Adoption and effect of sealants for occlusal noncavitated caries in a large dental network in the United States.

INTRODUCTION: Dental sealants applied to occlusal pit-and-fissure surfaces have been shown to prevent caries and arrest occlusal non-cavitated carious lesions (NCCLs). The American Dental Association (ADA) recommends that oral healthcare providers apply sealants on occlusal NCCLs. Though the evidence is clear that sealants are effective, few studies have examined the adoption of the ADA guideline by dentists and the duration of protection provided by sealants in a large real world setting. METHODS: This study used observational electronic health record (EHR) data from a network of dental clinics to follow teeth over a two year time period from when they were diagnosed as having an occlusal NCCL until either they were treated with a restoration or the time period ended with no restoration. The objectives of the study were to determine: 1) the degree to which dentists adopted the guideline, 2) whether the duration of protection was different for teeth that received a sealant from teeth that did not receive a sealant, and 3) whether dentists' experience placing sealants was associated with the duration of protection. RESULTS: Overall, there were 7,299 teeth in the sample. Of those, dentists restored 591 teeth and applied sealants on 164. The sealant application rate for eligible teeth was 2.2%. Sealant application was associated with provider, with 1.9% of providers placing more than half of the sealants. By the end of the observation period, the proportion of teeth progressing to restorations was 8.2% for teeth that had not received a sealant and 3.0% for teeth that had received one (RR=0.37; 95% CI (0.16-0.88); p=0.02) Multilevel survival analysis showed that teeth that had not received a sealant were restored sooner than teeth that had received a sealant (aHR=0.11; 95% CI 0.03 - 0.36; p<.01). Overall, teeth that received a sealant had an 89% reduced hazard of restoration within two years compared with teeth that did not receive sealants. CONCLUSION: This study found that by arresting decay, the presence of sealants led to fewer restorations and delayed restorations compared with teeth not receiving a sealant or restoration in the two years following diagnosis of occlusal NCCL in clinical settings.

Normative Cognitive Scores in Western India, Stratified by Age, Rurality, Cognitive Domains, and Psychiatric Comorbidity.

BACKGROUND AND OBJECTIVES: Indian ethnic and educational diversities necessitate obtaining normative cognitive data in different populations. We aimed to evaluate cognitive scores using a Marathi translation of the Kolkata cognitive battery (KCB) and to study the association of KCB components with depression and sociodemographic variables. MATERIALS AND METHODS: We studied 2,651 individuals aged ≥40 years without preexisting neuropsychiatric conditions from urban (Mumbai) and rural districts of Maharashtra. For each component of KCB, the lowest 10th percentile score was used to define cognitive impairment. RESULTS: We studied 1,435 (54%) rural and 1,216 (46%) urban residents equally divided by gender (1,316 women and 1,335 men), average age 54 years. KCB scores were significantly lower with female sex, older age, illiteracy, and depression. The largest effect sizes attributable to these factors were in the domains of calculation (gender), visuoconstructional ability (VCA) (rurality), and verbal fluency (VF) (depression). Scores remained significantly lower in rural residents after controlling for age, sex, and education, particularly for VCA, immediate recall, and calculation. CONCLUSION: This Marathi KCB, having been validated on large urban as well as rural samples, may be used to study cognition in Marathi-speaking populations with appropriate cutoffs tailored to the degree of urbanization of the population.

Personalized Approach in the Management of Difficult-to-Treat and Treatment-Resistant Depression With Second-Generation Antipsychotics: A Delphi Statement.

Background Major depressive disorder (MDD) has many facets including mixed or atypical depression that requires personalized care to improve treatment-related outcomes. Second-generation antipsychotics (SGAs) offer complementary mechanisms for clinical roles in difficult-to-treat depression and treatment-resistant depression cases. Aim/objective To further delineate a consensus on the clinical positioning of SGAs for MDD, mixed, or atypical depression, a Knowledge Attitude Perception (KAP)-mediated Delphi Statement was planned. Material/methods A literature review for the definition, diagnosis, and management of MDD, mixed, and atypical depression as treatment-resistant depression (TRD) or difficult-to-treat depression (DTD) was conducted by a steering committee of academic and clinical experts (n=6) while developing a validated KAP questionnaire. Scientific statements as clinical recommendations were evolved using the Delphi methodology before building a clinical expert consensus with an online survey (n=24). Results Twenty-four psychiatrists highlighted DTD to offer a multidimensional approach to assess treatment strategies involving selective serotonin reuptake inhibitors (SSRIs) or SGAs, while ensuring symptom, functional, and quality of life (QoL) domain improvement for improved outcomes and remission rates. MDD cases with anxiety, anhedonia, comorbidities, and risk traits require personalized care with early induction of SGAs for severe cases or symptom persisters with functional impairment. Early augmentation with SGAs including aripiprazole or cariprazine can provide a favorable risk-benefit profile for clinical cases of MDD with or without the antecedent of mixed depression or personality disorder.  Conclusion The literature review and KAP responses emphasize the importance of early identification for personalized care strategies with SGAs for DTD. Large-scale real-world evidence needs to evolve with due recognition of different phenotypes as TRD or DTD with partial or functional impairment to understand the impact of appropriate treatment pathways with SGAs.

