Volume 146, No. 4950

Johannes Nemeth, Enos Bernasconi, Ulrich Heininger, Mohamed Abbas, David Nadal, Carol Strahm, Stefan Erb, Stefan Zimmerli, Hansjakob Furrer, Julie Delaloye, Thierry Kuntzer, Ekkehard Altpeter, Mathias Sturzenegger, Rainer Weber, for the Swiss Society for Infectious Diseases and the Swiss Society for Neurology (Author)

Update of the Swiss guidelines on post-treatment Lyme disease syndrome

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Lyme borreliosis is caused by Borrelia burgdorferi sensu lato infection, which responds well to antibiotic therapy in the overwhelming majority of cases. However, despite adequate antibiotic treatment some patients report persisting symptoms which are commonly summarised as post-treatment Lyme disease syndrome (PTLDS). In 2005, the Swiss Society of Infectious Diseases published a case definition for PTLDS. We aimed to review the scientific literature with a special emphasis on the last 10 years, questioning whether the definitions from 2005 are still valid in the light of current knowledge. Furthermore, we describe the clinical history of infection with Borrelia burgdorferi sensu lato, the estimated prevalence of PTLDS, the possible pathogenesis of PTLDS, and treatment options with an emphasis on clinical studies.

In summary, we were unable to find a scientific reason for modification of the PTLDS definitions published in 2005. Thus, the diagnostic criteria remain unchanged, namely documented clinical and laboratory evidence of previous infection with B. burgdorferi, a completed course of appropriate antibiotic therapy, symptoms including fatigue, arthralgia, myalgia, cognitive dysfunction or radicular pain persisting for >6 months, a plausible timely association between documented B. burgdorferi infection and onset of symptoms (i.e., persistent or recurrent symptoms that began within 6 months of completion of a recommended antibiotic therapy for early or late Lyme borreliosis), and exclusion of other somatic or psychiatric causes of symptoms. The main therapeutic options remain cognitive behavioural therapy and low-impact aerobic exercise programmes. Growing and unequivocal evidence confirms that prolonged or repeated antibiotic therapy for PTLDS is not beneficial, but potentially harmful and therefore contraindicated.

The Guidelines of the Swiss Society of Infectious Diseases offer an evidence based, diagnostic and therapeutic framework for physicians caring for patients suffering from presumptive PTLDS in Switzerland.

Paolo Meda, Jacques-Antoine Haefliger (Author)

Connexins and pannexins: from biology towards clinical targets

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Efficient cell communication is a prerequisite for the coordinated function of tissues and organs. In vertebrates, this communication is mediated by a variety of mechanisms, including the exchange of molecules between cells, and between cells and the extracellular medium, via membrane channels made of connexin and pannexin proteins. These channels are a necessary component of all human tissues. Here, we review the biological essentials of the connexin and pannexin families, and the roles of these proteins in the function of cells which are central to major human diseases. We then discuss how connexins and pannexins participate in human pathology, and the clinical perspectives that this knowledge opens.

Zanfina Ademi, Viktoria Gloy, Dominik Glinz, Heike Raatz, Joris Van Stiphout, Heiner C Bucher, Matthias Schwenkglenks (Author)

Cost-effectiveness of primarily surgical versus primarily conservative treatment of acute and subacute radiculopathies due to intervertebral disc herniation from the Swiss perspective

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AIMS OF THE STUDY: To assess the cost-effectiveness of primarily surgical treatment (PST) versus primarily conservative treatment (PCT) in adults with intermediate severity, acute or subacute, lumbar radicular syndrome due to intervertebral disc herniation.

METHODS: A decision analytic model from healthcare system and societal perspectives was used to compare outcomes and costs of PST with those of PCT (physiotherapy, epidural injection and medication). Treatment pathways and quality of life were obtained from published clinical trials. Costs were derived from Swiss health insurance claims data. Swiss clinical experts provided information on use of medication and physiotherapy. The main outcome of interest was incremental cost per quality-adjusted-life-year (QALY) gained over a period of 2 years. Costs and QALYs gained were discounted from the second year, at a rate of 2% per year.

RESULTS: In the base-case analysis from a healthcare system perspective, over 2 years, PST compared with PCT led to 0.0634 additional QALYs per person, at an additional net cost of CHF 7198 per person. The corresponding incremental cost effectiveness ratio (ICER) amounted to CHF 113 396 per QALY gained. From a societal perspective the ICER was CHF 70 711 per QALY gained. ICERs were subject to substantial uncertainty because of limitations in available data.

