SADMFR Guidelines for the Use of Cone-Beam Computed Tomography/Digital Volume Tomography

In 2011, the first consensus conference on guidelines for the use of cone-beam computed tomography (CBCT) was convened by the Swiss Society of Dentomaxillofacial Radiology (SGDMFR). This conference covered topics of oral and maxillofacial surgery, temporomandibular joint dysfunctions and disorders, and orthodontics. In 2014, a second consensus conference was convened on guidelines for the use of CBCT in endodontics, periodontology, reconstructive dentistry and pediatric dentistry. The guidelines are intended for all dentists in order to facilitate the decision as to when the use of CBCT is justified. As a rule, the use of CBCT is considered restrictive, since radiation protection reasons do not allow its routine use. CBCT should therefore be reserved for complex cases where its application can be expected to provide further information that is relevant to the choice of therapy. In periodontology, sufficient information is usually available from clinical examination and periapical radiographs; in endodontics alternative methods can often be used instead of CBCT; and for implant patients undergoing reconstructive dentistry, CT is of interest for the workflow from implant planning to the superstructure. For pediatric dentistry no application of CBCT is seen for caries diagnosis.

SOMS: SurrOgate MultiStart algorithm for use with nonlinear programming for global optimization

SOMS is a general surrogate-based multistart algorithm, which is used in combination with any local optimizer to find global optima for computationally expensive functions with multiple local minima. SOMS differs from previous multistart methods in that a surrogate approximation is used by the multistart algorithm to help reduce the number of function evaluations necessary to identify the most promising points from which to start each nonlinear programming local search. SOMS’s numerical results are compared with four well-known methods, namely, Multi-Level Single Linkage (MLSL), MATLAB’s MultiStart, MATLAB’s GlobalSearch, and GLOBAL. In addition, we propose a class of wavy test functions that mimic the wavy nature of objective functions arising in many black-box simulations. Extensive comparisons of algorithms on the wavy testfunctions and on earlier standard global-optimization test functions are done for a total of 19 different test problems. The numerical results indicate that SOMS performs favorably in comparison to alternative methods and does especially well on wavy functions when the number of function evaluations allowed is limited.

How valuable are multiple treatment comparison methods in evidence-based health-care evaluation?

Objectives To compare the use of pair-wise meta-analysis methods to multiple treatment comparison (MTC) methods for evidence-based health-care evaluation to estimate the effectiveness and cost-effectiveness of alternative health-care interventions based on the available evidence. Methods Pair-wise meta-analysis and more complex evidence syntheses, incorporating an MTC component, are applied to three examples: 1) clinical effectiveness of interventions for preventing strokes in people with atrial fibrillation; 2) clinical and cost-effectiveness of using drug-eluting stents in percutaneous coronary intervention in patients with coronary artery disease; and 3) clinical and cost-effectiveness of using neuraminidase inhibitors in the treatment of influenza. We compare the two synthesis approaches with respect to the assumptions made, empirical estimates produced, and conclusions drawn. Results The difference between point estimates of effectiveness produced by the pair-wise and MTC approaches was generally unpredictable—sometimes agreeing closely whereas in other instances differing considerably. In all three examples, the MTC approach allowed the inclusion of randomized controlled trial evidence ignored in the pair-wise meta-analysis approach. This generally increased the precision of the effectiveness estimates from the MTC model. Conclusions The MTC approach to synthesis allows the evidence base on clinical effectiveness to be treated as a coherent whole, include more data, and sometimes relax the assumptions made in the pair-wise approaches. However, MTC models are necessarily more complex than those developed for pair-wise meta-analysis and thus could be seen as less transparent. Therefore, it is important that model details and the assumptions made are carefully reported alongside the results.

