Common Iatrogenic Complication Research Articles

Factors associated with knowledge and hypoglycemia experience among patients with diabetes mellitus in Ghana: A cross‐sectional study

AbstractBackgroundAmong persons with diabetes on treatment, hypoglycemia is the most common iatrogenic acute metabolic complication. Many factors influence hypoglycemia, highlighting the need for diabetic patients to recognize, and manage these potential factors in order to reduce the rate of hypoglycemia. In this study, we assessed the knowledge, experiences of hypoglycemia, and associated risk factors among Ghanaians with diabetes mellitus (DM).MethodsThis cross‐sectional study included 444 clinically diagnosed DM patients from the Suntreso Government Hospital, who were on treatment for at least a year. A structured validated questionnaire was used to collect sociodemographic, lifestyle, and clinical data from the participants. Statistical analyses were performed using SPSS Version 20.0 and GraphPad Prism 8.0.ResultsMore than half (52.7%) of the study participants had poor knowledge of hypoglycemia. Moreover, 52.9% of diabetics had experienced hypoglycemia. Participants who were in the age groups of 55–64 and 65–80 years, being retired, being diagnosed with diabetes for 11–20 years and more than 20 years, taking in alcohol, and having adequate knowledge were independent determinants of experiencing hypoglycemia.ConclusionKnowledge level of hypoglycemia among Ghanaian diabetics is low. Prompt recognition of risk factors of hypoglycemia and the careful monitoring and management of glycemic levels in high‐risk groups are important to lessen the prevalence of hypoglycemia in these populations.

Pterostilbene-isothiocyanate impedes RANK/TRAF6 interaction to inhibit osteoclastogenesis, promoting osteogenesis in vitro and alleviating glucocorticoid induced osteoporosis in rats

Prolonged glucocorticoid treatment often leads to glucocorticoid-induced osteoporosis (GIOP), a common iatrogenic complication. This study has explored the anti-osteoporotic potential of semi-synthetic compound, pterostilbene isothiocyanate (PTER-ITC) in GIOP rat model and bone formation potential in vitro. Dysregulated bone-remodelling leads to osteoporosis. PTER-ITC has shown anti-osteoclastogenic activity in vitro. However, its molecular target remains unidentified, which has been explored in this study through in silico and experimental approaches. Alizarin Red S and von-Kossa staining, and alkaline phosphatase (ALP) activity showed the osteogenic differentiation potential of PTER-ITC in pre-osteoblastic mouse MC3T3-E1 and human hFOB 1.19 cells, further, confirmed through the expressions of osteogenic markers at transcriptional (RT-qPCR) and translational (immunoblotting) levels. The anti-osteoclastogenic property of PTER-ITC was confirmed through inhibition of actin ring formation in mouse RAW 264.7 and human THP-1 macrophagic cells. Molecular docking and molecular dynamic simulation showed that PTER-ITC inhibited the crucial osteoclastogenic RANK/TRAF6 interaction, which was further confirmed biochemically through co-immunoprecipitation assay. Osteoporotic bone architecture [validated through scanning electron microscopy (SEM), X-ray radiography, and micro-computed tomography (µ-CT)], physiology (confirmed through compression testing, Young’s modulus and stress versus strain output) and histology (verified through hematoxylin-eosin, Alizarin Red S, von-Kossa and Masson-trichrome staining) of PTER-ITC-treated GIOP female Wistar rats were assuaged. Osteoporotic amelioration through PTER-ITC treatment was further substantiated through serum biomarkers, like, parathyroid hormone (PTH), ALP, calcium (Ca2+), Procollagen type I N-terminal propeptide (P1NP), and 25-hydroxy vitamin D. In conclusion, this study identifies the molecular target of PTER-ITC in impeding osteoclastogenesis and facilitating osteogenesis to ameliorate osteoporosis.

