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The current state of cranioplasty in Europe - Results from a European cranioplasty survey
Get PDFIntroduction
Cranioplasty, a surgical procedure to restore skull integrity and aesthetic contour following decompressive craniectomy, poses challenges in material selection and timing, driven by the lack of guidelines and ongoing regulatory changes.
Research question
This study aimed to provide an overview of current cranioplasty practices in Europe, explicitly addressing a potential shift towards alloplastic materials and the management of patients with concomitant hydrocephalus.
Material and methods
An online survey was conducted among European neurosurgical centers from January to March 2024, collecting data on material preferences, timing of procedures, and management strategies for cranioplasty. Descriptive and statistical analyses were performed on 110 complete responses.
Results
Respondents favored alloplastic materials over autologous bone for cranioplasty, citing regulatory constraints and reduced infection risk as primary reasons. Variability was observed in the timing of procedures and the management of patients with hydrocephalus, with most centers adopting staged approaches.
Discussion and conclusion
The shift towards alloplastic materials in cranioplasty reflects regulatory pressures rather than material-specific considerations. Despite variability in practice, our findings underscore the need for standardized guidelines and further research to optimize patient outcomes. This study provides valuable insights into current practices and highlights areas for future investigation in cranioplasty
All-cause and cause-specific mortality differences between migrant workers and local workers: a population-based cohort study in Denmark
Get PDFMigrants are prone to poor working conditions in high-risk industries, yet little is known about their mortality risk compared to local-born workers. This study compares all-cause and cause-specific mortality between foreign-born and local-born workers, and identifies at-risk foreign-born workers. A nationwide register-based cohort study was performed using data on migrant workers obtaining residence permits in Denmark during 2015–22. Comparison group comprised Danish-born workers matched by age and sex. Survival analysis using extended Cox model was used to estimate all-cause and cause-specific mortality. Subgroup analysis was conducted by region of birth, economic sector, and occupation. Male migrant workers from Central Europe, Eastern Europe, and Central Asia had higher risk of all-cause mortality than Danish-born workers (HR = 1.30 [95% CI: 1.09–1.54]), attributed to accident deaths (HR = 1.64 [1.06–2.53]), whereas migrants from other regions had lower risk. Migrant workers from these regions were more likely to work in high-risk economic sectors and occupations, such as agriculture and construction. When stratified by economic sector and by occupation, among the elementary occupations, migrant workers from these regions still had a higher risk of all-cause mortality (HR = 1.70 [1.10–2.64]) and accident mortality (HR = 1.51 [1.22–1.85]) than Danish-born workers. Migrant workers from Central Europe, Eastern Europe, and Central Asia are more likely to die from accidents than Danish-born workers. This increased risk was partially explained by their higher representation in at-risk sectors and occupations. There is a need to better understand the structural determinants of health faced by these migrants, particularly in elementary occupations, to prevent avoidable deaths
General practice chlamydia testing: a qualitative study of staff approaches using behavioural change theory
Get PDFBackground
Chlamydia is the most diagnosed bacterial sexually transmitted infection (STI) in England, but opportunistic testing remains low in general practice despite high prevalence among young people. Attempts to increase testing have been met with little success; therefore, there is a need to explore why rates remain low and how this may be improved.
Aim
To explore general practice staff perceptions of opportunistic chlamydia testing, including barriers, facilitators, interventions, and policies, using the Behaviour Change Wheel (BCW).
Design & setting
Qualitative interviews and focus groups were undertaken with general practice staff in England.
Method
Twenty-three semi-structured individual interviews and seven focus groups with general practice staff were conducted. Data were analysed using inductive thematic analysis, followed by thematic categorisation onto the BCW.
Results
Participants identified several barriers to chlamydia testing corresponding with BCW components, including low perceived knowledge (psychological capability), general practice context (physical opportunity), cultural norms (social opportunity), testing not prioritised (reflective motivation), and concerns about patient reactions (automatic motivation). Proposed intervention functions included education, persuasion (for example, posters), incentivisation (for example, financial incentives), and environmental restructuring (for example, computer reminders). Potential policy categories discussed were communication and marketing (for example, campaigns) and service provision (for example, GP drop-in sessions at other venues).
Conclusion
This study identified barriers to chlamydia testing in English general practice and potential ways to address these issues, contributing new insights to existing literature. This research can be utilised to design multi-component, impactful interventions to increase testing in general practice and ultimately reduce harm posed by chlamydia infections
Transvenous Lead Extraction: The Femoral Pull‐Through Technique
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Transvenous lead extraction (TLE) plays a significant role in maintaining device therapy. Conventional extraction involves advancing an extraction sheath via the implanting vein over the targeted lead, however advanced techniques involve the use of the jugular and femoral accesses which provide geometrical advantages. Femoral extraction can be used as a “bail‐out” and a primary extraction strategy but with significant challenges.
