Search results for: older adults oral health

Authors: A. M. Plante, F. O’Halloran, A. L. McCarthy

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By 2050 it is projected that 2 billion of the global population will be more than 60 years old. Older adults have unique dietary requirements and aging is associated with physiological changes that affect appetite, sensory perception, metabolism, and digestion. Therefore, it is essential that foods recommended and designed for older adults promote healthy aging. To assess cheese as a functional food for the elderly, a range of commercial cheese products were selected and compared for their antioxidant properties. Cheese from various milk sources (bovine, goats, sheep) with different textures and fat content, including cheddar, feta, goats, brie, roquefort, halloumi, wensleydale and gouda, were initially digested with two different simulated in vitro gastrointestinal digestion (SGID) models. One SGID model represented a validated in vitro adult digestion system and the second model, an elderly SGID, was designed to consider the physiological changes associated with aging. The antioxidant potential of all cheese digestates was investigated using in vitro chemical-based antioxidant assays, (2,2-Diphenyl-1-picrylhydrazyl (DPPH) radical scavenging, ferric reducing antioxidant power (FRAP) and total phenolic content (TPC)). All adult model digestates had high antioxidant activity across both DPPH ( > 70%) and FRAP ( > 700 µM Fe²⁺/kg.fw) assays. Following in vitro digestion using the elderly SGID model, full-fat red cheddar, low-fat white cheddar, roquefort, halloumi, wensleydale, and gouda digestates had significantly lower (p ≤ 0.05) DPPH radical scavenging properties compared to the adult model digestates. Full-fat white cheddar had higher DPPH radical scavenging activity following elderly SGID digestion compared to the adult model digestate, but the difference was not significant. All other cheese digestates from the elderly model were comparable to the digestates from the adult model in terms of radical scavenging activity. The FRAP of all elderly digestates were significantly lower (p ≤ 0.05) compared to the adult digestates. Goats cheese was significantly higher (p ≤ 0.05) in FRAP (718 µM Fe²/kg.fw) compared to all other digestates in the elderly model. TPC levels in the soft cheeses (feta, goats) and low-fat cheeses (red cheddar, white cheddar) were significantly lower (p ≤ 0.05) in the elderly digestates compared to the adult digestates. There was no significant difference in TPC levels, between the elderly and adult model for full-fat cheddar (red, white), roquefort, wensleydale, gouda, and brie digestates. Halloumi cheese was the only cheese that was significantly higher in TPC levels following elderly digestion compared to adult digestates. Low fat red cheddar had significantly higher (p ≤ 0.05) TPC levels compared to all other digestates for both adult and elderly digestive systems. Findings from this study demonstrate that aging has an impact on the bioactivity of cheese, as antioxidant activity and TPC levels were lower, following in vitro elderly digestion compared to the adult model. For older adults, soft cheese, particularly goats cheese, was associated with high radical scavenging and reducing power, while roquefort cheese had low antioxidant activity. Also, elderly digestates of halloumi and low-fat red cheddar were associated with high TPC levels. Cheese has potential as a functional food for the elderly, however, bioactivity can vary depending on the cheese matrix. Funding for this research was provided by the RISAM Scholarship Scheme, Cork Institute of Technology, Ireland.

Keywords: antioxidants, cheese, in-vitro digestion, older adults

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Authors: Florian Tille, Heide Weishaar, Bernhard Gibis, Susanne Schnitzer

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Introduction: The quality of patient-doctor communication and of written health information is central to organizational health literacy (HL). Whether patients understand their doctors’ explanations and textual material on health, however, is understudied. This study identifies the overall levels of patient understanding of health information and its associations with patients’ social characteristics in outpatient health care in Germany. Materials & Methods: This analysis draws on data collected via a 2017 national health survey with a sample of 6,105 adults. Quality of communication was measured for consultations with general practitioners (GPs) and specialists (SPs) via the Ask Me 3 program questions, and through a question on written health material. Correlations with social characteristics were explored employing bivariate and multivariate logistic regression analyses. Results: Over 90% of all respondents reported that they had understood their doctors’ explanations during the last consultation. Failed understanding was strongly correlated with patients’ very poor health (Odds Ratio [OR]: 5.19; 95% confidence interval [CI]: 2.23–12.10; ref. excellent/very good health), current health problem (OR: 6.54, CI: 1.70–25.12; ref. preventive examination) and age 65 years and above (OR: 2.97, CI: 1.10–8.00; ref. 18 to 34 years). Fewer patients answered they understood written material well (86.7% for las visit at GP, 89.7% at SP). Understanding written material poorly was highly associated with basic education (OR: 4.20, CI: 2.76–6.39; ref. higher education) and 65 years old and above (OR: 2.66, CI: 1.43–4.96). Discussion: Overall ratings of oral patient-doctor communication and written communication of health information are high. Yet, a considerable share of patients reports not-understanding their doctors and poor understanding of the written health-related material. Interventions that can contribute to improving organizational HL in outpatient care in Germany include HL training for doctors, reducing system barriers to easily-accessible health information for patients and combining oral and written health communication means. Conclusion: This work adds to the study of organizational HL in Germany. To increase patient understanding of health-relevant information and thereby possibly reduce health disparities, meeting the communication needs especially of persons in different age groups, with basic education and in very poor health is suggested.

Keywords: health survey, organizational health literacy, patient-doctor communication, social characteristics, outpatient care, Ask Me 3

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Authors: Vandana Singh, Subash Singh

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Introduction: Oral squamous cell carcinoma is the most common malignant tumor of the oral cavity. Normally the death of cell and the growth are active processes and depend not only on external factors but also on the expression of genes like Bcl-2, which activate and inhibit apoptosis. The term Bcl-2 is an acronym for B-cell lymphoma/ leukemia -2 genes. Objectives: An attempt was made to evaluate Bcl-2 oncoprotein expression in patients with oral precancer and cancer and to assess possible correlation between Bcl-2 oncoprotein expression and clinicopathological features of oral precancer and cancer. Material and Methods: This is a selective prospective clinical and immunohistochemical study. Clinicopathological examination is correlated with immunohistochemical findings. The immunolocalization of Bcl-2 protein is performed using the labeled streptavidin biotin (LSAB) method. To visualize the reaction, 3, 3-diaminobenzidine (DAB) is used. Results: Bcl-2 expression was positive in 11 [36.66 %, low Bcl-2 expression 3 (10.00 %), moderate Bcl-2 expression 7 (23.33 %), and high Bcl-2 expression 1 (3.33 %)] oral cancer cases and in 14 [87.50 %, low expression 8 (50 %), moderate expression 6 (37.50 %)] precancer cases. Conclusion: On the basis of the results of our study we conclude that positive Bcl-2 expression may be an indicator of poor prognosis in oral cancer and precancer. Relevance: It has been reported that there is deregulation of Bcl-2 expression during progression from oral epithelial dysplasia to squamous cell carcinoma. It can be used for revealing progression of epithelial dysplasia to malignancy and as a prognostic marker in oral precancer and cancer.

