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Martin NG, Defres S, Willis L, Beckley R, Hardwick H, Coxon A, Kadambari S, Yu LM, Liu X, Galal U, Conlin K, Griffiths MJ, Kneen R, Nadel S, Heath PT, Kelly DE, Solomon T, Sadarangani M, Pollard AJ. Paediatric meningitis in the conjugate vaccine era and a novel clinical decision model to predict bacterial aetiology. J Infect 2024; 88:106145. [PMID: 38552719 DOI: 10.1016/j.jinf.2024.106145] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 03/13/2024] [Accepted: 03/22/2024] [Indexed: 04/16/2024]
Abstract
OBJECTIVES The aims of this study were to assess aetiology and clinical characteristics in childhood meningitis, and develop clinical decision rules to distinguish bacterial meningitis from other similar clinical syndromes. METHODS Children aged <16 years hospitalised with suspected meningitis/encephalitis were included, and prospectively recruited at 31 UK hospitals. Meningitis was defined as identification of bacteria/viruses from cerebrospinal fluid (CSF) and/or a raised CSF white blood cell count. New clinical decision rules were developed to distinguish bacterial from viral meningitis and those of alternative aetiology. RESULTS The cohort included 3002 children (median age 2·4 months); 1101/3002 (36·7%) had meningitis, including 180 bacterial, 423 viral and 280 with no pathogen identified. Enterovirus was the most common pathogen in those aged <6 months and 10-16 years, with Neisseria meningitidis and/or Streptococcus pneumoniae commonest at age 6 months to 9 years. The Bacterial Meningitis Score had a negative predictive value of 95·3%. We developed two clinical decision rules, that could be used either before (sensitivity 82%, specificity 71%) or after lumbar puncture (sensitivity 84%, specificity 93%), to determine risk of bacterial meningitis. CONCLUSIONS Bacterial meningitis comprised 6% of children with suspected meningitis/encephalitis. Our clinical decision rules provide potential novel approaches to assist with identifying children with bacterial meningitis. FUNDING This study was funded by the Meningitis Research Foundation, Pfizer and the NIHR Programme Grants for Applied Research.
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Affiliation(s)
- N G Martin
- Department of Paediatrics, University of Oxford and the Oxford University Hospitals NHS Foundation Trust, Level 2, Children's Hospital, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK; Department of Paediatrics, University of Otago Christchurch, 2 Riccarton Avenue, Christchurch Central City, Christchurch 8011, New Zealand
| | - S Defres
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool L69 3BX, UK
| | - L Willis
- Department of Paediatrics, University of Oxford and the Oxford University Hospitals NHS Foundation Trust, Level 2, Children's Hospital, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
| | - R Beckley
- Department of Paediatrics, University of Oxford and the Oxford University Hospitals NHS Foundation Trust, Level 2, Children's Hospital, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
| | - H Hardwick
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool L69 3BX, UK
| | - A Coxon
- Department of Paediatrics, University of Oxford and the Oxford University Hospitals NHS Foundation Trust, Level 2, Children's Hospital, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
| | - S Kadambari
- Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK; Infection, Immunity & Inflammation Department, University College London, Great Ormond Street Institute of Child Health, 30 Guilford St, London WC1N 1EH, UK
| | - L-M Yu
- Nuffield Department of Primary Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Rd, Oxford OX2 6GG, UK
| | - X Liu
- Department of Paediatrics, University of Oxford and the Oxford University Hospitals NHS Foundation Trust, Level 2, Children's Hospital, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
| | - U Galal
- Department of Paediatrics, University of Oxford and the Oxford University Hospitals NHS Foundation Trust, Level 2, Children's Hospital, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
| | - K Conlin
- Department of Paediatrics, University of Oxford and the Oxford University Hospitals NHS Foundation Trust, Level 2, Children's Hospital, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
| | - M J Griffiths
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool L69 3BX, UK; Department of Neurology, Alder Hey Children's NHS Trust, E Prescot Rd, Liverpool L14 5AB, UK
| | - R Kneen
- Department of Neurology, Alder Hey Children's NHS Trust, E Prescot Rd, Liverpool L14 5AB, UK
| | - S Nadel
- Department of Paediatrics, St. Mary's Hospital, Praed St, London W2 1NY, UK
| | - P T Heath
- Centre for Neonatal and Paediatric Infection & Vaccine Institute, St. George's, University of London, Cranmer Terrace, London SW17 0RE, UK
| | - D E Kelly
- Department of Paediatrics, University of Oxford and the Oxford University Hospitals NHS Foundation Trust, Level 2, Children's Hospital, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
| | - T Solomon
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool L69 3BX, UK; Department of Neurology, Walton Centre NHS Foundation Trust, Lower Ln, Fazakerley, Liverpool L9 7LJ, UK
| | - M Sadarangani
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, 950 West 28th Ave, Vancouver, BC V5Z 4H4, Canada; Department of Pediatrics, University of British Columbia, 4480 Oak Street, Vancouver, BC V5Z 4H4, Canada.
| | - A J Pollard
- Department of Paediatrics, University of Oxford and the Oxford University Hospitals NHS Foundation Trust, Level 2, Children's Hospital, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
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Abdel-Mannan O, Champsas D, Tur C, Lee V, Manivannan S, Usman H, Skippen A, Desai I, Chitre M, Forsyth R, Kneen R, Ram D, Ramdas S, Rossor T, West S, Wright S, Palace J, Wassmer E, Hemingway C, Lim MJ, Mankad K, Ciccarelli O, Hacohen Y. Evolution of brain MRI lesions in paediatric myelin-oligodendrocyte glycoprotein antibody-associated disease (MOGAD) and its relevance to disease course. J Neurol Neurosurg Psychiatry 2024; 95:426-433. [PMID: 37979966 DOI: 10.1136/jnnp-2023-332542] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 10/23/2023] [Indexed: 11/20/2023]
Abstract
BACKGROUND Lesion resolution is often observed in children with myelin-oligodendrocyte glycoprotein antibody-associated disease (MOGAD), and asymptomatic lesions are less commonly reported in MOGAD than in multiple sclerosis (MS). OBJECTIVE We aimed to evaluate brain MRI changes over time in paediatric MOGAD. METHODS Retrospective study in eight UK paediatric neuroscience centres. Acute brain MRI and available follow-up MRIs were reviewed. Predictors for lesion dynamic were evaluated using multivariable regression and Kaplan-Meier survival analyses were used to predict risk of relapse, disability and MOG-Ab status. RESULTS 200 children were included (MOGAD 97; MS 103). At first MRI post attack, new symptomatic and asymptomatic lesions were seen more often in MS versus MOGAD (52/103 vs 28/97; p=0.002 and 37/103 vs 11/97; p<0.001); 83% of patients with MOGAD showed at least one lesion's resolution at first follow-up scan, and 23% had normal MRI. Only 1 patient with MS had single lesion resolution; none had normal MRI. Disappearing lesions in MOGAD were seen in 40% after the second attack, 21% after third attack and none after the fourth attack.New lesions at first follow-up scan were associated with increased likelihood of relapse (p=0.02) and persistent MOG-Ab serostatus (p=0.0016) compared with those with no new lesions. Plasma exchange was associated with increased likelihood of lesion resolution (p=0.01). Longer time from symptom onset to steroids was associated with increased likelihood of new lesions; 50% increase at 20 days (p=0.01). CONCLUSIONS These striking differences in lesion dynamics between MOGAD and MS suggest greater potential to repair. Early treatment with steroids and plasma exchange is associated with reduced likelihood of new lesions.
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Affiliation(s)
- Omar Abdel-Mannan
- Department of Neuroinflammation, UCL Institute of Neurology, University College London, London, UK
| | - Dimitrios Champsas
- Department of Neuroinflammation, UCL Institute of Neurology, University College London, London, UK
- Department of Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Carmen Tur
- Department of Neuroinflammation, UCL Institute of Neurology, University College London, London, UK
- Multiple Sclerosis Centre of Catalonia (Cemcat), Vall d'Hebron Institute of Research, Barcelona, Spain
| | - Vanessa Lee
- Children's Neurosciences, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Haroon Usman
- Department of Paediatric Neurology, The Great North Children's Hospital, Newcastle Upon Tyne, UK
| | - Alison Skippen
- Department of Paediatric Neurology, Oxford Radcliffe Hospitals NHS Trust, Oxford, UK
| | - Ishita Desai
- Department of Neurology, Royal Manchester Children's Hospital, Manchester, UK
| | - Manali Chitre
- Paediatric Neurology, Addenbrooke's Hospital, Cambridge, UK
| | - Rob Forsyth
- Paediatric Neurology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Rachel Kneen
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
- Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Dipak Ram
- Department of Neurology, Royal Manchester Children's Hospital, Manchester, UK
| | - Sithara Ramdas
- Department of Paediatric Neurology, Oxford Radcliffe Hospitals NHS Trust, Oxford, UK
| | - Thomas Rossor
- Children's Neurosciences, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Siobhan West
- Department of Neurology, Royal Manchester Children's Hospital, Manchester, UK
| | - Sukhvir Wright
- Paediatric Neurology, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
- Aston Neuroscience Institute, College of Health and Life Sciences, Aston University, Birmingham, UK
| | - Jacqueline Palace
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - Evangeline Wassmer
- Paediatric Neurology, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
- Aston Neuroscience Institute, College of Health and Life Sciences, Aston University, Birmingham, UK
| | - Cheryl Hemingway
- Department of Paediatric Neurology, Great Ormond Street Hospital, London, UK
| | - Ming J Lim
- Children's Neurosciences, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Kshitij Mankad
- Neuroradiology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Olga Ciccarelli
- Department of Neuroinflammation, UCL Institute of Neurology, University College London, London, UK
- NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Yael Hacohen
- Department of Neuroinflammation, UCL Institute of Neurology, University College London, London, UK
- Department of Neurology, Great Ormond Street Hospital for Children, London, UK
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Lang L, Dunbar-Creasey N, Kneen R, Neely L, Hawcutt DB. Female paediatric patients with epilepsy who continue to receive valproate in the UK. Arch Dis Child 2024; 109:174-175. [PMID: 38041674 DOI: 10.1136/archdischild-2023-326591] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2023] [Indexed: 12/03/2023]
Affiliation(s)
- Lilly Lang
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
- University of Liverpool Medical School, Liverpool, UK
| | | | - Rachel Kneen
- Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Laura Neely
- Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Daniel B Hawcutt
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
- Alder Hey Clinical Research Facility, Alder Hey Children's Hospital, National Institute for Health Research, Liverpool, UK
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Tolonen JP, Parolin Schnekenberg R, McGowan S, Sims D, McEntagart M, Elmslie F, Shears D, Stewart H, Tofaris GK, Dabir T, Morrison PJ, Johnson D, Hadjivassiliou M, Ellard S, Shaw‐Smith C, Znaczko A, Dixit A, Suri M, Sarkar A, Harrison RE, Jones G, Houlden H, Ceravolo G, Jarvis J, Williams J, Shanks ME, Clouston P, Rankin J, Blumkin L, Lerman‐Sagie T, Ponger P, Raskin S, Granath K, Uusimaa J, Conti H, McCann E, Joss S, Blakes AJ, Metcalfe K, Kingston H, Bertoli M, Kneen R, Lynch SA, Martínez Albaladejo I, Moore AP, Jones WD, Becker EB, Németh AH. Detailed Analysis of ITPR1 Missense Variants Guides Diagnostics and Therapeutic Design. Mov Disord 2024; 39:141-151. [PMID: 37964426 PMCID: PMC10952845 DOI: 10.1002/mds.29651] [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: 07/30/2023] [Revised: 09/16/2023] [Accepted: 10/16/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND The ITPR1 gene encodes the inositol 1,4,5-trisphosphate (IP3 ) receptor type 1 (IP3 R1), a critical player in cerebellar intracellular calcium signaling. Pathogenic missense variants in ITPR1 cause congenital spinocerebellar ataxia type 29 (SCA29), Gillespie syndrome (GLSP), and severe pontine/cerebellar hypoplasia. The pathophysiological basis of the different phenotypes is poorly understood. OBJECTIVES We aimed to identify novel SCA29 and GLSP cases to define core phenotypes, describe the spectrum of missense variation across ITPR1, standardize the ITPR1 variant nomenclature, and investigate disease progression in relation to cerebellar atrophy. METHODS Cases were identified using next-generation sequencing through the Deciphering Developmental Disorders study, the 100,000 Genomes project, and clinical collaborations. ITPR1 alternative splicing in the human cerebellum was investigated by quantitative polymerase chain reaction. RESULTS We report the largest, multinational case series of 46 patients with 28 unique ITPR1 missense variants. Variants clustered in functional domains of the protein, especially in the N-terminal IP3 -binding domain, the carbonic anhydrase 8 (CA8)-binding region, and the C-terminal transmembrane channel domain. Variants outside these domains were of questionable clinical significance. Standardized transcript annotation, based on our ITPR1 transcript expression data, greatly facilitated analysis. Genotype-phenotype associations were highly variable. Importantly, while cerebellar atrophy was common, cerebellar volume loss did not correlate with symptom progression. CONCLUSIONS This dataset represents the largest cohort of patients with ITPR1 missense variants, expanding the clinical spectrum of SCA29 and GLSP. Standardized transcript annotation is essential for future reporting. Our findings will aid in diagnostic interpretation in the clinic and guide selection of variants for preclinical studies. © 2023 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Jussi Pekka Tolonen
- Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordUK
- Kavli Institute of Nanoscience DiscoveryUniversity of OxfordOxfordUK
| | - Ricardo Parolin Schnekenberg
- Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordUK
- Oxford Center for Genomic MedicineOxford University Hospitals National Health Service Foundation Trust, University of OxfordOxfordUK
| | - Simon McGowan
- Centre for Computational Biology, MRC Weatherall Institute of Molecular MedicineUniversity of OxfordOxfordUK
| | - David Sims
- Centre for Computational Biology, MRC Weatherall Institute of Molecular MedicineUniversity of OxfordOxfordUK
| | - Meriel McEntagart
- South West Regional Genetics ServiceSt. George's University HospitalsLondonUK
| | - Frances Elmslie
- South West Regional Genetics ServiceSt. George's University HospitalsLondonUK
| | - Debbie Shears
- Oxford Center for Genomic MedicineOxford University Hospitals National Health Service Foundation Trust, University of OxfordOxfordUK
| | - Helen Stewart
- Oxford Center for Genomic MedicineOxford University Hospitals National Health Service Foundation Trust, University of OxfordOxfordUK
| | - George K. Tofaris
- Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordUK
- Kavli Institute of Nanoscience DiscoveryUniversity of OxfordOxfordUK
| | - Tabib Dabir
- Northern Ireland Regional Genetics ServiceBelfast City HospitalBelfastUK
| | - Patrick J. Morrison
- Patrick G. Johnston Centre for Cancer Research and Cell BiologyQueen's University BelfastBelfastUK
| | - Diana Johnson
- Sheffield Clinical Genetics ServiceSheffield Children's NHS Foundation TrustSheffieldUK
| | - Marios Hadjivassiliou
- Department of NeurologyRoyal Hallamshire Hospital, Sheffield Teaching Hospital NHS Foundation TrustSheffieldUK
| | - Sian Ellard
- Exeter Genomics LaboratoryRoyal Devon University Healthcare NHS Foundation TrustUK
| | - Charles Shaw‐Smith
- Peninsula Clinical Genetics Service, Royal Devon University HospitalRoyal Devon University Healthcare NHS Foundation TrustExeterUK
| | - Anna Znaczko
- Peninsula Clinical Genetics Service, Royal Devon University HospitalRoyal Devon University Healthcare NHS Foundation TrustExeterUK
| | - Abhijit Dixit
- Department of Clinical GeneticsNottingham University Hospitals NHS TrustNottinghamUK
| | - Mohnish Suri
- Department of Clinical GeneticsNottingham University Hospitals NHS TrustNottinghamUK
| | - Ajoy Sarkar
- Department of Clinical GeneticsNottingham University Hospitals NHS TrustNottinghamUK
| | - Rachel E. Harrison
- Department of Clinical GeneticsNottingham University Hospitals NHS TrustNottinghamUK
| | - Gabriela Jones
- Department of Clinical GeneticsNottingham University Hospitals NHS TrustNottinghamUK
| | - Henry Houlden
- Department of Neuromuscular DisordersUCL Queen Square Institute of Neurology, University College LondonLondonUK
| | - Giorgia Ceravolo
- Department of Neuromuscular DisordersUCL Queen Square Institute of Neurology, University College LondonLondonUK
- Unit of Pediatric Emergency, Department of Adult and Childhood Human PathologyUniversity Hospital of MessinaMessinaItaly
| | - Joanna Jarvis
- Birmingham Women's and Children's NHS Foundation TrustBirminghamUK
| | - Jonathan Williams
- Oxford Regional Genetics Laboratory, Churchill HospitalOxford University Hospitals NHS Foundation TrustOxfordUK
| | - Morag E. Shanks
- Oxford Regional Genetics Laboratory, Churchill HospitalOxford University Hospitals NHS Foundation TrustOxfordUK
| | - Penny Clouston
- Oxford Regional Genetics Laboratory, Churchill HospitalOxford University Hospitals NHS Foundation TrustOxfordUK
| | - Julia Rankin
- Department of Clinical GeneticsRoyal Devon and Exeter NHS Foundation TrustExeterUK
| | - Lubov Blumkin
- Sackler School of MedicineTel Aviv UniversityTel AvivIsrael
- Pediatric Movement Disorders Service, Pediatric Neurology UnitEdith Wolfson Medical CenterHolonIsrael
| | - Tally Lerman‐Sagie
- Sackler School of MedicineTel Aviv UniversityTel AvivIsrael
- Magen Center for Rare Diseases‐Metabolic, NeurogeneticWolfson Medical CenterHolonIsrael
| | - Penina Ponger
- Sackler School of MedicineTel Aviv UniversityTel AvivIsrael
- Movement Disorders Unit, Department of NeurologyTel Aviv Sourasky Medical CenterTel AvivIsrael
| | - Salmo Raskin
- Genetika Centro de Aconselhamento e LaboratórioCuritibaBrazil
| | - Katariina Granath
- Research Unit of Clinical MedicineMedical Research Center, Oulu University Hospital and University of OuluOuluFinland
| | - Johanna Uusimaa
- Research Unit of Clinical MedicineMedical Research Center, Oulu University Hospital and University of OuluOuluFinland
| | - Hector Conti
- All Wales Medical Genomics ServiceWrexham Maelor HospitalWrexhamUK
| | - Emma McCann
- Liverpool Women's Hospital Foundation TrustLiverpoolUK
| | - Shelagh Joss
- West of Scotland Centre for Genomic MedicineQueen Elizabeth University HospitalGlasgowUK
| | - Alexander J.M. Blakes
- Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of BiologyMedicine and Health, University of ManchesterManchesterUK
- Manchester Centre for Genomic MedicineUniversity of Manchester, St. Mary's Hospital, Manchester Academic Health Science CentreManchesterUK
| | - Kay Metcalfe
- Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of BiologyMedicine and Health, University of ManchesterManchesterUK
- Manchester Centre for Genomic MedicineUniversity of Manchester, St. Mary's Hospital, Manchester Academic Health Science CentreManchesterUK
| | - Helen Kingston
- Manchester Centre for Genomic MedicineUniversity of Manchester, St. Mary's Hospital, Manchester Academic Health Science CentreManchesterUK
| | - Marta Bertoli
- Northern Genetics ServiceInternational Centre for LifeNewcastle upon TyneUK
| | - Rachel Kneen
- Department of NeurologyAlder Hey Children's NHS Foundation TrustLiverpoolUK
| | - Sally Ann Lynch
- Department of Clinical GeneticsChildren's Health Ireland (CHI) at CrumlinDublinIreland
| | | | | | - Wendy D. Jones
- North East Thames Regional Genetics ServiceGreat Ormond Street Hospital for Children, Great Ormond Street NHS Foundation TrustLondonUK
| | | | - Esther B.E. Becker
- Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordUK
- Kavli Institute of Nanoscience DiscoveryUniversity of OxfordOxfordUK
| | - Andrea H. Németh
- Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordUK
- Oxford Center for Genomic MedicineOxford University Hospitals National Health Service Foundation Trust, University of OxfordOxfordUK
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Schoeler NE, Marston L, Lyons L, Halsall S, Jain R, Titre-Johnson S, Balogun M, Heales SJR, Eaton S, Orford M, Neal E, Reilly C, Eltze C, Stephen E, Mallick AA, O'Callaghan F, Agrawal S, Parker A, Kirkpatrick M, Brunklaus A, McLellan A, McCullagh H, Samanta R, Kneen R, Tan HJ, Devlin A, Prasad M, Rattihalli R, Basu H, Desurkar A, Williams R, Fallon P, Nazareth I, Freemantle N, Cross JH. Classic ketogenic diet versus further antiseizure medicine in infants with drug-resistant epilepsy (KIWE): a UK, multicentre, open-label, randomised clinical trial. Lancet Neurol 2023; 22:1113-1124. [PMID: 37977712 DOI: 10.1016/s1474-4422(23)00370-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 06/26/2023] [Revised: 08/08/2023] [Accepted: 09/21/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Many infancy-onset epilepsies have poor prognosis for seizure control and neurodevelopmental outcome. Ketogenic diets can improve seizures in children older than 2 years and adults who are unresponsive to antiseizure medicines. We aimed to establish the efficacy of a classic ketogenic diet at reducing seizure frequency compared with further antiseizure medicine in infants with drug-resistant epilepsy. METHODS In this phase 4, open-label, multicentre, randomised clinical trial, infants aged 1-24 months with drug-resistant epilepsy (defined as four or more seizures per week and two or more previous antiseizure medications) were recruited from 19 hospitals in the UK. Following a 1-week or 2-week observation period, participants were randomly assigned using a computer-generated schedule, without stratification, to either a classic ketogenic diet or a further antiseizure medication for 8 weeks. Treatment allocation was masked from research nurses involved in patient care, but not from participants. The primary outcome was the median number of seizures per day, recorded during weeks 6-8. All analyses were by modified intention to treat, which included all participants with available data. Participants were followed for up to 12 months. All serious adverse events were recorded. The trial is registered with the European Union Drug Regulating Authorities Clinical Trials Database (2013-002195-40). The trial was terminated early before all participants had reached 12 months of follow-up because of slow recruitment and end of funding. FINDINGS Between Jan 1, 2015, and Sept 30, 2021, 155 infants were assessed for eligibility, of whom 136 met inclusion criteria and were randomly assigned; 75 (55%) were male and 61 (45%) were female. 78 infants were assigned to a ketogenic diet and 58 to antiseizure medication, of whom 61 and 47, respectively, had available data and were included in the modifified intention-to-treat analysis at week 8. The median number of seizures per day during weeks 6-8, accounting for baseline rate and randomised group, was similar between the ketogenic diet group (5 [IQR 1-16]) and antiseizure medication group (3 [IQR 2-11]; IRR 1·33, 95% CI 0·84-2·11). A similar number of infants with at least one serious adverse event was reported in both groups (40 [51%] of 78 participants in the ketogenic diet group and 26 [45%] of 58 participants in the antiseizure medication group). The most common serious adverse events were seizures in both groups. Three infants died during the trial, all of whom were randomly assigned a ketogenic diet: one child (who also had dystonic cerebral palsy) was found not breathing at home; one child died suddenly and unexpectedly at home; and one child went into cardiac arrest during routine surgery under anaesthetic. The deaths were judged unrelated to treatment by local principal investigators and confirmed by the data safety monitoring committee. INTERPRETATION In this phase 4 trial, a ketogenic diet did not differ in efficacy and tolerability to a further antiseizure medication, and it appears to be safe to use in infants with drug-resistant epilepsy. A ketogenic diet could be a treatment option in infants whose seizures continue despite previously trying two antiseizure medications. FUNDING National Institute for Health and Care Research.
