Search

AbstractBackground Social prescribing (SP) is a patient pathway by which healthcare professionals connect patients with other sources of support, groups, or activities within their community. The awareness, practice, and perception of SP among GPs across Europe remains unclear.Objectives To explore the awareness, practice, and perception of GPs on SP in the WONCA Europe region.Methods An anonymous, cross-sectional online survey was distributed through a snowballing system, mailing lists, and at three international conferences in 2022/2023 to explore GPs’ awareness, practice, and perception of SP. The questionnaire in English contained 21 open and closed questions.Results Of the 208 participating GPs from 33 countries, 116 (56%) previously heard of ‘social prescribing’ and 66 (32%) regularly referred patients to community activities through a formal system. These 66 GPs reported different funding sources and varied activities, with an average of four activities and physical exercise being the most prevalent. Among them, 25 (38%) knew about national or local SP awareness campaigns. Of these 25, 17 (68%) agreed that SP increases their job satisfaction and 21 (84%) agreed that it has a positive impact on their patients. Variations in SP awareness and referral practice were evident across and within countries.Conclusion Despite disparities in awareness and referral practice as well as a diversity of activities and funding sources, most GPs who actively referred patients and were informed about SP campaigns agreed that SP positively impacts them and their patients.

Abstract There is a rising number in complications associated with more cardiac electrical devices implanted (CIED). Infection and lead dysfunction are reasons to perform transvenous lead extraction. An ideal anaesthetic approach has not been described yet. Most centres use general anaesthesia, but there is a lack in studies looking into deep sedation (DS) as an anaesthetic approach. We report our retrospective experience for a large number of procedures performed with deep sedation as a primary approach. Extraction procedures performed between 2011 and 2018 in our electrophysiology laboratory have been included retrospectively. We began by applying a bolus injection of piritramide followed by midazolam as primary medication and would add etomidate if necessary. For extraction of leads a stepwise approach with careful traction, locking stylets, dilator sheaths, mechanical rotating sheaths and if needed snares and baskets has been used. A total of 780 leads in 463 patients (age 69.9 ± 12.3, 31.3% female) were extracted. Deep sedation was successful in 97.8% of patients. Piritramide was used as the main analgesic medication (98.5%) and midazolam as the main sedative (94.2%). Additional etomidate was administered in 15.1% of cases. In 2.2% of patients a conversion to general anaesthesia was required as adequate level of DS was not achieved before starting the procedure. Sedation related complications occurred in 1.1% (n = 5) of patients without sequalae. Deep sedation with piritramide, midazolam and if needed additional etomidate is a safe and feasible strategy for transvenous lead extraction.

BackgroundPatients with progressive chronic kidney disease (CKD) are at higher risk of infections and complications from cardiac implantable electronic devices (CIED). In patients with a primary or secondary prophylactic indication, implantable cardiac defibrillators (ICD) can prevent sudden cardiac deaths (SCD). We retrospectively compared transvenous-ICD (TV-ICD) and intermuscularly implanted subcutaneous-ICD (S-ICD) associated infections and complication rates together with hospitalizations in recipients with stage 4 kidney disease.MethodsWe retrospectively analyzed 70 patients from six German centers with stage 4 CKD who received either a prophylactic TV-ICD with a single right ventricular lead, 49 patients, or a S-ICD, 21 patients. Follow-Ups (FU) were performed bi-annually.ResultsThe TV-ICD patients were significantly older. This group had more patients with a history of atrial arrhythmias and more were prescribed anti-arrhythmic medication compared with the S-ICD group. There were no significant differences for other baseline characteristics. The median and interquartile range of FU durations were 55.2 (57.6–69.3) months. During FU, patients with a TV-ICD system experienced significantly more device associated infections (n = 8, 16.3% vs. n = 0; p