INTRA- AND POSTOPERATIVE COMPLICATIONS IN 80 CASES OF GIANT THYROID GLAND TUMOUR

Thyroid Surgery is commonly performed by the general surgeons throughout the world. It is indicated as elective treatment for thyroid neoplasm. During surgery injury to RLN is common complication. Damage to the RLN has been reported as most common iatrogenic complications associated with surgeries of the thyroid gland. Injury to the RLN is most frequent and important cause of morbidity in thyroidectomies. Today most of the complications of thyroid surgery are related to either metabolic derangement or injury to recurrent laryngeal nerve. Other complications include hypoparathyroidism, hematoma, seroma, infection at surgical site, superior laryngeal nerve palsy. Hence before any thyroid surgery patient must be precisely informed the possible complications and their remedies. The present study aims to evaluate intra operative and post operative complications in 80 cases of giant thyroid gland tumours.

Canadian Association of Radiologists Guidance on Contrast Associated Acute Kidney Injury.

Iodinated contrast media (ICM) is one of the most frequently administered pharmaceuticals. In Canada, over 5.4 million computed tomography (CT) examinations were performed in 2019, of which 50% were contrast enhanced. Acute kidney injury (AKI) occurring after ICM administration was historically considered a common iatrogenic complication which was managed by screening patients, prophylactic strategies, and follow up evaluation of renal function. The Canadian Association of Radiologists (CAR) initially published guidelines on the prevention of contrast induced nephropathy in 2007, with an update in 2012. However, new developments in the field have led to the availability of safer contrast agents and changes in clinical practice, prompting a complete revision of the earlier recommendations. This revised guidance document was developed by a multidisciplinary CAR Working Group of radiologists and nephrologists, and summarizes changes in practice related to contrast administration, screening, and risk stratification since the last guideline. It reviews the scientific evidence for contrast associated AKI and provides consensus-based recommendations for its prevention and management in the Canadian healthcare context. This article is a joint publication in the Canadian Association of Radiologists Journal and Canadian Journal of Kidney Health and Disease, intended to inform both communities of practice.

Canadian Association of Radiologists Guidance on Contrast-Associated Acute Kidney Injury.

Purpose:Iodinated contrast media is one of the most frequently administered pharmaceuticals. In Canada, over 5.4 million computed tomography (CT) examinations were performed in 2019, of which 50% were contrast enhanced. Acute kidney injury (AKI) occurring after iodinated contrast administration was historically considered a common iatrogenic complication which was managed by screening patients, prophylactic strategies, and follow-up evaluation of renal function. The Canadian Association of Radiologists (CAR) initially published guidelines on the prevention of contrast induced nephropathy in 2007, with an update in 2012. However, new developments in the field have led to the availability of safer contrast agents and changes in clinical practice, prompting a complete revision of the earlier recommendations.Information sources:Published literature, including clinical trials, retrospective cohort series, review articles, and case reports, along with expert opinions from radiologists and nephrologists across Canada.Methods:The leadership of the CAR formed a working group of radiologists and nephrologists with expertise in contrast administration and patient management related to contrast-associated AKI. We conducted a comprehensive review of the published literature to evaluate the evidence about contrast as a cause of AKI, and to inform evidence-based recommendations. Based on the available literature, the working group developed consensus recommendations.Key Findings:The working group developed 21 recommendations, on screening, choice of iodinated contrast media, prophylaxis, medication considerations, and post contrast administration management. The key changes from the 2012 guidelines were (1) Simplification of screening to a simple questionnaire, and not delaying emergent examinations due to a need for creatinine measurements (2) Prophylaxis considerations only for patients with estimated glomerular filtration rate (eGFR) less than 30 mL/min/1.73 m2 (3) Not recommending the routine discontinuation of any drugs to decrease risk of AKI, except metformin when eGFR is less than 30 mL/min/1.73 m2 and (4) Not requiring routine follow up serum creatinine measurements post iodinated contrast administration.Limitations:We did not conduct a formal systematic review or meta-analysis. We did not evaluate our specific suggestions in the clinical environment.Implications:Given the importance of iodinated contrast media use in diagnosis and management, and the low risk of AKI after contrast use, these guidelines aim to streamline the processes around iodinated contrast use in most clinical settings. As newer evidence arises that may change or add to the recommendations provided, the working group will revise these guidelines.

