Post-mortem changes of the vascular system-a thanatological study using multidetector computed tomography.

Forensic pathologists have to deal with post-mortem changes of the human body. Those post-mortem phenomena are familiar and largely described in thanatology. However, knowledge about the influence of post-mortem phenomena on the vascular system is more limited, except for the apparition and development of cadaveric lividity. The introduction of multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) in the forensic field and the expansion of their usage in medico-legal routine, allow for exploring the inside of corpses differently and may play a part in the understanding of thanatological processes. This study aimed to describe post-mortem changes in the vascular system by investigating the presence of gas and collapsed vessels.We investigated post-mortem MDCT data of 118 human bodies. Cases with internal/external bleeding or corporal lesion allowing contamination with external air were excluded. Major vessels and heart cavities were systematically explored and a trained radiologist semi-quantitatively assessed the presence of gas.Collapsed veins were observed in 61.9% of cases (CI95% 52.5 to 70.6) and arteries in 33.1% (CI95% 24.7 to 42.3). Vessels most often affected were for arteries: common iliac (16.1%), abdominal aorta (15.3%), external iliac (13.6%), and for veins: infra-renal vena cava (45.8%), common iliac (22.0%), renal (16.9%), external iliac (16.1%), and supra-renal vena cava (13.6%). Cerebral arteries and veins, coronary arteries, and subclavian vein were unaffected. The presence of collapsed vessels was associated with a minor degree of cadaveric alteration. We observed that arteries and veins follow the same pattern of gas apparition for both the quantity and the location.In post-mortem radiology, collapsed vessels and intravascular gas are frequently visualized and as a result of all post-mortem changes, the assessment of the distribution of blood can be confusing. Therefore, knowledge of thanatological phenomena is crucial to prevent post-mortem radiological misapprehensions and possible false diagnoses.

Functional assessment of the stomatognathic system. Part 2: The role of dynamic elements of analysis.

OBJECTIVES: To review the dynamic analytical elements used in the functional assessment of the stomatognathic system, summarize the available scientific evidence, and consider interrelations with body posture and cognition. METHOD AND MATERIALS: A thorough literature search was conducted using PubMed, the Cochrane Library database, and Google Scholar. Peer-reviewed articles and literature reviews provided up-to-date information addressing three topics: (a) the available knowledge and recent evidence on the relationship between the morphologic aspects of dental/craniofacial anatomy and oral function/dysfunction, (b) mandibular dynamics, considering mobility, functional activity, and existing methodologies of analysis, and (c) a possible correlation between the stomatognathic system, body posture, and cognition. RESULTS: Modern dentistry may be regarded as a human adaptation strategy, helping to conserve healthy teeth for much longer without risking overall health. It is futile to treat patients using a mechanistic, sectorial approach that misrepresents patient behavior and requests, just as it is to affirm the absence of any structure-function relationships. However, it is also evident that there is a lack of general consensus on the precise functional assessment of the stomatognathic system, mostly due to the methodologic heterogeneity employed and the high risk of bias. Despite the abundant evidence produced with the aim of providing solid arguments to define dynamic models of functional assessment of the stomatognathic system, it is yet to become highly empirical, based as it is on operator experience in daily clinical practice. CONCLUSIONS: Further efforts from the scientific and clinical community, with the help of progress in technology, remain should this gap be filled and should substantial data on differences between pathologic and physiologic dynamic models of function be provided. Dentistry needs to employ - on a larger scale - objective, dynamic methods of analysis for the functional evaluation of the stomatognathic system, embracing concepts of "personalized medicine" and "interprofessional collaborations."

Functional assessment of the stomatognathic system. Part 1: The role of static elements of analysis.

