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Lee KM, Cheung YB. Estimation and reduction of bias in self-controlled case series with non-rare event dependent outcomes and heterogeneous populations. Stat Med 2024; 43:1955-1972. [PMID: 38438267 DOI: 10.1002/sim.10033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 10/19/2023] [Accepted: 01/23/2024] [Indexed: 03/06/2024]
Abstract
The self-controlled case series (SCCS) is a commonly adopted study design in the assessment of vaccine and drug safety. Recurrent event data collected from SCCS studies are typically analyzed using the conditional Poisson model which assumes event times are independent within-cases. This assumption is violated in the presence of event dependence, where the occurrence of an event influences the probability and timing of subsequent events. When event dependence is suspected in an SCCS study, the standard recommendation is to include only the first event from each case in the analysis. However, first event analysis can still yield biased estimates of the exposure relative incidence if the outcome event is not rare. We first demonstrate that the bias in first event analysis can be even higher than previously assumed when subpopulations with different baseline incidence rates are present and describe an improved method for estimating this bias. Subsequently, we propose a novel partitioned analysis method and demonstrate how it can reduce this bias. We provide a recommendation to guide the number of partitions to use with the partitioned analysis, illustrate this recommendation with an example SCCS study of the association between beta-blockers and acute myocardial infarction, and compare the partitioned analysis against other SCCS analysis methods by simulation.
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Affiliation(s)
| | - Yin Bun Cheung
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
- Signature Programme in Health Services & Systems Research, Duke-NUS Medical School, Singapore
- Tampere Center for Child, Adolescent and Maternal Health Research, Tampere University, Tampere, Finland
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2
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Reeve NF, Best V, Gillespie D, Hughes K, Lugg-Widger FV, Cannings-John R, Torabi F, Wootton M, Akbari A, Ahmed H. Myocardial infarction and stroke subsequent to urinary tract infection (MISSOURI): protocol for a self-controlled case series using linked electronic health records. BMJ Open 2022; 12:e064586. [PMID: 36137640 PMCID: PMC9511592 DOI: 10.1136/bmjopen-2022-064586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 09/07/2022] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION There is increasing interest in the relationship between acute infections and acute cardiovascular events. Most previous research has focused on understanding whether the risk of acute cardiovascular events increases following a respiratory tract infection. The relationship between urinary tract infections (UTIs) and acute cardiovascular events is less well studied. Therefore, the aim of this study is to determine whether there is a causal relationship between UTI and acute myocardial infarction (MI) or stroke. METHODS AND ANALYSIS We will undertake a self-controlled case series study using linked anonymised general practice, hospital admission and microbiology data held within the Secure Anonymised Information Linkage (SAIL) Databank. Self-controlled case series is a relatively novel study design where individuals act as their own controls, thereby inherently controlling for time-invariant confounders. Only individuals who experience an exposure and outcome of interest are included.We will identify individuals in the SAIL Databank who have a hospital admission record for acute MI or stroke during the study period of 2010-2020. Individuals will need to be aged 30-100 during the study period and be Welsh residents for inclusion. UTI will be identified using general practice, microbiology and hospital admissions data. We will calculate the incidence of MI and stroke in predefined risk periods following an UTI and in 'baseline' periods (without UTI exposure) and use conditional Poisson regression models to derive incidence rate ratios. ETHICS AND DISSEMINATION Data access, research permissions and approvals have been obtained from the SAIL independent Information Governance Review Panel, project number 0972. Findings will be disseminated through conferences, blogs, social media threads and peer-reviewed journals. Results will be of interest internationally to primary and secondary care clinicians who manage UTIs and may inform future clinical trials of preventative therapy.
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Affiliation(s)
- Nicola F Reeve
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Victoria Best
- Population Data Science, Swansea University Medical School, Swansea, UK
| | | | - Kathryn Hughes
- PRIME Centre Wales, Division of Population Medicine, Cardiff University, Cardiff, UK
| | | | | | - Fatemeh Torabi
- Population Data Science, Swansea University Medical School, Swansea, UK
| | - Mandy Wootton
- Specialist Antimicrobial Chemotherapy Unit, Public Health Wales, University Hospital of Wales Healthcare NHS Trust, Cardiff, UK
| | - Ashley Akbari
- Population Data Science, Swansea University Medical School, Swansea, UK
| | - Haroon Ahmed
- Division of Population Medicine, Cardiff University, Cardiff, UK
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3
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Müller CS, Bialas P, Becker SL. Herpes-zoster-Update – was gibt es Neues? AKTUELLE DERMATOLOGIE 2021. [DOI: 10.1055/a-1401-7354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AbstractShingles are triggered by the reactivation of an infection with the varicella zoster virus (VZV) and are characterized by specific vesicular skin lesions. Mostly, elderly patients are affected. Depending on the affected dermatome, some serious complications can be observed. The introduction of a vaccine against shingles in Germany offers a great potential for reducing the frequency and severity of this disease. There are both a live vaccine, which is no longer recommended, and an inactivated vaccine, which, however, is still not sufficiently recommended to the authorized patient groups and is also only available to a limited extent due to delivery bottlenecks. HZ neuralgia is a serious complication of the disease that requires rapid and effective therapy and should be handed over to experienced pain therapists rather too early than too late. Unfortunately, in everyday clinical practice only a few people are familiar with VZV vasculopathy, which is associated with a significantly increased risk of cerebral insults.
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4
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Namazova-Baranova L, Habib MA, Povey M, Efendieva K, Fedorova O, Fedoseenko M, Ivleva T, Kovshirina Y, Levina J, Lyamin A, Ogorodova L, Reshetko O, Romanenko V, Ryzhenkova I, Sidorenko I, Yakovlev Y, Zhestkov A, Tatochenko V, Scherbakov M, Shpeer EL, Casabona G. A randomized trial assessing the efficacy, immunogenicity, and safety of vaccination with live attenuated varicella zoster virus-containing vaccines: ten-year follow-up in Russian children. Hum Vaccin Immunother 2021; 18:1959148. [PMID: 34435933 PMCID: PMC9067519 DOI: 10.1080/21645515.2021.1959148] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
In Russia, a universal varicella vaccination (UVV) program has not been implemented, and varicella vaccination coverage is low. We assessed the efficacy, antibody persistence, and safety of one- and two-dose varicella vaccination schedules in Russian children with a ten-year follow-up period, as part of an international phase IIIB, observer-blind, randomized, controlled trial (NCT00226499). Children aged 12-22 months were randomized (3:3:1) to receive two doses of tetravalent measles-mumps-rubella-varicella vaccine (V2 group), one dose trivalent measles-mumps-rubella (MMR) vaccine and one dose of varicella vaccine (V1 group), or two doses of MMR vaccine (V0 [control] group), 42 days apart. Main study outcomes were: vaccine efficacy (VE) against confirmed varicella cases, anti-varicella zoster virus (VZV) seropositivity rates and geometric mean concentrations, and reporting of (serious) adverse events ([S]AEs). The total vaccinated cohort in Russia comprised 1000 children; 900 were followed up until study end (year [Y] 10). VE estimates against confirmed varicella (Y10) were 92.4% in the V2 group and 74.7% in the V1 group. Anti-VZV seropositivity rates remained ≥99.4% in the V2 group and ≥89.7% in the V1 group from day 42 post-vaccination 2 until Y10. Occurrence of (un)solicited AEs and SAEs was similar across groups and confirmed the safety profile of the vaccines. No vaccination-related SAEs or deaths were reported. These results are consistent with the global trial results, i.e., the highest VE estimates observed following the two-dose schedule compared to the one-dose schedule. These data may inform decision-making related to potential implementation of a UVV program.
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Affiliation(s)
- Leyla Namazova-Baranova
- Scientific Center of Children Health, Moscow, Russia.,Pediatrics and Child Health Research Institute, CCH RAS, Ministry of Science and Higher Education of the Russian Federation, Moscow, Russia.,Pirogov Russian National Research Medical University, Ministry of Health of the Russian Federation, Moscow, Russia
| | | | | | - Kamilla Efendieva
- Scientific Center of Children Health, Moscow, Russia.,Pediatrics and Child Health Research Institute, CCH RAS, Ministry of Science and Higher Education of the Russian Federation, Moscow, Russia.,Pirogov Russian National Research Medical University, Ministry of Health of the Russian Federation, Moscow, Russia
| | - Olga Fedorova
- Regional Children Hospital, Tomsk, Russia.,Siberian State Medical University, Ministry of Health of the Russian Federation, Tomsk, Russia
| | - Marina Fedoseenko
- Scientific Center of Children Health, Moscow, Russia.,Pediatrics and Child Health Research Institute, CCH RAS, Ministry of Science and Higher Education of the Russian Federation, Moscow, Russia.,Pirogov Russian National Research Medical University, Ministry of Health of the Russian Federation, Moscow, Russia
| | - Tatyana Ivleva
- Medical Clinicodiagnostic Center Reafan, Novosibirsk, Russia
| | - Yulia Kovshirina
- Regional Children Hospital, Tomsk, Russia.,Siberian State Medical University, Ministry of Health of the Russian Federation, Tomsk, Russia
| | - Julia Levina
- Scientific Center of Children Health, Moscow, Russia.,Pediatrics and Child Health Research Institute, CCH RAS, Ministry of Science and Higher Education of the Russian Federation, Moscow, Russia
| | | | | | - Olga Reshetko
- City outpatient clinic #11, Saratov, Russia.,Saratov State Medical University, Ministry of Health of the Russian Federation, Saratov, Russia
| | - Viktor Romanenko
- Ural State Medical University, Ministry of Health of the Russian Federation, Ekaterinburg, Russia
| | - Inna Ryzhenkova
- City outpatient clinic #11, Saratov, Russia.,Saratov State Medical University, Ministry of Health of the Russian Federation, Saratov, Russia
| | | | - Yakov Yakovlev
- Novokuznetsk Municipal Children Hospital, Novokuznetsk, Russia.,Novokuznetsk State Institute of Postgraduate Medicine, Novokuznetsk, Russia
| | | | - Vladimir Tatochenko
- City Children Hospital Named after T.G.Petrova, Ivanteevka Moscow Region, Russia
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5
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Widgren K, Persson Berg L, Mörner A, Lindquist L, Tegnell A, Giesecke J, Studahl M. Severe chickenpox disease and seroprevalence in Sweden - implications for general vaccination. Int J Infect Dis 2021; 111:92-98. [PMID: 34380088 DOI: 10.1016/j.ijid.2021.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/05/2021] [Accepted: 08/05/2021] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To describe the current panorama of severe chickenpox disease and seroprevalence in Sweden, as a basis for the approaching decision on universal vaccination. METHODS We included patients discharged with an International Classification of Diseases, 10th revision-code for chickenpox (B01.1-9) in eight pediatric and infectious diseases departments in Stockholm and Gothenburg in 2012-2014 and reviewed their medical charts. Further, residual serum samples collected from 16 laboratories across Sweden were analyzed for varicella zoster IgG-antibodies to investigate the age-specific seroprevalences. RESULTS In all, 218 children and 46 adults were included in the hospital-based study, 87.2% of children and 63.0% of adults had complications. An underlying condition was not associated with an increased risk for complication. In children dehydration (31.7%), bacterial skin infections (29.8%) and neurological involvement (20.6%) were most frequent complications. Among adult cases, 63 % were born abroad. The seroepidemiological analysis included 957 patient samples. Seroprevalence was 66.7% at 5 years and 91.5% at 12 years. Infants and adolescents/adults were overrepresented among admitted patients compared to seroprevalence data. CONCLUSIONS Half of all complications in hospitalized chickenpox cases was seen in previously healthy children, which supports universal childhood vaccination. Adult migrants was a risk group for chickenpox hospitalization. Age-specific seroprevalence was similar to neighboring countries.
