Systematic reviews and meta-analyses in Homeopathy: Recommendations for summarising evidence from homeopathic intervention studies (Sum-HomIS recommendations)

BACKGROUND

Mainly due to the use of different inclusion criteria and quality assessments, systematic reviews (SRs) and meta-analyses (MAs) with homeopathic intervention studies (HOMIS) have shown inconsistent results. We aimed to build recommendations for "Summarizing evidence from Homeopathic Intervention Studies" (Sum-HomIS recommendations) in order to approach standardization.

METHODS

Against the background of a framework-project to update the evidence from homeopathic intervention studies, we launched an expert panel on how to assess the quality of HOMIS and how to summarize evidence from HOMIS. The results of a literature review and the expert communications in advance of the panel as well as the consensus from the discussions are presented here. We added specific considerations for homeopathic veterinary research.

RESULTS

On top of the general guidelines when planning a review we report five basic Sum-HomIS recommendations. These are: 1) A broad literature search including special archives and consideration of so-called grey-literature; 2) The inclusion of controlled observational studies alongside randomized controlled trials; 3) The choice of a clear clinical research question in the terms that, if possible, the review project includes studies with predominantly homogeneous populations, interventions, comparators and outcomes (PICOs); 4) The use of a global quality assessment including the assessment of external, model and internal validity; 5) A summary of evidence using the GRADE-approach if the body of evidence is sufficiently large and homogenous or a descriptive summary if it is not so.

CONCLUSIONS

We present recommendations for designing, conducting, and reporting SRs and MAs with HOMIS.

Recommendations for Designing, Conducting and Reporting Clinical Observational Studies in Homeopathic Veterinary Medicine

BACKGROUND

Clinical observational studies are an important methodological approach in human and veterinary research, examining and describing treatment experience with good external validity. There are currently few observational studies in the field of homeopathic veterinary medicine.

AIM

The aim of the study was to develop recommendations for designing, conducting and reporting observational studies in homeopathic veterinary medicine.

MATERIALS AND METHODS

A literature review was performed using various search strategies for identifying guidelines and checklist tools relevant for observational studies, veterinary research and homeopathy. Useful guidelines were selected. Prior recommendations for designing and conducting observational studies in human homeopathic medicine were supplemented with recommendations for homeopathic veterinary medicine that were evaluated by an expert panel.

RESULTS

The veterinary extension of the Strengthening the Reporting of Observational Studies in Epidemiology - Veterinary (STROBE-Vet) statement was identified as a useful tool to improve the reporting quality of observational studies, and it has been supplemented here with additional recommendations that are applicable to homeopathy. STROBE-Vet is complemented in the literature by several reports, checklists and guidelines on veterinary medicine in general, such as the Checklist for One Health Epidemiological Reporting of Evidence (COHERE) and the Animal Health Surveillance Reporting Guidelines (AHSURED). Identified items that related to laboratory animal research were excluded as non-relevant to our study.

CONCLUSION

Clinical observational studies are an important methodological approach, having currently unrealized potential in the field of homeopathic veterinary medicine. With relatively minor adjustments, the practical guidelines and checklists available to researchers in designing, conducting and reporting observational studies in human homeopathic medicine have been adapted for homeopathic veterinary medicine, for which high quality can be assured by implementing recommendations such as those in STROBE-Vet. With the emergence of the One Health concept, the COHERE checklist can be viewed with growing significance.

Recommendations in the design and conduction of randomised controlled trials in human and veterinary homeopathic medicine

BACKGROUND

Randomised controlled trials (RCTs) are an established research method to investigate the effects of an intervention. Several recent systematic reviews and meta-analyses of RCTs with homeopathic interventions have identified shortcomings in design, conduct, analysis, and reporting of trials. Guidelines for RCTs in homeopathic medicine are lacking.

OBJECTIVES

This paper aims to fill this gap in order to enhance the quality of RCTs in the field of homeopathy.

METHODS

Identification of the homeopathy-specific requirements for RCTs by reviewing literature and experts' communications. Systematization of the findings using a suitable checklist for planning, conducting, and reporting RCTs, namely the SPIRIT statement, and high-quality homeopathy RCTs as examples. Cross-checking of the created checklist with the RedHot-criteria, the PRECIS criteria, and a qualitative evaluation checklist. Consideration of the REFLECT statement and the ARRIVE Guidelines 2.0 for veterinary homeopathy.

RESULTS

Recommendations for future implementation of RCTs in homeopathy are summarized in a checklist. Alongside, identified useful solutions to the issues encountered when designing and conducting homeopathy RCTs are presented.

CONCLUSIONS

The formulated recommendations present guidelines additional to those in the SPIRIT checklist, on how to better plan, design, conduct, and report RCTs in homeopathy.

Ventilation with the esophageal-tracheal Combitube during general anaesthesia: assessing complications in 540 patients

Background

The esophageal-tracheal Combitube (ETC) was developed for the management of difficult airways but can also be used for general anaesthesia.

Methods

This clinical study collected data from patients undergoing anaesthesia with the ETC in order to assess the rate of complications.

Results

Five hundred forty patients were ventilated with the ETC. In 94.8% (512/540), insertion was performed for the first time by the respective physician. The following minor complications were observed: 38.7% sore throat, 30.9% blood on tube as sign of mucosal lesions and 17.0% cyanotic tongue. Experience decreased the risk of mucosal lesions (odds ratio [OR]: 2.3, 95% confidence interval [CI]: 1.5-3.5). A higher than recommended volume of the oropharyngeal cuff was associated with blood on the ETC (OR: 1.5, 95% CI: 1.0-2.3) and tongue cyanosis (OR: 2.3, 95% CI: 1.4-3.7). Ventilation for more than 2 h was associated with tongue cyanosis (OR: 2.2, 95% CI: 1.6-3.1) and tongue protrusion (OR: 1.4, 95% CI: 1.1-1.9).

