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Interoception and dissociation in migraine: a case–control study of chronic and episodic subtypes
Get PDFBackground
Migraine is one of the most common neurological disorders. Despite advances in understanding of episodic migraine, little is understood about the mechanisms underlying the chronification of migraine. Recently, increasing attention has been given to the potential roles of interoceptive abnormalities and dissociation. Therefore, we sought to explore differences in interoception and dissociation in individuals with episodic and chronic migraine versus individuals without migraine.
Methods
A total of 49 participants were analysed of which 26 had migraine (15 chronic and 11 episodic) and 23 were control subjects without a headache disorder. Their objective interoceptive accuracy was assessed using the heartbeat tracking and discrimination tasks. Interoceptive sensibility was assessed using the Porges body perception questionnaire. Interoceptive trait prediction error (ITPE) was calculated based on the discrepancy between their task performance and sensibility. Interoceptive state prediction error (ISPE) was calculated based on the trial-by-trial correspondence between task performance and confidence. The level of their dissociation was assessed via self-report questionnaires.
Results
Patients with migraine had lower interoceptive accuracy for the tracking task (median (interquartile range) 0.50 (0.43) in migraine vs. 0.78 (0.26) in control, Mann–Whitney U test, effect size r = 0.35, p = 0.014), higher interoceptive sensibility (110 (52) vs. 39 (14), r = 0.74, p < 0.001), and greater ITPE than controls (for the tracking task: 1.08 (1.78) vs. − 1.16 (0.88), r = 0.72, p < 0.001 / for the discrimination task: 0.87 (1.44) vs. − 0.62 (0.97), r = 0.69, p < 0.001). Greater ISPE was also found in patients with chronic migraine than episodic migraine (2.30 (0.35) in chronic vs. 1.75 (0.19) in episodic, r = 0.39, p = 0.046). A greater level of somatoform dissociation was found in individuals with chronic, compared to episodic, migraine (27 (11) vs. 22 (2), r = 0.43, p = 0.029).
Conclusion
This is the first study to demonstrate interoceptive abnormalities in migraine, specifically of greater interoceptive prediction errors. Interoceptive abnormalities may represent a transdiagnostic mechanisms relevant to the chronification of migraine, and to frequent co-morbidities such as dissociation
Sudden cardiac death in patients with kidney failure on renal replacement therapy: An unsolved problem
Get PDFSudden cardiac death is an important cause of mortality in patients with kidney failure undergoing renal replacement therapy, either hemodialysis or peritoneal dialysis. The risk factors associated with sudden cardiac death in these patients only partly overlap with those in the general population. Kidney failure per se and hemodialysis therapy expose these patients to an increased risk of sudden cardiac death compared with individuals with preserved renal function. Studies of the implantable cardioverter defibrillator for primary prevention of sudden cardiac death in patients with kidney failure have failed to demonstrate its usefulness. Moreover, the incidence of complications associated with cardiac electronic device implantation in this population is extremely high. This review aims to provide an update on the available studies on the pathophysiology and prevention of sudden cardiac death in patients with kidney failure undergoing dialysis and to propose the adoption of clinical practices to reduce its incidence
Randomised controlled feasibility trial of online group acceptance and commitment therapy for functional cognitive disorder
Get PDFBackground
Functional cognitive disorder is an increasingly recognised subtype of functional neurological disorder for which treatment options are currently limited. We have developed a brief online group acceptance and commitment therapy (ACT)-based intervention.
Aims
To assess the feasibility of conducting a randomised controlled trial of this intervention versus treatment as usual (TAU).
Method
The study was a parallel-group, single-blind randomised controlled trial, with participants recruited from cognitive neurology, neuropsychiatry and memory clinics in London. Participants were randomised into two groups: ACT + TAU or TAU alone. Feasibility was assessed on the basis of recruitment and retention rates, the acceptability of the intervention, and signal of efficacy on the primary outcome measure (Acceptance and Action Questionnaire II (AAQ-II)) score, although the study was not powered to demonstrate this statistically. Outcome measures were collected at baseline and at 2, 4 and 6 months post-intervention, including assessments of quality of life, memory, anxiety, depression and healthcare use.
Results
We randomised 44 participants, with a participation rate of 51.1% (95% CI 40.8–61.5%); 36% of referred participants declined involvement, but retention was high, with 81.8% of ACT participants attending at least four sessions, and 64.3% of ACT participants reported being ‘satisfied’ or ‘very satisfied’ compared with 0% in the TAU group. Psychological flexibility as measured using the AAQ-II showed a trend towards modest improvement in the ACT group at 6 months. Other measures (quality of life, mood, memory satisfaction) also demonstrated small to modest positive trends.