OBJECTIVES: To review the elements of static analysis in the functional assessment of the stomatognathic system, as promoted for more than a century by gnathologists, and summarize the available scientific evidence, including anthropologic observations. METHOD AND MATERIALS: A thorough search was conducted using PubMed, the Cochrane Library database, and Google Scholar. From peer-reviewed articles and other scientific literature, up-to-date information addressing three topics was identified: (a) the anthropologic perspective with particular consideration for the role of progressive dental wear over time, (b) descriptions of gnathologic principles and evidence on their scientific validity, and (c) the methodologic inaccuracies introduced by seeking to correlate variables directly rather than allowing for causal inference. RESULTS: For decades gnathology attempted to describe a structure-function correlation within the stomatognathic system by means of a model whose principles were static and mechanistic references. No scientific validation was ever achieved, placing clinical and research consensus out of reach. CONCLUSIONS: A historical perspective helps to place the fundamentals of gnathology into context: They were conceived to solve technical difficulties but were then assumed to be physiologic stereotypes. This misconception led to a decades-long promotion of mechanistic theories to describe oral function, but the evidence available today supports a more flexible and adaptable approach. Gnathologic arguments have been relegated to become exclusively of technical relevance in oral rehabilitation.

Assessment of cognitive screening tests as predictors of driving cessation: A prospective cohort study of a median 4-year follow-up.

BACKGROUND: Assessing fitness to drive and predicting driving cessation remains a challenge for primary care physicians using standard screening procedures. The objective of this study was to prospectively evaluate the properties of neuropsychological screening tests, including the Trail Making Test (TMT), Clock Drawing Test (CDT), Montreal Cognitive Assessment (MoCA), Useful Field of View (UFOV), and Timed Up and Go (TUG) test, in predicting driving cessation for health reasons in drivers older than 70 years of age. DESIGN AND METHODS: This prospective cohort study, with a median follow-up of 4 years for drivers of 70 years old or older with an active driving license in Switzerland, included 441 participants from a driving refresher course dedicated to volunteer senior drivers. Cases were drivers reported in the national driving registry who lost their license following a health-related accident, who were reported as unfit to drive by their physician or voluntarily ceased driving for health reasons. Survival analysis was used to measure the hazard ratio of driving cessation by adjusting for age and sex and to evaluate the predictive value of combining 3 or more positive tests in predicting driving cessation during a 4-year follow-up. RESULTS: A total of 1738 person-years were followed-up in the cohort, with 19 (4.3%) having ceased driving for health reasons. We found that participants with a TMT-A < 54 sec and TMT-B < 150 sec at baseline had a significantly lower cumulative hazard of driving cessation in 4 years than those with slower performance (adjusted HR 3, 95% CI: 1.16-7.78, p = 0.023). Participants who performed a CDT ≥ 5 had a significantly lower cumulative hazard of driving cessation (adjusted HR 2.89, 95% CI: 1.01-7.71, p = 0.033). Similarly, an MoCA score ≥ 26, TUG test <12 sec or a UFOV of low risk showed a lower but not significant cumulative risk at a median follow-up of 4 years. When using tests as a battery, those with three or more positive tests out of five were 3.46 times more likely to cease driving (95% CI: 1.31-9.13, p = 0.012). CONCLUSIONS: The CDT and the TMT may predict driving cessation in a statistically significant way, with a better performance than the UFOV and MoCA tests during a median 4-year follow-up. Combining tests may increase the predictability of driving cessation. Although our results are consistent with current evidence, they should be interpreted with precaution; more than 95% of the participants above the set threshold were able to continue driving for 4 years without any serious incident.

Standardized on-road tests assessing fitness-to-drive in people with cognitive impairments: A systematic review.

OBJECTIVE: The on-road assessment is the gold standard because of its ecological validity. Yet existing instruments are heterogeneous and little is known about their psychometric properties. This study identified existing on-road assessment instruments and extracted data on psychometric properties and usability in clinical settings. METHOD: A systematic review identified studies evaluating standardized on-road evaluation instruments adapted for people with cognitive impairment. Published articles were searched on PubMed, CINHAL, PsycINFO, Web of Science, and ScienceDirect. Study quality and the level of evidence were assessed using the COSMIN checklist. The collected data were synthetized using a narrative approach. Usability was subjectively assessed for each instrument by extracting information on acceptability, access, cost, and training. RESULTS: The review identified 18 published studies between 1994 and 2016 that investigated 12 different on-road evaluation instruments: the Performance-Based Driving Evaluation, the Washington University Road Test, the New Haven, the Test Ride for Practical Fitness to Drive, the Rhode Island Road Test, the Sum of Manoeuvres Score, the Performance Analysis of Driving Ability, the Composite Driving Assessment Scale, the Nottingham Neurological Driving Assessment, the Driving Observation Schedule, the Record of Driving Errors, and the Western University's On-road Assessment. Participants were mainly male (64%), between 48 and 80 years old, and had a broad variety of cognitive disorders. Most instruments showed reasonable psychometric values for internal consistency, criterion validity, and reliability. However, the level of evidence was poor to support any of the instruments given the low number of studies for each. CONCLUSION: Despite the social and health consequences of decisions taken using these instruments, little is known about the value of a single evaluation and the ability of instruments to identify expected changes. None of the identified on-road evaluation instruments seem currently adapted for clinical settings targeting rehabilitation and occupational priorities rather than road security alone. STUDY REGISTRATION: PROSPERO registration number CRD42018103276.