Dural tear repair surgery comparative analysis: a stitch in time saves nine

PurposeA dural tear is a common iatrogenic complication of spinal surgery associated with a several post-operative adverse events. Despite their common occurrence, guidelines on how best to repair the defect remain unclear. This study uses five post-operative outcomes to the compare repair methods used to treat 106 dural tears to determine which method is clinically favourable.MethodsData were retrospectively collected from Southampton General Hospital’s online databases. 106 tears were identified and grouped per repair method. MANOVA was used to compare the following five outcomes: Length of stay, numbers of further admissions or revision surgeries, length of additional admissions, post-operative infection rate and dural tear associated neurological symptoms. Sub-analysis was conducted on patient demographics, primary vs non-primary closure and type of patch. Minimal clinically important difference (MCID) was calculated via the Delphi procedure.ResultsAge had a significant impact on patient outcomes and BMI displayed positive correlation with three-fifth of the predefined outcome measures. No significant difference was observed between repair groups; however, primary closure ± a patch achieved an MCID percentage improvement with regards to length of original stay, rate of additional admissions/surgeries and post-operative infection rate. Artificial over autologous patches resulted in shorter hospital stays, fewer readmissions, infections and neurological symptoms.ConclusionThis study reports primary closure ± dural patch as the most efficient repair method with regards to the five reported outcomes. This study provides limited evidence in favour of artificial over autologous patches and recommends that dural patches be used in conjunction with primary closure.Level of evidence IDiagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.

Predictive Factors Associated with Ovarian Hyperstimulation Syndrome in Indonesian Women Undergoing IVF

Background: In line with the increasing practice of in-vitro fertilization, it is crucial to pay attention onitscomplications. The most common iatrogenic complication of assisted reproductive technologies (ART)is ovarian hyperstimulation syndrome (OHSS). Several characteristics are useful in identifying high-riskpatients in order to prevent OHSS.Method: This study analysed characteristics of age, body mass index (BMI), antral follicle count (AFC),estradiol levels, and the number of oocytes between two unpaired groups of 20 women with OHSS and 19women, who did not experience OHSS.Results: The characteristics of AFC (p = 0.012), estradiol levels (p <0.001), and the number of oocytes (p<0.001) showed were significantly different between the two groups. Women with higher AFC were morelikely to have OHSS, with OR of 3.33 (95% CI 0.77–14.31). Additionally, women with higher levels ofestradiol and number of oocytes were also more likely to have OHSS, OR 76.5 (95% CI 9.66–605.67) and81 (95% CI 4.2–1561.6), respectively. Other patient’s characteristics did not differ significantly (p> 0.05).Conclusions: Women with AFC above ten follicles, estradiol levels above 3000 pg/ml, and oocytes countof more than 12 were more likely to develop OHSS.

Weight Loss Surgery Increases Risk of Unhealthy Drinking

Weight Loss Surgery Increases Risk of Unhealthy Drinking

Unhealthy Alcohol Use—A Common Iatrogenic Complication of Bariatric Surgery

Unhealthy Alcohol Use—A Common Iatrogenic Complication of Bariatric Surgery

Clinical practice guideline on the prevention and management of neonatal extravasation injury: a before-and-after study design

BackgroundExtravasation injury resulting from intravenous therapies delivered via peripheral intravenous catheters or umbilical and peripherally inserted central venous catheters is a common iatrogenic complication occurring in neonatal intensive care units. This study aimed to evaluate the effectiveness of an evidence-based clinical practice guideline in the prevention and management of neonatal extravasation injury by nurses.MethodsA controlled before-and-after study was conducted in a neonatal unit. The clinical practice guideline was developed, and a multifaceted educational program was delivered to nurses. Neonatal outcomes, including the rates of peripheral intravenous extravasation and extravasation from a central line, were collected at the pre- and post-intervention periods. Post-intervention data for nurses, including the nurses’ level of knowledge and adherence, were collected at six months after the program.Results104 and 109 neonates were recruited in the pre-intervention period (control) and the post-intervention period (intervention), respectively. The extravasation rate before and after the intervention was 14.04 and 2.90 per 1,000 peripheral intravenous catheters days, respectively. The adjusted odds ratio of peripheral intravenous extravasation post-intervention compared with that of pre-intervention was 0.20 (95% confidence interval: 0.05–0.74; p = 0.02) after adjusting for peripheral intravenous catheter days. The extravasation from a central line rate of the control and intervention groups post-intervention was 4.94 and zero per 1,000 central venous catheter days, respectively. Fifty-nine registered nurses were recruited. At six months post-program, there were significant improvements in the nurses’ level of knowledge and adherence.ConclusionsThese findings suggest that the implementation of an evidence-based clinical practice guideline significantly reduced the rate of peripheral intravenous extravasation and extravasation from a central line in neonates. However, to maintain nurses’ knowledge and adherence to the evidence-based practice, the educational program will have to be conducted periodically and incorporated into the nurses’ induction program.Trial registrationClinicalTrials.gov, Identifiers: NCT04321447. Registered 20 March 2020 - Retrospectively registered.

