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Cardioembolic stroke versus embolic stroke of undetermined source : early severity and long-term outcomes in a prospective cohort
(2025) Boettger, Priyanka; Sedighi, Jamschid; Juenemann, Martin; Buerke, Michael; Omar, Omar Alhaj
Background: Embolic stroke of undetermined source (ESUS) constitutes a substantial proportion of ischemic strokes. Its distinction from cardioembolic stroke (CES) may carry prognostic implications. This study aimed to compare early and long-term outcomes between ESUS and CES. Methods: We conducted a prospective cohort study of patients with ESUS and CES who underwent standardized diagnostic evaluation and prolonged cardiac monitoring. Stroke severity was assessed with the NIHSS, and functional outcome with the mRS at discharge, 30 days, and 12 months. ESUS patients were additionally evaluated for short-duration atrial fibrillation. Results: During a 6-month prospective enrollment period, 771 patients with suspected stroke were screened, of whom 529 had ischemic stroke confirmed by neuroimaging. After applying ESUS criteria, 98 patients were classified as ESUS and 209 as CES (total study cohort, n = 307; 41% women; mean age 72 ± 9 years). Patients with ESUS presented with significantly lower stroke severity and achieved better functional outcomes than those with CES. The mean NIHSS score on admission was 6 (95% CI, 5–7) in the ESUS group and 11 (95% CI, 10–12) in the cardioembolic group ( p< 0.001). At discharge, the mean mRS score was 2.1 (95% CI, 1.8–2.4) for ESUS and 3.8 (95% CI, 3.5–4.1) for CES (p < 0.001). A favorable outcome (mRS 0–2) was more common in ESUS (68% vs. 34%; p < 0.001). In-hospital mortality occurred in 10.0% of cardioembolic patients and in none of the ESUS patients (p = 0.02). At 12 months, ESUS patients continued to show more favorable recovery, with higher rates of functional independence (60% vs. 28%; p < 0.001) and lower cumulative mortality (7.1% vs. 21.5%; p< 0.001). Conclusions: Compared with CES, ESUS was associated with less severe neurological deficits and more favorable outcomes, both early and at 12 months, including lower mortality and better functional recovery.
Ethical perceptions of DRG-based hospital financing among physicians and hospital managers in Germany : a cross-sectional survey
(2026) Becker, Sara; Lemm, Henning; Stang, Andreas; Sossalla, Samuel; Buerke, Michael; Boettger, Priyanka
Background: Diagnosis-Related Groups (DRGs) have reshaped German hospital financing by linking reimbursement to case-based payment. While intended to increase efficiency, DRG-based reimbursement has been associated with concerns regarding professional autonomy, patient-centeredness, and organizational ethics. This study examines how physicians and hospital managerial stakeholders perceive the DRG system, focusing on professional identity, patient care, and moral conflict. Methods: We conducted a cross-sectional online survey among hospital physicians and managerial stakeholders in two German federal states (North Rhine–Westphalia and Saxony-Anhalt). The questionnaire assessed perceived economic pressure, ethical conflict, and quality-of-care implications under DRG conditions. Descriptive comparisons and multivariable logistic regression were used to estimate associations between professional role and reported ethical concerns. Results: Physicians more frequently reported perceived moral conflict (82% vs. 34%), reduced patient-centeredness (76% vs. 39%), and time pressure associated with DRG-linked hospital financing (85% vs. 71%) than managerial respondents. Managerial stakeholders more frequently emphasized efficiency and coordination gains. Both groups supported the use of quality indicators to protect care standards, though physicians were more likely to call for rebalancing financial and clinical priorities. Conclusions: Physicians and managerial stakeholders perceive DRG-linked incentives differently, and both groups identify ethical pressure points in current hospital financing. The findings suggest that hospital financing reforms should consider not only efficiency incentives but also their perceived interaction with professional ethics, continuity of care, and organizational culture.
Vitamin D status and atherogenic lipid profiles, including lipoprotein(a), in elite athletes
(2026) Groesser, Vincent; Most, Astrid; Sedighi, Jamschid; Böttger, Priyanka; Sossalla, Samuel; Bauer, Pascal
Background/Objectives: Vitamin D has been implicated in lipid metabolism, but data regarding its association with atherogenic lipoproteins in elite athletes remain limited. Elite athletes represent a unique research model to investigate these associations with reduced confounding from obesity, chronic disease, smoking, and physical inactivity. Methods: This cross-sectional study included 773 male professional athletes from mixed sports disciplines (mean age 25.5 ± 5.0 years). Serum 25-hydroxyvitamin D [25(OH)D] concentrations and lipid parameters, including total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides, and lipoprotein(a) [Lp(a)], were assessed. Associations were analyzed using correlation analyses, subgroup comparisons according to predefined 25(OH)D categories (<30, 30–50, and >50 ng/mL), and multivariable linear regression models adjusted for age, body mass index, season, and training-related variables. Results: Higher serum 25(OH)D concentrations were independently associated with lower LDL-C (p = 0.028), triglyceride (p = 0.002), and Lp(a) concentrations (p = 0.036), whereas no independent association was observed with HDL-C (p = 0.559). Athletes with 25(OH)D concentrations ≥30 ng/mL demonstrated lower LDL-C, triglyceride, and Lp(a) levels compared with athletes below this threshold (all p < 0.05). Higher vitamin D status was additionally associated with greater peak exercise performance (4.29 ± 1.15 vs. 3.36 ± 0.68 W/kg; p < 0.001). Conclusions: Higher 25(OH)D concentrations were independently associated with a more favorable lipid profile in elite athletes, including lower LDL-C, triglyceride, and Lp(a) concentrations. Prospective studies are warranted to further investigate the relationship between vitamin D status and lipid metabolism in athletic populations.
