ACP Conversations with Chinese and South Asian Patients: Physicians' Perspectives of Barriers and Facilitating Factors.

Introduction/Objective: Advance Care Planning (ACP) discussions are infrequently conducted with physicians, even fewer among minorities. We explored physicians' experiences in engaging Chinese (CH) and South Asian (SA) patients in ACP conversations to understand initiation and participation patterns, topics covered, and barriers and facilitating factors. Method: Twenty-two physicians with 15%+ SA patients aged 55+ and 19 with 15%+ CH patients aged 55+ were interviewed. Results: SA- and CH-serving physicians described similar initiation patterns, cultural context, and need for standardized ACP routines. However, the SA-serving physicians described greater involvement of family members, while CH-serving physicians described more communication barriers and family members' desire to hide the diagnosis from patients. Conclusion: Cultural taboos surrounding discussion around death and dying appear to influence CH older adults and families strongly. Lack of familiarity with ACP amongst the SA population accounts more for their limited engagement in ACP discussions.

Primary Care Physicians' and Hospitalists' Experience with Advance Care Planning with South Asian Canadian Older Adults before and during COVID-19.

Few older adults discuss their end-of-life care wishes with their physician, and even fewer minorities do this. We explored physicians' experience with advance care planning (ACP) including the barriers/facilitating factors encountered when initiating/conducting ACP discussions with South Asians (SA), one of Canada's largest minorities. Eleven primary care physicians (PC) and 11 hospitalists with ≥ 15 per cent SA patients ≥ 55 years of age were interviewed: 10 in 2020, 12 in 2021. Thematic analysis of transcripts indicated that cultural and communication barriers, physician's specialization, SA older adults' lack of ACP awareness, and decision-making deference to family and physicians were barriers to ACP discussions. Although the COVID-19 pandemic impacted physicians' practices, contrary to our hypothesis most reported no change in frequency of ACP discussions. Although ACP discussions were viewed as best conducted by PC physicians, only 55 per cent had ACP training and only 64 per cent had used ACP tools. Training in ACP facilitation, concerning ACP tool usage, and training in patient-physician communication are recommended.

Rhomboid Flap Reconstruction for Type 1 Postauricular Variant of Preauricular Sinus.

Preauricular sinuses are common congenital malformations in paediatric patients. We describe a case of preauricular sinus with postauricular extension, a "variant type" of pre-auricular sinus and its management. After control of infection with antibiotics, the sinus was excised in toto using bidirectional approach. The sinus tract along with rim of conchal cartilage and post auricular skin was excised. The defect was reconstructed using retroauricular rhomboid flap. At one month follow up, the post-operative wound showed no signs of infection, minimal scar formation and had satisfactory aesthetic outcome. This reconstruction technique can be considered in cases of defects in posterior pinna.

Ten-year distant-recurrence risk prediction in breast cancer by CanAssist Breast (CAB) in Dutch sub-cohort of the randomized TEAM trial.

BACKGROUND: Hormone receptor (HR)-positive, HER2/neu-negative breast cancers have a sustained risk of recurrence up to 20 years from diagnosis. TEAM (Tamoxifen, Exemestane Adjuvant Multinational) is a large, multi-country, phase III trial that randomized 9776 women for the use of hormonal therapy. Of these 2754 were Dutch patients. The current study aims for the first time to correlate the ten-year clinical outcomes with predictions by CanAssist Breast (CAB)-a prognostic test developed in South East Asia, on a Dutch sub-cohort that participated in the TEAM. The total Dutch TEAM cohort and the current Dutch sub-cohort were almost similar with respect to patient age and tumor anatomical features. METHODS: Of the 2754 patients from the Netherlands, which are part of the original TEAM trial, 592 patients' samples were available with Leiden University Medical Center (LUMC). The risk stratification of CAB was correlated with outcomes of patients using logistic regression approaches entailing Kaplan-Meier survival curves, univariate and multivariate cox-regression hazards model. We used hazard ratios (HRs), the cumulative incidence of distant metastasis/death due to breast cancer (DM), and distant recurrence-free interval (DRFi) for assessment. RESULTS: Out of 433 patients finally included, the majority, 68.4% had lymph node-positive disease, while only a minority received chemotherapy (20.8%) in addition to endocrine therapy. CAB stratified 67.5% of the total cohort as low-risk [DM = 11.5% (95% CI, 7.6-15.2)] and 32.5% as high-risk [DM = 30.2% (95% CI, 21.9-37.6)] with an HR of 2.90 (95% CI, 1.75-4.80; P < 0.001) at ten years. CAB risk score was an independent prognostic factor in the consideration of clinical parameters in multivariate analysis. At ten years, CAB high-risk had the worst DRFi of 69.8%, CAB low-risk in the exemestane monotherapy arm had the best DRFi of 92.7% [vs CAB high-risk, HR, 0.21 (95% CI, 0.11-0.43), P < 0.001], and CAB low-risk in the sequential arm had a DRFi of 84.2% [vs CAB high-risk, HR, 0.48 (95% CI, 0.28-0.82), P = 0.009]. CONCLUSIONS: Cost-effective CAB is a statistically robust prognostic and predictive tool for ten-year DM for postmenopausal women with HR+/HER2-, early breast cancer. CAB low-risk patients who received exemestane monotherapy had an excellent ten-year DRFi.