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Affiliation(s)
- Natasha E Schoeler
- Developmental Neurosciences Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, UK; Dietetics, Great Ormond Street Hospital for Children, London, UK
| | - Louise Marston
- Department of Primary Care and Population Health, University College London, London, UK; PRIMENT Clinical Trials Unit, University College London, London, UK
| | - Laura Lyons
- Developmental Neurosciences Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Sally Halsall
- Developmental Neurosciences Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Ruchika Jain
- Developmental Neurosciences Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Siobhan Titre-Johnson
- Developmental Neurosciences Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Maryam Balogun
- Developmental Neurosciences Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Simon J R Heales
- Genetics and Genomic Medicine, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Simon Eaton
- Stem Cells and Regenerative Medicine Section, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Michael Orford
- Genetics and Genomic Medicine, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Elizabeth Neal
- Developmental Neurosciences Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Colin Reilly
- Research Department, Young Epilepsy, Lingfield, Surrey, UK
| | - Christin Eltze
- Paediatric Neurosciences, Great Ormond Street Hospital for Children, London, UK
| | - Elma Stephen
- Child Neurology Service, Royal Aberdeen Children's Hospital, Aberdeen, UK
| | - Andrew A Mallick
- Department of Paediatric Neurology, Bristol Royal Hospital for Children, Bristol, UK
| | - Finbar O'Callaghan
- Developmental Neurosciences Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Shakti Agrawal
- Department of Neurology, Birmingham Children's Hospital, Birmingham, UK
| | - Alasdair Parker
- Clinical Medical School, University of Cambridge, Cambridge, UK
| | | | - Andreas Brunklaus
- Paediatric Neurosciences Unit, Royal Hospital for Children, Glasgow, UK
| | - Ailsa McLellan
- Department of Paediatric Neurosciences, Royal Hospital for Sick Children, Edinburgh, UK
| | - Helen McCullagh
- Department of Paediatric Neurology, Leeds Children's Hospital, Leeds, UK
| | - Rajib Samanta
- Department of Paediatric Neurology, University Hospital of Leicester, Leicester, UK
| | - Rachel Kneen
- Department of Neurology, Alder Hey Children's Hospital, Liverpool, UK
| | - Hui Jeen Tan
- Department of Paediatric Neurology, Royal Manchester Children's Hospital, Manchester, UK
| | - Anita Devlin
- Department of Paediatric Neurology, Great North Children's Hospital, Newcastle, UK
| | - Manish Prasad
- Department of Paediatric Neurology, Queens Medical Centre, Nottingham, UK
| | - Rohini Rattihalli
- Department of Paediatric Neurology, Oxford University Hospitals, Oxford, UK
| | - Helen Basu
- Department of Paediatric Neurology, Royal Preston Hospital, Preston, UK
| | - Archana Desurkar
- Neurology Department, Sheffield Children's Hospital, Sheffield, UK
| | - Ruth Williams
- Children's Neurosciences Centre, Evelina London Children's Hospital, London, UK
| | - Penny Fallon
- Department of Paediatric Neurology, St George's Hospital, London, UK
| | - Irwin Nazareth
- PRIMENT Clinical Trials Unit, University College London, London, UK
| | - Nick Freemantle
- Institute of Clinical Trials and Methodology, University College London, London, UK
| | - J Helen Cross
- Developmental Neurosciences Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, UK; Paediatric Neurosciences, Great Ormond Street Hospital for Children, London, UK.
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Southin JC, Avula S, du Plessis D, Kumar R, Kneen R. Baló's concentric sclerosis presenting asymptomatically in a child: clinico-radiological-pathological correlation. BMJ Case Rep 2023; 16:e256185. [PMID: 38011943 PMCID: PMC10685971 DOI: 10.1136/bcr-2023-256185] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2023] [Indexed: 11/29/2023] Open
Affiliation(s)
| | - Shivaram Avula
- Radiology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | | | - Ram Kumar
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Rachel Kneen
- Paediatric Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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7
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Hill M, Iro M, Sadarangani M, Absoud M, Cantrell L, Chong K, Clark C, Easton A, Gray V, Kneen R, Lim M, Liu X, Pike M, Solomon T, Vincent A, Willis L, Yu LM, Pollard AJ. Intravenous immunoglobulin treatment in childhood encephalitis (IgNiTE): a randomised controlled trial. BMJ Open 2023; 13:e072134. [PMID: 37945292 PMCID: PMC10649701 DOI: 10.1136/bmjopen-2023-072134] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 09/29/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVE To investigate whether intravenous immunoglobulin (IVIG) improves neurological outcomes in children with encephalitis when administered early in the illness. DESIGN Phase 3b multicentre, double-blind, randomised placebo-controlled trial. SETTING Twenty-one hospitals in the UK. PARTICIPANTS Children aged 6 months to 16 years with a diagnosis of acute or subacute encephalitis, with a planned sample size of 308. INTERVENTION Two doses (1 g/kg/dose) of either IVIG or matching placebo given 24-36 hours apart, in addition to standard treatment. MAIN OUTCOME MEASURE The primary outcome was a 'good recovery' at 12 months after randomisation, defined as a score of≤2 on the Paediatric Glasgow Outcome Score Extended. SECONDARY OUTCOME MEASURES The secondary outcomes were clinical, neurological, neuroimaging and neuropsychological results, identification of the proportion of children with immune-mediated encephalitis, and IVIG safety data. RESULTS 18 participants were recruited from 12 hospitals and randomised to receive either IVIG (n=10) or placebo (n=8) between 23 December 2015 and 26 September 2017. The study was terminated early following withdrawal of funding due to slower than anticipated recruitment, and therefore did not reach the predetermined sample size required to achieve the primary study objective; thus, the results are descriptive. At 12 months after randomisation, 9 of the 18 participants (IVIG n=5/10 (50%), placebo n=4/8 (50%)) made a good recovery and 5 participants (IVIG n=3/10 (30%), placebo n=2/8 (25%)) made a poor recovery. Three participants (IVIG n=1/10 (10%), placebo n=2/8 (25%)) had a new diagnosis of epilepsy during the study period. Two participants were found to have specific autoantibodies associated with autoimmune encephalitis. No serious adverse events were reported in participants receiving IVIG. CONCLUSIONS The IgNiTE (ImmunoglobuliN in the Treatment of Encephalitis) study findings support existing evidence of poor neurological outcomes in children with encephalitis. However, the study was halted prematurely and was therefore underpowered to evaluate the effect of early IVIG treatment compared with placebo in childhood encephalitis. TRIAL REGISTRATION NUMBER Clinical Trials.gov NCT02308982; ICRCTN registry ISRCTN15791925.
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Affiliation(s)
- Matilda Hill
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Mildred Iro
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Manish Sadarangani
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
- Department of Paediatrics, University of Oxford, Oxford, UK
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael Absoud
- Children's Neurosciences, Evelina London Children's Hospital Neurosciences Department, London, UK
- Department of Womens and Childrens Health, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Liberty Cantrell
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Kling Chong
- UCL Great Ormond Street Institute of Child Health, London, UK
| | | | - Ava Easton
- The Encephalitis Society, Malton, North Yorkshire, UK
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - Victoria Gray
- Clinical Health Psychology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Rachel Kneen
- Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Ming Lim
- Children's Neurosciences, Evelina London Children's Hospital Neurosciences Department, London, UK
- Department of Womens and Childrens Health, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Xinxue Liu
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Michael Pike
- Department of Paediatric Neurology, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Tom Solomon
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
- National Institute for Health Research Health Protection Research Unit in Emerging Zoonotic Infections, University of Liverpool, Liverpool, UK
- Walton Centre NHS Foundation Trust, Liverpool, UK
- The Pandemic Institute, Liverpool, UK
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
| | - Louise Willis
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Ly-Mee Yu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
- Department of Paediatrics, University of Oxford, Oxford, UK
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8
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Chen B, Gomez-Figueroa E, Redenbaugh V, Francis A, Satukijchai C, Wu Y, Messina S, Sa M, Woodhall M, Paul F, Robertson NP, Lim M, Wassmer E, Kneen R, Huda S, Blain C, Halfpenny C, Hemingway C, O'Sullivan E, Hobart J, Fisniku LK, Martin RJ, Dobson R, Cooper SA, Williams V, Waters P, Chen JJ, Pittock SJ, Ramdas S, Leite MI, Flanagan EP, Geraldes R, Palace J. Do Early Relapses Predict the Risk of Long-Term Relapsing Disease in an Adult and Paediatric Cohort with MOGAD? Ann Neurol 2023; 94:508-517. [PMID: 37394961 DOI: 10.1002/ana.26731] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 02/06/2023] [Revised: 05/21/2023] [Accepted: 05/31/2023] [Indexed: 07/04/2023]
Abstract
OBJECTIVE Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) can be monophasic or relapsing, with early relapse being a feature. However, the relevance of early relapse on longer-term relapse risk is unknown. Here, we investigate whether early relapses increase longer-term relapse risk in patients with MOGAD. METHODS A retrospective analysis of 289 adult- and pediatric-onset patients with MOGAD followed for at least 2 years in 6 specialized referral centers. "Early relapses" were defined as attacks within the first 12 months from onset, with "very early relapses" defined within 30 to 90 days from onset and "delayed early relapses" defined within 90 to 365 days. "Long-term relapses" were defined as relapses beyond 12 months. Cox regression modeling and Kaplan-Meier survival analysis were used to estimate the long-term relapse risk and rate. RESULTS Sixty-seven patients (23.2%) had early relapses with a median number of 1 event. Univariate analysis revealed an elevated risk for long-term relapses if any "early relapses" were present (hazard ratio [HR] = 2.11, p < 0.001), whether occurring during the first 3 months (HR = 2.70, p < 0.001) or the remaining 9 months (HR = 1.88, p = 0.001), with similar results yielded in the multivariate analysis. In children with onset below aged 12 years, only delayed early relapses were associated with an increased risk of long-term relapses (HR = 2.64, p = 0.026). INTERPRETATION The presence of very early relapses and delayed early relapses within 12 months of onset in patients with MOGAD increases the risk of long-term relapsing disease, whereas a relapse within 90 days appears not to indicate a chronic inflammatory process in young pediatric-onset disease. ANN NEUROL 2023;94:508-517.
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Affiliation(s)
- Bo Chen
- Nuffield Department of Clinical Neurosciences, Oxford University Hospitals, Oxford, UK
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science of Technology, Wuhan, China
| | - Enrique Gomez-Figueroa
- Nuffield Department of Clinical Neurosciences, Oxford University Hospitals, Oxford, UK
- Department of Neurology, Civil Hospital of Guadalajara, University of Guadalajara, Guadalajara, Mexico
| | - Vyanka Redenbaugh
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN
| | - Anna Francis
- Nuffield Department of Clinical Neurosciences, Oxford University Hospitals, Oxford, UK
| | | | - Yan Wu
- Department of Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Silvia Messina
- Nuffield Department of Clinical Neurosciences, Oxford University Hospitals, Oxford, UK
- Neurology Department, Wexham Park Hospital, Frimley Foundation Health Trust, Slough, UK
| | - Mario Sa
- Department of Paediatric Neurology, Oxford University NHS Foundation Trust, Oxford, UK
| | - Mark Woodhall
- Oxford Autoimmune Neurology Diagnostic Laboratory, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Friedemann Paul
- Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité Universitaetsmedizin Berlin
| | - Neil P Robertson
- Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité Universitaetsmedizin Berlin
| | - Ming Lim
- Department of Neurology, Division of Psychological Medicine and Clinical Neuroscience, Cardiff University, University Hospital of Wales, Cardiff, UK
- Children's Neuroscience Centre, Evelina London Children's Hospital, London, UK
| | - Evangeline Wassmer
- Women and Children's Department, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Rachel Kneen
- Department of Paediatric Neurology, Birmingham Women and Children's Hospital, Birmingham, UK
| | - Saif Huda
- Department of Paediatric Neurology, Alder Hey Children's NHS Foundation Trust and Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Camilla Blain
- Department of Neurology, Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Christopher Halfpenny
- Department of Neurology, St. George's University Hospitals National Health Service Foundation Trust, London, UK
| | - Cheryl Hemingway
- Department of Neurology, Southampton General Hospital, Southampton, UK
| | - Eoin O'Sullivan
- Department of Paediatric Neurology, Great Ormond St. Hospital for Children, London, UK
| | - Jeremy Hobart
- Department of Ophthalmology, King's College Hospital NHS Foundation Trust, London, UK
| | - Leonora K Fisniku
- Department of Neurology, University Hospitals Plymouth National Health Service Foundation Trust, Devon, UK
| | - Roswell J Martin
- Department of Neurosciences, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Ruth Dobson
- Department of Neurology, Gloucestershire Hospitals National Health Service Foundation Trust, Gloucestershire, UK
| | - Sarah A Cooper
- Preventive Neurology Unit, Queen Mary University London, London, UK
| | - Victoria Williams
- Department of Neurology, University Hospitals Sussex National Health Service Foundation Trust, Brighton, UK
- Department of Neurology, King's College Hospital NHS Foundation Trust, London, UK
| | - Patrick Waters
- Oxford Autoimmune Neurology Diagnostic Laboratory, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - John J Chen
- Department of Neurology, Guy's and St. Thomas' National Health Service Foundation Trust, London, UK
| | - Sean J Pittock
- Department of Ophthalmology and Neurology, Mayo Clinic, Rochester, MN
| | - Sithara Ramdas
- Centre MS and Autoimmune Neurology, Department Neurology, Mayo Clinic, Rochester, MN
- MDUK Neuromuscular Centre, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Maria Isabel Leite
- Nuffield Department of Clinical Neurosciences, Oxford University Hospitals, Oxford, UK
| | - Eoin P Flanagan
- Department of Paediatric Neurology, John Radcliffe Hospital, Oxford, UK
| | - Ruth Geraldes
- Nuffield Department of Clinical Neurosciences, Oxford University Hospitals, Oxford, UK
- Neurology Department, Wexham Park Hospital, Frimley Foundation Health Trust, Slough, UK
| | - Jacqueline Palace
- Nuffield Department of Clinical Neurosciences, Oxford University Hospitals, Oxford, UK
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9
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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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10
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Southern KW, Barben J, Goldring S, Kneen R, Southward S, Rajeev Y, Davies JC, Bush A. Raised Intracranial Pressure in Three Children with Cystic Fibrosis Receiving Elexacaftor-Tezacaftor-Ivacaftor Modulator Therapy. Am J Respir Crit Care Med 2023; 208:103-105. [PMID: 37159937 DOI: 10.1164/rccm.202303-0380le] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023] Open
Affiliation(s)
- Kevin W Southern
- Women's and Children's Health, University of Liverpool, Liverpool, United Kingdom
| | - Jürg Barben
- Division of Pediatric Pulmonary and CF Centre, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland
| | - Stephen Goldring
- Paediatrics, Hillingdon Hospitals NHS Foundation Trust, Uxbridge, United Kingdom
| | - Rachel Kneen
- Neurology Department, Alder Hey Children's Hospital, Liverpool, United Kingdom
| | | | - Yashasvi Rajeev
- Paediatrics, Hillingdon Hospitals NHS Foundation Trust, Uxbridge, United Kingdom
| | | | - Andrew Bush
- Imperial College London, London, United Kingdom
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11
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Kim NN, Abdel-Mannan O, Davidson J, Du Pre P, Kneen R, Mankad K, Hacohen Y. Leigh syndrome mimicking neuromyelitis optica spectrum disorder (NMOSD). Mult Scler 2023:13524585231172950. [PMID: 37227123 DOI: 10.1177/13524585231172950] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
We report two children with molecularly confirmed mitochondrial disease mimicking Neuromyelitis Optica Spectrum Disorder (NMOSD). The first patient presented at the age of 15 months with acute deterioration following a pyrexial illness with clinical features localising to the brainstem and spinal cord. The second patient presented at 5 years with acute bilateral visual loss. In both cases, MOG and AQP4 antibodies were negative. Both patients died within a year of symptoms onset from respiratory failure. Arriving at an early genetic diagnosis is important for redirection of care and avoiding potentially harmful immunosuppressant therapies.
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Affiliation(s)
- Nee Na Kim
- Queen Square Multiple Sclerosis Centre, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK/Department of Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Omar Abdel-Mannan
- Queen Square Multiple Sclerosis Centre, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK/Department of Neurology, Great Ormond Street Hospital for Children, London, UK
| | - James Davidson
- Department of Paediatric Metabolic Medicine, Great Ormond Street Hospital for Children, London, UK
| | - Pascale Du Pre
- Department of Paediatric Intensive Care, Great Ormond Street Hospital for Children, London, UK
| | - Rachel Kneen
- Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Kshitij Mankad
- Department of Neuroradiology, Great Ormond Street Hospital for Children, London, UK
| | - Yael Hacohen
- Queen Square Multiple Sclerosis Centre, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK/Department of Neurology, Great Ormond Street Hospital for Children, London, UK
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12
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Nguyen Thi Nguyen T, Parry CM, Campbell JI, Vinh PV, Kneen R, Baker S. Endemic erythromycin resistant Corynebacterium diphtheriae in Vietnam in the 1990s. Microb Genom 2022; 8:mgen000861. [PMID: 36259695 PMCID: PMC9676054 DOI: 10.1099/mgen.0.000861] [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: 12/23/2021] [Accepted: 06/10/2022] [Indexed: 11/18/2022] Open
Abstract
Diphtheria is a potentially fatal respiratory disease caused by toxigenic forms of the Gram-positive bacterium Corynebacterium diphtheriae. Despite the availability of treatments (antitoxin and antimicrobials) and effective vaccines, the disease still occurs sporadically in low-income countries and in higher income where use of diphtheria vaccine is inconsistent. Diphtheria was highly endemic in Vietnam in the 1990s; here, we aimed to provide some historical context to the circulation of erythromycin resistant organisms in Vietnam during this period. After recovering 54 C. diphtheriae isolated from clinical cases of diphtheria in Ho Chi Minh City between 1992 and 1998 we conducted whole genome sequencing and analysis. Our data outlined substantial genetic diversity among the isolates, illustrated by seven distinct Sequence Types (STs), but punctuated by the sustained circulation of ST67 and ST209. With the exception of one isolate, all sequences contained the tox gene, which was classically located on a corynebacteriophage. All erythromycin resistant isolates, accounting for 13 % of organisms in this study, harboured a novel 18 kb erm(X)-carrying plasmid, which exhibited limited sequence homology to previously described resistance plasmids in C. diphtheriae. Our study provides historic context for the circulation of antimicrobial resistant C. diphtheriae in Vietnam; these data provide a framework for the current trajectory in global antimicrobial resistance trends.
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Affiliation(s)
- To Nguyen Thi Nguyen
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Department of Microbiology, Monash University, Melbourne, Victoria, Australia
| | - Christopher M. Parry
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Pl, Liverpool L3 5QA, UK
- Alder Hey Children’s Hospital, NHS Foundation Trust, Liverpool, UK
| | - James I. Campbell
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Phat Voong Vinh
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Rachel Kneen
- Alder Hey Children’s Hospital, NHS Foundation Trust, Liverpool, UK
- Institute of Infection and Global Health, University of Liverpool, Liverpool L69 3BX, UK
| | - Stephen Baker
- University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, UK
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, UK
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13
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Satukijchai C, Mariano R, Messina S, Sa M, Woodhall MR, Robertson NP, Ming L, Wassmer E, Kneen R, Huda S, Jacob A, Blain C, Halfpenny C, Hemingway C, O'Sullivan E, Hobart J, Fisniku LK, Martin R, Dopson R, Cooper SA, Williams V, Waters PJ, Ramdas S, Leite MI, Palace J. Factors Associated With Relapse and Treatment of Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease in the United Kingdom. JAMA Netw Open 2022; 5:e2142780. [PMID: 35006246 PMCID: PMC8749481 DOI: 10.1001/jamanetworkopen.2021.42780] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
IMPORTANCE Longer-term outcomes and risk factors associated with myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) are not well established. OBJECTIVE To investigate longer-term risk of relapse and factors associated with this risk among patients with MOGAD. DESIGN, SETTING, AND PARTICIPANTS This large, single-nation, prospective cohort study was conducted among 276 patients with MOGAD at 5 health care centers in the UK. Data from January 1973 to March 2020 were collected from 146 patients at Oxford and its outreach sites, 65 patients at Liverpool, 32 patients at a children's hospital in Birmingham, 22 patients at a children's hospital in London, and 11 patients at Cardiff, Wales. Data were analyzed from April through July 2020. MAIN OUTCOMES AND MEASURES Risk of relapse and annualized relapse rate were evaluated according to different baseline features, including onset age, onset phenotype, and incident vs nonincident group, with the incident group defined as patients diagnosed with antibodies against myelin oligodendrocyte glycoprotein before a second attack. Time to next relapse among patients experiencing relapse was measured and compared between the maintenance therapy subgroup and each first-line treatment group. The no-treatment group was defined as the off-treatment phase among patients who were relapsing, which could occur between any attack or between the last attack and last follow-up. RESULTS Among 276 patients with MOGAD, 183 patients were identified as being part of the incident group. There were no differences in mean (SD) onset age between total and incident groups (26.4 [17.6] years vs 28.2 [18.1] years), and female patients were predominant in both groups (166 [60.1%] female patients vs 106 [57.9%] female patients). The most common presentation overall was optic neuritis (ON) (119 patients among 275 patients with presentation data [43.3%]), while acute disseminated encephalomyelitis (ADEM), brain, or brainstem onset was predominant among 69 patients aged younger than 12 years (47 patients [68.1%]), including 41 patients with ADEM (59.4%). In the incident group, the 8-year risk of relapse was 36.3% (95% CI, 27.1%-47.5%). ON at onset was associated with increased risk of relapse compared with transverse myelitis at onset (hazard ratio [HR], 2.66; 95% CI, 1.01-6.98; P = .047), but there was no statistically significant difference with adjustment for a follow-on course of corticosteroids. Any TM at onset (ie, alone or in combination with other presentations [ie, ON or ADEM, brain, or brain stem]) was associated with decreased risk of relapse compared with no TM (HR, 0.41; 95% CI, 0.20-0.88; P = .01). Young adult age (ie, ages >18-40 years) was associated with increased risk of relapse compared with older adult age (ie, ages >40 years) (HR, 2.71; 95% CI, 1.18-6.19; P = .02). First-line maintenance therapy was associated with decreased risk of relapse when adjusted for covariates (prednisolone: HR, 0.33; 95% CI, 0.12-0.92; P = .03; prednisolone, nonsteroidal immunosuppressant, or combined: HR, 0.51; 95% CI, 0.28-0.92; P = .03) compared with the no-treatment group. CONCLUSIONS AND RELEVANCE The findings of this cohort study suggest that onset age and onset phenotype should be considered when assessing subsequent relapse risk and that among patients experiencing relapse, prednisolone, first-line immunosuppression, or a combination of those treatments may be associated with decreased risk of future relapse by approximately 2-fold. These results may contribute to individualized treatment decisions.
