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Michael BD, Dunai C, Needham EJ, Tharmaratnam K, Williams R, Huang Y, Boardman SA, Clark JJ, Sharma P, Subramaniam K, Wood GK, Collie C, Digby R, Ren A, Norton E, Leibowitz M, Ebrahimi S, Fower A, Fox H, Tato E, Ellul MA, Sunderland G, Held M, Hetherington C, Egbe FN, Palmos A, Stirrups K, Grundmann A, Chiollaz AC, Sanchez JC, Stewart JP, Griffiths M, Solomon T, Breen G, Coles AJ, Kingston N, Bradley JR, Chinnery PF, Cavanagh J, Irani SR, Vincent A, Baillie JK, Openshaw PJ, Semple MG, Taams LS, Menon DK. Author Correction: Para-infectious brain injury in COVID-19 persists at follow-up despite attenuated cytokine and autoantibody responses. Nat Commun 2024; 15:2918. [PMID: 38575615 PMCID: PMC10995197 DOI: 10.1038/s41467-024-47320-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024] Open
Affiliation(s)
- Benedict D Michael
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK.
- NIHR Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, L69 7BE, UK.
- The Walton Centre NHS Foundation Trust, Liverpool, L9 7BB, UK.
| | - Cordelia Dunai
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
- NIHR Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, L69 7BE, UK
| | - Edward J Needham
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, CB2 0QQ, UK
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Kukatharmini Tharmaratnam
- Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, L69 3GF, UK
| | - Robyn Williams
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
- Departments of Neurology and Neuroscience, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Yun Huang
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Sarah A Boardman
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Jordan J Clark
- University of Liverpool, Liverpool, L69 7BE, UK
- Department of Microbiology, Icahn School of Medicine, Mount Sinai, NY, 10029, USA
- Center for Vaccine Research and Pandemic Preparedness (C-VARPP), Icahn School of Medicine, Mount Sinai, NY, 10029, USA
| | - Parul Sharma
- Infection Biology & Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L3 5RF, UK
| | - Krishanthi Subramaniam
- Infection Biology & Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L3 5RF, UK
| | - Greta K Wood
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Ceryce Collie
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Richard Digby
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Alexander Ren
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Emma Norton
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Maya Leibowitz
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Soraya Ebrahimi
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Andrew Fower
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
| | - Hannah Fox
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
| | - Esteban Tato
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE5 8AF, UK
- NIHR Maudsley Biomedical Research Centre, King's College London, London, SE5 8AF, UK
| | - Mark A Ellul
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
- The Walton Centre NHS Foundation Trust, Liverpool, L9 7BB, UK
| | - Geraint Sunderland
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Marie Held
- Centre for Cell Imaging, Liverpool Shared Research Facilities, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, L69 7ZB, UK
| | - Claire Hetherington
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Franklyn N Egbe
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Alish Palmos
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE5 8AF, UK
- NIHR Maudsley Biomedical Research Centre, King's College London, London, SE5 8AF, UK
| | - Kathy Stirrups
- NIHR BioResource, Cambridge University Hospitals NHS Foundation, Cambridge, CB2 0QQ, UK
- Department of Haematology, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Alexander Grundmann
- Clinical Neurosciences, Clinical and Experimental Science, Faculty of Medicine, University of Southampton, Southampton, SO17 1BF, UK
- Department of Neurology, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Anne-Cecile Chiollaz
- Département de médecine interne des spécialités (DEMED), University of Geneva, Geneva, CH-1211, Switzerland
| | - Jean-Charles Sanchez
- Département de médecine interne des spécialités (DEMED), University of Geneva, Geneva, CH-1211, Switzerland
| | - James P Stewart
- Infection Biology & Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L3 5RF, UK
| | - Michael Griffiths
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Tom Solomon
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
- NIHR Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, L69 7BE, UK
- The Walton Centre NHS Foundation Trust, Liverpool, L9 7BB, UK
- The Pandemic Institute, Liverpool, L7 3FA, UK
| | - Gerome Breen
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE5 8AF, UK
- NIHR Maudsley Biomedical Research Centre, King's College London, London, SE5 8AF, UK
| | - Alasdair J Coles
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Nathalie Kingston
- NIHR BioResource, Cambridge University Hospitals NHS Foundation, Cambridge, CB2 0QQ, UK
- University of Cambridge, Cambridge, CB2 0QQ, UK
| | - John R Bradley
- NIHR BioResource, Cambridge University Hospitals NHS Foundation, Cambridge, CB2 0QQ, UK
- Department of Medicine, School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Patrick F Chinnery
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, CB2 0QQ, UK
- NIHR BioResource, Cambridge University Hospitals NHS Foundation, Cambridge, CB2 0QQ, UK
| | - Jonathan Cavanagh
- Centre for Immunology, School of Infection & Immunity, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, G12 8TA, UK
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
- Departments of Neurology and Neuroscience, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
| | - J Kenneth Baillie
- Roslin Institute, University of Edinburgh, Edinburgh, EH25 9RG, UK
- Intensive Care Unit, Royal Infirmary of Edinburgh, Edinburgh, EH10 5HF, UK
| | - Peter J Openshaw
- National Heart and Lung Institute, Imperial College London, London, SW7 2BX, UK
- Imperial College Healthcare NHS Trust, London, W2 1NY, UK
| | - Malcolm G Semple
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
- NIHR Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, L69 7BE, UK
- Respiratory Unit, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, L14 5AB, UK
| | - Leonie S Taams
- Centre for Inflammation Biology and Cancer Immunology, King's College London, London, SE1 9RT, UK
| | - David K Menon
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
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Fanshawe JB, Sargent BF, Badenoch JB, Saini A, Watson CJ, Pokrovskaya A, Aniwattanapong D, Conti I, Nye C, Burchill E, Hussain ZU, Said K, Kuhoga E, Tharmaratnam K, Pendered S, Mbwele B, Taquet M, Wood GK, Rogers JP, Hampshire A, Carson A, David AS, Michael BD, Nicholson TR, Paddick SM, Leek CE. Cognitive domains affected post-COVID-19; a systematic review and meta-analysis. Eur J Neurol 2024:e16181. [PMID: 38375608 DOI: 10.1111/ene.16181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 10/23/2023] [Accepted: 11/29/2023] [Indexed: 02/21/2024]
Abstract
BACKGROUND AND PURPOSE This review aims to characterize the pattern of post-COVID-19 cognitive impairment, allowing better prediction of impact on daily function to inform clinical management and rehabilitation. METHODS A systematic review and meta-analysis of neurocognitive sequelae following COVID-19 was conducted, following PRISMA-S guidelines. Studies were included if they reported domain-specific cognitive assessment in patients with COVID-19 at >4 weeks post-infection. Studies were deemed high-quality if they had >40 participants, utilized healthy controls, had low attrition rates and mitigated for confounders. RESULTS Five of the seven primary Diagnostic and Statistical Manual of Mental Disorders (DSM-5) cognitive domains were assessed by enough high-quality studies to facilitate meta-analysis. Medium effect sizes indicating impairment in patients post-COVID-19 versus controls were seen across executive function (standardised mean difference (SMD) -0.45), learning and memory (SMD -0.55), complex attention (SMD -0.54) and language (SMD -0.54), with perceptual motor function appearing to be impacted to a greater degree (SMD -0.70). A narrative synthesis of the 56 low-quality studies also suggested no obvious pattern of impairment. CONCLUSIONS This review found moderate impairments across multiple domains of cognition in patients post-COVID-19, with no specific pattern. The reported literature was significantly heterogeneous, with a wide variety of cognitive tasks, small sample sizes and disparate initial disease severities limiting interpretability. The finding of consistent impairment across a range of cognitive tasks suggests broad, as opposed to domain-specific, brain dysfunction. Future studies should utilize a harmonized test battery to facilitate inter-study comparisons, whilst also accounting for the interactions between COVID-19, neurological sequelae and mental health, the interplay between which might explain cognitive impairment.