Method
We present a novel technique, transferring a 20‐year‐old passive fixation atrial lead with a deployed locking stylet from the subclavian vein to the femoral site, to complete the extraction of an infected system.
Result
Transfer of the lead from the implanting vein to the femoral vein, permitted linear alignment of the femoral sheath to the passive fixation atrial lead, safely enhancing the application of traction and counter‐traction. The lead was extracted without sequalae.
Conclusion
The femoral pull‐through technique is safe and effective, with potential application in a range of scenarios
Psilocybin-Assisted Physiotherapy for Refractory Motor Functional Neurological Disorder: Protocol for a Randomised Dose-Comparison Pilot Study
Get PDFBackground:
Motor functional neurological disorder (FND) is a common illness associated with significant functional impairment. There are no effective pharmacotherapies, and despite the early promise of physiotherapy studies, many suffer disabling symptoms in the long term. There is a theoretical rationale for combining psychedelics with physiotherapy; however, the potential benefit of this approach and optimal treatment model remains unexplored. Here, we present the protocol for the first study investigating the tolerability, feasibility, and potential efficacy of two distinct treatment regimens of psilocybin-assisted physiotherapy for refractory motor FND: a moderate dose that incorporates movement tasks during the acute drug effects versus a standard dose alone.
Methods:
Twenty-four participants with refractory motor FND will be randomised in a 1:1 ratio to either (1) psilocybin 15mg, with movement tasks conducted during the acute drug effects; or (2) psilocybin 25mg alone. All participants will receive two sessions of FND-specific physiotherapy pre-dosing, six sessions of physiotherapy post-dosing, and undergo follow-up visits one week and four weeks following their final physiotherapy session. A battery of outcome measures will be completed as scheduled, assessing tolerability, feasibility, motor FND symptom severity, psychiatric and physical symptoms, quality of life, treatment expectations, intensity of the acute drug effects, personality, motor function, force-matching performance, resting-state and task-based brain imaging, and subjective experiences of the study treatment.
Discussion:
These findings will assist the design of an adequately powered randomised controlled trial in this cohort. The findings may also inform the feasibility of psychedelic treatment in related functional and neuropsychiatric disorders
Inherited Susceptibility to Cancer: Past, Present and Future
Get PDFGermline pathogenic variants (GPVs, ‘mutations’) causing inherited susceptibility to certain cancers (cancer susceptibility genes, CSGs) broadly belong to one of two main classes—loss of function variants in tumour suppressor genes (TSGs) or gain of function variants in proto‐oncogenes (an over‐simplification). Genomic analyses of tumours identify ‘driver mutations’ promoting tumour growth and somatic variants which contribute to ‘mutation signatures’ which, with histopathology, can be used to subclassify cancers with implications for causality and treatment. The identification of susceptible individuals is important, as they and their relatives may be at elevated risk of tumours, and this can influence optimal cancer treatment. Classically, cancer risk assessment utilises family history, lifestyle/environment factors, and any non‐neoplastic clinical findings, followed by genetic testing of high/moderate penetrance CSGs. In cancer cases not caused by highly penetrant CSGs, multiple variants conferring relatively small risks play a major role. These were discovered by genome‐wide association (GWAS) studies. The utility of polygenic risk scores (PRS) derived from multiple such variants for clinical risk profiling is being assessed. Access to genetic tests is improved by widening eligibility criteria for testing and empowering non‐genetic clinicians to identify CSG GPVs and manage carriers. This will contribute to expanding programmes of screening, prevention and early detection (SPED), with personalised surveillance and prophylactic interventions, and exploit knowledge of the molecular mechanisms of cancer susceptibility to develop novel cancer therapies. In some jurisdictions, population testing is being considered, but GPV penetrance in this setting can be unclear, and the public health implications are complex
Key messages and critical approach of the 2024 guidelines of the European Society of Cardiology on chronic coronary syndromes
Get PDFThe updated European Society of Cardiology (ESC) guidelines empower physicians to tailor treatment plans more effectively to individual patient characteristics, preferences, and responses. With a more flexible and individualized approach to angina management, it seems that the traditional stepwise approach may not be optimal for all patients. In addition, there is a significant shift in the diagnostic approach for chronic coronary syndromes (CCS). In this review, we mainly refer to key points and queries concerning the current ESC recommendations regarding the diagnostic approach and treatment of patients with stable angina, recommending practical directions to physicians managing patients with CCS
Management of patients with heart failure at high risk of hyperkalaemia: The CARE-HK in HF registry
Get PDFAims
Patients with heart failure (HF) at high risk for hyperkalaemia are underrepresented in prospective HF registries. The CARE‐HK in HF registry sought to characterize prospectively the clinical profile, management, and outcomes for patients with HF at high risk of hyperkalaemia.
