Improvement in Serum Vitamin D Following Dental Rehabilitation to Treat Severe Early Childhood Caries.

Purpose: The purpose of this study was to investigate changes in 25-hydroxyvitamin D (25(OH)D) levels in children with severe early childhood caries (S-ECC) following rehabilitative surgery using general anesthesia (GA). Methods: Children with S-ECC were recruited on the day of surgery for a prospective study investigating changes in nutritional status and well-being before and after surgery. Venipunctures for 25(OH)D were performed while children were in the operating room, and parents completed a questionnaire regarding nutritional intake, oral health, quality of life, and family demographics. Participants returned at a minimum of three months for a follow-up venipuncture, questionnaire, and dental examination. Analyses included descriptive, bivariate, and multivariable regression analyses. A P-value of ≤ 0.05 was significant. Results: Overall, 150 children participated, with a mean age of 47.7±14.1 months. The mean baseline 25(OH)D concentration was 49.8±16.9 nmol/L, with 17 percent having deficient levels. Overall, 106 returned for follow-up. Paired t-tests revealed significant improvements in the mean 25(OH)D levels following rehabilitation (50.1±17.1 nmol/L versus 61.2±18.7, P<0.001). The proportion with optimal and adequate 25(OH)D levels increased from 9.2 percent to 24.1 percent and from 48.3 percent to 67.8 percent, respectively, while those classified as deficient decreased from 17.2 percent to 8.1 percent from baseline to follow-up. Conclusions: Significant improvements in vitamin D concentrations were observed following dental rehabilitation. This provides additional evidence of the association between oral health and nutritional status.

A systematic review to inform the development of a Canadian caries risk assessment tool for use by primary healthcare providers.

BACKGROUND: Caries risk assessment (CRA) tools may assist in identifying children at risk of early childhood caries. AIM: To complete a systematic review of CRA and develop a Canadian CRA tool for preschool children for use in non-dental clinical settings. DESIGN: Systematic searches of relevant databases were conducted. Potential variables were based on strength of associations (odd ratios, relative risk, hazard ratios, etc), frequency of occurrence, and existing CRA tools. Quality of the evidence assessments were performed by at least two review teams through consensus following GRADE. RESULTS: Overall, 25 publications met the inclusion criteria, all prospective in design. Based on this review, variables to be considered when developing a new CRA tool for use with preschool children are as follows: age, socioeconomic status, family toothbrushing habits, fluoride exposure, infant feeding practices, dietary habits/behaviours, dental home, caries experience, visible plaque, and enamel defects. The environmental scan identified 22 CRA tools suggesting other additional variables to consider including in a CRA tool, including special healthcare needs, enamel defects, and dental attendance. CONCLUSIONS: This review informed the development of a Canadian CRA tool for use by primary healthcare professionals, which may improve access to oral health assessments and increase interprofessional collaboration.

Continuation of Angiotensin-Converting Enzyme Inhibitors on the Day of Surgery Is Not Associated With Increased Risk of Hypotension Upon Induction of General Anesthesia in Elective Noncardiac Surgeries.

OBJECTIVE: The aim of this study was to find out whether the preoperative continuation of angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin II receptor blocker (ARB) treatment is associated with intraoperative hypotension immediately after induction of general anesthesia in elective noncardiac surgeries. DESIGN: Retrospective cohort study. SETTING: Single institutional university hospital. PARTICIPANTS: Four hundred patients who underwent elective noncardiac surgery under general anesthesia, with ACE-I or ARB on their list of preoperative home medications, were included. INTERVENTION: Preoperative ACE-I and ARB use was evaluated, and patients were divided into an ACE-I/ARB group versus non-ACE-I/ARB group. MEASUREMENTS: The primary outcome measure was intraoperative hypotension after induction of general anesthesia. The secondary outcome measure was preoperative medication use, medications taken the morning of surgery, induction medication and dosage, and vasopressor medication use during induction. RESULTS: Three hundred forty-nine patients were included for final analysis. The mean admission American Society of Anesthesiologists status was 2.7 ± 0.5, age 65 ± 11 years, and body mass index 31 ± 6.9 kg/m2. There were no statistically significant changes between the no ACE-I/ARB group and the ACE-I/ARB group in systolic blood pressure (p = 0.853), diastolic blood pressure (p = 0.357), and heart rate (p = 0.220) change over the 15 minutes. There was no statistical difference in induction medication dose (propofol, fentanyl, and rocuronium) and pressor use (p = 0.137) for hypotension between the 2 groups. Statistically significant hypotension (p < 0.001) occurred in both groups equally over 15 minutes. CONCLUSION: Continuation of ACE-I/ARB on the day of surgery was not associated with increased risk of intraoperative hypotension upon induction and within 15 minutes of general anesthesia in elective noncardiac surgeries.