Similarities and differences between physician and non-physician acupuncturists in using diagnostic methods - an explorative study

Purpose: Acupuncture is one of the complementary medicine therapies with the greatest demand in Switzerland and many other countries in the West and in Asia. Over the past decades, the pool of scientific literature in acupuncture has markedly increased. The diagnostic methods upon which acupuncture treatment is based, have only been addressed sporadically in scientific journals. The goal of this study is to assess the use of different diagnostic methods in the acupuncture practices and to investigate similarities and differences in using these diagnostic methods between physician and non-physician acupuncturists. Methods: 44 physician acupuncturists with certificates of competence in acupuncture – traditional chinese medicine (TCM) from ASA (Assoziation Schweizer Ärztegesellschaften für Akupunktur und Chinesische Medizin: the Association of Swiss Medical Societies for Acupuncture and Chinese Medicine) and 33 non-physician acupuncturists listed in the EMR (Erfahrungsmedizinisches Register: a national register, which assigns a quality label for CAM therapists in complementary and alternative medicine) in the cantons Basel-Stadt and Basel-Land were asked to fill out a questionnaire on diagnostic methods. The responder rate was 46.8% (69.7% non-physician acupuncturists and 29, 5% physician acupuncturists). Results: The results show that both physician and non-physician acupuncturists take patients’ medical history (94%), use pulse diagnosis (89%), tongue diagnosis (83%) and palpation of body and ear acupuncture points (81%) as diagnostic methods to guide their acupuncture treatments. Between the two groups, there were significant differences in the diagnostic tools being used. Physician acupuncturists do examine their patients significantly more often with western medical methods (p<.05) than this is the case for nonphysician acupuncturists. Non-physician acupuncturists use pulse diagnosis more often than physicians (p<.05). A highly significant difference was observed in the length of time spent with collecting patients’ medical history, where nonphysician acupuncturists clearly spent more time (p<.001). Conclusion: Depending on the educational background of the acupuncturist, different diagnostic methods are used for making the diagnosis. Especially the more time consuming methods like a comprehensive anamnesis and pulse diagnosis are more frequently employed by non-physician practitioners. Further studies will clarify if these results are valid for Switzerland in general, and to what extent the differing use of diagnostic methods has an impact on the diagnosis itself and on the resulting treatment methods, as well as on the treatment success and the patients’ satisfaction.

How many cancer patients use complementary and alternative medicine: a systematic review and metaanalysis

Background. No comprehensive systematic review has been published since 1998 about the frequency with which cancer patients use complementary and alternative medicine (CAM). Methods. MEDLINE, AMED, and Embase databases were searched for surveys published until January 2009. Surveys conducted in Australia, Canada, Europe, New Zealand, and the United States with at least 100 adult cancer patients were included. Detailed information on methods and results was independently extracted by 2 reviewers. Methodological quality was assessed using a criteria list developed according to the STROBE guideline. Exploratory random effects metaanalysis and metaregression were applied. Results. Studies from 18 countries (152; >65 000 cancer patients) were included. Heterogeneity of CAM use was high and to some extent explained by differences in survey methods. The combined prevalence for “current use” of CAM across all studies was 40%. The highest was in the United States and the lowest in Italy and the Netherlands. Metaanalysis suggested an increase in CAM use from an estimated 25% in the 1970s and 1980s to more than 32% in the 1990s and to 49% after 2000. Conclusions. The overall prevalence of CAM use found was lower than often claimed. However, there was some evidence that the use has increased considerably over the past years. Therefore, the health care systems ought to implement clear strategies of how to deal with this. To improve the validity and reporting of future surveys, the authors suggest criteria for methodological quality that should be fulfilled and reporting standards that should be required.

The supply of complementary and alternative medicine in Swiss hospitals

OBJECTIVES: Over the past few years, a considerable increase in complementary and alternative medicine (CAM) has been observed, particularly in primary care. In contrast little is known about the supply of CAM in Swiss hospitals. This study aims at the investigation of amount and structure of CAM activities of Swiss hospitals. MATERIALS AND METHODS: We designed a cross-sectional survey using a 2-step, questionnaire- based approach acquiring overview information form hospital managers in a first questionnaire leading to detailed information on CAM usage at medical department level (head of department). This second questionnaire provides data of physician-based and non-physician-based CAM supply. RESULTS: The size of hospitals was significantly associated with the provision of CAM. 33% of the hospital managers indicated 1 or more medical doctor (MD) using CAM in their hospital compared to 37% of confirmation on department level (Kappa value 0.5). Mostly different CAM methods were applied. Acupuncture was used most frequently. However only 13 hospitals (11%) occupied more than 3 CAM MDs and only 5 hospitals had more than 2 full-time equivalents for MDs. Furthermore, 74.7% of these personnel resources were dedicated for outpatient care. In terms of CAM methods anthroposophic medicine accounted for more than half of the total personnel costs. On the other hand usage of non-physician based CAM accounted for 41% according to hospital managers compared to 64% of CAM usage according to medical departments (Kappa values 0.31). Reflexology of the foot was used most frequently. CONCLUSION: Total supply of CAM in Swiss hospitals is low and concentrates on few hospitals. Acupuncture is the widest spread discipline but anthroposophic medicine spends the most resources. The study shows that a high patient demand for CAM faces low supply in hospitals.