Conclusion

We conclude that the Combitube may be used for short procedures requiring general anaesthesia, but the high rate of minor complications limits its value when other alternatives such as a laryngeal mask airway are available. The tested method appears safe regarding major complications, but minor complications are common. Adherence to recommended cuff volumes, experience with the ETC and limiting its use to surgeries lasting less than 2 h might reduce the rate of complications.

Bibliography of Homeopathic Intervention Studies (HOMIS) in Human Diseases

Objectives: Homeopathy (HOM) is a therapeutic method, which is widely used by patients and medical professionals. The medical conditions as well as the homeopathic medical products investigated vary strongly. There is an extensive amount of research, and this necessitates a bibliography that comprehensively presents the entire body of clinical evidence grouped according to medical conditions. Design: Thirty-seven online sources as well as print libraries were searched for HOM and related terms in eight languages (1980 to March 2021). We included studies that compared a homeopathic medicine or intervention with a control regarding the therapeutic or preventive outcome of a disease (classified according to International Classification of Diseases-10). The data were extracted independently by two reviewers and analyzed descriptively. Results: A total of 636 investigations met the inclusion criteria, of which 541 had a therapeutic and 95 a preventive purpose. Seventy-three percent were randomized controlled trials (n = 463), whereas the rest were non-randomized studies (n = 173). The leading comparator was placebo (n = 400). The type of homeopathic intervention was classified as multi-constituent or complex (n = 272), classical or individualized (n = 176), routine or clinical (n = 161) and isopathic (n = 19), or various (n = 8). The potencies ranged from 1X (dilution of -10,000) to 10 M (100^-10.000). The included studies explored the effect of HOM in 223 medical indications. We present the evidence in an online database. Conclusions: This bibliography maps the status quo of clinical research in HOM. The data will serve for future targeted reviews, which may focus on the most studied conditions and/or homeopathic medicines, clinical impact, and the risk of bias of the included studies.

Adjunctive homeopathic treatment of hospitalized COVID-19 patients (COVIHOM): A retrospective case series

Background

and purpose. COVID-19 is a novel viral disease causing worldwide pandemia. The aim of this study was to describe the effect of adjunctive individualized homeopathic treatment delivered to hospitalized patients with confirmed symptomatic SARS-CoV-2 infection.

Patient presentation

Thirteen patients with COVID-19 were admitted. Mean age was 73.4 ± 15.0 (SD) years. Twelve (92.3%) were speedily discharged without relevant sequelae after 14.4 ± 8.9 days. A single patient admitted in an advanced stage of septic disease died in hospital. A time-dependent improvement of relevant clinical symptoms was observed in the 12 surviving patients. Six (46.2%) were critically ill and treated in the intensive care unit (ICU). Mean stay at the ICU of the 5 surviving patients was 18.8 ± 6.8 days. In six patients (46.2%) gastrointestinal disorders accompanied COVID-19.

Conclusion

The observations suggest that adjunctive homeopathic treatment may be helpful to treat patients with confirmed COVID-19 even in high – risk patients especially since there is no conventional treatment of COVID-19 available at present.

[Evidence-based homeopathy and veterinary homeopathy, and its potential to help overcome the anti-microbial resistance problem - an overview]

INTRODUCTION

The basic principles of homeopathy, and its legal and scientific foundations, are discussed in an overview to address the positions of the World Health Organization (WHO) and the commission of the European Union (EU) on complementary medicine. According to the WHO, the antimicrobial resistance problem poses a global threat. The EU Commission's current One Health Action Plan requests research in complementary medicine, the WHO urges member states to include complementary medicine in their national health policies. Regarding external evidence on the general use of human and veterinary homeopathy, evidence level 1a studies are reviewed. Focusing on the external evidence on the use of homeopathy in infections, some evidence level 1a, 1b, 2c studies, and a case report, are described in more detail. In conclusion, evidence for the effectiveness of human and veterinary homeopathy in general, and in particular, of homeopathic treatment for infections, is available. Especially, individualized homeopathy demonstrates effects at all quality levels according to Cochrane criteria, even in the methodologically high-quality studies. As in most areas of veterinary medicine and medicine, further good/excellent studies are necessary. In compliance with the principles of homeopathy, further methodologically high-quality trials focusing on the homeopathic treatment of infections are the next logical step. The selection of the simile (individually fitting homeopathic medicinal product) by appropriately trained homeopathic doctors/veterinarians is essential for the effectiveness of homeopathy. Implementation of studies at university facilities is a prerequisite for quality assurance. Consequently, further integration of homeopathy at universities is a necessary requirement for the patients' best interests.

Homeopathic Treatment as an Add-On Therapy May Improve Quality of Life and Prolong Survival in Patients with Non-Small Cell Lung Cancer: A Prospective, Randomized, Placebo-Controlled, Double-Blind, Three-Arm, Multicenter Study

LESSONS LEARNED

Conventional medicine and homeopathy work well together. Quality of life improves with additive homeopathy in patients with non-small cell lung cancer (NSCLC). Survival improves with additive homeopathy in patients with NSCLC.

BACKGROUND

Patients with advanced non-small cell lung cancer (NSCLC) have limited treatment options. Alongside conventional anticancer treatment, additive homeopathy might help to alleviate side effects of conventional therapy. The aim of the present study was to investigate whether additive homeopathy might influence quality of life (QoL) and survival in patients with NSCLC.

