Patients' perspectives on quality and patient safety failures: lessons learned from an inquiry into transvaginal mesh in Australia.

BACKGROUND: Transvaginal mesh (TVM) surgeries emerged as an innovative treatment for stress urine incontinency and/or pelvic organ prolapse in 1996. Years after rapid adoption of these surgeries into practice, they are a key example of worldwide failure of healthcare quality and patient safety. The prevalence of TVM-associated harms eventually prompted action globally, including an Australian Commonwealth Government Senate Inquiry in 2017. METHOD: We analysed 425 submissions made by women (n = 417) and their advocates (n = 8) to the Australian Senate Inquiry, and documents from 5 public hearings, using deductive and inductive coding, categorisation and thematic analysis informed by three 'linked dilemmas' from healthcare quality and safety theory. We focused on women's accounts of: a) how harms arose from TVM procedures, and b) micro, meso and macro factors that contributed to their experience. Our aim was to explain, from a patient perspective, how these harms persisted in Australian healthcare, and to identify mechanisms at micro, meso and macro levels explaining quality and safety system failure. RESULTS: Our findings suggest three mechanisms explaining quality and safety failure: 1. Individual clinicians could ignore cases of TVM injury or define them as 'non-preventable'; 2. Women could not go beyond their treating clinicians to participate in defining and governing quality and safety; and. 3. Health services set thresholds for concern based on proportion of cases harmed, not absolute number or severity of harms. CONCLUSION: We argue that privileging clinical perspectives over patient perspectives in evaluating TVM outcomes allowed micro-level actors to dismiss women's lived experience, such that women's accounts of harms had insufficient or no weight at meso and macro levels. Establishing system-wide expectations regarding responsiveness to patients, and communication of patient reported outcomes in evaluation of healthcare delivery, may help prevent similar failures.

Estrangulated obturatory hernia. Case report of a challenging diagnosis of obstructive syndrome.

INTRODUCTION AND IMPORTANCE: Obturator hernia accounts for less than 1 % of all documented cases of pelvic hernias. It most commonly presents as an obstructive syndrome in elderly, multiparous, slim women, characterized by a wider pelvis that facilitates the passage of the hernia sac through the obturator foramen alongside the obturator nerve. In this case, adhering to the SCARE (Updating Consensus Surgical CAse REport) checklist criteria, we present a typical scenario involving an elderly woman who was initially misdiagnosed with a fecaloma, concealing an obturator hernia. CASE REPORT: An 85-year-old patient, displaying prodromal signs of senile disease, presented for medical attention with incapacitating abdominal pain in the right iliac fossa, accompanied by nausea and vomiting. Rectal examination revealed the presence of a fecaloma, and glycerin administration was performed rectally. The patient's condition worsened with the development of mental confusion and hyperactive delirium. Abdominal Computer tomography scan (CT scan) revealed right obturator hernia with enteral segment insinuation and dilation of the proximal bowel. An infraumbilical laparotomy was performed. The herniation of an ileal segment and the right ovary through the obturator foramen was identified. The content proved irreducible to manual maneuvers, leading to obturator muscle section following the dissection of the Retzius space. The right round ligament of the uterus was sectioned, and we manage to preserve the Obturatory branch of the lumbar plexus throughout dissection. A polypropylene mesh was positioned and secured with non-absorbable sutures on the Cooper's ligament, iliac crest, and obturator muscle and segmental enterectomy with primary anastomosis using a linear stapler was performed. CLINICAL DISCUSSION: This demanding case brings to the spotlight the importance of reevaluating even the usual cases. We provide our experience bringing together an unusual diagnosis after the conduction of a once diagnosed fecaloma that almost went down to a perforated acute abdomen. Hence the importance of suspect obturator hernia in unknown obstructive abdomen in elderly women. CONCLUSION: With this report we aim to raise awareness of careful propaedeutic inquiry of acute abdomen. We provide our experience bringing together the diagnosis that agrees with our literature review. Elderly patients commonly challenge the clinical evaluation, especially those with signs of senile disease. Thereby, inkling hidden diagnosis in typical scenarios can improve the patient's care in emergency settings.

Fortuitous detection of adult malrotated ectopic kidney during acute appendicitis: A unique case report.