Extent and structure of health insurance expenditures for complementary and alternative medicine in Swiss primary care

BACKGROUND: The study is part of a nationwide evaluation of complementary and alternative medicine (CAM) in primary care in Switzerland. The goal was to evaluate the extent and structure of basic health insurance expenditures for complementary and alternative medicine in Swiss primary care. METHODS: The study was designed as a cross-sectional evaluation of Swiss primary care providers and included 262 certified CAM physicians, 151 noncertified CAM physicians and 172 conventional physicians. The study was based on data from a mailed questionnaire and on reimbursement information obtained from health insurers. It was therefore purely observational, without interference into diagnostic and therapeutic procedures applied or prescribed by physicians. Main outcome measures included average reimbursed costs per patient, structured into consultation- and medication-related costs, and referred costs. RESULTS: Total average reimbursed cost per patient did not differ between CAM physicians and conventional practitioners, but considerable differences were observed in cost structure. The proportions of reimbursed costs for consultation time were 56% for certified CAM, 41% for noncertified CAM physicians and 40% for conventional physicians; medication costs--including expenditures for prescriptions and directly dispensed drugs--respectively accounted for 35%, 18%, and 51% of costs. CONCLUSION: The results indicate no significant difference for overall treatment cost per patient between CAM and COM primary care in Switzerland. However, CAM physicians treat lower numbers of patients and a more cost-favourable patient population than conventional physicians. Differences in cost structure reflect more patient-centred and individualized treatment modalities of CAM physicians.

Complementary and alternative medicine costs - a systematic literature review

Objective: The aim of this literature review, performed within the framework of the Swiss governmental Program of Evaluation of Complementary Medicine (PEK), was to investigate costs of complementary and alternative medicine (CAM). Materials and Methods: A systematic literature search was conducted in 11 electronic databases. All retrieved titles and reference lists were also hand-searched. Results: 38 publications were found: 23 on CAM of various definitions (medical and non-medical practitioners, over-the-counter products), 13 on homeopathy, 2 on phytotherapy. Studies investigated different kinds of costs (direct or indirect) and used different methods (prospective or retrospective questionnaires, data analyses, cost-effectiveness models). Most studies report 'out of pocket' costs, because CAM is usually not covered by health insurance. Costs per CAM-treatment / patient / month were AUD 7-66, CAD 250 and GBP 13.62 +/- 1.61. Costs per treatment were EUR 205 (range: 15-1,278), USD 414 +/- 269 and USD 1,127. In two analyses phytotherapy proved to be cost-effective. One study revealed a reduction of 1.5 days of absenteeism from work in the CAM group compared to conventionally treated patients. Another study, performed by a health insurance company reported a slight increase in direct costs for CAM. Costs for CAM covered by insurance companies amounted to approximately 0.2-0.5% of the total healthcare budget (Switzerland, 2003). Publications had several limitations, e.g. efficacy of therapies was rarely reported. As compared to conventional patients, CAM patients tend to cause lower costs. Conclusion: Results suggest lower costs for CAM than for conventional patients, but the limited methodological quality lowers the significance of the available data. Further well-designed studies and models are required.