Pathogenesis of glucocorticoid-induced osteoporosis and options for treatment.

Glucocorticoids are widely used to suppress inflammation or the immune system. High doses and long-term use of glucocorticoids lead to an important and common iatrogenic complication, glucocorticoid-induced osteoporosis, in a substantial proportion of patients. Glucocorticoids mainly increase bone resorption during the initial phase (the first year of treatment) by enhancing the differentiation and maturation of osteoclasts. Glucocorticoids also inhibit osteoblastogenesis and promote apoptosis of osteoblasts and osteocytes, resulting in decreased bone formation during long-term use. Several indirect effects of glucocorticoids on bone metabolism, such as suppression of production of insulin-like growth factor 1 or growth hormone, are involved in the pathogenesis of glucocorticoid-induced osteoporosis. Fracture risk assessment for all patients with long-term use of oral glucocorticoids is required. Non-pharmacological interventions to manage the risk of fracture should be prescribed to all patients, while pharmacological management is reserved for patients who have increased fracture risk. Various treatment options can be used, ranging from bisphosphonates to denosumab, as well as teriparatide. Finally, appropriate monitoring during treatment is also important.

Risk of gestational hypertension in pregnancies complicated with ovarian hyperstimulation syndrome.

Ovarian hyperstimulation syndrome (OHSS) is the most common iatrogenic complication due to ovulation stimulation during assisted reproductive technology. Pathophysiology of this syndrome is not completely clarified, and there is no some specific treatment. Human chorionic gonadotropin is considered as the most significant factor in etiopathogenesis of OHSS. The results of some clinical studies related to influence of OHSS on pregnancy are variable. The aim of this study was to investigate hypertensive disease of pregnancies in patients admitted to hospital due to severe forms of OHSS with reference to maternal characteristics. A case control study was conducted at the Obstetrics and Gynaecology Clinic "Narodni Front" and involved 50 patients admitted to hospital due to severe form of OHSS during a period from January 2008 to March 2015. A control group was created based on age and it involved 59 patients with pregnancy achieved with IVF/ICSI during the same period, but in which OHSS did not occur. For comparing mean values of continuous variables, Independent samples t test was applied. Patients with pregnancy complicated by OHSS, had considerably higher rate of hypertension (14% vs. 3.2 %, p=0.046). Pregnancies achieved by IVF/ICSI, being complicated with severe OHSS could be related to gestational hypertension.

The Dark Side of Gadolinium: A Study of Arthrographic Contrast at Extreme Concentrations.

Magnetic resonance arthrography is used to optimally image the detailed intraarticular anatomy of the joint space. A common iatrogenic complication of arthrography is the extra-articular injection of the gadolinium solution in the periarticular tissues; however, a less common complication involves the abnormal concentration of gadolinium within the prepared injectate. The following describes the inadvertent injection of a hyper-concentrated intraarticular solution of gadolinium and the subsequent appearance that resulted in the post-procedure magnetic resonance imaging examination. In addition, an in-vitro experiment was performed to determine the exact etiology of the abnormal magnetic resonance imaging findings that resulted in this case. The subsequent discussion revisits the signal intensity of gadolinium at extreme concentration ranges and proposes modifications of procedure protocol to mitigate the chance of a repeat event.

