Contemporary educational methods in periodontology.

AIM: The 1st European Workshop on Periodontal Education in 2009 made recommendations regarding the scope of periodontal education at undergraduate (UG), postgraduate (PG) and continuing professional development (CPD) levels, defining competencies and learning outcomes that were instrumental at the time in helping to define periodontal teaching curricula. The 19th European Workshop on Periodontology and 2nd European Consensus Workshop on Education in Periodontology (Education in Periodontology in Europe) was held in 2023 to identify changes and future developments in periodontal education (including those informed by the COVID-19 pandemic) and embracing methods and formats of periodontal teaching and training. The aim of this review was to assess current knowledge regarding education methods in periodontology, including traditional face-to-face (F2F) teaching and the move to student-centred methods, virtual learning methods and use of digital technology, as well as blended teaching and learning (including teaching delivery and assessment) at UG, PG and CPD levels. MATERIALS AND METHODS: Systematic searches were conducted to identify relevant studies from the literature. Data were extracted and descriptive summaries collated. RESULTS: The pandemic was a major disruptor of traditional F2F teaching but provided opportunities for rapid implementation of alternative and supplementary teaching methods. Although online learning has become an integral part of periodontal education, teachers and learners alike favour some form of F2F teaching. Blended teaching and learning are feasible in many areas of periodontal education, both for knowledge and skills acquisition as well as in assessment. Student-centred methods and blended approaches such as the flipped classroom seem highly effective, and online/virtual classrooms with both synchronous and asynchronous lectures are highly valued. Learning with haptic methods and virtual reality (VR) enhances the educational experience, especially when VR is integrated with traditional methods. The quality of the teacher continues to be decisive for the best knowledge transfer in all its forms. CONCLUSIONS: Live F2F teaching continues to be highly trusted; however, all types of student-centred and interactive forms of knowledge transfer are embraced as enhancements. While digital methods offer innovation in education, blended approaches integrating both virtual and traditional methods appear optimal to maximize the achievement of learning outcomes. All areas of periodontal education (UG, PG and CPD) can benefit from such approaches; however, more research is needed to evaluate their benefits, both for knowledge transfer and skills development, as well as in assessment.

Emergency department documentation of legal intervention injuries at a Washington, DC, hospital.

BACKGROUND: The U.S. Centers for Disease Control and Prevention (CDC) defines legal intervention injuries as injuries caused by law enforcement agents in the course of official duties. Public health databases utilize International Classification of Diseases, 10th Revision (ICD-10), coding to collect these data through the "Y35" family ICD-10 code. Prior studies report deficiencies in public health recording of fatal legal intervention injuries. Few studies have characterized nonfatal injuries. This study investigates emergency department (ED) capture of legal intervention injury diagnostic coding. METHODS: A retrospective chart review was performed on ED encounter data from January 1, 2017, to June 30, 2019, at an academic hospital in Washington, DC. Charts were identified using a keyword search program for "police." Chart abstracters reviewed the flagged charts and abstracted those that met injury definition. Primary outcomes included injury severity, patient demographics, and documented ICD-10 codes. One sample proportion testing was performed comparing sample census ED data. RESULTS: A total of 340 encounters had sufficient descriptions of legal intervention injuries. A total of 259 had descriptions consistent with the patient specifier of "suspect." Hospital coders recorded 74 charts (28.6%) with the Y35 family legal intervention injury code. A total of 212 involved a Black patient. A total of 122 patients had Medicaid and 94 were uninsured. Black patients made up a higher proportion of individuals in the "suspect identified legal intervention injury" group than the total population (0.819 vs. 0.609, p < 0.01, 95% CI 0.772-0.866). Patients with Medicaid or who were uninsured made up substantial proportions as well (0.471 vs. 0.175, p < 0.01, 95% CI 0.410-0.532 for Medicaid patients and 0.363 vs. 0.155, p < 0.01, 95% CI 0.304-0.424 for the uninsured patients). CONCLUSION: A large proportion of nonfatal legal intervention injuries remain unreported. Black and low-income patients are disproportionately affected. More research is needed but benefits from interprofessional data sharing, injury pattern awareness, and diagnostic coding guidance may improve reporting.