Negative association of SGLT2 inhibitors with epilepsy risk compared with DPP-4 inhibitors in type 2 diabetes : a target trial emulation
(2026) Doege, Corinna; Sedighi, Jamschid; Luedde, Mark; Sossalla, Samuel; Kostev, Karel
Background: Epilepsy is a frequent neurological comorbidity in type 2 diabetes. Sodium–glucose cotransporter-2 inhibitors (SGLT2i) exert metabolic, vascular, and anti-inflammatory actions beyond glucose lowering, suggesting potential neuroprotective properties. We assessed whether SGLT2i use is associated with a reduced incidence of epilepsy compared with dipeptidyl peptidase-4 inhibitors (DPP-4i). Methods: We emulated a target trial using a retrospective observational cohort of adults with type 2 diabetes initiating SGLT2i or DPP-4i from a large real-world database. Propensity scores were estimated using a SuperLearner algorithm, and stabilized inverse probability of treatment weights were applied to balance baseline characteristics. Weighted Kaplan–Meier and Cox regression models were used to estimate hazard ratios (HRs) for incident epilepsy. Results: Among 176,728 patients (mean age 68 years; 39% women), 43% received SGLT2i. The weighted incidence of epilepsy was 2.05 versus 2.45 per 1000 person-years for SGLT2i and DPP-4i, respectively. SGLT2i treatment was associated with a significantly lower risk of epilepsy (HR 0.72, 95% CI 0.61–0.86; p < 0.001). Conclusions: In this large real-world study, initiation of SGLT2 inhibitors was associated with a lower incidence of epilepsy compared with DPP-4 inhibitors. The absolute difference in event rates was small (2.05 vs. 2.45 cases per 1000 person-years), and residual confounding cannot be excluded. These findings should therefore be regarded as hypothesis-generating and warrant prospective research to confirm causality and clarify potential mechanisms.
Calculation of pulmonary capillary wedge pressure including left atrial function is superior to morphology alone and accurately identifies elevated filling pressures in left heart disease
(2026) Backhaus, Sören J.; Schmermund, Ben N.; Rieth, Andreas J.; Rademann, Matthias; Kriechbaum, Steffen D.; Wolter, Jan Sebastian; Wiedenroth, Christoph B.; Schulz, Alexander; Lange, Torben; Treiber, Julia M.; Sossalla, Samuel; Schuster, Andreas; Rolf, Andreas
Background: Right heart catheterization (RHC) with pulmonary capillary wedge pressure (PCWP) assessment is the reference standard for diagnosis of heart failure with preserved ejection fraction (HFpEF), but remains largely underused. Different approaches for non-invasive PCWP calculation have been proposed. However, as left atrial strain (LA Es) and end-systolic volume index (ESVi) emerge as key criteria in HFpEF, we sought to investigate them for PCWP calculation. Methods: The derivation population consisted of patients referred to RHC and cardiovascular magnetic resonance (CMR) imaging who were enrolled in a prospective monocentric registry. Patients were classified by RHC according to current guideline recommendations. The external validation population consisted of patients included in the HFpEF-Stress trial who underwent exercise-stress RHC and CMR with follow-up after 4 years for hospitalized cardiovascular events. Performance of strain-derived PCWP was compared to a published LA volume (LAV) and left ventricular mass (LVM) derived method. Results: The derivation population consisted of n = 209 patients, n = 123 underwent exercise-stress RHC (n = 55 without pulmonary hypertension [PH], n = 72 pre-capillary, n = 27 combined post- and pre-capillary pulmonary hypertension [CpcPH], n = 15 isolated post-capillary pulmonary hypertension [IpcPH], n = 34 exercise, and n = 6 unclassified PH). Linear regression models identified the following formulae for functional PCWPrest 10.304 − 0.095 * Es + 0.098 * ESVi and functional PCWPstress 24.666 − 0.251 * Es + 0.056 * ESVi calculation. The validation population consisted of n = 74 patients (n = 15 without, n = 5 pre-capillary, n = 8 CpcPH, n = 10 IpcPH, and n = 32 exercise PH with n = 4 remaining unclassified). Functional PCWPrest (11.8) and RHC-derived PCWPrest (11 mmHg) were statistically similar (p = 0.285) and showed moderate correlation (r = 0.53, p < 0.001). Functional PCWPrest (area under the curve [AUC] 0.80) and PCWPstress (AUC 0.85) accurately identified HFpEF patients, were superior to LAV/LVM-based PCWP (AUC 0.67, p ≤ 0.002) and showed prognostic implications (hazard ratio 1.37 (1.16–1.62) and 1.29 (1.14–1.46), p < 0.001). Conclusion: Functional PCWP may aid in the identification of post-capillary involvement in PH and HFpEF superiorly compared to morphology-derived PCWP and shows prognostic implications.