A comparative analysis of recurrence risk predictions in ER+/HER2- early breast cancer using NHS Nottingham Prognostic Index, PREDICT, and CanAssist Breast.

AIMS: Clinicians use multi-gene/biomarker prognostic tests and free online tools to optimize treatment in early ER+/HER2- breast cancer. Here we report the comparison of recurrence risk predictions by CanAssist Breast (CAB), Nottingham Prognostic Index (NPI), and PREDICT along with the differences in the performance of these tests across Indian and European cohorts. METHODS: Current study used a retrospective cohort of 1474 patients from Europe, India, and USA. NPI risk groups were categorized into three prognostic groups, good (GPG-NPI index ≤ 3.4) moderate (MPG 3.41-5.4), and poor (PPG > 5.4). Patients with chemotherapy benefit of < 2% were low-risk and ≥ 2% high-risk by PREDICT. We assessed the agreement between the CAB and NPI/PREDICT risk groups by kappa coefficient. RESULTS: Risk proportions generated by all tools were: CAB low:high 74:26; NPI good:moderate:poor prognostic group- 38:55:7; PREDICT low:high 63:37. Overall, there was a fair agreement between CAB and NPI[κ = 0.31(0.278-0.346)]/PREDICT [κ = 0.398 (0.35-0.446)], with a concordance of 97%/88% between CAB and NPI/PREDICT low-risk categories. 65% of NPI-MPG patients were called low-risk by CAB. From PREDICT high-risk patients CAB segregated 51% as low-risk, thus preventing over-treatment in these patients. In cohorts (European) with a higher number of T1N0 patients, NPI/PREDICT segregated more as LR compared to CAB, suggesting that T1N0 patients with aggressive biology are missed out by online tools but not by the CAB. CONCLUSION: Data shows the use of CAB in early breast cancer overall and specifically in NPI-MPG and PREDICT high-risk patients for making accurate decisions on chemotherapy use. CAB provided unbiased risk stratification across cohorts of various geographies with minimal impact by clinical parameters.

Applicability of moyer's probability tables in north indian population of 16-18 years old.

AIMS: To determine the applicability of Moyer's probability tables in North Indian population of 16-18 year olds and to formulate a new regression equation for the same group of population. SETTING AND DESIGN: Evaluative Study. METHODS AND MATERIAL: 1000 children aged 16-18 years were selected as sample for the measurement of mesiodistal widths of permanent mandibular incisors, maxillary and mandibular canines and premolars using study models. The recorded values were then subjected to statistical analysis. STATISTICAL ANALYSIS USED: Software Package for Social Sciences (SPSS) software version 22.0. RESULTS: The actual widths of the canine and premolars showed highly significant differences in maxilla and in mandible (P < 0.001), compared to widths predicted by Moyer's probability table at 75th percentile. CONCLUSION: Moyer's mixed dentition analysis was not an accurate method for prediction in North Indian population as it showed overestimation of tooth sizes. Hence, new regression equation has been formulated for the same.

Pilot Study of a Digital Screen-Based Calming Device for Managing Resistance During Morning and Evening Care of Persons With Dementia.

Resistance to care is among the most common behaviors exhibited by persons with dementia (PwD). Resistance to care is a barrier to safety and comfort of PwD and caregivers. Nonpharmacological interventions are recommended as first-line management. In the current study, 13 long-term care (LTC) residents aged 74 to 100 years with a history of behavioral and psychological symptoms of dementia (BPSD) were randomized to intervention (n = 7) and control (n = 6) groups. On Days 1 to 3, the intervention group received usual care plus exposure to MindfulGarden (MG), a novel digital calming device during morning and evening care, activities widely recognized as problematic for PwD and staff; the control group received usual care only. On Day 4, both groups were exposed to MG with verbal prompting. Trends in the data suggest that MG reduced BPSD and duration of care in the morning and may be a useful tool in management of resistance to routine care in PwD in LTC settings. [Journal of Gerontological Nursing, 47(11), 15-21.].