ИЗУЧЕНИЕ КАЧЕСТВА ЖИЗНИ ПАЦИЕНТОВ ПРИ ОСЛОЖНЕНИЯХ, ВОЗНИКШИХ ПОСЛЕ СТОМАТОЛОГИЧЕСКИХ ВМЕШАТЕЛЬСТВ

Subject. In the practice of a dentist there are patients with complications after dental interventions in the form of post-filling pains and overestimation of fillings, accompanied by intense and constant pain, discomfort and violation of occlusion. Patients turn to the dentist again with complaints of pain in a recently filled tooth, patients note a violation of mastication, loose closing of the jaws, pain in the temporomandibular joint. The subject of this article was the research of the influence of the most common iatrogenic complications in the treatment of caries on the quality of life of patients.
 Goal — improving the effectiveness of therapeutic treatment of tooth decay, taking into account the dynamics of indicators of quality of life for patients.
 Methodology. A survey was conducted of 25 patients aged 20 to 40 years who came to the dental clinic complaining of post-filling pains, pain in the temporomandibular joint and incomplete closure of the jaw using the SF-36 questionnaire and the Russian-adapted OHRQoL questionnaire. Clinical examination methods included questioning, examination, palpation and percussion of teeth.
 Results. After analyzing the results of the adapted OHRQoL questionnaire, it was found that the state of oral health “greatly affects” the quality of life of patients. The average results in a survey of 25 patients amounted to 11.12 points; according to the results of this questionnaire, oral health did not play an insignificant role for any patient. According to the results of the SF-36 questionnaire, quality of life declined on most scales. The largest negative dynamics was noted on a scale of role functioning (RP) of 46 ± 0.03 points out of 100 and vital activity indicators (VT) - 27 ± 0.06 points out of 50. A decrease in the quality of life is caused by a feeling of constant discomfort and pain in the jaw facial area, anxious state of the patient and psychological maladaptation.
 Findings. Dental health plays a significant role in maintaining the high quality of life of any person. Dentists need to timely diagnose pathologists, choose the right treatment tactics, avoiding mistakes, and prevent complications.

Do systemic steroids increase the risk of ocular complication in uveitis patients? Focus on a Italian referral center.

To describe the ocular inflammatory and iatrogenic complications in a cohort of uveitic patients treated in an Italian referral centre. Retrospective non-comparative case series. Medical history and clinical findings of all consecutive patients referred to the uveitis center of Pisa University from January 2015 to January 2017 were reviewed. Only patients with at least three follow-up visits in our center were included in our series. Three hundred and eighty-nine patients were visited in our center during study period; only 142 patients (90 men and 52 female) satisfied the inclusion criteria. Mean age at presentation was 41 ± 14years. The most common ocular feature was anterior uveitis (46%) and was mainly unilateral. A specific etiological diagnosis was established in 61% of patients. At presentation, 71.43% of patients were on medical therapy for rheumatic disease; 42.86% of patients used systemic steroids Cataract and ocular hypertension were the most common ocular complications during the study period but were not statistically related to systemic steroid treatment. Systemic steroids treatment in uveitis patients does not seem to increase the risk of iatrogenic complications such as cataract and glaucoma. In our series, increasing age appears to be the main risk factor for cataract and glaucoma development. Key points • Cataract, ocular hypertension, and glaucoma are the most common iatrogenic complications. • Systemic steroids can be safely used in uveitis patients.