Keywords: BcL-2, immunohistochemistry, oral cancer, oral precancer

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Authors: Maria Korman, Carmit Gal, Ella Gabitov, Avi Karni

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The main question addressed in this study was whether the time-of-day wherein training is afforded is a significant factor for motor skill ('how-to', procedural knowledge) acquisition and consolidation into long term memory in the healthy elderly population. Twenty-nine older adults (60-75 years) practiced an explicitly instructed 5-element key-press sequence by repeatedly generating the sequence ‘as fast and accurately as possible’. Contribution of three parameters to acquisition, 24h post-training consolidation, and 1-week retention gains in motor sequence speed was assessed: (a) time of training (morning vs. evening group) (b) sleep quality (actigraphy) and (c) chronotype. All study participants were moderately morning type, according to the Morningness-Eveningness Questionnaire score. All participants had sleep patterns typical of age, with average sleep efficiency of ~ 82%, and approximately 6 hours of sleep. Speed of motor sequence performance in both groups improved to a similar extent during training session. Nevertheless, evening group expressed small but significant overnight consolidation phase gains, while morning group showed only maintenance of performance level attained at the end of training. By 1-week retention test, both groups showed similar performance levels with no significant gains or losses with respect to 24h test. Changes in the tapping patterns at 24h and 1-week post-training were assessed based on normalized Pearson correlation coefficients using the Fisher’s z-transformation in reference to the tapping pattern attained at the end of the training. Significant differences between the groups were found: the evening group showed larger changes in tapping patterns across the consolidation and retention windows. Our results show that morning-oriented older adults effectively acquired, consolidated, and maintained a new sequence of finger movements, following both morning and evening practice sessions. However, time-of-training affected the time-course of skill evolution in terms of performance speed, as well as the re-organization of tapping patterns during the consolidation period. These results are in line with the notion that motor training preceding a sleep interval may be beneficial for the long-term memory in the elderly. Evening training should be considered an appropriate time window for motor skill learning in older adults, even in individuals with morning chronotype.

Keywords: time-of-day, elderly, motor learning, memory consolidation, chronotype

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Authors: B. Nair, S. Singh

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Oral health behaviors such as dietary preferences and tooth brushing are acquired during a child’s primary socialization period yet many oral health promotion interventions are implemented without taking into account the role and impact of parental influence in supporting healthy oral health behaviors. The aim and objective of this study was to determine the relationship between parental income and level of education with knowledge, attitudes and perceptions of oral health care practices. Methods: The study design was cross-sectional and exploratory, and data collection occurred in two phases. Phase 1 comprised of a self-administered questionnaire. The sample consisted of parents of 313 Grade 1 learners aged between 5-6 years old attending one of twelve selected public primary schools in the Chatsworth Circuit, Durban, South Africa. Phase 2 comprised of focus group discussions held at 5 purposively selected schools. Data collection comprised of a semi-structured face-to-face group interview with the objective of obtaining a deeper understanding of parental knowledge, attitudes and perceptions of dental caries. Results and Discussion: Almost 56% of participants earned a monthly income of less than R6000 (600 US dollars). Nearly three quarters (77.5%) of participants indicated that they did not have medical aid/insurance scheme. More than three-quarters of the participants (76.6%) identified diet as being the primary cause of decayed teeth. More than half of the study sample (56.1%) indicated that milk teeth were important and that rotten teeth (74.6%) could affect the child’s health. Almost half (49.8%) of participants reported that “bad teeth” were inherited. With more than two-thirds of the participants (77.7%), having at most a high school education, there was a correlation between the level of the caregiver’s education and the oral health care of the child. The analysis of the correlation between a child having decayed teeth and income (p=.007); and the manner in which the income is received (p=.003) was statistically significant. The results indicate that more effort needs to be placed in understanding parental knowledge, perceptions and attitudes towards dental caries. Parental level of education, income and oral health literacy is shown to be related to attitudes, and perceptions towards dental caries and its subsequent preventive measures. These findings have important implications for oral health planning at community and facility-based levels.

Keywords: oral health prevention, parental education, dental caries, attitudes and perceptions

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Authors: Ana Luiza Blanco, Juliana Cordeiro Carvalho, Tábatta Renata Pereira Brito, Ariene Angelini dos Santos Orlandi, Ligiana Pires Corona, Daniella Pires Nunes

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Depressive symptoms are recurrent in older adults and affect the quality of life and well-being of individuals. One of the strategies to reduce depression is social support, but studies are still needed to determine which types of social support are most effective in moderating this effect in certain populations. The objective was to identify the relationship between social support and depressive symptoms in participants of a University of the Third Age. This is a cross-sectional study. Participants were 82 individuals (≥ 50 years) who responded to the Geriatric Depression Scale - GDS and the Medical Outcomes Study - MOS. Data collection was carried out from November 2020 to May 2021. The Chi-Square and Mann Whitney tests were used, at a significance level of 5% for data analysis. Among the participants, 83.4% were female, 57.3% were age between 60 to 69 years, 83.1% studied 12 year or more and 48.1% receive from 4 to 10 minimum wages. The prevalence of depressive symptoms was 12.2%. The type of support with the highest median score was affective (100 points) and the lowest, or emotional (87.5 points). The results showed that participants without depressive symptoms had higher median scores for informational support when compared to those with depressive symptoms (p=0.029). The other types of social support were not statistically significant. The findings suggested that informational support is related to depressive symptoms in older adults. Promote informational support and educational actions in Universities of the Third Age may be an important strategy for preventing depressive symptoms and improve the quality of life of this population.