Contribution of 15 Years (2007-2022) of Indo-US Training Partnerships to the Emergency Physician Workforce Capacity in India.

BACKGROUND: Indo-US Masters in Emergency Medicine (MEM) certification courses are rigorous three-year emergency medicine (EM) training courses that operate as a partnership between affiliate hospitals or universities in the United States with established EM training programs and local partner sites in India. Throughout their 15 years of operation, these global training partnerships have contributed to the EM workforce in India. Our objective in this study was to describe Indo-US MEM program graduates, their work environments, and their contribution to the growth of academic EM and to the coronavirus disease 2019 (COVID-19) response. METHODS: An electronic survey was created by US and Indian MEM course stakeholders and distributed to 714 US-affiliated MEM program graduates. The survey questions investigated where graduates were working, their work environments and involvement in teaching and research, and their involvement in the COVID-19 response. We consolidated the results into three domains: work environment and clinical contribution; academic contribution; and contribution to the COVID-19 response. RESULTS: The survey response rate was 46.9% (335 responses). Most graduates reported working within India (210, 62.7%) and in an emergency department (ED) setting (304, 91.0%). The most common reason for practicing outside of India was difficulty with formal MEM certificate recognition within India (97, 79.5%). Over half of graduates reported dedicating over 25% of their work hours to teaching others about EM (223, 66.6%), about half reported presenting research projects at conferences on the regional, national, or international level (168, 50.5%), and almost all graduates were engaged in treating COVID-19 patients during the pandemic (333, 99.4%). Most graduates agreed or strongly agreed that they were satisfied with their overall MEM training (296, 88.4%) and confident in their ability to practice EM (306, 91.6%). CONCLUSION: Indo-US MEM graduates have made a notable contribution to EM in India through clinical service delivery, teaching, and research, even more essential in the context of the COVID-19 pandemic. The roles of these graduates should be acknowledged and can contribute further to expand EM specialty and systems development across India.

Dental education at Dundee Dental Hospital and School - a notable past and inspiring future.

Dundee Dental Hospital and School has been present on Park Place, Dundee for over 100 years. During this time, it has been at the forefront of dental care and education, first as part of the University of St Andrews and subsequently the University of Dundee. This innovation continues with novel undergraduate curricula for dental and dental therapy students, providing early clinical experience and integrating clinical teaching with the appropriate sciences. We also offer several taught postgraduate programmes, popular particularly with international students. Dundee was at the forefront of the response to the COVID-19 pandemic, with the Scottish Dental Clinical Effectiveness Programme leading the world on guidance for safe clinical practice. Innovative solutions for the ongoing delivery of teaching and assessment also were developed. Research underpins teaching and the delivery of dental care and Dundee has an international reputation for its research portfolio. All of the above can only be achieved by close working relationships between the University and NHS, which will be strengthened further by the creation of the Dundee Dental Research Hospital and School. Our international reputation will continue to attract students and staff from across the world.

Characteristics and expectations among emergency department patients in India.

In India, and many low-middle income countries (LMICs), emergency medicine (EM) remains a poorly defined specialty and an unregulated field of clinical practice. Recognition of the attitudes, understanding, and expectations of patients presenting to Indian EDs will be crucial to the continued development of EM as a specialty. This is a multicenter, prospective, cross sectional study of adult and pediatric patients presenting to the ED in three geographically distinct regions of India. Participants were surveyed about their expectations regarding the type of care that they expected to receive, previous treatment options they have utilized, basic understanding of ED operations, factors contributing to their decision to seek ED care, and basic demographic information. 779 patients were approached to participate in the study, of which 698 (90%) completed the survey. Common ways that patients reported learning about the ED were referral from another healthcare provider (45%) and recommendation by a family member (61%). Participants chose the ED was because they thought they would be seen quickly (89%), would receive acute pain management (45%), their regular outpatient care was closed (45%), or were sent by another doctor (45%). Patients expected to wait 0.3 hours (18 minutes) on average to see a doctor in the ED. Over 75% or patients expected to see a specialist consultant in the ED and 12% expected to see their personal physician. Eighty-five percent of patients were triaged as moderate or high acuity, and 74% of patients were admitted. This study found that ED in India is utilized by a population with an extremely high acuity of medical illness that attempts to access healthcare through multiple avenues. Patients most frequently visit the ED due to a referral from another healthcare provider or family member. Most patients are aware of the existence of the ED, though understanding of available services may be lacking. Future research should focus on community outreach and education initiatives on ED services.