The association of body mass index and severe early childhood caries in young children in Winnipeg, Manitoba: A cross-sectional study.

BACKGROUND: Associations between body mass index (BMI) and caries have been reported. AIM: To evaluate the direction of the relationship between BMI and severe early childhood caries (S-ECC). DESIGN: Children were recruited as part of a larger prospective cohort study assessing changes in nutritional status following dental rehabilitation under general anaesthetic. Pre-operative anthropometric measurements were used to calculate BMI z-scores (BMIz). Operative reports were reviewed to calculate caries scores based on treatment rendered. Analysis included descriptive statistics, bivariate analyses, and simple and multiple linear regression. RESULTS: Overall, 150 children were recruited with a mean age of 47.7 ± 14.2 (SD) months; 52% female. Over 42% were at risk for overweight, overweight or obese. Although simple linear regression demonstrated a significant positive association between dmfs score and BMIz, adjusted multiple linear regression found no significant relationship between BMIz and dmfs, but highlighted a relationship between BMI z-score and family income, Registered First Nations Status and physical activity. CONCLUSIONS: Although a significant relationship between BMI and S-ECC was not found, poverty was a key confounding variable. As both S-ECC and obesity are known predictors of future disease, it is important for healthcare professionals to identify children at risk. Diet and behaviour modification may play a role in disease prevention.

Oral Health-Related Quality of Life of Canadian Preschoolers with Severe Caries After Dental Rehabilitation Under General Anesthesia.

Purpose: The purpose was to determine changes in the oral health-related quality-of-life (OHRQoL) of children with severe early childhood caries (S-ECC) following dental rehabilitation under general anesthesia (DRGA). Methods: This prospective cohort study involved caregivers completing questionnaires, including the Early Childhood Oral Health Impact Scale (ECOHIS). Data analysis included descriptive statistics, bivariate analyses, effect size, and multiple linear regression. Results: Initially, 150 children were enrolled, mean age of 47.7±14.2 (SD) months. The baseline mean total ECOHIS score was 6.3±5.3. Higher baseline ECOHIS scores were associated with single-parent families, low-income house-holds, higher decayed, missing, and filled primary teeth (dmft) scores, and having extractions (P ≤ 0.05). Multiple linear regression results showed low household income (P=0.01) and the child not having Registered First Nation status (a specific population of Indigenous Canadians; P=0.03) were significantly and independently associated with higher total baseline ECOHIS scores. At follow-up, 103 children had a mean total ECOHIS score of 3.5±2.9 versus a baseline score of 6.3±5.4. Change in total ECOHIS and three of four Child Impact Section domains showed significant improvement (P<0.001) post-DRGA. Worse follow-up ECOHIS scores were only associated with the child being male (P=0.02). Conclusions: Improvements in oral health-related quality of life were observed following DRGA. Consideration should be given for using the Early Childhood Oral Health Impact Scale to help prioritize children waiting for DRGA. (Pediatr Dent 2019;41(3):221-8) Received November 22, 2018 | Last Revision February 28, 2019 | Accepted April 1, 2019.

Beyond hands-on and hands-off: supervisory approaches and entrustment on the inpatient ward.

CONTEXT: The concept of entrustment has garnered significant attention in medical specialties, despite variability in supervision styles and entrustment decisions. There is a need to further study the enactment of supervision on inpatient wards to inform competency-based assessment design. METHODS: Attending physicians, while supervising on clinical teaching inpatient wards, were invited to describe a recent moment of enacting supervision with an internal medicine resident. Constructivist grounded theory guided data collection and analysis. Interview transcripts were analysed in iterative cycles to inform data collection. Constant comparison was used to build a theory of supervision from the identified themes. RESULTS: In 2016-2017, 23 supervisors from two Canadian universities with supervision reputations ranging from very involved to less involved participated in one or two interviews (total: 28). Supervisors were not easily dichotomised into styles based on behaviour because all used similar oversight strategies. Supervisors described adjusting between 'hands-on' (e.g. detail oriented) and 'hands-off' (e.g. less visible on ward) styles depending on the context. All also contended with the competing roles of clinical teacher and care provider. Supervisors made a distinction between the terms `entrust' and `trust', and did not grant complete entrustment to senior residents. CONCLUSIONS: We propose that a supervisor's perceived responsibility for the ward underlies adjustments between 'hands-on' (i.e. personal ward responsibility) and 'hands-off' (i.e. shared ward responsibility) styles. Our approaches to clinical supervision model combines this responsibility tension with the tension between patient care and teaching to illustrate four supervisory approaches, each with unique priorities influencing entrustment. Given the fluidity in supervision, documenting changes in oversight strategies, rather than absolute levels of entrustment, may be more informative for assessment purposes. Research is needed to determine if there is sufficient association between the supervision provided, the entrustment decision made and the supervisor's trust in a trainee to use these as proxies in assessing a trainee's competence.