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Affiliation(s)
- Jack B Fanshawe
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Oxford, UK
| | - Brendan F Sargent
- Department of Psychiatry, University of Oxford, Oxford, UK
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - James B Badenoch
- Barts Health NHS Trust, London, UK
- Preventive Neurology Unit, Queen Mary University of London, London, UK
| | - Aman Saini
- School of Life and Medical Sciences, University College London, London, UK
| | - Cameron J Watson
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | | | - Daruj Aniwattanapong
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Department of Psychiatry, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Isabella Conti
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Charles Nye
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Ella Burchill
- Division of Psychiatry, University College London, London, UK
| | - Zain U Hussain
- NHS Greater Glasgow and Clyde, Glasgow, UK
- Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | - Khanafi Said
- Mbeya College of Health and Allied Sciences, University of Dar es Salaam, Mbeya, Tanzania
| | - Elinda Kuhoga
- Mbeya College of Health and Allied Sciences, University of Dar es Salaam, Mbeya, Tanzania
| | - Kukatharmini Tharmaratnam
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Sophie Pendered
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Bernard Mbwele
- Mbeya College of Health and Allied Sciences, University of Dar es Salaam, Mbeya, Tanzania
| | - Maxime Taquet
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Oxford, UK
| | - Greta K Wood
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | | | - Adam Hampshire
- Department of Brain Sciences, Imperial College London, London, UK
| | - Alan Carson
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Anthony S David
- Division of Psychiatry, University College London, London, UK
| | - Benedict D Michael
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, UK
- Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Timothy R Nicholson
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Stella-Maria Paddick
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Gateshead Health NHS Foundation Trust, Gateshead, UK
| | - Charles E Leek
- Department of Psychology, University of Liverpool, Liverpool, UK
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Burnside G, Cheyne CP, Leeming G, Humann M, Darby A, Green MA, Crozier A, Maskell S, O’Halloran K, Musi E, Carmi E, Khan N, Fisher D, Corcoran R, Dunning J, Edmunds WJ, Tharmaratnam K, Hughes DM, Malki-Epshtein L, Cook M, Roberts BM, Gallagher E, Howell K, Chand M, Kemp R, Boulter M, Fowler T, Semple MG, Coffey E, Ashton M, García-Fiñana M, Buchan IE. COVID-19 risk mitigation in reopening mass cultural events: population-based observational study for the UK Events Research Programme in Liverpool City Region. J R Soc Med 2024; 117:11-23. [PMID: 37351911 PMCID: PMC10858718 DOI: 10.1177/01410768231182389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 04/25/2023] [Indexed: 06/24/2023] Open
Abstract
OBJECTIVES To understand severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission risks, perceived risks and the feasibility of risk mitigations from experimental mass cultural events before coronavirus disease 2019 (COVID-19) restrictions were lifted. DESIGN Prospective, population-wide observational study. SETTING Four events (two nightclubs, an outdoor music festival and a business conference) open to Liverpool City Region UK residents, requiring a negative lateral flow test (LFT) within the 36 h before the event, but not requiring social distancing or face-coverings. PARTICIPANTS A total of 12,256 individuals attending one or more events between 28 April and 2 May 2021. MAIN OUTCOME MEASURES SARS-CoV-2 infections detected using audience self-swabbed (5-7 days post-event) polymerase chain reaction (PCR) tests, with viral genomic analysis of cases, plus linked National Health Service COVID-19 testing data. Audience experiences were gathered via questionnaires, focus groups and social media. Indoor CO2 concentrations were monitored. RESULTS A total of 12 PCR-positive cases (likely 4 index, 8 primary or secondary), 10 from the nightclubs. Two further cases had positive LFTs but no PCR. A total of 11,896 (97.1%) participants with scanned tickets were matched to a negative pre-event LFT: 4972 (40.6%) returned a PCR within a week. CO2 concentrations showed areas for improving ventilation at the nightclubs. Population infection rates were low, yet with a concurrent outbreak of >50 linked cases around a local swimming pool without equivalent risk mitigations. Audience anxiety was low and enjoyment high. CONCLUSIONS We observed minor SARS-CoV-2 transmission and low perceived risks around events when prevalence was low and risk mitigations prominent. Partnership between audiences, event organisers and public health services, supported by information systems with real-time linked data, can improve health security for mass cultural events.
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Affiliation(s)
- Girvan Burnside
- Deparment of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool L69 3GL, UK
| | - Christopher P Cheyne
- Deparment of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool L69 3GL, UK
| | - Gary Leeming
- Deparment of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool L69 3GL, UK
| | - Michael Humann
- Department of Psychology, University of Liverpool, Liverpool L69 7ZA, UK
| | - Alistair Darby
- Department of Infection Biology and Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool L69 3BX, UK
| | - Mark A Green
- Department of Geography and Planning, University of Liverpool L69 3BX, Liverpool, UK
| | - Alexander Crozier
- Division of Biosciences, University College London, London WC1E 6BT, UK
| | - Simon Maskell
- Department of Electrical Engineering and Electronics, University of Liverpool, Liverpool L69 3BX, UK
| | - Kay O’Halloran
- Department of Communication and Media, University of Liverpool, Liverpool L69 7ZG, UK
| | - Elena Musi
- Department of Communication and Media, University of Liverpool, Liverpool L69 7ZG, UK
| | - Elinor Carmi
- Department of Sociology and Criminology, City University, London EC1V 0HB, UK
| | - Naila Khan
- Department of Primary Care & Mental Health, Institute of Population Health, University of Liverpool, Liverpool L69 3BX, UK
| | - Debra Fisher
- Department of Primary Care & Mental Health, Institute of Population Health, University of Liverpool, Liverpool L69 3BX, UK
| | - Rhiannon Corcoran
- Department of Primary Care & Mental Health, Institute of Population Health, University of Liverpool, Liverpool L69 3BX, UK
| | - Jake Dunning
- Pandemic Sciences Institute, University of Oxford, Oxford OX3 7DQ, UK
| | - W John Edmunds
- Centre for Mathematical Modelling of Infectious Diseases and Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Kukatharmini Tharmaratnam
- Deparment of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool L69 3GL, UK
| | - David M Hughes
- Deparment of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool L69 3GL, UK
| | - Liora Malki-Epshtein
- Department of Civil, Environmental and Geomatic Engineering, University College London, London WC1E 6BT, UK
| | - Malcolm Cook
- Building Energy Research Group, School of Architecture, Building and Civil Engineering, Loughborough University, Loughborough LE11 3TU, UK
| | - Ben M Roberts
- Building Energy Research Group, School of Architecture, Building and Civil Engineering, Loughborough University, Loughborough LE11 3TU, UK
| | - Eileen Gallagher
- Clinical and Public Health Group, UK Health Security Agency, London SW1P 3JR, UK
| | - Kate Howell
- Clinical and Public Health Group, UK Health Security Agency, London SW1P 3JR, UK
| | - Meera Chand
- Clinical and Public Health Group, UK Health Security Agency, London SW1P 3JR, UK
| | - Robin Kemp
- William Harvey Research Institute, Queen Mary University of London, London EC1M 6BQ, UK
| | - Matthew Boulter
- Clinical and Public Health Group, UK Health Security Agency, London SW1P 3JR, UK
| | - Tom Fowler
- Clinical and Public Health Group, UK Health Security Agency, London SW1P 3JR, UK
- William Harvey Research Institute, Queen Mary University of London, London EC1M 6BQ, UK
| | - Malcolm G Semple
- Department of Clinical Infection, Microbiology & Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool L69 3BX, UK
| | - Emer Coffey
- Liverpool City Council, Liverpool L3 1AH, UK
| | - Matt Ashton
- Liverpool City Council, Liverpool L3 1AH, UK
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool L69 3GB, UK
| | - The COVID-19 Genomics UK (COG-UK) Consortium
- Deparment of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool L69 3GL, UK
- Department of Psychology, University of Liverpool, Liverpool L69 7ZA, UK
- Department of Infection Biology and Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool L69 3BX, UK
- Department of Geography and Planning, University of Liverpool L69 3BX, Liverpool, UK
- Division of Biosciences, University College London, London WC1E 6BT, UK
- Department of Electrical Engineering and Electronics, University of Liverpool, Liverpool L69 3BX, UK
- Department of Communication and Media, University of Liverpool, Liverpool L69 7ZG, UK
- Department of Sociology and Criminology, City University, London EC1V 0HB, UK
- Department of Primary Care & Mental Health, Institute of Population Health, University of Liverpool, Liverpool L69 3BX, UK
- Pandemic Sciences Institute, University of Oxford, Oxford OX3 7DQ, UK
- Centre for Mathematical Modelling of Infectious Diseases and Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Department of Civil, Environmental and Geomatic Engineering, University College London, London WC1E 6BT, UK
- Building Energy Research Group, School of Architecture, Building and Civil Engineering, Loughborough University, Loughborough LE11 3TU, UK
- Clinical and Public Health Group, UK Health Security Agency, London SW1P 3JR, UK
- William Harvey Research Institute, Queen Mary University of London, London EC1M 6BQ, UK
- Liverpool City Council, Liverpool L3 1AH, UK
- Department of Clinical Infection, Microbiology & Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool L69 3BX, UK
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool L69 3GB, UK
- *Shared senior authorship
| | - Marta García-Fiñana
- Deparment of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool L69 3GL, UK
| | - Iain E Buchan
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool L69 3GB, UK
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4
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Michael BD, Dunai C, Needham EJ, Tharmaratnam K, Williams R, Huang Y, Boardman SA, Clark JJ, Sharma P, Subramaniam K, Wood GK, Collie C, Digby R, Ren A, Norton E, Leibowitz M, Ebrahimi S, Fower A, Fox H, Tato E, Ellul MA, Sunderland G, Held M, Hetherington C, Egbe FN, Palmos A, Stirrups K, Grundmann A, Chiollaz AC, Sanchez JC, Stewart JP, Griffiths M, Solomon T, Breen G, Coles AJ, Kingston N, Bradley JR, Chinnery PF, Cavanagh J, Irani SR, Vincent A, Baillie JK, Openshaw PJ, Semple MG, Taams LS, Menon DK. Para-infectious brain injury in COVID-19 persists at follow-up despite attenuated cytokine and autoantibody responses. Nat Commun 2023; 14:8487. [PMID: 38135686 PMCID: PMC10746705 DOI: 10.1038/s41467-023-42320-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 10/06/2023] [Indexed: 12/24/2023] Open
Abstract
To understand neurological complications of COVID-19 better both acutely and for recovery, we measured markers of brain injury, inflammatory mediators, and autoantibodies in 203 hospitalised participants; 111 with acute sera (1-11 days post-admission) and 92 convalescent sera (56 with COVID-19-associated neurological diagnoses). Here we show that compared to 60 uninfected controls, tTau, GFAP, NfL, and UCH-L1 are increased with COVID-19 infection at acute timepoints and NfL and GFAP are significantly higher in participants with neurological complications. Inflammatory mediators (IL-6, IL-12p40, HGF, M-CSF, CCL2, and IL-1RA) are associated with both altered consciousness and markers of brain injury. Autoantibodies are more common in COVID-19 than controls and some (including against MYL7, UCH-L1, and GRIN3B) are more frequent with altered consciousness. Additionally, convalescent participants with neurological complications show elevated GFAP and NfL, unrelated to attenuated systemic inflammatory mediators and to autoantibody responses. Overall, neurological complications of COVID-19 are associated with evidence of neuroglial injury in both acute and late disease and these correlate with dysregulated innate and adaptive immune responses acutely.