INTRODUCTION AND IMPORTANCE: Renal ectopia, a rare congenital anomaly, can occur in various body regions and may be associated with other abnormalities. It is often asymptomatic, commonly found incidentally, as in our 70-year-old patient during appendicitis exploration. This case highlights the importance of recognizing renal ectopia and associated anomalies, such as vascular abnormalities and renal malrotation, which may predispose patients to potential complications and require vigilant monitoring for urinary tract infections and lithiasis events, as well as potential challenges during laparoscopic surgical procedures, as in our appendectomy case. CASE PRESENTATION: A 70-year-old female presented with right iliac fossa pain and elevated inflammatory markers. Abdominopelvic CT scan confirmed uncomplicated appendicitis and revealed a right ectopic and malrotated kidney. Laparoscopic appendectomy was performed without complications. Postoperative recovery was uneventful, and discharge occurred one day post-procedure. A four-week follow-up was scheduled to monitor for urinary infection and stone formation, with initiation of hygienic and dietary measures. CLINICAL DISCUSSION: Renal ectopia, a congenital anomaly, frequently positions the kidneys in the pelvic region. Iliac ectopias are often confused with pelvic or abdominal ectopias. Ectopic kidneys can result in complications like vesicoureteral reflux, urinary tract infections, or kidney stones. Despite being typically left-sided, our patient presented with right-sided renal ectopia with malrotation. Despite lacking urinary symptoms, a urological consultation was advised due to the potential risk of infection or kidney stones. Surgical intervention is reserved for complication management. CONCLUSION: Renal ectopia, a rare congenital anomaly, can be asymptomatic but often coincides with other renal or vascular issues. Early detection and accurate imaging are essential, emphasizing clinical vigilance and interdisciplinary collaboration for better patient care.

Development and implementation of a treatment pathway to reduce coronary angiograms - lessons from a failure.

BACKGROUND: The rates of coronary angiograms (CA) and related procedures (percutaneous intervention [PCI]) are significantly higher in Germany than in other Organisation for Economic Co-ordination and Development (OECD) countries. The current guidelines recommend non-invasive diagnosis of coronary heart disease (CHD); CA should only have a limited role in choosing the appropriate revascularisation procedure. The aim of the present study was to explore whether improvements in guideline adherence can be achieved through the implementation of regional treatment pathways. We chose four regions of Germany with high utilisation of CAs for the study. Here we report the results of the concomitant qualitative study. METHODS: General practitioners and specialist physicians (cardiologists, hospital-based cardiologists, emergency physicians, radiologists and nuclear medicine specialists) caring for patients with suspected CHD were invited to develop regional treatment pathways. Four academic departments provided support for moderation, provision of materials, etc. The study team observed session discussions and took notes. After the development of the treatment pathways, 45 semi-structured interviews were conducted with the participating physicians. Interviews and field notes were transcribed verbatim and underwent qualitative content analysis. RESULTS: Pathway development received little support among the participants. Although consensus documents were produced, the results were unlikely to improve practice. The participants expressed very little commitment to change. Although this attempt clearly failed in all study regions, our experience provides relevant insights into the process of evidence appraisal and implementation. A lack of organisational skills, ignorance of current evidence and guidelines, and a lack of feedback regarding one's own clinical behaviour proved to be insurmountable. CA was still seen as the diagnostic gold standard by most interviewees. CONCLUSIONS: Oversupply and overutilisation can be assumed to be present in study regions but are not immediately perceived by clinicians. The problem is unlikely to be solved by regional collaborative initiatives; optimised resource planning within the health care system combined with appropriate economic incentives might best address these issues.

Two cases of intraoperative diagnosed Amyand hernia: Case report and literature review.

INTRODUCTION: Amyand hernia is the presence of an incarcerated vermiform appendix (either inflamed or not) within the hernia sac. This type of hernia is very rare with an incidence reported to be 0.5 to 1 % and even rarer in adults. CASES PRESENTATION: We present here two cases of male patients found the have an Amyand Hernia diagnosed incidentally intraoperatively, and managed with appendectomy and mesh herniorrhaphy. CLINICAL DISCUSSION: For the management of this type of hernia, in general, the surgeon should perform an appendectomy with the repair to prevent future herniation or appendicitis, but some opinions differ, and state that when there are no signs of inflammation, it is not required to perform a preventative appendectomy. CONCLUSION: The decision on how to manage depends on multiple factors including inflammation of the appendix, the possibility of abdominal sepsis, and the patient comorbidities. The status of the appendix determines whether to undergo hernia repair with or without mesh.