A rare genetic variant of the ryanodine receptor in a suspected malignant hyperthermia susceptible patient.

Malignant hyperthermia (MH) remains a diagnostic challenge. This case report describes the anesthetic management of a suspected intraoperative MH episode and the subsequent, genetic sequence analysis of 3 genes associated with MH. The results of the molecular genetic testing revealed heterozygosity for a rare variant, c.12553G>A (p.Ala4185Thr), in the RYR1 gene encoding the ryanodine receptor. Although the RYR1 gene has previously been implicated in the pathogenesis of MH, (1) this particular variant has only been reported in one other case of MH; (2) the role for diagnostic genetic testing in the diagnosis of MH will be examined.

'It's a cultural expectation...' The pressure on medical trainees to work independently in clinical practice.

CONTEXT: Medical trainees demonstrate a reluctance to ask for help unless they believe it is absolutely necessary, a situation which could impact on the safety of patients. This study aimed to develop a theoretical exploration of the pressure on medical trainees to be independent and to generate theory-based approaches to the implications for patient safety of this pressure towards independent working. METHODS: In Phase 1, 88 teaching team members from internal and emergency medicine were observed during clinical activities (216 hours), and 65 participants completed brief interviews. In Phase 2, 36 in-depth interviews were conducted using video vignettes. Data collection and analysis employed grounded theory methodology. RESULTS: Participants conceived that the pressure towards independence in clinical work originated in trainees' desire to lay claim to the identity of a doctor (as a member of a group of autonomous high achievers), and in organisational issues such as heavy workloads and constant evaluations. DISCUSSION: The identity and organisational issues related to the pressure towards independence were explored through the lenses of established theories from education and psychology. Consideration of Lave and Wenger's situated learning theory suggests that giving attention to the 'independent doctor' ideal, through measures such as involving trainees when their supervisors ask for help, could impact the safety of teaching team practice. Amalberti et al.'s migration model explains how pressures to maximise productivity and individual gain may cause teaching teams to migrate beyond the boundaries of safe practice and suggests that managing triggers (such as workload and high-stakes evaluations) for violations of safe practice might improve safety. Implementation and evaluation of these theory-based approaches to the safety of teaching team practice would contribute to a better understanding of the links between trainee independence and patient safety.

Preserving professional credibility: grounded theory study of medical trainees' requests for clinical support.

OBJECTIVE: To develop a conceptual framework of the influences on medical trainees' decisions regarding requests for clinical support from a supervisor. DESIGN: Phase 1: members of teaching teams in internal and emergency medicine were observed during regular clinical activities (216 hours) and subsequently completed brief interviews. Phase 2: 36 in depth interviews were conducted using videotaped vignettes to probe tacit influences on decisions to request support. Data collection and analysis used grounded theory methods. SETTING: Three teaching hospitals in an urban setting in Canada. PARTICIPANTS: 124 members of teaching teams on general internal medicine wards and in the emergency department, comprising 31 attending physicians, 57 junior and senior residents, 28 medical students, and eight nurses. Purposeful sampling to saturation was conducted. RESULTS: Trainees' decisions about whether or not to seek clinical support were influenced by three issues: the clinical question (clinical importance, scope of practice), supervisor factors (availability, approachability), and trainee factors (skill, desire for independence, evaluation). Trainees perceived that requesting frequent/inappropriate support threatened their credibility and used rhetorical strategies to preserve credibility. These strategies included building a case for the importance of requests, saving requests for opportune moments, making a plan before requesting support, and targeting requests to specific team members. CONCLUSIONS: Trainees consider not only clinical implications but also professional credibility when requesting support from clinical supervisors. Exposing the complexity of this process provides the opportunity to make changes to training programmes to promote timely supervision and provides a framework for further exploration of the impact of clinical training on quality of care of patients.

Point-of-care assessment of medical trainee competence for independent clinical work.

BACKGROUND: Clinical supervisors make frequent assessments of medical trainees' competence so they can provide appropriate opportunities for trainees to experience clinical independence. This study explored context-specific assessments of trainees' competence for independent clinical work. METHOD: In Phase One, 88 teaching team members from internal and emergency medicine were observed during clinical activities (216 hours), and 65 participants completed brief interviews. In Phase Two, 36 in-depth interviews were conducted using video vignettes. Data collection and analysis employed grounded theory methodology. RESULTS: Supervisors' assessments of trainee trustworthiness for independent clinical work involved consideration of four dimensions: knowledge/skill, discernment of limitations, truthfulness, and conscientiousness. Supervisors' reliance on language cues as a source of trustworthiness data was revealed. CONCLUSIONS: This study provides an initial exploration of context-specific competence assessments, which affect both patient safety and education, and provides a novel framework for study of the links between language use and competence.