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Affiliation(s)
- Benedict D Michael
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK.
- NIHR Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, L69 7BE, UK.
- The Walton Centre NHS Foundation Trust, Liverpool, L9 7BB, UK.
| | - Cordelia Dunai
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
- NIHR Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, L69 7BE, UK
| | - Edward J Needham
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, CB2 0QQ, UK
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Kukatharmini Tharmaratnam
- Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, L69 3GF, UK
| | - Robyn Williams
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
- Departments of Neurology and Neuroscience, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Yun Huang
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Sarah A Boardman
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Jordan J Clark
- University of Liverpool, Liverpool, L69 7BE, UK
- Department of Microbiology, Icahn School of Medicine, Mount Sinai, NY, 10029, USA
- Center for Vaccine Research and Pandemic Preparedness (C-VARPP), Icahn School of Medicine, Mount Sinai, NY, 10029, USA
| | - Parul Sharma
- Infection Biology & Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L3 5RF, UK
| | - Krishanthi Subramaniam
- Infection Biology & Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L3 5RF, UK
| | - Greta K Wood
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Ceryce Collie
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Richard Digby
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Alexander Ren
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Emma Norton
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Maya Leibowitz
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Soraya Ebrahimi
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Andrew Fower
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
| | - Hannah Fox
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
| | - Esteban Tato
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE5 8AF, UK
- NIHR Maudsley Biomedical Research Centre, King's College London, London, SE5 8AF, UK
| | - Mark A Ellul
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
- The Walton Centre NHS Foundation Trust, Liverpool, L9 7BB, UK
| | - Geraint Sunderland
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Marie Held
- Centre for Cell Imaging, Liverpool Shared Research Facilities, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, L69 7ZB, UK
| | - Claire Hetherington
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Franklyn N Egbe
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Alish Palmos
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE5 8AF, UK
- NIHR Maudsley Biomedical Research Centre, King's College London, London, SE5 8AF, UK
| | - Kathy Stirrups
- NIHR BioResource, Cambridge University Hospitals NHS Foundation, Cambridge, CB2 0QQ, UK
- Department of Haematology, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Alexander Grundmann
- Clinical Neurosciences, Clinical and Experimental Science, Faculty of Medicine, University of Southampton, Southampton, SO17 1BF, UK
- Department of Neurology, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Anne-Cecile Chiollaz
- Département de médecine interne des spécialités (DEMED), University of Geneva, Geneva, CH-1211, Switzerland
| | - Jean-Charles Sanchez
- Département de médecine interne des spécialités (DEMED), University of Geneva, Geneva, CH-1211, Switzerland
| | - James P Stewart
- Infection Biology & Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L3 5RF, UK
| | - Michael Griffiths
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Tom Solomon
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
- NIHR Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, L69 7BE, UK
- The Walton Centre NHS Foundation Trust, Liverpool, L9 7BB, UK
- The Pandemic Institute, Liverpool, L7 3FA, UK
| | - Gerome Breen
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE5 8AF, UK
- NIHR Maudsley Biomedical Research Centre, King's College London, London, SE5 8AF, UK
| | - Alasdair J Coles
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Nathalie Kingston
- NIHR BioResource, Cambridge University Hospitals NHS Foundation, Cambridge, CB2 0QQ, UK
- University of Cambridge, Cambridge, CB2 0QQ, UK
| | - John R Bradley
- NIHR BioResource, Cambridge University Hospitals NHS Foundation, Cambridge, CB2 0QQ, UK
- Department of Medicine, School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Patrick F Chinnery
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, CB2 0QQ, UK
- NIHR BioResource, Cambridge University Hospitals NHS Foundation, Cambridge, CB2 0QQ, UK
| | - Jonathan Cavanagh
- Centre for Immunology, School of Infection & Immunity, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, G12 8TA, UK
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
- Departments of Neurology and Neuroscience, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
| | - J Kenneth Baillie
- Roslin Institute, University of Edinburgh, Edinburgh, EH25 9RG, UK
- Intensive Care Unit, Royal Infirmary of Edinburgh, Edinburgh, EH10 5HF, UK
| | - Peter J Openshaw
- National Heart and Lung Institute, Imperial College London, London, SW7 2BX, UK
- Imperial College Healthcare NHS Trust, London, W2 1NY, UK
| | - Malcolm G Semple
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
- NIHR Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, L69 7BE, UK
- Respiratory Unit, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, L14 5AB, UK
| | - Leonie S Taams
- Centre for Inflammation Biology and Cancer Immunology, King's College London, London, SE1 9RT, UK
| | - David K Menon
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
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5
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Defres S, Tharmaratnam K, Michael BD, Ellul M, Davies NWS, Easton A, Griffiths MJ, Bhojak M, Das K, Hardwick H, Cheyne C, Kneen R, Medina-Lara A, Salter AC, Beeching NJ, Carrol E, Vincent A, Garcia-Finana M, Solomon T. Clinical predictors of encephalitis in UK adults-A multi-centre prospective observational cohort study. PLoS One 2023; 18:e0282645. [PMID: 37611003 PMCID: PMC10446234 DOI: 10.1371/journal.pone.0282645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 02/19/2023] [Indexed: 08/25/2023] Open
Abstract
OBJECTIVES Encephalitis, brain inflammation and swelling, most often caused by an infection or the body's immune defences, can have devastating consequences, especially if diagnosed late. We looked for clinical predictors of different types of encephalitis to help clinicians consider earlier treatment. METHODS We conducted a multicentre prospective observational cohort study (ENCEPH-UK) of adults (> 16 years) with suspected encephalitis at 31 UK hospitals. We evaluated clinical features and investigated for infectious and autoimmune causes. RESULTS 341 patients were enrolled between December 2012 and December 2015 and followed up for 12 months. 233 had encephalitis, of whom 65 (28%) had HSV, 38 (16%) had confirmed or probable autoimmune encephalitis, and 87 (37%) had no cause found. The median time from admission to 1st dose of aciclovir for those with HSV was 14 hours (IQR 5-50); time to 1st dose of immunosuppressant for the autoimmune group was 125 hours (IQR 45-250). Compared to non-HSV encephalitis, patients with HSV more often had fever, lower serum sodium and lacked a rash. Those with probable or confirmed autoimmune encephalitis were more likely to be female, have abnormal movements, normal serum sodium levels and a cerebrospinal fluid white cell count < 20 cells x106/L, but they were less likely to have a febrile illness. CONCLUSIONS Initiation of treatment for autoimmune encephalitis is delayed considerably compared with HSV encephalitis. Clinical features can help identify patients with autoimmune disease and could be used to initiate earlier presumptive therapy.
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Affiliation(s)
- Sylviane Defres
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
- Tropical and Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Kukatharmini Tharmaratnam
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Benedict D. Michael
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
- Tropical and Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Mark Ellul
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | | | - Ava Easton
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
- Encephalitis Society, Malton, United Kingdom
| | - Michael J. Griffiths
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
- Department of Paediatric Neurology, Alder Hey Hospital Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Maneesh Bhojak
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Kumar Das
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Hayley Hardwick
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Chris Cheyne
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Rachel Kneen
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
- Department of Paediatric Neurology, Alder Hey Hospital Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | | | | | - Nicholas J. Beeching
- Tropical and Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Enitan Carrol
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
- Department of Paediatric Infectious Diseases, Alder Hey Hospital Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | | | - Marta Garcia-Finana
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Tom Solomon
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
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6
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Wood GK, Babar R, Ellul MA, Thomas RH, Van Den Tooren H, Easton A, Tharmaratnam K, Burnside G, Alam AM, Castell H, Boardman S, Collie C, Facer B, Dunai C, Defres S, Granerod J, Brown DWG, Vincent A, Marson AG, Irani SR, Solomon T, Michael BD. Acute seizure risk in patients with encephalitis: development and validation of clinical prediction models from two independent prospective multicentre cohorts. BMJ Neurol Open 2022; 4:e000323. [PMID: 36110928 PMCID: PMC9445799 DOI: 10.1136/bmjno-2022-000323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/23/2022] [Indexed: 11/10/2022] Open
Abstract
Objective In patients with encephalitis, the development of acute symptomatic seizures is highly variable, but when present is associated with a worse outcome. We aimed to determine the factors associated with seizures in encephalitis and develop a clinical prediction model. Methods We analysed 203 patients from 24 English hospitals (2005-2008) (Cohort 1). Outcome measures were seizures prior to and during admission, inpatient seizures and status epilepticus. A binary logistic regression risk model was converted to a clinical score and independently validated on an additional 233 patients from 31 UK hospitals (2013-2016) (Cohort 2). Results In Cohort 1, 121 (60%) patients had a seizure including 103 (51%) with inpatient seizures. Admission Glasgow Coma Scale (GCS) ≤8/15 was predictive of subsequent inpatient seizures (OR (95% CI) 5.55 (2.10 to 14.64), p<0.001), including in those without a history of prior seizures at presentation (OR 6.57 (95% CI 1.37 to 31.5), p=0.025).A clinical model of overall seizure risk identified admission GCS along with aetiology (autoantibody-associated OR 11.99 (95% CI 2.09 to 68.86) and Herpes simplex virus 3.58 (95% CI 1.06 to 12.12)) (area under receiver operating characteristics curve (AUROC) =0.75 (95% CI 0.701 to 0.848), p<0.001). The same model was externally validated in Cohort 2 (AUROC=0.744 (95% CI 0.677 to 0.811), p<0.001). A clinical scoring system for stratifying inpatient seizure risk by decile demonstrated good discrimination using variables available on admission; age, GCS and fever (AUROC=0.716 (95% CI 0.634 to 0.798), p<0.001) and once probable aetiology established (AUROC=0.761 (95% CI 0.6840.839), p<0.001). Conclusion Age, GCS, fever and aetiology can effectively stratify acute seizure risk in patients with encephalitis. These findings can support the development of targeted interventions and aid clinical trial design for antiseizure medication prophylaxis.