Self-prescribing of antibiotics by patients seeking care in Indian emergency departments.

STUDY OBJECTIVE: Antibiotic resistance is a global health threat. India has one of the highest rates of antibiotic use in the world. The objective of this study was to evaluate the prevalence of self-prescribed antibiotic use of patients presenting with febrile and infectious disease-related complaints to Indian emergency departments. METHODS: This was a prospective observational study conducted at 6 Indian emergency departments (EDs) between January 1, 2019 and December 31, 2019. Adult patients who presented with a chief complaint of febrile illness or infectious disease complaints were included. Our principal outcomes of interest were self-prescribed use of antibiotics within the prior 6 months or for the presenting complaint. We queried respondents about source of antibiotics as well as about demographic characteristics that influenced use. RESULTS: A total of 1421 patients were enrolled. Sixty percent (n = 856) of respondents reported using antibiotics in the prior 6 months or for their current complaint. Those who reported self-prescribing antibiotics either in the past or currently had at least some college education (P < 0.001), tended to use the pharmacy (P < 0.001) or the ED (P = 0.001) for their care when sick, and were more likely to have some comorbid conditions (P = 0.014) as compared to the group that did not self-prescribe antibiotics. The most common reason respondents reported self-prescribing antibiotics was because they did not want to wait to see their doctor (n = 278, 33%). Thirty-five percent of patients who were self-prescribed antibiotics before presentation did not receive and were not prescribed antibiotics in the ED, at discharge, or both. CONCLUSIONS: Self-prescribing of antibiotics occurs commonly in India. This use increases the risk for resistance due to inappropriate or unnecessary use. Promotion of antibiotic stewardship is needed to curtail such use.

Inference to the best explanation and Norton's material theory of induction.

I argue that we should consider Norton's material theory of induction as consisting of two largely independent claims. First, there is the claim that material facts license inductions - a claim which I interpret as a type of contextualism about induction. Second, there is the claim that there are no universal rules of induction. While a good case can be made for the first claim, I believe that Norton's arguments for the second claim are lacking. In particular, I spell out Norton's argument against the claim that all induction may be reduced to inference to the best explanation, and argue that it is not persuasive. Rejecting this part of Norton's theory does not however require us to abandon the first claim that material facts license inductions. In this way, I distinguish the parts of the material theory of induction we should happily accept from the parts about which we should be more skeptical.

Prevalence of undiagnosed HIV, hepatitis B, and hepatitis C among patients in an Indian emergency department.

OBJECTIVES: HIV, hepatitis B, and hepatitis C remain significant causes of morbidity and mortality in low resource settings. Emergency department (ED)-based screening has proven effective in decreasing the spread of undiagnosed disease, although such programs are rare in low-middle income countries. METHODS: A prospective, cross sectional study of all adult patients presenting to the ED in a 600-bed teaching hospital in Tamil Nadu, India. This study used an opt-in strategy in which patients were offered testing at the end of their ED visit. Costs of testing were paid out of pocket by patients. Patients with known HIV, hepatitis B, or hepatitis C were excluded from the study. RESULTS: During the study period 26,465 patients presented to the ED, and 18,286 patients consented to participate (68.9%). Among the 18,286 patients tested, 174 were positive for either HIV (39, 0.21%), hepatitis C (52, 0.28%), or hepatitis B (83, 0.45%). Three patients tested positive for both HIV and hepatitis C, and 1 patient tested positive for both HIV and hepatitis B. A total of 69.2% of patients with HIV, 61.2% of patients with hepatitis B, and 83% of patients with hepatitis C presented for reasons unrelated to their underlying diagnosis. CONCLUSION: Although limited to only 1 hospital in southern India, this study represents the largest ED-based screening program for HIV, hepatitis B, and hepatitis C ever conducted in India or any other low-middle income countries. The majority of patients presented for reasons unrelated to their underlying diagnosis. Future research is needed on implementation strategies, cost feasibility, and linkage to care.

Patients Presenting with Bull-related Injuries to a Southern Indian Emergency Department.