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Affiliation(s)
- K Widgren
- Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden; Department of Public Health Analysis and Data Management, the Public Health Agency of Sweden, Solna, Sweden.
| | - L Persson Berg
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden; Department of Clinical Microbiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - A Mörner
- Department of Microbiology, the Public Health Agency of Sweden,Solna, Sweden
| | - L Lindquist
- Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden
| | - A Tegnell
- Department of Public Health Analysis and Data Management, the Public Health Agency of Sweden, Solna, Sweden
| | - J Giesecke
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - M Studahl
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden; Department of Infectious Diseases, Sahlgrenska University Hospital, Gothenburg, Sweden
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6
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Saberi A, Akhondzadeh S, Kazemi S, Kazemi S. Infectious Agents and Stroke: A Systematic Review. Basic Clin Neurosci 2021; 12:427-440. [PMID: 35154584 PMCID: PMC8817172 DOI: 10.32598/bcn.2021.1324.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 04/25/2020] [Accepted: 05/30/2021] [Indexed: 12/15/2022] Open
Abstract
Introduction: A major cause of injury and the second cause of death worldwide is stroke. Among several infectious agents considered as the risk factor of stroke, some pathogens demonstrated stronger robust associations with stroke. Proposing an accurate correlation between infectious microorganisms and stroke provides valuable information for early intervention and control of the infections. Methods: In this study, we searched the literature using the Web of Science, PMC/Medline via PubMed, and Scopus databases up to July 2018 without time and language restrictions. After quality assessment, 16 articles were included in the study. The whole data extraction process was independently conducted by two reviewers. Results: Based on the results of the studies, viruses, such as Hepatitis C virus (HCV), Hepatitis B virus (HBV), Human Immunodeficiency Virus (HIV), Herpes Simplex Virus Type-1, 2 (HSV-1, 2), Varicella-Zoster Virus (VZV or Chickenpox), and West Nile virus (WNV) seem to be common causes of ischemic stroke. Moreover, the association of other microbial categories, such as Streptococcus mutans (in bacteria), Toxocara spp. and Toxoplasma gondii (in parasites), and Rhizopus sp. (in fungi) with stroke was reported. Conclusion: Considering the adverse role of the above-mentioned microorganisms, it is necessary to implement some preventive measures for stroke treatment.
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Affiliation(s)
- Alia Saberi
- Department of Neurology, Neuroscience Research Center, Poursina Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Shahin Akhondzadeh
- Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Samira Kazemi
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Samaneh Kazemi
- Deputy of Research and Technology, Guilan University of Medical Sciences, Rasht, Iran
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7
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Bertamino M, Signa S, Veneruso M, Prato G, Caorsi R, Losurdo G, Teutonico F, Esposito S, Formica F, Tovaglieri N, Nagel MA, Amico G, Zanetti A, Tortora D, Rossi A, Moretti P, Gattorno M, Ravelli A, Severino M. Expanding the clinical and neuroimaging features of post-varicella arteriopathy of childhood. J Neurol 2021; 268:4846-4865. [PMID: 34046727 DOI: 10.1007/s00415-021-10606-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 05/06/2021] [Accepted: 05/08/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Post-varicella arterial ischemic stroke (AIS) is considered an uncommon cause of pediatric stroke that is considered a self-limiting, monophasic disease. However, in a subset of patients, disease recurs; the prevalence of vasculopathy or AIS recurrence, severity of clinical outcomes, and standardized therapies have not been well characterized. Herein, we determined the clinical-neuroradiological features, long-term evolution, and relationship between acute phase treatment and vasculopathy recurrence in a pediatric population with post-varicella AIS. METHODS Clinical, laboratory, and neuroradiological features of 22 children with post-varicella AIS between 2010 and 2019 (16 males, mean age at stroke 4 years, range 1.7-10) were reviewed. Statistical analyses were performed using χ2 and Fisher exact tests. RESULTS Of the 22 cases, mean time from varicella to stroke was 4.5 months with 3 cases presenting more than 12 months after rash; 21 (95%) were not vaccinated for varicella; 3 (13.6%) had posterior circulation involvement; and 5 (22.7%) had AIS or vasculopathy recurrence, of which 4 recurred 6.1 months to 2.8 years after initial clinical onset. Recurrence was associated with lack of antiviral treatment during the first episode (p = 0.02). CONCLUSIONS Post-varicella AIS can occur months after rash making diagnosis challenging. Because recurrent vasculopathy was seen predominantly in cases not treated with antiviral therapy during initial presentation, it is important to rapidly diagnose post-varicella AIS through clinical criteria and/or virological testing then treat with antivirals to prevent recurrence.
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Affiliation(s)
- Marta Bertamino
- Physical Medicine and Rehabilitation Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Sara Signa
- DINOGMI, University of Genoa, Genoa, Italy. .,Center for Autoinflammatory Diseases and Immunodeficiencies, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
| | | | - Giulia Prato
- Child Neuropsychiatry Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Roberta Caorsi
- Center for Autoinflammatory Diseases and Immunodeficiencies, IRCCS Istituto Giannina Gaslini, Genoa, Italy.,Rheumatology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Giuseppe Losurdo
- Infectious Diseases Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | | | - Silvia Esposito
- Developmental Neurology Unit, IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Francesca Formica
- Acquired Brain Injury Unit, Scientific Institute IRCCS E. Medea, Bosisio Parini, Italy
| | | | - Maria A Nagel
- Department of Neurology, University of Colorado, Boulder, USA
| | - Giulia Amico
- DINOGMI, University of Genoa, Genoa, Italy.,Laboratory of Genetic and Genomics, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Alice Zanetti
- Physical Medicine and Rehabilitation Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Domenico Tortora
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Andrea Rossi
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy.,DISSAL, University of Genoa, Genoa, Italy
| | - Paolo Moretti
- Physical Medicine and Rehabilitation Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Marco Gattorno
- Center for Autoinflammatory Diseases and Immunodeficiencies, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Angelo Ravelli
- Rheumatology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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8
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Baldovsky MD, Okada PJ. Pediatric stroke in the emergency department. J Am Coll Emerg Physicians Open 2020; 1:1578-1586. [PMID: 33392566 PMCID: PMC7771757 DOI: 10.1002/emp2.12275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 09/08/2020] [Accepted: 09/22/2020] [Indexed: 01/09/2023] Open
Abstract
Strokes are more commonly seen in adults but also occur in the pediatric population. Similar to adult strokes, pediatric strokes are considered medical emergencies and require prompt diagnosis and treatment to maximize favorable outcomes. Unfortunately, the diagnosis of stroke in children is often delayed, commonly because of parental delay or failure to consider stroke in the differential diagnosis. Children, especially young children, often present differently than adults. Much of the treatment for pediatric strokes has been adapted from adult guidelines but the optimal treatment has not been clearly defined. In this article, we review pediatric strokes and the most recent recommendations for treatment.