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Affiliation(s)
- Greta K Wood
- Institute of Infection, Veterinary, and Ecological Science, University of Liverpool Department of Clinical Infection Microbiology and Immunology, Liverpool, UK
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, UK
| | - Roshan Babar
- Institute of Infection, Veterinary, and Ecological Science, University of Liverpool Department of Clinical Infection Microbiology and Immunology, Liverpool, UK
| | - Mark A Ellul
- Institute of Infection, Veterinary, and Ecological Science, University of Liverpool Department of Clinical Infection Microbiology and Immunology, Liverpool, UK
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Rhys Huw Thomas
- Faculty of Medical Sciences, Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
- Neurosciences, Royal Victoria Infirmary, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Harriet Van Den Tooren
- Institute of Infection, Veterinary, and Ecological Science, University of Liverpool Department of Clinical Infection Microbiology and Immunology, Liverpool, UK
| | - Ava Easton
- Encephalitis Society, Malton, UK
- University of Liverpool Department of Clinical Infection Microbiology and Immunology, Liverpool, UK
| | - Kukatharmini Tharmaratnam
- Department of Health Data Science, University of Liverpool Faculty of Health and Life Sciences, Liverpool, UK
| | - Girvan Burnside
- Department of Health Data Science, University of Liverpool Faculty of Health and Life Sciences, Liverpool, UK
| | - Ali M Alam
- Institute of Infection, Veterinary, and Ecological Science, University of Liverpool Department of Clinical Infection Microbiology and Immunology, Liverpool, UK
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, UK
| | - Hannah Castell
- Institute of Infection, Veterinary, and Ecological Science, University of Liverpool Department of Clinical Infection Microbiology and Immunology, Liverpool, UK
- Institute of Infection, Veterinary, and Ecological Science, NIHR Health Protection Research Unit in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, UK
| | - Sarah Boardman
- Institute of Infection, Veterinary, and Ecological Science, University of Liverpool Department of Clinical Infection Microbiology and Immunology, Liverpool, UK
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, UK
| | - Ceryce Collie
- Institute of Infection, Veterinary, and Ecological Science, University of Liverpool Department of Clinical Infection Microbiology and Immunology, Liverpool, UK
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, UK
| | - Bethany Facer
- Institute of Infection, Veterinary, and Ecological Science, University of Liverpool Department of Clinical Infection Microbiology and Immunology, Liverpool, UK
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, UK
| | - Cordelia Dunai
- Institute of Infection, Veterinary, and Ecological Science, University of Liverpool Department of Clinical Infection Microbiology and Immunology, Liverpool, UK
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, UK
| | - Sylviane Defres
- Institute of Infection, Veterinary, and Ecological Science, University of Liverpool Department of Clinical Infection Microbiology and Immunology, Liverpool, UK
- Tropical and Infectious Diseases Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | | | - David W G Brown
- Virus Reference Department, UK Health Security Agency, London, UK
| | - Angela Vincent
- Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, UK
| | - Anthony Guy Marson
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
- Department of Pharmacology and Therapeutics, University of Liverpool Institute of Systems, Molecular and Integrative Biology, Liverpool, UK
| | - Sarosh R Irani
- Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, UK
| | - Tom Solomon
- Institute of Infection, Veterinary, and Ecological Science, University of Liverpool Department of Clinical Infection Microbiology and Immunology, Liverpool, UK
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, UK
| | - Benedict D Michael
- Institute of Infection, Veterinary, and Ecological Science, University of Liverpool Department of Clinical Infection Microbiology and Immunology, Liverpool, UK
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, UK
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7
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Smith EMD, Tharmaratnam K, Al-Abadi E, Armon K, Bailey K, Brennan M, Ciurtin C, Gardner-Medwin J, Haslam KE, Hawley D, Leahy A, Leone V, Malik G, McLaren Z, Pilkington C, Ramanan AV, Rangaraj S, Ratcliffe A, Riley P, Sen E, Sridhar A, Wilkinson N, Hedrich CM, Jorgensen A, Beresford MW. Attainment of Low Disease Activity and Remission Targets reduces the risk of severe flare and new damage in Childhood Lupus. Rheumatology (Oxford) 2021; 61:3378-3389. [PMID: 34894234 PMCID: PMC9348762 DOI: 10.1093/rheumatology/keab915] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 12/03/2021] [Indexed: 11/14/2022] Open
Abstract
Objectives To assess the achievability and effect of attaining low disease activity (LDA) or remission in childhood-onset SLE (cSLE). Methods Attainment of three adult-SLE derived definitions of LDA (LLDAS, LA, Toronto-LDA), and four definitions of remission (clinical-SLEDAI-defined remission on/off treatment, pBILAG-defined remission on/off treatment) was assessed in UK JSLE Cohort Study patients longitudinally. Prentice–Williams–Petersen gap recurrent event models assessed the impact of LDA/remission attainment on severe flare/new damage. Results LLDAS, LA and Toronto-LDA targets were reached in 67%, 73% and 32% of patients, after a median of 18, 15 or 17 months, respectively. Cumulatively, LLDAS, LA and Toronto-LDA was attained for a median of 23%, 31% and 19% of total follow-up-time, respectively. Remission on-treatment was more common (61% cSLEDAI-defined, 42% pBILAG-defined) than remission off-treatment (31% cSLEDAI-defined, 21% pBILAG-defined). Attainment of all target states, and disease duration (>1 year), significantly reduced the hazard of severe flare (P < 0.001). As cumulative time in each target increased, hazard of severe flare progressively reduced. LLDAS attainment reduced the hazard of severe flare more than LA or Toronto-LDA (P < 0.001). Attainment of LLDAS and all remission definitions led to a statistically comparable reduction in the hazards of severe flare (P > 0.05). Attainment of all targets reduced the hazards of new damage (P < 0.05). Conclusions This is the first study demonstrating that adult-SLE-derived definitions of LDA/remission are achievable in cSLE, significantly reducing risk of severe flare/new damage. Of the LDA definitions, LLDAS performed best, leading to a statistically comparable reduction in the hazards of severe flare to attainment of clinical remission.
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Affiliation(s)
- Eve M D Smith
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Kukatharmini Tharmaratnam
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Eslam Al-Abadi
- Department of Rheumatology, Birmingham Children's Hospital, Birmingham, UK
| | - Kate Armon
- Department of Paediatric Rheumatology, Cambridge University Hospitals, Cambridge, UK
| | - Kathryn Bailey
- Department of Paediatric Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mary Brennan
- Department of Paediatric Rheumatology, Royal Hospital for Sick Children, Edinburgh, UK
| | - Coziana Ciurtin
- Centre for Adolescent Rheumatology, University College London, London, UK
| | | | - Kirsty E Haslam
- Department of Paediatrics, Bradford Royal Infirmary, Bradford, UK
| | - Daniel Hawley
- Department of Paediatric Rheumatology, Sheffield Children's Hospital, Sheffield, UK
| | - Alice Leahy
- Department of Paediatric Rheumatology, Southampton General Hospital, Southampton, UK
| | - Valentina Leone
- Department of Paediatric Rheumatology, Leeds Children Hospital, Leeds, UK
| | - Gulshan Malik
- Paediatric Rheumatology, Royal Aberdeen Children's Hospital, Aberdeen, UK
| | - Zoe McLaren
- Rheumatology Department, Aintree University Hospital, Liverpool, UK
| | - Clarissa Pilkington
- Department of Paediatric Rheumatology, Great Ormond Street Hospital, London, UK
| | - Athimalaipet V Ramanan
- University Hospitals Bristol NHS Foundation Trust & Bristol Medical School, University of Bristol, Bristol, UK
| | - Satyapal Rangaraj
- Department of Paediatric Rheumatology, Nottingham University Hospitals, Nottingham, UK
| | - Annie Ratcliffe
- Department of Paediatrics, Musgrove Park Hospital, Taunton, UK
| | - Philip Riley
- Department of Paediatric Rheumatology, Royal Manchester Children's Hospital, Manchester, UK
| | - Ethan Sen
- Paediatric Rheumatology, Great North Children's Hospital & Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Arani Sridhar
- Leicester Children's Hospital, University Hospitals of Leicester NHS trust, Leicester, UK
| | - Nick Wilkinson
- Guy's & St Thomas's NHS Foundation Trust, Evelina Children's Hospital, London, UK
| | - Christian M Hedrich
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Andrea Jorgensen
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Michael W Beresford
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
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8
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Bradley P, Frost F, Tharmaratnam K, Wootton DG. Utility of established prognostic scores in COVID-19 hospital admissions: multicentre prospective evaluation of CURB-65, NEWS2 and qSOFA. BMJ Open Respir Res 2020; 7:7/1/e000729. [PMID: 33293361 PMCID: PMC7722817 DOI: 10.1136/bmjresp-2020-000729] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/21/2020] [Accepted: 11/08/2020] [Indexed: 12/24/2022] Open
Abstract
Introduction The COVID-19 pandemic is ongoing, yet, due to the lack of a COVID-19-specific tool, clinicians must use pre-existing illness severity scores for initial prognostication. However, the validity of such scores in COVID-19 is unknown. Methods The North West Collaborative Organisation for Respiratory Research performed a multicentre prospective evaluation of adult patients admitted to the hospital with confirmed COVID-19 during a 2-week period in April 2020. Clinical variables measured as part of usual care at presentation to the hospital were recorded, including the Confusion, Urea, Respiratory Rate, Blood Pressure and Age Above or Below 65 Years (CURB-65), National Early Warning Score 2 (NEWS2) and Quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) scores. The primary outcome of interest was 30-day mortality. Results Data were collected for 830 people with COVID-19 admitted across seven hospitals. By 30 days, a total of 300 (36.1%) had died and 142 (17.1%) had been in the intensive care unit. All scores underestimated mortality compared with pre-COVID-19 cohorts, and overall prognostic performance was generally poor. Among the ‘low-risk’ categories (CURB-65 score<2, NEWS2<5 and qSOFA score<2), 30-day mortality was 16.7%, 32.9% and 21.4%, respectively. NEWS2≥5 had a negative predictive value of 98% for early mortality. Multivariable logistic regression identified features of respiratory compromise rather than circulatory collapse as most relevant prognostic variables. Conclusion In the setting of COVID-19, existing prognostic scores underestimated risk. The design of new prognostic tools should focus on features of respiratory compromise rather than circulatory collapse. We provide a baseline set of variables which are relevant to COVID-19 outcomes and may be used as a basis for developing a bespoke COVID-19 prognostication tool.
