh7, PLC, Hep3B, and Chang liver cells. Likewise, a lower replication rate was observed in the de-differentiated HA22T cells. Differentiation-related factors seem to play an important role in dengue virus replication. Further study showed that sodium butyrate (NaB, a differentiation inducer) treatment enhanced dengue virus replication in HA22T cells. Moreover, we found that the severity of morphologic aberration and the increase in aspartate aminotransferase (AST) levels correlated with the virus replication rate in the four infected hepatoma cells. In conclusion, we showed that dengue virus can infect diverse liver cells with differing replication efficiency, which causes cytopathic effects (CPEs) of diverse severity. Among the CPEs, the increased AST levels correlated with the clinical results from 24 dengue fever patients, who showed increased AST levels at the onset of fever. In summary, we find that dengue-2 virus replicates actively and causes severe CPEs in differentiated hepatoma cells. Factors related to differentiation as well as tumorigenicity seem to play critical roles, though the mechanisms of action remain unclear.

Liver is suggested to be the major target of dengue virus infection and plays an important role in the immunopathogenesis of dengue hemorrhagic fever. Previously, we reported that five human liver cell lines (HuH-7, HA22T, Hep3B, PLC, and Chang liver) with various degrees of differentiation and tumorigenicity showed different susceptibility for dengue virus infection. Here, we demonstrate that heparin, an analogue of heparan sulfate (HS), can compete with HS on cell membrane for virus binding and subsequently inhibits the replication of dengue-2 and Japanese encephalitis viruses in hepatoma and BHK-21 cells, respectively. It indicates that the binding of these viruses with HS is an important process for their invasion. Moreover, the inhibitory effect of heparin correlates with the infectivity of the virus in the cells. All together, our results suggest that HS is an important host component for dengue and Japanese encephalitis virus replication, which can be effectively blocked by heparin.

The liver has been suspected to be one of the major targets of dengue virus infection. Here, we detected increasing secretion of the chemokine RANTES (regulated upon activation, normal T cell expressed and secreted), which functions to recruit the immune cells, in dengue-virus-infected liver cells and patients. Three luciferase reporter genes with various deletions at the 5′-end of the RANTES promoter were constructed to explore the RANTES activation mechanism in human liver cells. The reporter gene was optimally activated by dengue-2 virus when the RANTES promoter contains the region from the transcription starting site (+1) to the nucleotide at the −181 position. NF-IL-6 and an undefined factor forming DNA–protein complexes in the RANTES promoter E and A/B regions in the infected cells were demonstrated by electrophoretic mobility shift assay. Further analysis showed that oxidative stress was an upstream inducer of NF-IL-6 and RANTES signaling in dengue-virus-infected liver cells. This finding was demonstrated by three antioxidants (N-acetyl-l-cysteine, nitro-l-arginine methyl ester, and pyrrolidine dithiocarbamate) used to suppress the activation. In contrast, the DNA binding activity of the undefined factor was not affected by the antioxidant treatment, indicating the existence of an oxidant-independent pathway. We hypothesize that dengue virus infection of the liver cells may trigger both an oxidant-dependent and an oxidant-independent pathway to up-regulate RANTES mRNA expression through activating NF-IL-6 and an undefined factor, respectively. In conclusion, the present study suggests a new direction for the study of liver pathogenesis involving RANTES in host immune responses during dengue virus infection.