Conclusions
It has proven feasible to conduct a randomised controlled trial of ACT versus TAU
Immediate titanium mesh cranioplasty after debridement of post-craniotomy infection
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For post-craniotomy surgical site infection (SSI) involving the bone, typical management involves removal of the bone flap and delayed cranioplasty. The disadvantages of delayed cranioplasty include cosmetic deformity, vulnerability of unprotected brain, skin contraction, syndrome of the trephined and the risks of further surgery. Second procedures also add to cost due to surgical time, hospital stay, and opportunity costs for patients from being away from work.
Methods
We retrospectively reviewed patients who underwent post-craniotomy bone flap removal due to SSI, with immediate titanium mesh cranioplasty. The primary outcome was re-operation due to persistent infection or wound healing complications. The secondary outcome was re-operation due to unacceptable cosmetic result.
Results
Nineteen patients were included between 2018 to 2024. Two patients required additional debridement and removal of the titanium mesh due to persistent infection. Another patient had the plate replaced with PEEK due to poor skin quality, wound breakdown and an unacceptable cosmetic result. Two further patients with bifrontal craniotomies had the mesh replaced for cosmetic reasons. Fourteen patients had long term resolution with no further procedure.
Conclusion
Immediate TM insertion at the time of bone flap removal is an acceptable option in the management of post-craniotomy SSI. It seems the overall complication rate is comparable to delayed titanium cranioplasty, with the benefit of avoiding the risks and costs of a second operation. Cosmetic results are worse with larger defects, but these patients can still benefit from early TM placement by making operative conditions easier when the custom made, delayed cranioplasty is inserted
Sphingosine-1-Phosphate (S1P) Receptor Modulators for the Treatment of Inflammatory Bowel Disease (IBD): Mechanisms, Clinical Evidence, and Practical Insights
Get PDFInflammatory bowel disease commonly requires advanced therapies to induce and maintain durable remission. Sphingosine-1-phosphate receptor modulators are the latest class of orally administered small molecules that have been added to the therapeutic armamentarium for inflammatory bowel disease. These molecules reduce inflammation by sequestering lymphocytes in lymph nodes, thereby reducing immune cell trafficking to the gut. Etrasimod and ozanimod are both licensed for moderate-to-severe ulcerative colitis and have both shown superiority over placebo, with emerging data for their use in Crohn’s disease. By modulating immune cell distribution, without reducing overall immune function, they offer a highly favourable safety profile. This narrative review explores the pharmacology, safety and efficacy of sphingosine-1-phosphate receptor modulators based on clinical trials and real-world evidence and offers practical guidance on their initiation and monitoring
Comparison of Insertion Difficulties and Performance of Thoracoamniotic Shunts for Fetal Hydrothorax
Get PDFObjective
This study compared insertion difficulties, shunt failure, reintervention rates, maternal adverse events, and neonatal outcomes among different shunt types used in fetal hydrothorax.
Method
A retrospective multicenter cohort study (2012–2022) was conducted across 12 international centers. The primary outcome was the occurrence of complications, classified as insertion difficulties and shunt failure (dislocation, occlusion, or unexplained shunt failure). Secondary outcomes included reintervention rates, maternal complications, and neonatal survival.
Results
Among 349 cases, 345 were included in the analysis of the outcome measures. Rodeck shunts had significantly fewer complications (19.5%) compared to Somatex (38.3%, OR 2.53, p = 0.016) and Harrison shunts (50.0%, OR 3.82, p < 0.001). Somatex shunts had the highest rate of incorrect positioning (16%), while dislocation was most frequent with Harrison shunts (31.1%). Reintervention rates were lowest for Rodeck (12.1%) and highest for Harrison (32.2%). Maternal body mass index, fetal hydrops, laterality and year of shunt placement did not significantly influence complication rates. No significant differences in live birth rates or gestational age at delivery were observed.
Conclusions
The Rodeck shunt was associated with fewer insertion difficulties, better shunt performance and lower reintervention rates. There was no difference in perinatal survival among the three shunt types
Maternal vaccination service provision in London and Liverpool: Organisation, recording of vaccinations and midwife training
Get PDFRecommended vaccinations during pregnancy are safe and can prevent serious illness in both pregnant women and newborns. Despite this, uptake remains low in England. We explored maternal vaccination services at selected maternity sites in London and Liverpool, focusing on service delivery, vaccination recording and midwife training. Services included walk-in vaccination clinics, nurse-led rather than midwife-led vaccination, telephone and text reminders with links to online vaccination booking, multilingual leaflets, posters and digital apps with vaccine information links. However, practical barriers persist. These include poor integration between maternity and primary care data systems for recording vaccinations, limited and inconsistent midwife training, and logistical constraints on vaccine administration. Midwives reported difficulties accessing electronic vaccine records, and vaccination discussions with patients were often absent, particularly in group models of antenatal care. System-level improvements such as integrated data access, protected training time, clear documentation protocols and tailored outreach are needed to strengthen maternal vaccination services
Six-Month Survivorship Prediction in Spinal Metastatic Patients by Oncologists Shows Reliable Prognostication.