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Affiliation(s)
- Patrick Bradley
- Department of Respiratory Medicine, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Freddy Frost
- Department of Respiratory Medicine, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.,Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | | | - Daniel G Wootton
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
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9
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Møller P, Seppälä TT, Bernstein I, Holinski-Feder E, Sala P, Gareth Evans D, Lindblom A, Macrae F, Blanco I, Sijmons RH, Jeffries J, Vasen HFA, Burn J, Nakken S, Hovig E, Rødland EA, Tharmaratnam K, de Vos tot Nederveen Cappel WH, Hill J, Wijnen JT, Jenkins MA, Green K, Lalloo F, Sunde L, Mints M, Bertario L, Pineda M, Navarro M, Morak M, Renkonen-Sinisalo L, Valentin MD, Frayling IM, Plazzer JP, Pylvanainen K, Genuardi M, Mecklin JP, Moeslein G, Sampson JR, Capella G. Cancer risk and survival in path_MMR carriers by gene and gender up to 75 years of age: a report from the Prospective Lynch Syndrome Database. Gut 2018; 67:1306-1316. [PMID: 28754778 PMCID: PMC6031262 DOI: 10.1136/gutjnl-2017-314057] [Citation(s) in RCA: 340] [Impact Index Per Article: 56.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/09/2017] [Accepted: 05/10/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Most patients with path_MMR gene variants (Lynch syndrome (LS)) now survive both their first and subsequent cancers, resulting in a growing number of older patients with LS for whom limited information exists with respect to cancer risk and survival. OBJECTIVE AND DESIGN This observational, international, multicentre study aimed to determine prospectively observed incidences of cancers and survival in path_MMR carriers up to 75 years of age. RESULTS 3119 patients were followed for a total of 24 475 years. Cumulative incidences at 75 years (risks) for colorectal cancer were 46%, 43% and 15% in path_MLH1, path_MSH2 and path_MSH6 carriers; for endometrial cancer 43%, 57% and 46%; for ovarian cancer 10%, 17% and 13%; for upper gastrointestinal (gastric, duodenal, bile duct or pancreatic) cancers 21%, 10% and 7%; for urinary tract cancers 8%, 25% and 11%; for prostate cancer 17%, 32% and 18%; and for brain tumours 1%, 5% and 1%, respectively. Ovarian cancer occurred mainly premenopausally. By contrast, upper gastrointestinal, urinary tract and prostate cancers occurred predominantly at older ages. Overall 5-year survival for prostate cancer was 100%, urinary bladder 93%, ureter 85%, duodenum 67%, stomach 61%, bile duct 29%, brain 22% and pancreas 0%. Path_PMS2 carriers had lower risk for cancer. CONCLUSION Carriers of different path_MMR variants exhibit distinct patterns of cancer risk and survival as they age. Risk estimates for counselling and planning of surveillance and treatment should be tailored to each patient's age, gender and path_MMR variant. We have updated our open-access website www.lscarisk.org to facilitate this.
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Affiliation(s)
- Pål Møller
- Department of Medical Genetics, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway,Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, part of Oslo University Hospital, Olso, Norway,Center for Hereditary Tumors, HELIOS-Klinikum Wuppertal, University of Witten-Herdecke, Wuppertal, Germany
| | - Toni T Seppälä
- Department of Gastrointestinal Surgery, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
| | - Inge Bernstein
- The Danish Hereditary Non-polyposis Colorectal Cancer Register, Clinical Research Centre, Copenhagen University Hospital, Hvidovre, Denmark,Department of Surgical Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | - Elke Holinski-Feder
- Medizinische Klinik und Poliklinik IV, Campus Innenstadt, Klinikum der Universität München, Ziemssenstr, Germany,MGZ – Medizinisch Genetisches Zentrum, Munich, Germany
| | - Paulo Sala
- Unit of Hereditary Digestive Tract Tumors IRCCS Istituto Nazionale Tumori Milan, Milano, Italy
| | - D Gareth Evans
- Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, London, UK,Manchester Centre for Genomic Medicine, University of Manchester, London, UK
| | - Annika Lindblom
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Finlay Macrae
- Colorectal Medicine and Genetics, The Royal Melbourne Hospital, Melborne, Australia,Department of Medicine, Melbourne University, Melborne, Australia
| | - Ignacio Blanco
- Hereditary Cancer Program, Institut Català d’Oncologia-IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Rolf H Sijmons
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jacqueline Jeffries
- Division of Cancer and Genetics, Institute of Medical Genetics, Cardiff University School of Medicine, Heath Park, UK
| | - Hans F A Vasen
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - John Burn
- Institute of Genetic Medicine Newcastle University, Newcastle upon Tyne, UK
| | - Sigve Nakken
- Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, part of Oslo University Hospital, Olso, Norway
| | - Eivind Hovig
- Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, part of Oslo University Hospital, Olso, Norway,Institute of Cancer Genetics and Informatics, The Norwegian Radium Hospital, part of Oslo University Hospital, Olso, Norway,Department of Informatics, University of Oslo, Olso, Norway
| | - Einar Andreas Rødland
- Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, part of Oslo University Hospital, Olso, Norway
| | | | | | - James Hill
- Department of Surgery, Central Manchester University Hospitals NHS Foundation Trust and University of Manchester, London, UK
| | - Juul T Wijnen
- Department of Clinical Genetics and Department of Human Genetics Leiden, University Medical Centre, Leiden, The Netherlands
| | - Mark A Jenkins
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Kate Green
- Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, London, UK,Manchester Centre for Genomic Medicine, University of Manchester, London, UK
| | - Fiona Lalloo
- Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, London, UK,Manchester Centre for Genomic Medicine, University of Manchester, London, UK
| | - Lone Sunde
- Department of Surgical Gastroenterology, Aalborg University Hospital, Aalborg, Denmark,Department of Clinical Genetics, Aarhus University Hospital, Aarhus, Denmark,Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Miriam Mints
- Department of Women’s and Children’s health, Division of Obstetrics and Gyneacology, Karolinska Institutet, Karolinska University Hospital, Solna, Stockholm, Sweden
| | - Lucio Bertario
- Unit of Hereditary Digestive Tract Tumors IRCCS Istituto Nazionale Tumori Milan, Milano, Italy
| | - Marta Pineda
- Hereditary Cancer Program, Institut Català d’Oncologia-IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Matilde Navarro
- Hereditary Cancer Program, Institut Català d’Oncologia-IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Monika Morak
- Medizinische Klinik und Poliklinik IV, Campus Innenstadt, Klinikum der Universität München, Ziemssenstr, Germany,MGZ – Medizinisch Genetisches Zentrum, Munich, Germany
| | - Laura Renkonen-Sinisalo
- Department of Gastrointestinal Surgery, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland,Genome-Scale Biology Research Program, University of Helsinki, Helsinki, Finland
| | - Mev Dominguez Valentin
- Department of Medical Genetics, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway,Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, part of Oslo University Hospital, Olso, Norway
| | | | - John-Paul Plazzer
- Colorectal Medicine and Genetics, The Royal Melbourne Hospital, Melborne, Australia
| | - Kirsi Pylvanainen
- Department of Education and Science, Central Finland Health Care District, yväskylä, Finland
| | - Maurizio Genuardi
- Institute of Genomic Medicine, “A. Gemelli” Faculty of Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | | | | | - Julian R Sampson
- Division of Cancer and Genetics, Institute of Medical Genetics, Cardiff University School of Medicine, Heath Park, UK
| | - Gabriel Capella
- Hereditary Cancer Program, Institut Català d’Oncologia-IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain,Center for Hereditary Tumors, HELIOS-Klinikum Wuppertal, University of Witten-Herdecke, Wuppertal, Germany
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Seppälä T, Pylvänäinen K, Evans DG, Järvinen H, Renkonen-Sinisalo L, Bernstein I, Holinski-Feder E, Sala P, Lindblom A, Macrae F, Blanco I, Sijmons R, Jeffries J, Vasen H, Burn J, Nakken S, Hovig E, Rødland EA, Tharmaratnam K, de Vos Tot Nederveen Cappel WH, Hill J, Wijnen J, Jenkins M, Genuardi M, Green K, Lalloo F, Sunde L, Mints M, Bertario L, Pineda M, Navarro M, Morak M, Frayling IM, Plazzer JP, Sampson JR, Capella G, Möslein G, Mecklin JP, Møller P. Colorectal cancer incidence in path_MLH1 carriers subjected to different follow-up protocols: a Prospective Lynch Syndrome Database report. Hered Cancer Clin Pract 2017; 15:18. [PMID: 29046738 PMCID: PMC5635542 DOI: 10.1186/s13053-017-0078-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 10/02/2017] [Indexed: 12/31/2022] Open
Abstract