Oxidative Stress and FOXO-1 Relationship in Stage III Periodontitis.

OBJECTIVES: 8-Hydroxideoxyguanosine (8-OHdG) is a marker of oxidative stress, and Forkhead Box-O1 (FOXO1) is a transcription factor and signaling integrator in cell and tissue homeostasis. This study aims to determine FOXO1 and 8-OHdG levels in serum and saliva samples of periodontitis patients and to evaluate their relationship with clinical periodontal parameters. MATERIALS AND METHODS: Twenty healthy individuals, twenty generalized Stage III Grade B periodontitis patients, and nineteen generalized Stage III Grade C periodontitis patients were included in the study. Clinical periodontal parameters (plaque index (PI), probing depth (PD), bleeding on probing (BOP), and clinical attachment level (CAL)) were recorded. Salivary and serum 8-OHdG and FOX-O1 levels were analyzed by enzyme-linked immunosorbent assay (ELISA). RESULTS: Clinical periodontal parameters showed a statistically significant increase in periodontitis groups compared to the control group (p < 0.05). 8-OHdG salivary levels were significantly higher in both periodontitis groups compared to the control group. The salivary FOXO1 levels were significantly lower in both periodontitis groups compared to the control group. Salivary FOXO1 level had a low-grade negative correlation with BOP and salivary 8-OHdG level. CONCLUSIONS: While reactive oxygen species increase in periodontal inflammation, low expression of FOXO1, an important transcription factor for antioxidant enzymes, supports that this molecule plays a vital role in tissue destruction, and FOXO1 can be seen as a potential immune modulator. CLINICAL RELEVANCE: The role of FOXO1 in supporting antioxidant defense may suggest that FOXO1 is a candidate target for periodontitis treatment.

Amyand's Hernia With Sliding Component: A Case Report.

Amyand's hernia (AH) occurs when the appendix becomes part of an inguinal hernia. Amyand's hernias are typically discovered incidentally during surgery due to their variable clinical manifestations and features, such as caecum and appendix forming the sliding component in the present case. Claudius Amyand operated it for the first time in 1735. Due to the simple presentations that these patients typically exhibit, the diagnosis is extremely challenging. The choice between surgical modalities is influenced by the numerous, logically accepted advantages and disadvantages of management modalities, which are subject to debate. That being said, we believe that, in the absence of sepsis or inflammation, open repair using mesh - as long as a clean operating room and competent surgical skill are available - should be the gold standard approach.

Concomitant Panniculectomy in Abdominal Wall Reconstruction: A Narrative Review Focusing on Obese Patients.

The global prevalence of obesity continues to rise, contributing to an increased frequency of abdominal wall reconstruction procedures, particularly ventral hernia repairs, in individuals with elevated body mass indexes. Undertaking these operations in obese patients poses inherent challenges. This review focuses on the current literature in this area, with special attention to the impact of concomitant panniculectomy. Obese individuals undergoing abdominal wall reconstruction face elevated rates of wound healing complications and hernia recurrence. The inclusion of concurrent panniculectomy heightens the risk of surgical site occurrences but does not significantly influence hernia recurrence rates. While this combined approach can be executed in obese patients, caution is warranted, due to the higher risk of complications. Physicians should carefully balance and communicate the potential risks, especially regarding the increased likelihood of wound healing complications. Acknowledging these factors is crucial in shared decision making and ensuring optimal patient outcomes in the context of abdominal wall reconstruction and related procedures in the obese population.

The long-term impact of vaginal surgical mesh devices on pain clinic and psychological service referrals, anti-inflammatory testing and pelvic scans in UK primary care: A cohort study with the Clinical Practice Research Datalink.

