Ali Kapan

Background: Spontaneous intracranial hypotension (SIH) can cause substantial functional and psychosocial impairment, but patient-reported outcomes after surgical treatment remain incompletely understood. This study aimed to describe postoperative symptom burden, functional outcomes, psychosocial impact, and headache-related disability in surgically treated patients with self-reported SIH recruited through international patient support networks. Methods: A cross-sectional online survey (February–April 2025) recruited 92 surgically treated SIH patients via international patient support networks. Variables were obtained by participant report and included comorbidities, surgical characteristics, time metrics, symptom course, psychosocial factors, and HIT-6 scores. Multivariable linear regression was performed to examine factors associated with HIT-6. Results: Median age was 42 years (IQR 38–46), and 88.0% were female. Median time from diagnosis to most recent surgery was 21 months (IQR 13–41), and time since most recent surgery was 20 months (IQR 12–36). Structural abnormalities (e.g., pseudomeningoceles, neo-membranes) were reported by 33.7% of participants. Ventral dural leaks predominated (59.8%), followed by lateral leaks (15.2%) and CSF-venous fistulae (13.0%). Complete symptom resolution was reported by 15.2% of participants. Mean HIT-6 was 56.75 (SD 12.50). In exploratory adjusted analyses, no significant associations were observed between HIT-6 scores and pre-existing headache, number of surgeries, or CSF leak type. Conclusion: In this international cross-sectional sample of surgically treated patients with self-reported SIH, a substantial proportion reported persistent symptoms, self-reported rebound intracranial hypertension, headache-related disability, and psychosocial burden. These results suggest a heterogeneous postoperative status and emphasise the importance of structured long-term follow-up.

Background: To evaluate long-term postoperative symptoms, recovery and treatment responses at least 12 months after surgical repair of spinal CSF leaks in patients with spontaneous intracranial hypotension (SIH) and iatrogenic CSF leaks. Methods: This cross-sectional, self-report, online survey was conducted from January to April 2025, with participants recruited through international patient support groups. Descriptive analyses included 92 individuals with SIH and 136 with iatrogenic CSF leaks. The questionnaire assessed pre- and postoperative symptoms, functional recovery, complications and the perceived effectiveness of pharmacological and interventional treatments. Results: Among 228 respondents, complete recovery was reported by 13.6% (12/92) of patients with SIH and 5.8% (8/136) of those with iatrogenic CSF leaks. Orthostatic headache showed the greatest postoperative improvement, whereas fatigue, cognitive impairment and tinnitus improved only moderately. The median duration of sick leave was eight months, and 18% of participants remained on medical leave at the time of assessment. Clinician-diagnosed long-term complications were reported by 14.9% of respondents, including peripheral nerve injury. Acetazolamide was the most effective treatment for rebound high-pressure headache, particularly in patients with SIH. Occipital nerve blocks and therapeutic lumbar punctures provided moderate benefit in selected patients, while most other pharmacological treatments showed limited effectiveness. Conclusion: Many patients in this self-report cohort experience persistent symptoms years after undergoing surgery to repair spinal CSF leaks. These findings emphasise the importance of structured, multidisciplinary and long-term postoperative care.