Abstract Background In Germany, homeless people are entitled to health care within the regular health care system. However, due to their specific living conditions they make little use of these services. In 2013, three Medical centres for the homeless (MCH) were opened in Hamburg to provide general health care. This study aims to analyse the consultation reasons and diagnoses prevalent among the homeless in comparison to regular primary care patients. It also examines the means and obstacles of integrating the homeless into Germany’s regular health care system. Methods From 2013 to 2014, routine medical data of all patients of the MCH consenting to participate in the study were analysed descriptively, in particular consultation reasons (categorised by ICPC-2), ICD-10 diagnoses and data on health insurance status and the use of the regular health care system. Consultation reasons and diagnoses of homeless patients were compared descriptively with data from regular general practices. Additionally, anonymous data on patient numbers, gender and insurance status was exported from the MCH’s software and analysed descriptively for the years 2013 to 2020. Results A total of 840 homeless patients in 2013 and 2014 gave consent to the evaluation of consultation reasons and diagnoses. The most frequent consultation reasons in the MCH in 2013 were skin conditions (24%), musculoskeletal conditions (16%) and psychological disorders (14%), in GP practices these were musculoskeletal conditions (22%), conditions affecting the digestive system (14%) and skin conditions (12%). Essential (primary) hypertension, diabetes mellitus type 2 and back pain are among the top-10-diagnoses in GP practices, as well as in MCH. With regard to the other top-10-diagnoses, there are clear differences between GP practices and MCH: “Psychological behavioural disorder due to alcohol” and diagnoses in connection with trauma, skin infections and acute respiratory infections stand out in MCH. 35% of the homeless patients reported a lack of health insurance as the reason for “not making use of” the regular health care system, while 10% reported they were unable to visit a regular general practitioner due to physical or psychological reasons. In the years 2013–2020 46% to 73% of the 8.380 MCH patients had no health care insurance. Conclusion Patients consulting the MCH suffer from medical conditions typical for the homeless, namely skin diseases, wounds, injuries and behavioural disorders due to alcohol abuse, but also from “typical” symptoms in regular GP care as cough or lower back symptoms. Consultation reasons mostly are acute illnesses. Chronic diseases are equally present in regular GP and MCH patients, but pose a great challenge for the homeless among other things due to their irregular contact with the health care system. The lack of health insurance poses the greatest hurdle to the integration of the homeless into the regular health care system.

Abstract Background The huge increase of refugees to Germany caused a great challenge to the health system. We aimed to examine the level of patient-centredness in medical consultations with refugee patients, aided by video interpreters in primary care walk-in clinics (PCWC) in Hamburg. Methods Videotaped consultations (N = 92) of 83 patients from 2017 to 2018 were analysed. Two raters used the Measure of Patient-Centered Communication (MPCC) and the International Classification of primary care (ICPC-2). MPCC scores with regard to patients’ reason for seeking medical care and the procedures taken were explored using variance analyses adjusted for age, gender, and the duration of the consultation. The duration was further explored by Pearson correlations. Results Patient-centredness of all consultations on average was 64% (95% CI 60–67) according to MPCC, with health-related issues affecting the results. The highest level of patient-centredness was achieved in psychological health issues with 79% (65–94), the lowest in respiratory ones with 55% (49–61). Longer consultations resulted in higher MPCC scores. Conclusions The level of patient-centredness varied in the addressed health issues as well as in the duration of the consultation. Despite the variation, video interpreting in consultations supports a solid patient-centredness. Practice implications We recommend the use of remote video interpreting services for outpatient healthcare to support patient-centred communication and to fill the gap of underrepresentation of qualified interpreters on site, regarding a high diversity of spoken languages.

Abstract Background It has been shown previously that a relevant proportion of childhood cancer survivors suffers from late effects, which are often directly related to the cancer itself or its therapy, resulting in particular follow-up needs, additionally burdening healthcare systems. Being diagnosed with cancer at a vulnerable stage of development, this group of cancer survivors is at comparatively higher risk of relapse or subsequent cancer. Although national and international follow-up guidelines based on treatment modalities have been developed, their implementation seems to leave room for improvement. Additionally, they lack a sufficient consideration of the survivors’ psychosocial needs, affecting their adherence to them. The aim of the VersKiK study is to provide representative information on late effects in childhood and adolescence cancer survivors in Germany. The main research objectives are: (1) to describe the state of follow-up care among survivors after a cancer diagnosis in childhood or adolescence; (2) to quantify the occurrence of late effects among this group of survivors; (3) to examine the adherence to selected audiological and cardiological follow-up guidelines and to identify factors affecting it; (4) to explore actual follow-up needs of paediatric cancer survivors; (5) to review selected follow-up guidelines with the aim to improve and expand them. Methods VersKiK is designed as a mixed-methods non-interventional study. We will use claims data from statutory health insurance companies in combination with individually linked population-based registry data from the German Childhood Cancer Registry (GCCR). This data base will permit us to quantify diagnoses and procedures in comparison to the general population as well as the adherence to existing follow-up guidelines. Additional information will be obtained through interviews with childhood and adolescence cancer survivors and their informal caregivers, as well as in focus groups with healthcare professionals. Discussion The present study aims to research the actual needs of individuals after cancer diagnosis and treatment in childhood or adolescence – physical, psychological and organisational – in order to improve existing follow-up guidelines. These improvements might further positively affect not only actual care provided to paediatric cancer survivors, but also benefit healthcare systems in general while decreasing consequent medical visits in this group of patients. Trial registration Registered at German Clinical Trial Register (ID: DRKS00025960 and DRKS00026092).