Keywords: aged, depressive symptoms, social support, university of the third age

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Authors: Zena F. Mushtaq, Iqbal M. Abbas

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Background: Diabetes mellitus during pregnancy is one of the major medical and social problems with increasing prevalence in last decades and may lead to more vulnerable to dental problems and increased risk for periodontal diseases. Objectives: To assess oral hygiene behaviors among pregnant women with diabetes who attended primary health care centers and find out the relationship between oral hygiene behaviors and studied variables. Methodology: A cross sectional design was conducted from 7 July to 30 September 2014 on non probability (convenient sample) of 150 pregnant women with diabetes was selected from twelve Primary Health Care Centers at Baghdad city. Questionnaire format is tool for data collection which had designed and consisted of three main parts including: socio demographic, reproductive characteristics and items of oral hygiene behaviors among pregnant women with diabetes. Reliability of the questionnaire was determined through internal consistency of correlation coefficient (R= 0.940) and validity of content was determined through reviewing it by (12) experts in different specialties and was determined through pilot study. Descriptive and inferential statistics were used to analyze collected data. Result: Result of study revealed that (35.3%) of study sample was (35-39) years old with mean and SD is (X & SD = 33.57 ± 5.54) years, and (34.7%) of the study sample was graduated from primary school and less, half of the study sample was government employment and self employed, (42.7%) of the study sample had moderate socioeconomic status, the highest percentage (70.0%) of the study sample was nonsmokers, The result indicates that oral hygiene behaviors have moderate mean score in all items. There are no statistical significant association between oral hygiene domain and studied variables. Conclusions: All items related to health behavior concerning oral hygiene is in moderate mean of score, which may expose pregnant women with diabetes to high risk of periodontal diseases. Recommendations: Dental care provider should perform a dental examination at least every three months for each pregnant woman with diabetes, explanation of the effect of DM on periodontal health, oral hygiene instruction, oral prophylaxis, professional cleaning and treatment of periodontal diseases(scaling and root planing) when needed.

Keywords: diabetes, health behavior, pregnant women, oral hygiene

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Authors: C. Vázquez, L. M. Gigirey, C. P. del Oro, S. Seoane

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Poor vision is common among older people, and several studies show connections between visual impairment and cognitive function. 15 older adult live in Galician Government nursing homes, and cognitive decline is one of the main reasons of admission. Objectives: (1) To evaluate functional far and near vision of older people with cognitive impairment. (2) To determine connections between visual and cognitive state of “our” residents. Methodology: A total of 364 older adults (aged 65 years or more) underwent a visual and cognitive screening. We tested presenting visual acuity (binocular visual acuity with habitual correction if warn) for distance and near vision (E-Snellen, usual working distance for near vision). Binocular presenting visual acuity less than 0.3 was used as cut point for diagnosis of visual impairment. Exclusion criteria included immobilized residents unable to reach the USC Dual Sensory Loss Unit for visual screening. To screen cognition we employed the mini-mental examination test (Spanish version). Analysis of categorical variables was performed using chi-square tests. We utilized Pearson and Spearman correlation tests and the variance analysis to determine differences between groups of interest (SPSS 19.0 version). Results: the percentage of residents with cognitive decline reaches 32.2% Prevalence of visual impairment for distance and near vision increases among those subjects with cognitive impairment respect those with normal cognition. Shift correlation exists between distance visual acuity and mini-mental test (age and sex controlled), and moderate association was found in case of near vision (p<0.01). Conclusion: First results shows that people with cognitive impairment have poor functional distance and near vision than those with normal cognition. Next step will be to analyse the individual contribution of distance and near vision loss on cognition.

Keywords: visual impairment, cognition, aging, nursing homes

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Authors: A. Marais

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A challenging aspect of teaching cello to novice adult learners is finding adequate lesson material and applying relevant teaching methodologies. It could play a crucial role in adult learners' decision to commence or stop taking music lessons. This study contributes to the theory and practises of continuing education. This study is important to lifelong learning, especially with the focus on adult teaching and learning and the difficulties concerning these themes. The research problem identified for this study is we are not aware of adults' life stories; thus, cello lesson material is not always relevant for adult's specific needs for motivation and goals for starting cello lessons. In my experience, an adult does not necessarily want to play children songs when they learn a new instrument. They want material and lessons fitted to adult learners. Adults also learn differently from younger beginners. Adults ask questions such as how and why, while children more readily accept what is being taught. This research creates awareness of adults' musical needs and learning methods. If every adult shares their own story for commencing and continuing with cello lessons, material should be created, revised, or adapted for more individually appropriate lessons. A number of studies show that adults taking music lessons experience a decrease in feelings of loneliness and isolation. It gives adults a sense of wellbeing and can help improve immune systems. The purpose of this research study will be to discover the life stories of adult amateur cellists. At this stage in the research, the life stories of amateur cellists can generally be defined as personal reflections of their motivations for and experiences of commencing and continuing with individual lessons. The findings of this study will contribute to the development of cello lesson material for adult beginners based on their stories. This research could also encourage adults to commence with music lessons and could, in that way, contribute to their quality of life. Music learners become aware of deep spiritual, emotional, and social values incorporated or experienced through musical learning. This will be a qualitative study with a narrative approach making use of oral history. The chosen method will encapsulate the stories of amateur individual adults starting and continuing with cello lessons. The narrative method entails experiences as expressed in lived and told stories of individuals. Oral history is used as part of the narrative method and entails gathering of personal reflections of events and their cause and effects from an individual or several individuals. These findings from this study will contribute to adult amateur cellists' motivations to continue with music lessons and inspire others to commence. The inspiring life stories of the amateur cellists would provide insight into finding and creating new cello lesson material and enhance existing teaching methodologies for adult amateur cellists.

Keywords: adult, amateur, cello, education, learning, music, stories

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Authors: A. Alhusban, M. Alqawasmeh, F. Alfawares

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Introduction: Diabetes is a chronic health problem and a major risk factor of stroke. A number of therapeutic modalities exist for diabetes management. It’s still unknown whether the different oral hypoglycemic agents would ameliorate the detrimental effect of diabetes on stroke severity. The objective of this work is to assess the effect of pretreatment with oral hypoglycemic agents, insulin and their combination on stroke severity at presentation. Patients and Methods: Patients admitted to the King Abdullah University Hospital (KAUH)-Jordan with ischemic stroke between January 2015 and December 2016 were evaluated and their comorbid diseases, treatment on admission and their neurologic severity was assessed using the National Institute of Health Stroke Scale (NIHSS) were documented. Stroke severity was compared for non-diabetic patients and diabetic patients treated with different antidiabetic agents. Results: Data from 324 patients with acute stroke was documented. The median age of participants was 69 years. Diabetes was documented in about 50% of the patients. Multinomial regression analysis identified diabetes treatment status as an independent predictor of neurological severity of stroke (p=0.032). Patients treated with oral hypoglycemic agents had a significantly lower NIHSS as compared to nondiabetic patients and insulin treated patients (p < 0.02). The positive effect of oral hypoglycemic agents was blunted by insulin co-treatment. Insulin did not alter the severity of stroke as compared to non-diabetics. Conclusion: Oral hypoglycemic agents may reduce the severity of neurologic deficit of ischemic stroke and may have neuroprotective effect.