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Affiliation(s)
- Michael D. Baldovsky
- Division of Pediatric Emergency MedicineUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Pamela J. Okada
- Division of Pediatric Emergency MedicineUniversity of Texas Southwestern Medical CenterDallasTexasUSA
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9
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Khatami M. Deceptology in cancer and vaccine sciences: Seeds of immune destruction-mini electric shocks in mitochondria: Neuroplasticity-electrobiology of response profiles and increased induced diseases in four generations - A hypothesis. Clin Transl Med 2020; 10:e215. [PMID: 33377661 PMCID: PMC7749544 DOI: 10.1002/ctm2.215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/08/2020] [Accepted: 10/13/2020] [Indexed: 12/16/2022] Open
Abstract
From Rockefeller's support of patent medicine to Gates' patent vaccines, medical establishment invested a great deal in intellectual ignorance. Through the control over medical education and research it has created a public illusion to prop up corporate profit and encouraged the lust for money and power. An overview of data on cancer and vaccine sciences, the status of Americans' health, a survey of repeated failed projects, economic toxicity, and heavy drug consumption or addiction among young and old provide compelling evidence that in the twentieth century nearly all classic disease categories (congenital, inheritance, neonatal, or induced) shifted to increase induced diseases. Examples of this deceptology in ignoring or minimizing, and mocking fundamental discoveries and theories in cancer and vaccine sciences are attacks on research showing that (a), effective immunity is responsible for defending and killing pathogens and defective cancerous cells, correcting and repairing genetic mutations; (b) viruses cause cancer; and (c), abnormal gene mutations are often the consequences of (and secondary to) disturbances in effective immunity. The outcomes of cancer reductionist approaches to therapies reveal failure rates of 90% (+/-5) for solid tumors; loss of over 50 million lives and waste of $30-50 trillions on too many worthless, out-of-focus, and irresponsible projects. Current emphasis on vaccination of public with pathogen-specific vaccines and ingredients seems new terms for drugging young and old. Cumulative exposures to low level carcinogens and environmental hazards or high energy electronic devices (EMF; 5G) are additional triggers to vaccine toxicities (antigen-mitochondrial overload) or "seeds of immune destruction" that create mini electrical shocks (molecular sinks holes) in highly synchronized and regulated immune network that retard time-energy-dependent biorhythms in organs resulting in causes, exacerbations or consequences of mild, moderate or severe immune disorders. Four generations of drug-dependent Americans strongly suggest that medical establishment has practiced decades of intellectual deception through its claims on "war on cancer"; that cancer is 100, 200, or 1000 diseases; identification of "individual" genetic mutations to cure diseases; "vaccines are safe". Such immoral and unethical practices, along with intellectual harassment and bullying, censoring or silencing of independent and competent professionals ("Intellectual Me Too") present grave concerns, far greater compared with the sexual harassment of 'Me Too' movement that was recently spearheaded by NIH. The principal driving forces behind conducting deceptive and illogical medical/cancer and vaccine projects seem to be; (a) huge return of investment and corporate profit for selling drugs and vaccines; (b) maintenance of abusive power over public health; (c) global control of population growth via increased induction of diseases, infertility, decline in life-span, and death. An overview of accidental discoveries that we established and extended since 1980s, on models of acute and chronic ocular inflammatory diseases, provides series of the first evidence for a direct link between inflammation and multistep immune dysfunction in tumorigenesis and angiogenesis. Results are relevant to demonstrate that current emphasis on vaccinating the unborn, newborn, or infant would induce immediate or long-term immune disorders (eg, low birth weight, preterm birth, fatigue, autism, epilepsy/seizures, BBB leakage, autoimmune, neurodegenerative or digestive diseases, obesity, diabetes, cardiovascular problems, or cancers). Vaccination of the unborn is likely to disturb trophoblast-embryo-fetus-placenta biology and orderly growth of embryo-fetus, alter epithelial-mesenchymal transition or constituent-inducible receptors, damage mitochondria, and diverse function of histamine-histidine pathways. Significant increased in childhood illnesses are likely due to toxicities of vaccine and incipient (eg, metals [Al, Hg], detergents, fetal tissue, DNA/RNA) that retard bioenergetics of mitochondria, alter polarization-depolarization balance of tumoricidal (Yin) and tumorigenic (Yang) properties of immunity. Captivated by complex electobiology of immunity, this multidisciplinary perspective is an attempt to initiate identifying bases for increased induction of immune disorders in three to four generations in America. We hypothesize that (a) gene-environment-immune biorhythms parallel neuronal function (brain neuroplasticity) with super-packages of inducible (adaptive or horizontal) electronic signals and (b) autonomic sympathetic and parasympathetic circuitry that shape immunity (Yin-Yang) cannot be explained by limited genomics (innate, perpendicular) that conventionally explain certain inherited diseases (eg, sickle cell anemia, progeria). Future studies should focus on deep learning of complex electrobiology of immunity that requires differential bioenergetics from mitochondria and cytoplasm. Approaches to limit or control excessive activation of gene-environment-immunity are keys to assess accurate disease risk formulations, prevent inducible diseases, and develop universal safe vaccines that promote health, the most basic human right.
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Affiliation(s)
- Mahin Khatami
- Inflammation, Aging and Cancer, National Cancer Institute (NCI)the National Institutes of Health (NIH) (Retired)BethesdaMarylandUSA
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10
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Dedman D, Cabecinha M, Williams R, Evans SJW, Bhaskaran K, Douglas IJ. Approaches for combining primary care electronic health record data from multiple sources: a systematic review of observational studies. BMJ Open 2020; 10:e037405. [PMID: 33055114 PMCID: PMC7559041 DOI: 10.1136/bmjopen-2020-037405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To identify observational studies which used data from more than one primary care electronic health record (EHR) database, and summarise key characteristics including: objective and rationale for using multiple data sources; methods used to manage, analyse and (where applicable) combine data; and approaches used to assess and report heterogeneity between data sources. DESIGN A systematic review of published studies. DATA SOURCES Pubmed and Embase databases were searched using list of named primary care EHR databases; supplementary hand searches of reference list of studies were retained after initial screening. STUDY SELECTION Observational studies published between January 2000 and May 2018 were selected, which included at least two different primary care EHR databases. RESULTS 6054 studies were identified from database and hand searches, and 109 were included in the final review, the majority published between 2014 and 2018. Included studies used 38 different primary care EHR data sources. Forty-seven studies (44%) were descriptive or methodological. Of 62 analytical studies, 22 (36%) presented separate results from each database, with no attempt to combine them; 29 (48%) combined individual patient data in a one-stage meta-analysis and 21 (34%) combined estimates from each database using two-stage meta-analysis. Discussion and exploration of heterogeneity was inconsistent across studies. CONCLUSIONS Comparing patterns and trends in different populations, or in different primary care EHR databases from the same populations, is important and a common objective for multi-database studies. When combining results from several databases using meta-analysis, provision of separate results from each database is helpful for interpretation. We found that these were often missing, particularly for studies using one-stage approaches, which also often lacked details of any statistical adjustment for heterogeneity and/or clustering. For two-stage meta-analysis, a clear rationale should be provided for choice of fixed effect and/or random effects or other models.
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Affiliation(s)
- Daniel Dedman
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Melissa Cabecinha
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Rachael Williams
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Stephen J W Evans
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Krishnan Bhaskaran
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Ian J Douglas
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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11
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Elevated serum substance P during simian varicella virus infection in rhesus macaques: implications for chronic inflammation and adverse cerebrovascular events. J Neurovirol 2020; 26:945-951. [PMID: 32964407 DOI: 10.1007/s13365-020-00907-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/24/2020] [Accepted: 08/28/2020] [Indexed: 01/16/2023]
Abstract
Varicella and zoster, produced by varicella-zoster virus (VZV), are associated with an increased risk of stroke that may be due to persistent inflammation and hypercoagulability. Because substance P is associated with inflammation, hypercoagulability, and atherosclerotic plaque rupture that may contribute to increased stroke risk after VZV infection, we measured serum substance P in simian varicella virus-infected rhesus macaques. We found significantly increased and persistent serum substance P concentrations during varicella and zoster compared with pre-inoculation, supporting the hypothesis that VZV-induced increases in serum substance P may contribute to increased stroke risk associated with VZV infection.
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12
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Elkind MSV, Boehme AK, Smith CJ, Meisel A, Buckwalter MS. Infection as a Stroke Risk Factor and Determinant of Outcome After Stroke. Stroke 2020; 51:3156-3168. [PMID: 32897811 DOI: 10.1161/strokeaha.120.030429] [Citation(s) in RCA: 130] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Understanding the relationship between infection and stroke has taken on new urgency in the era of the coronavirus disease 2019 (COVID-19) pandemic. This association is not a new concept, as several infections have long been recognized to contribute to stroke risk. The association of infection and stroke is also bidirectional. Although infection can lead to stroke, stroke also induces immune suppression which increases risk of infection. Apart from their short-term effects, emerging evidence suggests that poststroke immune changes may also adversely affect long-term cognitive outcomes in patients with stroke, increasing the risk of poststroke neurodegeneration and dementia. Infections at the time of stroke may also increase immune dysregulation after the stroke, further exacerbating the risk of cognitive decline. This review will cover the role of acute infections, including respiratory infections such as COVID-19, as a trigger for stroke; the role of infectious burden, or the cumulative number of infections throughout life, as a contributor to long-term risk of atherosclerotic disease and stroke; immune dysregulation after stroke and its effect on the risk of stroke-associated infection; and the impact of infection at the time of a stroke on the immune reaction to brain injury and subsequent long-term cognitive and functional outcomes. Finally, we will present a model to conceptualize the many relationships among chronic and acute infections and their short- and long-term neurological consequences. This model will suggest several directions for future research.
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Affiliation(s)
- Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY. (M.S.V.E., A.K.B.).,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY. (M.S.V.E., A.K.B.)
| | - Amelia K Boehme
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY. (M.S.V.E., A.K.B.).,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY. (M.S.V.E., A.K.B.)
| | - Craig J Smith
- Division of Cardiovascular Sciences, Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester Centre for Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, United Kingdom (C.J.S.)
| | - Andreas Meisel
- Center for Stroke Research Berlin, Department for Experimental Neurology, Department of Neurology, NeuroCure Clinical Research Center, Charité Universitätsmedizin Berlin, Germany (A.M.)
| | - Marion S Buckwalter
- Department of Neurology and Neurological Sciences, Stanford University Medical Center, CA (M.S.B.)
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13
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Willame C, Cheuvart B, Aris E, Vetter V, Cohet C. Association between rotavirus gastroenteritis and intussusception: suggested evidence from a retrospective study in claims databases in the United States. Hum Vaccin Immunother 2020; 17:269-277. [PMID: 32609045 PMCID: PMC7872044 DOI: 10.1080/21645515.2020.1770514] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
The etiology of intussusception (IS), a serious gastrointestinal obstruction, remains unclear. Limited evidence suggests a role for viral infection. We investigated the risk of IS after rotavirus gastroenteritis (RV GE) in the first year of life. In this retrospective, self-controlled case series (SCCS), we assessed the risk of IS after RV GE using data from United States administrative claims databases. Incidence rate ratios (IRR) of IS were calculated for the 7- and 21-day risk periods after RV GE (main analysis) or after fracture (sensitivity analysis). A total of 290,912,068 subjects were screened; 42 presented claims for RV GE and IS, and 66 for fracture and IS. The IRRs of IS after RV GE were 79.6 (95% confidence interval, CI: 38.6-164.4) and 25.5 (95% CI: 13.2-49.2) in the 7- and 21-day risk periods. The sensitivity analysis showed an association between IS and fracture for both periods, suggesting potential confounding. Post-hoc analyses did not confirm the association between fracture and IS but suggested a potential association between RV GE and IS. A temporal association between RV GE and IS was detected using claims databases. Due to some limitations of the data sources, this association should be further investigated.