Background We have previously reported a high incidence of colorectal cancer (CRC) in carriers of pathogenic MLH1 variants (path_MLH1) despite follow-up with colonoscopy including polypectomy. Methods The cohort included Finnish carriers enrolled in 3-yearly colonoscopy (n = 505; 4625 observation years) and carriers from other countries enrolled in colonoscopy 2-yearly or more frequently (n = 439; 3299 observation years). We examined whether the longer interval between colonoscopies in Finland could explain the high incidence of CRC and whether disease expression correlated with differences in population CRC incidence. Results Cumulative CRC incidences in carriers of path_MLH1 at 70-years of age were 41% for males and 36% for females in the Finnish series and 58% and 55% in the non-Finnish series, respectively (p > 0.05). Mean time from last colonoscopy to CRC was 32.7 months in the Finnish compared to 31.0 months in the non-Finnish (p > 0.05) and was therefore unaffected by the recommended colonoscopy interval. Differences in population incidence of CRC could not explain the lower point estimates for CRC in the Finnish series. Ten-year overall survival after CRC was similar for the Finnish and non-Finnish series (88% and 91%, respectively; p > 0.05). Conclusions The hypothesis that the high incidence of CRC in path_MLH1 carriers was caused by a higher incidence in the Finnish series was not valid. We discuss whether the results were influenced by methodological shortcomings in our study or whether the assumption that a shorter interval between colonoscopies leads to a lower CRC incidence may be wrong. This second possibility is intriguing, because it suggests the dogma that CRC in path_MLH1 carriers develops from polyps that can be detected at colonoscopy and removed to prevent CRC may be erroneous. In view of the excellent 10-year overall survival in the Finnish and non-Finnish series we remain strong advocates of current surveillance practices for those with LS pending studies that will inform new recommendations on the best surveillance interval. Electronic supplementary material The online version of this article (10.1186/s13053-017-0078-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Toni Seppälä
- Department of Surgery, Helsinki University Hospital and University of Helsinki, Post Box 340, 00029 Helsinki, Finland.,Finnish Lynch Syndrome registry, Helsinki University Hospital, Helsinki, Finland
| | - Kirsi Pylvänäinen
- Finnish Lynch Syndrome registry, Helsinki University Hospital, Helsinki, Finland.,Department of Education and Science, Central Finland Health Care District, Jyväskylä, Finland
| | - Dafydd Gareth Evans
- Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK.,Manchester Centre for Genomic Medicine, Institute of Human Development, MAHSC, University of Manchester, Manchester, UK
| | - Heikki Järvinen
- Department of Surgery, Helsinki University Hospital and University of Helsinki, Post Box 340, 00029 Helsinki, Finland.,Finnish Lynch Syndrome registry, Helsinki University Hospital, Helsinki, Finland
| | - Laura Renkonen-Sinisalo
- Department of Surgery, Helsinki University Hospital and University of Helsinki, Post Box 340, 00029 Helsinki, Finland.,Genome-Scale Biology Research Program, University of Helsinki, Helsinki, Finland
| | - Inge Bernstein
- Danish HNPCC Register, Hvidovre University Hospital, Copenhagen, Denmark.,Department Surgical Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | - Elke Holinski-Feder
- Medizinische Klinik und Poliklinik IV, Campus Innenstadt, Klinikum der Universität München, Ziemssenstr. 1, 80336 Munich, Germany.,MGZ - Medizinisch Genetisches Zentrum, Bayerstr. 3-5, 80335 Munich, Germany
| | - Paola Sala
- Unit of Hereditary Digestive Tract Tumors IRCCS Istituto Nazionale Tumori Milan, Milan, Italy
| | - Annika Lindblom
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Finlay Macrae
- Colorectal Medicine and Genetics, The Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, Melbourne University, Melbourne, Australia
| | - Ignacio Blanco
- Hereditary Cancer Program. Institut Català d'Oncologia-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Rolf Sijmons
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Jacqueline Jeffries
- Institute of Medical Genetics, Cardiff University School of Medicine, Heath Park, Cardiff, CF14 4XN UK
| | - Hans Vasen
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - John Burn
- Institute of Human Genetics, Newcastle upon Tyne, UK
| | - Sigve Nakken
- Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, part of Oslo University Hospital, Oslo, Norway
| | - Eivind Hovig
- Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, part of Oslo University Hospital, Oslo, Norway.,Institute of Cancer Genetics and Informatics, The Norwegian Radium Hospital, part of Oslo University Hospital, Oslo, Norway.,Department of Informatics, University of Oslo, Oslo, Norway
| | - Einar Andreas Rødland
- Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, part of Oslo University Hospital, Oslo, Norway
| | | | | | - James Hill
- Department of Surgery, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Juul Wijnen
- Department of Clinical Genetics and Department of Human Genetics Leiden University Medical Centre, Leiden, The Netherlands
| | - Mark Jenkins
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, VIC Australia
| | | | - Kate Green
- Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Fiona Lalloo
- Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Lone Sunde
- Danish HNPCC Register, Hvidovre University Hospital, Copenhagen, Denmark.,Department of Clinical Genetics, Aarhus University Hospital, Aarhus, Denmark.,Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Miriam Mints
- Department of Women's and Children's health, Division of Obstetrics and Gynecology, Karolinska Institutet, Karolinska University Hospital, Solna S171 76, Stockholm, Sweden
| | - Lucio Bertario
- Unit of Hereditary Digestive Tract Tumors IRCCS Istituto Nazionale Tumori Milan, Milan, Italy
| | - Marta Pineda
- Hereditary Cancer Program. Institut Català d'Oncologia-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Matilde Navarro
- Hereditary Cancer Program. Institut Català d'Oncologia-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Monika Morak
- Medizinische Klinik und Poliklinik IV, Campus Innenstadt, Klinikum der Universität München, Ziemssenstr. 1, 80336 Munich, Germany.,MGZ - Medizinisch Genetisches Zentrum, Bayerstr. 3-5, 80335 Munich, Germany
| | - Ian M Frayling
- Institute of Medical Genetics, Cardiff University School of Medicine, Heath Park, Cardiff, CF14 4XN UK
| | - John-Paul Plazzer
- Colorectal Medicine and Genetics, The Royal Melbourne Hospital, Melbourne, Australia
| | - Julian R Sampson
- Institute of Medical Genetics, Cardiff University School of Medicine, Heath Park, Cardiff, CF14 4XN UK
| | - Gabriel Capella
- Hereditary Cancer Program. Institut Català d'Oncologia-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Gabriela Möslein
- Center for Hereditary Tumors, HELIOS University Hospital Wuppertal, University Witten/Herdecke, Witten, Germany.,Department für Humanmedizin, Universität Witten/Herdecke, Witten, Germany
| | - Jukka-Pekka Mecklin
- Department of Education and Science, Central Finland Health Care District, Jyväskylä, Finland.,University of Eastern Finland, Kuopio, Finland
| | - Pål Møller
- Research Group Inherited Cancer, The Norwegian Radium Hospital, Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
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11
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Møller P, Seppälä T, Bernstein I, Holinski-Feder E, Sala P, Evans DG, Lindblom A, Macrae F, Blanco I, Sijmons R, Jeffries J, Vasen H, Burn J, Nakken S, Hovig E, Rødland EA, Tharmaratnam K, de Vos tot Nederveen Cappel WH, Hill J, Wijnen J, Jenkins M, Green K, Lalloo F, Sunde L, Mints M, Bertario L, Pineda M, Navarro M, Morak M, Renkonen-Sinisalo L, Frayling IM, Plazzer JP, Pylvanainen K, Genuardi M, Mecklin JP, Möslein G, Sampson JR, Capella G. Incidence of and survival after subsequent cancers in carriers of pathogenic MMR variants with previous cancer: a report from the prospective Lynch syndrome database. Gut 2017; 66:1657-1664. [PMID: 27261338 PMCID: PMC5561364 DOI: 10.1136/gutjnl-2016-311403] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 05/06/2016] [Accepted: 05/10/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Today most patients with Lynch syndrome (LS) survive their first cancer. There is limited information on the incidences and outcome of subsequent cancers. The present study addresses three questions: (i) what is the cumulative incidence of a subsequent cancer; (ii) in which organs do subsequent cancers occur; and (iii) what is the survival following these cancers? DESIGN Information was collated on prospectively organised surveillance and prospectively observed outcomes in patients with LS who had cancer prior to inclusion and analysed by age, gender and genetic variants. RESULTS 1273 patients with LS from 10 countries were followed up for 7753 observation years. 318 patients (25.7%) developed 341 first subsequent cancers, including colorectal (n=147, 43%), upper GI, pancreas or bile duct (n=37, 11%) and urinary tract (n=32, 10%). The cumulative incidences for any subsequent cancer from age 40 to age 70 years were 73% for pathogenic MLH1 (path_MLH1), 76% for path_MSH2 carriers and 52% for path_MSH6 carriers, and for colorectal cancer (CRC) the cumulative incidences were 46%, 48% and 23%, respectively. Crude survival after any subsequent cancer was 82% (95% CI 76% to 87%) and 10-year crude survival after CRC was 91% (95% CI 83% to 95%). CONCLUSIONS Relative incidence of subsequent cancer compared with incidence of first cancer was slightly but insignificantly higher than cancer incidence in patients with LS without previous cancer (range 0.94-1.49). The favourable survival after subsequent cancers validated continued follow-up to prevent death from cancer. The interactive website http://lscarisk.org was expanded to calculate the risks by gender, genetic variant and age for subsequent cancer for any patient with LS with previous cancer.
