Background Several clinical guidelines exist to identify intracranial injury (ICI) after head injury. The Scandinavian Neurotrauma Committee (SNC) published evidence- and consensus-based guidelines in 2000, updated in 2013. Since then, demographic changes, including an ageing population and increased use of antithrombotic therapy have prompted further revision. The aim of this study is to provide a clinically relevant update to the SNC guidelines for the initial management of adults with minimal, mild, or moderate head injury. Methods A PRISMA-compliant systematic review and meta-analysis addressed population, exposure, comparator, and outcome questions on which emergency department patients with minimal or mild head injury require head computed tomography (CT), direct discharge, in-hospital observation, or repeat CT. Evidence was graded using the GRADE approach. Recommendations were developed through a modified Delphi process with stakeholder review. Findings Twenty-nine stakeholders participated in developing a seven-point recommendation set and updated management flowcharts. Key changes include reduced emphasis on routine CT in patients receiving direct oral anticoagulants, incorporation of glial fibrillary acidic protein and ubiquitin C-terminal hydrolase L1 biomarkers, and use of structured observation as an alternative to CT in selected risk groups. Interpretation The updated guidelines support risk-adapted imaging and observation strategies that may reduce unnecessary CT scans and hospital admissions, although further validation of safety and effectiveness is needed. Funding No specific funding.
Community-acquired pneumonia (CAP) remains a leading cause of hospital and intensive care admission and infectious death in Europe, particularly among older adults, people with multimorbidity, and immunocompromised patients. This Review argues that persistent uncertainty in CAP evidence largely reflects heterogeneity across eight domains: case definition, host, pathogen ascertainment, severity, inflammatory response, treatment exposure, timing and trajectory, and outcome measurement. We examine how these domains distort incidence estimates, pathogen rankings, diagnostic accuracy, severity classification, and trial findings. Within this framework, we highlight developments relevant to Europe: randomised vaccine trials assessing hospitalisation rather than immunogenicity; national data suggesting a changing, increasingly β-lactam-resistant role for Haemophilus influenzae; evidence suggesting that discordant corticosteroid trials reflect heterogeneity of treatment effect rather than drug or protocol differences; and the first randomised trial of host-response-directed immunotherapy in pneumonia-predominant sepsis. We also examine continuing fragmentation in European adult vaccination policy, surveillance, and diagnostic capacity. We propose a diagnostic approach organised by clinical group, a minimum CAP dataset with explicit governance, and a research agenda separating interventions applicable now, evidence required before implementation, and unresolved questions. This approach connects advances in prevention, diagnosis, and treatment with the methodological and organisational changes needed to generate more reliable, clinically actionable European evidence.
Background Implementation and long-term persistence of guideline-directed medical therapy (GDMT) following ST-segment elevation myocardial infarction (STEMI) remain suboptimal. We assessed the implementation and persistence of four-class GDMT after STEMI and its association with outcomes. Methods We performed a patient-level pooled analysis of three randomised trials of patients undergoing percutaneous coronary intervention for STEMI. GDMT was defined by the number of drug classes prescribed (0–4). External validation was conducted using a real-world PCI registry. Findings The study included 2270 patients from the randomised trials and 5643 from a real-world PCI registry. More than two-thirds of patients received all four GDMT classes at discharge (ranging from 66.9% [398/595] to 83.5% [339/406]), but this proportion declined over 5 years (ranging from 40.5% [408/1008] to 53.1% [276/520]). In exploratory analyses, higher GDMT class at discharge was associated with a lower risk of the composite of cardiovascular death, stroke, or myocardial infarction at 5 years (adjusted HR [95% CI] for class 4 versus 0–2: 0.49 [0.33–0.72]; class 3 versus 0–2: 0.49 [0.28–0.85]). In a time-dependent analysis, higher GDMT class during follow-up was associated with a lower risk of the composite outcome (adjusted IRR [95% CI] for class 4 versus 0–2: 0.71 [0.52–0.95]; class 3 versus 0–2: 0.59 [0.41–0.86]). Similar longitudinal patterns were observed in the real-world PCI registry. Interpretation Although the majority of patients received all four GDMT classes at discharge after STEMI, this proportion declined during long-term follow-up. In exploratory analyses, higher GDMT class was associated with a lower risk of cardiovascular events. Funding No specific funding was received for the present study. Funding for the individual trials and registry is reported in the Acknowledgements.