What is the profile of older drivers considered medically unfit to drive? A cross-sectional survey in Western Switzerland.

OBJECTIVE: We aimed to assess how often and for what reasons general practitioners (GPs) consider older drivers medically unfit to drive. METHODS: All GPs certified to carry out fitness-to-drive assessments in Geneva (medical assessors, n = 69), as well as a random sample of 500 GPs practising in Vaud, Neuchatel and Jura, were asked to complete a questionnaire about the mean number of assessments per week, the number of negative decisions in the previous year and the main reason for the most recent negative decision. RESULTS: Completed questionnaires were returned by 268 respondents (45 medical assessors and 223 other GPs, participation rate: 47%). The mean proportion of drivers with a negative decision was 2.2% (standard deviation [SD] 3.3). The proportion was slightly lower among medical assessors (1.1%, SD 1.3) compared to other GPs (2.3%, SD 3.3, p <0.001). The main reasons for being considered medically unfit to drive were cognitive (64%) and visual acuity impairments (18%). CONCLUSIONS: GPs in this survey reported considering approximately 2% of older drivers as medically unfit to drive, mainly because of cognitive and visual acuity impairments. Further research should identify how GPs decide if older drivers are fit or unfit, and assess the effectiveness of medical screening in reducing car crashes involving older drivers.

Sex/gender bias in the management of chest pain in ambulatory care.

OBJECTIVE: Cardiovascular diseases (CVD) are the main cause of death worldwide and despite a higher prevalence in men, mortality from CVD is higher among women. Few studies have assessed sex differences in chest pain management in ambulatory care. The objective of this post hoc analysis of data from a prospective cohort study was to assess sex differences in the management of chest pain in ambulatory care. SETTING: We used data from the Thoracic Pain in Community cohort study that was realized in 58 primary care practices and one university ambulatory clinic in Switzerland. PARTICIPANTS: In total, 672 consecutive patients aged over 16 years attending a primary care practice or ambulatory care clinic with a complaint of chest pain were included between February and June 2001. Their mean age was 55.2 years and 52.5% were women. MAIN OUTCOME MEASURES: The main outcome was the proportion of patients referred to a cardiologist at 12 months follow-up. A panel of primary care physicians assessed the final diagnosis retained for chest pain at 12 months. RESULTS: The prevalence of chest pain of cardiovascular origin (n = 108, 16.1%) was similar for men and women (17.5% vs 14.8%, respectively, p = 0.4). Men with chest pain were 2.5 times more likely to be referred to a cardiologist than women (16.6% vs 7.4%, odds ratio: 2.49, 95% confidence interval: 1.52-4.09). After adjustment for the patients' age and cardiovascular disease risk factors, the estimates did not significantly change (odds ratio: 2.30, 95% confidence interval: 1.30-3.78). CONCLUSION: Although the same proportion of women and men present with a chest pain of cardiovascular origin in ambulatory care, there is a strong sex bias in their management. These data suggest that effort must be made to assure equity between men and women in medical care.

The role of osteopathy in the Swiss primary health care system: a practice review.