Keywords: diabetes, stroke, neuroprotection, oral hypoglycemic agents

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Authors: Reenu Yadav, S. K. Yadav

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Herbal therapy has been used for daily oral health care to prevent, treat or cure oral conditions from halitosis to periodontal diseases. The importance of mouth and teeth cleanliness has been recognized from the earliest days of civilization to the 21st century. In the present study, leaves and seeds of Cordia obliqua and barks and twigs of Beautea monosperma, which is used traditionally for oral diseases was evaluated for its antimicrobial activity. The antimicrobial activity tests indicated that the methanolic extract exhibited stronger activities against the commonly encountered oral bacterial and fungal pathogens. The mouthwash formulation prepared and it is compared with marketed formulation HiOra. The results indicated that the herbal mouthwash could inhibit the growth of oral pathogens and may prevent plaque and other periodontal diseases caused by dental pathogens.

Keywords: herbal mouthwash, bio medicine, life sciences, herbal extracts

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Authors: Cytha Nilam Chairani, Ditha Noviantika, Hidayati Amir, Nurul Khairiyah, Siti Rahmadita, Fadila Khairani

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Background: Dental caries is one of the most common diseases with high prevalence in children. The first permanent molar (FPM) has an essential role in establishing the occlusion. Nevertheless, FPM is very prone to caries because of various factors, such as their anatomical structure and early emergence in oral cavity. It is due to the little knowledge from parents and children regarding the timing of emergence of FPM in oral cavity which is still considered as primary teeth. Furthermore, the lack of knowledge from parents and children may affect their oral hygiene practice resulting to carious process. Objective: The aim of this study was to assess the status of FPM caries and its association with children’s oral hygiene practice in 9-12-year-old school children in Lubuk Kilangan Community Health Centre, Padang City. Methods: A cross-sectional study was performed in 50 school children (9-12 years old) using random sampling technique from two randomly selected schools in Lubuk Kilangan Community Health Centre, Padang City. A questionnaire was developed from other studies consisting of four closed ended questions regarding oral health practice. The data obtained were analyzed statistically using Mann-Whitney Test to assess the status of FPM caries and its association with children’s oral hygiene practice. Results: The results showed that 32% of children had FPMs sound and the remaining 68% had FPMs carious which were grouped into 1-2 FPMs carious (60%) and 3-4 FPMs carious (8%). The caries status of mandibular FPM (64%) was higher compared to maxillary FPM (10%). Conclusion: There was significant association in subject who did not visit dentist in the last 6 months which had more carious FPMs compared to subject who visited dentist (p < 0.05). There was no significant association between the status of FPM caries and knowledge of the timing eruption of FPM, oral hygiene instruction from parents and tooth brushing (p > 0.05).

Keywords: dental caries, children, first permanent molar, oral hygiene practice

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Authors: Karen J. Polvado, Betty Bowles, Jansen Lauren, Gibson Martha, Robin Lockhart

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The purpose of this study was to identify motivation to participate in the Hotter ‘n Hell Hundred (HHH) bicycling event, and the participants’ demographics, health risk factors, and preparation to ride in the event. A convenience sample of adults pre-registered for non-competitive cycling events (N = 7,472) were requested to complete a survey. Of these, 2,645 (35%) responded. Questions identified the participants’ demographics, preparation, previous experience with HHH, and motives for riding. The HHH attracted riders of all ages (18-80), genders, ethnicities, and educational levels. The majority were males, 40-59 years old, married, college graduates, and identified themselves as non-Hispanic whites. The majority (68%) reported no existing medical conditions, and were normal weight (70%), although 52% had been overweight or obese in the past. Preparation to ride in the HHH varied from riding more than five times a week for the last year, to riding 1-2 times per week one month before the event. Most (93%) had ridden in the HHH an average of 5 times. Motivations to ride included: personal challenge (75%); to experience the HHH ride (57%); a chance to ride with family/friends/coworkers (52%); improving health (47%); fun (33%); challenge by others (15%); part of a weight loss plan (11%); training for another event (10%); and raising money for a cause (2%). The motivation to participate appeared to move from extrinsic to intrinsic motivation as age increased. Exploration of the exercise habits and motivations of older adults (70+) is suggested by this study.

Keywords: cycling, motivation, physical activity, training

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Authors: Sintija Miļuna, Ričards Melderis, Loreta Briuka, Dagnija Rostoka, Ingus Skadiņš, Juta Kroiča

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Objectives Smokeless tobacco products in Latvia become more available and favorable to young adults, especially students and athletes like hockey and floorball players. The aim of the research was to detect visual mucosal changes in the oral cavity in smokeless tobacco users and to evaluate pro - inflammatory and anti - inflammatory cytokine (IL-6, IL-1, IL-8, TNF Alpha) levels in saliva from smokeless tobacco users. Methods A smokeless tobacco group (n=10) and a control group (non-tobacco users) (n=10) were intraorally examined for oral lesions and 5 ml of saliva were collected. Saliva was analysed for Il-6, IL-1, Il-8, TNF Alpha using ELISA Sigma-Aldrich. For statistical analysis IBM Statistics 27 was used (Mann - Whitney U test, Spearman’s Rank Correlation coefficient). This research was approved by the Ethics Committee of Rīga Stradiņš University No.22/28.01.2016. This research has been developed with financing from the European Social Fund and Latvian state budget within the project no. 8.2.2.0/20/I/004 “Support for involving doctoral students in scientific research and studies” at Rīga Stradiņš University. Results IL-1, IL-6, IL-8, TNF Alpha levels were higher in the smokeless tobacco group (IL-1 83.34 pg/ml vs. 74.26 pg/ml; IL-6 195.10 pg/ml vs. 6.16 pg/ml; IL-8 736.34 pg/ml vs. 285.26 pg/ml; TNF Alpha 489.27 pg/ml vs. 200.9 pg/ml), but statistically there is no difference between control group and smokeless tobacco group (IL1 p=0.190, IL6 p=0.052, IL8 p=0.165, TNF alpha p=0.089). There was statistical correlation between IL1 and IL6 (p=0.023), IL6 and TNF alpha (p=0.028), IL8 and IL6 (p=0.005). Conclusions White localized lesions were detected in places where smokeless tobacco users placed sachets. There is a statistical correlation between IL6 and IL1 levels, IL6 and TNF alpha levels, IL8 and IL6 levels in saliva. There are no differences in the inflammatory cytokine levels between control group and smokeless tobacco group.