CONCLUSION: A PST approach, when compared with PCT, may be cost effective from a societal perspective based on a willingness-to-pay threshold of CHF 100 000 per QALY gained. However, it is less likely to be cost effective from the perspective of the Swiss healthcare system. More research is needed to understand the long-term economic implications among this patient group.

Alexander Zink, Elisabeth Koch, Florian Seifert, Markus Rotter, Christoph D Spinner, Tilo Biedermann (Author)

Nonmelanoma skin cancer in mountain guides: high prevalence and lack of awareness warrant development of evidence-based prevention tools

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AIMS OF THE STUDY: Nonmelanoma skin cancer (NMSC) is the most common cancer in Switzerland and Europe. The main causative factor is exposure to ultraviolet radiation, which puts outdoor workers in general at a higher risk of developing NMSC than indoor workers. However, few studies have clinically examined the risk of developing NMSC to outdoor workers, especially mountain guides. We aimed to investigate the prevalence of NMSC and corresponding precancerous lesions, and the associated risk behaviour of mountain and ski guides in order to develop future prevention programmes.

METHODS: We conducted a cross-sectional study including mountain and ski guides from southern Germany, who underwent a full-body skin check-up by a dermatologist. We assessed their NMSC awareness and risk behaviour using a paper-based questionnaire.

RESULTS: Of the 62 state-certified mountain and ski guides (55 men, 7 women; mean age 52.9 ± 13.4 years) included in this study, 27 (43.5%) were diagnosed with NMSC or its premalignant stages. In addition, 59.7% of the participants expressed the opinion that their protection from ultraviolet radiation exposure needs to be improved; 83.6% requested further information on NMSC, and 48.5% had never undergone a skin check-up or consulted a dermatologist before.

CONCLUSIONS: Mountain and ski guides are at a high risk for developing NMSC. Their unmet medical needs indicate an underestimation of NMSC prevalence, which is usually based on reports by insurance companies, and offer the chance for developing evidence-based awareness and prevention tools that can be promoted to individuals with other outdoor jobs.

Ana M Vicedo-Cabrera, Martina S Ragettli, Christian Schindler, Martin Röösli (Author)

Excess mortality during the warm summer of 2015 in Switzerland

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QUESTION UNDER STUDY: In Switzerland, summer 2015 was the second warmest summer for 150 years (after summer 2003). For summer 2003, a 6.9% excess mortality was estimated for Switzerland, which corresponded to 975 extra deaths. The impact of the heat in summer 2015 in Switzerland has not so far been evaluated.

METHODS: Daily age group-, gender- and region-specific all-cause excess mortality during summer (June–August) 2015 was estimated, based on predictions derived from quasi-Poisson regression models fitted to the daily mortality data for the 10 previous years. Estimates of excess mortality were derived for 1 June to 31 August, at national and regional level, as well as by month and for specific heat episodes identified in summer 2015 by use of seven different definitions.

RESULTS: 804 excess deaths (5.4%, 95% confidence interval [CI] 3.0‒7.9%) were estimated for summer 2015 compared with previous summers, with the highest percentage obtained for July (11.6%, 95% CI 3.7‒19.4%). Seventy-seven percent of deaths occurred in people aged 75 years and older. Ticino (10.3%, 95% CI −1.8‒22.4%), Northwestern Switzerland (9.5%, 95% CI 2.7‒16.3%) and Espace Mittelland (8.9%, 95% CI 3.7‒14.1%) showed highest excess mortality during this three-month period, whereas fewer deaths than expected (−3.3%, 95% CI −9.2‒2.6%) were observed in Eastern Switzerland, the coldest region. The largest excess estimate of 23.7% was obtained during days when both maximum apparent and minimum night-time temperature reached extreme values (+32 and +20 °C, respectively), with 31.0% extra deaths for periods of three days or more.

CONCLUSIONS: Heat during summer 2015 was associated with an increase in mortality in the warmer regions of Switzerland and it mainly affected older people. Estimates for 2015 were only a little lower compared to those of summer 2003, indicating that mitigation measures to prevent heat-related mortality in Switzerland have not become noticeably effective in the last 10 years.

Joris Budweg, Till Sprenger, Anthony De Vere-Tyndall, Anne Hagenkord, Christoph Stippich, Christoph T. Berger (Author)

Factors associated with significant MRI findings in medical walk-in patients with acute headache

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