Introduction: Postural orthostatic tachycardia syndrome (POTS) is a multifactorial disorder of the autonomic nervous system characterised by an excessive increase in heart rate (HR) on standing and a wide range of debilitating symptoms, including fatigue, exercise intolerance, cognitive impairment and a high prevalence of depression, anxiety and sleep disturbances. Conventional pharmacological strategies often offer limited relief and do not sufficiently address non-cardiac symptoms. Auricular vagal neuromodulation therapy (AVNT) and slow-paced diaphragmatic breathing (SDB) have each demonstrated promise in modulating autonomic function and alleviating symptom burden but their combined effects in POTS have yet to be investigated. Methods and analysis: This single-centre, partially blinded, 12-week randomised controlled trial will be conducted at the Medical University of Vienna. A total of 100 participants with confirmed POTS will be recruited, with 25 per group. This sample size is already accounting for an anticipated 30% dropout rate. Participants will be randomised using stratified block randomisation with a 1:1:1:1 allocation ratio, stratified based on the presence or absence of post-exertional malaise (yes/no) to one of four groups: (1) AVNT+SDB, (2) AVNT+normal breathing, (3) sham AVNT+SDB and (4) sham AVNT+normal breathing. The primary endpoint is the change in orthostatic HR (ΔHR) during a 70° head-up tilt test. Secondary outcomes include beat-to-beat blood pressure responses, respiratory sinus arrhythmia, end-tidal CO₂, handgrip strength, activity monitoring and validated patient-reported measures, including Chalder Fatigue Scale, Malmö POTS Symptom Score, Nijmegen Questionnaire, Short Form Health Survey, Hospital Anxiety and Depression Scale and Vanderbilt Orthostatic Symptom Score. Interventions consist of daily 60-minute AVNT (or sham) sessions combined with standardised breathing training (10–15 min/day). Ethics and dissemination: This study has been approved by the Ethics Committee of the Medical University of Vienna (EK number 1270/2024) and will be conducted in accordance with the Declaration of Helsinki and International Conference on Harmonisation-Good Clinical Practice guidelines. Results will be disseminated through peer-reviewed publications, conference presentations and reporting in the trial registry. Participants will receive study results in an accessible format. Trial registration number: NCT06996314 .

Objectives Post-exertional malaise (PEM) is increasingly understood not as a singular symptom but as a multidimensional exertion-response pattern involving diverse triggers, variable onset, and prolonged recovery. This study aimed to develop and content-validate the Vienna Post-Exertional Malaise (VPEM) Questionnaire, a multidimensional patient-reported outcome measure for PEM in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), designed to assess the consequences of PEM, including functional decline, prolonged recovery, new crash-associated symptoms, and pacing-related adaptations. Methods An iterative mixed-methods instrument-development study was conducted, combining quantitative ratings and qualitative feedback across sequential evaluation cycles involving individuals with lived experience and an interdisciplinary expert panel. An initial 13-item draft, derived from PEM, fatigue, and functional-capacity instruments, as well as consensus literature, was evaluated by individuals with lived experience of ME/CFS or Long COVID using Likert ratings, open-ended feedback, and semi-structured interviews. Quantitative data were summarised descriptively; qualitative data were analysed using deductive–inductive structuring content analysis. Revisions were agreed upon by a core development team and documented in revision matrices. The revised instrument version was evaluated by an interdisciplinary expert panel using domain-level ratings and item-level ratings of relevance and clarity. Results Twelve individuals with ME/CFS and one individual with Long COVID who also fulfilled ME/CFS criteria evaluated the questionnaire. Ratings showed high approval for questionnaire length (92.3%) and terminology (76.9%), while ratings for completeness and clarity were more heterogeneous. Qualitative analysis revealed conceptual ambiguities concerning the distinction between PEM and non-specific fatigue, the absence of trigger domains such as sensory, orthostatic and positively valenced emotional triggers, and inadequate representation of intra-individual variability. Following revision, the expert panel (n = 11) rated PEM coverage as either complete or largely complete (100%), and the multidimensional structure as either suitable or very suitable (90.9%). Item-level ratings revealed high content validity in terms of relevance (S-CVI/Ave = 0.96) and acceptable clarity (S-CVI/Ave = 0.82). The complete revised questionnaire was subsequently pretested online with five participants. Conclusions The VPEM Questionnaire operationalises PEM as a multidimensional pattern of post-exertional deterioration. Findings support initial content and face validity and provide the basis for psychometric validation.

