Design propositions for nudging in healthcare: Adoption of national electronic health record systems.

Objectives: Electronic health records (EHRs) are considered important for improving efficiency and reducing costs of a healthcare system. However, the adoption of EHR systems differs among countries and so does the way the decision to participate in EHRs is presented. Nudging is a concept that deals with influencing human behaviour within the research stream of behavioural economics. In this paper, we focus on the effects of the choice architecture on the decision for the adoption of national EHRs. Our study aims to link influences on human behaviour through nudging with the adoption of EHRs to investigate how choice architects can facilitate the adoption of national information systems. Methods: We employ a qualitative explorative research design, namely the case study method. Using theoretical sampling, we selected four cases (i.e., countries) for our study: Estonia, Austria, the Netherlands, and Germany. We collected and analyzed data from various primary and secondary sources: ethnographic observation, interviews, scientific papers, homepages, press releases, newspaper articles, technical specifications, publications from governmental bodies, and formal studies. Results: The findings from our European case studies show that designing for EHR adoption should encompass choice architecture elements (i.e., defaults), technical elements (i.e., choice granularity and access transparency), and institutional elements (i.e., regulations for data protection, information campaigns, and financial incentives) in combination. Conclusions: Our findings provide insights on the design of the adoption environments of large-scale, national EHR systems. Future research could estimate the magnitude of effects of the determinants.

Mitigation of climate change in health care: A survey for the evaluation of providers' attitudes and knowledge, and their view on their organization's readiness for change.

BACKGROUND: Climate change is the 21st century's greatest threat to health. Anaesthesia is responsible for high levels of waste production, significant greenhouse gas emissions and extensive energy consumption. Our aim was to design an instrument to assess attitudes and knowledge among anaesthetists as well as their organisation's readiness for change regarding climate action. METHODS: In 2020, the Provider Education and Evaluation Project (PEEP) questionnaire was sent to anaesthetists working at a university hospital, which contains 65 items in five areas: demographics, personal attitudes, organisational readiness, opportunities, and specific anaesthesiologic knowledge regarding climate action. Except for two open text questions, all questions were closed questions. RESULTS: 104 anaesthetists responded to the survey (response rate 62%). Environmental protection and sustainability were important to all participants (100%). Most felt threatened by the ongoing climate crisis (94.2%). While most participants agreed that their employer had the financial or technological capacities and that sustainability targets were compatible with core business activities (approval >60% for all), they felt unprepared and stated that they had too little time to consider environmental aspects during daily routines (disapproval >60% for all). Furthermore, knowledge on topics such as ongoing efforts to tackle climate change or the climate footprint of drugs and medical products, was rather scarce. CONCLUSION: The PEEP questionnaire is an applicable and viable tool to assess anaesthetists' knowledge and attitudes towards climate change and organisational readiness for change. While participants care about the climate crisis, organisational readiness was low, especially when it comes to staff readiness (i.e., skills and knowledge) and cultural readiness (i.e., shared values). These aspects need to be considered in order to successfully implement a carbon neutral health care system.

Measuring mesiodistal width of impacted maxillary canines: CT-assisted determination.

AIM: Precise, three-dimensional localization of impacted maxillary canines is central to their clinical management. Predicting precisely the crown's mesiodistal width is paramount in planning orthodontic treatment. The aim of this study was to verify the exact mesiodistal width of impacted canines via MSCT (multislice spiral computed tomography) examinations. PATIENTS AND METHODS: 3D MSCT images from 17 patients with a total of 24 impacted maxillary canines were taken to obtain the largest mesiodistal diameter using mesial and distal contact points. All existing maxillary canines were included in this study. Mesiodistal tooth width was also determined using callipers on a plaster model after canine eruption. Each measurement was taken twice by 3 observers after a 10-day interval. Statistical analysis entailed calculating and comparing the systematic error, intrarater and interrater standard deviations (Deming regression and ANOVA with random effects). RESULTS: Comparison of the different methods revealed good agreement between the pre-eruption and post-eruption values regarding the canine's mesiodistal width. Total standard deviation was 0.16 mm for values obtained from MSCT measurements and 0.12 mm for those taken with callipers. For both methods intrarater measurement error differed by a factor of 2 (repeatability; model versus MSCT: 0.07 mm versus 0.12 mm), while interrater deviation did not differ significantly (reproducibility; model versus MSCT: 0.10 mm versus 0.10 mm). The reproducibility of our measurements whether taken on the model or with CT was below biological variability. CONCLUSIONS: The volumetric data from an MSCT system gives highly accurate information on the mesiodistal width of displaced canines.