Abstract Background Social problems of patients such as family or work-related conflicts as well as financial difficulties affect the individual health situation and the treatment of diseases in general practice. General practitioners (GPs) would like to have direct access to professionals in social care services. In Germany, there are many different social care facilities for people with a wide range of social problems. As the social and health care systems hardly interact collaborations between social professionals (SPs) and GPs are rare exceptions. This study explored perspectives of GPs regarding their patients with social problems in combination with the perspectives of SPs. Aim of this study was to explore how a systematic interprofessional collaboration between GPs and SPs could be realised. Methods We carried out a participatory sequential qualitative study design consisting of two focus groups with GPs, two with SPs and two mixed-professional focus groups with GPs and SPs. The focus groups were conducted with semi-structured moderating guidelines and analysed with a qualitative content analysis approach using inductive and deductive categories. Results GPs view themselves as the first point of contact for their patients' social problems. For persistent social problems, they expressed a desire for support and SPs were willing to provide this. We developed a stepped care implementation model for a systematic cooperation consisting of nine collaboration strategies. These strategies included: index or website of social care services, referrals to the social care system, using flyers and posters of social care services, direct contact/hotline to local social care services, participation in meetings of social care facilities, involving physician assistants, external social care advice service in GP rooms, implementation in education and training and access to volunteers. Conclusions Our stepped care implementation model for a systematic cooperation of GPs and SPs could be a feasible need- and resource-oriented approach for the collaborative care of patients with social problems to improve their medical treatment in most western healthcare systems. GPs and SPs are ready to generate the necessary evidence for policy makers in high quality RCTs.

Introduction Cardiovascular diseases are the most common cause of death in Germany and among the most frequent reasons for encounters in primary care. Most patients with cardiovascular risks (CVRs) have difficulties implementing health-promoting behavioural changes. In this study, a complex intervention containing evidence-based patient materials and structured follow-up consultations are intended to strengthen patients’ self-management to improve health behaviour.Methods and analysis In this cluster randomised controlled trial, we investigate the effects of the intervention Decision aid, action planning and follow-up support for patients to reduce the 10-year risk of cardiovascular diseases (DECADE) using a 2×2 design. All patients, including the control group (CG), receive a CVR calculation. Three intervention groups (IGs) receive one or both of two different components of the DECADE intervention: IG1 (patient materials), IG2 (follow-up consultations) and IG3 (patient materials and follow-up consultations). The study was planned to be conducted with 77 general practitioners in 3 German regions and a target sample size of 924 patients. The observation period for each patient amounts to 12 months with three patient surveys: baseline (t0), after 6 and 12 months (t1 and t2). The primary outcome is patient activation (Patient Activation Measure 13 (PAM13-D)) at t1. Secondary outcomes include PAM13-D at t2 and further patient-reported and clinical outcomes at t1 and t2. We will also analyse the cost-effectiveness of the intervention, the degree of usage and satisfaction with the intervention.Ethics and dissemination The study was first approved by the lead ethics committee of the University of Freiburg on 15 April 2021 (vote number: 21-1078) and subsequently by the other ethics committees in the study regions (Ethics committee of medical association Baden-Württemberg (B-F-2021-078), Ethics Committee of the Technische Universität Dresden, Dresden (BO-EK-251052021), Ethics Committee of the State Chamber of Physicians of Saxony (EK-BR-92/21-1), Ethics Committee of the Hamburg Medical Association (2021-200013-BO-bet)). Informed consent is required for patients to participate in the study. The results of this study will be published in peer-reviewed journals and presented at congresses by the DECADE team. The DECADE lead management will communicate the results to the funder of this study.Trial registration number German Clinical Trials Register, DRKS00025401 (registration date: 21 June 2021); International Clinical Trials Registry Platform, DRKS00025401.