METHODS

In this prospective, randomized, placebo-controlled, double-blind, three-arm, multicenter, phase III study, we evaluated the possible effects of additive homeopathic treatment compared with placebo in patients with stage IV NSCLC, with respect to QoL in the two randomized groups and survival time in all three groups. Treated patients visited the outpatients' centers every 9 weeks: 150 patients with stage IV NSCLC were included in the study; 98 received either individualized homeopathic remedies (n = 51) or placebo (n = 47) in a double-blinded fashion; and 52 control patients without any homeopathic treatment were observed for survival only. The constituents of the different homeopathic remedies were mainly of plant, mineral, or animal origin. The remedies were manufactured by stepwise dilution and succussion, thereby preparing stable Good Manufacturing Practice grade formulations.

RESULTS

QoL as well as functional and symptom scales showed significant improvement in the homeopathy group when compared with placebo after 9 and 18 weeks of homeopathic treatment (p < .001). Median survival time was significantly longer in the homeopathy group (435 days) versus placebo (257 days; p = .010) as well as versus control (228 days; p < .001). Survival rate in the homeopathy group differed significantly from placebo (p = .020) and from control (p < .001).

CONCLUSION

QoL improved significantly in the homeopathy group compared with placebo. In addition, survival was significantly longer in the homeopathy group versus placebo and control. A higher QoL might have contributed to the prolonged survival. The study suggests that homeopathy positively influences not only QoL but also survival. Further studies including other tumor entities are warranted.

The Hydra-Headed Coronaviruses: Implications of COVID-19 for Homeopathy

Successful homeopathic prescriptions are based on careful individualization of symptoms, either for an individual patient or collectively in the case of epidemic outbreaks. The ongoing COVID-19 pandemic was initially represented as a severe acute respiratory illness, with eventual dramatic complications. However, over time it revealed to be a complex systemic disease with manifestations derived from viral-induced inflammation and hypercoagulability, thus liable to affect any body organ or system. As a result, clinical presentation is variable, in addition to variations associated with several individual and collective risk factors. Given the extreme variability of pathology and clinical manifestations, a single, or a few, universal homeopathic preventive Do not split medicine(s) do not seem feasible. Yet homeopathy may have a relevant role to play, inasmuch as the vast majority of patients only exhibit the mild form of disease and are indicated to self-care at home, without standard monitoring, follow-up, or treatment. For future pandemics, homeopathy agencies should prepare by establishing rapid-response teams and efficacious lines of communication.

Comparison of the new flexible tip bougie catheter and standard bougie stylet for tracheal intubation by anesthesiologists in different difficult airway scenarios: a randomized crossover trial

Background

Incidence of difficult endotracheal intubation ranges between 3 and 10%. Bougies have been recommended as an airway adjunct for difficult intubation, but reported success rates are variable. A new generation flexible tip bougie appears promising but was not investigated so far. We therefore compared the new flexible tip with a standard bougie in simulated normal and difficult airway scenarios, and used by experienced anesthesiologists.

Methods

We conducted a observational, randomized, cross-over simulation study. Following standardized training, experienced anesthesiologists performed endotracheal intubation using a Macintosh blade and one of the bougies in six different airway scenarios in a randomized sequence: normal airway, tongue edema, pharyngeal obstruction, manual cervical inline stabilization, cervical collar stabilization, cervical collar stabilization and pharyngeal obstruction. Overall success rate with a maximum of 3 intubation attempts was the primary endpoint. Secondary endpoints included number of intubation attempts, time to intubation and dental compression.

Results

Thirty-two anesthesiologist participated in this study between January 2019 and May 2019. Overall success rate was similar for the flexible tip bougie and the standard bougie. The flexible tip bougie tended to need less intubation attempts in more difficult airway scenarios. Time to intubation was less if using the flexible tip bougie compared to the standard bougie. Reduced severity of dental compression was noted for the flexible tip bougie in difficult airway scenarios except cervical collar stabilization.

Conclusion

In this simulation study of normal and difficult airways scenarios, overall success rate was similar for the flexible tip and standard bougie. Especially in more difficult airway scenarios, less intubation attempts, and less optimization maneuvers were needed if using the flexible tip bougie.

Trial registration

clinicaltrials.gov Identifier: NCT03733158. 7th November 2018.

The TrueCPR device in the process of teaching cardiopulmonary resuscitation: A randomized simulation trial

BACKGROUND

International resuscitation guidelines emphasize the importance of high quality chest compressions, including correct chest compression depth and rate and complete chest recoil. The aim of the study was to assess the role of the TrueCPR device in the process of teaching cardiopulmonary resuscitation in nursing students.

METHODS

A prospective randomized experimental study was performed among 94 first year students of nursing. On the next day, the participants were divided into 2 groups-the control group practiced chest compressions without the use of any device for half an hour, and the experimental group practiced with the use of TrueCPR. Further measurement of chest compressions was performed after a month.

RESULTS

The chest compression rate achieved the value of 113 versus 126 (P < .001), adequate chest compression rate (%) was 86 versus 68 (P < .001), full chest release (%) 92 versus 69 (P = .001), and correct hand placement (%) 99 versus 99 (P, not significant) in TrueCPR and standard BLS groups, respectively. As for the assessment of the confidence of chest compression quality, 1 month after the training, the evaluation in the experimental group was statistically significantly higher (91 vs 71; P < .001) than in the control group.

CONCLUSIONS

Cardiopulmonary resuscitation training with the use of the TrueCPR device is associated with better resuscitation skills 1 month after the training. The participants using TrueCPR during the training achieved a better chest compression rate and depth with in international recommendations and better full chest release percentage and self-assessed confidence of chest compression quality comparing with standard cardiopulmonary resuscitation training.