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Affiliation(s)
- Pål Møller
- Research Group Inherited Cancer, Department of Medical Genetics, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
- Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, Part of Oslo University Hospital, Oslo, Norway
- Surgical Center for Hereditary Tumors, HELIOS University Clinic Wuppertal, University Witten-Herdecke, Wuppertal, Germany
| | - Toni Seppälä
- Department of Surgery, Central Finland Health Care District, Jyväskylä, Finland
| | - Inge Bernstein
- The Danish Hereditary Non-polyposis Colorectal Cancer Register, Clinical Research Centre, Copenhagen University Hospital, Hvidovre, Denmark
- Department Surgical Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | - Elke Holinski-Feder
- Medizinische Klinik und Poliklinik IV, Campus Innenstadt, Klinikum der Universität München, Munich, Germany
- MGZ—Medizinisch Genetisches Zentrum, Munich, Germany
| | - Paola Sala
- Unit of Hereditary Digestive Tract Tumors IRCCS, Istituto Nazionale Tumori, Milan, Italy
| | - D Gareth Evans
- Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
- Manchester Centre for Genomic Medicine, University of Manchester, Manchester, UK
| | - Annika Lindblom
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Finlay Macrae
- Colorectal Medicine and Genetics, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine, Melbourne University, Melbourne, Australia
| | - Ignacio Blanco
- Hereditary Cancer Program, Institut Català d'Oncologia-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Rolf Sijmons
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jacqueline Jeffries
- Institute of Medical Genetics, Cardiff University School of Medicine, Cardiff, UK
| | - Hans Vasen
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - John Burn
- Institute of Genetic Medicine Newcastle University, Newcastle upon Tyne, UK
| | - Sigve Nakken
- Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, Part of Oslo University Hospital, Oslo, Norway
| | - Eivind Hovig
- Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, Part of Oslo University Hospital, Oslo, Norway
- Institute of Cancer Genetics and Informatics, The Norwegian Radium Hospital, Part of Oslo University Hospital, Oslo, Norway
- Department of Informatics, University of Oslo, Oslo, Norway
| | - Einar Andreas Rødland
- Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, Part of Oslo University Hospital, Oslo, Norway
| | | | | | - James Hill
- Department of Surgery, Central Manchester University Hospitals NHS Foundation Trust and University of Manchester, Manchester, UK
| | - Juul Wijnen
- Department of Clinical Genetics and Department of Human Genetics Leiden University Medical Centre, Leiden, The Netherlands
| | - Mark Jenkins
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Kate Green
- Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Fiona Lalloo
- Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Lone Sunde
- The Danish Hereditary Non-polyposis Colorectal Cancer Register, Clinical Research Centre, Copenhagen University Hospital, Hvidovre, Denmark
- Department of Clinical Genetics, Aarhus University Hospital, Aarhus, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Miriam Mints
- Division of Obstetrics and Gynecology, Department of Women's and Children's health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Lucio Bertario
- Unit of Hereditary Digestive Tract Tumors IRCCS, Istituto Nazionale Tumori, Milan, Italy
| | - Marta Pineda
- Hereditary Cancer Program, Institut Català d'Oncologia-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Matilde Navarro
- Hereditary Cancer Program, Institut Català d'Oncologia-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Monika Morak
- Medizinische Klinik und Poliklinik IV, Campus Innenstadt, Klinikum der Universität München, Munich, Germany
- MGZ—Medizinisch Genetisches Zentrum, Munich, Germany
| | - Laura Renkonen-Sinisalo
- Department of Surgery, Helsinki University Hospital, Helsinki, Finland
- Genome-Scale Biology Research Program, University of Helsinki, Helsinki, Finland
| | - Ian M Frayling
- Institute of Medical Genetics, Cardiff University School of Medicine, Cardiff, UK
| | - John-Paul Plazzer
- Colorectal Medicine and Genetics, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Kirsi Pylvanainen
- Department of Education and Science, Central Finland Health Care District, Jyväskylä, Finland
| | - Maurizio Genuardi
- Institute of Genomic Medicine, “A. Gemelli” Faculty of Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | - Jukka-Pekka Mecklin
- Department of Education and Science, Central Finland Health Care District, Jyväskylä, Finland
- University of Eastern Finland, Jyvaskyla, Finland
| | - Gabriela Möslein
- Surgical Center for Hereditary Tumors, HELIOS University Clinic Wuppertal, University Witten-Herdecke, Wuppertal, Germany
| | - Julian R Sampson
- Institute of Medical Genetics, Cardiff University School of Medicine, Cardiff, UK
| | - Gabriel Capella
- Hereditary Cancer Program, Institut Català d'Oncologia-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
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Møller P, Seppälä T, Bernstein I, Holinski-Feder E, Sala P, Evans DG, Lindblom A, Macrae F, Blanco I, Sijmons R, Jeffries J, Vasen H, Burn J, Nakken S, Hovig E, Rødland EA, Tharmaratnam K, de Vos tot Nederveen Cappel WH, Hill J, Wijnen J, Green K, Lalloo F, Sunde L, Mints M, Bertario L, Pineda M, Navarro M, Morak M, Renkonen-Sinisalo L, Frayling IM, Plazzer JP, Pylvanainen K, Sampson JR, Capella G, Mecklin JP, Möslein G. Cancer incidence and survival in Lynch syndrome patients receiving colonoscopic and gynaecological surveillance: first report from the prospective Lynch syndrome database. Gut 2017; 66:464-472. [PMID: 26657901 PMCID: PMC5534760 DOI: 10.1136/gutjnl-2015-309675] [Citation(s) in RCA: 341] [Impact Index Per Article: 48.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 11/06/2015] [Accepted: 11/17/2015] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Estimates of cancer risk and the effects of surveillance in Lynch syndrome have been subject to bias, partly through reliance on retrospective studies. We sought to establish more robust estimates in patients undergoing prospective cancer surveillance. DESIGN We undertook a multicentre study of patients carrying Lynch syndrome-associated mutations affecting MLH1, MSH2, MSH6 or PMS2. Standardised information on surveillance, cancers and outcomes were collated in an Oracle relational database and analysed by age, sex and mutated gene. RESULTS 1942 mutation carriers without previous cancer had follow-up including colonoscopic surveillance for 13 782 observation years. 314 patients developed cancer, mostly colorectal (n=151), endometrial (n=72) and ovarian (n=19). Cancers were detected from 25 years onwards in MLH1 and MSH2 mutation carriers, and from about 40 years in MSH6 and PMS2 carriers. Among first cancer detected in each patient the colorectal cancer cumulative incidences at 70 years by gene were 46%, 35%, 20% and 10% for MLH1, MSH2, MSH6 and PMS2 mutation carriers, respectively. The equivalent cumulative incidences for endometrial cancer were 34%, 51%, 49% and 24%; and for ovarian cancer 11%, 15%, 0% and 0%. Ten-year crude survival was 87% after any cancer, 91% if the first cancer was colorectal, 98% if endometrial and 89% if ovarian. CONCLUSIONS The four Lynch syndrome-associated genes had different penetrance and expression. Colorectal cancer occurred frequently despite colonoscopic surveillance but resulted in few deaths. Using our data, a website has been established at http://LScarisk.org enabling calculation of cumulative cancer risks as an aid to genetic counselling in Lynch syndrome.