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14
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Myocardial Infarction and Ischemic Stroke after Exacerbations of Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2019; 15:935-946. [PMID: 29723057 DOI: 10.1513/annalsats.201710-815oc] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Previous studies have suggested that acute exacerbations of chronic obstructive pulmonary disease (COPD) may be associated with increased risk of myocardial infarction and ischemic stroke. OBJECTIVES We aimed to quantify the increased risks of myocardial infarction and ischemic stroke risk associated with both moderate and severe acute exacerbation, and to investigate factors that may modify these risks. METHODS We performed a self-controlled case series to investigate the rates of myocardial infarction and ischemic stroke after acute exacerbation compared with stable time, within individuals. The participants were 5,696 adults with COPD with a first myocardial infarction (n = 2,850) or ischemic stroke (n = 3,010) and at least one acute exacerbation from the UK Clinical Practice Research Datalink with linked Hospital Episodes Statistics data. RESULTS The risks of both myocardial infarction and ischemic stroke were increased in the 91 days after an acute exacerbation. The risks were greater after a severe exacerbation (incidence rate ratio [IRR], 2.58; 95% confidence interval [CI], 2.26-2.95 for myocardial infarction; and IRR, 1.97; 95% CI, 1.66-2.33 for ischemic stroke) than after a moderate exacerbation (IRR, 1.58; 95% CI, 1.46-1.71 for myocardial infarction; and IRR, 1.45; 95% CI, 1.33-1.57 for ischemic stroke). The relative risks of myocardial infarction and ischemic stroke associated with acute exacerbation were lower among those with more frequent exacerbations (IRR, 1.42; 95% CI, 1.24-1.62 vs. IRR, 1.69; 95% CI, 1.50-1.91 for myocardial infarction; and IRR, 1.30; 95% CI, 1.15-1.48 vs. IRR, 1.68; 95% CI, 1.50-1.89 for ischemic stroke). Higher GOLD stage was associated with a lower rate of myocardial infarction (IRR, 1.98; 95% CI, 1.61-2.05 vs. IRR, 1.69; 95% CI, 1.45-1.98) but not for ischemic stroke. Aspirin use at baseline was associated with a lower risk of ischemic stroke (IRR, 1.28; 95% CI, 1.10-1.50 vs. IRR, 1.63; 95% CI, 1.47-1.80) but not with myocardial infarction. CONCLUSIONS Acute exacerbations of COPD are associated with an increased risk of myocardial infarction and ischemic stroke within 28 days of their onset. Several patient characteristics were identified that are associated with these events.
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15
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Guedes M, Filipe R, Costa A, Soares C, Sarmento A, Tavares M. Central nervous system varicella zoster vasculopathy in an immunocompromised patient. IDCases 2018; 15:e00483. [PMID: 30701156 PMCID: PMC6348231 DOI: 10.1016/j.idcr.2018.e00483] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 12/26/2018] [Accepted: 12/26/2018] [Indexed: 12/26/2022] Open
Abstract
Central nervous system (CNS) vasculopathy associated with Varicella Zoster Virus (VZV) infection, usually manifesting as stroke due to ischemic lesions by involvement of small arteries, is frequently misdiagnosed. Immunocompromised patients have a particularly higher risk of severe disease and also CNS involvement during or following VZV presentations. We report a case of an 84-year-old man, with myelodysplastic syndrome, who presented with herpes zoster ophthalmicus complicated with left periocular cellulitis and an abnormal neurological exam. Intravenous treatment with acyclovir and amoxicillin/clavulanic acid was began. VZV DNA was detected in the cerebrospinal fluid (CSF) and brain magnetic resonance imaging revealed three acute ischemic lesions in the left frontal and both cerebellar lobes. A VZV CNS multifocal vasculopathy was diagnosed and treatment with intravenous acyclovir continued for 21 days. Immunocompromised patients with VZV infection can have a more severe course of disease with disseminated involvement and multifocal vasculopathy. In these patients the CSF detection of anti-VZV IgG as well as VZV DNA can be helpful in the diagnosis of CNS VZV vasculopathy. The antiviral treatment can improve the outcome and should be adjusted taking in consideration the degree of immunosuppression. This clinical case and review of the literature highlights the challenges in the diagnosis and management of VZV CNS vasculopathy in immunocompromised patients.
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Affiliation(s)
- Mariana Guedes
- Infectious Diseases Department, Centro Hospitalar Universitário São João, Oporto, Portugal
| | - Rita Filipe
- Infectious Diseases Department, Centro Hospitalar Universitário São João, Oporto, Portugal
| | - Andreia Costa
- Neurology Department, Centro Hospitalar Universitário São João, Oporto, Portugal
| | - Carolina Soares
- Neurology Department, Centro Hospitalar Universitário São João, Oporto, Portugal
| | - António Sarmento
- Infectious Diseases Department, Centro Hospitalar Universitário São João, Oporto, Portugal.,Nephrology and Infectious Diseases R&D Group - Health Investigation and Innovation 17 Institutive (I3S), University of Oporto, Oporto, Portugal.,Oporto Medical School, University of Oporto, Oporto, Portugal
| | - Margarida Tavares
- Infectious Diseases Department, Centro Hospitalar Universitário São João, Oporto, Portugal.,EPI Unit - Instituto de Saúde Pública, University of Oporto, Oporto, Portugal
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16
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Forbes HJ, Williamson E, Benjamin L, Breuer J, Brown MM, Langan SM, Minassian C, Smeeth L, Thomas SL, Warren-Gash C. Association of herpesviruses and stroke: Systematic review and meta-analysis. PLoS One 2018; 13:e0206163. [PMID: 30462656 PMCID: PMC6248930 DOI: 10.1371/journal.pone.0206163] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 10/08/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Herpesviruses induce a range of inflammatory effects potentially contributing to an increased risk of stroke. OBJECTIVES To investigate whether patients with infection, or reactivation of, human herpesviruses are at increased stroke risk, compared to those without human herpesviruses. DATA SOURCES Six medical databases and grey literature sources from inception to January 2017. STUDY ELIGIBILITY CRITERIA Studies where the exposure was any human herpesvirus and the outcome was stroke. We included randomised controlled trials, cohort, case-control, case-crossover and self-controlled case series designs. METHODS Meta-analyses when sufficiently homogeneous studies were available. Quality of evidence across studies was assessed. RESULTS We identified 5012 publications; 41 met the eligibility criteria. Across cohort and self-controlled case series studies, there was moderate quality evidence that varicella infection in children was associated with a short-term increased stroke risk. Zoster was associated with a 1.5-fold increased stroke risk four weeks following onset (summary estimate: 1.55, 95%CI 1.46-1.65), which resolved after one year. Subgroup analyses suggested post-zoster stroke risk was greater among ophthalmic zoster patients, younger individuals and those not prescribed antivirals. Recent infection/reactivation of cytomegalovirus and herpes simplex viruses, but not past infection, was associated with increased stroke risk; however the evidence across studies was mainly derived from small, very low quality case-control studies. CONCLUSIONS Our review shows an increased stroke risk following zoster and suggests that recent infection or reactivation of other herpesviruses increases stroke risk, although better evidence is needed. Herpesviruses are common and potentially preventable; these findings may have implications for reducing stroke burden.
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Affiliation(s)
- Harriet J. Forbes
- Faculty of Epidemiology & Population Health, LSHTM, London, United Kingdom
| | | | - Laura Benjamin
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, UCL, London, United Kingdom
| | - Judith Breuer
- UCL Division of Infection & Immunity, UCL, London, United Kingdom
| | - Martin M. Brown
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, UCL, London, United Kingdom
| | - Sinéad M. Langan
- Faculty of Epidemiology & Population Health, LSHTM, London, United Kingdom
| | - Caroline Minassian
- Faculty of Epidemiology & Population Health, LSHTM, London, United Kingdom
| | - Liam Smeeth
- Faculty of Epidemiology & Population Health, LSHTM, London, United Kingdom
| | - Sara L. Thomas
- Faculty of Epidemiology & Population Health, LSHTM, London, United Kingdom
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17
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Herpes zoster in the context of varicella vaccination – An equation with several variables. Vaccine 2018; 36:7072-7082. [DOI: 10.1016/j.vaccine.2018.09.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 09/07/2018] [Accepted: 09/10/2018] [Indexed: 12/12/2022]
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18
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Vora SB, Amlie-Lefond C, Perez FA, Melvin AJ. Varicella-Associated Stroke. J Pediatr 2018; 199:281-281.e1. [PMID: 29681448 DOI: 10.1016/j.jpeds.2018.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 03/01/2018] [Indexed: 11/30/2022]
Affiliation(s)
| | | | | | - Ann J Melvin
- Department of Pediatrics Division of Infectious Disease Seattle Children's Hospital University of Washington Seattle, Washington
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19
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MacDonald SE, Dover DC, Hill MD, Kirton A, Simmonds KA, Svenson LW. Is varicella vaccination associated with pediatric arterial ischemic stroke? A population-based cohort study. Vaccine 2018; 36:2764-2767. [DOI: 10.1016/j.vaccine.2018.04.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 04/03/2018] [Accepted: 04/04/2018] [Indexed: 11/17/2022]
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20
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Helmuth IG, Mølbak K, Uldall PV, Poulsen A. Post-varicella Arterial Ischemic Stroke in Denmark 2010 to 2016. Pediatr Neurol 2018; 80:42-50. [PMID: 29307566 DOI: 10.1016/j.pediatrneurol.2017.11.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 10/17/2017] [Accepted: 11/27/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Varicella, most often a benign disease of childhood, is associated with an increased risk of arterial ischemic stroke in children. The aim of the present study was to estimate the incidence of post-varicella arterial ischemic stroke in the Danish child population and describe clinical characteristics of children admitted with post-varicella arterial ischemic stroke. METHODS In the Danish National Patient Register, we identified inpatients 28 days to 16 years of age with a discharge diagnosis of stroke or cerebrovascular disease from 2010 to 2016. Medical files were reviewed, and children with arterial ischemic stroke and varicella infection less than 12 months before onset of symptoms were included. RESULTS We identified 15 children with arterial ischemic stroke and varicella less than 12 months before. In nine children, the diagnosis was confirmed by detection of varicella zoster virus DNA or varicella zoster virus immunoglobulin G in the cerebrospinal fluid. All children were previously healthy, the mean age was four years, and 67% were male. The median time from varicella rash to arterial ischemic stroke was 4.6 months. The most common location of arterial ischemic stroke was the basal ganglia, and affected vessels were most often in the anterior circulation. Fifty-three percent experienced neurological sequelae of varying degree. CONCLUSIONS In Denmark, where varicella vaccination is not part of the childhood vaccination program, the estimated risk of post-varicella arterial ischemic stroke was one case (including possible cases) per 26,000 children with varicella.