The effect of chest compression frequency on the quality of resuscitation by lifeguards. A prospective randomized crossover multicenter simulation trial

BACKGROUND

The ability to perform high-quality cardiopulmonary resuscitation is one of the basic skills for lifeguards. The aim of the study was to assess the influence of chest compression frequency on the quality of the parameters of chest compressions performed by lifeguards.

METHODS

This prospective observational, randomized, crossover simulation study was performed with 40 lifeguards working in Warsaw, Wroclaw, and Poznan, Poland. The subjects then participated in a target study, in which they were asked to perform 2-min cycles of metronome-guided chest compressions at different rates: 80, 90, 100, 110, 120, 130, 140, and 150 compressions per minute (CPM).

RESULTS

The study involved 40 lifeguards. Optimal chest compression score calculated by manikin software was achieved for 110-120 CPM. Chest compression depth achieved 53 (interquartile range [IQR] 52-54) mm, 56 (IQR 54-57) mm, 52.5 (IQR 50-54) mm, 53 (IQR 52-53) mm, 50 (IQR 49-51) mm, 47 (IQR 44-51) mm, 41 (IQR 40-42) mm, 38 (IQR 38-43) mm for 80, 90, 100, 110, 120, 130, 140 and 150 CPM, respectively. The percentage of chest compressions with the correct depth was lower for rates exceeding 120 CPM.

CONCLUSIONS

The rate of 100-120 CPM, as recommended by international guidelines, is the optimal chest compression rate for cardiopulmonary resuscitation performed by lifeguards. A rate above 120 CPM was associated with a dramatic decrease in chest compression depth and overall chest compression quality. The role of full chest recoil should be emphasized in basic life support training.

Comparison of blind intubation via supraglottic airway devices versus standard intubation during different airway emergency scenarios in inexperienced hand: Randomized, crossover manikin trial

BACKGROUND

Securing the airway and enabling adequate oxygenation and ventilation is essential during cardiopulmonary resuscitation (CPR). The aim of the study was to evaluate the success rate of blind intubation via the I-Gel and the Air-Q compared with direct laryngoscopy guided endotracheal intubation by inexperienced physician and to measure time to successful intubation.

METHODS

The study was designed as a randomized, cross-over simulation study. A total of 134 physicians, from specialties other than Anesthesia or Emergency Medicine, who considered themselves skilled in endotracheal intubation but who have never used any kind of supraglottic airway device performed blind intubation via the I-Gel and Air-Q and direct laryngoscopy guided endotracheal intubation in 3 randomized scenarios: normal airway without chest compression during intubation attempt; normal airway with continuous chest compression during intubation attempt; difficult airway with continuous chest compression.

RESULTS

Scenario A: Success rate with initial intubation attempt was 72% for endotracheal intubation, 75% in Air-Q, and 81% in I-Gel. Time to endotracheal intubation and ease of intubation was comparable with all 3 airway devices used. Scenario B: Success rate with the initial intubation attempt was 42% for endotracheal intubation, compared with 75% in Air-Q and 80% in I-Gel. Time for endotracheal intubation was significantly prolonged in endotracheal intubation (42 seconds, 35-49), compared with Air-Q (21 seconds, 18-32) and I-Gel (19 seconds, 17-27). Scenario C: The success rate with the initial intubation attempt was 23% in endotracheal intubation, compared with 65% in Air-Q and 74% in I-Gel. Time to intubation was comparable with both supraglottic airway devices (20 vs 22 seconds) but was significantly shorter compared with endotracheal intubation (50 seconds, P < .001).

CONCLUSIONS

Less to moderately experienced providers are able to perform endotracheal intubation in easy airways but fail during ongoing chest compressions and simulated difficult airway. Consequently, less to moderately experienced providers should refrain from endotracheal intubation during ongoing chest compressions during CPR and in expected difficult airways. Supraglottic airway devices are reliable alternatives and blind intubation through these devices is a valuable airway management strategy.

Development of a whole plant bioassay to test effects of potentized calcium carbonate in pillule formulation

OBJECTIVES

From a pharmaceutical point of view, we see a need to develop stable preclinical test systems to identify and investigate effects of potentized remedies as used in Anthroposophic Medicine and Homeopathy. We evaluated a plant bioassay regarding its capacity to distinguish homeopathic remedies from placebo, applied as sucrose pillules.

METHODS

Pea seed (Pisum sativum L) was soaked for 24 hours in water with dissolved homeopathic or placebo pillules, or in water only. Shoot length was measured 14 days after planting and treatment groups were compared by analysis of variance (ANOVA). The stability of the system was validated by systematic negative control experiments.

RESULTS

The system is suitable to test a common application form - sucrose pillules - of a potentized preparation without influence of the pharmaceutical carrier substance. A screening of 13 potentized preparations revealed Calcium carbonicum to affect pea shoot growth (p < 0.05). Three independent series of main experiments were performed with potentized Calcium carbonicum to assess reproducibility. Meta-analysis of all data revealed significant effects of Calcium carbonicum 12c and 30c on pea shoot growth (p < 0.05), which were however dependent on the date of experiment and/or the experimental series.

CONCLUSIONS

Potentized Calcium carbonicum, applied as sucrose pillules, influenced pea shoot growth in the assay investigated. However, due to the small effect size and due to the modulation of the effects by still unknown external factors, further optimization of this bioassay is necessary to be used in pharmaceutical quality control or in investigating the biological or pharmaceutical mode of action of potentized preparations.