Profile changes following maxillary impaction and autorotation of the mandible.

OBJECTIVE: The aim of this study was the evaluation and prediction of profile changes after Le Fort I osteotomy including maxillary impaction and subsequent autorotation of the mandible. MATERIALS AND METHODS: A group of 42 patients (32 female, 10 male) underwent a Le Fort I osteotomy with posterior impaction after preoperative orthodontic treatment. No surgical intervention in the mandible was performed. Pre- and postoperative lateral cephalograms of each patient were analyzed in two steps using the Wilcoxon and Mann-Whitney U test. All patients were evaluated for vertical and sagittal skeletal and soft tissue changes. These results led to further classification into three groups according to the type and extent of maxillary impaction. These groups included parallel impaction, posterior impaction with additional anterior subsidence, and posterior impaction only. RESULTS: The results of the first evaluation step revealed that the chin had advanced on average by 79%, while the lower face was shortened by as much as 70% in the pogonion point. However, the second evaluation showed that the type and extent of maxillary impaction led to significant changes in these parameters. Parallel maxillary impaction resulted in 100%, posterior impaction in 80% and posterior impaction with anterior subsidence in 50% advancement of the mandible in the pogonion point in relation to the distance covered during impaction. CONCLUSION: This study showed that the change in the facial profile caused by autorotation of the mandible after Le Fort I osteotomy and maxillary impaction can be predicted in relation to the dimensions of maxillary impaction.

Surgically assisted rapid maxillary expansion: midfacial and cranial stress distribution.

INTRODUCTION: Our aim in this study was to investigate the stresses in the midface and at the cranial base during surgically assisted rapid maxillary expansion, to determine whether surgically assisted separation of the maxilla from the cranial base can be considered justified and necessary. METHODS: By using finite element models, surgically assisted rapid maxillary expansion with or without separation of the pterygomaxillary junction was simulated, and the stresses at various points in the midface and the cranial base were analyzed. The finite element models consisted of more than 50,000 individual elements and almost 100,000 nodes. RESULTS: The stresses recorded at the measurement points of the midface and the cranial base were usually lower upon separation of the pterygomaxillary junction than those measured without this additional surgical measure. The stress measured at the optic foramen without separation was 122.4 MPa, whereas, with separation of the pterygomaxillary junction, it was only 32.7 MPa. The finite element method proved to be a suitable procedure for comparing the biomechanical influences of various therapeutic measures involving a combined surgical-orthodontic procedure. The results confirm the effectiveness of an additional separation of the pterygomaxillary junction as a protective measure to reduce stress to the foramina of the cranial base. CONCLUSIONS: To protect the cranial base from undesirable side effects, separation of the pterygomaxillary junction appears to be a reasonable and necessary additional measure for surgically assisted palatal suture expansion.

Rapid maxillary expansion in adults: cranial stress reduction depending on the extent of surgery.

The objective of this study on surgically assisted rapid maxillary expansion (RME) was to examine the extent of stress reduction in the midface and the cranial base with various surgical procedures. Four finite element models of the skull were generated (one without and three with different surgical incisions), in which a virtual RME (5 mm gap width) was simulated. In all four simulations, von-Mises stresses were measured at 30 anatomical structures of the midface and cranial base (in MPa) and compared. The highest von-Mises stresses were measured with the model that did not involve any osteotomies. A reduction of the observed stresses was found after isolated weakening of the zygomaticoalveolar crest on both sides. The model with a complete lateral osteotomy from the piriform aperture to the pterygopalatal junction clearly showed lower stresses than the model with isolated weakening of the zygomaticoalveolar crest. The lowest stress values, however, were seen on the model with a complete osteotomy at the Le Fort I level. In order to prevent complications at the cranial base, surgical assistance is an important aspect of RME in adults. The extent of osteotomies can be varied. The older the patient and the less the bone elasticity, the more extensive should be the surgical weakening in order to minimize the stresses induced at the cranial base and the midface. In older patients, a complete lateral osteotomy from the piriform aperture to the pterygopalatal junction seems to reduce stresses at the cranial base more effectively than isolated weakening of the zygomaticoalveolar crest.