Network resilience of FitzHugh-Nagumo neurons in the presence of nonequilibrium dynamics.

Many complex networks are known to exhibit sudden transitions between alternative steady states with contrasting properties. Such a sudden transition demonstrates a network's resilience, which is the ability of a system to persist in the face of perturbations. Most of the research on network resilience has focused on the transition from one equilibrium state to an alternative equilibrium state. Although the presence of nonequilibrium dynamics in some nodes may advance or delay sudden transitions in networks and give early warning signals of an impending collapse, it has not been studied much in the context of network resilience. Here we bridge this gap by studying a neuronal network model with diverse topologies, in which nonequilibrium dynamics may appear in the network even before the transition to a resting state from an active state in response to environmental stress deteriorating their external conditions. We find that the percentage of uncoupled nodes exhibiting nonequilibrium dynamics plays a vital role in determining the network's transition type. We show that a higher proportion of nodes with nonequilibrium dynamics can delay the tipping and increase networks' resilience against environmental stress, irrespective of their topology. Further, predictability of an upcoming transition weakens, as the network topology moves from regular to disordered.

A Novel Intervention for Management of Behavioral and Psychological Symptoms of Dementia in Nursing Home Communal Areas: Results of a Small-Scale Pilot Trial.

BACKGROUND: Behavioral and psychological symptoms of dementia (BPSD) exhibited by persons with dementia (PwD) in nursing home communal areas are generally managed by segregation and/or pharmacological interventions. OBJECTIVE: This study trialed MindfulGarden (MG), a novel digital calming device, in a Canadian nursing home. METHODS: Participants were 15 PwD (mean age = 87.67; 5m,10f; mean MMSE = 11.64±7.85). Each was observed by a research assistant (RA) for an average of 8-10 hours on two separate days. The RA followed them during time spent in communal areas of the nursing home including their unit's dining space, lounges, and corridors and spaces shared with other units (e.g., gym and gift shop) and documented any BPSD exhibited. Day-1 provided baseline data; on Day-2, residents were exposed to MG if nursing staff considered their BPSD were sufficiently intense or sustained to warrant intervention. Staff rated the impact as positive, neutral, or negative. RESULTS: On Day-1, 9 participants exhibited both aggressive and non-aggressive behaviors, 4 non-aggressive behaviors only, and 2 no BPSD. On Day-2, 7 exhibiting aggressive behaviors were exposed to MG. Staff reported MG as having distracting/calming effects and gave positive impact ratings to 6/13 exposures; there were no negative ratings. The most common aggressive BPSD on days of observation were pushing/shoving and screaming. CONCLUSION: MG may have value as a "psychiatric crash cart" in de-escalating agitation and aggression in care home settings.

Anticipating the Novel Coronavirus Disease (COVID-19) Pandemic.

The COVID-19 outbreak was first declared an international public health, and it was later deemed a pandemic. In most countries, the COVID-19 incidence curve rises sharply over a short period of time, suggesting a transition from a disease-free (or low-burden disease) equilibrium state to a sustained infected (or high-burden disease) state. Such a transition is often known to exhibit characteristics of "critical slowing down." Critical slowing down can be, in general, successfully detected using many statistical measures, such as variance, lag-1 autocorrelation, density ratio, and skewness. Here, we report an empirical test of this phenomena on the COVID-19 datasets of nine countries, including India, China, and the United States. For most of the datasets, increases in variance and autocorrelation predict the onset of a critical transition. Our analysis suggests two key features in predicting the COVID-19 incidence curve for a specific country: (a) the timing of strict social distancing and/or lockdown interventions implemented and (b) the fraction of a nation's population being affected by COVID-19 at that time. Furthermore, using satellite data of nitrogen dioxide as an indicator of lockdown efficacy, we found that countries where lockdown was implemented early and firmly have been successful in reducing COVID-19 spread. These results are essential for designing effective strategies to control the spread/resurgence of infectious pandemics.

Experimental measurement of effective atomic numbers and albedo factors for some alloys using the backscattering technique.