Keywords: smokeless tobacco, Snus, inflammatory biomarkers, oral lesions, oral pathology

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Authors: Ya-Hui Lee, Ching-Yi Lu, Chien Hung, Hsieh

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The purpose of this study is to explore the difference between state-owned-enterprise employees and the civil servants regarding their future-oriented thinking and retirement planning. The researchers investigated 687 middle age and older adults (345 state-owned-enterprise employees and 342 civil servants) through survey research, to understand the relevance between and the prediction of their future-oriented thinking and retirement planning. The findings of this study are: 1.There are significant differences between these two professions regarding future-oriented thinking but not retirement planning. The results of the future-oriented thinking of civil servants are overall higher than that of the state-owned-enterprise employees. 2. There are significant differences both in the aspects of future-oriented thinking and retirement planning among civil servants of different ages. The future-oriented thinking and retirement planning of ages 55 and above are more significant than those of ages 45 or under. For the state-owned-enterprise employees, however, there is no significance found in their future-oriented thinking, but in their retirement planning. Moreover, retirement planning is higher at ages 55 or above than at other ages. 3. With regard to education, there is no correlation to future-oriented thinking or retirement planning for civil servants. For state-owned-enterprise employees, however, their levels of education directly affect their future-oriented thinking. Those with a master degree or above have greater future-oriented thinking than those with other educational degrees. As for retirement planning, there is no correlation. 4. Self-assessment of economic status significantly affects the future-oriented thinking and retirement planning of both civil servants and state-owned-enterprise employees. Those who assess themselves more affluently are more inclined to future-oriented thinking and retirement planning. 5. For civil servants, there are significant differences between their monthly income and retirement planning, but none with future-oriented thinking. As for state-owned-enterprise employees, there are significant differences between their monthly income and retirement planning as well as future-oriented thinking. State-owned-enterprise employees who have significantly higher monthly incomes (1,960 euros and above) have more significant future-oriented thinking and retirement planning than those with lower monthly incomes (1,469 euros and below). 6. The middle age and older adults of both professions have positive correlations with future-oriented thinking and retirement planning. Through stepwise multiple regression analysis, the results indicate that future-oriented thinking and retirement planning have positive predictions. The authors then present the findings of this study for state-owned-enterprises, public authorities, and older adult educational program designs in Taiwan as references.

Keywords: state-owned-enterprise employees, civil servants, future-oriented thinking, retirement planning

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Authors: Suhathai Tosangwarn, Philip Clissett, Holly Blake

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Background: High prevalence of depression has been reported among older adults living in care homes in Thailand, associated with physical impairment, low social support, low self-esteem and particularly stigma associated with living in a care home. However, little is understood about how such stigma is experienced among Thai care home residents. This study examines residents’ perceptions of stigma and their strategies for coping with stigma. Method/Design: Case study research was used to gain an in-depth view about the stigma of residents’ perspectives and experiences from two care homes in the northeast of Thailand by conducting an in-depth interview and non-participant observation. Qualitative interviews were conducted with 30 older residents (aged >60 years), purposively sampled from both care homes. Non-participant observation was conducted in various public spaces of the care homes, including the dining room, corridors, and activities areas for approximately one to two hours per day at different times; morning and afternoon including weekdays and weekend in both care homes for one month. Thematic analysis was used to analyse the data. Results: The study identified three major themes related to the causes of stigma, the reactions towards stigma and the mitigating factors. Negative beliefs about care homes, negative attitudes, and stereotypes toward the elderly and perceptions of unequal power relations between staff and residents were the main factors precipitating stigma. Consequently, residents exhibited negative emotions and behaviours, including depressive symptoms, while living in care homes. Residents reported the use of particular coping strategies, including accessing support from the public and staff and engaging in care home activities which these helped them to cope with their perception of stigma. Conclusion: Improved understanding of the underlying factors behind perceived stigma in care home residents may help to prevent depression and reduce perceptions of stigma associated with living in a care home, by informing strategy, supportive intervention and guidelines for appropriate care for older Thai residents.

Keywords: care home, depression, older adult, stigma, Thailand

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Authors: Mai Ashraf Talaat

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Background: Vitamin C (ascorbic acid) is an essential nutrient for the development and repair of all body tissues. It can be obtained from a healthy diet or through supplementation. Due to its importance, vitamin C has become a mainstay in the treatment and prevention of many diseases and in maintaining immune, skin, bone and overall health. This review article aims to discuss the studies and case reports conducted to evaluate the effect of Vitamin C on oral health and the recent advances in oral medicine that involve the use of vitamin C. Data/Sources: The review was conducted for clinical studies, case reports and published literature in the English language that addresses this topic. An extensive search in the electronic databases of PubMed, PubMed Central, Web of Science, National Library of Medicine and ResearchGate was performed. Conclusion: Vitamin C is thought to treat periodontal diseases and gingival enlargement. It also affects biofilm formation and therefore, it helps in reducing caries incidence. Recently, vitamin C mesotherapy has been used to treat inflamed gingiva, bleeding gums and gingival hyperpigmentation. More research and randomized controlled trials are needed on this specific topic for more accurate judgment. Clinical significance: A minimally invasive approach - the usage of vitamin C in dental care could drastically reduce the need for surgical intervention.