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Affiliation(s)
- Chanjira Satukijchai
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
- Neuroscience Center, Bangkok International Hospital, Bangkok, Thailand
- Division of Neurology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Romina Mariano
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Silvia Messina
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
- Department of Clinical Neurology, John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, United Kingdom
| | - Mario Sa
- Paediatric Neurology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Mark R. Woodhall
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Neil P. Robertson
- Department of Neurology, Division of Psychological Medicine and Clinical Neuroscience, Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Lim Ming
- Children’s Neurosciences, Evelina London Children’s Hospital at Guy’s and St Thomas’ National Health Service Foundation Trust, London, United Kingdom
- Department of Women and Children’s Health, School of Life Course Sciences, King’s College London, United Kingdom
| | - Evangeline Wassmer
- Birmingham Women’s and Children’s National Health Service Foundation Trust, Birmingham, United Kingdom
- School of Life and Health Sciences, Aston University, Birmingham, United Kingdom
| | - Rachel Kneen
- Alder Hey Children's National Health Service Foundation Trust, Liverpool, United Kingdom
| | - Saif Huda
- Department of Neurology, Walton Centre National Health Service Foundation Trust, Liverpool, United Kingdom
| | - Anu Jacob
- Department of Neurology, Walton Centre National Health Service Foundation Trust, Liverpool, United Kingdom
- Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Camilla Blain
- St George’s University Hospitals National Health Service Foundation Trust, London, United Kingdom
| | - Christopher Halfpenny
- University Hospitals Southampton National Health Service Foundation Trust, Southampton, United Kingdom
| | - Cheryl Hemingway
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Eoin O'Sullivan
- Department of Ophthalmology, Kings College Hospital, London, United Kingdom
| | - Jeremy Hobart
- Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, United Kingdom
- University Hospitals Plymouth National Health Service Foundation Trust, United Kingdom
| | - Leonora K. Fisniku
- University Hospitals Sussex National Health Service Foundation Trust, Brighton, United Kingdom
- Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Roswell Martin
- Gloucestershire Hospitals National Health Service Foundation Trust, Gloucestershire, United Kingdom
| | - Ruth Dopson
- Preventive Neurology Unit, Wolfson Institute of Preventive Medicine, Queen Mary University London, London, United Kingdom
- Royal London Hospital, Barts Health National Health Service Foundation Trust, United Kingdom
| | - Sarah A. Cooper
- University Hospitals Sussex National Health Service Foundation Trust, Brighton, United Kingdom
| | - Victoria Williams
- Guy’s and St Thomas’ National Health Service Foundation Trust, London, United Kingdom
| | - Patrick J. Waters
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Sithara Ramdas
- Department of Paediatric Neurology, John Radcliffe Hospital, Oxford, United Kingdom
| | - Maria Isabel Leite
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
- Department of Clinical Neurology, John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, United Kingdom
| | - Jacqueline Palace
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
- Department of Clinical Neurology, John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, United Kingdom
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14
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Sabanathan S, Abdel‐Mannan O, Mankad K, Siddiqui A, Das K, Carr L, Eltze C, Eyre M, Gadian J, Hemingway C, Kaliakatsos M, Kneen R, Krishnakumar D, Lynch B, Parida A, Rossor T, Taylor M, Wassmer E, Wright S, Lim M, Hacohen Y. Clinical features, investigations, and outcomes of pediatric limbic encephalitis: A multicenter study. Ann Clin Transl Neurol 2022; 9:67-78. [PMID: 35015932 PMCID: PMC8791799 DOI: 10.1002/acn3.51494] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/12/2021] [Accepted: 12/13/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To describe the clinical presentation, investigations, management, and disease course in pediatric autoimmune limbic encephalitis (LE). METHODS In this retrospective observational study, from the UK Childhood Neuroinflammatory Disease network, we identified children from six tertiary centers with LE <18 years old between 2008 and 2021. Clinical and paraclinical data were retrieved from medical records. RESULTS Twenty-five children fulfilling LE criteria were identified, with median age of 11 years (IQR 8, 14) and median follow-up of 24 months (IQR 18, 48). All children presented with seizures; 15/25 (60%) were admitted to intensive care. Neuroimaging demonstrated asymmetric mesial temporal changes in 8/25 (32%), and extra-limbic changes with claustrum involvement in 9/25 (38%). None were positive for LGI1/CASPR2 antibodies (Abs), 2/25 were positive for serum anti-NMDAR Abs, and 2/15 positive for anti-Hu Abs; one died from relapsing neuroblastoma. Two children had serum and CSF anti-GAD antibodies. Initial immune therapy included steroids in 23/25 (92%), intravenous immunoglobulin (IVIg) in 14/25 (56%), and plasma exchange in 7/25 (28%). The commonest second-line treatment was rituximab in 15/25 (60%). Median duration of hospital admission was 21 days (IQR 11, 30). At last follow-up, 13/25 (52%) had refractory seizures and 16/25 (64%) had memory impairment. Six children (24%) had modified Rankin Scale (mRS) scores ≥3. There was no significant difference in mRS, or long-term cognitive and epilepsy outcomes in those who received rituximab versus those who did not. INTERPRETATION A diagnosis of autoimmune LE was associated with significant morbidity and adverse outcomes in this pediatric cohort.
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Affiliation(s)
- Saraswathy Sabanathan
- Children's Neurosciences, Evelina London Children's HospitalGuy's and St Thomas' NHS Foundation TrustLondonUnited Kingdom
| | - Omar Abdel‐Mannan
- Queen Square MS Centre, UCL Queen Square Institute of Neurology, Faculty of Brain SciencesUniversity College LondonLondonUnited Kingdom
- Department of NeurologyGreat Ormond Street Hospital for ChildrenLondonUnited Kingdom
| | - Kshitij Mankad
- Department of NeuroradiologyGreat Ormond Street Hospital for ChildrenLondon
| | - Ata Siddiqui
- Department of Neuroradiology, Evelina London Children's HospitalGuy's and St Thomas' NHS Foundation TrustLondonUnited Kingdom
| | - Krishna Das
- Department of NeurophysiologyGreat Ormond Street Hospital for ChildrenLondonUnited Kingdom
| | - Lucinda Carr
- Department of NeurologyGreat Ormond Street Hospital for ChildrenLondonUnited Kingdom
| | - Christin Eltze
- Department of NeurologyGreat Ormond Street Hospital for ChildrenLondonUnited Kingdom
| | - Michael Eyre
- Children's Neurosciences, Evelina London Children's HospitalGuy's and St Thomas' NHS Foundation TrustLondonUnited Kingdom
- School of Biomedical Engineering & Imaging SciencesKing's College LondonLondonUnited Kingdom
| | - Jon Gadian
- Department of Paediatric NeurologyKing’s College Hospital NHS Foundation TrustLondonUnited Kingdom
| | - Cheryl Hemingway
- Department of NeurologyGreat Ormond Street Hospital for ChildrenLondonUnited Kingdom
| | - Marios Kaliakatsos
- Department of NeurologyGreat Ormond Street Hospital for ChildrenLondonUnited Kingdom
| | - Rachel Kneen
- Department of NeurologyAlder Hey Children’s NHS Foundation TrustLiverpoolUnited Kingdom
| | - Deepa Krishnakumar
- Department of Paediatric NeurologyAddenbrooke’s HospitalCambridgeUnited Kingdom
| | - Bryan Lynch
- Department of Paediatric NeurologyChildren’s University HospitalDublinIreland
| | - Amitav Parida
- Department of NeurologyBirmingham Children’s HospitalBirminghamUnited Kingdom
| | - Thomas Rossor
- Queen Square MS Centre, UCL Queen Square Institute of Neurology, Faculty of Brain SciencesUniversity College LondonLondonUnited Kingdom
- Department of NeurologyGreat Ormond Street Hospital for ChildrenLondonUnited Kingdom
| | - Micheal Taylor
- Department of Paediatric NeurologyLeeds Children’s HospitalLeedsUnited Kingdom
| | - Evangeline Wassmer
- Department of NeurologyBirmingham Children’s HospitalBirminghamUnited Kingdom
- Aston Neuroscience Institute, College of Health and Life SciencesAston UniversityBirminghamUnited Kingdom
| | - Sukhvir Wright
- Department of NeurologyBirmingham Children’s HospitalBirminghamUnited Kingdom
- Aston Neuroscience Institute, College of Health and Life SciencesAston UniversityBirminghamUnited Kingdom
| | - Ming Lim
- Children's Neurosciences, Evelina London Children's HospitalGuy's and St Thomas' NHS Foundation TrustLondonUnited Kingdom
- King’s Health Partners Academic Health Science CentreLondonUnited Kingdom
| | - Yael Hacohen
- Queen Square MS Centre, UCL Queen Square Institute of Neurology, Faculty of Brain SciencesUniversity College LondonLondonUnited Kingdom
- Department of NeurologyGreat Ormond Street Hospital for ChildrenLondonUnited Kingdom
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15
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Huda S, Whittam D, Jackson R, Karthikeayan V, Kelly P, Linaker S, Mutch K, Kneen R, Woodhall M, Murray K, Hunt D, Waters P, Jacob A. Predictors of relapse in MOG antibody associated disease: a cohort study. BMJ Open 2021; 11:e055392. [PMID: 34848526 PMCID: PMC8634280 DOI: 10.1136/bmjopen-2021-055392] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To identify factors predictive of relapse risk and disability in myelin oligodendrocyte glycoprotein associated disease (MOGAD). SETTING Patients were seen by the neuromyelitis optica spectrum disorders (NMOSD) service in Liverpool, UK, a national referral centre for adult patients with MOGAD, NMOSD and related conditions. PARTICIPANTS Patients with MOGAD=76 from England, Northern Ireland and Scotland were included in this cohort study. RESULTS Relapsing disease was observed in 55% (42/76) of cases. Steroid treatment >1 month (OR 0.2, 95% CI 0.05 to 0.80; p=0.022), transverse myelitis (TM) at first attack (OR 0.03, 95% CI 0.004 to 0.23; p=0.001) and male sex (OR 0.16, 95% CI 0.04 to 0.68; p=0.014) were associated with monophasic disease (area under the curve=0.85). Male sex (HR 0.46, 95% CI 0.24 to 0.89; p=0.011) and TM at disease onset (HR 0.42, 95% CI 0.22 to 0.82; p=0.011) were also associated with an increased latency to first relapse. 45% (32/71) of patients became MOG-antibody negative and in relapsing patients negative seroconversion was associated with a lower relapse risk (relative risk 0.11 95% CI 0.05 to 0.26; p<0.001). No specific factors were predictive of visual or overall disability. CONCLUSIONS Male patients with spinal cord involvement at disease onset have a lower risk of relapsing disease and longer latency to first relapse. Steroid treatment for at least 1 month at first attack was also associated with a monophasic disease course. MOG-antibody negative seroconversion was associated with a lower risk of relapse and may help inform treatment decisions and duration.
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Affiliation(s)
- Saif Huda
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Daniel Whittam
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
- Department of Neurology, Salford Royal Hospital, Salford, UK
| | - Richard Jackson
- Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, Merseyside, UK
| | | | - Patricia Kelly
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Sam Linaker
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Kerry Mutch
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Rachel Kneen
- Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Mark Woodhall
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Katy Murray
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
| | - David Hunt
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute, University of Edinburgh, Edinburgh, Scotland
| | - Patrick Waters
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Anu Jacob
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
- Department of Neurology, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
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16
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Russell AR, Hardwick M, Jeyanantham A, White L, Deb S, Burnside G, Joy H, Smith C, Pollak T, Nicholson T, Davies N, Manji H, Easton A, Ray S, Zandi M, Coles J, Menon D, Varatharaj A, Mccausland B, Ellul M, Thomas N, Breen G, Keddie S, Lunn M, Salman RAS, Carson A, Joyce E, Turner M, Benjamin L, Solomon T, Kneen R, Pett S, Thomas R, Michael B, Galea I. Spectrum, risk factors and outcomes of neurological complications of COVID-19. J Neurol Sci 2021. [PMCID: PMC8498347 DOI: 10.1016/j.jns.2021.117807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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17
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Whitfield T, Fernandez C, Davies K, Defres S, Griffiths M, Hooper C, Tangney R, Burnside G, Rosala-Hallas A, Moore P, Das K, Zuckerman M, Parkes L, Keller S, Roberts N, Easton A, Touati S, Kneen R, Stahl JP, Solomon T. Protocol for DexEnceph: a randomised controlled trial of dexamethasone therapy in adults with herpes simplex virus encephalitis. BMJ Open 2021; 11:e041808. [PMID: 34301646 PMCID: PMC8728349 DOI: 10.1136/bmjopen-2020-041808] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 06/17/2020] [Revised: 02/23/2021] [Accepted: 02/25/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Herpes simplex virus (HSV) encephalitis is a rare severe form of brain inflammation that commonly leaves survivors and their families with devastating long-term consequences. The virus particularly targets the temporal lobe of the brain causing debilitating problems in memory, especially verbal memory. It is postulated that immunomodulation with the corticosteroid, dexamethasone, could improve outcomes by reducing brain swelling. However, there are concerns (so far not observed) that such immunosuppression might facilitate increased viral replication with resultant worsening of disease. A previous trail closed early because of slow recruitment. METHOD DexEnceph is a pragmatic multicentre, randomised, controlled, open-label, observer-blind trial to determine whether adults with HSV encephalitis who receive dexamethasone alongside standard antiviral treatment with aciclovir for have improved clinical outcomes compared with those who receive standard treatment alone. Overall, 90 patients with HSV encephalitis are being recruited from a target of 45 recruiting sites; patients are randomised 1:1 to the dexamethasone or control arms of the study. The primary outcome measured is verbal memory as assessed by the Weschler Memory Scale fourth edition Auditory Memory Index at 26 weeks after randomisation. Secondary outcomes are measured up to 72 weeks include additional neuropsychological, clinical and functional outcomes as well as comparison of neuroimaging findings. Patient safety monitoring occurs throughout and includes the detection of HSV DNA in cerebrospinal fluid 2 weeks after randomisation, which is indicative of ongoing viral replication. Innovative methods are being used to ensure recrutiment targets are met for this rare disease. DISCUSSION DexEnceph aims to be the first completed randomised controlled trial of corticosteroid therapy in HSV encephalitis. The results will provide evidence for future practice in managing adults with the condition and has the potential to improve outcomes . ETHICS AND DISSEMINATION The trial has ethical approval from the UK National Research Ethics Committee (Liverpool Central, REF: 15/NW/0545, 10 August 2015). Protocol V.2.1, July 2019. The results will be published and presented as soon as possible on completion. TRIAL REGISTRATION NUMBERS ISRCTN11774734, EUDRACT 2015-001609-16.
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Affiliation(s)
- Thomas Whitfield
- Department of Clinical Infection, Medical Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - Cristina Fernandez
- Department of Clinical Infection, Medical Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - Kelly Davies
- Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | - Sylviane Defres
- Department of Clinical Infection, Medical Microbiology and Immunology, University of Liverpool, Liverpool, UK
- PLEASE REMOVE THIS ADDRESS ENTRY, X, X, X
- Tropical and Infectious Diseases Unit, Liverpool University Hospitals Foundation Trust, Liverpool, UK
| | - Michael Griffiths
- Department of Clinical Infection, Medical Microbiology and Immunology, University of Liverpool, Liverpool, UK
- Neurology Department, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Cory Hooper
- Department of Clinical Infection, Medical Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - Rebecca Tangney
- Pharmacy Department, Liverpool University Hospitals NHS Foundation Trust, Liverpool, Liverpool, UK
| | - Girvan Burnside
- Department of Biostatistics, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, Liverpool, UK
| | - Anna Rosala-Hallas
- Department of Biostatistics, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, Liverpool, UK
| | - Perry Moore
- Deptment of Clinical Neuropsychology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Kumar Das
- Neuroradiology Department, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Mark Zuckerman
- South London Specialist Virology Centre, King's College Hospital NHS Foundation Trust, London, London, UK
| | - Laura Parkes
- Division of Neuroscience & Experimental Psychology, University of Manchester, Manchester, UK
| | - Simon Keller
- Pharmacy Department, Liverpool University Hospitals NHS Foundation Trust, Liverpool, Liverpool, UK
| | - Neil Roberts
- The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, Edinburgh, UK
| | - Ava Easton
- The Encephalitis Society, Malton, North Yorkshire, UK
| | - Saber Touati
- Service des Maladies Infectieuses et Tropicales, CHU Grenoble Alpes, Grenoble, Rhône-Alpes, France
| | - Rachel Kneen
- Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- REMOVE THI ADDRESS, XXXXX, XXX, XXX
| | - J P Stahl
- Infectious Diseases Department, University of Grenoble, Grenoble, UK
| | - Tom Solomon
- Department of Neurology, Walton Centre NHS Foundation Trust, Liverpool, Liverpool, UK
- National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection Ecology and Veterinary Sciences, University of Liverpool, Liverpool, UK
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18
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Ross Russell AL, Hardwick M, Jeyanantham A, White LM, Deb S, Burnside G, Joy HM, Smith CJ, Pollak TA, Nicholson TR, Davies NWS, Manji H, Easton A, Ray S, Zandi MS, Coles JP, Menon DK, Varatharaj A, McCausland B, Ellul MA, Thomas N, Breen G, Keddie S, Lunn MP, Burn JPS, Quattrocchi G, Dixon L, Rice CM, Pengas G, Al-Shahi Salman R, Carson A, Joyce EM, Turner MR, Benjamin LA, Solomon T, Kneen R, Pett S, Thomas RH, Michael BD, Galea I. Spectrum, risk factors and outcomes of neurological and psychiatric complications of COVID-19: a UK-wide cross-sectional surveillance study. Brain Commun 2021; 3:fcab168. [PMID: 34409289 PMCID: PMC8364668 DOI: 10.1093/braincomms/fcab168] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [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] [Accepted: 05/24/2021] [Indexed: 01/06/2023] Open
Abstract
SARS-CoV-2 is associated with new-onset neurological and psychiatric conditions. Detailed clinical data, including factors associated with recovery, are lacking, hampering prediction modelling and targeted therapeutic interventions. In a UK-wide cross-sectional surveillance study of adult hospitalized patients during the first COVID-19 wave, with multi-professional input from general and sub-specialty neurologists, psychiatrists, stroke physicians, and intensivists, we captured detailed data on demographics, risk factors, pre-COVID-19 Rockwood frailty score, comorbidities, neurological presentation and outcome. A priori clinical case definitions were used, with cross-specialty independent adjudication for discrepant cases. Multivariable logistic regression was performed using demographic and clinical variables, to determine the factors associated with outcome. A total of 267 cases were included. Cerebrovascular events were most frequently reported (131, 49%), followed by other central disorders (95, 36%) including delirium (28, 11%), central inflammatory (25, 9%), psychiatric (25, 9%), and other encephalopathies (17, 7%), including a severe encephalopathy (n = 13) not meeting delirium criteria; and peripheral nerve disorders (41, 15%). Those with the severe encephalopathy, in comparison to delirium, were younger, had higher rates of admission to intensive care and a longer duration of ventilation. Compared to normative data during the equivalent time period prior to the pandemic, cases of stroke in association with COVID-19 were younger and had a greater number of conventional, modifiable cerebrovascular risk factors. Twenty-seven per cent of strokes occurred in patients <60 years. Relative to those >60 years old, the younger stroke patients presented with delayed onset from respiratory symptoms, higher rates of multi-vessel occlusion (31%) and systemic thrombotic events. Clinical outcomes varied between disease groups, with cerebrovascular disease conferring the worst prognosis, but this effect was less marked than the pre-morbid factors of older age and a higher pre-COVID-19 frailty score, and a high admission white cell count, which were independently associated with a poor outcome. In summary, this study describes the spectrum of neurological and psychiatric conditions associated with COVID-19. In addition, we identify a severe COVID-19 encephalopathy atypical for delirium, and a phenotype of COVID-19 associated stroke in younger adults with a tendency for multiple infarcts and systemic thromboses. These clinical data will be useful to inform mechanistic studies and stratification of patients in clinical trials.
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Affiliation(s)
- Amy L Ross Russell
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Department of Neurology, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Marc Hardwick
- Department of Neurology, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Athavan Jeyanantham
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Laura M White
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, L9 7AL, UK
| | - Saumitro Deb
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, L3 5TR, UK
| | - Girvan Burnside
- Department of Health Data Science, University of Liverpool, Liverpool, L69 3BX, UK
| | - Harriet M Joy
- Neuroradiology Department, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Craig J Smith
- Manchester Centre for Clinical Neurosciences, Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Salford Royal Foundation Trust, Salford, M6 8HD, UK
- Division of Cardiovascular Sciences, Lydia Becker Institute for Immunology and Inflammation, University of Manchester, Manchester, M13 9PL, UK
| | - Thomas A Pollak
- Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, London, SE5 8AF, UK
| | - Timothy R Nicholson
- Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, London, SE5 8AF, UK
| | | | - Hadi Manji
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology, London, WC1N 3BG, UK
- UCL Queen Square Institute of Neurology, University College London, London, WC1N 3BG, UK
| | - Ava Easton
- Encephalitis Society, Malton, Malton, YO17 7DT, UK
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Sciences, University of Liverpool, Liverpool, L7 3EA, UK
| | - Stephen Ray
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Sciences, University of Liverpool, Liverpool, L7 3EA, UK
- The National Institute for Health Research Health Protection Research Unit for Emerging and Zoonotic Infections, University of Liverpool, Liverpool, L69 7BE, UK
| | - Michael S Zandi
- UCL Queen Square Institute of Neurology, University College London, London, WC1N 3BG, UK
| | - Jonathan P Coles
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0SP, UK
| | - David K Menon
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0SP, UK
| | - Aravinthan Varatharaj
- Department of Neurology, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Beth McCausland
- Department of Neurology, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
- Memory Assessment and Research Centre, Moorgreen Hospital, Southern Health Foundation Trust, Southampton, SO40 2RZ, UK
| | - Mark A Ellul
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Sciences, University of Liverpool, Liverpool, L7 3EA, UK
- The National Institute for Health Research Health Protection Research Unit for Emerging and Zoonotic Infections, University of Liverpool, Liverpool, L69 7BE, UK
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, L9 7LJ, UK
| | - Naomi Thomas
- Translational and Clinical Research Institute, Newcastle University, Newcastle, NE1 7RU, UK
- Wellcome Centre for Mitochondrial Research, Newcastle University, Newcastle, NE2 4HH, UK
| | - Gerome Breen
- Department of Social Genetic and Developmental Psychiatry, King’s College London, London, SE5 8AF, UK
| | - Stephen Keddie
- Department of Neuromuscular Diseases, University College London, London, WC1N 3BG, UK
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, WC1N 3BG, UK
| | - Michael P Lunn
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology, London, WC1N 3BG, UK
- UCL Queen Square Institute of Neurology, University College London, London, WC1N 3BG, UK
| | - John P S Burn
- Rehabilitation Department, Poole Hospital, University Hospitals Dorset NHS Foundation Trust, Poole, BH15 2JB, UK
| | - Graziella Quattrocchi
- Department of Neurology, North Middlesex University Hospital NHS Trust, London, N18 1QX, UK
| | - Luke Dixon
- Department of Neuroradiology, Imperial College NHS Healthcare Trust, London, W2 1NY, UK
| | - Claire M Rice
- Department of Neurology, Southmead Hospital, North Bristol NHS Trust, Bristol, S10 5NB, UK
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 1TH, UK
| | - George Pengas
- Department of Neurology, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | | | - Alan Carson
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, EH16 4SB, UK
| | - Eileen M Joyce
- UCL Queen Square Institute of Neurology, University College London, London, WC1N 3BG, UK
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
| | - Laura A Benjamin
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Sciences, University of Liverpool, Liverpool, L7 3EA, UK
- The National Institute for Health Research Health Protection Research Unit for Emerging and Zoonotic Infections, University of Liverpool, Liverpool, L69 7BE, UK
- Laboratory of Molecular and Cell Biology, UCL, Gower St, King’s Cross, London, London, WC1E 6BT, UK
| | - Tom Solomon
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Sciences, University of Liverpool, Liverpool, L7 3EA, UK
- The National Institute for Health Research Health Protection Research Unit for Emerging and Zoonotic Infections, University of Liverpool, Liverpool, L69 7BE, UK
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, L9 7LJ, UK
| | - Rachel Kneen
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Sciences, University of Liverpool, Liverpool, L7 3EA, UK
- Department of Neurology, Alder Hey Children’s NHS Foundation Trust, Liverpool, Liverpool, L14 5AB, UK
| | - Sarah Pett
- Medical Research Council Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, WC1V 6LJ, UK
- Institute for Global Health, University College London, London, WC1N 1EH, UK
| | - Rhys H Thomas
- Translational and Clinical Research Institute, Newcastle University, Newcastle, NE1 7RU, UK
- Wellcome Centre for Mitochondrial Research, Newcastle University, Newcastle, NE2 4HH, UK
- Department of Neurology, Royal Victoria Infirmary, Newcastle, NE1 4LP, UK
| | - Benedict D Michael
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Sciences, University of Liverpool, Liverpool, L7 3EA, UK
- The National Institute for Health Research Health Protection Research Unit for Emerging and Zoonotic Infections, University of Liverpool, Liverpool, L69 7BE, UK
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, L9 7LJ, UK
| | - Ian Galea
- Department of Neurology, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
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19
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Millward CP, Van Tonder L, Williams D, Thornton O, Foster M, Griffiths M, Puthuran M, Chandran A, Israni A, Sinha A, Kneen R, Mallucci C. Screening for cerebrovascular disorder on the basis of family history in asymptomatic children. Br J Neurosurg 2021; 35:584-590. [PMID: 34169790 DOI: 10.1080/02688697.2021.1922607] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Background: Cerebrovascular disorders represent a group of uncommon, heterogeneous, and complex conditions in children. We reviewed the screening practice for the detection of cerebrovascular disorder in asymptomatic children referred to our neurovascular service on the basis of a positive family history and parental and/or treating physician concern.Methods: Retrospective case-note review of referrals to our neurovascular service (July 2008-April 2018). Patients were included if the referral was made for screening, on the basis of a positive family history of cerebrovascular disorder. Symptomatic children, those with previous cranial imaging, or children under the care of a clinical geneticist (i.e. due to the child or their relative having HHT or mutations in KRIT1) were not eligible for inclusion.Results: Forty-one children were reviewed, 22 males (Median age 10.7 years, range 0.6-15.6 years). This represented 22% of the total number of referrals over a 10-year period. Twenty-nine children had an MRI/MRA brain. Twenty-eight children were referred due to a family history of intracranial aneurysm and/or subarachnoid haemorrhage, but only two had two first-degree relatives affected. Ten children were referred due to a family history of arteriovenous malformation. Three children were referred due to a family history of stroke. No cerebrovascular disease was detected during the study period (n = 29).Conclusions: Parental and/or physician concern generated a substantial number of referrals but no pathology was detected after screening. Whilst general screening guidance exists for the detection of intracranial aneurysms, consensus guidelines for the screening of children with a positive family history do not, but are required both to guide clinical practice and to assuage parental and/or physician concerns.