OBJECTIVES: The aim of this study was to describe osteopathic activity and scope of practice to understand the current and future role of osteopathy in the Swiss healthcare system. DESIGN: A questionnaire survey that included a patient record-based retrospective clinical audit. SETTING/POPULATION: Osteopaths with a national diploma (n=1086) were invited by mail to participate in an online survey. Osteopathic assistants (n=84) were identified through their national association. QUESTIONNAIRE: The survey was constructed from previous surveys and tested for face validity with experts, osteopaths and patient representatives. The questionnaires were completed online in English, German and French between April and August 2017. Osteopaths anonymously reported information about themselves, their practice, and the treatment and care for four randomly selected patients they managed in 2016. RESULTS: The response rate from the survey was 44.5% (521/1171). Data on osteopathic care were collected for 1144 patients and 3449 consultations. In 2016, osteopaths saw approximately 6.8% of the Swiss population for 1700 000 consultations and an overall estimated cost of 200 million Swiss francs. 76% of patients sought care directly without a referral from another care provider. Few osteopaths (<1%) work in a hospital setting and 46% work in isolation in private practice. Infants (under 2 years old) made up 10% of all patients and 9% of patients were ≥65 years. Patients most commonly sought treatment for musculoskeletal conditions (81%) with the spine being the most frequent location (66%). Treatments also included exercise advice (34.2%) and lifestyle management (35.4%). Fewer than 1 patient out of 10 were referred to another health profession or provider. CONCLUSIONS: In Switzerland, osteopathic care represents an important first line management for musculoskeletal conditions that alleviates some of the burden of care in the Swiss primary healthcare system.

Adherence to guidelines when evaluating fitness-to-drive in the elderly: a practice review of Swiss physicians.

OBJECTIVE: We aimed to explore the extent to which general practitioners (GPs) in Western Switzerland adhere to Swiss recommendations when assessing fitness-to-drive in the elderly. METHODS: A random sample of 500 GPs practicing in Vaud, Neuchatel and Jura, and all GPs certified to conduct fitness-to-drive assessments in Geneva ("experts", n = 69) were invited to participate. They were asked how often they performed twenty procedures (recommended in Swiss guidelines developed by experts in traffic medicine) when assessing older drivers during the previous year, scored on a five-point Likert scale ranging from "never" to "always performed". The GPs were considered to be adhering to the recommended procedure if they performed it often or always. We computed the proportion of GPs adhering to each procedure, and compared GPs with or without specialised expertise. RESULTS: A total of 268 GPs completed the questionnaire (participation rate 47%). The most frequently reported procedures were asking for current medication (96%), cardiovascular (94%) and neurological diseases (91%), and screening for visual acuity impairment (93%), whereas the least frequently reported procedures were screening for cognitive impairment in drivers aged between 70 and 80 years (44%) and for mood disorder (31%), asking for a history of driving license withdrawal (38%), and interviewing close relatives (10%). Six procedures were statistically significantly more frequently performed by the experts than by the other GPs. In general, GPs reported using validated tools, except when screening for at-risk drinking and mood disorder (tools used by 26 and 28%, respectively). CONCLUSIONS: Many Swiss GPs seem not to systematically follow the current Swiss recommendations. Although several important procedures appear to routinely be part of older drivers' assessment, others are infrequently performed. Further research should identify how GPs select the recommended items to which they adhere and those they never apply, and how to facilitate the use of recommended procedures to help them decide if a person is fit, unfit or requiring further evaluation.

The effect of vitamin B12 and folic acid supplementation on routine haematological parameters in older people: an individual participant data meta-analysis.

BACKGROUND/OBJECTIVES: Low vitamin B12 and folate levels in community-dwelling older people are usually corrected with supplements. However, the effect of this supplementation on haematological parameters in older persons is not known. Therefore, we executed a systematic review and individual participant data meta-analysis of randomised placebo-controlled trials (RCTs). SUBJECTS/METHODS: We performed a systematic search in PubMed, EMBASE, Web of Science, Cochrane and CENTRAL for RCTs published between January 1950 and April 2016, where community-dwelling elderly (60+ years) who were treated with vitamin B12 or folic acid or placebo. The presence of anaemia was not required. We analysed the data on haematological parameters with a two-stage IPD meta-analysis. RESULTS: We found 494 full papers covering 14 studies. Data were shared by the authors of four RCTs comparing vitamin B12 with placebo (n = 343) and of three RCTs comparing folic acid with placebo (n = 929). We found no effect of vitamin B12 supplementation on haemoglobin (change 0.00 g/dL, 95% CI: -0.19;0.18), and no effect of folic acid supplementation (change -0.09 g/dL, 95% CI: -0.19;0.01). The effects of supplementation on other haematological parameters were similar. The effects did not differ by sex or by age group. Also, no effect was found in a subgroup of patients with anaemia and a subgroup of patients who were treated >4 weeks. CONCLUSIONS: Evidence on the effects of supplementation of low concentrations of vitamin B12 and folate on haematological parameters in community-dwelling older people is inconclusive. Further research is needed before firm recommendations can be made concerning the supplementation of vitamin B12 and folate.