Keywords: oral health, periodontology, vitamin C, Gingivitis

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Authors: Nepton Kiani

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Dental decay is one of the most common chronic diseases worldwide and imposes significant costs annually on people and healthcare systems. Addressing this issue is among the important programs of the World Health Organization in the field of oral and dental disease prevention and health promotion. In this context, oral and dental health in vulnerable groups, especially pregnant women, is of greater importance due to the health maintenance of the mother and fetus. The aim of this study is to investigate the DMFT index and various factors affecting it in order to identify different factors influencing the process of dental decay and to take an effective step in reducing the progression of this disease, control, and prevention. In this cross-sectional descriptive study, 120 pregnant women attending Nepton Policlinica clinic in Malaga, Spain, were evaluated for the DMFT index and oral and dental hygiene. In this regard, interviews, precise observations, and data collection were used. Subsequently, data analysis was performed using SPSS software and employing correlation tests, Kruskal-Wallis, and Mann-Whitney tests. The DMFT index for pregnant women in three age groups 22-26, 27- 31, and 32-36 years was respectively 2.8, 4.5, and 5.6. The results of logistic regression analysis showed that demographic variables (age, education, job, economic status) and the frequency of brushing and flossing lead to preventive behavior up to 49.58 percent (P<0.05). Generally, the results indicated that oral and dental care during pregnancy is poor. Only a small number of pregnant women regularly used toothbrush and dental floss or visited the dentist regularly. On the other hand, poor performance in adopting oral and dental care was more observed in pregnant women with lower economic and educational status. The present study showed that raising the level of awareness and education on oral and dental health in pregnant women is essential. In this field, it is necessary to focus on conducting educational-care courses at the level of healthcare centers for midwives, healthcare personnel, and at the community level for families, to prevent and perform dental treatments before the pregnancy period

Keywords: Malaga, oral and dental health, pregnant women, Spain

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Authors: Sreelekha Prakash, Yulong Gu

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Background: About 61% of adults surveyed across 25 states reported they had experienced at least one type of Adverse Childhood Experience (ACE) before 18 years of age. Relationships between ACEs and a variety of substance-related behaviors and behavioral health have been reported in previous studies. ACEs can have lasting, negative effects on health, well-being, as well as life opportunities such as education and job potential. Objectives: For the current research, the aim was to assess the factors affecting substance use behavior in young adults. The further onset of drug use and its association was analyzed with ACEs and mental health. Method: The young adults from a county in the north-eastern United States were invited to participate in an online questionnaire survey with prior consent through an IRB approved study. The Survey included questions related to social determinants of health, 10 item ACE questionnaire, and substance use related to Alcohol, Marijuana, Opioids, Stimulants, and other drugs. PHQ-9 questionnaire was used to assess cognitive health. Results: Data was analyzed for the 244 completed surveys {68% (165) were females, and 78% (190) were Whites}. The average age of the participants was 26.7 years, and approximately 80% were lifelong residents of the county or year-round residents. Of the respondents, 50% (122) were high school graduates with some college education, and 56% (136) had a full-time jobs. Past 30-day usage for alcohol was 76% (72), and marijuana was 28.4% (27). The data showed that the higher the ACE scores, the younger they start using any substance (p < 0.0001). The data for PHQ-9 and ACE scores showed that the higher the ACE score, the higher the PHQ-9 score, with a significant p-value (p 0.0001). The current data also showed a significant association with other drugs; marijuana use showed significance for 30 days of use (p 0.0001), stimulant use (0.0008), prescription drug misuse (0.01), and opioids (0.01). Conclusion: These findings further support the association between ACEs and initiation of drug use and its correlation with mental health symptoms. Promoting a safe and supportive environment for children and youth in their earlier ages can prevent the youth and young adults from the effects of drug use and create healthy living habits for young adults.

Keywords: subtance use, young adults, adverse childhood experience, PHQ-9

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Authors: Rina Yadav, Lih-Yau Song

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The claim for elderly care center has increased enormously with the world demographic revolution as the number of senior citizens increased in the 21st century. As per the world progress into contemporaneousness, a large number of people are engaged in daily routine to bring about the senior citizens to lose the care that they in fact need. New design suggestions have been made on the basis of available guidelines and two case studies in Taiwan. Interior design can provide positive and sensory stimulation through memory stimulation, and by creating a friendly and comfortable environment for demented older people, which can reduce patient anxiety and reduce stress on caregivers. This report pursues to reveal the better design of an elderly care center with a new tactic in a direction to offer better service for demented elderly people which could upraise their living standard.

Keywords: daycare center, dementia patients, interior designing, older adults

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Authors: Zakaria Mowafy Emam Mowafy, Hamed Abd Allah Hamed, Marwa Mahmoud Abd-Elmotalb, Andrew Anis Fakhray Mosaad

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The purpose of this paper is to determine the efficacy of polarized light therapy for chemotherapy-treated cancer patients who have oral mucositis. Methods of evaluation are the measurement of the WHO oral mucositis scale and the common toxicity criteria scale. Methods: Thirty cancer patients receiving chemotherapy (males and females) who had oral mucositis and ulceration pain, and their ages ranged from 30 to 55 years, were divided into two groups. Group (A), composed of 15 patients, received the Bioptron light therapy (BLT) in addition to the routine medical care of oral mucositis. Group (B) received only the routine medical care of oral mucositis; the duration of the BLT application was 10 minutes applied daily for 30 days. Results and conclusion: Results showed that the application of the BLT had valuable healing effects on oral mucositis in cancer patients receiving chemotherapy, as evidenced by the high decreases of the WHO oral mucositis scale and the common toxicity criteria scale.

Keywords: Bioptron light therapy, oral mucositis, WHO oral mucositis scale, common toxicity criteria scale

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Authors: Sara Sousa, Veronique Gomes, Nélio Veiga, Maria José Correia

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Objectives: To assess the presence or absence of Streptococcus mutans, Streptococcus gordonii and Streptococcus salivarius in the oral biofilm of children in an elementary school of Viseu, Portugal, and verify the relationship between Streptococcus gordonii and Streptococcus salivarius and the absence of dental caries. Methods: A cross-sectional study was designed with a final sample of 40 children aged 6-11 years old. Oral examination was accomplished with the identification of their oral health status and oral biofilm collection. Analysis of biological samples by molecular techniques of DNA isolation and identification of three Streptococci bacteria by Polimerase Chain Reaction (PCR) was made. Results: We identified Streptococcus salivarius and Streptococcus gordoni only in the lower interincisal region. These species were also present mainly in the first permanent non-decayed molars. On the contrary, Streptococcus mutans was found mostly in decayed first permanent molars. Conclusion: This preliminary study establishes a possible association between the absence of dental caries and the presence of Streptococcus gordonii and Streptococcus salivarius. Since these two species are described as alkali producers, it is suggested that their presence somehow confers protection against caries. These results support new dental caries prevention strategies based on oral biofilm modulation by enrichment with alkalinogenic species.