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Affiliation(s)
- Christopher Paul Millward
- Neurosurgery Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK.,University of Liverpool, Liverpool, UK
| | - Libby Van Tonder
- Neurosurgery Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,University of Liverpool, Liverpool, UK
| | - Dawn Williams
- Neurosurgery Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Owen Thornton
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Mitchell Foster
- Neurosurgery Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Michael Griffiths
- Neurosurgery Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,University of Liverpool, Liverpool, UK
| | - Mani Puthuran
- Neurosurgery Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Arun Chandran
- Neurosurgery Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Anil Israni
- Neurosurgery Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Ajay Sinha
- Neurosurgery Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Rachel Kneen
- Neurosurgery Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,University of Liverpool, Liverpool, UK
| | - Conor Mallucci
- Neurosurgery Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,University of Liverpool, Liverpool, UK
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20
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Abdel-Mannan OA, Manchoon C, Rossor T, Southin JC, Tur C, Brownlee W, Byrne S, Chitre M, Coles A, Forsyth R, Kneen R, Mankad K, Ram D, West S, Wright S, Wassmer E, Lim M, Ciccarelli O, Hemingway C, Hacohen Y. Use of Disease-Modifying Therapies in Pediatric Relapsing-Remitting Multiple Sclerosis in the United Kingdom. Neurol Neuroimmunol Neuroinflamm 2021; 8:8/4/e1008. [PMID: 34021056 PMCID: PMC8143699 DOI: 10.1212/nxi.0000000000001008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 03/18/2021] [Indexed: 11/18/2022]
Abstract
Objectives To compare the real-world effectiveness of newer disease-modifying therapies (DMTs) vs injectables in children with relapsing-remitting multiple sclerosis (RRMS). Methods In this retrospective, multicenter study, from the UK Childhood Inflammatory Demyelination Network, we identified children with RRMS receiving DMTs from January 2012 to December 2018. Clinical and paraclinical data were retrieved from the medical records. Annualized relapse rates (ARRs) before and on treatment, time to relapse, time to new MRI lesions, and change in Expanded Disability Status Scale (EDSS) score were calculated. Results Of 103 children treated with DMTs, followed up for 3.8 years, relapses on treatment were recorded in 53/89 (59.5%) on injectables vs 8/54 (15%) on newer DMTs. The ARR was reduced from 1.9 to 1.1 on injectables (p < 0.001) vs 1.6 to 0.3 on newer DMTs (p = 0.002). New MRI lesions occurred in 77/89 (86.5%) of patients on injectables vs 26/54 (47%) on newer DMTs (p = 0.0001). Children on newer DMTs showed longer time to relapse, time to switch treatment, and time to new radiologic activity than patients on injectables (log-rank p < 0.01). After adjustment for potential confounders, multivariable analysis showed that injectables were associated with 12-fold increased risk of clinical relapse (adjusted hazard ratio [HR] = 12.12, 95% CI = 1.64–89.87, p = 0.015) and a 2-fold increased risk of new radiologic activity (adjusted HR = 2.78, 95% CI = 1.08–7.13, p = 0.034) compared with newer DMTs. At 2 years from treatment initiation, 38/103 (37%) patients had MRI activity in the absence of clinical relapses. The EDSS score did not change during the follow-up, and only 2 patients had cognitive impairment. Conclusion Newer DMTs were associated with a lower risk of clinical and radiologic relapses in patients compared with injectables. Our study adds weight to the argument for an imminent shift in practice toward the use of newer, more efficacious DMTs in the first instance. Classification of Evidence This study provides Class IV evidence that newer DMTs (oral or infusions) are superior to injectables (interferon beta/glatiramer acetate) in reducing both clinical relapses and radiologic activity in children with RRMS.
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Affiliation(s)
- Omar A Abdel-Mannan
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Celeste Manchoon
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Thomas Rossor
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Justine-Clair Southin
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Carmen Tur
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Wallace Brownlee
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Susan Byrne
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Manali Chitre
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Alasdair Coles
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Rob Forsyth
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Rachel Kneen
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Kshitij Mankad
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Dipak Ram
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Siobhan West
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Sukhvir Wright
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Evangeline Wassmer
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Ming Lim
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Olga Ciccarelli
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Cheryl Hemingway
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Yael Hacohen
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.).
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Varatharaj A, Thomas N, Ellul MA, Davies NWS, Pollak TA, Tenorio EL, Sultan M, Easton A, Breen G, Zandi M, Coles JP, Manji H, Al-Shahi Salman R, Menon DK, Nicholson TR, Benjamin LA, Carson A, Smith C, Turner MR, Solomon T, Kneen R, Pett SL, Galea I, Thomas RH, Michael BD. Neurological and neuropsychiatric complications of COVID-19 in 153 patients: a UK-wide surveillance study. Lancet Psychiatry 2020; 7:875-882. [PMID: 32593341 PMCID: PMC7316461 DOI: 10.1016/s2215-0366(20)30287-x] [Citation(s) in RCA: 812] [Impact Index Per Article: 203.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/03/2020] [Accepted: 06/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Concerns regarding potential neurological complications of COVID-19 are being increasingly reported, primarily in small series. Larger studies have been limited by both geography and specialty. Comprehensive characterisation of clinical syndromes is crucial to allow rational selection and evaluation of potential therapies. The aim of this study was to investigate the breadth of complications of COVID-19 across the UK that affected the brain. METHODS During the exponential phase of the pandemic, we developed an online network of secure rapid-response case report notification portals across the spectrum of major UK neuroscience bodies, comprising the Association of British Neurologists (ABN), the British Association of Stroke Physicians (BASP), and the Royal College of Psychiatrists (RCPsych), and representing neurology, stroke, psychiatry, and intensive care. Broad clinical syndromes associated with COVID-19 were classified as a cerebrovascular event (defined as an acute ischaemic, haemorrhagic, or thrombotic vascular event involving the brain parenchyma or subarachnoid space), altered mental status (defined as an acute alteration in personality, behaviour, cognition, or consciousness), peripheral neurology (defined as involving nerve roots, peripheral nerves, neuromuscular junction, or muscle), or other (with free text boxes for those not meeting these syndromic presentations). Physicians were encouraged to report cases prospectively and we permitted recent cases to be notified retrospectively when assigned a confirmed date of admission or initial clinical assessment, allowing identification of cases that occurred before notification portals were available. Data collected were compared with the geographical, demographic, and temporal presentation of overall cases of COVID-19 as reported by UK Government public health bodies. FINDINGS The ABN portal was launched on April 2, 2020, the BASP portal on April 3, 2020, and the RCPsych portal on April 21, 2020. Data lock for this report was on April 26, 2020. During this period, the platforms received notification of 153 unique cases that met the clinical case definitions by clinicians in the UK, with an exponential growth in reported cases that was similar to overall COVID-19 data from UK Government public health bodies. Median patient age was 71 years (range 23-94; IQR 58-79). Complete clinical datasets were available for 125 (82%) of 153 patients. 77 (62%) of 125 patients presented with a cerebrovascular event, of whom 57 (74%) had an ischaemic stroke, nine (12%) an intracerebral haemorrhage, and one (1%) CNS vasculitis. 39 (31%) of 125 patients presented with altered mental status, comprising nine (23%) patients with unspecified encephalopathy and seven (18%) patients with encephalitis. The remaining 23 (59%) patients with altered mental status fulfilled the clinical case definitions for psychiatric diagnoses as classified by the notifying psychiatrist or neuropsychiatrist, and 21 (92%) of these were new diagnoses. Ten (43%) of 23 patients with neuropsychiatric disorders had new-onset psychosis, six (26%) had a neurocognitive (dementia-like) syndrome, and four (17%) had an affective disorder. 18 (49%) of 37 patients with altered mental status were younger than 60 years and 19 (51%) were older than 60 years, whereas 13 (18%) of 74 patients with cerebrovascular events were younger than 60 years versus 61 (82%) patients older than 60 years. INTERPRETATION To our knowledge, this is the first nationwide, cross-specialty surveillance study of acute neurological and psychiatric complications of COVID-19. Altered mental status was the second most common presentation, comprising encephalopathy or encephalitis and primary psychiatric diagnoses, often occurring in younger patients. This study provides valuable and timely data that are urgently needed by clinicians, researchers, and funders to inform immediate steps in COVID-19 neuroscience research and health policy. FUNDING None.
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Affiliation(s)
- Aravinthan Varatharaj
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, UK; University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Naomi Thomas
- Translational and Clinical Research Institute, University of Newcastle, Newcastle, UK; Wellcome Centre for Mitochondrial Research, University of Newcastle, Newcastle, UK
| | - Mark A Ellul
- The National Institute for Health Research Health Protection Research Unit for Emerging and Zoonotic Infections, Liverpool, UK; Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Sciences, University of Liverpool, Liverpool, UK; The Walton Centre NHS Foundation Trust, Liverpool, UK
| | | | - Thomas A Pollak
- Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
| | - Elizabeth L Tenorio
- Forcepoint X-Labs, Boston, MA, USA; Department of Medicinal Chemistry, University of Utah, Salt Lake City, UT, USA
| | - Mustafa Sultan
- Translational and Clinical Research Institute, University of Newcastle, Newcastle, UK
| | - Ava Easton
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Sciences, University of Liverpool, Liverpool, UK; The Encephalitis Society, Malton, UK
| | - Gerome Breen
- Department of Social Genetic and Developmental Psychiatry, King's College London, London, UK
| | - Michael Zandi
- UCL Queen Square Institute of Neurology, University College London, London, UK
| | | | - Hadi Manji
- UCL Queen Square Institute of Neurology, University College London, London, UK
| | | | - David K Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Timothy R Nicholson
- Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
| | - Laura A Benjamin
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Sciences, University of Liverpool, Liverpool, UK; UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Alan Carson
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Craig Smith
- Division of Cardiovascular Sciences, Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Tom Solomon
- The National Institute for Health Research Health Protection Research Unit for Emerging and Zoonotic Infections, Liverpool, UK; Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Sciences, University of Liverpool, Liverpool, UK; The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Rachel Kneen
- The National Institute for Health Research Health Protection Research Unit for Emerging and Zoonotic Infections, Liverpool, UK; Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Sciences, University of Liverpool, Liverpool, UK; Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Sarah L Pett
- Medical Research Council Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK; Institute for Global Health, University College London, London, UK
| | - Ian Galea
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, UK; University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Rhys H Thomas
- Translational and Clinical Research Institute, University of Newcastle, Newcastle, UK; Department of Neurology, Royal Victoria Infirmary, Newcastle, UK
| | - Benedict D Michael
- The National Institute for Health Research Health Protection Research Unit for Emerging and Zoonotic Infections, Liverpool, UK; Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Sciences, University of Liverpool, Liverpool, UK; The Walton Centre NHS Foundation Trust, Liverpool, UK.
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22
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Ellul MA, Benjamin L, Singh B, Lant S, Michael BD, Easton A, Kneen R, Defres S, Sejvar J, Solomon T. Neurological associations of COVID-19. Lancet Neurol 2020; 19:767-783. [PMID: 32622375 PMCID: PMC7332267 DOI: 10.1016/s1474-4422(20)30221-0] [Citation(s) in RCA: 1281] [Impact Index Per Article: 320.3] [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: 04/24/2020] [Revised: 05/27/2020] [Accepted: 06/04/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is of a scale not seen since the 1918 influenza pandemic. Although the predominant clinical presentation is with respiratory disease, neurological manifestations are being recognised increasingly. On the basis of knowledge of other coronaviruses, especially those that caused the severe acute respiratory syndrome and Middle East respiratory syndrome epidemics, cases of CNS and peripheral nervous system disease caused by SARS-CoV-2 might be expected to be rare. RECENT DEVELOPMENTS A growing number of case reports and series describe a wide array of neurological manifestations in 901 patients, but many have insufficient detail, reflecting the challenge of studying such patients. Encephalopathy has been reported for 93 patients in total, including 16 (7%) of 214 hospitalised patients with COVID-19 in Wuhan, China, and 40 (69%) of 58 patients in intensive care with COVID-19 in France. Encephalitis has been described in eight patients to date, and Guillain-Barré syndrome in 19 patients. SARS-CoV-2 has been detected in the CSF of some patients. Anosmia and ageusia are common, and can occur in the absence of other clinical features. Unexpectedly, acute cerebrovascular disease is also emerging as an important complication, with cohort studies reporting stroke in 2-6% of patients hospitalised with COVID-19. So far, 96 patients with stroke have been described, who frequently had vascular events in the context of a pro-inflammatory hypercoagulable state with elevated C-reactive protein, D-dimer, and ferritin. WHERE NEXT?: Careful clinical, diagnostic, and epidemiological studies are needed to help define the manifestations and burden of neurological disease caused by SARS-CoV-2. Precise case definitions must be used to distinguish non-specific complications of severe disease (eg, hypoxic encephalopathy and critical care neuropathy) from those caused directly or indirectly by the virus, including infectious, para-infectious, and post-infectious encephalitis, hypercoagulable states leading to stroke, and acute neuropathies such as Guillain-Barré syndrome. Recognition of neurological disease associated with SARS-CoV-2 in patients whose respiratory infection is mild or asymptomatic might prove challenging, especially if the primary COVID-19 illness occurred weeks earlier. The proportion of infections leading to neurological disease will probably remain small. However, these patients might be left with severe neurological sequelae. With so many people infected, the overall number of neurological patients, and their associated health burden and social and economic costs might be large. Health-care planners and policy makers must prepare for this eventuality, while the many ongoing studies investigating neurological associations increase our knowledge base.
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Affiliation(s)
- Mark A Ellul
- National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK; The Walton Centre National Health Service (NHS) Foundation Trust, Liverpool, UK
| | - Laura Benjamin
- Queen Square Institute of Neurology, University College London, London, UK
| | - Bhagteshwar Singh
- National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK; Tropical and Infectious Diseases Unit, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK; Christian Medical College, Vellore, India
| | - Suzannah Lant
- National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Benedict Daniel Michael
- National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK; The Walton Centre National Health Service (NHS) Foundation Trust, Liverpool, UK
| | - Ava Easton
- National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK; Encephalitis Society, Malton, UK
| | - Rachel Kneen
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Sylviane Defres
- National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK; Tropical and Infectious Diseases Unit, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Jim Sejvar
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Tom Solomon
- National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK; The Walton Centre National Health Service (NHS) Foundation Trust, Liverpool, UK; Tropical and Infectious Diseases Unit, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK.
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Ellul M, Varatharaj A, Nicholson TR, Pollak TA, Thomas N, Easton A, Zandi MS, Manji H, Solomon T, Carson A, Turner MR, Kneen R, Galea I, Pett S, Thomas RH, Michael BD. Defining causality in COVID-19 and neurological disorders. J Neurol Neurosurg Psychiatry 2020; 91:811-812. [PMID: 32503883 PMCID: PMC7299654 DOI: 10.1136/jnnp-2020-323667] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/01/2020] [Accepted: 05/01/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Mark Ellul
- NIHR Health Protection Research Unit for Emerging and Zoonotic Infection, Liverpool, UK
- Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Aravinthan Varatharaj
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Wessex Neurosciences Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Timothy R Nicholson
- Institute of Psychiatry Psychology & Neuroscience (IoPPN), King's College London, London, UK
| | - Thomas Arthur Pollak
- Institute of Psychiatry Psychology & Neuroscience (IoPPN), King's College London, London, UK
| | - Naomi Thomas
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
- Royal Victoria Infirmary, Newcastle, UK
| | | | - Michael S Zandi
- Queen Square Institute of Neurology, University College London, London, UK
| | - Hadi Manji
- Queen Square Institute of Neurology, University College London, London, UK
| | - Tom Solomon
- NIHR Health Protection Research Unit for Emerging and Zoonotic Infection, Liverpool, UK
- Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Alan Carson
- Department of Psychiatry, University of Edinburgh, Edinburgh, UK
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK
| | - Rachel Kneen
- NIHR Health Protection Research Unit for Emerging and Zoonotic Infection, Liverpool, UK
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
- Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Ian Galea
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Wessex Neurosciences Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Sarah Pett
- Institute for Global Health, University College London, London, UK
- MRC CTU at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Rhys Huw Thomas
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
- Department of Neurology, Royal Victoria Infirmary, Newcastle, UK
| | - Benedict Daniel Michael
- NIHR Health Protection Research Unit for Emerging and Zoonotic Infection, Liverpool, UK
- Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
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24
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Lemon J, Cooper J, Defres S, Easton A, Sadarangani M, Griffiths MJ, Pollard AJ, Solomon T, Kneen R. Understanding parental perspectives on outcomes following paediatric encephalitis: A qualitative study. PLoS One 2019; 14:e0220042. [PMID: 31525232 PMCID: PMC6746349 DOI: 10.1371/journal.pone.0220042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 11/02/2018] [Accepted: 07/08/2019] [Indexed: 11/18/2022] Open
Abstract
Background Encephalitis, characterised as inflammation of the brain tissue, is an important cause of acquired brain injury in children. Objective clinical outcomes vary significantly between affected patients, however they do not always correlate with quality of life as reported by parents. The aim of this study was to explore how parents experience and interpret outcomes in relation to their child who has been affected by encephalitis. Methods Data were derived from in-depth, semi-structured interviews, with 15 parents of 12 children and young people affected by encephalitis. Paediatric cases were identified from the retrospective arm of the research programme ‘ENCEPH-UK-Understanding and Improving the Outcome of Encephalitis’, and from the prospective UK childhood meningitis and encephalitis cohort study (UK-ChiMES, 2012 to 2016). Data were analysed thematically. Results Parents’ perspectives on important outcomes for their child and family changed during the different stages of the encephalitis illness trajectory: from acute illness, recovery and rehabilitation, then reintegration into everyday life. Parents’ understanding of their children’s overall outcome was informed by their own experiences, involving comparisons with other children and reflections on their child’s problems before, during and after the acute illness. Conclusion Outcomes in paediatric encephalitis need to be understood in terms of the context of the patient and family experience as well as the timeframe of recovery. The research highlights the need to include more patient, parent and/or carer reported outcome measures during patient assessment, and that assessment should be repeated during recovery as family concerns change. In the longer term, these parameters could be included in clinical and rehabilitation practice to further support child recovery.
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Affiliation(s)
- Jennifer Lemon
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Jessie Cooper
- School of Health Sciences, Division of Health Services Research and Management, City University of London, London, United Kingdom
| | - Sylviane Defres
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Tropical Infectious Diseases Unit, Royal Liverpool University and Broadgreen NHS Trust, Liverpool, United Kingdom
| | - Ava Easton
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Encephalitis Society, Malton, United Kingdom
| | - Manish Sadarangani
- Vaccine Evaluation Center, BC Children’s Hospital Research Institute, Vancouver, Canada
- Division of Infectious Diseases, Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Michael J. Griffiths
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, United Kingdom
| | - Andrew J. Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
- NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Tom Solomon
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, United Kingdom
- Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
- * E-mail:
| | - Rachel Kneen
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
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25
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Eyre M, Hacohen Y, Lamb K, Absoud M, Agrawal S, Gadian J, Gupta R, Kneen R, Milford DV, Philip S, Rose K, Smith M, Spinty S, Wassmer E, Lim M, Hemingway C. Utility and safety of plasma exchange in paediatric neuroimmune disorders. Dev Med Child Neurol 2019; 61:540-546. [PMID: 30659589 DOI: 10.1111/dmcn.14150] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2018] [Indexed: 12/27/2022]
Abstract
AIM Our aim was to ascertain the indications, side effects, and outcomes in children receiving therapeutic plasma exchange (TPE) for neurological disorders. METHOD Medical records were retrospectively reviewed for 58 consecutive children (age ≤16y) undergoing 67 courses of TPE across four tertiary centres. Patient characteristics, treatment schedules, complications, and outcomes were analysed. RESULTS Median age at initiation of TPE was 9 years (range 1-15y). Indications included peripheral nervous system (PNS; n=18) and central nervous system (CNS; n=40) disorders. Courses comprised a median six exchanges (range 2-179) over 8 days (range 3-466). Forty-two out of 58 (73%) children were severely disabled (bedridden) at initiation and 24 out of 58 (41%) were admitted to intensive care units. Treating clinicians' impression of response was positive in 16 out of 18 of those with PNS disorders versus 22 out of 40 with CNS disorders (p=0.016). Improvements in disability (modified Rankin Scale) occurred in 13 out of 58 (22%) children by completion of TPE (p=0.003). Complications occurred in 40 out of 67 (60%) courses, of which 16 out of 67 (24%) were line related. Potentially life-threatening complications occurred in 2 out of 67 (3%) courses. INTERPRETATION This cohort study provides safety and efficacy information for clinicians and families and a basis for future prospective studies. WHAT THIS PAPER ADDS Disability scores for severe neuroimmune disorders remained stable or improved during therapeutic plasma exchange treatment. Complications occurred frequently but were typically mild and correctable.