Background: Implantable cardioverter defibrillators (ICD) prevent sudden cardiac death (SCD). Patients with end-stage renal disease (ESRD) requiring dialysis are at a very high risk of infection from cardiac implantable electronic device (CIED) implantation as well as mortality. In the present study, we compared the long-term complications and outcomes between subcutaneous ICD (S-ICD) and transvenous ICD (TV-ICD) recipients. Methods: In this retrospective analysis, we analyzed a total of 43 patients with ESRD requiring dialysis who received either a prophylactic S-ICD (26 patients) or a single right ventricular lead TV-ICD (17 patients) at seven experienced centers in Germany. Follow-up was performed bi-annually, at the end of which the data concerning comorbidities and, if applicable, reason for death were checked and confirmed with patients' general practitioner, nephrologist and cardiologist. Results: The median follow up duration was 95.6 months (range 42.8–126.3 months). Baseline characteristics were without noteworthy significant differences between groups. During follow-up (FU), there were significantly more device-associated infections (HR 8.72, 95% confidence interval (CI), 1.18 to 12.85, p < 0.05) and device-associated hospitalizations (HR 10.20, 95% CI 1.22 to 84.61, p < 0.001), as well as a higher cardiovascular mortality (HR 9.17, 95% CI 1.12 to 8.33, p < 0.05), in the TV-ICD group. The number of patients requiring hospitalization for any reason was significantly higher in the TV-ICD group (HR 2.59, 95% CI 1.12 to 6.41, p < 0.05). There was no significant difference in overall mortality (HR 1.92, 95% CI 0.96 to 6.15, p = 0.274). Conclusions: Our data suggest that, in this extended follow-up in seriously compromised renal patients on dialysis, the S-ICD patients have statistically fewer device infections and hospitalizations as well as lower cardiac mortality compared with the TV-ICD cohort. [ABSTRACT FROM AUTHOR]

The aim of this policy commentary is two-fold. First, to examine new historical research regarding the political, cultural, and social drivers informing the design and implementation of Mexico’s ‘war on drugs’ – a set of state policies centered on punitive and militarized responses towards the drug problem – during the first and second halves of the twentieth-century. Second, to analyze how the longer history of Mexico’s war on drugs can help us better understand this country’s enduring reliance on such punitive and militarized approaches despite the detrimental consequences these had and continue to have on citizens’ wellbeing and on the country’s democratic institutions.

The globally distributed causal agent of powdery mildew on wheat, Blumeria graminis f. sp. tritici (Bgt), is one of the most rapidly adapting plant pathogens and requires monitoring for shifts in virulence to wheat resistance (Pm) genes. Virulence frequencies were assessed in a total of 346 Bgt isolates from several countries that had either lately recorded increasing powdery mildew epidemics (Brazil, South Africa, and Australia) or not recently been surveyed (Turkey and Russia). The results were compared to previously published surveys of United States and Egyptian Bgt (390 isolates). Many of the Pm genes that have potentially been employed longer (Pm1a–Pm17) were shown to have lost effectiveness, and the complexity of virulence to those genes was higher among Brazilian isolates than those from any other country. Some cases of high virulence frequency could be linked to specific Pm gene deployments, such as the widespread planting of cultivar Wyalkatchem (Pm1a) in Australia. Virulence was also assessed to a set of Pm genes recently introgressed from diploid and tetraploid wheat relatives into a hexaploid winter wheat background and not yet commercially deployed. The isolate collections from Fertile Crescent countries (Egypt and Turkey) stood out for their generally moderate frequencies of virulence to both the older and newer Pm genes, consistent with that region’s status as the center of origin for both host and pathogen. It appeared that the recently introgressed Pm genes could be the useful sources of resistance in wheat breeding for other surveyed regions.

Social Prescribing is a mechanism by which primary care team members can refer patients to community groups to improve their health and well-being. It integrates health, social care, and community, allowing patients to actively improve their health and well-being by participating in community initiatives and activities. These activities have traditionally been part of community life in European countries, and the benefits need to be consistently recognized.