PIN2 BACTERIAL INFECTIONS CAUSED BY INTRAVENOUS SUPPLIES

Blood stream infections (BSIs) caused by intravenous tools are more and more common iatrogenic complications. Infections related to cannulas, especially high morbidity ratio, lethality around 25%, protracted hospitalization and elevated costs are inherent in BSIs. The aim of this study was to assess the detection of health workers according to the emergence of phlebitis’ risk factors, and to map the nurses’ awareness of new protocols and supplies. A descriptive, quantitative, cross-sectional study was carried out within nurses working in a university clinic’s different departments (internal medicine, surgery, intensive care) and in a city hospital’s departments (internal medicine, surgery) between 06.14.2018.-09.05.2018. Assessment was made with a self-made questionnaire that contained questions about socio-demographic data, general knowledge (protocol of hand disinfection, types of peripheral cannulas, bandages, symptoms of phlebitis, pathogens) and tasks related to cannulation of peripheral veins. We calculated descriptive statistics and χ2-test (p<0.05). Results were calculated with Microsoft Excel and SPSS Statistics 20.0. 79.6% of respondents think that peripheral venous cannulas should be changed in every 72 hours, according to an old protocol. Regarding to transparent film dressing, 55.4% of respondents say that it must be changed as regularly as generic gauze dressing. Workers older than 50 years are significantly less aware than their younger colleagues (p=0.02). There was no significant difference between departments and health institutions in the results of knowledge test (number of points) (p>0.05). Health workers are competent in detecting risk factors and early symptoms of phlebitis, however their knowledge is less sufficient about new protocols and supplies. Cannula infections can harden the everyday of health care. Training nurses regularly is important, so their knowledge can unify regardless to work experience and educational attainment, and they can be informed about newest protocols and the proper use of modern tools.

Magnitude of post dural puncture headache and associated factors in obstetric mothers undergone spinal anesthesia for caesarean section

Background: Although modern anesthesiology has made great progress in the last decades, neuraxial anesthesia (NA) is still the keynote of regional blockade. It is popular for its effectiveness in producing anesthesia and analgesia. As the NA techniques popularly used in clinics, post dural puncture headache (PDPH), a common iatrogenic complication resulted from post-spinal taps or accidental dural puncture (ADP) subsequent to epidural block, frequently reported and becomes a challenging to health caregivers. The objective of the study was to assess the magnitude of post dural puncture headache (PDPH) and Associated Factors in Obstetric Mothers Undergone Spinal Anesthesia for Cesarean Section from February 1 – June 30, 2018 Methods and Materials: Institutional based cross-sectional study design conducted in Dilchora Hospital and Sabian Primary Hospital from February 1 – June 30, 2018. 391 obstetric mothers was systematically selected every 2 other patient interval. The data was collect from both patient chart review and interview using structured checklist. Results: 85/391 (21.7%) obstetric mothers present with headache characteristic of post-dural puncture headache (PDPH). Larger gauge spinal needle [AOR= 3.105: 95% CI (1.116 - 8.638), P = 0.03] and multiple spinal attempts [AOR 0.374; 95% CI (0.220 - 0.635) P = 0.000] was statistically significantly related with PDPH after Spinal anesthesia. Conclusion and Recommendation: In our study, we observe a relatively higher prevalence of PDPH (21.7%), as compared to other literatures. Large gauge spinal needles (≥ 23 G) and multiple spinal attempts is also find statistically significantly related with PDPH after Spinal Anesthesia. In order to decrease the higher prevalence of PDPH in those Hospitals, Anesthetists should avoid utilization of large gauge spinal needles, and repeated dural puncture during Spinal Anesthesia.

Assessment of Splints Applied for Pediatric Fractures in an Emergency Department/Urgent Care Environment.

Fractures are common in the pediatric population. The initial evaluation is rarely by an orthopaedic surgeon, but commonly an emergency room or urgent care center physician/extender. This typically involves splint application by a nonorthopaedist to immobilize the extremity and provide stabilization. Iatrogenic injuries from inappropriate splint placement are a potential public health and legal concern that can lead to complications. The primary purpose of this study was to prospectively evaluate the adequacy of all splints placed on patients who presented to a pediatric orthopaedic office; secondary outcomes included assessing prevalence and types of complications that were associated with inadequate splints. Patients aged 0 to 18 years who presented with a splint were prospectively enrolled. Information was obtained regarding demographics of the patient and splint placement. Splints were evaluated for functional position, appropriate length, and presence of elastic bandage on the skin. Photographs were taken of each splint, and the extremity was examined for any soft tissue complications. Splints were not removed in 31 patients who had undergone fracture reduction. In total, 275 patients were prospectively enrolled. Splints were improperly placed in 93%, with application of elastic bandage directly to the skin accounting for 77%. Improper positioning was observed in 59%, and inappropriate splint length was present in 52%. Skin and soft tissue complications were observed in 40%. The most common iatrogenic splint-related complication was excessive edema, seen in 28%. Direct injury to the skin and soft tissue was seen in 6%. Many practitioners incorrectly apply splints, potentially leading to suboptimal results or causing injury. Complications of poor splint placement include excessive swelling, skin breakdown, and poor immobilization. Health care workers who treat pediatric fractures may benefit from more extensive education regarding proper splinting techniques. Level 2-therapeutic study.