OBJECTIVE: To examine long-term complications in women with stress urinary incontinence (SUI) and pelvic organ prolapse (POP), with and without surgical mesh implants. DESIGN: Longitudinal open cohort study from 1 April 2006 (or 1 April 2012) to 30 November 2018. SETTING: The Clinical Practice Research Datalink (CPRD) Gold database, which is linked to Hospital Episodes Statistics (HES) inpatient data, the HES Diagnostic Imaging Dataset (DID), Office for National Statistics mortality data and Index of Multiple Deprivation socio-economic status data. SAMPLE: Women aged ≥18 years with a diagnostic SUI/POP Read code. METHODS: Rates are estimated using negative binomial regression. MAIN OUTCOME MEASURES: Rates of referrals for: psychological and pain services; urinalysis, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) testing; and pelvic ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) scans. RESULTS: A cohort of 220 544 women were eligible for inclusion; 74% (n = 162 687) had SUI, 37% (n = 82 123) had POP and 11% (n = 24 266) had both. Rates of psychological referrals and CT scans were lower in women with SUI mesh surgery, but this was offset by higher rates of CRP testing in women with SUI or POP mesh, MRI scans in women with SUI mesh, and urinalysis testing and referrals to pain clinics for women with POP mesh. CONCLUSIONS: Our results suggest a higher burden of morbidity in women with SUI/POP mesh surgery, and that these women may require ongoing follow-up in the primary care setting.

Effect of Interrupting Heated Humidification on Nebulized Drug Delivery Efficiency, Temperature, and Absolute Humidity During Mechanical Ventilation: A Multi-Lab In Vitro Study.

Introduction: During mechanical ventilation (MV), inspired gases require heat and humidification. However, such conditions may be associated with reduced aerosol delivery efficiency. The practice of turning off heated humidification before nebulization and the impact of nebulization on humidity in a dry ventilator circuit remain topics of debate. This study aimed to assess the effect of turning off heated humidification on inhaled dose and humidity with nebulizer use during adult MV. Methods: A bronchodilator (albuterol) and two antibiotics (Colistimethate sodium and Amikacin sulfate) were nebulized with a vibrating mesh nebulizer placed at the humidifier inlet and in the inspiratory limb at the Y-piece. Additionally, albuterol was nebulized using a jet nebulizer in both placements. Aerosol particle size distribution was determined through a cascade impactor. Absolute humidity (AH) and temperature of inspired gases were determined with anemometer/hygrometers before, during, and after nebulization, before, during, and up to 60 minutes after interrupting active humidification. Aerosol collected on a filter distal to the endotracheal tube and on impactor stages were eluted and assayed by spectrophotometry. Results: The inhaled dose was greater when both nebulizers were placed at the humidifier inlet than the inspiratory limb at the Y-piece. Irrespective of the nebulizer types and placements, the inhaled dose either decreased or showed no significant change after the humidifier was turned off. The aerosol particle size ranged from 1.1 to 2.7 µm. With interruption of active humidification, humidity of inspired gas quickly dropped below recommended levels, and nebulization in dry ventilator circuit produced an AH between 10 and 20 mgH2O/L, lower than the recommended minimum of 30 mgH2O/L. Conclusion: Interrupting active humidification during MV before nebulization did not improve aerosol delivery efficiency for bronchodilator or antibiotics, but did reduce humidity below recommended levels.

Management of symptomatic, asymptomatic, and recurrent hiatal hernia: a systematic review and meta-analysis.

BACKGROUND: The surgical management of hiatal hernia remains controversial. We aimed to compare outcomes of mesh versus no mesh and fundoplication versus no fundoplication in symptomatic patients; surgery versus observation in asymptomatic patients; and redo hernia repair versus conversion to Roux-en-Y reconstruction in recurrent hiatal hernia. METHODS: We searched PubMed, Embase, CINAHL, Cochrane Library and the ClinicalTrials.gov databases between 2000 and 2022 for randomized controlled trials (RCTs), observational studies, and case series (asymptomatic and recurrent hernias). Screening was performed by two trained independent reviewers. Pooled analyses were performed on comparative data. Risk of bias was assessed using the Cochrane Risk of Bias tool and Newcastle Ottawa Scale for randomized and non-randomized studies, respectively. RESULTS: We included 45 studies from 5152 retrieved records. Only six RCTs had low risk of bias. Mesh was associated with a lower recurrence risk (RR = 0.50, 95%CI 0.28, 0.88; I2 = 57%) in observational studies but not RCTs (RR = 0.98, 95%CI 0.47, 2.02; I2 = 34%), and higher total early dysphagia based on five observational studies (RR = 1.44, 95%CI 1.10, 1.89; I2 = 40%) but was not statistically significant in RCTs (RR = 3.00, 95%CI 0.64, 14.16). There was no difference in complications, reintervention, heartburn, reflux, or quality of life. There were no appropriate studies comparing surgery to observation in asymptomatic patients. Fundoplication resulted in higher early dysphagia in both observational studies and RCTs ([RR = 2.08, 95%CI 1.16, 3.76] and [RR = 20.58, 95%CI 1.34, 316.69]) but lower reflux in RCTs (RR = 0.31, 95%CI 0.17, 0.56, I2 = 0%). Conversion to Roux-en-Y was associated with a lower reintervention risk after 30 days compared to redo surgery. CONCLUSIONS: The evidence for optimal management of symptomatic and recurrent hiatal hernia remains controversial, underpinned by studies with a high risk of bias. Shared decision making between surgeon and patient is essential for optimal outcomes.