Background Use of antibiotic prophylaxis (AP) prior to invasive dental procedures (IDPs) to prevent infective endocarditis (IE) fell dramatically in the UK when the National Institute for Health and Care Excellence (NICE) recommended its cessation in 2008. However, guidance implementation by dentists, general medical practitioners (GPs) and others differed in England and Scotland, particularly after 2018 when the Scottish Dental Clinical Effectiveness Programme advised Scottish dentists to consider AP for high-risk individuals. We compared the effects of this differing guidance on AP prescribing and IE-admissions. Methods A quasi-experimental (natural) longitudinal-study design was used to compare aggregated national AP prescribing (2002–2025) and IE-admissions data (1998–2025) for England and Scotland. Interrupted time series and difference-in-differences analyses were used to evaluate changes. Findings AP prescribing fell 93% in England after the 2008 NICE guidelines and remained low (2567 [95% CI 2433–2701] prescriptions/million/annum before 2008 vs 185 [95% CI 165–204] prescriptions/million/annum after 2021/2, p < 0.0001), while IE-admissions increased by 112% (26 [95% CI 25–27] admissions/million/annum before 2008 vs 55 [95% CI 54–56]/million/annum after 2021/2, p < 0.0001). In Scotland, AP prescribing fell less, because GP prescribing replaced some dental prescribing, then rose again after 2018 and finished 2.86 times higher than in England (1884 [95% CI 1816–1952] prescriptions/million before 2008 vs 528 [95% CI 350–705] prescriptions/million after 2021/2). Correspondingly, Scottish IE-admissions rose less (24 [95% CI 23–25] admissions/million before 2008 vs 34 [95% CI 32–37] admissions/million after 2021/2, p < 0.0001) than in England, and English IE-admissions/million ended 61% higher than in Scotland (p < 0.0001). Interpretation Although our data do not establish causality, they suggest that cessation of AP may be followed by a significant increase in IE-admissions compared with policies recommending AP for high-risk individuals. Funding None.
Background Despite limited evidence for non-cancer pain, opioid use has increased substantially in Europe. We aimed to characterize patterns and treatment trajectories of inpatient opioid use and to identify clinically distinct patient subgroups of heightened risk for opioid-related harm using predefined deprescribing indicators to inform hospital-based stewardship interventions. Methods This five-year, multicenter, longitudinal, observational cohort study across three Swiss tertiary referral centers (2020–2024) included adult inpatient cases with at least one systemic opioid administration during the index hospitalization using linked electronic health record data. Daily morphine milligram equivalents (MMEs) were calculated from medication administration records. Sustained therapy was defined as ≥3 consecutive treatment days. Deprescribing indicators included high-dose therapy (>90 MMEs on the final hospital day), high-risk comorbidities, and concurrent use of central nervous system depressants. Non-cancer opioid treatment trajectories were clustered using k-means analysis. Findings Among 68,129 opioid-treated cases, 78.6% (n = 53,558) had no documented cancer diagnosis. Approximately half received sustained therapy. Collectively, 11.4% (n = 7791) of 68,129 cases met at least one predefined deprescribing indicator. Musculoskeletal disorders and injury-related conditions were the primary admission diagnoses (22.9% [n = 15,575] of 68,129 cases). Opioid treatment trajectory analysis identified three distinct MME patterns among non-cancer cases, including a stable-dose subgroup (36% [n = 19,292] of 53,558) characterized by sustained therapy (89.3% [n = 17,235] of 19,292 cases), higher comorbidity burden, and greater prevalence of deprescribing indicators (33.4% [n = 17,235] of 19,292 cases). Annually, over 1200 cases were eligible for deprescribing, predominantly older adults with musculoskeletal conditions. Interpretation Inpatient opioid exposure was overall more common in non-cancer cases and often characterized by sustained therapy with only marginal dose reductions prior to discharge. Hospitals therefore represent critical intervention points for structured deprescribing approaches to prevent transitions to potentially harmful, persistent opioid use. Funding This research did not receive external funding.