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Affiliation(s)
- Michael Eyre
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK.,Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK
| | - Yael Hacohen
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK.,Department of Neuroinflammation, Queen Square MS Centre, UCL Institute of Neurology, London, UK
| | - Kate Lamb
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Michael Absoud
- Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK.,Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Shakti Agrawal
- Department of Neurology, Birmingham Children's Hospital, Birmingham, UK
| | - Jonathan Gadian
- Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK
| | - Rajat Gupta
- Department of Neurology, Birmingham Children's Hospital, Birmingham, UK
| | - Rachel Kneen
- Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - David V Milford
- Department of Nephrology, Birmingham Children's Hospital, Birmingham, UK
| | - Sunny Philip
- Department of Neurology, Birmingham Children's Hospital, Birmingham, UK
| | - Katie Rose
- Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Martin Smith
- Department of Paediatric Neurology, Oxford Children's Hospital, Oxford, UK
| | - Stefan Spinty
- Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | | | - Ming Lim
- Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK.,Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Cheryl Hemingway
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
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26
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Millward CP, Tonder LV, Foster M, Williams D, Griffiths M, Kneen R, Sinha A, Mallucci C. P96 Screening for cerebrovascular pathology on the basis of positive family history in the paediatric population. J Neurol Neurosurg Psychiatry 2019. [DOI: 10.1136/jnnp-2019-abn.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
ObjectivesNeurovascular disorders are uncommon, complex conditions in children. We reviewed the screening practice and outcome of children referred to the neurovascular service on the basis of positive family history.DesignRetrospective review of prospectively maintained database.SubjectsChildren referred to the neurovascular service on the basis of family history, for screening at our hospital.MethodsWe retrospectively examined our database between July 2008 and April 2018 for the reasons for referral, family history, investigations performed, and the outcome of the screening process.Results44 children were reviewed (23 male, median age 10). Thirty-one children had an MRI/MRA brain. One child subsequently had uncomplicated digital subtraction angiography. Thirty children were referred due to a family history of subarachnoid haemorrhage, of which 17 had a single first-degree relative, and two had two first-degree relatives. Nine children were referred with a family history of arteriovenous malformation, (2 were associated with hereditary haemorrhagic telangiectasia). Five children were discussed due to a family history of non-specific haemorrhagic stroke. Seven children had a history of headache, (4 were prescribed Pizotifen for migraine). No neurovascular pathology was detected following screening within our cohort.ConclusionsA consensus screening policy does not exist but is required both to guide clinical practice and to assuage parental or patient concerns. We will survey UK paediatric centres to commence this process.
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27
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Tonder LV, Foster M, Hennigan D, Kneen R, Iyer A, Parks C, Burn S, Mallucci C. TP1-10 Non tumour brain biopsies in alder hey paediatric neurosurgery. J Neurol Neurosurg Psychiatry 2019. [DOI: 10.1136/jnnp-2019-abn.39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
ObjectivesTo review the utility of non-tumour brain biopsies in Alder Hey Children’s NHS Foundation Trust Paediatric Neurosurgery Department.MethodsOperative records were searched for ‘biopsy’. Case notes were reviewed for referral source, histology, surgical complication and outcome. Tumour, epilepsy and non-brain biopsy cases were excluded.Results83 ‘biopsy’ cases were identified between 2008 and 2017. 31 tumour, 5 epilepsy, 2 infections and 28 non brain/other biopsies were excluded. 17 brain biopsies for non-tumour causes were seen. 15 patients were referred by neurology, 2 by rheumatology. 14 underwent a craniotomy/mini-craniotomy, 3 had burrholes.4 biopsies were non diagnostic, 2 were abnormal but inconclusive for diagnosis. Diagnoses included: 3 demyelinating lesions, 2 normal brain tissue, 1 neurosarcoidosis, 1 autoimmune encephalitis, 1 definite Rasmussen’s Encephalitis, 1 possible Rasmussen’s Encephalitis, 1 systemic lupus erythematosus associated CNS vasculitis, 1 inflammatory infiltrate (secondary to hydrocephalus/ventriculitis), 1 patient developed a late wound infection. No other surgical morbidities/mortalities were recorded. 11 of these cases had a change in management or the treating team were reassured due to the result of the biopsy (i.e. were able to start immunomodulatory drugs in the absence of infection).Conclusions65% of brain biopsies were diagnostic. 71% of biopsies either changed management or reassured the treating team about a line of management. The procedure is low risk with 0.06% morbidity and 0% mortality.
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28
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Neame M, King C, Riordan A, Iyer A, Kneen R, Sinha I, Hawcutt DB. Seizures and quinolone antibiotics in children: a systematic review of adverse events. Eur J Hosp Pharm 2019; 27:60-64. [PMID: 32133130 DOI: 10.1136/ejhpharm-2018-001805] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 11/29/2018] [Accepted: 12/13/2018] [Indexed: 11/04/2022] Open
Abstract
Background Quinolone antibiotics have a broad spectrum of activity including against Gram-negative organisms (especially Pseudomonas), but their use has been associated with the development of seizures. Our objective was to evaluate the association between the administration of quinolones and seizures for three groups of children: those with epilepsy; those with other CNS disorders; and those without any CNS disorder. Method We conducted a systematic review of the MEDLINE, EMBASE and CENTRAL databases. Any studies reporting the administration of quinolones to children and including a methodology for identifying or reporting adverse events were identified by two authors who worked independently. Data relating to study characteristics (including population, intervention, comparison and outcome data) and study quality (including the quality of adverse event reporting) were extracted. Results We identified 140 studies involving 21 884 children. No studies reported involving children with epilepsy and 21 studies reported the involvement of 317 children with CNS disorders. 2/317 (0.63%) children with CNS disorders developed seizures and at least 4/21 567 (0.023%) children without CNS pathology were reported to have developed seizures. The quality of adverse event reporting in included studies was low. Only 8/140 (5.71%) included studies provided details of a methodology for actively identifying adverse neurological events. Discussion Even for children with CNS disorders the risk of developing seizures in association with the use of quinolones seems to be low. Further evaluations of quinolone use in children should include methodologies for actively identifying and reporting adverse neurological events.
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Affiliation(s)
| | - Charlotte King
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | | | - Anand Iyer
- Alder Hey Children's Hospital, Liverpool, UK
| | | | - Ian Sinha
- Alder Hey Children's Hospital, Liverpool, UK
| | - Daniel B Hawcutt
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,NIHR Alder Hey Clinical Research Facility, University of Liverpool, Liverpool, UK
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29
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Backman R, Foy R, Diggle PJ, Kneen R, Easton A, Defres S, McGill F, Michael BD, Solomon T. A pragmatic cluster randomised controlled trial of a tailored intervention to improve the initial management of suspected encephalitis. PLoS One 2018; 13:e0202257. [PMID: 30521521 PMCID: PMC6283633 DOI: 10.1371/journal.pone.0202257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 08/31/2017] [Accepted: 07/04/2018] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To determine whether a tailored multifaceted implementation strategy improves the initial management of patients with suspected encephalitis. DESIGN Pragmatic two arm cluster randomised controlled trial. SETTING Hospitals within the United Kingdom. PARTICIPANTS Twenty-four hospitals nested within 12 postgraduate deaneries. Patients were identified retrospectively by searching discharge, microbiology, radiology and pharmacy records and included if they met clinical criteria or had a recorded suspicion of encephalitis. INTERVENTION An implementation strategy designed to overcome barriers to change, comprising local action planning, education and training, feedback on performance, a lumbar puncture pack and a range of optional components. OUTCOMES The primary outcome was the proportion of patients with suspected encephalitis undergoing diagnostic lumbar puncture within 12 hours of admission and starting aciclovir treatment within six hours. Secondary outcomes included the proportions of adults and children who had a lumbar puncture, who had appropriate cerebrospinal fluid investigations, and who had appropriate radiological imaging within 24 hours of admission. Data were collected from patient records for 12 months before and 12 months during the intervention period, and analysed blind to allocation. RESULTS 13 hospitals were randomised to intervention and 11 to control (no intervention), with 266 and 223 patients with suspected encephalitis identified respectively. There was no significant difference in primary outcome between intervention and control hospitals (13.5% and 14.8% respectively, p = 0.619; treatment effect -0.188, 95% confidence interval -0.927 to 0.552), but both had improved compared to pre-intervention (8.5%). CONCLUSION The improvement in both intervention and control arms may reflect overall progress in management of encephalitis through wider awareness and education. TRIAL REGISTRATION Controlled Trials: ISRCTN06886935.
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Affiliation(s)
- Ruth Backman
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Peter J. Diggle
- Lancaster Medical School, Lancaster University, Lancaster, United Kingdom
- Department Epidemiology and Population Health, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Rachel Kneen
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Department of Neurology, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Ava Easton
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- The Encephalitis Society, Malton, North Yorkshire, United Kingdom
| | - Sylviane Defres
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, United Kingdom
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, United Kingdom
| | - Fiona McGill
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, United Kingdom
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, United Kingdom
| | - Benedict Daniel Michael
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Tom Solomon
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, United Kingdom
- The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
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30
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Tho-Calvi SC, Thompson D, Saunders D, Agrawal S, Basu A, Chitre M, Chow G, Gibbon F, Hart A, Tallur KK, Kirkham F, Kneen R, McCullagh H, Mewasingh L, Vassallo G, Vijayakumar K, Wraige E, Yeo TH, Ganesan V. Clinical features, course, and outcomes of a UK cohort of pediatric moyamoya. Neurology 2018; 90:e763-e770. [DOI: 10.1212/wnl.0000000000005026] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 11/17/2017] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo describe characteristics and course of a large UK cohort of children with moyamoya from multiple centers and examine prognostic predictors.MethodsRetrospective review of case notes/radiology, with use of logistic regression to explore predictors of outcome.ResultsEighty-eight children (median presentation age 5.1 years) were included. Thirty-six presented with arterial ischemic stroke (AIS) and 29 with TIA. Eighty had bilateral and 8 unilateral carotid circulation disease; 29 patients had posterior circulation involvement. Acute infarction was present in 36/176 hemispheres and chronic infarction in 86/176 hemispheres at the index presentation. Sixty-two of 82 with symptomatic presentation had at least one clinical recurrence. Fifty-five patients were treated surgically, with 37 experiencing fewer recurrences after surgery. Outcome was categorized as good using the Recovery and Recurrence Questionnaire in 39/85 patients. On multivariable analysis, presentation with TIA (odds ratio [OR] 0.09, 95% confidence interval [CI] 0.02–0.35), headache (OR 0.10, 95% CI 0.02–0.58), or no symptoms (OR 0.08, 95% CI 0.01–0.68) was less likely to predict poor outcome than AIS presentation. Posterior circulation involvement predicted poor outcome (OR 4.22, 95% CI 1.23–15.53). Surgical revascularization was not a significant predictor of outcome.ConclusionsMoyamoya is associated with multiple recurrences, progressive arteriopathy, and poor outcome in half of patients, especially with AIS presentation and posterior circulation involvement. Recurrent AIS is rare after surgery. Surgery was not a determinant of overall outcome, likely reflecting surgical case selection and presentation clinical status.
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31
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McTague A, Nair U, Malhotra S, Meyer E, Trump N, Gazina EV, Papandreou A, Ngoh A, Ackermann S, Ambegaonkar G, Appleton R, Desurkar A, Eltze C, Kneen R, Kumar AV, Lascelles K, Montgomery T, Ramesh V, Samanta R, Scott RH, Tan J, Whitehouse W, Poduri A, Scheffer IE, Chong WKK, Cross JH, Topf M, Petrou S, Kurian MA. Clinical and molecular characterization of KCNT1-related severe early-onset epilepsy. Neurology 2018; 90:e55-e66. [PMID: 29196579 PMCID: PMC5754647 DOI: 10.1212/wnl.0000000000004762] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [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: 11/07/2016] [Accepted: 09/26/2017] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To characterize the phenotypic spectrum, molecular genetic findings, and functional consequences of pathogenic variants in early-onset KCNT1 epilepsy. METHODS We identified a cohort of 31 patients with epilepsy of infancy with migrating focal seizures (EIMFS) and screened for variants in KCNT1 using direct Sanger sequencing, a multiple-gene next-generation sequencing panel, and whole-exome sequencing. Additional patients with non-EIMFS early-onset epilepsy in whom we identified KCNT1 variants on local diagnostic multiple gene panel testing were also included. When possible, we performed homology modeling to predict the putative effects of variants on protein structure and function. We undertook electrophysiologic assessment of mutant KCNT1 channels in a xenopus oocyte model system. RESULTS We identified pathogenic variants in KCNT1 in 12 patients, 4 of which are novel. Most variants occurred de novo. Ten patients had a clinical diagnosis of EIMFS, and the other 2 presented with early-onset severe nocturnal frontal lobe seizures. Three patients had a trial of quinidine with good clinical response in 1 patient. Computational modeling analysis implicates abnormal pore function (F346L) and impaired tetramer formation (F502V) as putative disease mechanisms. All evaluated KCNT1 variants resulted in marked gain of function with significantly increased channel amplitude and variable blockade by quinidine. CONCLUSIONS Gain-of-function KCNT1 pathogenic variants cause a spectrum of severe focal epilepsies with onset in early infancy. Currently, genotype-phenotype correlations are unclear, although clinical outcome is poor for the majority of cases. Further elucidation of disease mechanisms may facilitate the development of targeted treatments, much needed for this pharmacoresistant genetic epilepsy.
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Affiliation(s)
- Amy McTague
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK.
| | - Umesh Nair
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK
| | - Sony Malhotra
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK
| | - Esther Meyer
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK
| | - Natalie Trump
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK
| | - Elena V Gazina
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK
| | - Apostolos Papandreou
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK
| | - Adeline Ngoh
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK
| | - Sally Ackermann
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK
| | - Gautam Ambegaonkar
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK
| | - Richard Appleton
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK
| | - Archana Desurkar
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK
| | - Christin Eltze
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK
| | - Rachel Kneen
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK
| | - Ajith V Kumar
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK
| | - Karine Lascelles
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK
| | - Tara Montgomery
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK
| | - Venkateswaran Ramesh
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK
| | - Rajib Samanta
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK
| | - Richard H Scott
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK
| | - Jeen Tan
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK
| | - William Whitehouse
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK
| | - Annapurna Poduri
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK
| | - Ingrid E Scheffer
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK
| | - W K Kling Chong
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK
| | - J Helen Cross
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK
| | - Maya Topf
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK
| | - Steven Petrou
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK
| | - Manju A Kurian
- From Molecular Neurosciences (A.M., E.M., A., A.N., M.A.K.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health; Department of Neurology (A.M., A., A.N., C.E., J.H.C., M.A.K.) and Neuroradiology (W.K.C.), Great Ormond Street Hospital for Children, London, UK; Florey Institute of Neuroscience and Mental Health (U.N., E.V.G., I.E.S., S.P.), Melbourne, Australia; Department of Biological Sciences (S.M., M.T.), Institute of Structural and Molecular Biology, Birkbeck College, University of London; Regional Molecular Genetics Laboratory (N.T., R.H.S.), North East Thames Regional Genetics Service, and Department of Clinical Genetics (A.V.K., R.H.S.), Great Ormond Street Hospital, London, UK; Department of Paediatric Neurology (S.A.), Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Department of Paediatric Neurology (G.A.), Addenbrooke's Hospital, Cambridge; Roald Dahl EEG Unit (R.A.), Department of Neurology, and Department of Neurology (R.K.), Alder Hey Children's Hospital, Liverpool; Department of Paediatric Neurology (A.D.), Sheffield Children's Hospital; Clinical Neurosciences (C.E., J.H.C.), Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London; Institute of Infection and Global Health (R.K.), University of Liverpool; Department of Paediatric Neurology (K.L.), Evelina Children's Hospital, Guys and St. Thomas' NHS Foundation Trust, London; Department of Clinical Genetics (T.M.), Northern Genetics Service; Department of Pediatric Neurology (V.R.), Great North Children's Hospital, Newcastle Upon Tyne; Department of Paediatric Neurology (R.S.), University Hospital Leicester Children's Hospital; Department of Paediatric Neurology (J.T.), Royal Manchester Children's Hospital; Department of Paediatric Neurology (W.W.), Nottingham University Hospitals NHS Trust, UK; Epilepsy Genetics Program (A. Poduri), Department of Neurology, Boston Children's Hospital; Department of Neurology (A. Poduri), Harvard Medical School, Boston, MA; University of Melbourne (I.E.S.), Austin Health and Royal Children's Hospital, Australia; and Department of Medicine (S.P.), Royal Melbourne Hospital, University of Melbourne, Australia. Dr. Malhotra is currently at the Department of Biochemistry, University of Cambridge, UK.
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Awad A, Avula S, DeGoede C, Nair P, Rakshi K, Iyer A, Kneen R. PO174 Undergraduate prize 2016: clinical case category. two cases of mild encephalopathy with a reversible splenial lesion (mers) in two uk teaching hospitals. J Neurol Neurosurg Psychiatry 2017. [DOI: 10.1136/jnnp-2017-abn.197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Ray S, Rayamajhi A, Bonnett LJ, Solomon T, Kneen R, Griffiths MJ. The inter-rater reliability and prognostic value of coma scales in Nepali children with acute encephalitis syndrome. Paediatr Int Child Health 2017; 38:60-65. [PMID: 29143568 PMCID: PMC5801644 DOI: 10.1080/20469047.2017.1398503] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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] [Indexed: 11/17/2022]
Abstract
Background Acute encephalitis syndrome (AES) is a common cause of coma in Nepali children. The Glasgow coma scale (GCS) is used to assess the level of coma in these patients and predict outcome. Alternative coma scales may have better inter-rater reliability and prognostic value in encephalitis in Nepali children, but this has not been studied. The Adelaide coma scale (ACS), Blantyre coma scale (BCS) and the Alert, Verbal, Pain, Unresponsive scale (AVPU) are alternatives to the GCS which can be used. Methods Children aged 1-14 years who presented to Kanti Children's Hospital, Kathmandu with AES between September 2010 and November 2011 were recruited. All four coma scales (GCS, ACS, BCS and AVPU) were applied on admission, 48 h later and on discharge. Inter-rater reliability (unweighted kappa) was measured for each. Correlation and agreement between total coma score and outcome (Liverpool outcome score) was measured by Spearman's rank and Bland-Altman plot. The prognostic value of coma scales alone and in combination with physiological variables was investigated in a subgroup (n = 22). A multivariable logistic regression model was fitted by backward stepwise. Results Fifty children were recruited. Inter-rater reliability using the variables scales was fair to moderate. However, the scales poorly predicted clinical outcome. Combining the scales with physiological parameters such as systolic blood pressure improved outcome prediction. Conclusion This is the first study to compare four coma scales in Nepali children with AES. The scales exhibited fair to moderate inter-rater reliability. However, the study is inadequately powered to answer the question on the relationship between coma scales and outcome. Further larger studies are required.
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Key Words
- ACS, Adelaide coma scale
- AES, acute encephalitis syndrome
- AVPU, alert, verbal, pain, unresponsive
- Acute encephalitis syndrome
- BCS, Blantyre coma scale
- ETAT, emergency triage assessment and treatment
- LOS, Liverpool outcome score
- NTBI, non-traumatic brain injury
- PIM, paediatric risk of mortality
- PRISM, paediatric risk of mortality score
- RPS, resource-poor setting
- TBI, traumatic brain injury
- coma scales
- inter-rater reliability
- prognostic value
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Affiliation(s)
- Stephen Ray
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK,Littlewoods Neurosciences Unit, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK,National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, UK,Corresponding author. Emails:
| | - Ajit Rayamajhi
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK,Department of Paediatrics, Kanti Children’s Hospital, Kathmandu, Nepal,Department of Paediatrics, National Academy of Medical Sciences, Kathmandu, Nepal
| | - Laura J. Bonnett
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Tom Solomon
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK,National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, UK
| | - Rachel Kneen
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK,Littlewoods Neurosciences Unit, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Michael J. Griffiths
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK,Littlewoods Neurosciences Unit, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK,National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, UK
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Mithyantha R, Kneen R, McCann E, Gladstone M. Current evidence-based recommendations on investigating children with global developmental delay. Arch Dis Child 2017; 102:1071-1076. [PMID: 29054862 PMCID: PMC5738593 DOI: 10.1136/archdischild-2016-311271] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 09/20/2017] [Accepted: 09/21/2017] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Global developmental delay (GDD) affects 1%-3% of the population of children under 5 years of age, making it one of the most common conditions presenting in paediatric clinics; causes are exogenous, genetic (non-metabolic) or genetic (metabolic). Recent advances in biotechnology and genetic testing mean that the investigations available to perform for children under 5 years are increasing and are more sensitive than previously. This change in availability and type of testing necessitates an update in the recommendations for investigating GDD. METHODS We conducted a review of the literature from 2006 to 2016 to identify articles with evidence relating to the investigation of developmental delay in children under the age of 5 years. We collated the evidence into first-line and second-line investigations and, where available, on their yield and cost implications. RESULTS We have provided up-to-date guidance for first-line and second-line investigations for children with GDD under the age of 5 years. Recent evidence demonstrates that genetic testing for all children with unexplained GDD should be first line, if an exogenous cause is not already established. Our review of the literature demonstrates that all patients, irrespective of severity of GDD, should have investigations for treatable conditions. Evidence demonstrates that the yield for treatable conditions is higher than previously thought and that investigations for these metabolic conditions should be considered as first line. Additional second-line investigations can be led by history, examination and developmental trajectories. DISCUSSION We may need to update present recommendations in the UK for investigation of developmental delay. This would include microarray testing as first line and a more thorough approach to investigations for metabolic disorders that can be treated. Clinical assessment remains vital for guiding investigations.
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Affiliation(s)
- Renuka Mithyantha
- Department of Developmental Paediatrics, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Rachel Kneen
- Department of Paediatric Neurology, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK,Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Emma McCann
- Department of Clinical Genetics, Liverpool Women’s Hospital, Liverpool, UK
| | - Melissa Gladstone
- Department of Developmental Paediatrics, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK,Department of Women and Children’s Health, Institute of Translational Medicine, University of Liverpool, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
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Cooper J, Kierans C, Defres S, Easton A, Kneen R, Solomon T. Care beyond the hospital ward: understanding the socio-medical trajectory of herpes simplex virus encephalitis. BMC Health Serv Res 2017; 17:646. [PMID: 28899392 PMCID: PMC5596960 DOI: 10.1186/s12913-017-2608-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 09/08/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Herpes simplex virus (HSV) encephalitis is a life-threatening infection of the brain, which has significant physical, cognitive and social consequences for survivors. Despite increasing recognition of the long-term effects of encephalitis, research and policy remains largely focused on its acute management, meaning there is little understanding of the difficulties people face after discharge from acute care. This paper aims to chart the problems and challenges which people encounter when they return home after treatment for HSV encephalitis. METHODS The paper reports on data from 30 narrative interviews with 45 people affected by HSV encephalitis and their significant others. The study was conducted as part of the ENCEPH-UK programme grant on Understanding and Improving the Outcome of Encephalitis. RESULTS The findings show the diverse challenges which are experienced by people after treatment for HSV encephalitis. We first chart how peoples' everyday lives are fragmented following their discharge from hospital. Second, we document the social consequences which result from the longer-term effects of encephalitis. Finally, we show how the above struggles are exacerbated by the lack of support systems for the post-acute effects of encephalitis, and describe how people are consequently forced to devise their own care routines and strategies for managing their problems. CONCLUSION The paper argues that in order to improve long-term outcomes in encephalitis, it is vital that we develop pathways of support for the condition beyond the acute hospital setting. We conclude by making recommendations to enhance communication and care for the post-acute consequences of encephalitis, to ensure those affected are fully supported through the chronic effects of this devastating disease.