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Affiliation(s)
- Ida Glode Helmuth
- Department of Paediatric and Adolescent Medicine, Rigshospitalet, Copenhagen Ø, Denmark; Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen S, Denmark.
| | - Kåre Mølbak
- Division of Infectious Disease Preparedness, Statens Serum Institut, Copenhagen S, Denmark
| | - Peter Vilhelm Uldall
- Department of Paediatric and Adolescent Medicine, Rigshospitalet, Copenhagen Ø, Denmark
| | - Anja Poulsen
- Department of Paediatric and Adolescent Medicine, Rigshospitalet, Copenhagen Ø, Denmark
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21
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Medina MT, Medina-Montoya M. New spectrum of the neurologic consequences of Zika. J Neurol Sci 2017; 383:214-215. [DOI: 10.1016/j.jns.2017.10.046] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 10/26/2017] [Indexed: 02/02/2023]
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22
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Dalton HR, van Eijk JJJ, Cintas P, Madden RG, Jones C, Webb GW, Norton B, Pique J, Lutgens S, Devooght-Johnson N, Woolson K, Baker J, Saunders M, Househam L, Griffiths J, Abravanel F, Izopet J, Kamar N, van Alfen N, van Engelen BGM, Hunter JG, van der Eijk AA, Bendall RP, Mclean BN, Jacobs BC. Hepatitis E virus infection and acute non-traumatic neurological injury: A prospective multicentre study. J Hepatol 2017; 67:925-932. [PMID: 28734938 DOI: 10.1016/j.jhep.2017.07.010] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 06/22/2017] [Accepted: 07/10/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Hepatitis E virus (HEV) has been associated with a number of neurological syndromes, but causality has not yet been established. The aim of this study was to explore the relationship between HEV and neurological illness by prospective HEV testing of patients presenting with acute non-traumatic neurological injury. METHODS Four hundred and sixty-four consecutive patients presenting to hospital with acute non-traumatic neurological illnesses were tested for HEV by serology and PCR from four centres in the UK, France and the Netherlands. RESULTS Eleven of 464 patients (2.4%) had evidence of current/recent HEV infection. Seven had HEV RNA identified in serum and four were diagnosed serologically. Neurological cases in which HEV infection was found included neuralgic amyotrophy (n=3, all PCR positive); cerebral ischemia or infarction (n=4); seizure (n=2); encephalitis (n=1); and an acute combined facial and vestibular neuropathy (n=1). None of these cases were clinically jaundiced and median ALT at presentation was 24IU/L (range 8-145). Cases of HEV-associated neuralgic amyotrophy were found in each of the participating countries: all were middle-aged males with bilateral involvement of the brachial plexus. CONCLUSIONS In this cohort of patients with non-traumatic neurological injury, 2.4% had evidence of HEV infection. Symptoms of hepatitis were mild or absent and no patients were jaundiced. The cases of HEV-associated neuralgic amyotrophy had similarities with other HEV-associated cases described in a large retrospective study. This observation supports a causal relationship between HEV and neuralgic amyotrophy. To further understand the relevance of HEV infection in patients with acute neurological illnesses, case-control studies are warranted. Lay summary: Hepatitis E virus (HEV), as its name suggests, is a hepatotropic virus, i.e. it causes damage to the liver (hepatitis). Our findings show that HEV can also be associated with a range of injury to the nervous system.
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Affiliation(s)
- Harry R Dalton
- Royal Cornwall Hospital, University of Exeter, Truro, UK; European Centre for Environment and Human Health, University of Exeter, Truro, UK.
| | | | - Pascal Cintas
- Department of Neurology, Pierre Paul Riquet Hospital, CHU Purpan, Toulouse, France
| | | | | | - Glynn W Webb
- European Centre for Environment and Human Health, University of Exeter, Truro, UK
| | - Benjamin Norton
- European Centre for Environment and Human Health, University of Exeter, Truro, UK
| | - Julie Pique
- Department of Neurology, Pierre Paul Riquet Hospital, CHU Purpan, Toulouse, France
| | | | | | - Kathy Woolson
- Royal Cornwall Hospital, University of Exeter, Truro, UK
| | | | | | | | | | - Florence Abravanel
- INSERM, UMR1043, Toulouse F-31300, France; Department of Virology, National Reference Center for hepatitis E virus, CHU Purpan, Toulouse F-31300, France; Université Paul Sabatier, Toulouse, France
| | - Jacques Izopet
- INSERM, UMR1043, Toulouse F-31300, France; Department of Virology, National Reference Center for hepatitis E virus, CHU Purpan, Toulouse F-31300, France; Université Paul Sabatier, Toulouse, France
| | - Nassim Kamar
- Departments of Nephrology and Organ Transplantation, CHU Rangueil, INSERM U1043, IFR-BMT, Université Paul Sabatier, Toulouse, France
| | - Nens van Alfen
- Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | | | | | | | - Richard P Bendall
- Royal Cornwall Hospital, University of Exeter, Truro, UK; European Centre for Environment and Human Health, University of Exeter, Truro, UK
| | | | - Bart C Jacobs
- Department of Neurology and Immunology, Erasmus MC, University Medical Centre Rotterdam, The Netherlands
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23
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Steinlin M, Bigi S, Stojanovski B, Gajera J, Regényi M, El-Koussy M, Mackay MT. Focal Cerebral Arteriopathy. Stroke 2017; 48:2375-2382. [DOI: 10.1161/strokeaha.117.016818] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 05/20/2017] [Accepted: 06/21/2017] [Indexed: 12/19/2022]
Affiliation(s)
- Maja Steinlin
- From the Division of Child Neurology, Department of Pediatrics, University Children’s Hospital Bern, University of Bern, Switzerland (M.S., S.B., M.R.); Department of Neurology, Royal Children’s Hospital Melbourne, Murdoch Children’s Research Institute Melbourne, Parkville, Victoria, Australia (B.S., J.G., M.T.M.); Department of Neuroradiology, University Hospital and University of Bern, Switzerland (M.E.-K.); and the Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Sandra Bigi
- From the Division of Child Neurology, Department of Pediatrics, University Children’s Hospital Bern, University of Bern, Switzerland (M.S., S.B., M.R.); Department of Neurology, Royal Children’s Hospital Melbourne, Murdoch Children’s Research Institute Melbourne, Parkville, Victoria, Australia (B.S., J.G., M.T.M.); Department of Neuroradiology, University Hospital and University of Bern, Switzerland (M.E.-K.); and the Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Belinda Stojanovski
- From the Division of Child Neurology, Department of Pediatrics, University Children’s Hospital Bern, University of Bern, Switzerland (M.S., S.B., M.R.); Department of Neurology, Royal Children’s Hospital Melbourne, Murdoch Children’s Research Institute Melbourne, Parkville, Victoria, Australia (B.S., J.G., M.T.M.); Department of Neuroradiology, University Hospital and University of Bern, Switzerland (M.E.-K.); and the Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Jay Gajera
- From the Division of Child Neurology, Department of Pediatrics, University Children’s Hospital Bern, University of Bern, Switzerland (M.S., S.B., M.R.); Department of Neurology, Royal Children’s Hospital Melbourne, Murdoch Children’s Research Institute Melbourne, Parkville, Victoria, Australia (B.S., J.G., M.T.M.); Department of Neuroradiology, University Hospital and University of Bern, Switzerland (M.E.-K.); and the Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Maria Regényi
- From the Division of Child Neurology, Department of Pediatrics, University Children’s Hospital Bern, University of Bern, Switzerland (M.S., S.B., M.R.); Department of Neurology, Royal Children’s Hospital Melbourne, Murdoch Children’s Research Institute Melbourne, Parkville, Victoria, Australia (B.S., J.G., M.T.M.); Department of Neuroradiology, University Hospital and University of Bern, Switzerland (M.E.-K.); and the Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Marwan El-Koussy
- From the Division of Child Neurology, Department of Pediatrics, University Children’s Hospital Bern, University of Bern, Switzerland (M.S., S.B., M.R.); Department of Neurology, Royal Children’s Hospital Melbourne, Murdoch Children’s Research Institute Melbourne, Parkville, Victoria, Australia (B.S., J.G., M.T.M.); Department of Neuroradiology, University Hospital and University of Bern, Switzerland (M.E.-K.); and the Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Mark T. Mackay
- From the Division of Child Neurology, Department of Pediatrics, University Children’s Hospital Bern, University of Bern, Switzerland (M.S., S.B., M.R.); Department of Neurology, Royal Children’s Hospital Melbourne, Murdoch Children’s Research Institute Melbourne, Parkville, Victoria, Australia (B.S., J.G., M.T.M.); Department of Neuroradiology, University Hospital and University of Bern, Switzerland (M.E.-K.); and the Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
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24
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Forbes HJ, Benjamin L, Breuer J, Brown MM, Langan SM, Minassian C, Smeeth L, Thomas SL, Warren-Gash C. The association between human herpesvirus infections and stroke: a systematic review protocol. BMJ Open 2017; 7:e016427. [PMID: 28554940 PMCID: PMC5726106 DOI: 10.1136/bmjopen-2017-016427] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION After primary infection, human herpesviruses establish latency and persist lifelong. Periodic virus reactivation can lead to serious inflammatory complications. Recent research suggests that herpesvirus reactivation may also be linked to acute stroke. An improved understanding of this relationship is vital to inform public health prevention strategies. We will review the evidence regarding the role of human herpesviruses in triggering stroke. METHODS AND ANALYSIS A systematic literature review of published and grey literature studies with a human herpesvirus (infection or reactivation) as an exposure and stroke as an outcome will be carried out. Randomised controlled trials, cohort, case-control, case crossover and self-controlled case series designs will be eligible; no restrictions will be placed on publication status, language and geographical or healthcare setting. The Cochrane Central Register of Controlled Trials, Embase, Global Health, Medline, Scopus and Web of Science will be searched from dates of inception to January 2017. A prespecified search strategy of medical subject headings and free text terms (in the title and abstract) for human herpesviruses AND stroke will be used. Two reviewers will independently screen titles and abstracts for eligible studies, followed by full-text screening. The reviewers will then extract data from the eligible studies using standardised, pilot-tested tables and assess risk of bias in individual studies, in line with the Cochrane Collaboration approach. The data will be synthesised in a narrative format, and meta-analyses considered where there are sufficient data. Quality of evidence will be assessed in line with theGrading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. ETHICS AND DISSEMINATION As this is a systematic review, ethical approval is not required. The results will be submitted for peer-review publication and presented at national conferences. A lay and short summary will be disseminated on appropriate webpages. PROSPERO REGISTRATION NUMBER CRD42017054502.
