A tabletop exercise approach to global disaster preparedness: insights from Nepal's first international conference on disaster preparedness and management.

Considering recent earthquakes and the COVID-19 pandemic, disaster preparedness has come to the forefront of the public health agenda in Nepal. To strengthen the developing health system, many initiatives are being implemented at different levels of society to build resiliency, one of which is through training and education. The first International Conference on Disaster Preparedness and Management convened in Dhulikhel, Nepal on December 1-3, 2023. It brought together international teaching faculty to help deliver didactic and simulation-based sessions on various topics pertaining to disaster preparedness and management for over 140 Nepali healthcare professionals. This paper focuses on the tabletop exercise-based longitudinal workshop portion of the conference on disaster leadership and communication, delivered by United States-based faculty. It delves into the educational program and curriculum, delivery method, Nepali organizer and US facilitator reflections, and provides recommendations for such future conferences, and adaptation to other settings.

Exploring deep caries management and barriers to the use of vital pulp treatments by primary care dental practitioners.

AIM: The European Society of Endodontology outlines best practices for the management of deep caries and the pulp. Despite evidence supporting vital pulp treatments (VPTs) as predictable alternatives to conventional endodontic treatment, studies have shown they are not widely adopted in the UK. This study aimed to explore the barriers to implementation of VPTs by primary care general dental practitioners (GDPs). METHODOLOGY: Qualitative one-to-one semi-structured online interviews were conducted with purposively sampled UK GDPs. Interview transcripts were analysed using reflexive thematic analysis. Recurring themes were iteratively refined as additional transcripts were reviewed. RESULTS: Eleven participants were interviewed. A range of barriers to the provision of VPTs were identified, which aligned with two core themes: 'Motivational barriers to service provision' and 'Educational access & opportunities'. Sub-themes included lack of access to materials and equipment, deficiencies in knowledge of treatment (including protocols, outcomes and prognosis), lack of confidence (in treatment efficacy and clinical ability), time constraints and public dental service funding and remuneration. CONCLUSIONS: This study identifies barriers to the widespread adoption of VPTs among primary care GDPs in public and private settings. Economic constraints, practitioner confidence, time limitations and educational gaps are key challenges. Addressing these may require systemic changes such as policy interventions, education and improved resource allocation.

Evidence for the presence of Borrelia burgdorferi in invasive breast cancer tissues.

Borrelia burgdorferi, the causative agent of Lyme disease, has recently been demonstrated to infect and enhance the invasive properties of breast cancer cells, while also influencing the expression of inflammatory chemokines (CXCL8 and CXCL10). This study investigates the presence of B. burgdorferi in invasive breast cancer tissues using commercially available, FDA-approved breast cancer tissue microarrays consisting of 350 ductal, 32 lobular, and 22 intraductal invasive breast carcinomas, alongside 29 normal breast tissues. Employing fluorescent immunohistochemical staining and high-resolution imaging, the findings revealed that approximately 20% of invasive lobular and ductal carcinomas, followed by 14% of intraductal carcinomas, tested positive for B. burgdorferi, while all normal breast tissues tested negative. PCR analysis further confirmed the presence of B. burgdorferi DNA in breast cancer tissues. Moreover, 25% of B. burgdorferi-positive tissues exhibited expression of both chemokines, CXCL8 and CXCL10, which was not observed in B. burgdorferi-negative tissues. Analysis of available patient data, including age, indicated a correlation between older patients and B. burgdorferi-positive tissues. This study validates the presence of B. burgdorferi in invasive breast cancer tissues and highlights the involvement of key CXCL family members associated with inflammatory processes.

A study on histological grading systems of oral squamous cell carcinoma and comparison of their efficacy in determining the nature (clinical and histopathological) and prognosis of oral squamous cell carcinoma.

Purpose: Tumour-Node-Metastasis (TNM) staging has been widely used for treatment planning and prognostication of oral cancers; however, TNM staging system alone is insufficient for optimal prognostication. A combined assessment of clinical staging and cytomorphology might serve as a more specific measure for prognostication. The present study attempted to compare the efficacy of histologic grading systems (Jakobbson et al., Anneroth et al. and Bryne et al.) of malignancy in determining the nature and prognosis of oral squamous cell carcinoma (OSCC). Tumour protein (TP53) immunohistochemical marker was used to determine the aggressiveness of OSCC. Materials and Methods: Tissue sections from 24 biopsy-proven cases of OSCC were stained with anti-TP53 antibody. Hundred cells in each case were counted and tabulated. Cases were graded using three histopathological grading systems. Findings were compared and correlated with TP53 immunopositivity and clinical parameters. Results: Positive correlation was observed between TP53 immunostaining and grading scores of each system. Highest correlation was observed with Jakobbson et al. grading system (r2 value = 0.91, P < 0.001). Significant results were observed on comparing grades of Jakobsson et al., Anneroth et al. and Bryne et al. grading system with segregated groups of TP53 immunopositive cases (P = 0.004, P = 0.003, P = 0.001, respectively). No significant results were observed on comparing grades of histopathological systems with clinical parameters. Conclusion: Both, clinical and histopathological grading systems, with immunohistochemistry, should be taken into account during the assessment of OSCC, for treatment planning and better prediction of tumour prognosis.