Abstract Aims The objective of this paper is to assess whether cardiac contractility modulation (via the Optimizer System) plus standard of care (SoC) is a cost‐effective treatment for people with heart failure [New York Heart Association (NYHA) III, left ventricular ejection fraction of 25–45%, and narrow QRS] compared against SoC alone from the perspective of the English National Health Service. Methods and results We developed a regression equation‐based cost‐effectiveness model, using individual patient data from three randomized control trials (FIX‐HF‐5 Phases 1 and 2, and FIX‐HF‐5C) to populate the majority of parameters. A series of regression equations predicted NYHA class over time, mortality, all‐cause hospitalization rates, and health‐related quality of life. We conducted the analysis in line with the National Institute for Health and Care Excellence reference case, modelling costs from an English National Health Service perspective, and considering outcomes in quality‐adjusted life years (QALYs) over a patient lifetime perspective. Our base case analysis produced an incremental cost per additional QALY of GBP22 988 (€25 750) when comparing Optimizer + SoC to SoC alone. This result was not sensitive to parameter uncertainty but was sensitive to the time horizon over which costs and QALYs were captured and the duration over which a survival benefit with Optimizer + SoC can be assumed to apply. Conclusions Cardiac contractility modulation is likely to be cost‐effective in people with heart failure with reduced ejection fraction, NYHA III, and narrow QRS, provided that the treatment benefit can be maintained beyond the duration of the existing clinical trial follow‐up. This analysis supports the current recommendations of the European Society of Cardiology that this therapy may be considered for such patients.

Background: Bipolar active fixation (BipolarAFL) and quadripolar passive fixation left-ventricular leads (QuadPFL) have been designed to reduce the risk of phrenic nerve stimulation (PNS), enable targeted left-ventricular pacing, and overcome problems of difficult coronary venous anatomy and lead dislodgment. This study sought to report the long-term safety and performance of a BipolarAFL, Medtronic Attain Stability 20066, compared to QuadPFL.Methods: We performed a single-operator retrospective analysis of 81 patients receiving cardiac resynchronization therapy (CRT) (36 BipolarAFL, 45 QuadPFL). Immediate implant data and electrical and clinical data during follow-up (FU) were analyzed.Results: BipolarAFL has been chosen in patients with significantly larger estimated vein diameter (at the lead tip: 7.2 ± 4.1 Fr vs. 4.1 ± 2.3 Fr, p < 0.001) without significant time difference until the final lead position was achieved (BipolarAFL: 20.9 ± 10.5 min, vs. QuadPFL: 18.9 ± 8.9 min, p = 0.35). At 12 month FU no difference in response rate to CRT was recorded between BipolarAFL and QuadPFL according to left ventricular end-systolic volume (61.1 vs. 60.0%, p = 0.82) and New York Heart Association (66.7 vs. 62.2%, p = 0.32). At median FU of 48 months (IQR: 44–54), no lead dislodgment occurred in both groups but a significantly higher proportion of PNS was recorded in QuadPFL (13 vs. 0%, p < 0.05). Electrical parameters were stable during FU in both groups without significant differences.Conclusion: BipolarAFL can be implanted with ease in challenging coronary venous anatomy, shows excellent electrical performance and no difference in clinical outcome compared to QuadPFL.

Background: Cephalic vein cutdown (CVC) and subclavian vein puncture (SVP) are the most commonly used access sites for transvenous lead placement of cardiac implantable electronic devices (CIEDs). Limited knowledge exists about the long-term patency of the vascular lumen housing the leads. Methods: Among the 2703 patients who underwent CIED procedures between 2005 and 2013, we evaluated the phlebographies of 162 patients scheduled for an elective CIED replacement (median of 6.4 years after the first operation). The phlebographies were divided into four stenosis types: Type I = 0%, Type II = 1–69%, Type III = 70–99%, and Type IV = occlusion. Due to the fact that no standardized stenosis categorization exists, experienced physicians in consensus with the involved team made the applied distribution. The primary endpoint was the occurrence of stenosis Type III or IV in the CVC group and in the SVP group. Results: In total, 162 patients with venography were enrolled in this study. The prevalence of high-degree stenosis was significantly lower in the CVC group (7/89, 7.8%) than in the SVP group (15/73, 20.5%, p = 0.023). In the CVC group, venographies showed a lower median stenosis (33%) than in the SVP group (median 42%). Conclusions: The present study showed that the long-term patency of the subclavian vein is higher after CVC than after SVP for venous access in patients with CIED. [ABSTRACT FROM AUTHOR]