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Affiliation(s)
- Harriet J Forbes
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Laura Benjamin
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Institute of Neurology, University College London, London, UK
| | - Judy Breuer
- UCL Division of Infection & Immunity, UCL, London, UK
| | - Martin M Brown
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Institute of Neurology, University College London, London, UK
| | - Sinéad M Langan
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Caroline Minassian
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Liam Smeeth
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Sara L Thomas
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Charlotte Warren-Gash
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Leung J, Harpaz R. Impact of the Maturing Varicella Vaccination Program on Varicella and Related Outcomes in the United States: 1994-2012. J Pediatric Infect Dis Soc 2016; 5:395-402. [PMID: 26407276 PMCID: PMC4752432 DOI: 10.1093/jpids/piv044] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 06/30/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Although the 1-dose varicella vaccination program, introduced in 1996, has led to significant declines in varicella disease, outbreaks continued to occur, which led to the adoption of a 2-dose vaccination program in 2007. We previously reported an 88% decline in varicella-related hospitalizations and a 59% decline in outpatient visits during 1994-2002. We now update data on varicella healthcare utilization with 10 years of additional data, during a period of stabilizing first-dose coverage and rapidly increasing second-dose coverage. METHODS We performed a retrospective cohort study using claims data from 1994-2012 Truven Health MarketScan databases. We examined trends in rates of varicella-related outpatient visits and hospitalizations for MarketScan enrollees aged 0-49 years, including outpatient laboratory testing, outpatient antiviral use, and pediatric strokes, with 1994-1995 as the prevaccination period and 2006-2012 as the 2-dose varicella vaccination period. RESULTS Varicella outpatient visits declined 84% in 2012 versus the prevaccination period, with a 60% decline during the 2-dose period. Varicella hospitalizations declined 93% in 2012 versus the prevaccination period, with a 38% decline during the 2-dose period. The proportion of those with a varicella outpatient visit having varicella laboratory testing increased from 6% in 2003 to 17% in 2012. There were 21 445 (17%) with a claim for antivirals, which was relatively stable over time. There was no reduction in pediatric strokes during 1994-2012. CONCLUSIONS We document from our large study population that the varicella vaccination program has led to significant declines in outpatient visits and hospitalizations from the prevaccination period through 2012, with additional declines during the 2-dose varicella vaccination period.
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Affiliation(s)
- Jessica Leung
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA,Corresponding author: Jessica Leung, MPH, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, MS A-34, Atlanta, GA 30333, Tel: 404-639-6067, Fax: 404-315-2486,
| | - Rafael Harpaz
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Widgren K, Giesecke J, Lindquist L, Tegnell A. The burden of chickenpox disease in Sweden. BMC Infect Dis 2016; 16:666. [PMID: 27832745 PMCID: PMC5103480 DOI: 10.1186/s12879-016-1957-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Accepted: 10/25/2016] [Indexed: 02/07/2023] Open
Abstract
Background Chickenpox vaccine is not included in the routine childhood vaccination programme in Sweden. The aim of this study was to estimate the baseline of national chickenpox disease burden, as comprehensive studies, required for an assessment regarding vaccine introduction, are lacking. Methods We used available health care registers and databases; the death register, hospitalisations register, communicable disease notifications database, Stockholm County registers on consultations in specialist and primary care, temporary parental benefit to care for a sick child, and searches on the health care system’s website. From each data source, records regarding chickenpox were identified and extracted, either using relevant diagnosis codes (ICD-10) or key words. A descriptive analysis with regards to number of cases and incidence, severity, and seasonality, was carried out covering the time period 2007 to 2013. Results There were on average 333 patients hospitalised annually due to chickenpox, yielding a hospitalisation rate of 3.56/100,000 person-years. We found a slight male predominance in hospitalised cases. The highest hospitalisation rate was seen in 1 year-olds, whereas the peak in primary care consultations was in 2 year-olds. Nearly a quarter of children had parents who reported absence from work to care for them when sick with chickenpox. The average yearly death rate from chickenpox was 0.034/100,000 person-years. The duration of hospital stay increased with age. The seasonality in number of searches on the health care website corresponded well with hospitalisations and primary care consultations with peaks in spring. Conclusions This study shows chickenpox death and hospitalisation rates in range with other European countries without routine vaccination. Swedish children fall ill with chickenpox at a very young age. The study provides essential input for future discussions on the introduction of routine chickenpox vaccination in Sweden.
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Affiliation(s)
- Katarina Widgren
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden. .,Department of Monitoring and Evaluation, The Public Health Agency of Sweden, Solna, Sweden. .,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden.
| | - Johan Giesecke
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Lars Lindquist
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Anders Tegnell
- Department of Monitoring and Evaluation, The Public Health Agency of Sweden, Solna, Sweden
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Yang SY, Li HX, Yi XH, Han GL, Zong Q, Wang MX, Peng XX. Risk of Stroke in Patients with Herpes Zoster: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2016; 26:301-307. [PMID: 27810150 DOI: 10.1016/j.jstrokecerebrovasdis.2016.09.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 09/13/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Several observational studies suggest that herpes zoster (HZ) may increase the risk of stroke, but the results are inconsistent. Our study was designed to assess the association between HZ and the risk of stroke through a meta-analysis of cohort studies. METHODS The electronic databases PubMed and EMBASE were searched from inception to May 31, 2016 to identify relevant cohort studies that assess the risk of stroke in patients with HZ. Reference lists were also reviewed to identify potential studies. The random-effects model and fixed-effects model were used to calculate the summary relative risks (RRs) with 95% confidence intervals (CIs). RESULTS Six cohort studies (251,076 HZ patients and 8462 cases of stroke) were identified in the study. The result showed that HZ was significantly correlated with increased risk of stroke, and the pooled RR was 1.36 (95% confidence interval [CI]: 1.10, 1.67) (P = .004). In the subgroup analysis, the significant association was observed except for stroke type (hemorrhage group). In the sensitivity analysis, excluding 1 study, the pooled RR was 1.45 (95% CI: 1.17, 1.80) (P = .001) for HZ, and 4.42 (95% CI: 2.75, 7.11) (P = .000) for herpes zoster ophthalmicus. Considerable heterogeneity was observed in our study. CONCLUSION Our study furnishes evidence of a positive association between HZ and the risk of stroke.
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Affiliation(s)
- Sheng-Ye Yang
- Department of Dermatology, Shengli Oilfield Central Hospital, 31 Jinan Road, Dongying, Shandong 257000, China
| | - Hong-Xing Li
- Department of Neurosurgery, Shengli Oilfield Central Hospital, 31 Jinan Road, Dongying, Shandong 257000, China
| | - Xin-Hao Yi
- Department of Central Laboratory, Shengli Oilfield Central Hospital, 31 Jinan Road, Dongying, Shandong 257000, China
| | - Guang-Liang Han
- Department of Neurosurgery, Shengli Oilfield Central Hospital, 31 Jinan Road, Dongying, Shandong 257000, China
| | - Qiang Zong
- Department of Neurosurgery, Shengli Oilfield Central Hospital, 31 Jinan Road, Dongying, Shandong 257000, China
| | - Ming-Xing Wang
- Department of Neurosurgery, Shengli Oilfield Central Hospital, 31 Jinan Road, Dongying, Shandong 257000, China
| | - Xiao-Xiao Peng
- Department of Intensive Care Unit (ICU), Shengli Oilfield Central Hospital, 31 Jinan Road, Dongying, Shandong 257000, China.
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28
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Amlie-Lefond C, Gilden D. Varicella Zoster Virus: A Common Cause of Stroke in Children and Adults. J Stroke Cerebrovasc Dis 2016; 25:1561-1569. [PMID: 27138380 DOI: 10.1016/j.jstrokecerebrovasdis.2016.03.052] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 03/27/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Varicella zoster virus (VZV) is a neurotropic, exclusively human herpesvirus. Primary infection causes varicella (chickenpox), after which the virus becomes latent in ganglionic neurons along the entire neuraxis. As cell-mediated immunity to VZV declines with advancing age and immunosuppression, VZV reactivates to produce zoster (shingles). One of the most serious complications of zoster is VZV vasculopathy. METHODS We reviewed recent studies of stroke associated with varicella and zoster, how VZV vasculopathy is verified virologically, vaccination to prevent varicella and immunization to prevent zoster, and VZV in giant cell arteritis (GCA). FINDINGS We report recent epidemiological studies revealing an increased risk of stroke after zoster; the clinical, laboratory, and imaging features of VZV vasculopathy; that VZV vasculopathy is confirmed by the presence of either VZV DNA or anti-VZV IgG antibody in cerebrospinal fluid; special features of VZV vasculopathy in children; vaccination to prevent varicella and immunization to prevent zoster; and the latest evidence linking VZV to GCA. CONCLUSION In children and adults, VZV is a common cause of stroke.