Reducing iatrogenic complications in the treatment of cleft lip and palate

Abstract All patients receiving orthodontic treatment with fixed appliances have a significantly higher risk of developing white spot lesions (WSLs), which are considered the most common iatrogenic complication of treatment. Cleft lip and/or palate (CLP) is a common craniofacial anomaly occurring in approximately one in 800 births. Patients affected by cleft lip and/or palate tend to have poorer oral hygiene and a greater risk of WSLs and caries than non-cleft sibling controls. Patients presenting with a cleft lip and/or palate also have a higher prevalence of molar-incisor hypomineralisation (MIH), which suggests that clinicians involved in the oral health management of cleft patients need to consider all available caries prevention protocols. Cases presenting with hypomineralised teeth create more difficulty in bonding attachments to affected enamel using an acid etch technique and a composite resin material due to the abnormal prism structure. The bond strength to hypomineralised enamel can be as low as two-thirds that of the bond strength to unaffected enamel, which may not be adequate for routine fixed appliance treatment. Furthermore, the removal of orthodontic brackets from hypomineralised enamel may lead to more severe damage to the affected teeth. Resin modified glass-ionomer cement (RMGIC), bonded after conditioning the enamel with polyacrylic acid, creates no resin tags as a result of a chemical rather than a mechanical bond. Therefore, there is less enamel loss during bracket debonding when compared with acid-etch preparation and composite resin bonding. Furthermore, in cases in which the quality of the enamel is deficient causing limits to the shear bond strength of the acid-etched composite resin, the chemical bonding action of RMGIC overcomes the lack of adherence and protects the enamel. RMGIC has cariostatic properties and clinical evidence supports the routine use of these adhesives for bonding in all fixed appliance cases as a strategy for reducing the incidence of white spot lesions and damage to the enamel during bracket debonding.

Effect of new persistent opioid use on physiologic and psychologic outcomes following bariatric surgery.

New persistent opioid use following surgery is a common iatrogenic complication, developing in roughly 6% of patients after elective surgery. Despite increased awareness of misuse and associated morbidity, opioids remain the cornerstone of pain management in bariatric surgery. The potential impact of new persistent opioid use on long-term postoperative outcomes is unknown. We sought to determine the relationship between new persistent opioid use and 1-year postoperative outcomes for patients undergoing bariatric surgery. Using data from the MBSC registry, we identified patients undergoing primary bariatric surgery between 2006 and 2016. Using previously validated patient-reported survey methodology, we evaluated patient opioid use preoperatively and at 1year following surgery. New persistent use was defined as a previously opioid-naïve patient who self-reported opioid use 1year after surgery. We used multivariable logistic regression models to evaluate the association between new persistent opioid use, risk-adjusted weight loss, and psychologic outcomes (psychological wellbeing, body image, and depression). 27,799 patients underwent primary bariatric surgery between 2006 and 2016. Among opioid-naïve patients, the rate of new persistent opioid use was 6.3%. At 1-year after surgery, patients with new persistent opioid user lost significantly less excess body weight compared to those without new persistent use (57.6% vs. 60.3%; p < 0.0001). Patients with new persistent opioid use had significantly worse psychological wellbeing (35.0 vs. 33.1; p < 0.0001), body image (19.9 vs. 18.0; p < 0.0001), and depression scores (2.4 vs. 5.0; p < 0.0001). New persistent opioid users also reported less overall satisfaction with their bariatric surgery (75.1% vs. 85.7%; p < 0.0001). New persistent opioid use is common following bariatric surgery and associated with significantly worse physiologic and psychologic outcomes. More effective screening and postoperative surveillance tools are needed to identify these patients, who likely require more aggressive counseling and treatment to maximize the benefits of bariatric surgery.