Mental health and inclusivity support and education in a UK dental school: a cross-sectional survey.

Aims To establish the current support and knowledge around mental health and equality, diversity and inclusion at a UK Dental School and make suggestions about improvements.Objectives Conduct a survey of dental undergraduate students at Newcastle Dental School to elicit responsesMethods Bachelor of Dental Surgery and Bachelor of Oral and Dental Health Science students at Newcastle University were invited to participate in this cross-sectional survey via email. Following electronic consent, an electronic questionnaire via an online form builder was distributed via email. Participants were asked questions on experiences and feelings towards wellbeing support, mental health and equality, diversity and inclusion topics, including improvements that could be made.Results In total, 89 students participated. The majority of participants were white, women and heterosexual. Wellbeing support was present and generally accessible. Students were aware of mental health conditions but unsure how to manage them in a clinical setting. Students were generally unaware of barriers to care faced by LGBT+ and racialised minority patients. Students were mainly uncomfortable disclosing personal issues with their personal tutor. Students responded positively to some suggested improvements in support and education surrounding mental health and inclusivity.Conclusion Our study highlighted the areas where Newcastle Dental School continues to provide high levels of support for students but also areas that may require attention through further study and focus groups, with an aim to increase diversity of respondents so that further exploration regarding the intersectionality of identity can be undertaken.

Emergency Medicine Residents' Perceptions of Working and Training in a Pandemic Epicenter: A Qualitative Analysis.

INTRODUCTION: We sought to describe the range of emergency medicine (EM) resident physicians' perceptions and experiences of working and training during the initial coronavirus 2019 (COVID-19) pandemic surge at two, large-volume, urban training hospitals in Brooklyn, New York. METHODS: A total of 25 EM resident physicians who worked at either of two large emergency departments (ED) from March 15-April 11, 2020 participated in semi-structured interviews conducted in July and August 2020. Interviews were conducted by the authors who were also emergency medicine resident physicians working in the ED during this time. We asked open-ended questions to residents about their experiences and emotions at work and outside of work, including their relationship with co-workers, patients, and their community. The interviews were audio-recorded and transcribed. We then conducted a thematic analysis to identify, classify, and define themes from interview transcripts. Iterative commonalities and differences between interview response themes were grouped to create a broadly applicable narrative of the residents' perceptions and experiences of working and training during this initial wave of a novel pandemic. Interviewees also responded to a demographics survey. RESULTS: Study participants described four major aspects of their perceptions and experiences of working and training during the stated time, including emotional challenges such as anxiety and feeling underappreciated; protective thoughts, including camaraderie, and sense of duty; workplace challenges such as limited knowledge surrounding COVID-19 and a higher volume of acute patients; and adaptive strategies including increased communication with ED administrators. CONCLUSION: Emergency medicine residents have a unique perspective and were key frontline hospital responders during a prolonged disaster and mass triage event within a local health system. Considering the chronic case and mortality fluctuations and new variants of COVID-19, as well as the anticipation of future infectious disease pandemics, we believe it is important for key decision-makers in resident education, hospital administration, and all levels of public health management to inform themselves about residents' emotional and workplace challenges when establishing hospital and residency program disaster protocols.

Language diversity and challenges to communication in Indian emergency departments.