Resumen: Objetivo: Estimar la prevalencia de uso de anticoncepción hormonal de solo gestágenos (AHSG) entre las mujeres demandantes de anticoncepción reversible en atención primaria (AP). Diseño: Estudio descriptivo transversal multicéntrico. Emplazamiento: AP de la Comunidad de Madrid. Participantes: Mujeres entre 16-50 años, usuarias de anticoncepción reversible, que hablen español y hubieran acudido en el último año a consulta de AP. Mediciones principales: Encuesta telefónica. Variable principal: método anticonceptivo utilizado: solo gestágenos (sí/no). Edad, paridad, país de origen, tipo de método anticonceptivo (MAC) utilizado, motivo de elección, duración, fuente de información, lugar de obtención, satisfacción con el método. Resultados: 417 mujeres. Edad: media 30,3 años (DE: 7,7). Españolas: 69%, estudios secundarios y universitarios: 82%, nulíparas: 57%. Tipo de MAC utilizado: AHSG 14%, hormonal combinado (AHC): 74%, DIU cobre: 2%, preservativo: 10%. La prevalencia de uso de AHSG fue del 13,9% (IC 95%: 10,6-17,2). Entre los AHSG el método más utilizado fue el inyectable trimestral de acetato de medroxiprogesterona (4,6%), píldora oral de desogestrel (4,1%), DIU-LNG (3,9%), implante subdérmico de etonogestrel (1,9%). El médico de familia fue el prescriptor del MAC en el 71% de las mujeres. Satisfacción: alta (mediana 10 sobre 10). Utilizar AHSG se asoció con mayor edad, ser extranjera y motivos de prescripción: lactancia y tener contraindicación médica para AHC (p

Background: Current recommendations for valve size selection are based on multidimensional annular measurements, yet the overlap between two different transcatheter heart valve (THV) sizes remains. We sought to evaluate whether undersizing but overfilling eliminates the gray zones of valve sizing. Methods: Data of 246 consecutive patients undergoing transcatheter aortic valve replacement (TAVR) with the balloon-expandable bioprosthesis with either conventional sizing and nominal filling (group 1 (NF-TAVR), n = 154) or undersizing but overfilling under a Less Is More (LIM)-Principle (group 2 (LIM-TAVR), n = 92) were compared. Paravalvular leakage (PVL) was graded angiographically and quantitatively using invasive hemodynamics. Results: Annulus rupture (AR) occurred only in group 1 (n = 3). Due to AR adequate evaluation of PVL was possible in 152 patients of group 1. More than mild PVL was found in 13 (8.6%) patients of group 1 and 1 (1.1%) patient of group 2 (p = 0.019). Postdilatation was performed in 31 (20.1%) patients of group 1 and 6 patients (6.5%) of group 2 (p = 0.003). For patients with borderline annulus size in group 1 (n = 35, 22.7%) valve size selection was left to the physiciańs choice resulting in selection of the larger prosthesis in 10 (28.6%). In group 2 all patients with borderline annulus (n = 36, 39.1%) received the smaller prosthesis (LIM-TAVR). The postprocedural mean transvalvular pressure gradient was significantly higher in the NF-TAVR-group (11.7 ± 4 vs. 10.1 ± 3.6 mmHg, p = 0.005). Conclusion: LIM-TAVR eliminates the gray zones of sizing and associated PVL, can improve THV-performance, reduce incidence of annular rupture and simplify the procedure especially in borderline cases.

Background: Treatment of depressive disorders in old age is hindered by several barriers. Most common are time pressure in primary care and latency for specialized therapeutic care. To improve treatment, the collaborative care approach GermanIMPACT was evaluated in a cluster-randomized controlled trial. Care managers offered a complex stepped-care intervention of monitoring, psychoeducation, and behavioral activation techniques. Twenty-six percent of the intervention group responds with a remission of depressive symptoms compared with 11% who received treatment as usual (TAU). The low-threshold intervention was more successful than TAU. Nevertheless, three-quarters did not respond with a remission. The aim of this study is to identify and describe the different types of utilization and of treatment response to understand what constitutes an effective intervention.Methods: Of 64 patients from the intervention group, we carried out problem-centered interviews with 26 patients from the intervention group. We analyzed the interviews using a qualitative type-building content analysis. For type construction, we performed a contrasting case comparison, regarding inductive and deductive categories of the intervention utilization and the symptom development.Results: The 26 participants' ages ranged from 62 to 87 years (mean = 72 years). Three participants were male. We identified five types of utilization, which differ primarily in the realization of pleasant activations, depending on own activity at the beginning and during the therapy: “activatable relief seekers,” “active relief seekers,” “active relaxation seekers,” “passive problem-solving seekers,” and “passive relief seekers.” In the second typology, we analyzed four deductively determined types of treatment response responders, slight improvers, constant moderates, and non-responders. Patient-specific characteristics are a recent history of depression, an affinity for activities, supportive contacts, and limited comorbidity. In contrast, non-responders report contrary characteristics.Conclusion: Our two typologies emphasize that an effective intervention requires a match between intervention components and patient characteristics. We saw no intersections between utilization and treatment response. GermanIMPACT is an effective low-threshold intervention for moderately burdened patients, who are still capable of self-activation. An expansion of the intervention, especially for depression with a long history and comorbidities impairing mobility, could increase the effectiveness and improve the care situation of older people suffering from depression.