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Affiliation(s)
- Jessie Cooper
- Division of Health Services Research & Management, City, University of London, London, UK
| | - Ciara Kierans
- Department of Public Health and Policy, University of Liverpool, Liverpool, UK
| | - Sylviane Defres
- Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
- Tropical and infectious diseases Unit, The Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, UK
- NIHR HPRU in Emerging and Zoonotic Infections, Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Ava Easton
- Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
- The Encephalitis Society, Malton, North Yorkshire, UK
| | - Rachel Kneen
- Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
- Department of Neurology, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Tom Solomon
- Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
- NIHR HPRU in Emerging and Zoonotic Infections, Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
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Titre-Johnson S, Schoeler N, Eltze C, Williams R, Vezyroglou K, McCullagh H, Freemantle N, Heales S, Kneen R, Marston L, Martland T, Nazareth I, Neal E, Lux A, Parker A, Agrawal S, Fallon P, Cross JH. Ketogenic diet in the treatment of epilepsy in children under the age of 2 years: study protocol for a randomised controlled trial. Trials 2017; 18:195. [PMID: 28446244 PMCID: PMC5406967 DOI: 10.1186/s13063-017-1918-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [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] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 03/25/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The incidence of epilepsy is greatest in the first 2 years of life, an age group where there is generally a poor prognosis for both seizure control and neurodevelopmental outcome. Early control of seizures can be associated with better developmental outcome but many of the epilepsies presenting in infancy are poorly responsive to antiepileptic medication. The ketogenic diet (KD) is a high-fat, low-carbohydrate diet designed to mimic the effects of starvation on the body. Dietary fat is converted into ketones in the body and used as an energy source by the brain. The KD has been shown to be successful in controlling seizures in many observational studies, and in two randomised controlled trials (RCTs) in older children. However, little evidence is available in the very young. METHODS/DESIGN An open-label RCT where eligible children (age 3 months to 2 years with epilepsy who have failed two antiepileptic drugs (AEDs)) undergo baseline assessment, including medical and seizure history. Participants then start an observation period (7 or 14 days) with documentation of seizure frequency. Randomisation will occur on day 8 or day 15 to receive the KD or a further AED; the allocated treatment will commence on day 15, with instruction and training. A second assessment (4 weeks after start of treatment) will include a clinical review and tolerability questionnaire (modified Hague Scale of Side Effects - for those allocated to the KD group). Assessments will be repeated at 8 weeks after the start of treatment including biochemical investigations, after which, according to patient response, KD (diet group) or AED (standard AED group) will then be continued or changed. Those in the AED group who have failed to achieve seizure control at the 8-week assessment will then be offered KD outside the context of the trial. Those in the KD arm who fail to achieve seizure control will be changed to standard clinical management. All patients will be followed up for 12 months from randomisation for retention, seizure outcome, quality of life and neurodevelopmental status. DISCUSSION The slow rate of recruitment is an ongoing practical issue. There is a limitation to the number of eligible patients compared to what was predicted, mainly due to the nature of this patient group. After a substantial amendment to widen inclusion criteria and reduce the baseline period to 7 days for patients with a high seizure burden, the rate of recruitment steadily increased. A number of operational concerns regarding dietetic time were also highlighted impacting on the recruitment rate. However, the combination of a low dropout rate and the opening of further centres, the trial should successfully meet the final recruitment target. All nine centres are now recruiting and we hope to open further centres within the UK. TRIAL REGISTRATION ClinicalTrials.gov, identifier: NCT02205931 . Registered on 16 December 2013.
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Affiliation(s)
| | | | | | | | | | | | | | - Simon Heales
- UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | - Louise Marston
- PRIMENT Clinical Trials Unit, Department of Primary Care and Population Health, UCL, London, UK
| | - Tim Martland
- Royal Manchester Children’s Hospital, Manchester, UK
| | - Irwin Nazareth
- PRIMENT Clinical Trials Unit, Department of Primary Care and Population Health, UCL, London, UK
| | | | | | | | | | | | - J. Helen Cross
- UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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Awadh M, O'Regan M, Martland T, Kneen R, Tan H. Effectiveness and Tolerability of Rufinamide in Children and Young People: A Survey of Experience from the United Kingdom. J Pediatr Epilepsy 2017. [DOI: 10.1055/s-0037-1599190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Mostafa Awadh
- Department of Neurology, Ain Shams University Hospital, Cairo, Egypt
| | - Mary O'Regan
- Fraser of Allander Neurosciences Unit, Royal Hospital for Sick Children (Yorkhill), Glasgow, United Kingdom
| | - Timothy Martland
- Department of Paediatric Neurology, Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Rachel Kneen
- The Roald Dahl EEG Unit, Department of Neurology, Royal Liverpool Children's (Alder Hey) NHS Foundation Trust, Liverpool, United Kingdom
| | - Hui Tan
- Department of Paediatric Neurology, Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
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Iro MA, Sadarangani M, Absoud M, Chong WK, Clark CA, Easton A, Gray V, Kneen R, Lim M, Pike M, Solomon T, Vincent A, Willis L, Yu LM, Pollard AJ. ImmunoglobuliN in the Treatment of Encephalitis (IgNiTE): protocol for a multicentre randomised controlled trial. BMJ Open 2016; 6:e012356. [PMID: 27810972 PMCID: PMC5129051 DOI: 10.1136/bmjopen-2016-012356] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [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] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Infectious and immune-mediated encephalitides are important but under-recognised causes of morbidity and mortality in childhood, with a 7% death rate and up to 50% morbidity after prolonged follow-up. There is a theoretical basis for ameliorating the immune response with intravenous immunoglobulin (IVIG), which is supported by empirical evidence of a beneficial response following its use in the treatment of viral and autoimmune encephalitis. In immune-mediated encephalitis, IVIG is often used after a delay (by weeks in some cases), while diagnosis is confirmed. Wider use of IVIG in infectious encephalitis and earlier use in immune-mediated encephalitis could improve outcomes for these conditions. We describe the protocol for the first ever randomised control trial of IVIG treatment for children with all-cause encephalitis. METHODS AND ANALYSIS 308 children (6 months to 16 years) with a diagnosis of acute/subacute encephalitis will be recruited in ∼30 UK hospitals and randomised to receive 2 doses (1 g/kg/dose) of either IVIG or matching placebo, in addition to standard treatment. Recruitment will be over a 42-month period and follow-up of each participant will be for 12 months post randomisation. The primary outcome is 'good recovery' (score of 2 or lower on the Glasgow Outcome Score Extended-paediatric version), at 12 months after randomisation. Additional secondary neurological measures will be collected at 4-6 weeks after discharge from acute care and at 6 and 12 months after randomisation. Safety, radiological, other autoimmune and tertiary outcomes will also be assessed. ETHICS AND DISSEMINATION This trial has been approved by the UK National Research Ethics committee (South Central-Oxford A; REC 14/SC/1416). Current protocol: V4.0 (10/03/2016). The findings will be presented at national and international meetings and conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBERS NCT02308982, EudraCT201400299735 and ISRCTN15791925; Pre-results.
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Affiliation(s)
- M A Iro
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - M Sadarangani
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Department of Paediatrics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, University of British Columbia, Vancouver BC, Canada
| | - M Absoud
- Department of Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas’ NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK
| | - W K Chong
- Department of Radiology, Great Ormond Street Hospital for Children, London, UK
| | - C A Clark
- Institute of Child Health, University College London, London, UK
| | - A Easton
- The Encephalitis Society, Malton, North Yorkshire, UK
| | - V Gray
- Psychological services (Paediatrics), Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - R Kneen
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
- Littlewoods Neuroscience Foundation, Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - M Lim
- Department of Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas’ NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK
| | - M Pike
- Department of Paediatric Neurology, Oxford University Hospitals NHS Trust, Oxford, UK
| | - T Solomon
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
- National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, UK
- Walton Centre NHS Foundation Trust, Liverpool, UK
| | - A Vincent
- Department of Clinical Neurosciences, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
| | - L Willis
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - L-M Yu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - A J Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Department of Paediatrics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Ray S, Iyer A, Avula S, Kneen R. Acquired torticollis due to primary pyomyositis of the paraspinal muscles in an 11-year-old boy. BMJ Case Rep 2016; 2016:bcr-2015-213409. [PMID: 26994045 DOI: 10.1136/bcr-2015-213409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Torticollis is characterised by tilting and rotation of the cervical spine in opposite directions. Causes can be congenital or acquired. Primary pyomyositis is a rare subacute deep bacterial infection of skeletal muscles that typically affects individuals under 20 years of age from tropical countries. Infrequently, pyomyositis occurs in individuals from temperate regions, usually in immunocompromised adults, and this is defined as secondary pyomyositis. We report a case of acquired torticollis due to primary pyomyositis of the paraspinal muscles in a previously healthy boy from the UK. A prolonged course of antibiotics and physiotherapy led to a complete resolution of his illness. We review how to differentiate pyomyositis from focal myositis, a more common inflammatory muscular cause of acquired torticollis.
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Affiliation(s)
- S Ray
- Department of Neurosciences, Alder Hey Children's Hospital, Liverpool, UK University of Liverpool, Institute of Infection and Global Health, Liverpool, UK
| | - A Iyer
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - S Avula
- Department of Radiology, Alder Hey Children's Hospital, Liverpool, UK
| | - R Kneen
- Litttlewoods Neurosciences Unit, Alder Hey Children's Hospital, Liverpool, UK
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Cooper J, Kierans C, Defres S, Easton A, Kneen R, Solomon T. Diagnostic Pathways as Social and Participatory Practices: The Case of Herpes Simplex Encephalitis. PLoS One 2016; 11:e0151145. [PMID: 26960197 PMCID: PMC4784735 DOI: 10.1371/journal.pone.0151145] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [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: 11/02/2015] [Accepted: 02/24/2016] [Indexed: 11/21/2022] Open
Abstract
Herpes simplex virus (HSV) encephalitis is a potentially devastating disease, with significant rates of mortality and co-morbidities. Although the prognosis for people with HSV encephalitis can be improved by prompt treatment with aciclovir, there are often delays involved in the diagnosis and treatment of the disease. In response, National Clinical Guidelines have been produced for the UK which make recommendations for improving the management of suspected viral encephalitis. However, little is currently known about the everyday experiences and processes involved in the diagnosis and care of HSV encephalitis. The reported study aimed to provide an account of the diagnosis and treatment of HSV encephalitis from the perspective of people who had been affected by the condition. Thirty narrative interviews were conducted with people who had been diagnosed with HSV encephalitis and their significant others. The narrative accounts reveal problems with gaining access to a diagnosis of encephalitis and shortfalls in care for the condition once in hospital. In response, individuals and their families work hard to obtain medical recognition for the problem and shape the processes of acute care. As a consequence, we argue that the diagnosis and management of HSV encephalitis needs to be considered as a participatory process, which is co-produced by health professionals, patients, and their families. The paper concludes by making recommendations for developing the current management guidelines by formalising the critical role of patients and their significant others in the identification, and treatment of, HSV encephalitis.
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Affiliation(s)
- Jessie Cooper
- Department of Public Health and Policy, University of Liverpool, Liverpool, United Kingdom
- * E-mail:
| | - Ciara Kierans
- Department of Public Health and Policy, University of Liverpool, Liverpool, United Kingdom
| | - Sylviane Defres
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Tropical and Infectious Diseases Unit, The Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, United Kingdom
| | - Ava Easton
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- The Encephalitis Society, Malton, North Yorkshire, United Kingdom
| | - Rachel Kneen
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Department of Neurology, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Tom Solomon
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, United Kingdom
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Ellul MA, Griffiths MJ, Iyer A, Avula S, Defres S, Baborie A, Vincent A, Martin NG, Sadarangani M, Pollard AJ, Solomon T, Kneen R. Anti-N-Methyl-D-Aspartate Receptor Encephalitis In A Young Child With Histological Evidence On Brain Biopsy Of Coexistent Herpes Simplex Virus Type 1 Infection. Pediatr Infect Dis J 2016; 35:347-9. [PMID: 26658379 DOI: 10.1097/inf.0000000000001011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
We report a 3-year-old boy with anti-N-methyl-D-aspartate receptor encephalitis with a typical syndrome of movement disorder and encephalopathy and evidence of herpes simplex virus (HSV) type 1 infection on brain biopsy. HSV type 1 infection and anti-N-methyl-D-aspartate receptor encephalitis are temporally linked in some cases: this case suggests that prodromal HSV type-1 infection may be clinically subtle and easily missed.
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Affiliation(s)
- Mark A Ellul
- From the *Institute of Infection and Global Health, University of Liverpool; †Alder Hey Children's NHS Foundation Trust; ‡The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom; §Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital; and ¶Department of Paediatrics, University of Oxford, and the NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
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Defres S, Mayer J, Backman R, Kneen R. Performing lumbar punctures for suspected CNS infections: experience and practice of trainee doctors. Br J Hosp Med (Lond) 2016; 76:658-62. [PMID: 26551497 DOI: 10.12968/hmed.2015.76.11.658] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Lumbar punctures are essential in the management of suspected CNS infections. However, despite clear guidelines their use can be haphazard. This survey investigated the training, knowledge and experience of UK doctors in training in relation to lumbar punctures.
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Affiliation(s)
- Sylviane Defres
- Clinical Research Fellow in the Institute of Infection and Global Health, University of Liverpool, Liverpool and Specialist Registrar in Infectious Diseases in the Department of Tropical and Infectious Diseases Unit, Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool
| | | | - Ruth Backman
- Postdoctoral Health Services Researcher in the Institute of Infection and Global Health
| | - Rachel Kneen
- Consultant Paediatric Neurologist, Alder Hey Children's NHS Foundation Trust, Liverpool and Honorary Senior Clinical Lecturer in the Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool L69 7BE
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Elkind MSV, Hills NK, Glaser CA, Lo WD, Amlie-Lefond C, Dlamini N, Kneen R, Hod EA, Wintermark M, deVeber GA, Fullerton HJ. Herpesvirus Infections and Childhood Arterial Ischemic Stroke: Results of the VIPS Study. Circulation 2016; 133:732-41. [PMID: 26813104 DOI: 10.1161/circulationaha.115.018595] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 01/11/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Epidemiological studies demonstrate that childhood infections, including varicella zoster virus, are associated with an increased risk of arterial ischemic stroke (AIS). Other herpesviruses have been linked to childhood AIS in case reports. We sought to determine whether herpesvirus infections, which are potentially treatable, increase the risk of childhood AIS. METHODS AND RESULTS We enrolled 326 centrally confirmed cases of AIS and 115 stroke-free controls with trauma (29 days to 18 years of age) with acute blood samples (≤3 weeks after stroke/trauma); cases had convalescent samples (7-28 days later) when feasible. Samples were tested by commercial enzyme-linked immunosorbent assay kits for immunoglobulin M/immunoglobulin G antibodies to herpes simplex virus 1 and 2, cytomegalovirus, Epstein-Barr virus, and varicella zoster virus. An algorithm developed a priori classified serological evidence of past and acute herpesvirus infection as dichotomous variables. The median (quartiles) age was 7.7 (3.1-14.3) years for cases and 10.7 (6.9-13.2) years for controls (P=0.03). Serological evidence of past infection did not differ between cases and controls. However, serological evidence of acute herpesvirus infection doubled the odds of childhood AIS, even after adjusting for age, race, and socioeconomic status (odds ratio, 2.2; 95% confidence interval, 1.2-4.0; P=0.007). Among 187 cases with acute and convalescent blood samples, 85 (45%) showed evidence of acute herpesvirus infection; herpes simplex virus 1 was found most often. Most infections were asymptomatic. CONCLUSIONS Herpesviruses may act as a trigger for childhood AIS, even if the infection is subclinical. Antivirals like acyclovir might have a role in the prevention of recurrent stroke if further studies confirm a causal relationship.
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Affiliation(s)
- Mitchell S V Elkind
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Nancy K Hills
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Carol A Glaser
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Warren D Lo
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Catherine Amlie-Lefond
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Nomazulu Dlamini
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Rachel Kneen
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Eldad A Hod
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Max Wintermark
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Gabrielle A deVeber
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Heather J Fullerton
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.).
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Abstract
This article provides an overview of encephalitis and addresses its diagnosis, some of the common presenting signs and symptoms, and the different aspects of nursing care required for these patients. In particular, it addresses how to explain encephalitis to the patient's relatives, the rehabilitation needs of these patients, and important aspects of discharge planning. Tests that are necessary for diagnosis in patients with suspected encephalitis and the importance of these are explained.
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Affiliation(s)
| | - Ava Easton
- Encephalitis Society, Malton, North Yorkshire
| | - Benedict Michael
- Institute of Infection and Global Health, University of Liverpool and The Walton Centre NHS Foundation Trust, Liverpool
| | - Becky Evans
- Alder Hey Children's Hospital NHS Foundation Trust, Liverpool
| | - Deborah Ward
- Infection prevention and control, School of Nursing, Midwifery & Social Work, University of Manchester, Manchester
| | - Tom Solomon
- University of Liverpool and neurology consultant, The Walton Centre Neurology NHS Trust, Liverpool
| | - Rachel Kneen
- Institute of Infection and Global Health, University of Liverpool and Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, England
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Rayamajhi A, Nightingale S, Bhatta NK, Singh R, Ledger E, Bista KP, Lewthwaite P, Mahaseth C, Turtle L, Robinson JS, Galbraith SE, Wnek M, Johnson BW, Faragher B, Kneen R, Griffiths MJ, Solomon T. Correction: A Preliminary Randomized Double Blind Placebo-Controlled Trial of Intravenous Immunoglobulin for Japanese Encephalitis in Nepal. PLoS One 2015; 10:e0136008. [PMID: 26270465 PMCID: PMC4536009 DOI: 10.1371/journal.pone.0136008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
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Backman R, Foy R, Michael BD, Defres S, Kneen R, Solomon T. The development of an intervention to promote adherence to national guidelines for suspected viral encephalitis. Implement Sci 2015; 10:37. [PMID: 25889994 PMCID: PMC4373454 DOI: 10.1186/s13012-015-0224-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 02/20/2015] [Indexed: 11/28/2022] Open
Abstract
Background Central nervous system infections can have devastating clinical outcomes if not diagnosed and treated promptly. There is a documented gap between recommended and actual practice and a limited understanding of its causes. We identified and explored the reasons for this gap, focusing on points in the patient pathway most amenable to change and the development of a tailored intervention strategy to improve diagnosis and treatment. Methods Using theoretically-informed semi-structured interviews, we explored barriers and enablers to diagnosing and managing patients with suspected encephalitis, specifically performing lumbar punctures and initiating antiviral therapy within 6 h. We purposively sampled hospitals and hospital staff in the UK. We audio recorded and transcribed all interviews prior to a framework analysis. We mapped identified barriers and enablers to the patient pathway. We matched behaviour change techniques targeting clinicians to the most salient barriers and enablers and embedded them within an intervention package. Results We interviewed 43 staff in six hospitals. Clinical staff expressed uncertainty when and how to perform lumbar punctures and highlighted practical difficulties in undertaking them within busy clinical settings. Once treatment need was triggered, clinicians generally felt able to take appropriate therapeutic action, albeit within organisational and resource constraints. Matched behaviour change techniques largely targeted antecedents of treatment. These included decision support to prompt recognition, highlighting the consequences of missed diagnoses for clinicians and patients, and practical support for lumbar punctures. We subsequently devised an evidence-informed package comprising ‘core’ interventions and, to allow for local flexibility, ‘optional’ interventions. Conclusions We identified several points in the patient pathway where practice could improve, the most critical being around clinical suspicion and initial investigation. Interventions targeting professional beliefs and behaviours whilst optimising their clinical environment were amongst the most promising approaches to improve the care of suspected encephalitis. Trial registration Randomised trial registered with Controlled Trials ISRCTN06886935. Electronic supplementary material The online version of this article (doi:10.1186/s13012-015-0224-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ruth Backman
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Ronald Ross Building, 8 West Derby Street, Liverpool, L69 7BE, UK.
| | - Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Charles Thackrah Building, 101 Clarendon Road, Leeds, LS2 9LJ, UK.
| | - Benedict Daniel Michael
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Ronald Ross Building, 8 West Derby Street, Liverpool, L69 7BE, UK. .,The Walton Centre NHS Foundation Trust, Lower Lane, Liverpool, L9 7LJ, Fazakerly, UK.
| | - Sylviane Defres
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Ronald Ross Building, 8 West Derby Street, Liverpool, L69 7BE, UK. .,Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, L7 8XP, UK.
| | - Rachel Kneen
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Ronald Ross Building, 8 West Derby Street, Liverpool, L69 7BE, UK. .,Department of Neurology, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP, UK.
| | - Tom Solomon
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Ronald Ross Building, 8 West Derby Street, Liverpool, L69 7BE, UK. .,The Walton Centre NHS Foundation Trust, Lower Lane, Liverpool, L9 7LJ, Fazakerly, UK.
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Backman R, Foy R, Diggle PJ, Kneen R, Defres S, Michael BD, Medina-Lara A, Solomon T. The evaluation of a tailored intervention to improve the management of suspected viral encephalitis: protocol for a cluster randomised controlled trial. Implement Sci 2015; 10:14. [PMID: 25623603 PMCID: PMC4314797 DOI: 10.1186/s13012-014-0201-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 12/23/2014] [Indexed: 12/03/2022] Open
Abstract
Background Viral encephalitis is a devastating condition for which delayed treatment is associated with increased morbidity and mortality. Clinical audits indicate substantial scope for improved detection and treatment. Improvement strategies should ideally be tailored according to identified needs and barriers to change. The aim of the study is to evaluate the effectiveness and cost-effectiveness of a tailored intervention to improve the secondary care management of suspected encephalitis. Methods/Design The study is a two-arm cluster randomised controlled trial with allocation by postgraduate deanery. Participants were identified from 24 hospitals nested within 12 postgraduate deaneries in the United Kingdom (UK). We developed a multifaceted intervention package including core and flexible components with embedded behaviour change techniques selected on the basis of identified needs and barriers to change. The primary outcome will be a composite of the proportion of patients with suspected encephalitis receiving timely and appropriate diagnostic lumbar puncture within 12 h of hospital admission and aciclovir treatment within 6 h. We will gather outcome data pre-intervention and up to 12 months post-intervention from patient records. Statistical analysis at the cluster level will be blind to allocation. An economic evaluation will estimate intervention cost-effectiveness from the health service perspective. Trial registration Controlled Trials: ISRCTN06886935. Electronic supplementary material The online version of this article (doi:10.1186/s13012-014-0201-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ruth Backman
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Ronald Ross Building, 8 West Derby Street, Liverpool, L69 7BE, United Kingdom.
| | - Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Charles Thackrah Building, 101 Clarendon Road, Leeds, LS2 9LJ, United Kingdom.
| | - Peter J Diggle
- Department Epidemiology and Population Health, Institute of Infection and Global Health, University of Liverpool, Ronald Ross Building, 8 West Derby Street, Liverpool, L69 7BE, United Kingdom.
| | - Rachel Kneen
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Ronald Ross Building, 8 West Derby Street, Liverpool, L69 7BE, United Kingdom. .,Department of Neurology, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP, United Kingdom.
| | - Sylviane Defres
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Ronald Ross Building, 8 West Derby Street, Liverpool, L69 7BE, United Kingdom. .,Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, L7 8XP, United Kingdom.
| | - Benedict Daniel Michael
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Ronald Ross Building, 8 West Derby Street, Liverpool, L69 7BE, United Kingdom. .,The Walton Centre NHS Foundation Trust, Lower Lane, Fazakerly, Liverpool, L9 7LJ, United Kingdom.
| | - Antonieta Medina-Lara
- Health Economics Group, University of Exeter Medical School, Veysey Building, Salmon Pool Lane, Exeter, EX2 4SG, United Kingdom.
| | - Tom Solomon
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Ronald Ross Building, 8 West Derby Street, Liverpool, L69 7BE, United Kingdom. .,The Walton Centre NHS Foundation Trust, Lower Lane, Fazakerly, Liverpool, L9 7LJ, United Kingdom.