Keywords: dental caries, oral biofilm, Streptococcus gordonii, Streptococcus salivarius

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Authors: M. Pawlaczyk-Łuszczyńska, T. Wszołek, A. Dudarewicz, P. Małecki, M. Kłaczyński, A. Bortkiewicz

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Human tolerance to infrasound is defined by the hearing threshold. Infrasound that cannot be heard (or felt) is not annoying and is not thought to have any other adverse or health effects. Recent research has largely confirmed earlier findings. ISO 7196:1995 recommends the use of G-weighted characteristics for the assessment of infrasound. There is a strong correlation between G-weighted SPL and annoyance perception. The aim of this study was to propose exposure limits for infrasound from wind turbines. However, only a few countries have set limits for infrasound. These limits are usually no higher than 85-92 dBG, and none of them are specific to wind turbines. Over the years, a number of studies have been carried out to determine hearing thresholds below 20 Hz. It has been recognized that 10% of young people would be able to perceive 10 Hz at around 90 dB, and it has also been found that the difference in median hearing thresholds between young adults aged around 20 years and older adults aged over 60 years is around 10 dB, irrespective of frequency. This shows that older people (up to about 60 years of age) retain good hearing in the low frequency range, while their sensitivity to higher frequencies is often significantly reduced. In terms of exposure limits for infrasound, the average hearing threshold corresponds to a tone with a G-weighted SPL of about 96 dBG. In contrast, infrasound at Lp,G levels below 85-90 dBG is usually inaudible. The individual hearing threshold can, therefore be 10-15 dB lower than the average threshold, so the recommended limits for environmental infrasound could be 75 dBG or 80 dBG. It is worth noting that the G86 curve has been taken as the threshold of auditory perception of infrasound reached by 90-95% of the population, so the G75 and G80 curves can be taken as the criterion curve for wind turbine infrasound. Finally, two assessment methods and corresponding exposure limit values have been proposed for wind turbine infrasound, i.e. method I - based on G-weighted sound pressure level measurements and method II - based on frequency analysis in 1/3-octave bands in the frequency range 4-20 Hz. Separate limit values have been set for outdoor living areas in the open countryside (Area A) and for noise sensitive areas (Area B). In the case of Method I, infrasound limit values of 80 dBG (for areas A) and 75 dBG (for areas B) have been proposed, while in the case of Method II - criterion curves G80 and G75 have been chosen (for areas A and B, respectively).

Keywords: infrasound, exposure limit, hearing thresholds, wind turbines

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Authors: Ming-Juei Chang, Hui-Ing Ma, Tsung-Hsueh Lu

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Introduction: Because of the advance of medical care (e.g., ventilation techniques and gastrostomy feeding), more and more children with CP can live to adulthood. However, little is known about the use of health care services from children to adults who have CP. The patterns of utilization of ambulatory care are heavily influenced by insurance coverage and primary care gatekeeper regulation. The purpose of this study was to examine patterns of ambulatory care utilization among individuals with CP in Taiwan, a country with universal coverage and no gatekeeper regulation. Methods: A representative sample of one million patients (about 1/23 of total population) covered by Taiwan’s National Health Insurance was used to analyze the ambulatory care utilization in individuals with CP. Data were analyzed by 3 different age groups (children, youth and adults) during 2000 to 2003. Participants were identified by the presence of CP diagnosis made by pediatricians or physicians of physical and rehabilitation medicine and stated at least three times in claims data. Results: Annual rates of outpatient physician visits were 31680 for children, 16492 for youth, and 28617 for adults with CP (per 1000 persons). Individuals with CP received over 50% of their outpatient care from hospital outpatient department. Higher use of specialist physician services was found in children (54.7%) than in the other two age groups (28.4% in youth and 18.8% in adults). Diseases of respiratory system were the most frequent diagnoses for visits in both children and youth with CP. Diseases of the circulatory system were the main reasons (24.3%) that adults with CP visited hospital outpatient care department or clinics. Conclusion: This study showed different patterns of ambulatory care utilization among different age groups. It appears that youth and adults with CP continue to have complex health issues and rely heavily on the health care system. Additional studies are needed to determine the factors which influence ambulatory care utilization among individuals with CP.

Keywords: cerebral palsy, health services, lifespan, universal coverage

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Authors: Taner Ersoz, Filiz Ersoz

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This study was designed enable application of multivariate technique in the interpretation of categorical data for measuring health care services satisfaction in Turkey. The data was collected from a total of 17726 respondents. The establishment of the sample group and collection of the data were carried out by a joint team from The Ministry of Health and Turkish Statistical Institute (Turk Stat) of Turkey. The multiple correspondence analysis (MCA) was used on the data of 2882 respondents who answered the questionnaire in full. The multiple correspondence analysis indicated that, in the evaluation of health services females, public employees, younger and more highly educated individuals were more concerned and complainant than males, private sector employees, older and less educated individuals. Overall 53 % of the respondents were pleased with the improvements in health care services in the past three years. This study demonstrates the public consciousness in health services and health care satisfaction in Turkey. It was found that most the respondents were pleased with the improvements in health care services over the past three years. Awareness of health service quality increases with education levels. Older individuals and males would appear to have lower expectancies in health services.

Keywords: multiple correspondence analysis, multivariate categorical data, health care services, health satisfaction survey

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Authors: Tetiana Boriak

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The study is called to test correlation between official sources, preserved in the archives, and “unofficial” oral history regarding the Great Famine of 1932–1933 in Ukraine. The research shows poor preservation of the sources, being deliberately destroyed by the totalitarian regime. It involves analysis of five stages of Holodomor oral history development. It is oral history that provides the mechanism of mass killing. The research proves that using only one type of historical sources leads to a certain line of reading history of the Holodomor, while usage of both types provides in-depth insight in the history of the famine.

Keywords: the Holodomor (the Great Famine), oral history, historical source, historical memory, totalitarianism.