Objectives To compare the effectiveness of oral versus intramuscular (IM) vitamin B12 (VB12) in patients aged ≥65 years with VB12 deficiency.Design Pragmatic, randomised, non-inferiority, multicentre trial in 22 primary healthcare centres in Madrid (Spain).Participants 283 patients ≥65 years with VB12 deficiency were randomly assigned to oral (n=140) or IM (n=143) treatment arm.Interventions The IM arm received 1 mg VB12 on alternate days in weeks 1–2, 1 mg/week in weeks 3–8 and 1 mg/month in weeks 9–52. The oral arm received 1 mg/day in weeks 1–8 and 1 mg/week in weeks 9–52.Main outcomes Serum VB12 concentration normalisation (≥211 pg/mL) at 8, 26 and 52 weeks. Non-inferiority would be declared if the difference between arms is 10% or less. Secondary outcomes included symptoms, adverse events, adherence to treatment, quality of life, patient preferences and satisfaction.Results The follow-up period (52 weeks) was completed by 229 patients (80.9%). At week 8, the percentage of patients in each arm who achieved normal B12 levels was well above 90%; the differences in this percentage between the oral and IM arm were −0.7% (133 out of 135 vs 129 out of 130; 95% CI: −3.2 to 1.8; p>0.999) by per-protocol (PPT) analysis and 4.8% (133 out of 140 vs 129 out of 143; 95% CI: −1.3 to 10.9; p=0.124) by intention-to-treat (ITT) analysis. At week 52, the percentage of patients who achieved normal B12 levels was 73.6% in the oral arm and 80.4% in the IM arm; these differences were −6.3% (103 out of 112 vs 115 out of 117; 95% CI: −11.9 to −0.1; p=0.025) and −6.8% (103 out of 140 vs 115 out of 143; 95% CI: −16.6 to 2.9; p=0.171), respectively. Factors affecting the success rate at week 52 were age, OR=0.95 (95% CI: 0.91 to 0.99) and having reached VB12 levels ≥281 pg/mL at week 8, OR=8.1 (95% CI: 2.4 to 27.3). Under a Bayesian framework, non-inferiority probabilities (Δ>−10%) at week 52 were 0.036 (PPT) and 0.060 (ITT). Quality of life and adverse effects were comparable across groups. 83.4% of patients preferred the oral route.Conclusions Oral administration was no less effective than IM administration at 8 weeks. Although differences were found between administration routes at week 52, the probability that the differences were below the non-inferiority threshold was very low.Trial registration numbers NCT 01476007; EUDRACT (2010-024129-20).

Background: Infection, lead dysfunction and system upgrades are all reasons that transvenous lead extraction is being performed more frequently. Many centres focus on a single method for lead extraction, which can lead to either lower success rates or higher rates of major complications. We report our experience with a systematic approach from a less invasive to a more invasive strategy without the use of laser sheaths. Methods: Consecutive extraction procedures performed over a period of seven years in our electrophysiology laboratory were included. We performed a stepwise approach with careful traction, lead locking stylets (LLD), mechanical non-powered dilator sheaths, mechanical powered sheaths and, if needed, femoral snares. Results: In 463 patients (age 69.9 ± 12.3, 31.3% female) a total of 780 leads (244 ICD leads) with a mean lead dwelling time of 5.4 ± 4.9 years were identified for extraction. Success rates for simple traction, LLD, mechanical non-powered sheaths and mechanical powered sheaths were 31.5%, 42.7%, 84.1% and 92.6%, respectively. A snare was used for 40 cases (as the primary approach for 38 as the lead structure was not intact and stepwise approach was not feasible) and was successful for 36 leads (90.0% success rate). Total success rate was 93.1%, clinical success rate was 94.1%. Rate for procedural failure was 1.1%. Success for less invasive steps and overall success for extraction was associated with shorter lead dwelling time (p < 0.001). Major procedure associated complications occurred in two patients (0.4%), including one death (0.2%). A total of 36 minor procedure-associated complications occurred in 30 patients (6.5%). Pocket hematoma correlated significantly with uninterrupted dual antiplatelet therapy (p = 0.001). Pericardial effusion without need for intervention was associated with long lead dwelling time (p = 0.01) and uninterrupted acetylsalicylic acid (p < 0.05). Conclusion: A stepwise approach with a progressive invasive strategy is effective and safe for transvenous lead extraction. [ABSTRACT FROM AUTHOR]