Cross-sectional study assessing the addition of contrast sensitivity to visual acuity when testing for fitness to drive.

OBJECTIVES: The aim of this study is to quantify the importance of loss of contrast sensitivity (CS) and its relationship to loss of visual acuity (VA), driving restrictions and daytime, on-road driving evaluations in drivers aged 70+. DESIGN: A predictive cross-sectional study. SETTING: Volunteer participants to a drivers' refresher course for adults aged 70+ delivered by the Swiss Automobile Club in western Switzerland from 2011 to 2013. PARTICIPANTS: 162 drivers, male and female, aged 70 years or older. CLINICAL PREDICTORS: We used a vision screener to estimate VA and the The Mars Letter Contrast Sensitivity Test to test CS. OUTCOMES: We asked drivers to report whether they found five driving restrictions useful for their condition; restrict driving to known roads, avoid driving on highways, avoid driving in the dark, avoid driving in dense traffic and avoid driving in fog. All participants also underwent a standardised on-road evaluation carried out by a driving instructor. RESULTS: Moderate to severe loss of CS for at least one eye was frequent (21.0% (95% CI 15.0% to 28.1%)) and often isolated from a loss of VA (11/162 cases had a VA ≥0.8 decimal and a CS of ≤1.5 log(CS); 6.8% (95% CI 3.4% to 11.8%)). Drivers were more likely (R2=0.116, P=0.004) to report a belief that self-imposed driving restrictions would be useful if they had reduced CS in at least one eye. Daytime evaluation of driving performance seems limited in its ability to correctly identify difficulties related to CS loss (VA: R2=0.004, P=0.454; CS: R2=0.006, P=0.332). CONCLUSION: CS loss is common for older drivers. Screening CS and referring for cataract surgery even in the absence of VA loss could help maintain mobility. Reduced CS and moderate reduction of VA were both poor predictors of daytime on-road driving performances in this research study.

The role of angiography in the congruence of cardiovascular measurements between autopsy and postmortem imaging.

INTRODUCTION: Postmortem CT angiography is the method of choice for the postmortem imaging investigations of the cardiovascular (CV) system. However, autopsy still remains the gold standard for CV measurement. Nevertheless, there are not any studies on CV measurements on the multi-phase postmortem angiography (MPMCTA) which includes comparisons with autopsy. Therefore, the aim of this study is to compare CV measurements between the native CT scan and the three phases of the MPMCTA to find out which of these modalities correlate the best with autopsy measurements. METHODS: For this study, we selected retrospectively 50 postmortem cases that underwent both MPMCTA and autopsy. A comparison was carried out between the CV measurements obtained with imaging (aorta; heart cavities and cardiac wall thicknesses; maximum cardiac diameter and cardiothoracic ratio) and at the autopsy (aorta; cardiac valves, ventricular thicknesses, and weight). RESULTS: Our results show that the dynamic phase displays an advantage for the measurement of the aortas. However, the MPMCTA is not accurate to measure the cardiac wall thicknesses. The measurements of the heart cavities show no correlation with the heart valves. The cardiothoracic ratio measured by the MPMCTA shows no correlation with the heart weight. Nevertheless, the maximum cardiac diameter exhibits a correlation with the latter on the venous and dynamic phase. CONCLUSIONS: These results show that only few CV parameters measured with imaging correlate with measurement obtained at the autopsy. These results indicate that in order to better estimate values obtained at the autopsy, we need to define new reference values for the CV measurement on MPMCTA.

Hemoglobin Levels and the Risk of Malaria in Papua New Guinean Infants: A Nested Cohort Study.