Does the use of cardiopulmonary resuscitation feedback devices improve the quality of chest compressions performed by doctors? A prospective, randomized, cross-over simulation study

BACKGROUND

The aim of the study was to compare the quality of chest compressions (CCs) carried out with and without the use of the TrueCPR device during simulated cardiopulmonary resuscitations conducted by trainee doctors.

METHODS

The study was a prospective, randomized, cross-over simulation study. The study involved 65 trainee doctors who were tasked with performing a 2-min cycle of uninterrupted CCs under conditions of a simulated cardiopulmonary resuscitation of adults. CC were carried out in two scenarios: with and without TrueCPR chest compression support. Participants did not have experience in the use of CCs prior to this study.

RESULTS

The depth of compressions in regard to CC techniques were varied by 45 mm (IQR 43-48) for manual CC and 53 mm (IQR 51-55) for the TrueCPR device (p < 0.001). The incidence of CCs with and without TrueCPR was: 112 (IQR 103-113) vs. 129 (IQR 122-135) compressions (p = 0.002). The degree of complete chest relaxation with the TrueCPR device was 95% (IQR 76-99) and without the device, 33% (IQR 29-38) (p < 0.001).

CONCLUSIONS

In the simulation study performed, the use of the TrueCPR device resulted in a significant improvement in the quality of CCs in relation to frequency and depth of CCs and correctness of chest relaxation.

Case Reports of Five Cancer Patients with Unusual Course

INTRODUCTION

 The analysis of the periodic table of elements by Jan Scholten opened the way for a new kind of classification and repertorisation of homeopathic remedies. Thereby, group analysis (resorting to series and stages) makes precise prescriptions possible. This approach appears to yield striking results, even in severe cases. Whereas Hahnemann stressed the emotional state ('Gemüthssymptome', Organon § 210) when choosing a remedy, Scholten 200 years later investigated the mental picture that represents a life conflict or even a life theme that may maintain the disease process. The person's environment, emotional traumas or a conflict drives him or her to suppress and dissect painful emotions. Such compensations can become subconscious and so strong that they can no longer be controlled; they then influence the patient with a highly destructive energy.

METHODS

 We present five case reports, each dealing with an unusual clinical course of severe cancer associated with homeopathic treatment using the Scholten method.

RESULTS

 By presenting these cases, we consider how the constitution (lifelong signs and symptoms of the patient) and the mental state are interwoven and, as a complex mechanism, might provoke disease.

CONCLUSION

 The appropriate homeopathic remedy, reflecting the Scholten approach, seemed to have beneficial impact on the disease process of the five individuals presented.

Which position should we take during newborn resuscitation? A prospective, randomised, multicentre simulation trial

BACKGROUND

Early bystander cardiopulmonary resuscitation (CPR) for cardiac arrest is crucial in the chain of survival. Cardiac arrest in infants is rare, but CPR is also performed in severe bradycardia. European Resuscitation Council and American Heart Association guidelines recommend continuing CPR until the heart muscle is sufficiently oxygenated and regains sufficient contractility and function. The most common and recommended CPR techniques that can be applied in newborns are the two-finger technique and two-thumb technique.

AIM

We sought to assess the quality of CPR performed in newborns with the two-finger technique depending on the posi-tion of the rescuer during resuscitation.

METHODS

This was a prospective, randomised, crossover, simulated study. It involved 93 nurses who were required to perform a two-minute CPR using the two-finger technique in three scenarios: (A) with the newborn lying on the floor; (B) on a table; and (C) with the newborn on the rescuer's forearm. The Newborn Tory® S2210 manikin was used to simulate a neonatal patient in cardiac arrest. The following parameters were measured: chest compression (CC) depth, CC rate, no-flow time, percentage of full release, ventilation rate, and ventilation volume, as well as the number of effective compressions and effective ventilations.

RESULTS

Statistical analysis showed significant differences in CC rates between scenarios A and B (p < 0.001) and between scenarios B and C (p = 0.002). Significant differences were also observed between the median CC depth. The median per-centage of no-flow-fraction was the highest for scenario A (55%), followed by scenario B (48%), and scenario C (46%). There were significant differences between the values of no-flow-fraction between scenarios A and B (p < 0.001), and between scenarios A and C (p < 0.001). The percentage of chest full releases for scenarios A, B, and C amounted to 94%, 1%, and 92%, respectively. Significant differences in the number of effective CCs between scenarios A and B (p < 0.001) as well as B and C (p < 0.001) were revealed. The median ventilation rate was highest for scenario B (13 × min-1), and lowest for scenario A (9 × min-1). The highest tidal volume was obtained in scenario A (27 mL), and the lowest in scenario C (26 mL). The most effective CPR was performed when resuscitation was carried out on the rescuer's forearm.

CONCLUSIONS

The quality of CCs in newborns depends on the location of the patient and the rescuer. The optimal form of resuscitation of newborns is resuscitation on the rescuer's forearm.

Petroleum: a series of 25 cases

This study is based on 25 well documented reports of cases which responded well to treatment with Petroleum. Materia medica data were compared with results in contemporary clinical practice. Many patients had characteristic skin problems; children often had recurrent or chronic upper respiratory tract problems. The most prominent mental feature is a quiet, withdrawn or stubborn disposition. The mental symptoms may be difficult to recognise.

Detailed documentation in daily practice can be helpful for preserving data of the effect of a medicine; confirmation of statements given in materia medica; improving understanding of homeopathic medicines and differentiating the indications for medicines.