PurposeMaternal obesity has emerged as an important risk factor for the development of metabolic disorders in the offspring. The hypothalamus as the center of energy homeostasis regulation is known to function based on complex neuronal networks that evolve during fetal and early postnatal development and maintain their plasticity into adulthood. Development of hypothalamic feeding networks and their functional plasticity can be modulated by various metabolic cues, especially in early stages of development. Here, we aimed at determining the underlying molecular mechanisms that contribute to disturbed hypothalamic network formation in offspring of obese mouse dams.MethodsFemale mice were fed either a control diet (CO) or a high-fat diet (HFD) after weaning until mating and during pregnancy and gestation. Male offspring was sacrificed at postnatal day (P) 21. The hypothalamus was subjected to gene array analysis, quantitative PCR and western blot analysis.ResultsP21 HFD offspring displayed increased body weight, circulating insulin levels, and strongly increased activation of the hypothalamic insulin signaling cascade with a concomitant increase in ionized calcium binding adapter molecule 1 (IBA1) expression. At the same time, the global gene expression profile in CO and HFD offspring differed significantly. More specifically, manifest influences on several key pathways of hypothalamic neurogenesis, axogenesis, and regulation of synaptic transmission and plasticity were detectable. Target gene expression analysis revealed significantly decreased mRNA expression of several neurotrophic factors and co-factors and their receptors, accompanied by decreased activation of their respective intracellular signal transduction.ConclusionTaken together, these results suggest a potential role for disturbed neurotrophin signaling and thus impaired neurogenesis, axogenesis, and synaptic plasticity in the pathogenesis of the offspring’s hypothalamic feeding network dysfunction due to maternal obesity.

What are the factors behind citizen support for the use of extralegal violence in Latin America? The prevailing argument is that, in countries overwhelmed by skyrocketing levels of criminal violence, people endorse the use of extralegal violence as a way to cope with insecurity. Other scholars believe that support for extralegal violence is the result of state withdrawal and failure. Few empirical studies, however, have tested any of these arguments. In this article, using regional data from the 2012 AmericasBarometer, we examine different explanations regarding citizen support for the utilization of extralegal violence in Latin America and the Caribbean. We developed a multi-item scale that gauges support for different forms of extralegal violence across the Americas, and we hypothesize that support for extralegal violence is higher not only in countries with extreme levels of violence but especially in countries in which people distrust the political system. Results indicate that support for extralegal violence is significantly higher in societies characterized by little support for the existing political system. Resumen ¿Cuáles son los factores que determinan el apoyo ciudadano al uso de la violencia extralegal en América Latina? El argumento predominante es que en países con niveles altos de violencia criminal, las personas apoyan el uso de la violencia extralegal como un mecanismo para hacer frente a la inseguridad. Otros trabajos consideran que el apoyo a la violencia extralegal es el resultado del fracaso o ausencia del Estado. Pocos estudios empíricos, sin embargo, han tratado de probar dichos argumentos. En este artículo, utilizando datos regionales de la encuesta de 2012 del Barómetro de las Américas, analizamos las diferentes explicaciones detrás del apoyo ciudadano al uso de la violencia extralegal en América Latina y el Caribe. Desarrollamos una escala que contiene múltiples ítems, la cual estima el apoyo a distintas formas de violencia ilegal en las Américas y planteamos la hipótesis de que el apoyo a la violencia extralegal no es solo alto en países con niveles de violencia extrema, sino que lo es especialmente en aquellos en los cuales las personas no creen en el sistema político. Los resultados obtenidos indican que el apoyo a la violencia extralegal es significativamente más alto en sociedades caracterizadas por bajos niveles de apoyo al sistema político existente.