Inter-individual variability of the facial morphology during conscious smiling.

INTRODUCTION: Since many simulation and animation procedures for mimicry are based on averaged values and do not take into account an individual's situation, the goal of this study was to investigate the intra- and inter-individual variability of conscious smiling. MATERIALS AND METHODS: Twenty-three surface points were marked on the faces of 31 adult test individuals. Six photographs of each subject's face were then taken under standardized conditions, one with a neutral facial expression and five while the individual was asked to smile (conscious smile "on command"). After digital superposition of the individual images (neutral and smiling) the displacements were measured for every measurement point on each individual. All data underwent statistical evaluation after normalization in the vertical and horizontal directions. Evaluation of intra- and inter-individual variability was carried out by analyzing the corresponding coefficients of variation and the formation of confidence intervals (confidence level 95%). RESULTS: The repeated measurements upon conscious smiling showed a moderate intra-individual variability with coefficients of variation under 10%. In contrast, the inter-individual variability of the measured values was relatively high. Here variation coefficients were measured of between 28% and 60% depending on the localization of the measuring point. The displacements' absolute magnitude was greatest in the lower facial third. The two corners of the mouth, the upper lip in the philtrum area, the cheeks and the side wings of the nose revealed the highest displacements. CONCLUSION: Due to the high inter-individual variability, an analysis based on averaged values or a simulation of the conscious smile must be viewed with a certain amount of criticism.

Cone-beam computed tomography in orthodontics: benefits and limitations.

INTRODUCTION: In order to obtain an overlay-free assessment of dental structures for resorption and ankylosis diagnostics, conebeam computed tomography (CBCT) is being employed more and more often in orthodontics alongside dental CT. OBJECTIVE: The aim of this study was to investigate the quality and accuracy of CBCT in the imaging of dental structures and to compare it with the imaging quality produced by dental CT. Moreover, we intended to assess the specific advantages and disadvantages of CBCT in clinical use. MATERIALS AND METHODS: The image quality of CBCT and dental CT was examined for a total of 417 teeth and their surrounding structures. 208 teeth were diagnostically recorded using volume tomography and 209 with dental CT. The axial images were assessed for metal and movement artifacts and whether there was an imprecise depiction of the enamel-dentin and pulp interface. The definition and reproductive quality of all teeth were evaluated when imaging the periodontal ligament space in the cervical, middle and apical root thirds. RESULTS: In contrast to dental CT, metal artifacts were barely apparent in the CBCT and when so, only very feebly, whereas we only observed disruptions in image quality from movement artifacts with CBCT. Image quality of the dental and surrounding bony structures was far better with dental CT on the whole than it was with CBCT. During imaging by CBCT, the periodontal ligament space either could not be, or if so, then only poorly assessed for 86% of the teeth, while this figure was only 20% for dental CT. Furthermore, the enamel-dentin interface and pulp cavity's edges were on the whole much more sharply defined in the dental CT. CONCLUSION: Dental CT still represents the gold-standard for inspecting the dental roots and their surrounding bone.

Cytotoxic and mutagenic effects of dental composite materials.

Mutagenicity of single compounds of dental resinous materials has been investigated on many occasions before, but the induction of mutagenic effects by extracts of clinically used composites is still unknown. Here, cytotoxic effects and the formation of micronuclei were determined in V79 fibroblasts after exposure to extracts of modern composite filling materials (Solitaire, Solitaire 2, Tetric Ceram, Dyract AP, Definite). For cytotoxicity testing, test specimens were aged for various time periods (0, 24, and 168 h), and V79 cells were then exposed to dilutions of the original extracts for 24, 48, and 72 h. The ranking of the cytotoxic effects of the composites according to EC50 values after a 24-h exposure period was as follows: Solitaire (most toxic)=Solitaire 2