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Affiliation(s)
- Pål Møller
- Research Group Inherited Cancer, Department of Medical Genetics, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Toni Seppälä
- Department of Surgery, Central Finland Health Care District, Jyväskylä, Finland
| | - Inge Bernstein
- Danish HNPCC Register; Hvidovre University Hospital, Copenhagen, Denmark
- Department Surgical Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | - Elke Holinski-Feder
- Medizinische Klinik und Poliklinik IV, Campus Innenstadt, Klinikum der Universität München, Ziemssenstr. 1, Munich, Germany
- MGZ—Medizinisch Genetisches Zentrum, Munich, Germany
| | - Paola Sala
- Unit of Hereditary Digestive Tract Tumors IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - D Gareth Evans
- Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
- Manchester Centre for Genomic Medicine, University of Manchester, Manchester, UK
| | - Annika Lindblom
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Finlay Macrae
- Colorectal Medicine and Genetics, The Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, Melbourne University, Melbourne, Australia
| | - Ignacio Blanco
- Hereditary Cancer Program, Institut Català d'Oncologia-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Rolf Sijmons
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jacqueline Jeffries
- Institute of Medical Genetics, Cardiff University School of Medicine, Heath Park, Cardiff, UK
| | - Hans Vasen
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - John Burn
- Institute of Genetic Medicine Newcastle University, Newcastle upon Tyne, UK
| | - Sigve Nakken
- Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, part of Oslo University Hospital, Oslo, Norway
- Institute of Cancer Genetics and Informatics, The Norwegian Radium Hospital, part of Oslo University Hospital, Oslo, Norway
| | - Eivind Hovig
- Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, part of Oslo University Hospital, Oslo, Norway
- Institute of Cancer Genetics and Informatics, The Norwegian Radium Hospital, part of Oslo University Hospital, Oslo, Norway
- Department of Informatics, University of Oslo, Oslo, Norway
| | - Einar Andreas Rødland
- Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, part of Oslo University Hospital, Oslo, Norway
| | | | | | - James Hill
- Department of Surgery, Central Manchester University Hospitals NHS Foundation Trust and University of Manchester, Manchester, UK
| | - Juul Wijnen
- Department of Clinical Genetics and Department of Human Genetics Leiden University Medical Centre, Leiden, The Netherlands
| | - Kate Green
- Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Fiona Lalloo
- Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Lone Sunde
- Danish HNPCC Register; Hvidovre University Hospital, Copenhagen, Denmark
- Department of Clinical Genetics, Aarhus University Hospital, Aarhus, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Miriam Mints
- Division of Obstetrics and Gynecology, Department of Women's and Children's health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Lucio Bertario
- Unit of Hereditary Digestive Tract Tumors IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Marta Pineda
- Hereditary Cancer Program, Institut Català d'Oncologia-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Matilde Navarro
- Hereditary Cancer Program, Institut Català d'Oncologia-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Monika Morak
- Medizinische Klinik und Poliklinik IV, Campus Innenstadt, Klinikum der Universität München, Ziemssenstr. 1, Munich, Germany
- MGZ—Medizinisch Genetisches Zentrum, Munich, Germany
| | - Laura Renkonen-Sinisalo
- Department of Surgery, Helsinki University Hospital, Helsinki, Finland
- Genome-Scale Biology Research Program, University of Helsinki, Helsinki, Finland
| | - Ian M Frayling
- Institute of Medical Genetics, Cardiff University School of Medicine, Heath Park, Cardiff, UK
| | - John-Paul Plazzer
- Colorectal Medicine and Genetics, The Royal Melbourne Hospital, Melbourne, Australia
| | - Kirsi Pylvanainen
- Department of Education and Science, Central Finland Health Care District, Jyväskylä, Finland
| | - Julian R Sampson
- Institute of Medical Genetics, Cardiff University School of Medicine, Heath Park, Cardiff, UK
| | - Gabriel Capella
- Hereditary Cancer Program, Institut Català d'Oncologia-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Jukka-Pekka Mecklin
- Department of Education and Science, Central Finland Health Care District, Jyväskylä, Finland
- University of Eastern Finland, Jyväskylä, Finland
| | - Gabriela Möslein
- Department of Surgery, HELIOS St Josefs Hospital Bochum-Linden (Helios), Bochum, Germany
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Lamont A, Lyons MD, Jaki T, Stuart E, Feaster DJ, Tharmaratnam K, Oberski D, Ishwaran H, Wilson DK, Van Horn ML. Identification of predicted individual treatment effects in randomized clinical trials. Stat Methods Med Res 2016; 27:142-157. [DOI: 10.1177/0962280215623981] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
In most medical research, treatment effectiveness is assessed using the average treatment effect or some version of subgroup analysis. The practice of individualized or precision medicine, however, requires new approaches that predict how an individual will respond to treatment, rather than relying on aggregate measures of effect. In this study, we present a conceptual framework for estimating individual treatment effects, referred to as predicted individual treatment effects. We first apply the predicted individual treatment effect approach to a randomized controlled trial designed to improve behavioral and physical symptoms. Despite trivial average effects of the intervention, we show substantial heterogeneity in predicted individual treatment response using the predicted individual treatment effect approach. The predicted individual treatment effects can be used to predict individuals for whom the intervention may be most effective (or harmful). Next, we conduct a Monte Carlo simulation study to evaluate the accuracy of predicted individual treatment effects. We compare the performance of two methods used to obtain predictions: multiple imputation and non-parametric random decision trees. Results showed that, on average, both predictive methods produced accurate estimates at the individual level; however, the random decision trees tended to underestimate the predicted individual treatment effect for people at the extreme and showed more variability in predictions across repetitions compared to the imputation approach. Limitations and future directions are discussed.
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Affiliation(s)
- Andrea Lamont
- Department of Psychology, Barnwell College, University of South Carolina, Columbia, USA
| | - Michael D Lyons
- Department of Psychology, University of Houston, Houston, USA
| | - Thomas Jaki
- Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
| | - Elizabeth Stuart
- Department of Mental Health, Department of Biostatistics, and Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins, Baltimore, MD, USA
| | - Daniel J Feaster
- Department of Public Health Sciences, Division of Biostatistics, University of Miami, Miami, FL, USA
| | | | - Daniel Oberski
- Department of Methodology and Statistics, Tilburg University, Tilburg, the Netherlands
| | - Hemant Ishwaran
- Department of Public Health Sciences, Division of Biostatistics, University of Miami, Miami, FL, USA
| | - Dawn K Wilson
- Department of Psychology, Barnwell College, University of South Carolina, Columbia, USA
| | - M Lee Van Horn
- Department of Individual, Family and Community Education, University of New Mexico, Albuquerque, NM, USA
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Heramb C, Ekstrøm PO, Tharmaratnam K, Hovig E, Møller P, Mæhle L. Ten modifiers of BRCA1 penetrance validated in a Norwegian series. Hered Cancer Clin Pract 2015; 13:14. [PMID: 26052370 PMCID: PMC4456774 DOI: 10.1186/s13053-015-0035-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 05/19/2015] [Indexed: 11/13/2022] Open
Abstract
Background Common genetic variants have been shown to modify BRCA1 penetrance. The aim of this study was to validate these reports in a special cohort of Norwegian BRCA1 mutation carriers that were selected for their extreme age of onset of disease. Methods The ten variants rs13387042, rs3803662, rs8170, rs9397435, rs700518, rs10046, rs3834129, rs1045485, rs2363956 and rs16942 were selected to be tested on samples from our biobank. We selected female BRCA1 mutation carriers having had a diagnosis of breast or ovarian cancer below 40 years of age (young cancer group, N = 40), and mutation carriers having had neither breast nor ovarian cancer above 60 years of age (i.e., old no cancer group, N = 38). Relative risks and odd ratios of belonging to the young cancer versus old no cancer groups were calculated as a function of having or not having the SNPs in question. Results Five of the ten variants were found to be significantly associated with early onset cancer. Some of the variation between our results and those previously reported may be ascribed to stochastic effects in our limited number of patient studies, and/or genetic drift in linkage disequilibrium in the genetically isolated Norwegian population. This is in accordance with the understanding that the SNPs are markers in linkage disequilibrium with their respective disease-causing genetic variants, and that this may vary between different populations. Conclusions The results confirmed associations previously reported, with the notion that the degree of association may differ between other populations, which must be considered when discussing the clinical use of the associations described. Electronic supplementary material The online version of this article (doi:10.1186/s13053-015-0035-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Cecilie Heramb
- Research Group on Inherited Cancer, Department of Medical Genetics, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway
| | - Per Olaf Ekstrøm
- Department of Tumor Biology, Institute for Cancer Research The Norwegian Radium Hospital, Oslo, Norway
| | | | - Eivind Hovig
- Department of Tumor Biology, Institute for Cancer Research The Norwegian Radium Hospital, Oslo, Norway
| | - Pål Møller
- Research Group on Inherited Cancer, Department of Medical Genetics, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway
| | - Lovise Mæhle
- Research Group on Inherited Cancer, Department of Medical Genetics, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway
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Møller P, Tharmaratnam K, Howell A, Stavrinos P, Sampson S, Wallace A, Maxwell AJ, Hagen AI, Evans DG. Tumour characteristics and survival in familial breast cancer prospectively diagnosed by annual mammography. Breast Cancer Res Treat 2015; 152:87-94. [PMID: 26037256 PMCID: PMC4468806 DOI: 10.1007/s10549-015-3448-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 05/25/2015] [Indexed: 11/26/2022]
Abstract
Women from breast cancer families without a demonstrable BRCA1/2 mutation were subjected to annual mammography from age 30 years onwards. One-hundred and ninety-eight patients were diagnosed prospectively with invasive breast cancer and followed for a total of 1513 years. Overall 10-year survival was 88 %. Together with our previous report that women in such kindreds had about twice the population risk of breast cancer, the combined conclusion was that the overall chances of developing breast cancer causing death within 10 years before 50 years of age was 1 % or less when subjected to annual mammography and current treatment. These are empirical prospective observations which may be used for genetic counselling. The majority (160/194 = 84 %) of patients had ER+ and/or low grade tumours with 92 % 10-year survival. One minor group of the patients had ER- tumours, another small group had high grade tumours with nodal spread, both groups were associated with worse prognosis, but the two groups were not mutually associated.
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Affiliation(s)
- Pål Møller
- Research Group Inherited Cancer, Oslo University Hospital, Oslo, Norway.
| | | | - Anthony Howell
- Nightingale and Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester NHS Foundation Trust, Wythenshawe, Manchester, M23 9LT, United Kingdom
- Institute of Cancer Sciences, University of Manchester, Oxford Road, Manchester, M13 9PT, United Kingdom
| | - Paula Stavrinos
- Nightingale and Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester NHS Foundation Trust, Wythenshawe, Manchester, M23 9LT, United Kingdom
| | - Sarah Sampson
- Nightingale and Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester NHS Foundation Trust, Wythenshawe, Manchester, M23 9LT, United Kingdom
| | - Andrew Wallace
- Genomic Medicine, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom
- Institute of Human Development and Central Manchester Foundation Trust, Manchester, M13 9WL, United Kingdom
| | - Anthony J Maxwell
- Nightingale and Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester NHS Foundation Trust, Wythenshawe, Manchester, M23 9LT, United Kingdom
- Institute of Population Health, University of Manchester, Oxford Road, Manchester, M13 9PT, United Kingdom
| | - Anne Irene Hagen
- Department of Breast and Endocrine Surgery, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Laboratory Medicine, Children's and Women's Health, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - D Gareth Evans
- Nightingale and Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester NHS Foundation Trust, Wythenshawe, Manchester, M23 9LT, United Kingdom
- Genomic Medicine, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom
- Institute of Human Development and Central Manchester Foundation Trust, Manchester, M13 9WL, United Kingdom
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