A comparison of four self-controlled study designs in an analysis of COVID-19 vaccines and myocarditis using five European databases.

INTRODUCTION: The aim of this study was to assess the possible extent of bias due to violation of a core assumption (event-dependent exposures) when using self-controlled designs to analyse the association between COVID-19 vaccines and myocarditis. METHODS: We used data from five European databases (Spain: BIFAP, FISABIO VID, and SIDIAP; Italy: ARS-Tuscany; England: CPRD Aurum) converted to the ConcePTION Common Data Model. Individuals who experienced both myocarditis and were vaccinated against COVID-19 between 1 September 2020 and the end of data availability in each country were included. We compared a self-controlled risk interval study (SCRI) using a pre-vaccination control window, an SCRI using a post-vaccination control window, a standard SCCS and an extension of the SCCS designed to handle violations of the assumption of event-dependent exposures. RESULTS: We included 1,757 cases of myocarditis. For analyses of the first dose of the Pfizer vaccine, to which all databases contributed information, we found results consistent with a null effect in both of the SCRI and extended SCCS, but some indication of a harmful effect in a standard SCCS. For the second dose, we found evidence of a harmful association for all study designs, with relatively similar effect sizes (SCRI pre = 1.99, 1.40 - 2.82; SCRI post 2.13, 95 %CI - 1.43, 3.18; standard SCCS 1.79, 95 %CI 1.31 - 2.44, extended SCCS 1.52, 95 %CI = 1.08 - 2.15). Adjustment for calendar time did not change these conclusions. Findings using all designs were also consistent with a harmful effect following a second dose of the Moderna vaccine. CONCLUSIONS: In the context of the known association between COVID-19 vaccines and myocarditis, we have demonstrated that two forms of SCRI and two forms of SCCS led to largely comparable results, possibly because of limited violation of the assumption of event-dependent exposures.

Laparoscopic ventral mesh rectopexy in the oldest old is safe: the race is run.

BACKGROUND: Laparoscopic ventral mesh rectopexy (LVMR) is considered to be the gold standard for managing rectal prolapse. Nevertheless, concerns have been expressed about the use of this procedure in elderly patients. The aim of the current study was to examine the perioperative safety of primary LVMR operations in the oldest old in comparison to younger individuals and to assess our hospital policy of offering LVMR to all patients, regardless of age and morbidity. METHODS: A retrospective study analysed demographic information, operation notes, meshes utilised, operation times, lengths of hospital stay (LOS) and American Society of Anesthesiologists (ASA) scores of patients who underwent LVMR at Elisabeth-TweeSteden Hospital between 2012 and 2023. RESULTS: Eighty-seven female patients underwent LVMR. Nineteen patients were 80 years of age or older (OLD group); the remaining 65 patients were under the age of 80 (YOUNG group). The difference between the groups in terms of age was statistically significant. ASA scores were not significantly different. No mortality was observed. There was no statistically significant difference between the groups in terms of LOS, operation time or morbidity. Moreover, the postoperative morbidity profile was excellent in both groups. CONCLUSION: LVMR seems to be a safe operation for the "oldest old" patients with comorbidity, despite a single-centre, retrospective trial with limited follow-up. The present study suggests abandoning the dogma that "frail patients with rectal prolapse are not suitable for laparoscopic ventral mesh rectopexy."

Monowave vs. Polywave Light - Curing Units: Effect on Light Transmission of Composite without Alternative Photoinitiators.