Alloys of the type Pb60Sn20ZnxCd(20-x) where x = 0, 5, 10, 15 or 20 were prepared by a conventional melt quench technique. The intensity distribution of backscattered photons from the radioactive isotopes 22Na and 137Cs (with photon energies of 511 keV and 662 keV, respectively) were recorded for different thicknesses of alloy samples and some metallic samples (Al, Zn, Sn and Pb) with use of a GAMMA-RAD5 spectrometer (76 mm × 76 mm NaI(Tl) scintillation detector). Backscattered photon intensities were plotted as a function of both the atomic number and the target thickness. A best fit curve was drawn between backscattered photon counts and the atomic number of the metallic samples, from which the effective atomic numbers (Zeff) of the alloys were obtained at a particular photon energy as well as thickness. The experimentally obtained Zeff values are in good agreement with the theoretical ones (based on mass attenuation coefficients from the WinXCom database). The plot of intensity versus thickness shows that the intensity of backscattered photons increases with sample thickness. The albedo factors (energy albedo, number albedo and dose albedo) were also determined experimentally at these photon energies for the alloys and metallic samples. In the Compton scattering dominant region, the albedo factors decrease with an increase in atomic number as well as with an increase in photon energy.

Long-range dispersal promotes species persistence in climate extremes.

Anthropogenic global warming in this century can act as a leading factor for large scale species extinctions in the near future. Species, in order to survive, need to develop dispersal strategies depending upon their environmental niche. Based on empirical evidence only a few previous studies have addressed how dispersal can evolve with changing temperature. However, for the analytical tractability, there is a need to develop an explicit model to ask how the temperature-dependent dispersal alters ecological dynamics. We investigate the persistence of species in a spatial ecological model, where dispersal is considered as a function of temperature. Spatial persistence is of major concern and dispersal is reasonably an important factor for extinction risk in the context of promoting synchrony. Our study yields how the temperature influences species decision of dispersal, resulting in either short-range or long-range dispersal. We examine synchronous or asynchronous behavior of species under their thermal dependence of dispersal. Moreover, we also analyze the transients to study the collective behavior of species away from their final or asymptotic dynamics. One of the key findings is at the most unfavorable environmental conditions long-range dispersal works out as the driving force for the persistence of species.

Ferulic Acid Supplementation for Management of Depression in Epilepsy.

Neuroinflammation driven altered neurochemical milieu have been reported to play a significant role in pathogenesis of comorbid depression in epilepsy. Most of the antiepileptic drugs (AEDs) such as levetiracetam, taigabine, topiramate have not been reported any significant effect in alleviating neuroinflammation, which may explain their ineffectiveness in ameliorating depression associated with epilepsy. The supplementation of antidepressants (ADs) attracts various pharmacokinetic and pharmacodynamic interactions with AEDs and was considered unsafe in epilepsy. This scenario pushes us to search therapies beyond ADs by critically exploring the disease mechanism. Thus, as suggested by our previous findings, anti-inflammatory phytotherapy (Ferulic acid) appears a promising adjuvant therapy with levetiracetam for effective and safe management of depression associated with epilepsy. Pentylenetetrazole kindling induced epileptic animals were treated with vehicle, levetiracetam (40 mg/kg/day i.p.) and levetiracetam in combination with two doses of ferulic acid (40, 80 mg/kg)/day/p.o. for 15 days. Every 5th day during the treatment, depression was evaluated and animals were administered pentylenetetrazole to evaluate the effect of different pharmacological interventions on seizure severity. The epileptic animals were reported decreased seizure threshold associated with comorbid depression. The treatment with levetiracetam was found ineffective in ameliorating the associated depression. However ferulic acid supplementation with levetiracetam ameliorated comorbid depression supported with restored circulating corticosterone levels, decreased proinflammatory cytokines (IL-1ß, TNF-α) and indoleamine 2,3-dioxygenase activity in mice brain. Thus, suggesting supplementation of anti-inflammatory phytomolecules such as ferulic acid as safe and effective adjuvant therapy for the management of comorbid depression in epilepsy.

Adjuvant quercetin therapy for combined treatment of epilepsy and comorbid depression.