INTRODUCTION: Bull-related injuries are commonly observed in rural areas of India as result of the animal's use in sporting events as well as for agricultural purposes. These patients need early resuscitation due to complications from severe injuries. Previous work examining the epidemiology of bull-related injuries is limited, with most studies focusing on injuries in Spain and Latin America. There is scant literature examining the prevalence of such injuries in India. The objective of this study was to evaluate the demographic and clinical characteristics of bull-related injuries at a hospital in Tamil Nadu, India. METHODS: This was a prospective, observational study of patients who presented to an emergency department (ED) in Madurai, India, with a reported history of bull-related injuries between June 2017 and March 2019. We recorded information about patient demographics, location of injury, disposition, initial Injury Severity Score (ISS), and transport time. RESULTS: Our sample included a total of 42 patients. Almost a third of patients who presented were between the ages of 20-30 years (31%, n = 13), and most were male (86%, n = 36). Approximately 59% of patients (n = 25) had provoked injuries, occurring as a result of active participation during sporting activities. Injuries to the trunk were most common (55%, n = 23), followed by injuries to the perineum (19%, n = 19). The majority of patients (59.5%) had penetrating injuries (n = 25), The mean ISS was 10.1 (standard deviation 6.3). Five (12%) patients had a complication after injury including intra-abdominal abscess formation, peritonitis, and sepsis. Two patients died as a result of septicemia from peritonitis. CONCLUSION: Bull-related injuries may result in significant morbidity and mortality. Education of the population about the dangers of bull injuries from sporting events and the need for early transportation to the ED have the potential for significant reduction in morbidity and mortality.

A qualitative study of workplace violence among healthcare providers in emergency departments in India.

BACKGROUND: Emergency department (ED) workplace violence is increasingly recognized as an important issue for ED providers. Most studies have occurred in developed countries with established laws and repercussions for violence against healthcare providers. There is a paucity of data on workplace violence against ED providers in less developed countries. The aim of this study was to learn more about workplace violence among healthcare providers in EDs in India. RESULTS: Semi-structured interviews were conducted in-person with physicians, nurses, and paramedics in Indian EDs. Interviews were coded independently using the NVivo qualitative research software. A hybrid thematic analysis approach was used to determine dominant themes. Sixty-three interviews were conducted at 7 sites across India. Interview participants include attending physicians (11), resident physicians (36), nurses (10), and paramedics (5). Events were most often described as involving accompanying persons to the patient, not the patient themselves. Most events involved verbal abuse, although a significant percentage of responses described some kind of physical violence. ED factors such as busy times with high patient volumes or periods of waiting are associated with increased violence, as well as incidents with unanticipated outcomes such as patients with severe illness or death. Decreased levels of health literacy among patients often contribute as the financial stressors of paying for medical care. Providers reported negative consequences of workplace violence on quality of care for patients and their own motivation to work in the ED. Communication strategies were frequently proposed as interventions to mitigate violence in the future including both provider communication as well as public awareness campaigns. CONCLUSION: Workplace violence is a frequent reality for this sample of Indian ED healthcare providers. Alarming levels of verbal and physical abuse and their impact on patient care are described. This qualitative study identified unique challenges to Indian ED providers that differ from those in more developed settings, including financial stressors, inadequate enforcement of rules governing behavior in the hospital, and an overwhelming frequency of violence emanating from patient family members and attendants rather than the patients themselves. Further investigation into preventive strategies is needed.

Operation Navajeevan: A Public-Private Partnership Model for Disaster Relief in Kozhikode, India.

INTRODUCTION: In August 2018, India's southern state of Kerala experienced its worst flooding in over a century. This report describes the relief efforts in Kozhikode, a coastal region of Kerala, where Operation Navajeevan was initiated. SOURCES: Data were collected from a centralized database at the command center in the District Medical Office as well as first-hand accounts from providers who participated in the relief effort. OBSERVATIONS: From August 15 through September 8, 2018, 36,846 flood victims were seen at 280 relief camps. The most common cause for presentation was exacerbation of an on-going chronic medical condition (18,490; 50.2%). Other common presentations included acute respiratory infection (7,451; 20.2%), traumatic injuries (3,736; 10.4%), and psychiatric illness (5,327; 14.5%). ANALYSIS: The prevalence of chronic disease exacerbation as the primary presentation during Operation Navajeevan represents an epidemiologic shift in disaster relief in India. It is foreseeable that as access to health care improves in low- and middle-income countries (LMICs), and climate change increases the prevalence of extreme weather events around the world, that this trend will continue.