Alternative protocol to initiate high-frequency oscillatory ventilation: an experimental study

INTRODUCTION: The objective was to study the effects of a novel lung volume optimization procedure (LVOP) using high-frequency oscillatory ventilation (HFOV) upon gas exchange, the transpulmonary pressure (TPP), and hemodynamics in a porcine model of surfactant depletion. METHODS: With institutional review board approval, the hemodynamics, blood gas analysis, TPP, and pulmonary shunt fraction were obtained in six anesthetized pigs before and after saline lung lavage. Measurements were acquired during pressure-controlled ventilation (PCV) prior to and after lung damage, and during a LVOP with HFOV. The LVOP comprised a recruitment maneuver with a continuous distending pressure (CDP) of 45 mbar for 2.5 minutes, and a stepwise decrease of the CDP (5 mbar every 5 minute) from 45 to 20 mbar. The TPP level was identified during the decrease in CDP, which assured a change of the PaO2/FIO2 ratio < 25% compared with maximum lung recruitment at CDP of 45 mbar (CDP45). Data are presented as the median (25th-75th percentile); differences between measurements are determined by Friedman repeated-measures analysis on ranks and multiple comparisons (Tukey's test). The level of significance was set at P < 0.05. RESULTS: The PaO2/FiO2 ratio increased from 99.1 (56.2-128) Torr at PCV post-lavage to 621 (619.4-660.3) Torr at CDP45 (CDP45) (P < 0.031). The pulmonary shunt fraction decreased from 51.8% (49-55%) at PCV post-lavage to 1.03% (0.4-3%) at CDP45 (P < 0.05). The cardiac output and stroke volume decreased at CDP45 (P < 0.05) compared with PCV, whereas the heart rate, mean arterial pressure, and intrathoracic blood volume remained unchanged. A TPP of 25.5 (17-32) mbar was required to preserve a difference in PaO2/FIO2 ratio < 25% related to CDP45; this TPP was achieved at a CDP of 35 (25-40) mbar. CONCLUSION: This HFOV protocol is easy to perform, and allows a fast determination of an adequate TPP level that preserves oxygenation. Systemic hemodynamics, as a measure of safety, showed no relevant deterioration throughout the procedure.

[Alternative sonographic determination of liver size by intercostal scans]

BACKGROUND: The evaluation of hepatic size is a daily question in abdominal ultrasound, especially to determine the presence of hepatomegaly. In the literature, different methods of measurement are described, mostly as a subcostal measured organ diameter in one direction. This method has its limits in patients with obesity, accumulation of abdominal gas or in uncooperative patients (lack of coordinative respiration) so that alternative measurements are necessary. METHODS: In 241 patients hepatic size was first measured in two conventional sections: midclavicular line (MCL) and anterior axillary line (AAL). Additionally, we measured the organs in midaxillary line craniocaudal (MAL) by determination of the cranio-caudal diameter. In 58 patients additional computed tomography was performed due to special diagnostical reasons so that liver size in MCL could be revealed and compared with ultrasonographical values. RESULTS: The mean value in MCL was 10.7 +/- 2.1 cm measured by ultrasound, 11.4 +/- 3.7 cm measured by computed tomography, 14.0 +/- 1.9 cm in AAL and 14.9 +/- 2.0 cm in MAL. In 5% of the cases the liver could not be measured in the conventional subcostal sections due to obesity or masking by gas, but this was possible in MAL. CONCLUSIONS: We revealed a good correlation of liver size in MCL between ultrasound and computed tomography, as well as in the measurement of AAL and MAL diameters. However, even in cases with difficult subcostal approach intercostal diameters allow for an accurate determination of hepatic size.

Functional imbalance of visual pathways indicates alternative face processing strategies in autism

OBJECTIVE: To investigate whether autistic subjects show a different pattern of neural activity than healthy individuals during processing of faces and complex patterns. METHODS: Blood oxygen level-dependent (BOLD) signal changes accompanying visual processing of faces and complex patterns were analyzed in an autistic group (n = 7; 25.3 [6.9] years) and a control group (n = 7; 27.7 [7.8] years). RESULTS: Compared with unaffected subjects, autistic subjects demonstrated lower BOLD signals in the fusiform gyrus, most prominently during face processing, and higher signals in the more object-related medial occipital gyrus. Further signal increases in autistic subjects vs controls were found in regions highly important for visual search: the superior parietal lobule and the medial frontal gyrus, where the frontal eye fields are located. CONCLUSIONS: The cortical activation pattern during face processing indicates deficits in the face-specific regions, with higher activations in regions involved in visual search. These findings reflect different strategies for visual processing, supporting models that propose a predisposition to local rather than global modes of information processing in autism.