ET-View compared to direct laryngoscopy in patients with immobilized cervical spine by unexperienced physicians: A randomized crossover manikin trial

BACKGROUND

Immobilization of the cervical spine is indicated in all patients with the potential risk of any cervical spine injury. Airway management in these patients is challenging and direct laryngoscopy is the standard of care. Videolaryngoscopes like the ET-View were introduced into clinical practice to provide better airway visualization and ease intubation. The ET-View is essentially a conventional endotracheal tube, but is equipped with a miniature camera on the tip. The ET-View has not been investigated in patients with immobilized cervical spine so far. The aim was to evaluate the performance of the VivaSight SL compared with Macintosh when performed in patients with immobilized cervical spine by unexperienced physicians.

METHODS

This was prospective, randomized, cross-over manikin trial. 50 novice physicians were randomly assigned to intubate a manikin in three airway scenarios including a normal airway and two cervical immobilization techniques. Overall and first intubation attempt success rate, time to intubation, dental compression and airway visualization according to the Cormack&Lehane graduation were assessed.

RESULTS

All physicians were able to intubate the manikin in all scenarios using the ETView, whereas direct laryngoscopy failed in 16 % with immobilized cervical spine using the patriot cervical extraction collar. First intubation attempt success rate was higher and airway visualization was better in all three scenarios using the ET-View compared to direct laryngoscopy.

CONCLUSION

The ET-View offered much better 62 airway visualization and provided higher overall and first intubation attempt success rates. Therefore, the ET-View is a valuable alternative in patients with difficult intubation due to immobilized cervical spine. Further clinical trials are indicated to confirm these findings.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02733536.

Inter-center comparison of EasyTube and endotracheal tube during general anesthesia in minor elective surgery

Background

The EasyTube^® (EzT) is a supraglottic airway device (SAD) enabling ventilation irrespective of its placement into the esophagus or trachea. Data obtained on SADs from multicenter studies, performed in highly specialized centers cannot always be transferred to other sites. However, data on comparability of different sites are scarce. This study focused on inter-site variability of ventilatory and safety parameters during general anesthesia with the EzT.

Methods

400 patients with ASA physical status I-II undergoing general anesthesia for elective surgery in four medical centers (EzT group (n = 200), ETT group (n = 200)). Mallampati classification, success of insertion, insertion time, duration of ventilation, number of insertion attempts, ease of insertion, tidal volumes, leakage, hemodynamic parameters, oxygenation, and complications rates with the EasyTube (EzT) or endotracheal tube (ETT) in comparison within the sites and in between the sites were recorded.

Results

Intra-site and inter-site comparison of insertion success as primary outcome did not differ significantly. The inter-site comparison of expiratory minute volumes showed that the volumes achieved over the course of anesthesia did not differ significantly, however, mean leakage at one site was significantly higher with the EzT (0.63 l/min, p = 0.02). No significant inter-site differences in heart rate, blood pressure, or oxygenation were observed. Sore throat and blood on the cuff after removal of the device were the most frequent complications with significantly more complications at one site with the EzT (p = 0.01) where insertion was also reported significantly more difficult (p = 0.02).

Conclusion

Performance of the EzT but not the ETT varied between sites with regard to insertion difficulty, leakage, and complications but not insertion success, ventilation, hemodynamics, and oxygenation parameters in patients with ASA physical status 1–2 during general anesthesia undergoing minor elective surgery.

The EasyTube during general anesthesia for minor surgery: A randomized, controlled trial

BACKGROUND

The EasyTube (EzT) is a supraglottic airway device that is used for emergency airway situations. Ventilation during general anesthesia should also be feasible, but literature on the EzT is scarce. We evaluated the EzT in comparison with the endotracheal tube (ETT) in its use during general anesthesia in a comparative study.

METHODS

A total of 400 patients with American Society of Anesthesiologists (ASA) physical status I to II scheduled for minor surgery in 4 centers were randomized for ventilation via the ETT or EzT.

RESULTS

In all patients, the EzT and the ETT could be inserted within 3 attempts. In all EzT patients, the inspiratory and expiratory minute volumes (6.64 ± 0.71 and 6.34 ± 0.69 L/min) were sufficient to reach target oxygenation values, similar to ETT patients (P  =  .59). Mean peak pressure, mean plateau pressure, and mean dynamic compliance did not differ between the groups. Sore throat and blood on the cuff after removal were the most frequent complications in both groups.

CONCLUSION

Ventilation for up to 1 hour during general anesthesia in patients with ASA physical status I to II with the EzT is feasible and safe.

Human Cytomegalovirus Infection in Nonimmunocompromised Patients: A Retrospective Analysis and Review of the Literature

In a retrospective analysis of patients visiting the Outpatient Department of the Division of Infectious Diseases and Tropical Medicine over a period of 3 years, we found a high incidence of symptomatic nonsevere human cytomegalovirus (HCMV) infection in nonimmunocompromised patients. We present 11 symptomatic cases of HCMV infection in nonimmunocompromised patients with non-life-threatening symptoms like long-lasting depletion, fatigue, and subfebrile fever with or without muscular pain and arthralgia. Although the symptoms were not life-threatening, all of the patients suffered a prolonged duration of the disease until improvement. These cases reinforce the important fact that HCMV infections in nonimmunocompromised patients are not always asymptomatic. Therefore, HCMV infection should always be included in the differential diagnosis of patients with unspecific signs of disease like depletion, subfebrile fever, and arthralgia.