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Affiliation(s)
- Catherine Amlie-Lefond
- Department of Neurology, Seattle Children's Hospital, University of Washington, Seattle, Washington.
| | - Don Gilden
- Departments of Neurology and Immunology and Microbiology, University of Colorado School of Medicine, Aurora, Colorado
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Buerki SE, Grandgirard D, Datta AN, Hackenberg A, Martin F, Schmitt-Mechelke T, Leib SL, Steinlin M. Inflammatory markers in pediatric stroke: An attempt to better understanding the pathophysiology. Eur J Paediatr Neurol 2016; 20:252-260. [PMID: 26778232 DOI: 10.1016/j.ejpn.2015.12.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 11/11/2015] [Accepted: 12/06/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND The mechanisms of childhood and perinatal arterial ischemic stroke (AIS) are poorly understood. Multiple risk factors include cerebral arteriopathy, congenital cardiac disease, infection, sickle cell disease, and maternal-fetal conditions in neonates. For infections and parainfectious conditions being the most important a possible inflammatory pathophysiology has long been suspected. This pilot study aims to detect, whether there are any abnormalities of inflammatory markers associated with childhood and neonatal stroke. METHODS The concentration of 23 different metalloproteinases (MMPs), tissue inhibitors of MMPs (TIMPs), endothelial factors, vascular cell adhesion proteins, and cytokines in plasma were measured in 12 children with AIS, 7 healthy age matched controls and 6 full term neonates with perinatal AIS. RESULTS At the time of the acute event children with AIS had significantly elevated levels of MMP-9, TIMP4, IL-6, IL-8 and CRP compared to controls (p < 0.05). Except for lower IL-6 and CRP levels the pattern of children with a history of varizella-zoster virus (VZV) and other viral infections did not differ to the non-infectious group. Median levels of MMP-1, MMP-2, TIMP-1, TIMP-2, sE-selectin, sICAM-1, sVCAM-1, IL-8, IL-10, TNF-alpha, VEGF, Fetuin A were found to be higher in the neonatal group when compared with older children. CONCLUSION This pilot study supports the assumption of an inflammatory process and up-regulation of metalloproteinases and their inhibitors, and altered pattern of circulating pro-inflammatory cytokines, CRP and vWF levels in pediatric and neonatal AIS. It highlights the feasibility but also difficulties for similar larger future studies that should aim to clarify childhood stroke etiopathogenesis and consecutive further therapeutic options.
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Affiliation(s)
- Sarah E Buerki
- Division of Neurology, Department of Pediatrics, Children's Hospital and University of British Columbia, Canada; Department of Neuropediatrics, Development and Rehabilitation, University Children's Hospital, Inselspital, Berne, Switzerland.
| | - Denis Grandgirard
- Institute for Infectious Diseases, University of Bern, Neuroinfectiology Laboratory, Institute for Infectious Diseases, Postfach 8571, CH-3001 Bern, Switzerland
| | - Alexandre N Datta
- University Children's Hospital Basel, Universitäts-Kinderspital beider Basel, Spitalstrasse 33, CH-4056 Basel, Switzerland
| | - Annette Hackenberg
- University Children's Hospital Zürich, Kinderspital Zürich, University Children's Hospital Zürich, Steinwiesstrasse 75, CH-8032 Zürich, Switzerland
| | - Florence Martin
- Children's Hospital Winterthur, Kantonsspital Winterthur, Brauerstrasse 15, Postfach 834, CH-8401 Winterthur, Switzerland
| | - Thomas Schmitt-Mechelke
- Children's Hospital Lucerne, Luzerner Kantonsspital, Kinderspital Luzern, CH-6000 Luzern 16, Switzerland
| | - Stephen L Leib
- Institute for Infectious Diseases, University of Bern, Neuroinfectiology Laboratory, Institute for Infectious Diseases, Postfach 8571, CH-3001 Bern, Switzerland; Biology Division, Spiez Laboratory, Swiss Federal Office for Civil Protection, Spiez, Switzerland
| | - Maja Steinlin
- Department of Neuropediatrics, Development and Rehabilitation, University Children's Hospital, Inselspital, Berne, Switzerland
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Elkind MSV, Hills NK, Glaser CA, Lo WD, Amlie-Lefond C, Dlamini N, Kneen R, Hod EA, Wintermark M, deVeber GA, Fullerton HJ. Herpesvirus Infections and Childhood Arterial Ischemic Stroke: Results of the VIPS Study. Circulation 2016; 133:732-41. [PMID: 26813104 DOI: 10.1161/circulationaha.115.018595] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 01/11/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Epidemiological studies demonstrate that childhood infections, including varicella zoster virus, are associated with an increased risk of arterial ischemic stroke (AIS). Other herpesviruses have been linked to childhood AIS in case reports. We sought to determine whether herpesvirus infections, which are potentially treatable, increase the risk of childhood AIS. METHODS AND RESULTS We enrolled 326 centrally confirmed cases of AIS and 115 stroke-free controls with trauma (29 days to 18 years of age) with acute blood samples (≤3 weeks after stroke/trauma); cases had convalescent samples (7-28 days later) when feasible. Samples were tested by commercial enzyme-linked immunosorbent assay kits for immunoglobulin M/immunoglobulin G antibodies to herpes simplex virus 1 and 2, cytomegalovirus, Epstein-Barr virus, and varicella zoster virus. An algorithm developed a priori classified serological evidence of past and acute herpesvirus infection as dichotomous variables. The median (quartiles) age was 7.7 (3.1-14.3) years for cases and 10.7 (6.9-13.2) years for controls (P=0.03). Serological evidence of past infection did not differ between cases and controls. However, serological evidence of acute herpesvirus infection doubled the odds of childhood AIS, even after adjusting for age, race, and socioeconomic status (odds ratio, 2.2; 95% confidence interval, 1.2-4.0; P=0.007). Among 187 cases with acute and convalescent blood samples, 85 (45%) showed evidence of acute herpesvirus infection; herpes simplex virus 1 was found most often. Most infections were asymptomatic. CONCLUSIONS Herpesviruses may act as a trigger for childhood AIS, even if the infection is subclinical. Antivirals like acyclovir might have a role in the prevention of recurrent stroke if further studies confirm a causal relationship.
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Affiliation(s)
- Mitchell S V Elkind
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Nancy K Hills
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Carol A Glaser
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Warren D Lo
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Catherine Amlie-Lefond
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Nomazulu Dlamini
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Rachel Kneen
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Eldad A Hod
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Max Wintermark
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Gabrielle A deVeber
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Heather J Fullerton
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.).
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Casey JA, Schwartz BS, Stewart WF, Adler NE. Using Electronic Health Records for Population Health Research: A Review of Methods and Applications. Annu Rev Public Health 2015; 37:61-81. [PMID: 26667605 DOI: 10.1146/annurev-publhealth-032315-021353] [Citation(s) in RCA: 311] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The use and functionality of electronic health records (EHRs) have increased rapidly in the past decade. Although the primary purpose of EHRs is clinical, researchers have used them to conduct epidemiologic investigations, ranging from cross-sectional studies within a given hospital to longitudinal studies on geographically distributed patients. Herein, we describe EHRs, examine their use in population health research, and compare them with traditional epidemiologic methods. We describe diverse research applications that benefit from the large sample sizes and generalizable patient populations afforded by EHRs. These have included reevaluation of prior findings, a range of diseases and subgroups, environmental and social epidemiology, stigmatized conditions, predictive modeling, and evaluation of natural experiments. Although studies using primary data collection methods may have more reliable data and better population retention, EHR-based studies are less expensive and require less time to complete. Future EHR epidemiology with enhanced collection of social/behavior measures, linkage with vital records, and integration of emerging technologies such as personal sensing could improve clinical care and population health.
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Affiliation(s)
- Joan A Casey
- Robert Wood Johnson Foundation Health and Society Scholars Program at the University of California, San Francisco, and the University of California, Berkeley, Berkeley, California 94720-7360;
| | - Brian S Schwartz
- Departments of Environmental Health Sciences and Epidemiology, Bloomberg School of Public Health, and the Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland 21205; .,Center for Health Research, Geisinger Health System, Danville, Pennsylvania 17822
| | - Walter F Stewart
- Research, Development and Dissemination, Sutter Health, Walnut Creek, California 94596;
| | - Nancy E Adler
- Center for Health and Community and the Department of Psychiatry, University of California, San Francisco, California 94118;
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Abstract
Stroke and deep venous thrombosis are rare complications of varicella zoster infection. We report 3 cases of children with a stroke and 1 case of a boy with a deep venous thrombosis after recent chicken pox.
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Asiki G, Stockdale L, Kasamba I, Vudriko T, Tumwekwase G, Johnston T, Kaleebu P, Kamali A, Seeley J, Newton R. Pilot study of antibodies against varicella zoster virus and human immunodeficiency virus in relation to the risk of developing stroke, nested within a rural cohort in Uganda. Trop Med Int Health 2015; 20:1306-10. [PMID: 26083834 DOI: 10.1111/tmi.12556] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The risk of stroke rises after episodes of herpes zoster and chickenpox, which are caused by varicella zoster virus (VZV). We conducted a pilot case-control study of stroke, nested within a long-standing cohort in Uganda (the General Population Cohort), to examine antibodies against VZV prior to diagnosis. METHODS We used stored sera to examine the evolution of IgG and IgM antibodies against VZV among 31 clinically confirmed cases of stroke and 132 matched controls. For each participant, three samples of sera were identified: one each, taken at or near the time of (pseudo)diagnosis, between 5 and 10 years prior to diagnosis and at 15 years prior to diagnosis. RESULTS All participants had detectable antibodies against VZV, but there were no significant differences between cases and controls in the 15 years prior to diagnosis. As a secondary finding, 16% (5/31) of cases and 6% (8/132) of controls had HIV (OR 3.0; 95% CI 0.8-10.1; P = 0.06). CONCLUSIONS This is the first prospective study to examine a biological measure of exposure to VZV prior to diagnosis of stroke and although we identified no significant association, in this small pilot, with limited characterisation of cases, we cannot exclude the possibility that the virus is causal for a subset. The impact of HIV on risk of stroke has not been well characterised and warrants further study.