BACKGROUND: Communication in emergency departments (ED) in India is complicated by the country's immense language diversity. Prior research has revealed challenges in language and communication as barriers to care. Our objective was to quantify language diversity among clinicians in Indian EDs and better understand issues related to clinician-clinician and clinician-patient communication. METHODOLOGY: A cross-sectional survey of ED clinicians was conducted. Survey participants were recruited in-person and through email at six partner sites in India. ANOVA and binary logistic regression were used for subgroup analysis. Semi-structured interviews were conducted with ED clinicians. Interview data was analyzed using the rapid assessment process to determine predominant themes. RESULTS: 106 clinicians completed the survey. On average, clinicians spoke 3.75 languages. Seventy-one percent used a non-English language to speak to fellow clinicians most of the time, and 53% reported at least one critical incident over the last year where poor communication played a part. Interviews revealed challenges including low health literacy, high patient volume, and workplace hierarchy. CONCLUSIONS: This study is the first to document the impact of language diversity and communication barriers in Indian EDs. The results highlight the need for effective strategies to improve communication between the multiple languages spoken by clinicians and patients.

A correlation of immunohistochemical expression of TP53 and severity of inflammation with varying grades of oral squamous cell carcinoma.

PURPOSE: Epithelial cells exposed to carcinogens and genetic damage, once surpass reversible cell damage, either undergo apoptosis or transform into malignancy, chiefly oral squamous cell carcinoma (OSCC). Progressive accumulation of genetic errors in TP53 results in tumorigenesis. Inflammation is also a modulator in this process. The present study attempted to correlate the immunohistochemical expression of TP53 with increased aggressiveness of OSCC, to determine how these immune cells regulate the path of carcinogenesis and to define the role of inflammation in TP53 immunoexpression. MATERIALS AND METHODS: Tissue sections from 24 biopsy-proven cases of OSCC were stained with anti-TP53 antibody. Five hundred neoplastic epithelial cells and inflammatory cells, each, were counted at invasive tumor front. Two hundred peritumoral neutrophils were counted based on nuclear lobes present. RESULTS: The least TP53 expression was seen in well-differentiated OSCC (P < 0.001), whereas neutrophil count and plasma cell count were found to be least in well-differentiated OSCC (P < 0.001), whereas the number of lymphocytes and macrophages decreased with increased grading of OSCC (P < 0.001). Four- and five-lobed neutrophils were found to be highest in poorly differentiated OSCC (P < 0.001), whereas two-lobed neutrophil count was seen to be maximum in well-differentiated OSCC (P < 0.001). CONCLUSION: TP53 plays a significant role in the initiation and progression of OSCC. Inflammation plays a role of friend and a foe simultaneously, and little modification in the present treatment modalities for OSCC can bring a favorable change in the life of cancer survivors.

Identification of Patients with Osteoporotic Vertebral Fractures via Simple Text Search of Routine Radiology Reports.

Secondary fracture prevention programs mostly identify patients with symptomatic non-vertebral fractures, whereas asymptomatic vertebral fractures are usually missed. We here describe the development and validation of a simple method to systematically identify patients with radiographic vertebral fractures using simple text-based searching of free-text radiology reports. The study consisted of two phases. In the development phase (DP), twelve search terms were used to identify vertebral fractures in all X-ray and CT reports issued over a period of 6 months. Positive reports were manually reviewed to confirm whether or not a vertebral fracture had in fact been reported. The three search terms most effective in detecting vertebral fractures during the DP were then applied during the implementation phase (IP) over several weeks to test their ability to identify patients with vertebral fractures. The search terms 'Loss of Height' (LoH), 'Compression Fracture' (CoF) and 'Crush Fracture' (CrF) identified the highest number of imaging reports with a confirmed vertebral fracture. These three search terms identified 581 of 689 (84%) of all true vertebral fractures with a positive predictive value of 76%. Using these three terms in the IP, 126 reports were identified of which 100 (79%) had a vertebral fracture confirmed on manual review. Amongst a sample of 587 reports in week 1 of the IP, 7 (1.2%) were false negatives. Many patients with vertebral fractures can be identified via a simple text-based search of electronic radiology reports. This method may be utilised by secondary fracture prevention programs to narrow the 'care gap' in osteoporosis management.

Management of rotator cuff tears in the elderly population.

Rotator cuff tears (RCTs) are a common cause of shoulder pain and weakness in the elderly (age > 65yrs) and result in reduced quality of life, loss of income and a burden on health care. With the elderly population living longer there is a growing interest in the effective and efficient management of RCTs. In a majority of cases, the initial treatment is conservative, with physical therapy, analgesics and possibly corticosteroid or plasma rich protein injections. There are various surgical options, including rotator cuff repair, superior capsule reconstruction, subacromial decompression and reverse shoulder arthroplasty. The aim of this article is to provide a narrative review of evidence guiding the management options for RCTs in the elderly.

A correlation of immunohistochemical expression of TP53 and CDKN1A in oral epithelial dysplasia and oral squamous cell carcinoma.