Intelligent play: How improv can improve clinician's emotional intelligence.

BACKGROUND: Emotional intelligence (EI) of physicians significantly impacts their personal well-being and professional success with broad implications in health care. A focused training on EI is often lacking in medical curricula. We sought to understand the impact of improvisation training on clinicians' EI. APPROACH: Four online medical improv workshops were offered to a diverse group of physicians with varied levels of practice experience including medicine-paediatric residents, paediatric educators, practising paediatricians and internal/family medicine clinicians. The improv training was thoughtfully curated and remained consistent for all four cohorts, lasting 2 h. Self-reported EI scales (pre and post) were captured using an online survey tool. The overall EI score and the scores of three EI components were compared before and after training. EVALUATION: Out of 64 participants, 41 participants (64%) completed both the pre- and post-surveys and were included in the final analysis. Participant's pre-training score (mean:123.9, range: 121.1-126.7) was compared to their post-training score (mean:128.9, range: 126.3-131.3). The t tests comparing EI scores showed that compared to pre-intervention, participants on average scored 4.9 points higher (95% CI: 3.1-6.7; p < 0.01) on the overall scale, 2.2 points higher (95% CI: 1.2-3.2; p < 0.01) on the appraisal score, 1.4 points higher (95% CI: 0.8-2.0; p < 0.01) on the regulation score and 1.2 points higher (95% CI: 0.4-2.1; p = 0.01) on the utilisation score. IMPLICATIONS: Improv training is an innovative method to fill the crucial gap in EI curricula. There was a statistically significant improvement in average score for clinicians' EI after a pilot improv training programme.

Evaluation of 'Normal' Cognitive Functions and Correlation With MRI Volumetry: Towards a Definition of Vascular Cognitive Impairment.

Introduction It is important to establish criteria to define vascular cognitive impairment (VCI) in India as VCI is an image-based diagnosis and magnetic resonance imaging (MRI) changes resulting from age with prevalent vascular risk factors may confound MRI interpretation. The objective of this study was to establish normative community data for MRI volumetry including white matter hyperintensity volume (WMHV), correlated with age-stratified cognitive scores and vascular risk factors (VRFs), in adults aged 40 years and above.  Methods We screened 2651 individuals without known neurological morbidity, living in Mumbai and nearby rural areas, using validated Marathi translations of Kolkata Cognitive Battery (KCB) and geriatric depression score (GDS). We stratified 1961 persons with GDS ≤9 by age and cognitive score, and randomly selected 10% from each subgroup for MRI brain volumetry. Crude volumes were standardized to reflect percentage of intracranial volume.  Results MRI volumetry studies were done in 199 individuals (F/M = 90/109; 73 with body mass index (BMI) ≥25; 44 hypertensives; 29 diabetics; mean cognitive score 76.3). Both grey and white matter volumes decreased with increasing age. WMHV increased with age and hypertension. Grey matter volume (GMV) decreased with increasing WMHV. Positive predictors of cognition included standardized hippocampal volume (HCV), urban living, education, and BMI, while WMHV and age were negative predictors. Urban dwellers had higher cognitive scores than rural, and, paradoxically, smaller HCV.  Conclusion In this study of MRI volumetry correlated with age, cognitive scores and VRFs, increasing age and WMHV predicted lower cognitive scores, whereas urban living and hippocampal volume predicted higher scores. Age and WMHV also correlated with decreasing GMV. Further study is warranted into sociodemographic and biological factors that mutually influence cognition and brain volumes, including nutritional and endocrine factors, especially at lower cognitive score bands. In this study, at the lower KCB score bins, the lack of laboratory data pertaining to nutritional and endocrine deficiencies is a drawback that reflects the logistical limitations of screening large populations at the community level. Our volumetric data which is age and cognition stratified, and takes into account the vascular risk factors associated, nevertheless constitutes important baseline data for the Indian population. Our findings could possibly contribute to the formulation of baseline criteria for defining VCI in India and could help in early diagnosis and control of cognitive decline and its key risk factors.