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Authors: Adama NS Bah

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Background: Loss of teeth has a negative influence on essential oral functions such as phonetics, mastication, and aesthetics. Dentists treat people with prosthodontic rehabilitation to recover essential oral functions. The oral health quality of life inventory reflects the success of prosthodontic rehabilitation. In many countries, the current conventional care delivered to replace missing teeth for adult patients involves the provision of removable partial dentures. Aim: The aim of this systematic review and meta-analysis is to gather the best available evidence to determine patients’ oral health-related quality of life improvement after treatment with partial dentures. Methods: We searched electronic databases from January 2010 to September 2019, including PubMed, ProQuest, Science Direct, Scopus and Google Scholar. In this paper, studies were included only if the average age was 30 years and above and also published in English. Two reviewers independently screened and selected all the references based on inclusion criteria using the PRISMA guideline, and assessed the quality of the included references using the Joanna Briggs Institute quality assessment tools. Data extracted were analyzed in RevMan 5.0 software, the heterogeneity between the studies was assessed using Forest plot, I2 statistics and chi-square test with a statistical P value less than 0.05 to indicate statistical significance. Random effect models were used in case of moderate or high heterogeneity. Four studies were included in the systematic review and three studies were pooled for meta-analysis. Results: Four studies included in the systematic review and three studies included in the meta-analysis with a total of 285 patients comparing the improvement in oral health-related quality of life before and after rehabilitation with partial denture, the pooled results showed a better improvement of oral health-related quality of life after treatment with partial dentures (mean difference 5.25; 95% CI [3.81, 6.68], p < 0.00001) favoring the wearing of partial dentures. In order to ascertain the reliability of the included studies for meta-analysis risk of bias was assessed and found to be low in all included studies for meta-analysis using the Cochrane collaboration tool for risk of bias assessment. Conclusion: There is high evidence that rehabilitation with partial dentures can improve the patient’s oral health-related quality of life measured with Oral Health Impact Profile 14. This review has clinical evidence value for dentists treating the expanding vulnerable adult population.

Keywords: meta-analysis, oral health impact profile, partial dentures, systematic review

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Authors: Farzaneh Badinlou, Reza Kormi-Nouri, Monika Knopf

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Studies of adults' episodic memory have found that enacted encoding not only improve recall performance but also retrieve faster during the recall period. The current study focused on exploring the temporal progression of different encoding conditions in younger and older school children. 204 students from two age group of 8 and 14 participated in this study. During the study phase, we studied action encoding in two forms; participants performed the phrases by themselves (SPT), and observed the performance of the experimenter (EPT), which were compared with verbal encoding; participants listened to verbal action phrases (VT). At test phase, we used immediate and delayed free recall tests. We observed significant differences in memory performance as function of age group, and encoding conditions in both immediate and delayed free recall tests. Moreover, temporal progression of recall was faster in older children when compared with younger ones. The interaction of age-group and encoding condition was only significant in delayed recall displaying that younger children performed better in EPT whereas older children outperformed in SPT. It was proposed that enactment effect in form of SPT enhances item-specific processing, whereas EPT improves relational information processing and this differential processes are responsible for the results achieved in younger and older children. The role of memory strategies and information processing methods in younger and older children were considered in this study. Moreover, the temporal progression of recall was faster in action encoding in the form of SPT and EPT compared with verbal encoding in both immediate and delayed free recall and size of enactment effect was constantly increased throughout the recall period. The results of the present study provide further evidence that the action memory is explained with an emphasis on the notion of information processing and strategic views. These results also reveal the temporal progression of recall as a new dimension of episodic memory in children.

Keywords: action memory, enactment effect, episodic memory, school-aged children, temporal progression

Procedia PDF Downloads 248

Authors: Corbel Camille, Le Cerf Flora, Corveleyn Xavier

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Introduction: Aging is a physiological phenomenon accompanied by anatomical and cognitive changes leading to anxiety and pain. This could have significant impacts on quality of life, life expectancy, and the progression of cognitive disorders. Virtual Reality Intervention (VRI) is increasingly recognized as a non-pharmacological approach to alleviate pain and anxiety in children and young adults. However, while recent studies have explored the feasibility of applying VRI in the older population, confirmation through studies is still required to establish its benefits in various contexts. Objective: This pilot study, following a clinical trial methodology international recommendation for VRI in healthcare, aims to evaluate the feasibility and effects of using VRI with a 101-year-old woman residing in a nursing home undergoing weekly painful and anxious wound dressing changes. Methods: Following the international recommendations, this study focused on feasibility and preliminary results. A Single Case Experimental Design protocol consists of two distinct phases: control (Phase A) and personalized VRI (Phase B), each lasting for 6 sessions. Data were collected before, during and after the care, using measures of pain (Algoplus and numerical scale), anxiety (Hospital anxiety scale and numerical scale), VRI experience (semi-structured interview) and physiological measures. Results: The results suggest that the utilization of VRI is both feasible and well-tolerated by the participant. VRI contributed to a decrease in pain and anxiety during care sessions, with a more significant impact on pain compared to anxiety, which showed a gradual and slight decrease. Physiological data, particularly those related to stress, also indicate a reduction in physiological activity during VRI. Conclusion: This pilot study confirms the feasibility and benefits of using virtual reality in managing pain and anxiety in an older adult in a nursing home. In light of these results, it is essential that future studies focus on setting up randomized controlled trials (RCTs). These studies should involve a representative number of older adults to ensure generalizable data. This rigorous, controlled methodology will enable us to assess the effectiveness of virtual reality more accurately in various care settings, measure its impact on clinical parameters such as pain and anxiety, and explore the long-term implications of this intervention.

Keywords: anxiety reduction, nursing home, older adult, pain management, virtual reality

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Authors: Lukasz Grzegorz Broda, Taiwo Oseni, Andrew Stranieri, Rodrigo Marino, Ronelle Welton, Mark Yates

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The oral health of residents in aged care centres in Australia is poor, contributing to infections, hospital admissions, and increased suffering. Although the use of electric toothbrushes has been deployed in many centres, smartbrushes that record and transmit information about brushing patterns and duration are not routinely deployed. Yet, the use of smartbrushes for aged care residents promises better oral care. Thus, a study aimed at investigating the appropriateness and suitability of a smartbrush for aged care residents is currently underway. Due to the peculiarity of the aged care setting, the incorporation of smartbrushes into residents’ care does require careful planning and design considerations. This paper describes an initial design process undertaken through the use of an actor to understand the important elements to be incorporated whilst installing a smartbrush for use in aged care settings. The design covers the configuration settings of the brush and app, including ergonomic factors related to brush and smartphone placement. A design science approach led to an installation re-design and a revised protocol for the planned study, the ultimate aim being to design installations to enhance perceived usefulness, ease of use, and attitudes towards the incorporation of smartbrushes for improving oral health care for aged care residents.

Keywords: smartbrush, applied computing, life and medical sciences, health informatics

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