PURPOSE: Oral epithelial dysplasia (OED) occurs on exposure of epithelial cells to carcinogens and genetic alteration. Once the reversible cell damage is surpassed, cells either undergo apoptosis or transform into malignancy, chiefly oral squamous cell carcinoma (OSCC). Progressive accumulation of genetic errors (including mutations in TP53 and CDKN1A) is associated with the initiation and progression of potentially malignant oral lesions toward frank malignancy. The present study attempted to correlate the immunohistochemical expression of CDKN1A and TP53 with increasing severity of OED along with increased aggressiveness of OSCC as reflected in the clinicopathologic variables. MATERIALS AND METHODS: Tissue sections from forty biopsy-proven cases of OED and OSCC were stained with anti-TP53 and anti-CDKN1A mouse monoclonal antibodies. One hundred cells in each case were counted under high power magnification. RESULTS: Poorly differentiated OSCC showed the highest TP53 expression (mean = 70.285), with least expression seen in mild dysplasia (mean = 22.125) (P < 0.001). Higher TP53 count was seen in cases with margin involvement, without recurrence and lymph node involvement and in cases which died of disease. CDKN1A expression was seen only in five cases and that too focally in the cytoplasm, thereby warranting removal of analysis of CDKN1A positivity from the study. CONCLUSION: The expression of TP53 in OED highlights its role in initial carcinogenesis. Although the role of CDKN1A in the cell cycle has been documented, its relationship to various clinical and pathological variables of OSCC and its different treatment modalities could not be adequately assessed.

Acute arthritis: predictive factors and current practice in the approach to diagnosis and management across two hospitals in Sydney.

BACKGROUND: Literature pertaining to the predictive factors for septic arthritis is limited. AIMS: The primary objective was to investigate the predictive factors for septic arthritis. The secondary objectives were to investigate the predictive factors for crystal arthritis and to explore current practices in the management of acute arthritis. METHODS: A retrospective analysis was undertaken. All patients with an acute arthritis who underwent a joint aspiration for diagnostic and management purposes were considered for inclusion. The outcome measures were patient demographics, findings on physical examination, findings on blood and synovial fluid analysis and management. RESULTS: Of the patients who presented with an acute arthritis, 24 of the 172 joint aspirations undertaken were positive for bacteria (13.95%). Of the 172 joint aspirations, 90 were positive for crystals (52.33%). Investigated variables associated with increased risk for the presence of bacteria on synovial fluid included features of sepsis (P < 0.001), joint-restricted range of motion (P = 0.048), elevated C-reactive protein (P < 0.001) and elevated total leukocyte count on synovial fluid (P < 0.001). Of the 24 joint aspirations that were positive for bacteria, 13 had associated positive blood cultures (54.17%). Of the 172 joint aspirations, antibiotics were administered in 96 cases (55.81%). Of these, antibiotics were administered prior to joint aspiration in 41 cases (42.71%). CONCLUSIONS: In our study, the most common cause of acute arthritis was crystal arthropathy. An accurate physical examination in conjunction with synovial fluid analysis is of particular importance in diagnosing septic arthritis. Blood cultures are not a reliable substitute for joint aspiration but should nevertheless be undertaken.

Shoulder replacement for osteoarthritis: A review of surgical management.

Osteoarthritis of the shoulder is caused by progressive cartilage wear of the glenohumeral joint. Its prevalence is increasing due to our ageing population and it may affect up to one-third of people over 60 years of age. Patients usually complain of pain with restricted shoulder movement and function. Initial treatment should be non-operative, such as activity modification, oral analgesics (e.g. non-steroidal anti-inflammatories) and possibly physical therapy or corticosteroid injections. Patients with ongoing severe pain and functional restriction despite non-operative treatment would be candidates for surgery, usually a shoulder replacement. There are various forms of shoulder replacements and the aim of this review is to discuss the types available, the indications for using one over another and recent worldwide trends in the use of shoulder replacements.

Nuclear Fractal Dimensions as a Tool for Prognostication of Oral Squamous Cell Carcinoma.