Comparison of the Macintosh laryngoscope and blind intubation via the iGEL for Intubation With C-spine immobilization: A Randomized, crossover, manikin trial

INTRODUCTION

Endotracheal intubation (ETI) using a Macintosh laryngoscope (MAC) requires the head to be positioned in a modified Jackson position, slightly reclined and elevated. Intubation of trauma patients with an injured neck or spine is therefore difficult, since the neck usually cannot be turned or is already immobilized in order to prevent further injury. The iGEL supraglottic airway seems optimal for such conditions due to its blind insertion without the need of a modified Jackson position.

METHODS

Prospective, randomized, crossover study in 46 paramedics. Participants performing standard intubation and blind intubation via iGEL supraglottic airway device in three airway scenarios: Scenario A - normal airway; Scenario B - manual inline cervical immobilization, performed by an independent instructor; scenario C: cervical immobilization using a standard Patriot cervical extraction collar.

RESULTS

In Scenario A, nearly all participants performed ETI successfully both with MAC and iGEL (100% vs. 95.7%). The time to intubation (TTI) using the MAC and iGEL amounted to 19 [IQR, 18-21]s vs. 12 [IQR, 11-13]s (P<0.001). Head extension angle as well as tooth compression were significantly better with the iGEL compared to the MAC (P<0.001). In scenario B and C, the results with the iGEL were significantly better than with MAC for all analyzed variables (TTI, success of first intubation attempt, head extension angle, tooth compression and VAS scores).

CONCLUSION

We showed that blind intubation with the iGEL supraglottic airway was superior to ETI performed by paramedics in a simulated cervical immobilization scenario in a manikin in terms of success rate, time to definite tube placement, head extension angle, tooth compression, and rating.

A comparison of a traditional endotracheal tube versus ETView SL in endotracheal intubation during different emergency conditions: A randomized, crossover cadaver trial

BACKGROUND

Airway management is a crucial skill essential to paramedics and personnel working in Emergency Medical Services and Emergency Departments: Lack of practice, a difficult airway, or a trauma situation may limit the ability of paramedics to perform direct laryngoscopy during cardiopulmonary resuscitation. Videoscope devices are alternatives for airway management in these situations. The ETView VivaSight SL (ETView; ETView Ltd., Misgav, Israel) is a new, single-lumen airway tube with an integrated high-resolution imaging camera. To assess if the ETView VivaSight SL can be a superior alternative to a standard endotracheal tube for intubation in an adult cadaver model, both during and without simulated CPR.

METHODS

ETView VivaSight SL tube was investigated via an interventional, randomized, crossover, cadaver study. A total of 52 paramedics participated in the intubation of human cadavers in three different scenarios: a normal airway at rest without concomitant chest compression (CC) (scenario A), a normal airway with uninterrupted CC (scenario B) and manual in-line stabilization (scenario C). Time and rate of success for intubation, the glottic view scale, and ease-of-use of ETView vs. sETT intubation were assessed for each emergency scenario.

RESULTS

The median time to intubation using ETView vs. sETT was compared for each of the aforementioned scenarios. For scenario A, time to first ventilation was achieved fastest for ETView, 19.5 [IQR, 16.5-22] sec, when compared to that of sETT at 21.5 [IQR, 20-25] sec (p = .013). In scenario B, the time for intubation using ETView was 21 [IQR, 18.5-24.5] sec (p < .001) and sETT was 27 [IQR, 24.5-31.5] sec. Time to first ventilation for scenario C was 23.5 [IQR, 19-25.5] sec for the ETView and 42.5 [IQR, 35-49.5] sec for sETT.

CONCLUSIONS

In normal airways and situations with continuous chest compressions, the success rate for intubation of cadavers and the time to ventilation were improved with the ETView. The time to glottis view, tube insertion, and cuff block were all found to be shorter with the ETView.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02733536.

CPR using the lifeline ARM mechanical chest compression device: a randomized, crossover, manikin trial

INTRODUCTION

European Resuscitation Council as well as American Heart Association guidelines for cardiopulmonary resuscitation (CPR) stress the importance of uninterrupted and effective chest compressions (CCs). Manual CPR decreases in quality of CCs over time because of fatigue which impacts outcome. We report the first study with the Lifeline ARM automated CC device for providing uninterrupted CCs.

METHODS

Seventy-eight paramedics participated in this randomized, crossover, manikin trial. We compared the fraction of effective CCs between manual CPR and automated CPR using the ARM.

RESULTS

Using the ARM during resuscitation resulted in a higher percentage of effective CCs (100/min [interquartile range, 99-100]) compared with manual CCs (43/min [interquartile range, 39-46]; P<.001). The number of effective CCs decreased less over time with the ARM (P<.001), more often reached the required depth of 5 cm (97% vs 63%, P<.001), and more often reached the recommended CC rate (P<.001). The median tidal volume was higher and hands-off time was lower when using the ARM.

CONCLUSION

Mechanical CCs in our study adhere more closely to current guidelines than manual CCs. The Lifeline ARM provides more effective CCs, more ventilation time and minute volume, less hands-off time, and less decrease in effective CCs over time compared with manual Basic Life Support and might therefore impact outcome.

Comparative study of three different supraglottic airway devices in simulated difficult airway situations

BACKGROUND

Supraglottic airway devices (SAD) provide an effective way for managing difficult airways. Numerous SADs have been developed in recent years. We compared three SADs utilizing simulated airways. The major aim of this study was to provide evidence for the efficacy of SADs in the management of simulated difficult airway situations.

METHODS

The study utilized an airway simulation manikin (Laerdal SimMan® 3G) to assess feasibility and time to final placement of three different airway devices (the classic laryngeal mask airway [LMA], the Laryngeal tube [LT], and the EasyTube® [EzT]). Thirty anesthesiologists inserted each of the SADs under standard physiologic airway conditions (STD) as well as pathological airway conditions, including tongue edema (TE) and trismus combined with limited mobility of the cervical spine (TCS), mimicking a patient with cramps.