Postgraduate Diploma in Emergency Medicine in India.

BACKGROUND: In India, and other low- and middle-income countries (LMICs), the majority of emergency care is provided by frontline providers without specialty training in emergency medicine. In order to fill this need, we developed the Indian Postgraduate Diploma in Emergency Medicine (PGDEM), a 1-year skills-focused course for practicing doctors. This article describes the curriculum development and implementation as well as the follow-up survey conducted to gauge the impact of the course. METHODS: Programme graduates were surveyed via e-mail. All participation was voluntary and survey data remained anonymous. RESULTS: A total of 98.1% of graduates reported that the skills and knowledge they gained during the programme were important to their current job; 94.7% reported using their training from the course on a regular basis. Graduates reported an improvement in confidence performing all procedures taught during the course. Respondents work in a variety of medical specialties, including emergency medicine (50.0%), cardiology (5.8%), internal medicine (11.5%) and family medicine (23.1%). DISCUSSION: PGDEM graduates overwhelmingly view the knowledge and skills they learned as essential training that they use on a regular basis and practice in a variety of medical specialties after completing the course. The PGDEM represents a unique model to provide training in emergency medicine and acute care to the frontline doctors who are frequently responsible for providing emergency care in LMICs. The PGDEM training model can be scaled up rapidly, with the potential to increase capacity in developing emergency care systems.

Emergency centre diagnosis and treatment of purulent pericarditis: A case report from Tanzania.

INTRODUCTION: Purulent pericarditis poses diagnostic and therapeutic challenges, especially in resource-limited settings due to the unavailability of diagnostic tools, equipment, and expertise. CASE REPORT: A three-year-old female presented to the emergency centre at Muhimbili National Hospital in Dar es Salaam, Tanzania with altered mental status, lethargy, intermittent fevers, worsening difficulty in breathing, and progressive lower extremity swelling over two months. The child was in shock upon arrival. Point-of-care ultrasound demonstrated cardiac tamponade secondary to purulent pericarditis. An ultrasound guided pericardiocentesis and lavage was successfully done in the emergency centre and antibiotics were started. Though definitive management (pericardiectomy) was delayed, the child survived to hospital discharge. CONCLUSION: Pericardiocentesis, pericardial lavage, and the initiation of broad spectrum antibiotics are the mainstay of early treatment of purulent pericarditis. This treatment can be done safely in an emergency centre with little specialised equipment aside from point-of-care ultrasound.

Application of the Canadian Computed Tomography Head Rule to Patients With Minimal Head Injury.