Epilepsy is one of the major neurological disorders frequently associated with psychiatric disorders such as depression. The predisposition of tryptophan metabolism towards kynurenine pathway has been reported as one of the plausible reasons for association of depression in epilepsy. Hence, this study was envisaged to evaluate the dose dependent inhibition of indoleamine 2,3-dioxygenase (IDO) enzyme employing quercetin (screened employing in vitro method) with levetiracetam for combined management of epilepsy and comorbid depression. Kindling was induced in male swiss albino mice by administration of pentylenetetrazole subconvulsive doses (35 mg/kg, i.p.) at an interval of 48 ± 2 h. Kindled animals were treated with vehicle, levetiracetam (40 mg/kg/day i.p.) levetiracetam in combination with different doses of quercetin (10 mg/kg; 20 mg/kg; 40 mg/kg)/day/p.o. for 15 days. Except naïve, all the groups were challenged with pentylenetetrazole (35 mg/kg i.p.) on day 5, 10, and 15 to evaluate the seizure severity score. Depression was evaluated in all experimental groups using the tail suspension and sucrose preference test on days 1, 5, 10 and 15, 2 h after pentylenetetrazole challenge. Results suggested that vehicle treated kindled animals were significantly associated with depression. Chronic levetiracetam treatment significantly reduced seizure severity score, but further worsened the associated depression. Quercetin supplementation with levetiracetam dose dependently ameliorated depression associated with epilepsy. Neurochemical and biochemical findings also supported the behavioural findings of the study. Thus, our results suggested that supplementation of quercetin with levetiracetam could be explored further for combined treatment of epilepsy and comorbid depression.

Dentistry to the rescue of missing children: A review.

Today's society is becoming increasingly unsafe for children: we frequently hear about new incidents of missing children, which lead to emotional trauma for the loved ones and expose systemic failures of law and order. Parents can take extra precautions to ensure the safety of their children by educating them about ways to protect themselves and keep important records of the child such as updated color photographs, fingerprints, deoxyribonucleic acid (DNA) samples, etc., handy. However, in spite of all efforts, the problem of missing children still remains. Developments in the field of dentistry have empowered dentists with various tools and techniques to play a pivotal role in tracing a missing child. One such tool is Toothprints, a patented arch-shaped thermoplastic dental impression wafer developed by Dr. David Tesini, a paediatric dentist from Massachusetts. Toothprints enables a unique identification of the missing children not only through the bite impression but also through salivary DNA. Besides the use of Toothprints, a dentist can assist investigating agencies in identifying the missing children in multiple ways, including postmortem dental profiling, labeled dental fixtures, DNA extraction from teeth, and serial number engraving on the children's teeth. More importantly, all these tools cause minimal inconvenience to the individual, making a dentist's role in tracking a missing child even more significant. Thus, the simple discipline of maintaining timely dental records with the help of their dentists can save potential hassles for the parents in the future.

Avaliação comparativa do Carisolv na remoção da dentina cariada em molares decíduos: estudo in vitro / Comparative evaluation of Carisolv in removal of carious dentin in primary molar teeth: in vitro study

Objetivo: Avaliar e comparar a eficiência e efetividade do Carisolv na remoção de tecido cariado em molares decíduos. Método: Trinta molares decíduos cariados foram seccionados mésio-distalmente e obtidos 60 espécimes. O Carisolv foi utilizado para remoção do tecido cariado nas 30 seções as quais foram denominadas de Grupo Experimental (GE) e nas 30 seções restantes executou-se a remoção convencional, sendo denominado de Grupo Controle (GC). O tempo gasto para a remoção foi registrado (em minutos) e comparado entre os grupos. Todas as amostras foram analisadas quanto à quantidade de dentina desminaralizada remanescente sob estereomicroscópio. O valores foram registrados em microns. A quantidade de tecido cariado remanescente foi verificada por meio da aplicação de corantes detectores de cárie. Em seguida, a dureza da dentina remanescente foi analisada através da dureza Vicker's, sendo realizada a comparação entre os grupos através do uso do Teste T de Student. Resultados: Verificou-se que os valores médios para a remoção da dentina cariada mostraram-se estatisticamente significante e maiores para o Carisolv (GE) quando comparado à remoção convencional (GC). Ademais, observou-se que a remoção com o Carisolv deixa muito mais quantidade de dentina desmineralizada e a camada de dentina apresenta menor dureza quando comparada à remoção convencional. Conclusão: Carisolv mostrou-se menos efetivo e eficiente quando comparado à remoção de tecido cariado convencional que demanda maior tempo para remoção do tecido cariado. Além do mais, a remoção com Carisolv deixa maior quantidade de dentina desmineralizada, a qual possui menor dureza do que as amostras obtidas com a remoção convencional.

Bilateral fusion of permanent mandibular incisors with Talon's cusp: A rare case report.

Whenever nature diverts from the "normal or usual" it gives rise to something called "abnormal or unusual," which we call "a Disorder". Fusion of two teeth is a common developmental disorder that is seen by a clinician. However, bilateral fusion along with Talon's cusp is very rarely seen and reported in literature. This article describes a rare case of the bilateral fusion of permanent mandibular central and lateral incisors, along with presence of Talon's cusp on the left fused teeth.