Studies are available that assess the risk of malaria in accordance to the body's iron store and the systematic iron supplementation of preschool children. However, only a few studies evaluated the temporal association between hemoglobin and malaria and their results are opposing. A total of 1,650 3-month-old Papua New Guinean infants were enrolled in this study and followed-up for 12 months. The risk of malaria was assessed in all children every 3 months and with each episode of fever. The incidence of clinical malaria between 3 and 15 months of age was 249 cases per 1,000 infants per year. After adjustment for potential confounding factors, a decrease of 1 g/dL of hemoglobin was associated with a nonsignificant increase of 11% for risk of malaria infection (hazard ratio, 1.11, 95% confidence interval; CI, 0.99-1.25, P = 0.076). Only children with severe anemia (hemoglobin < 8.0 g/dL) at baseline were at higher risk of malaria infection (hazard ratio, 1.72, 95% CI, 1.08-2.76, P = 0.023) during the follow-up year compared with the control group (Hemoglobin > 10.0 g/dL). This association was not statistically significant if only clinical malaria episodes were taken into account (hazard ratio, 1.42, 95% CI, 0.77-2.61, P = 0.26). Our study suggests that infants with lower hemoglobin levels are not protected against malaria infection. Further research that examines the risk of malaria in relation to both hemoglobin and iron store levels would be important to better understand this complex interaction.

Benefits of short educational programmes in preventing drink-driving recidivism: A ten-year follow-up randomised controlled trial.

BACKGROUND: One fifth of drivers convicted of drink-driving for the first time will be convicted again for the same offence in subsequent years. Lecture-based educational programmes are believed to reduce recidivism. Little is known about the modalities of enhancing the benefits of such programs. METHODS: This parallel randomised controlled trial measured the effects of the duration of lectures and the presence of a close relative 'in class' on rates of recidivism during the ten years following an initial drink-driving conviction. Of 1588 drivers in the Canton of Geneva convicted of a first-time offence with a blood alcohol concentration (BAC) of between 0.80 and 2.49g/kg from May 2001 to February 2004, 727 agreed to participate and were randomly assigned to either a seven-hour series of lectures, a four-hour series with a friend or close relative, or a brief two-hour lecture. Time until recidivism was retrieved from a national registry that contains details of recidivism that took place up to ten years after the first offence. RESULTS: Significant effects of briefer lectures over the standard day-long series of lectures were observed only during the most influential time period with regards to recidivism levels-the two years following the intervention. Replacing the usual one-day series of lectures by briefer two-hour lectures would reduce, by 25% (CI95%; 3-44%), the risk of recidivism. CONCLUSION: This study does not support policymakers' decision to rely on a seven-hour series of lectures to decrease DUI recidivism. The advantages of shorter lectures over no lecture still need to be evaluated.

Evaluating Preoperative Models: A Methodologic Contribution.

BACKGROUND: Three-dimensional (3D) printed models of the human skull and parts of it are being increasingly used for surgical education and customized preoperative planning. OBJECTIVE: This study, using the calvaria as a model, provides a methodologic analysis with regard to future investigations aimed at evaluating patient-specific skull replicas. METHODS: Postmortem computed tomography was used for 3D reconstruction of a skull. The digital model obtained was converted to a physical replica by 3D printing. This copy was compared qualitatively and quantitatively with the original, using both a classical anthropometric and a 3D surface scanning approach. RESULTS: Qualitatively, the replica and the original displayed good qualitative concordance. The quantitative deviations, as measured by osteometric tools, lay partly in the submillimetric area, partly between 1 and 2 mm. The maximum difference was 3.7 mm. On the basis of the surface scans, a mean deviation of 0.2930 mm (±0.2677 mm) and a median difference of 0.2125 mm (0.0000-1.5509 mm) were observed for the inner surface. For the whole object, corresponding figures amounted to 0.9101 mm (±0.5390 mm) and 0.8851 mm (0.000-3.2647 mm). CONCLUSIONS: Qualitatively flawless replicas of the skull region investigated are feasible, subject to extensive manual CT image editing. However, neurosurgeons should be aware that models of one and the same patient will vary according to the production chain used by the 3D printing laboratory in charge. Methodologically, both classic anthropological and light-stripe-based comparisons are justified for use in future studies. For trials aimed at assessing mean deviations and topographic distribution patterns, optical 3D scanning technologies can be recommended.