BACKGROUND: Carcinogenesis follows complex molecular alterations, which are triggered by subtle chromatin architectural changes that are imperceptible to the human eye. As the treatment decisions in Oral Squamous Cell Carcinoma (OSCC) are hindered by the imprecise clinical stage determination and inter-observer variability in histological grading, focus in recent years has shifted to discovering identifiers related to neoplastic cell morphology studied through computer-aided image analysis. One such approach is the assessment of fractal geometry, a technique first described by Mandelbrot, which aids in precise assessment of architecture of natural objects. Assessment and quantification of degree of complexity of these fractal objects (self-similarities in structural complexity at different magnifying scales) is described as fractal dimension (FD). AIM: To evaluate the nuclear fractal dimension (NFD) in OSCC using computer-aided image analysis. MATERIALS AND METHODS: Histological sections of 14 selected cases of Oral Squamous Cell Carcinoma (OSCC) and 6 samples of normal buccal mucosa (as control) were stained with Haematoxylin-Eosin and Feulgen stain for histopathological examination and evaluation of nuclear complexity respectively. Fifteen HPF at Invasive Tumour Front (ITF) and Tumour Proper (TP) of Feulgen-stained sections were selected and photographed in test and control samples. At ITF, TP and normal buccal mucosa 200 nuclei each were selected and analyzed using Image J software to quantify FD. The test and control groups were compared statistically using Independent sample t-test and One-way ANOVA. RESULTS: Nuclear FD increased progressively towards worst tumour staging as compared to normal buccal mucosa. CONCLUSION: Nuclear FD can be considered for quantification of nuclear architectural changes as a prognostic indicator in OSCC.

Driving the Mineral out Faster: Simple Modifications of the Decalcification Technique.

INTRODUCTION: Quicker decalcification is essential for faster diagnosis of hard tissue pathology. Heat and mechanical agitation are known to hasten decalcification. AIM: To compare the rate of decalcification, cellular and staining characteristics of decalcified specimens of bone and teeth by using the conventional method (10% formal formic acid), heating to 45(o)C and by physical agitation with magnetic stirrer. MATERIALS AND METHODS: Weight-matched samples of caprine-origin bone (n=15) and teeth (n=15) were decalcified using three methods namely: a) Gooding and Stewart's fluid; b) Gooding and Stewart's fluid heated to 45(o)C for 6 hours daily; and c) Gooding and Stewart's fluid agitated using a magnetic stirrer for 6 hours daily. Non-lesional skin tissue samples were placed along with each specimen. End point of decalcification (chemical test) was noted; 4 micron sections were taken and stained with H&E. STATISTICAL ANALYSIS: Differences in rate of decalcification and staining characteristics were assessed by Kruskal Wallis test and chi-square test respectively. RESULTS: Hard tissues decalcified faster with stirring and heating methods. The amount of osteocyte retraction noted in bone was significantly reduced in the stirring method. In tooth specimens, modified techniques resulted in poorer nuclear-cytoplasmic contrast of pulp cells. Heating affected the odontoblast layer. Soft tissues exhibited higher eosinophilia in stirring and conventional methods, whereas nuclear-cytoplasmic contrast and chromatin staining was poorest in heating and conventional methods. CONCLUSION: Physical agitation of decalcifying fluid may be recommended while maintaining satisfactory quality of tissue morphology and staining.

Post-radiation changes in oral tissues - An analysis of cancer irradiation cases.

INTRODUCTION: Radiation, commonly employed as neoadjuvant, primary, and adjuvant therapy for head and neck cancer causes numerous epithelial and stromal changes, prominent among which is fibrosis with its early and late consequences. Very little is known about the true nature of the fibrosed tissue and the type of fibers accumulated. Radiotherapy affects the supporting tumor stroma often resulting in a worsening grade of tumor post-radiation. AIM: To study epithelial, neoplastic, stromal, and glandular changes in oral cavity induced by radiation therapy for oral squamous cell carcinoma (OSCC) using special stains. MATERIALS AND METHODS: The study included 27 samples of recurrent OSCC following completion of radiotherapy (recurrence within an average span of 11 months), and 26 non-irradiated cases of OSCC. Patients with a history of combined radiotherapy and chemotherapy were not included in the study. The epithelial changes assessed included epithelial atrophy, apoptosis, necrosis, dysplasia, and neoplasia. The connective tissue was evaluated for amount of fibrosis, quality of fibers (using picrosirius red staining), fibrinous exudate, necrosis, pattern of invasion, vessel wall thickening, and salivary gland changes. The aforementioned changes were assessed using light and polarizing microscopy and tabulated. STATISTICAL ANALYSIS: Epithelial and connective tissue parameters were compared between the irradiated and non-irradiated cases using chi square and t-tests. RESULTS: Epithelial and connective tissue parameters were found to be increased in irradiated patients. Pattern of invasion by tumor cells varied from strands and  cords between the two groups studied. The effect of radiation was seen to reflect on the maturity of fibers and the regularity of their distribution.