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Affiliation(s)
- Gershim Asiki
- Medical Research Council, Uganda Virus Research Institute Research Unit on AIDS, Entebbe, Uganda
| | - Lisa Stockdale
- London School of Hygiene and Tropical Medicine, London, UK
| | - Ivan Kasamba
- Medical Research Council, Uganda Virus Research Institute Research Unit on AIDS, Entebbe, Uganda
| | - Tobias Vudriko
- Medical Research Council, Uganda Virus Research Institute Research Unit on AIDS, Entebbe, Uganda
| | - Grace Tumwekwase
- Medical Research Council, Uganda Virus Research Institute Research Unit on AIDS, Entebbe, Uganda
| | - Tom Johnston
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York, UK
| | - Pontiano Kaleebu
- Medical Research Council, Uganda Virus Research Institute Research Unit on AIDS, Entebbe, Uganda
| | - Anatoli Kamali
- Medical Research Council, Uganda Virus Research Institute Research Unit on AIDS, Entebbe, Uganda
| | - Janet Seeley
- Medical Research Council, Uganda Virus Research Institute Research Unit on AIDS, Entebbe, Uganda
- London School of Hygiene and Tropical Medicine, London, UK
| | - Robert Newton
- Medical Research Council, Uganda Virus Research Institute Research Unit on AIDS, Entebbe, Uganda
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York, UK
- International Agency for Research on Cancer, Lyon, France
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Leung J, Lopez AS, Blostein J, Thayer N, Zipprich J, Clayton A, Buttery V, Andersen J, Thomas CA, del Rosario M, Seetoo K, Woodall T, Wiseman R, Bialek SR. Impact of the US Two-dose Varicella Vaccination Program on the Epidemiology of Varicella Outbreaks: Data from Nine States, 2005-2012. Pediatr Infect Dis J 2015; 34:1105-9. [PMID: 26186103 PMCID: PMC4606850 DOI: 10.1097/inf.0000000000000821] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A routine 2-dose varicella vaccination program was adopted in 2007 in the US to help further decrease varicella disease and prevent varicella outbreaks. We describe trends and characteristics of varicella outbreaks reported to the Centers for Disease Control and Prevention (CDC) during 2005-2012 from 9 states. METHODS Data on varicella outbreaks collected by 9 state health departments were submitted to CDC using the CDC outbreak reporting worksheet. Information was collected on dates of the outbreak, outbreak setting and number of cases by outbreak; aggregate data were provided on the numbers of outbreak-related cases by age group, vaccination status and laboratory confirmation. RESULTS Nine hundred and twenty-nine outbreaks were reported from the 6 states, which provided data for each year during 2005-2012. Based on data from these 6 states, the number of outbreaks declined by 78%, decreasing from 147 in 2005 to 33 outbreaks in 2012 (P = 0.0001). There were a total of 1015 varicella outbreaks involving 13,595 cases reported by the 9 states from 2005 to 2012. The size and duration of outbreaks declined significantly over time (P < 0.001). The median size of outbreaks was 12, 9 and 7 cases and median duration of outbreaks was 38, 35 and 26 days during 2005-2006, 2007-2009 and 2010-2012, respectively. Majority of outbreaks (95%) were reported from schools, declining from 97% in 2005-2006 to 89% in 2010-2012. Sixty-five percent of outbreak-related cases occurred among 5-year to 9-year olds, with the proportion declining from 76% in 2005-2006 to 45% during 2010-2012. CONCLUSIONS The routine 2-dose varicella vaccination program appears to have significantly reduced the number, size and duration of varicella outbreaks in the US.
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Affiliation(s)
- Jessica Leung
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Adriana S. Lopez
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Joel Blostein
- Division of Immunization, Michigan Dept. of Community Health, Lansing, MI, USA
| | - Nancy Thayer
- Vermont Department of Health, Burlington, VT, USA
| | - Jennifer Zipprich
- Immunization Branch, California Department of Public Health, Richmond, CA, USA
| | - Anna Clayton
- Immunization Branch, California Department of Public Health, Richmond, CA, USA
| | - Vicki Buttery
- Vaccine-Preventable Disease Unit, Minnesota Department of Health, St. Paul, MN, USA
| | - Jannifer Andersen
- Office of Epidemiology, Mississippi State Department of Health, Jackson MS, USA
| | - Carrie A. Thomas
- West Virginia Department of Health and Human Resources, Charleston, WV, USA
| | - Maria del Rosario
- West Virginia Department of Health and Human Resources, Charleston, WV, USA
| | - Kurt Seetoo
- Center for Immunization, Maryland Department of Health and Mental Hygiene, Baltimore, MD, USA
| | - Tracy Woodall
- Disease Control and Environmental Epidemiology Division, Colorado Department of Public Health and Environment, Denver, CO, USA
| | - Rachel Wiseman
- Infectious Disease Control Unit, Texas Department of State Health Services, Austin, TX, USA
| | - Stephanie R. Bialek
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Varicella-zoster virus infections of the central nervous system – Prognosis, diagnostics and treatment. J Infect 2015; 71:281-93. [DOI: 10.1016/j.jinf.2015.06.004] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 06/03/2015] [Accepted: 06/06/2015] [Indexed: 11/23/2022]
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Abstract
Stroke is as common as brain tumor in children. The etiology of childhood arterial ischemic stroke (AIS) appears to be multifactorial, resulting from the interaction between genetic predisposition and environmental triggers. The risk factors for AIS in children are markedly different from the atherosclerotic risk factors in adults. Trauma and infections have been identified as associations in previous studies and are exposures of particular interest because of their increased prevalence in the children. The aim of this review article is to provide an overview of the research studies that have addressed the role of infections and trauma in pediatric AIS.
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Affiliation(s)
- Elena Moraitis
- Rheumatology/Infectious Diseases and Immunity Unit UCL Institute of Child Health and Rheumatology Department, Great Ormond Street Hospital for Children, London, UK,
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Science M, MacGregor D, Richardson SE, Mahant S, Tran D, Bitnun A. Central nervous system complications of varicella-zoster virus. J Pediatr 2014; 165:779-85. [PMID: 25063723 DOI: 10.1016/j.jpeds.2014.06.014] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 04/14/2014] [Accepted: 06/05/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To describe the spectrum of central nervous system complications of varicella-zoster virus (VZV) in children admitted to The Hospital for Sick Children between January 1999 and December 2012. STUDY DESIGN Children aged 1 month to 18 years (n = 84) admitted with neurologic manifestations associated with a characteristic VZV rash or a confirmatory laboratory test (positive lesion scraping or cerebrospinal fluid polymerase chain reaction) were included in the study. Acute neurologic complications were included if they occurred within 4 weeks of VZV infection. Stroke was considered related to VZV if it occurred within 6 months of VZV infection, the neuroimaging was characteristic, and other causes were excluded. RESULTS Clinical syndromes included acute cerebellar ataxia (n = 26), encephalitis (n = 17), isolated seizures (n = 16), stroke (n = 10), meningitis (n = 10), Guillain-Barré syndrome (n = 2), acute disseminated encephalomyelitis (n = 2), and Ramsay Hunt syndrome (n = 1). In those with acute complications (nonstroke), neurologic symptoms occurred a median of 5 days after rash onset (range -6 to +16). The time between rash onset and stroke ranged from 2 weeks to 26 weeks (median 16.0 weeks). Three children with encephalitis died. Residual neurologic sequelae at one year occurred in 9 of 39 (23%) of children with follow-up data. Only 4 children were reported to have received the varicella vaccine. CONCLUSION Neurologic complications of VZV infection continue to occur despite the availability of an effective vaccine. Neurologic symptom onset can predate the appearance of the VZV exanthem and in rare cases may occur in the absence of an exanthem.
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Affiliation(s)
- Michelle Science
- Division of Infectious Diseases, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Daune MacGregor
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Susan E Richardson
- Division of Microbiology, Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Sanjay Mahant
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Dat Tran
- Division of Infectious Diseases, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Ari Bitnun
- Division of Infectious Diseases, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.
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Smithson A, Ruiz J, Ramos X, Niño E, Armestar F. Varicella pneumonia associated with spontaneous popliteal arterial thrombosis in an adult: a case study and review of the literature. JMM Case Rep 2014. [DOI: 10.1099/jmmcr.0.003640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Alex Smithson
- Emergency Department, Fundació Hospital de l’Esperit Sant, Santa Coloma Gramenet, Spain
| | - Jessica Ruiz
- Internal Medicine Department, Fundació Hospital de l’Esperit Sant, Santa Coloma de Gramenet, Spain
| | - Xavi Ramos
- Internal Medicine Department, Fundació Hospital de l’Esperit Sant, Santa Coloma de Gramenet, Spain
| | - Esther Niño
- Internal Medicine Department, Fundació Hospital de l’Esperit Sant, Santa Coloma de Gramenet, Spain
| | - Fernando Armestar
- Intensive Care Unit, Hospital Universitari Germans Tries i Pujol, Badalona, Spain
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Post-varicella angiopathy: a series of 4 patients with focus on virologic and neuroimaging findings. Pediatr Neurol 2014; 50:581-5. [PMID: 24674843 DOI: 10.1016/j.pediatrneurol.2014.01.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 12/26/2013] [Accepted: 01/05/2014] [Indexed: 11/20/2022]
Abstract
BACKGROUND Post-varicella angiopathy is an important cause of childhood stroke and follows a particular pattern. Specific treatment guidelines have not been developed because of a lack of epidemiological, laboratory, and neuroimaging data. Prospective randomized controlled trials evaluating different treatment strategies have not been performed, and expert opinions on diagnostic criteria, prognosis, and treatment are diverging. METHODS This case series describes the clinical course, laboratory, and neuroimaging findings of four children with post-varicella angiopathy, who all underwent cerebrospinal fluid assessment and received antiviral, immunosuppressive, and antiplatelet treatment. RESULTS Cerebrospinal fluid analysis was positive for varicella-zoster virus markers in three children. At follow-up, three children had a mild hemiparesis and one child had no neurological symptoms. Neuroimaging showed complete vascular remission in three patients and improvement in one. CONCLUSIONS Systematic search for virologic markers in cerebrospinal fluid will contribute to the understanding of the pathogenesis of idiopathic childhood stroke and can be considered as a prerequisite for the development of clear diagnostic criteria and relevant treatment strategies for post-varicella angiopathy. The role of antiviral and immunosuppressive medication needs to be clarified.
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