Get PDFSTUDY DESIGN: A retrospective analysis of oncologist-provided prognoses vs actual survival outcomes of patients referred with Metastatic spinal cord compression (MSCC) to a supra-regional multidisciplinary team (MDT). OBJECTIVES: Prognostic scoring systems, such as the revised Tokuhashi, are commonly used to help guide the treatment of MSCC. However, scoring systems do not accommodate for the improved outcomes of contemporary cancer therapy. Oncologist-provided prognoses play an important role in real world rapid decision making. There is a paucity of evidence assessing the accuracy of the oncologist-provided prognosis. We conducted a retrospective study to evaluate this. METHODS: Data was captured between January 2015 and December 2018. Patients were split into 2 groups: Group 1 (prognosis estimated 6 months). Median overall survival (mOS) and hazard ratio for death (HR) was assessed. Receiver operating characteristic (ROC) analysis was performed to assess the accuracy of the oncologist's prognosis. RESULTS: 829 patients were included. mOS in Group 1 was 5.8 months (95% CI 4.2-7.4 m), and in Group 2 mOS was not reached. Log rank test gave a Chi2 of 131 (P < .001). Cox regression analysis revealed a HR of .30 (P < .001). Area under the ROC curve was 78%. CONCLUSIONS: Oncologist-provided prognosis is accurate in this cohort of unselected, consecutive MSCC patients. It reduced reliance on scoring systems that can become outdated. Given the rapid progress in cancer treatment, the oncologist's prognostic prediction is integral in efficient and effective MSCC management to help rapidly determine surgical candidacy
Going 'meta': a systematic review of metacognition and functional neurological disorder.
Get PDFIn functional neurological disorder (FND), there is a fundamental disconnect between an apparently intact nervous system and the individuals' ability to consistently perform motor actions, perceive sensory signals and/or access effective cognition. Metacognition, the capacity to self-evaluate cognitive performance, appears highly relevant to FND pathophysiology. Poor metacognition is a potential mechanism via which abnormal models of self and the state of the world could arise and persist unchecked. There is therefore a justified enthusiasm that studies of metacognition may give substance to FND's intangible nature. However, many assume an impairment in metacognition even though experimental studies are still in their infancy. This systematic review provides an analytical checkpoint of the evidence after the first five years of experimental work. We firstly summarize current methods for testing metacognition, prerequisite knowledge that allows readers to independently evaluate the evidence. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we then screened the 21 articles on this topic and review the experimental data of the eight studies that specifically tested metacognition in subjects with FND. Questionnaire metrics used to estimate global metacognition and general confidence in FND revealed a mixed picture of low or normal confidence. Of the five studies that used performance-controlled metrics, the gold-standard to estimate local metacognition in FND, four found metacognition to be equivalent to healthy controls and one paper supported impaired metacognition. We consequently try and broaden the debate and discuss alternative headline scenarios. We review how positive studies may offer insight and debate whether null studies could represent false negatives. However, since most studies find equivalent metacognition to controls, we also discuss whether metacognition could be intact and how this could inform mechanistic models of FND and have potential clinical utility. In summary, this review highlights signal of interest within the data, exposes current limitations and flags the many open questions
Self‐Reported Motor and Non‐Motor Symptoms in People With Functional Gait Disorder: A Cross‐Sectional Study
Get PDFBackground
Functional gait disorder is a common presentation of functional neurological disorder. Altered gait is the defining feature, along with a range of associated motor and nonmotor symptoms. The aim of this study was to explore the prevalence and impact of these symptoms in people with functional gait disorder.
Methods
A total of 156 people with functional gait disorder completed an online survey that included demographic information, self-reported symptoms, and standardized questionnaires.
Results
Weakness (85.9%) and reduced balance (80.1%) were the most prevalent motor symptoms, while fatigue (85.9%), somatosensory (69.9%), and cognitive (69.9%) symptoms were the most prevalent nonmotor symptoms. Logistic regression indicated that dependent ambulation had the greatest association with fear of falling and functional seizures (X2 (11, n = 128) = 40.68, p < 0.001). Stepwise regression indicated that functional seizures, muscle rigidity, depression, fear of falling, pain, and speech symptoms were associated with reduced participation in work and social function (adjusted R2 = 0.39, F (6, 120) = 14.31, p < 0.001). Stepwise regression revealed that lower physical quality of life was associated with pain, bradykinesia, fatigue, and dystonia (adjusted R2 = 0.32, F (4, 122) = 15.92, p < 0.001) while depression, anxiety, and functional seizures were associated with reduced mental quality of life (adjusted R2 = 0.46, F (3, 123) = 36.89, p < 0.001).
Conclusions
Motor and nonmotor symptoms are highly prevalent in people with functional gait disorder and are associated with high levels of disability, reduced participation in work and social function, and reduced quality of life
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