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48
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Baker GA, Bromley RL, Briggs M, Cheyne CP, Cohen MJ, García-Fiñana M, Gummery A, Kneen R, Loring DW, Mawer G, Meador KJ, Shallcross R, Clayton-Smith J. IQ at 6 years after in utero exposure to antiepileptic drugs: a controlled cohort study. Neurology 2014; 84:382-90. [PMID: 25540307 DOI: 10.1212/wnl.0000000000001182] [Citation(s) in RCA: 157] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To delineate the risk to child IQ associated with frequently prescribed antiepileptic drugs. METHODS Children born to women with epilepsy (n = 243) and women without epilepsy (n = 287) were recruited during pregnancy and followed prospectively. Of these, 408 were blindly assessed at 6 years of age. Maternal and child demographics were collected and entered into statistical models. RESULTS The adjusted mean IQ was 9.7 points lower (95% confidence interval [CI] -4.9 to -14.6; p < 0.001) for children exposed to high-dose (>800 mg daily) valproate, with a similar significant effect observed for the verbal, nonverbal, and spatial subscales. Children exposed to high-dose valproate had an 8-fold increased need of educational intervention relative to control children (adjusted relative risk, 95% CI 8.0, 2.5-19.7; p < 0.001). Valproate at doses <800 mg daily was not associated with reduced IQ, but was associated with impaired verbal abilities (-5.6, 95% CI -11.1 to -0.1; p = 0.04) and a 6-fold increase in educational intervention (95% CI 1.4-18.0; p = 0.01). In utero exposure to carbamazepine or lamotrigine did not have a significant effect on IQ, but carbamazepine was associated with reduced verbal abilities (-4.2, 95% CI -0.6 to -7.8; p = 0.02) and increased frequency of IQ <85. CONCLUSIONS Consistent with data from younger cohorts, school-aged children exposed to valproate at maternal doses more than 800 mg daily continue to experience significantly poorer cognitive development than control children or children exposed to lamotrigine and carbamazepine.
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Affiliation(s)
- Gus A Baker
- From the Departments of Molecular and Clinical Pharmacology (G.A.B.), Biostatistics (C.P.C., M.G.-F.), and Clinical Psychology (R.S.), Institute of Infection and Global Health (M.J.C., A.G.), and Alder Hey Children's Hospital & Institute of Infection & Global Health (R.K.), University of Liverpool; Institute of Human Development (R.L.B., J.C.-S.), University of Manchester; Manchester Academic Health Sciences Centre (R.L.B., M.B., G.M., J.C.-S.), Central Manchester University Hospitals Foundation Trust, UK; Department of Neurology (M.J.C.), Georgia Regents University, Augusta; Department of Neurology & Pediatrics (D.W.L.), Emory University, Atlanta, GA; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA
| | - Rebecca L Bromley
- From the Departments of Molecular and Clinical Pharmacology (G.A.B.), Biostatistics (C.P.C., M.G.-F.), and Clinical Psychology (R.S.), Institute of Infection and Global Health (M.J.C., A.G.), and Alder Hey Children's Hospital & Institute of Infection & Global Health (R.K.), University of Liverpool; Institute of Human Development (R.L.B., J.C.-S.), University of Manchester; Manchester Academic Health Sciences Centre (R.L.B., M.B., G.M., J.C.-S.), Central Manchester University Hospitals Foundation Trust, UK; Department of Neurology (M.J.C.), Georgia Regents University, Augusta; Department of Neurology & Pediatrics (D.W.L.), Emory University, Atlanta, GA; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA.
| | - Maria Briggs
- From the Departments of Molecular and Clinical Pharmacology (G.A.B.), Biostatistics (C.P.C., M.G.-F.), and Clinical Psychology (R.S.), Institute of Infection and Global Health (M.J.C., A.G.), and Alder Hey Children's Hospital & Institute of Infection & Global Health (R.K.), University of Liverpool; Institute of Human Development (R.L.B., J.C.-S.), University of Manchester; Manchester Academic Health Sciences Centre (R.L.B., M.B., G.M., J.C.-S.), Central Manchester University Hospitals Foundation Trust, UK; Department of Neurology (M.J.C.), Georgia Regents University, Augusta; Department of Neurology & Pediatrics (D.W.L.), Emory University, Atlanta, GA; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA
| | - Christopher P Cheyne
- From the Departments of Molecular and Clinical Pharmacology (G.A.B.), Biostatistics (C.P.C., M.G.-F.), and Clinical Psychology (R.S.), Institute of Infection and Global Health (M.J.C., A.G.), and Alder Hey Children's Hospital & Institute of Infection & Global Health (R.K.), University of Liverpool; Institute of Human Development (R.L.B., J.C.-S.), University of Manchester; Manchester Academic Health Sciences Centre (R.L.B., M.B., G.M., J.C.-S.), Central Manchester University Hospitals Foundation Trust, UK; Department of Neurology (M.J.C.), Georgia Regents University, Augusta; Department of Neurology & Pediatrics (D.W.L.), Emory University, Atlanta, GA; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA
| | - Morris J Cohen
- From the Departments of Molecular and Clinical Pharmacology (G.A.B.), Biostatistics (C.P.C., M.G.-F.), and Clinical Psychology (R.S.), Institute of Infection and Global Health (M.J.C., A.G.), and Alder Hey Children's Hospital & Institute of Infection & Global Health (R.K.), University of Liverpool; Institute of Human Development (R.L.B., J.C.-S.), University of Manchester; Manchester Academic Health Sciences Centre (R.L.B., M.B., G.M., J.C.-S.), Central Manchester University Hospitals Foundation Trust, UK; Department of Neurology (M.J.C.), Georgia Regents University, Augusta; Department of Neurology & Pediatrics (D.W.L.), Emory University, Atlanta, GA; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA
| | - Marta García-Fiñana
- From the Departments of Molecular and Clinical Pharmacology (G.A.B.), Biostatistics (C.P.C., M.G.-F.), and Clinical Psychology (R.S.), Institute of Infection and Global Health (M.J.C., A.G.), and Alder Hey Children's Hospital & Institute of Infection & Global Health (R.K.), University of Liverpool; Institute of Human Development (R.L.B., J.C.-S.), University of Manchester; Manchester Academic Health Sciences Centre (R.L.B., M.B., G.M., J.C.-S.), Central Manchester University Hospitals Foundation Trust, UK; Department of Neurology (M.J.C.), Georgia Regents University, Augusta; Department of Neurology & Pediatrics (D.W.L.), Emory University, Atlanta, GA; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA
| | - Alison Gummery
- From the Departments of Molecular and Clinical Pharmacology (G.A.B.), Biostatistics (C.P.C., M.G.-F.), and Clinical Psychology (R.S.), Institute of Infection and Global Health (M.J.C., A.G.), and Alder Hey Children's Hospital & Institute of Infection & Global Health (R.K.), University of Liverpool; Institute of Human Development (R.L.B., J.C.-S.), University of Manchester; Manchester Academic Health Sciences Centre (R.L.B., M.B., G.M., J.C.-S.), Central Manchester University Hospitals Foundation Trust, UK; Department of Neurology (M.J.C.), Georgia Regents University, Augusta; Department of Neurology & Pediatrics (D.W.L.), Emory University, Atlanta, GA; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA
| | - Rachel Kneen
- From the Departments of Molecular and Clinical Pharmacology (G.A.B.), Biostatistics (C.P.C., M.G.-F.), and Clinical Psychology (R.S.), Institute of Infection and Global Health (M.J.C., A.G.), and Alder Hey Children's Hospital & Institute of Infection & Global Health (R.K.), University of Liverpool; Institute of Human Development (R.L.B., J.C.-S.), University of Manchester; Manchester Academic Health Sciences Centre (R.L.B., M.B., G.M., J.C.-S.), Central Manchester University Hospitals Foundation Trust, UK; Department of Neurology (M.J.C.), Georgia Regents University, Augusta; Department of Neurology & Pediatrics (D.W.L.), Emory University, Atlanta, GA; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA
| | - David W Loring
- From the Departments of Molecular and Clinical Pharmacology (G.A.B.), Biostatistics (C.P.C., M.G.-F.), and Clinical Psychology (R.S.), Institute of Infection and Global Health (M.J.C., A.G.), and Alder Hey Children's Hospital & Institute of Infection & Global Health (R.K.), University of Liverpool; Institute of Human Development (R.L.B., J.C.-S.), University of Manchester; Manchester Academic Health Sciences Centre (R.L.B., M.B., G.M., J.C.-S.), Central Manchester University Hospitals Foundation Trust, UK; Department of Neurology (M.J.C.), Georgia Regents University, Augusta; Department of Neurology & Pediatrics (D.W.L.), Emory University, Atlanta, GA; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA
| | - George Mawer
- From the Departments of Molecular and Clinical Pharmacology (G.A.B.), Biostatistics (C.P.C., M.G.-F.), and Clinical Psychology (R.S.), Institute of Infection and Global Health (M.J.C., A.G.), and Alder Hey Children's Hospital & Institute of Infection & Global Health (R.K.), University of Liverpool; Institute of Human Development (R.L.B., J.C.-S.), University of Manchester; Manchester Academic Health Sciences Centre (R.L.B., M.B., G.M., J.C.-S.), Central Manchester University Hospitals Foundation Trust, UK; Department of Neurology (M.J.C.), Georgia Regents University, Augusta; Department of Neurology & Pediatrics (D.W.L.), Emory University, Atlanta, GA; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA
| | - Kimford J Meador
- From the Departments of Molecular and Clinical Pharmacology (G.A.B.), Biostatistics (C.P.C., M.G.-F.), and Clinical Psychology (R.S.), Institute of Infection and Global Health (M.J.C., A.G.), and Alder Hey Children's Hospital & Institute of Infection & Global Health (R.K.), University of Liverpool; Institute of Human Development (R.L.B., J.C.-S.), University of Manchester; Manchester Academic Health Sciences Centre (R.L.B., M.B., G.M., J.C.-S.), Central Manchester University Hospitals Foundation Trust, UK; Department of Neurology (M.J.C.), Georgia Regents University, Augusta; Department of Neurology & Pediatrics (D.W.L.), Emory University, Atlanta, GA; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA
| | - Rebekah Shallcross
- From the Departments of Molecular and Clinical Pharmacology (G.A.B.), Biostatistics (C.P.C., M.G.-F.), and Clinical Psychology (R.S.), Institute of Infection and Global Health (M.J.C., A.G.), and Alder Hey Children's Hospital & Institute of Infection & Global Health (R.K.), University of Liverpool; Institute of Human Development (R.L.B., J.C.-S.), University of Manchester; Manchester Academic Health Sciences Centre (R.L.B., M.B., G.M., J.C.-S.), Central Manchester University Hospitals Foundation Trust, UK; Department of Neurology (M.J.C.), Georgia Regents University, Augusta; Department of Neurology & Pediatrics (D.W.L.), Emory University, Atlanta, GA; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA
| | - Jill Clayton-Smith
- From the Departments of Molecular and Clinical Pharmacology (G.A.B.), Biostatistics (C.P.C., M.G.-F.), and Clinical Psychology (R.S.), Institute of Infection and Global Health (M.J.C., A.G.), and Alder Hey Children's Hospital & Institute of Infection & Global Health (R.K.), University of Liverpool; Institute of Human Development (R.L.B., J.C.-S.), University of Manchester; Manchester Academic Health Sciences Centre (R.L.B., M.B., G.M., J.C.-S.), Central Manchester University Hospitals Foundation Trust, UK; Department of Neurology (M.J.C.), Georgia Regents University, Augusta; Department of Neurology & Pediatrics (D.W.L.), Emory University, Atlanta, GA; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA
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49
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Peall KJ, Lumsden D, Kneen R, Madhu R, Peake D, Gibbon F, Lewis H, Hedderly T, Meyer E, Robb SA, Lynch B, King MD, Lin JP, Morris HR, Jungbluth H, Kurian MA. Benign hereditary chorea related to NKX2.1: expansion of the genotypic and phenotypic spectrum. Dev Med Child Neurol 2014; 56:642-8. [PMID: 24171694 DOI: 10.1111/dmcn.12323] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/26/2013] [Indexed: 11/28/2022]
Abstract
AIM Benign hereditary chorea is a dominantly inherited, childhood-onset hyperkinetic movement disorder characterized by non-progressive chorea and variable degrees of thyroid and respiratory involvement. Loss-of-function mutations in NKX2.1, a gene vital to the normal development and function of the brain, lungs, and thyroid, have been identified in a number of individuals. METHOD Clinical data from individuals with benign hereditary chorea identified through paediatric neurology services were collected in a standardized format. The NKX2.1 gene was analysed by Sanger sequencing, multiplex ligation-dependent probe amplification, and microarray analysis. RESULTS Six of our cohort were female and four male, median age at assessment was 8 years 6 months (range 1 y 6 mo-18 y). We identified 10 probands with NKX2.1 mutations; nine of these mutations are novel (including two whole-gene deletions) and one has been previously reported. Of the 10 individuals, eight presented with muscle hypotonia and four had evidence of hypothyroidism or respiratory involvement. Only three out of the 10 individuals had the full triad of 'brain-lung-thyroid syndrome' symptoms. Additional clinical characteristics occurring in individual participants included growth hormone deficiency, pes cavus, kyphosis, duplex kidney, and obsessive-compulsive disorder. INTERPRETATION Our data suggest that the neurological phenotype is prominent in this condition and that many patients with benign hereditary chorea do not have the classic triad of brain-lung-thyroid syndrome. The extended phenotype may include obsessive-compulsive disorder and skeletal abnormalities.
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Affiliation(s)
- Kathryn J Peall
- MRC Centre for Neuropsychiatric Genetics and Genomics, Institute of Psychological Medicine & Clinical Neurosciences, Cardiff University, Cardiff, UK
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50
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Dale RC, Brilot F, Duffy LV, Twilt M, Waldman AT, Narula S, Muscal E, Deiva K, Andersen E, Eyre MR, Eleftheriou D, Brogan PA, Kneen R, Alper G, Anlar B, Wassmer E, Heineman K, Hemingway C, Riney CJ, Kornberg A, Tardieu M, Stocco A, Banwell B, Gorman MP, Benseler SM, Lim M. Utility and safety of rituximab in pediatric autoimmune and inflammatory CNS disease. Neurology 2014; 83:142-50. [PMID: 24920861 DOI: 10.1212/wnl.0000000000000570] [Citation(s) in RCA: 224] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To assess the utility and safety of rituximab in pediatric autoimmune and inflammatory disorders of the CNS. METHODS Multicenter retrospective study. RESULTS A total of 144 children and adolescents (median age 8 years, range 0.7-17; 103 female) with NMDA receptor (NMDAR) encephalitis (n = 39), opsoclonus myoclonus ataxia syndrome (n = 32), neuromyelitis optica spectrum disorders (n = 20), neuropsychiatric systemic lupus erythematosus (n = 18), and other neuroinflammatory disorders (n = 35) were studied. Rituximab was given after a median duration of disease of 0.5 years (range 0.05-9.5 years). Infusion adverse events were recorded in 18/144 (12.5%), including grade 4 (anaphylaxis) in 3. Eleven patients (7.6%) had an infectious adverse event (AE), including 2 with grade 5 (death) and 2 with grade 4 (disabling) infectious AE (median follow-up of 1.65 years [range 0.1-8.5]). No patients developed progressive multifocal leukoencephalopathy. A definite, probable, or possible benefit was reported in 125 of 144 (87%) patients. A total of 17.4% of patients had a modified Rankin Scale (mRS) score of 0-2 at rituximab initiation, compared to 73.9% at outcome. The change in mRS 0-2 was greater in patients given rituximab early in their disease course compared to those treated later. CONCLUSION While limited by the retrospective nature of this analysis, our data support an off-label use of rituximab, although the significant risk of infectious complications suggests rituximab should be restricted to disorders with significant morbidity and mortality. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that in pediatric autoimmune and inflammatory CNS disorders, rituximab improves neurologic outcomes with a 7.6% risk of adverse infections.
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Affiliation(s)
- Russell C Dale
- From the Neuroimmunology Group (R.C.D., F.B.), Children's Hospital at Westmead, University of Sydney, Australia; Boston Children's Hospital (L.V.D., M.P.G.), MA; the Division of Rheumatology (M.T., S.M.B.), The Hospital for Sick Children, University of Toronto, Canada; Children's Hospital of Philadelphia (A.T.W., S.N., B.B.), University of Pennsylvania; Paediatric Neurology and Rheumatology (E.M., A.S.), Texas Children's Hospital, Baylor College of Medicine, Houston; Assistance Publique-Hopitaux de Paris (K.D., M.T.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children, Pediatric Neurology Department and Université Paris-Sud, Inserm U1012, Le Kremlin-Bicêtre, France; Royal Children's Hospital Melbourne (E.A., A.K.), Australia; Great Ormond Street Hospital NHS Trust (M.R.E., C.H.), London; UCL Institute of Child Health (D.E., P.A.B.), London; Alder Hey Children's NHS Foundation Trust and the Institute of Infection and Global Health (R.K.), University of Liverpool, UK; Children's Hospital of Pittsburgh (G.A.), University of Pittsburgh, PA; Hacettepe University Child Neurology (B.A.), Turkey; Birmingham Children's Hospital (E.W.); John Radcliffe Hospital (K.H.), Oxford, UK; Neurosciences Unit and Mater Medical Research Institute (C.J.R.), Mater Children's Hospital, South Brisbane, University of Queensland, Australia; Alberta Children's Hospital (S.M.B.), Calgary, University of Calgary, Canada; and Evelina Children's Hospital (M.L.), London, UK.