Objective: The aim of this study was to compare the light transmission of monowave and polywave-curing devices by a bulk-fill composite containing only camphorquinone as a photoinitiator. Materials and methods: Three light-curing devices were used to cure bulk-fill composite QuiXfil: one monowave (Translux® Wave) and two polywave (VALO Cordless and Bluephase® PowerCure. The NIST-calibrated spectrometer (MARC Resin Calibrator, BlueLight Analytics Inc.) was used to measure the incident and transmitted light through a 2-mm composite specimen over 20 s. Light transmittance was calculated from the ratio of the amount of transmitted and incident light. For data analysis (ANOVA, α = 0.05), total irradiation of the entire spectrum, irradiation with wavelengths of 360-420 nm for the violet spectrum, and 420-540 nm for the blue spectrum were selected. Results: Monowave curing unit Translux® Wave had the lowest light transmission (13.78 ± 0.5%), similar to the violet light transmission of polywave devices (12.02 ± 0.94% and 13.81 ± 1.72% for Valo Cordless and Bluephase PowerCure, respectively). Blue light transmittance (32.15-23.70%) was more than twofold higher than for the wavelengths in the violet region of the spectrum (13.81-12.02%) for the two polywave devices. VALO Cordless showed the highest total and blue light transmission (p<0.001). There was no significant difference in the transmission of the violet part of the spectrum between VALO Cordless and Bluephase® PowerCure (p = 0.465). Conclusion: Within the limitations of this study, we could conclude that polywave curing devices can be used for the polymerization of the bulk-fill composite with camphorquinone as the sole photoinitiator.

The Effects of Grape Seed Oligomeric Proanthocyanidin and Nisin on Dental Pulp Stem Cells.

Objective: This study aimed to evaluate the biological effects of "proanthocyanidin" (PA), and "nisin" (Ni), on dental pulp stem cells (DPSCs) and LPS-induced DPSCs as well as their antimicrobial effects against S. aureus and E. coli. Materials and methods: After characterization of DPSCs, cytotoxicity of PA and Ni on DPSCs were evaluated using a water-soluble tetrazolium salt (WST-1). The cytokines and chemokines released by DPSCs and the expression levels of IL-6, IL-8, and TNF alpha were detected with human Cytokine Array C5 and enzyme-linked immunosorbent assay (ELISA), respectively. The antibacterial activities of PA and Ni were tested using the drop plate method. Results: PA at 75 µg/ml increased cell viability, decreased TNF-α expression of DPSCs, did not show any cytotoxic effects on LPS-induced DPSCs, and also showed a tendency to decrease TNF-α expression. PA at 75 µg/ml exhibited higher expressions of TIMP-2, OPG, IL-7, and IL-8 in LPS-induced DPSCs compared to DPSCs. Ni at 100 µg/ml decreased TNF-α expression in DPSCs with no cytotoxic effects. It provided increased cell viability and a downregulation trend of TNF-α expression in LPS-induced DPSCs. Both Ni and PA provided strong antibacterial effects against S. aureus. Ni at 200µg/ml had strong antibacterial effects against E. coli without affecting negatively the viability of both DPSCs and LPS-induced DPSCs and showed anti-inflammatory activity by decreasing TNF-α expression. PA provided strong antibacterial effects against E. coli at 200 µg/ml but affected DPSCs viability negatively. Conclusion: PA and Ni at specific concentrations exhibited immunomodulatory activity on DPSCs and LPS-induced DPSCs without any cytotoxic effects and strong antibacterial effects on S. aureus.

Comparison of Three Different Orthodontic Adhesives Bonded to Metallic and Ceramic Brackets: SEM and SEM/EDX Analysis (In Vitro Study).