RESULTS

In STD and TE, all participants were able to successfully place the LMA, LT, and EzT correctly. In TCS, one participant failed to place the LMA correctly, whereas six participants failed to place the LT correctly (P=0.031). Under STD and TE conditions, we found a significantly longer time to final placement with the EzT (P=0.001). Under TCS conditions, there was no significant difference between the tested SADs. Under STD conditions, the participants rated the LMA best (P<0.001). Under TE and TCS condition, the EzT was significantly higher rated (P<0.001).

CONCLUSION

The EzT showed benefits in two difficult airway situations (TE and TCS) in a prospective manikin study amongst anesthesiologists.

Feasibility and speed of insertion of seven supraglottic airway devices under simulated airway conditions

OBJECTIVES

Endotracheal intubation (ETI) is considered the gold standard for protecting the airway. Alternative devices for airway protection have been developed that can be used by untrained personnel, by those with less experience, and for when ETI is not possible. The main goals of our study were to evaluate the success rate and speed of insertion of different supraglottic airway devices and to determine whether the devices could be properly inserted under simulated critical conditions.

METHODS

Fifty medical students used an airway simulation trainer (Laerdal SimMan 3G) to assess the success rate and time used to insert seven different supraglottic airway devices under simulated physiologic and pathologic conditions in two different runs.

RESULTS

Although all airway devices could be inserted without problems, only the Combitube and the EasyTube could be successfully inserted in simulations of trismus, limited mobility of the cervical spine, or a combination of pathologic conditions such as trismus plus limited mobility of the spine and trismus plus tongue edema. The insertion time was significantly longer with LMA Unique, Fastrach, and I-Gel devices in both the first and second runs.

CONCLUSION

The Combitube and the EasyTube were most easily inserted under simulated conditions such as trismus, limited mobility of the cervical spine, and combined pathologic conditions. Although all devices are useful for establishing an airway by nontrained medical students in standard simulations, we suggest that the Combitube and the EasyTube may offer advantages in difficult airway situations.

Middle Age Like Fight or Modern Symbiosis? Comment on "Substitutes or Complements? Diagnosis and Treatment With Non-conventional and Conventional Medicine"

Complementary and alternative medicine (CAM) is widely used by patients worldwide. Financial factors may influence the decision to use CAM. National Health Systems are requested to consider CAM in their health plans.

Comparison of 4 supraglotttic devices used by paramedics during simulated CPR : a randomized controlled crossover trial

BACKGROUND

Ensuring an open airway during cardiopulmonary resuscitation is fundamental. The aim of this study was to determine the success rate of blind intubation during simulated cardiopulmonary resuscitation by untrained personnel.

METHODS

Four devices were compared in a simulated resuscitation scenario: ILMA (Intavent Direct Ltd, Buckinghamshire, United Kingdom), Cobra PLA (Engineered Medical Systems Inc, Indianapolis, IN), Supraglottic Airway Laryngopharyngeal Tube (SALT) (ECOLAB, St. Paul, MN), and Air-Q (Mercury Medical, Clearwater, FL). A group of 210 paramedics intubated a manikin with continuous chest compressions.

RESULTS

The mean times to intubation were 40.46 ± 4.64, 33.96 ± 6.23, 17.2 ± 4.63, and 49.23 ± 13.19 seconds (SALT vs ILMA, Cobra PLA, and Air-Q; P < .05). The success ratios of blind intubation for the devices were 86.7%, 85.7%, 100%, and 71.4% (SALT vs ILMA, Cobra PLA, and Air-Q; P < .05).

CONCLUSION

The study showed that the most efficient device with the shortest blind intubation time was the SALT device.

Current status of the EasyTube: a review of the literature

EasyTube is an esophageal-tracheal double lumen airway device that combines the features of an endotracheal tube with a supraglottic airway device, enabling ventilation with either tracheal or esophageal insertion. EasyTube can be inserted blindly or by using a laryngoscope. Its main indication is for airway emergencies both in pre-and in-hospital areas. In this article we review the current knowledge on the use of the EasyTube.

Influence of adjunctive classical homeopathy on global health status and subjective wellbeing in cancer patients - A pragmatic randomized controlled trial

OBJECTIVES

The use of complementary and alternative medicine has increased over the past decade. The aim of this study was to evaluate whether homeopathy influenced global health status and subjective wellbeing when used as an adjunct to conventional cancer therapy.

DESIGN

In this pragmatic randomized controlled trial, 410 patients, who were treated by standard anti-neoplastic therapy, were randomized to receive or not receive classical homeopathic adjunctive therapy in addition to standard therapy. The study took place at the Medical University Vienna, Department of Medicine I, Clinical Division of Oncology.

MAIN OUTCOME MEASURES

The main outcome measures were global health status and subjective wellbeing as assessed by the patients. At each of three visits (one baseline, two follow-up visits), patients filled in two different questionnaires.

RESULTS

373 patients yielded at least one of three measurements. The improvement of global health status between visits 1 and 3 was significantly stronger in the homeopathy group by 7.7 (95% CI 2.3-13.0, p=0.005) when compared with the control group. A significant group difference was also observed with respect to subjective wellbeing by 14.7 (95% CI 8.5-21.0, p<0.001) in favor of the homeopathic as compared with the control group. Control patients showed a significant improvement only in subjective wellbeing between their first and third visits.

CONCLUSION

Results suggest that the global health status and subjective wellbeing of cancer patients improve significantly when adjunct classical homeopathic treatment is administered in addition to conventional therapy.