STUDY OBJECTIVE: Two clinical decision rules, the Canadian CT Head Rule and the New Orleans Criteria, set the standard to guide clinicians in determining which patients with minor head trauma need computed tomography (CT) imaging. Both rules were derived with patients with minor head injury who had had a loss of consciousness or witnessed disorientation. No evidence exists for evaluating patients and need for CT imaging with minimal head injury; that is, patients who had a head injury but no loss of consciousness or disorientation and therefore would have been excluded from the Canadian CT Head Rule and New Orleans Criteria trials. We evaluate the Canadian CT Head Rule in patients with head injury without loss of consciousness or witnessed disorientation (minimal head injury). METHODS: We studied a prospective convenience sample of patients with minimal head injury who received head CTs as part of their evaluations in the emergency department (ED). Participants were enrolled after head CT was ordered, but before the physician received the imaging results. Physicians were surveyed on their clinical reasoning for ordering imaging in this low-risk cohort of patients. Physicians surveyed consisted of ED attending physicians and senior-level emergency medicine residents. Final patient disposition was recorded when it became available. Patients with positive CT findings had their medical records reviewed for specific disposition, admission length of stay, ICU stay, and any operative or procedural interventions. RESULTS: Two hundred forty patients with minimal head injury were enrolled. Five patients (2.1%) had head CTs that were positive for intracranial hemorrhage. All instances of intracranial hemorrhage occurred in patients who were at high or moderate risk by the Canadian CT Head Rule (2 high risk [age], 3 moderate risk [mechanism]). No patient with intracranial hemorrhage went to the ICU or underwent any intervention; the average hospital length of stay was 1.25 days. The Canadian CT Head Rule was 100% sensitive (95% confidence interval 40% to 100%) and 29% specific (95% confidence interval 23% to 35%) for the presence of intracranial hemorrhage. Physicians listed their own reassurance (24.6%), patient reassurance (24.2%), patient expectation (14.6%), and reduction of legal liability (11.7%) as the rationale for ordering head CT in patients with minimal head injury. Shared decisionmaking was used in 51% of cases. CONCLUSION: Risk of intracranial hemorrhage in patients with minimal head injury was very low, and even in patients found to have an intracranial hemorrhage, none had any serious adverse outcome (eg, death, intubation, prolonged hospitalization, surgical procedure). The Canadian CT Head Rule was 100% sensitive in this small cohort of patients with minimal head injury. Among our study cohort, which specifically included only patients who had CT scanning, applying the Canadian CT Head Rule may have reduced the need for CT, potentially saving costs and resources. However, because many patients with minimal head injury who present to the ED may not have CTs, it is unclear what effect the broad application of this rule would have on overall CT use. Providers' rationale for obtaining CT was multifactorial. These represent barriers that may need to be overcome before physicians are comfortable changing CT ordering patterns in this group of head injury patients.

Global Health and Emergency Care: Defining Clinical Research Priorities.

OBJECTIVES: Despite recent strides in the development of global emergency medicine (EM), the field continues to lag in applying a scientific approach to identifying critical knowledge gaps and advancing evidence-based solutions to clinical and public health problems seen in emergency departments (EDs) worldwide. Here, progress on the global EM research agenda created at the 2013 Academic Emergency Medicine Global Health and Emergency Care Consensus Conference is evaluated and critical areas for future development in emergency care research internationally are identified. METHODS: A retrospective review of all studies compiled in the Global Emergency Medicine Literature Review (GEMLR) database from 2013 through 2015 was conducted. Articles were categorized and analyzed using descriptive quantitative measures and structured data matrices. The Global Emergency Medicine Think Tank Clinical Research Working Group at the Society for Academic Emergency Medicine 2016 Annual Meeting then further conceptualized and defined global EM research priorities utilizing consensus-based decision making. RESULTS: Research trends in global EM research published between 2013 and 2015 show a predominance of observational studies relative to interventional or descriptive studies, with the majority of research conducted in the inpatient setting in comparison to the ED or prehospital setting. Studies on communicable diseases and injury were the most prevalent, with a relative dearth of research on chronic noncommunicable diseases. The Global Emergency Medicine Think Tank Clinical Research Working Group identified conceptual frameworks to define high-impact research priorities, including the traditional approach of using global burden of disease to define priorities and the impact of EM on individual clinical care and public health opportunities. EM research is also described through a population lens approach, including gender, pediatrics, and migrant and refugee health. CONCLUSIONS: Despite recent strides in global EM research and a proliferation of scholarly output in the field, further work is required to advocate for and inform research priorities in global EM. The priorities outlined in this paper aim to guide future research in the field, with the goal of advancing the development of EM worldwide.

Locally delivered antimicrobials in the management of periodontitis: a critical review of the evidence for their use in practice.

UNLABELLED: Plaque bacteria are the primary initiators of periodontal disease in susceptible persons and therapy is largely based on mechanical bacterial biofilm disruption. Patients' response to periodontal treatment is unpredictable and periodontal stability is not always achieved. Locally delivered antimicrobials (LDAs) may be used as adjuncts to mechanical therapy in treatment of recalcitrant deep (> or = 5mm), active, non-responding sites, providing the patient's oral hygiene is adequate. Their use as a monotherapy cannot be justified. The literature reveals that LDAs are safe and that they achieve statistically significant, yet clinically modest, gains in clinical attachment and reductions in pocket depths. CLINICAL RELEVANCE: It has been suggested that LDAs may improve the clinical outcome in the treatment of recurrent and refractory cases of periodontitis when used as an adjunct to scaling and root surface instrumentation. This paper examines and discusses the evidence.