Objectives: To compare three different orthodontic adhesives (Transbond XT Light Cure Adhesive, Heliosit Orthodontic, Fuji Ortho LC) bonded to two types of orthodontic brackets: ceramic brackets (Fascination Roth 0.22) and metallic brackets (Topic Roth 0.22, Dentaurum). Materials and methods: The study was performed on 18 human teeth (6 for each adhesive). The prepared teeth were divided into three groups according to the examination time. Subsequently, they were observed after 1, 2 and 3 weeks following bonding. After the experimental procedure, the teeth samples were cut in half along the longitudinal axis in the vestibulo-oral direction, fixed with conductive carbon cement, placed in a high-vacuum evaporator and then coated with carbon. One half of each sample was observed under a Field-emission gun scanning electron microscope (FEG-SEM Hitachi SU 8030, Japan), while on the second half of the samples qualitative (X-ray line-scans) and semi-quantitative point X-ray energy dispersive analyses (EDX) were performed with Thermo Noran (USA) NSS System 7, equipped with Ultra Dry detector (30 mm2 window). Results: Transbond XT had an ideal bond with the enamel and the bracket base, with rare presence of microgaps and cracks in the enamel. Heliosit Orthodontic demonstrated a better bond relationship with the bracket base than the enamel, whereas in the latter the presence of microgaps in the bond was observed. The microphotographs of Fuji Ortho LC demonstrated many cracks inside the adhesive, and some of them continued to move forward into the enamel surface. Therefore, an impression of a very solid bond relationship with the enamel exists, with cracks being present in the enamel surface and never at the enamel-adhesive interface. Microgaps also appeared at the bracket-adhesive interface. Conclusion: Transbond XT is a highly filled composite resin and is an ideal orthodontic adhesive in each aspect examined, with an ideal enamel-adhesive and bracket-adhesive interface. Heliosit Orthodontic provides better bracket-adhesive interface compared to the enamel. Fuji Ortho LC as a solid resin-modified GIC provides a better enamel-adhesive interface, compared to the bracket base.

Are Dentists Hypocrites? Oral Self-care Habits and Self-reported Oral Health Status among Dentists and Non-dentists in Croatia.

Objectives: Dentists provide dental care to their patients and educate them on their oral hygiene and how to maintain oral health. This paper aimed to determine whether dentists are hypocritical when advising their patients on oral hygiene procedures and dental treatments because they do not apply to themselves what they recommend to others. Material and methods: This is a self-reported study conducted through an online survey questionnaire completed by 1001 participants, of whom 551 were non-dentists and 450 dentists. This is the first study on oral hygiene habits and oral status among dentists in Croatia. This research included almost 10% of the total number of working dentists in Croatia. Results: In terms of dental hygiene habits, dentists brushed, flossed and used interdental brushes more frequently, and they also changed toothbrushes more frequently, whereas they attended check-ups less frequently. Dentists also reported a smaller number of teeth with cavities, a greater number of teeth with fillings, a greater number of extracted teeth, and a greater number of dental crowns, but a smaller number of healthy teeth compared to general population. However, dentists had a much higher proportion of participants over 30 years of age, and when sub-analysis of participants over 30 years of age was performed, dentists had a greater number of healthy teeth compared to the general population. Conclusions: The results showed that dentists are aware of the importance of their oral health and that they do not pay attention only to their oral hygiene habits, but also apply advice they give their patients. Therefore, they cannot be considered hypocritical.

Understanding and Practices of Oral Hygiene in the Intensive Care Units: Perspectives of Medical Staff at Two University Hospital Centers.

Objective: This study assesses the knowledge, practices, and attitudes of medical staff in intensive care units (ICUs) regarding oral hygiene care for critically ill, bedridden patients. Material and methods: A cross-sectional study included 65 employees from the Intensive Care Units of the Sestre Milosrdnice Clinical Hospital Centre (CHC SM) and the Clinic for Anesthesiology and Intensive Care at the University Clinical Hospital Centre Zagreb (CHC ZG). A self-administered questionnaire was used to assess knowledge, methods, frequency, and attitudes towards oral care for mechanically ventilated patients. The data were examined through descriptive statistical methods, presented in terms of proportions (percentages). For the purpose of comparing the feedback across the two hospital centers and different educational backgrounds, the Chi-square and Fisher's exact tests were employed. Results: Results of a survey of 65 participants (18 from CHC SM and 47 from CHC ZG) revealed a notable disparity in oral hygiene knowledge, with graduate nurses displaying the highest proportion of adequate knowledge (100%) and regular nurses showing the least (30.3%) (p<.001). Although the execution of oral care practices did not vary significantly among the groups, graduate nurses performed oral care more frequently (80% vs. baccalaureate technicians 33.33% and nurses 57.6%, three or more times a day) and demonstrated better proficiency in both mechanical (p=.005) and chemical (p<.001) biofilm management compared to their counterparts. No significant difference was observed in the delivery of oral care to orotracheally intubated patients across different educational levels (p=.127). However, a marked difference was noted in the perception of being adequately trained for such care, with nurses feeling less prepared (12.1%, p<.001). Despite these variances, all respondents recognized the importance of oral hygiene, thus showing a strong dedication to oral health care. Conclusions: This study highlights variability in ICU oral hygiene practices and points to the importance of standardized care protocols and improved training for healthcare staff.