3D C-arm as an alternative modality to CT in postmortem imaging: technical feasibility

OBJECT: The aim of our study was to demonstrate the image quality of the new device using human cadavers, extending the horizon of available imaging modalities in forensic medicine. MATERIALS AND METHODS: Six human cadavers were examined, revealing C-arm data sets of the head, neck thorax, abdomen and pelvis. High-resolution mode was performed with 500 fluoroscopy shots during a 190 degrees orbital movement with a constant tube voltage of 100 kV and a current of 4.6 mA. Based on these data sets subsequent three-dimensional reconstructions were generated. RESULTS: Reconstructed data sets revealed high-resolution images of all skeletal structures in a near-CT quality. The same image quality was available in all reconstruction planes. Artefacts caused by restorative dental materials are less accentuated in CBCT data sets. The system configuration was not powerful enough to generate sufficient images of intracranial structures. CONCLUSION: After the here-demonstrated encouraging preliminary results, the forensic indications that would be suitable for imaging with a 3D C-arm have to be defined. Promising seems the visualization local limited region of interest as the cervical spine or the facial skeleton.

The Shelhigh No-React bovine internal mammary artery: a questionable alternative conduit in coronary bypass surgery?

BACKGROUND: Increasing age and comorbidities among patients undergoing coronary artery bypass surgery (CABG) stimulates the exhaustive research for alternative grafts. No-React treatment should render the tissue resistant against degeneration and reduce early inflammatory response. The aim of the present study was an invasive assessment of the patency of No-React bovine internal mammary artery (NRIMA grafts) used as bypass conduit in CABG surgery. PATIENTS AND METHODS: Nineteen NRIMA grafts were used in 17 patients (2.9%) out of a total of 572 patients undergoing CABG surgery within a 12-month period. All intraoperative data were assessed and in-hospital outcome was analysed. Follow-up examination was performed 7.0+/-4.0 months after initial surgery, including clinical status and coronary angiography to assess patency of the NRIMA grafts. RESULTS: Average perioperative flow of all NRIMA grafts was 71+/-60 ml/min. One patient died in hospital due to a multi-organ failure. Four patients refused invasive assessment. Follow-up was complete in 12 patients with overall 13 NRIMA grafts. Nine NRIMA grafts (69.2%) were used for the right coronary system, two NRIMA grafts (15.4%) on the LAD and two on the circumflex artery. Graft patency was 23.1% and was independent of the intraoperative flow measurement. CONCLUSIONS: NRIMA grafts show a very low patency and cannot be recommended as coronary bypass graft conduits. Patency was independent of the perioperative flow, assessed by Doppler ultrasound. Because of this unsatisfying observation, this type of graft should be utilised as a last resource conduit and used only to revascularise less important target vessels, such as the end branches of the right coronary artery.

[Complementary and alternative medicine in primary care in Switzerland]

OBJECTIVE: This study investigated the current supply of complementary and alternative medicine (CAM) in Swiss primary care. Information was collected on physicians' qualifications in CAM, frequency of patients' demand for CAM, physicians' supply and temporal resources for CAM as well as physicians' referrals to CAM. MATERIAL AND METHODS: 750 (500 German-speaking and 250 French-speaking) randomly selected Swiss female and male primary care physicians were asked to complete a questionnaire (response rate 50.4%). Sociodemographic data on professional training, place of residence, and sex were used to calculate a weighting factor to correct the responders' data in the analysis accordingly. RESULTS: 14.2% of the physicians were qualified in at least one CAM discipline. Around 30% (95% confidence interval 25.4-34.6%) of the physicians were asked for CAM by their patients more than once a week. Homeopathy and phytotherapy were the most frequently offered therapies, followed by traditional Chinese medicine (TCM)/acupuncture. 62.5% (57.6-67.4%) of the physicians refer their patients to CAM. Most patients were referred to TCM/acupuncture. Of the 37.2% (32.6-42.4%) of the physicians who do not refer their patients to CAM, around 40% (35.1-44.9%) offer it themselves. CONCLUSION: About three quarters of the physicians offer CAM themselves or refer their patients to CAM treatments. CAM is very important in primary medical care in Switzerland. Clear regulations for CAM are required in order to ensure a high quality in care.