Aim: This study aims to examine weight‐loss history and pre‐treatment concerns, and their associations with current functioning and well‐being in adults undergoing incretin‐based pharmacotherapy for obesity. Materials and Methods: This cross‐sectional study analysed 411 adults treated with three different incretin‐based medications. Demographics, previous weight‐loss interventions, barriers to earlier attempts, reasons for initiating incretin therapy, treatment characteristics and Treatment‐Related Impact Measure for Weight (TRIM‐Weight) total scores were assessed. Associations between specific pre‐treatment concerns and functioning and well‐being were analysed using univariate models and a multivariable regression model that adjusted for treatment related variables. Results: Participants had a median age of 39 years (IQR 33–47), 79.1% were women, and the median BMI was 36.3 kg/m ² (IQR 32.2–42.3). The median TRIM‐Weight total score was 68.2 (IQR 64.0–73.4). Most respondents (95.1%) had attempted weight loss, typically through combined diet and physical activity (71.8%), intermittent fasting (69.6%) and digital tracking tools (65.7%). In fully adjusted models, fear of side effects ( β = −3.53, 95% CI −4.05 to −3.01), concerns about cost ( β = −0.92, 95% CI −1.37 to −0.47) and injection anxiety ( β = −0.67, 95% CI −1.16 to −0.18) were associated with lower functioning and well‐being. Doubts regarding effectiveness showed a small positive association ( β = 0.61, 95% CI 0.03–1.19). Conclusion: Among retrospectively reported pre‐treatment concerns, fear of side effects, treatment costs and injection anxiety were most strongly associated with lower functioning and well‐being, whereas moral or psychosocial concerns showed no independent associations after multivariable adjustment.

Aims: Real‐time continuous glucose monitoring (rtCGM) is crucial to diabetes management in type 1 diabetes (T1D), but its accuracy decreases during glucose fluctuations triggered by physical activity and exercise. Materials and methods: Twenty adults with T1D (9 females; age 50 ± 12 years; HbA1c 6.6 ± 0.5%) participated in this study, which included a 3‐day lab phase where three group exercise sessions (each lasting 90 min) were performed, followed by a 4‐day home phase. Participants were required to wear a Dexcom G7 (Dexcom), FreeStyle Libre 3 (Abbott), and Simplera (Medtronic) rtCGM simultaneously. From 8:00 AM (initial measurement) to 10:00 PM (final measurement), duplicate capillary blood glucose measurements were taken at 2‐h intervals using the Contour Next One glucometer (Ascensia Diabetes Care) and recorded in addition to the actual displayed sensor glucose values. The performance of the rtCGM systems was evaluated by means of median absolute relative difference (MedARD) and interquartile range [IQR] against the reference blood glucose. Absolute relative differences (|ARD|) of the three rtCGMs were analysed using the Kruskal–Wallis test ( p < 0.05). Results: Overall, the MedARD [IQR] for Dexcom G7 was 8.4% [3.6–14.0] (723 comparison points), for Libre 3 7.5% [3.1–13.4] (723 comparison points), and Simplera 13.8% [6.9–22.5] (719 comparison points). No significant differences were found between Libre 3 versus Dexcom G7 ( p = 0.35). A significant difference was found for Dexcom G7 versus Simplera and Libre 3 versus Simplera ( p < 0.0001). Conclusions: Dexcom G7 and FreeStyle Libre 3 showed very high accuracy, which could not be found for the Simplera rtCGM system. Clinical registration: German Clinical Trial Register, DRKS: DRKS00035836.

Introduction: The aim of this study was to examine associations between psychological and behavioural factors and body weight, appetite, satiety, and food cravings in individuals with obesity receiving incretin therapy. Methods: Between January and February 2025, 411 adults completed an online survey. They provided data using the Weight Efficacy Lifestyle Questionnaire – Short Form, the Three-Factor Eating Questionnaire, and the Salzburg Emotional Eating Scale, and rated their perceptions of satiety, appetite, and food cravings. Multivariable linear and logistic regression analyses were used to assess associations between psychological factors and these outcomes, adjusting for relevant confounders. Results: The sample was mainly female (71.8%), with a median age of 40 years (Q1–Q3: 33–47). Participants had a median treatment duration of 43 weeks (Q1–Q3: 30–58) and a median body mass index (BMI) difference of 5.9 kg/m2 (Q1–Q3: 4.0–7.4). In fully adjusted models, higher self-efficacy was associated with lower BMI values (β = −0.22; p < 0.001) and greater satiety (adjusted odds ratio [AOR] = 1.46; p < 0.001). Emotional eating in response to happiness was related to higher BMI (β = 0.46; p < 0.001) but also to higher satiety and lower cravings (AOR = 1.31–1.41; p < 0.05). Conclusion: Eating self-efficacy and emotion-related eating patterns were linked to body weight, appetite, satiety, and cravings. Considering these psychological profiles may help tailor behavioural support, improve adherence, and enhance the effectiveness of incretin-based therapy.