Methods and results
CARE‐HK in HF was a multinational prospective registry of outpatients with HF (regardless of left ventricular ejection fraction [LVEF]) treated with an angiotensin‐converting enzyme inhibitor/angiotensin II receptor blocker/angiotensin receptor–neprilysin inhibitor (ACEI/ARB/ARNI) and either receiving or potential candidate for a mineralocorticoid receptor antagonist (MRA). All patients were at increased risk of hyperkalaemia, defined as hyperkalaemia at baseline, prior hyperkalaemia, or estimated glomerular filtration rate (eGFR) <45 ml/min/1.73 m2. Outcomes included frequency of hyperkalaemic events (defined by clinician report with associated potassium value), achievement of renin–angiotensin system inhibitor (RASi) optimization (defined as ≥50% target doses for ACEI/ARB/ARNI and MRA), medication changes following hyperkalaemic episodes, and clinical events. Overall, 2558 patients from 111 sites across nine countries were included. Median (25th–75th) age was 73 (65–80) years, 32% were women, 61% had LVEF ≤40%, and 40% had prior laboratory evidence of hyperkalaemia. Median baseline eGFR and serum potassium were 44 (33–60) ml/min/1.73 m2 and 5.0 (4.4–5.3) mEq/L, respectively. Over a median follow‐up of 12.3 (9.4–18.1) months, 29% of patients had a hyperkalaemic event, and 7% had multiple events. In characterizing treatment prescribed for most of follow‐up, 29% of patients received optimal RASi/MRA therapy, 69% received suboptimal RASi/MRA therapy, and 3% received no RASi/MRA. In the 30 days following the first hyperkalaemic event, RASi/MRA was down‐titrated or discontinued in 3.6% of cases. Potassium binder use was low (patiromer 9.1%, sodium zirconium cyclosilicate 5.9%). Compared with patients without a hyperkalaemic event, patients experiencing a hyperkalaemic event had similar risk of all‐cause mortality (hazard ratio [HR] 1.22, 95% confidence interval [CI] 0.92–1.62, p = 0.16) and a higher risk of subsequent hospitalization (HR 1.59, 95% CI 1.35–1.86, p < 0.001).
Conclusions
In this contemporary multinational prospective registry of patients with HF at high risk for hyperkalaemia, hyperkalaemic events were common but infrequently associated with RASi/MRA modification or potassium binder use. Fewer than one in three patients received optimal RASi/MRA therapy for the majority of follow‐up, and hyperkalaemic events were associated with higher risk of adverse clinical outcomes.
Clinical Trial Registration: ClinicalTrials.gov NCT04864795
Effects of a Self-Management Program on Adults with Stroke: A Quasi-Experimental Study
Get PDFBackground: Stroke is a leading cause of death and disability, underscoring the importance of effective self-management programs to improve the quality of life for survivors. Objectives: This study investigates the impact of the ComVida (Bridges-PT) self-management program on self-efficacy, physical function, health-related quality of life, and emotional state of stroke survivors in Portugal. Methods: A quasi-experimental study was conducted with 28 participants from hospital and community settings. The ComVida program, combining personalized rehabilitation sessions and the use of a self-management workbook was implemented. Assessments were conducted at baseline, 6 weeks, and 12 weeks using the Stroke Self-Efficacy Questionnaire (SSEQ), the Stroke Impact Scale (SIS-16), Hospital Anxiety and Depression Scale (HADS), and Short Form Questionnaire-12 (SF-12v2). Results: Significant improvements were observed in self-efficacy, physical function, emotional state, and health-related quality of life over the study period. The SSEQ scores increased from 23.3 at baseline to 33.3 at 12 weeks, while SIS-16 scores improved from 47.5 to 67.2. Anxiety and depression levels, measured by HADS, also showed significant reductions, as did health-related quality of life, evaluated by the SF-12v2. Conclusions: The results suggest that the program may enhance self-efficacy, physical function, and emotional well-being in stroke survivors, highlighting its potential as a valuable component of post-stroke care in Portugal
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