| | - Fabienne Brilot
- From the Neuroimmunology Group (R.C.D., F.B.), Children's Hospital at Westmead, University of Sydney, Australia; Boston Children's Hospital (L.V.D., M.P.G.), MA; the Division of Rheumatology (M.T., S.M.B.), The Hospital for Sick Children, University of Toronto, Canada; Children's Hospital of Philadelphia (A.T.W., S.N., B.B.), University of Pennsylvania; Paediatric Neurology and Rheumatology (E.M., A.S.), Texas Children's Hospital, Baylor College of Medicine, Houston; Assistance Publique-Hopitaux de Paris (K.D., M.T.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children, Pediatric Neurology Department and Université Paris-Sud, Inserm U1012, Le Kremlin-Bicêtre, France; Royal Children's Hospital Melbourne (E.A., A.K.), Australia; Great Ormond Street Hospital NHS Trust (M.R.E., C.H.), London; UCL Institute of Child Health (D.E., P.A.B.), London; Alder Hey Children's NHS Foundation Trust and the Institute of Infection and Global Health (R.K.), University of Liverpool, UK; Children's Hospital of Pittsburgh (G.A.), University of Pittsburgh, PA; Hacettepe University Child Neurology (B.A.), Turkey; Birmingham Children's Hospital (E.W.); John Radcliffe Hospital (K.H.), Oxford, UK; Neurosciences Unit and Mater Medical Research Institute (C.J.R.), Mater Children's Hospital, South Brisbane, University of Queensland, Australia; Alberta Children's Hospital (S.M.B.), Calgary, University of Calgary, Canada; and Evelina Children's Hospital (M.L.), London, UK
| | - Lisa V Duffy
- From the Neuroimmunology Group (R.C.D., F.B.), Children's Hospital at Westmead, University of Sydney, Australia; Boston Children's Hospital (L.V.D., M.P.G.), MA; the Division of Rheumatology (M.T., S.M.B.), The Hospital for Sick Children, University of Toronto, Canada; Children's Hospital of Philadelphia (A.T.W., S.N., B.B.), University of Pennsylvania; Paediatric Neurology and Rheumatology (E.M., A.S.), Texas Children's Hospital, Baylor College of Medicine, Houston; Assistance Publique-Hopitaux de Paris (K.D., M.T.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children, Pediatric Neurology Department and Université Paris-Sud, Inserm U1012, Le Kremlin-Bicêtre, France; Royal Children's Hospital Melbourne (E.A., A.K.), Australia; Great Ormond Street Hospital NHS Trust (M.R.E., C.H.), London; UCL Institute of Child Health (D.E., P.A.B.), London; Alder Hey Children's NHS Foundation Trust and the Institute of Infection and Global Health (R.K.), University of Liverpool, UK; Children's Hospital of Pittsburgh (G.A.), University of Pittsburgh, PA; Hacettepe University Child Neurology (B.A.), Turkey; Birmingham Children's Hospital (E.W.); John Radcliffe Hospital (K.H.), Oxford, UK; Neurosciences Unit and Mater Medical Research Institute (C.J.R.), Mater Children's Hospital, South Brisbane, University of Queensland, Australia; Alberta Children's Hospital (S.M.B.), Calgary, University of Calgary, Canada; and Evelina Children's Hospital (M.L.), London, UK
| | - Marinka Twilt
- From the Neuroimmunology Group (R.C.D., F.B.), Children's Hospital at Westmead, University of Sydney, Australia; Boston Children's Hospital (L.V.D., M.P.G.), MA; the Division of Rheumatology (M.T., S.M.B.), The Hospital for Sick Children, University of Toronto, Canada; Children's Hospital of Philadelphia (A.T.W., S.N., B.B.), University of Pennsylvania; Paediatric Neurology and Rheumatology (E.M., A.S.), Texas Children's Hospital, Baylor College of Medicine, Houston; Assistance Publique-Hopitaux de Paris (K.D., M.T.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children, Pediatric Neurology Department and Université Paris-Sud, Inserm U1012, Le Kremlin-Bicêtre, France; Royal Children's Hospital Melbourne (E.A., A.K.), Australia; Great Ormond Street Hospital NHS Trust (M.R.E., C.H.), London; UCL Institute of Child Health (D.E., P.A.B.), London; Alder Hey Children's NHS Foundation Trust and the Institute of Infection and Global Health (R.K.), University of Liverpool, UK; Children's Hospital of Pittsburgh (G.A.), University of Pittsburgh, PA; Hacettepe University Child Neurology (B.A.), Turkey; Birmingham Children's Hospital (E.W.); John Radcliffe Hospital (K.H.), Oxford, UK; Neurosciences Unit and Mater Medical Research Institute (C.J.R.), Mater Children's Hospital, South Brisbane, University of Queensland, Australia; Alberta Children's Hospital (S.M.B.), Calgary, University of Calgary, Canada; and Evelina Children's Hospital (M.L.), London, UK
| | - Amy T Waldman
- From the Neuroimmunology Group (R.C.D., F.B.), Children's Hospital at Westmead, University of Sydney, Australia; Boston Children's Hospital (L.V.D., M.P.G.), MA; the Division of Rheumatology (M.T., S.M.B.), The Hospital for Sick Children, University of Toronto, Canada; Children's Hospital of Philadelphia (A.T.W., S.N., B.B.), University of Pennsylvania; Paediatric Neurology and Rheumatology (E.M., A.S.), Texas Children's Hospital, Baylor College of Medicine, Houston; Assistance Publique-Hopitaux de Paris (K.D., M.T.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children, Pediatric Neurology Department and Université Paris-Sud, Inserm U1012, Le Kremlin-Bicêtre, France; Royal Children's Hospital Melbourne (E.A., A.K.), Australia; Great Ormond Street Hospital NHS Trust (M.R.E., C.H.), London; UCL Institute of Child Health (D.E., P.A.B.), London; Alder Hey Children's NHS Foundation Trust and the Institute of Infection and Global Health (R.K.), University of Liverpool, UK; Children's Hospital of Pittsburgh (G.A.), University of Pittsburgh, PA; Hacettepe University Child Neurology (B.A.), Turkey; Birmingham Children's Hospital (E.W.); John Radcliffe Hospital (K.H.), Oxford, UK; Neurosciences Unit and Mater Medical Research Institute (C.J.R.), Mater Children's Hospital, South Brisbane, University of Queensland, Australia; Alberta Children's Hospital (S.M.B.), Calgary, University of Calgary, Canada; and Evelina Children's Hospital (M.L.), London, UK
| | - Sona Narula
- From the Neuroimmunology Group (R.C.D., F.B.), Children's Hospital at Westmead, University of Sydney, Australia; Boston Children's Hospital (L.V.D., M.P.G.), MA; the Division of Rheumatology (M.T., S.M.B.), The Hospital for Sick Children, University of Toronto, Canada; Children's Hospital of Philadelphia (A.T.W., S.N., B.B.), University of Pennsylvania; Paediatric Neurology and Rheumatology (E.M., A.S.), Texas Children's Hospital, Baylor College of Medicine, Houston; Assistance Publique-Hopitaux de Paris (K.D., M.T.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children, Pediatric Neurology Department and Université Paris-Sud, Inserm U1012, Le Kremlin-Bicêtre, France; Royal Children's Hospital Melbourne (E.A., A.K.), Australia; Great Ormond Street Hospital NHS Trust (M.R.E., C.H.), London; UCL Institute of Child Health (D.E., P.A.B.), London; Alder Hey Children's NHS Foundation Trust and the Institute of Infection and Global Health (R.K.), University of Liverpool, UK; Children's Hospital of Pittsburgh (G.A.), University of Pittsburgh, PA; Hacettepe University Child Neurology (B.A.), Turkey; Birmingham Children's Hospital (E.W.); John Radcliffe Hospital (K.H.), Oxford, UK; Neurosciences Unit and Mater Medical Research Institute (C.J.R.), Mater Children's Hospital, South Brisbane, University of Queensland, Australia; Alberta Children's Hospital (S.M.B.), Calgary, University of Calgary, Canada; and Evelina Children's Hospital (M.L.), London, UK
| | - Eyal Muscal
- From the Neuroimmunology Group (R.C.D., F.B.), Children's Hospital at Westmead, University of Sydney, Australia; Boston Children's Hospital (L.V.D., M.P.G.), MA; the Division of Rheumatology (M.T., S.M.B.), The Hospital for Sick Children, University of Toronto, Canada; Children's Hospital of Philadelphia (A.T.W., S.N., B.B.), University of Pennsylvania; Paediatric Neurology and Rheumatology (E.M., A.S.), Texas Children's Hospital, Baylor College of Medicine, Houston; Assistance Publique-Hopitaux de Paris (K.D., M.T.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children, Pediatric Neurology Department and Université Paris-Sud, Inserm U1012, Le Kremlin-Bicêtre, France; Royal Children's Hospital Melbourne (E.A., A.K.), Australia; Great Ormond Street Hospital NHS Trust (M.R.E., C.H.), London; UCL Institute of Child Health (D.E., P.A.B.), London; Alder Hey Children's NHS Foundation Trust and the Institute of Infection and Global Health (R.K.), University of Liverpool, UK; Children's Hospital of Pittsburgh (G.A.), University of Pittsburgh, PA; Hacettepe University Child Neurology (B.A.), Turkey; Birmingham Children's Hospital (E.W.); John Radcliffe Hospital (K.H.), Oxford, UK; Neurosciences Unit and Mater Medical Research Institute (C.J.R.), Mater Children's Hospital, South Brisbane, University of Queensland, Australia; Alberta Children's Hospital (S.M.B.), Calgary, University of Calgary, Canada; and Evelina Children's Hospital (M.L.), London, UK
| | - Kumaran Deiva
- From the Neuroimmunology Group (R.C.D., F.B.), Children's Hospital at Westmead, University of Sydney, Australia; Boston Children's Hospital (L.V.D., M.P.G.), MA; the Division of Rheumatology (M.T., S.M.B.), The Hospital for Sick Children, University of Toronto, Canada; Children's Hospital of Philadelphia (A.T.W., S.N., B.B.), University of Pennsylvania; Paediatric Neurology and Rheumatology (E.M., A.S.), Texas Children's Hospital, Baylor College of Medicine, Houston; Assistance Publique-Hopitaux de Paris (K.D., M.T.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children, Pediatric Neurology Department and Université Paris-Sud, Inserm U1012, Le Kremlin-Bicêtre, France; Royal Children's Hospital Melbourne (E.A., A.K.), Australia; Great Ormond Street Hospital NHS Trust (M.R.E., C.H.), London; UCL Institute of Child Health (D.E., P.A.B.), London; Alder Hey Children's NHS Foundation Trust and the Institute of Infection and Global Health (R.K.), University of Liverpool, UK; Children's Hospital of Pittsburgh (G.A.), University of Pittsburgh, PA; Hacettepe University Child Neurology (B.A.), Turkey; Birmingham Children's Hospital (E.W.); John Radcliffe Hospital (K.H.), Oxford, UK; Neurosciences Unit and Mater Medical Research Institute (C.J.R.), Mater Children's Hospital, South Brisbane, University of Queensland, Australia; Alberta Children's Hospital (S.M.B.), Calgary, University of Calgary, Canada; and Evelina Children's Hospital (M.L.), London, UK
| | - Erik Andersen
- From the Neuroimmunology Group (R.C.D., F.B.), Children's Hospital at Westmead, University of Sydney, Australia; Boston Children's Hospital (L.V.D., M.P.G.), MA; the Division of Rheumatology (M.T., S.M.B.), The Hospital for Sick Children, University of Toronto, Canada; Children's Hospital of Philadelphia (A.T.W., S.N., B.B.), University of Pennsylvania; Paediatric Neurology and Rheumatology (E.M., A.S.), Texas Children's Hospital, Baylor College of Medicine, Houston; Assistance Publique-Hopitaux de Paris (K.D., M.T.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children, Pediatric Neurology Department and Université Paris-Sud, Inserm U1012, Le Kremlin-Bicêtre, France; Royal Children's Hospital Melbourne (E.A., A.K.), Australia; Great Ormond Street Hospital NHS Trust (M.R.E., C.H.), London; UCL Institute of Child Health (D.E., P.A.B.), London; Alder Hey Children's NHS Foundation Trust and the Institute of Infection and Global Health (R.K.), University of Liverpool, UK; Children's Hospital of Pittsburgh (G.A.), University of Pittsburgh, PA; Hacettepe University Child Neurology (B.A.), Turkey; Birmingham Children's Hospital (E.W.); John Radcliffe Hospital (K.H.), Oxford, UK; Neurosciences Unit and Mater Medical Research Institute (C.J.R.), Mater Children's Hospital, South Brisbane, University of Queensland, Australia; Alberta Children's Hospital (S.M.B.), Calgary, University of Calgary, Canada; and Evelina Children's Hospital (M.L.), London, UK
| | - Michael R Eyre
- From the Neuroimmunology Group (R.C.D., F.B.), Children's Hospital at Westmead, University of Sydney, Australia; Boston Children's Hospital (L.V.D., M.P.G.), MA; the Division of Rheumatology (M.T., S.M.B.), The Hospital for Sick Children, University of Toronto, Canada; Children's Hospital of Philadelphia (A.T.W., S.N., B.B.), University of Pennsylvania; Paediatric Neurology and Rheumatology (E.M., A.S.), Texas Children's Hospital, Baylor College of Medicine, Houston; Assistance Publique-Hopitaux de Paris (K.D., M.T.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children, Pediatric Neurology Department and Université Paris-Sud, Inserm U1012, Le Kremlin-Bicêtre, France; Royal Children's Hospital Melbourne (E.A., A.K.), Australia; Great Ormond Street Hospital NHS Trust (M.R.E., C.H.), London; UCL Institute of Child Health (D.E., P.A.B.), London; Alder Hey Children's NHS Foundation Trust and the Institute of Infection and Global Health (R.K.), University of Liverpool, UK; Children's Hospital of Pittsburgh (G.A.), University of Pittsburgh, PA; Hacettepe University Child Neurology (B.A.), Turkey; Birmingham Children's Hospital (E.W.); John Radcliffe Hospital (K.H.), Oxford, UK; Neurosciences Unit and Mater Medical Research Institute (C.J.R.), Mater Children's Hospital, South Brisbane, University of Queensland, Australia; Alberta Children's Hospital (S.M.B.), Calgary, University of Calgary, Canada; and Evelina Children's Hospital (M.L.), London, UK
| | - Despina Eleftheriou
- From the Neuroimmunology Group (R.C.D., F.B.), Children's Hospital at Westmead, University of Sydney, Australia; Boston Children's Hospital (L.V.D., M.P.G.), MA; the Division of Rheumatology (M.T., S.M.B.), The Hospital for Sick Children, University of Toronto, Canada; Children's Hospital of Philadelphia (A.T.W., S.N., B.B.), University of Pennsylvania; Paediatric Neurology and Rheumatology (E.M., A.S.), Texas Children's Hospital, Baylor College of Medicine, Houston; Assistance Publique-Hopitaux de Paris (K.D., M.T.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children, Pediatric Neurology Department and Université Paris-Sud, Inserm U1012, Le Kremlin-Bicêtre, France; Royal Children's Hospital Melbourne (E.A., A.K.), Australia; Great Ormond Street Hospital NHS Trust (M.R.E., C.H.), London; UCL Institute of Child Health (D.E., P.A.B.), London; Alder Hey Children's NHS Foundation Trust and the Institute of Infection and Global Health (R.K.), University of Liverpool, UK; Children's Hospital of Pittsburgh (G.A.), University of Pittsburgh, PA; Hacettepe University Child Neurology (B.A.), Turkey; Birmingham Children's Hospital (E.W.); John Radcliffe Hospital (K.H.), Oxford, UK; Neurosciences Unit and Mater Medical Research Institute (C.J.R.), Mater Children's Hospital, South Brisbane, University of Queensland, Australia; Alberta Children's Hospital (S.M.B.), Calgary, University of Calgary, Canada; and Evelina Children's Hospital (M.L.), London, UK
| | - Paul A Brogan
- From the Neuroimmunology Group (R.C.D., F.B.), Children's Hospital at Westmead, University of Sydney, Australia; Boston Children's Hospital (L.V.D., M.P.G.), MA; the Division of Rheumatology (M.T., S.M.B.), The Hospital for Sick Children, University of Toronto, Canada; Children's Hospital of Philadelphia (A.T.W., S.N., B.B.), University of Pennsylvania; Paediatric Neurology and Rheumatology (E.M., A.S.), Texas Children's Hospital, Baylor College of Medicine, Houston; Assistance Publique-Hopitaux de Paris (K.D., M.T.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children, Pediatric Neurology Department and Université Paris-Sud, Inserm U1012, Le Kremlin-Bicêtre, France; Royal Children's Hospital Melbourne (E.A., A.K.), Australia; Great Ormond Street Hospital NHS Trust (M.R.E., C.H.), London; UCL Institute of Child Health (D.E., P.A.B.), London; Alder Hey Children's NHS Foundation Trust and the Institute of Infection and Global Health (R.K.), University of Liverpool, UK; Children's Hospital of Pittsburgh (G.A.), University of Pittsburgh, PA; Hacettepe University Child Neurology (B.A.), Turkey; Birmingham Children's Hospital (E.W.); John Radcliffe Hospital (K.H.), Oxford, UK; Neurosciences Unit and Mater Medical Research Institute (C.J.R.), Mater Children's Hospital, South Brisbane, University of Queensland, Australia; Alberta Children's Hospital (S.M.B.), Calgary, University of Calgary, Canada; and Evelina Children's Hospital (M.L.), London, UK
| | - Rachel Kneen
- From the Neuroimmunology Group (R.C.D., F.B.), Children's Hospital at Westmead, University of Sydney, Australia; Boston Children's Hospital (L.V.D., M.P.G.), MA; the Division of Rheumatology (M.T., S.M.B.), The Hospital for Sick Children, University of Toronto, Canada; Children's Hospital of Philadelphia (A.T.W., S.N., B.B.), University of Pennsylvania; Paediatric Neurology and Rheumatology (E.M., A.S.), Texas Children's Hospital, Baylor College of Medicine, Houston; Assistance Publique-Hopitaux de Paris (K.D., M.T.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children, Pediatric Neurology Department and Université Paris-Sud, Inserm U1012, Le Kremlin-Bicêtre, France; Royal Children's Hospital Melbourne (E.A., A.K.), Australia; Great Ormond Street Hospital NHS Trust (M.R.E., C.H.), London; UCL Institute of Child Health (D.E., P.A.B.), London; Alder Hey Children's NHS Foundation Trust and the Institute of Infection and Global Health (R.K.), University of Liverpool, UK; Children's Hospital of Pittsburgh (G.A.), University of Pittsburgh, PA; Hacettepe University Child Neurology (B.A.), Turkey; Birmingham Children's Hospital (E.W.); John Radcliffe Hospital (K.H.), Oxford, UK; Neurosciences Unit and Mater Medical Research Institute (C.J.R.), Mater Children's Hospital, South Brisbane, University of Queensland, Australia; Alberta Children's Hospital (S.M.B.), Calgary, University of Calgary, Canada; and Evelina Children's Hospital (M.L.), London, UK
| | - Gulay Alper
- From the Neuroimmunology Group (R.C.D., F.B.), Children's Hospital at Westmead, University of Sydney, Australia; Boston Children's Hospital (L.V.D., M.P.G.), MA; the Division of Rheumatology (M.T., S.M.B.), The Hospital for Sick Children, University of Toronto, Canada; Children's Hospital of Philadelphia (A.T.W., S.N., B.B.), University of Pennsylvania; Paediatric Neurology and Rheumatology (E.M., A.S.), Texas Children's Hospital, Baylor College of Medicine, Houston; Assistance Publique-Hopitaux de Paris (K.D., M.T.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children, Pediatric Neurology Department and Université Paris-Sud, Inserm U1012, Le Kremlin-Bicêtre, France; Royal Children's Hospital Melbourne (E.A., A.K.), Australia; Great Ormond Street Hospital NHS Trust (M.R.E., C.H.), London; UCL Institute of Child Health (D.E., P.A.B.), London; Alder Hey Children's NHS Foundation Trust and the Institute of Infection and Global Health (R.K.), University of Liverpool, UK; Children's Hospital of Pittsburgh (G.A.), University of Pittsburgh, PA; Hacettepe University Child Neurology (B.A.), Turkey; Birmingham Children's Hospital (E.W.); John Radcliffe Hospital (K.H.), Oxford, UK; Neurosciences Unit and Mater Medical Research Institute (C.J.R.), Mater Children's Hospital, South Brisbane, University of Queensland, Australia; Alberta Children's Hospital (S.M.B.), Calgary, University of Calgary, Canada; and Evelina Children's Hospital (M.L.), London, UK
| | - Banu Anlar
- From the Neuroimmunology Group (R.C.D., F.B.), Children's Hospital at Westmead, University of Sydney, Australia; Boston Children's Hospital (L.V.D., M.P.G.), MA; the Division of Rheumatology (M.T., S.M.B.), The Hospital for Sick Children, University of Toronto, Canada; Children's Hospital of Philadelphia (A.T.W., S.N., B.B.), University of Pennsylvania; Paediatric Neurology and Rheumatology (E.M., A.S.), Texas Children's Hospital, Baylor College of Medicine, Houston; Assistance Publique-Hopitaux de Paris (K.D., M.T.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children, Pediatric Neurology Department and Université Paris-Sud, Inserm U1012, Le Kremlin-Bicêtre, France; Royal Children's Hospital Melbourne (E.A., A.K.), Australia; Great Ormond Street Hospital NHS Trust (M.R.E., C.H.), London; UCL Institute of Child Health (D.E., P.A.B.), London; Alder Hey Children's NHS Foundation Trust and the Institute of Infection and Global Health (R.K.), University of Liverpool, UK; Children's Hospital of Pittsburgh (G.A.), University of Pittsburgh, PA; Hacettepe University Child Neurology (B.A.), Turkey; Birmingham Children's Hospital (E.W.); John Radcliffe Hospital (K.H.), Oxford, UK; Neurosciences Unit and Mater Medical Research Institute (C.J.R.), Mater Children's Hospital, South Brisbane, University of Queensland, Australia; Alberta Children's Hospital (S.M.B.), Calgary, University of Calgary, Canada; and Evelina Children's Hospital (M.L.), London, UK
| | - Evangeline Wassmer
- From the Neuroimmunology Group (R.C.D., F.B.), Children's Hospital at Westmead, University of Sydney, Australia; Boston Children's Hospital (L.V.D., M.P.G.), MA; the Division of Rheumatology (M.T., S.M.B.), The Hospital for Sick Children, University of Toronto, Canada; Children's Hospital of Philadelphia (A.T.W., S.N., B.B.), University of Pennsylvania; Paediatric Neurology and Rheumatology (E.M., A.S.), Texas Children's Hospital, Baylor College of Medicine, Houston; Assistance Publique-Hopitaux de Paris (K.D., M.T.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children, Pediatric Neurology Department and Université Paris-Sud, Inserm U1012, Le Kremlin-Bicêtre, France; Royal Children's Hospital Melbourne (E.A., A.K.), Australia; Great Ormond Street Hospital NHS Trust (M.R.E., C.H.), London; UCL Institute of Child Health (D.E., P.A.B.), London; Alder Hey Children's NHS Foundation Trust and the Institute of Infection and Global Health (R.K.), University of Liverpool, UK; Children's Hospital of Pittsburgh (G.A.), University of Pittsburgh, PA; Hacettepe University Child Neurology (B.A.), Turkey; Birmingham Children's Hospital (E.W.); John Radcliffe Hospital (K.H.), Oxford, UK; Neurosciences Unit and Mater Medical Research Institute (C.J.R.), Mater Children's Hospital, South Brisbane, University of Queensland, Australia; Alberta Children's Hospital (S.M.B.), Calgary, University of Calgary, Canada; and Evelina Children's Hospital (M.L.), London, UK
| | - Kirsten Heineman
- From the Neuroimmunology Group (R.C.D., F.B.), Children's Hospital at Westmead, University of Sydney, Australia; Boston Children's Hospital (L.V.D., M.P.G.), MA; the Division of Rheumatology (M.T., S.M.B.), The Hospital for Sick Children, University of Toronto, Canada; Children's Hospital of Philadelphia (A.T.W., S.N., B.B.), University of Pennsylvania; Paediatric Neurology and Rheumatology (E.M., A.S.), Texas Children's Hospital, Baylor College of Medicine, Houston; Assistance Publique-Hopitaux de Paris (K.D., M.T.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children, Pediatric Neurology Department and Université Paris-Sud, Inserm U1012, Le Kremlin-Bicêtre, France; Royal Children's Hospital Melbourne (E.A., A.K.), Australia; Great Ormond Street Hospital NHS Trust (M.R.E., C.H.), London; UCL Institute of Child Health (D.E., P.A.B.), London; Alder Hey Children's NHS Foundation Trust and the Institute of Infection and Global Health (R.K.), University of Liverpool, UK; Children's Hospital of Pittsburgh (G.A.), University of Pittsburgh, PA; Hacettepe University Child Neurology (B.A.), Turkey; Birmingham Children's Hospital (E.W.); John Radcliffe Hospital (K.H.), Oxford, UK; Neurosciences Unit and Mater Medical Research Institute (C.J.R.), Mater Children's Hospital, South Brisbane, University of Queensland, Australia; Alberta Children's Hospital (S.M.B.), Calgary, University of Calgary, Canada; and Evelina Children's Hospital (M.L.), London, UK
| | - Cheryl Hemingway
- From the Neuroimmunology Group (R.C.D., F.B.), Children's Hospital at Westmead, University of Sydney, Australia; Boston Children's Hospital (L.V.D., M.P.G.), MA; the Division of Rheumatology (M.T., S.M.B.), The Hospital for Sick Children, University of Toronto, Canada; Children's Hospital of Philadelphia (A.T.W., S.N., B.B.), University of Pennsylvania; Paediatric Neurology and Rheumatology (E.M., A.S.), Texas Children's Hospital, Baylor College of Medicine, Houston; Assistance Publique-Hopitaux de Paris (K.D., M.T.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children, Pediatric Neurology Department and Université Paris-Sud, Inserm U1012, Le Kremlin-Bicêtre, France; Royal Children's Hospital Melbourne (E.A., A.K.), Australia; Great Ormond Street Hospital NHS Trust (M.R.E., C.H.), London; UCL Institute of Child Health (D.E., P.A.B.), London; Alder Hey Children's NHS Foundation Trust and the Institute of Infection and Global Health (R.K.), University of Liverpool, UK; Children's Hospital of Pittsburgh (G.A.), University of Pittsburgh, PA; Hacettepe University Child Neurology (B.A.), Turkey; Birmingham Children's Hospital (E.W.); John Radcliffe Hospital (K.H.), Oxford, UK; Neurosciences Unit and Mater Medical Research Institute (C.J.R.), Mater Children's Hospital, South Brisbane, University of Queensland, Australia; Alberta Children's Hospital (S.M.B.), Calgary, University of Calgary, Canada; and Evelina Children's Hospital (M.L.), London, UK
| | - Catherine J Riney
- From the Neuroimmunology Group (R.C.D., F.B.), Children's Hospital at Westmead, University of Sydney, Australia; Boston Children's Hospital (L.V.D., M.P.G.), MA; the Division of Rheumatology (M.T., S.M.B.), The Hospital for Sick Children, University of Toronto, Canada; Children's Hospital of Philadelphia (A.T.W., S.N., B.B.), University of Pennsylvania; Paediatric Neurology and Rheumatology (E.M., A.S.), Texas Children's Hospital, Baylor College of Medicine, Houston; Assistance Publique-Hopitaux de Paris (K.D., M.T.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children, Pediatric Neurology Department and Université Paris-Sud, Inserm U1012, Le Kremlin-Bicêtre, France; Royal Children's Hospital Melbourne (E.A., A.K.), Australia; Great Ormond Street Hospital NHS Trust (M.R.E., C.H.), London; UCL Institute of Child Health (D.E., P.A.B.), London; Alder Hey Children's NHS Foundation Trust and the Institute of Infection and Global Health (R.K.), University of Liverpool, UK; Children's Hospital of Pittsburgh (G.A.), University of Pittsburgh, PA; Hacettepe University Child Neurology (B.A.), Turkey; Birmingham Children's Hospital (E.W.); John Radcliffe Hospital (K.H.), Oxford, UK; Neurosciences Unit and Mater Medical Research Institute (C.J.R.), Mater Children's Hospital, South Brisbane, University of Queensland, Australia; Alberta Children's Hospital (S.M.B.), Calgary, University of Calgary, Canada; and Evelina Children's Hospital (M.L.), London, UK
| | - Andrew Kornberg
- From the Neuroimmunology Group (R.C.D., F.B.), Children's Hospital at Westmead, University of Sydney, Australia; Boston Children's Hospital (L.V.D., M.P.G.), MA; the Division of Rheumatology (M.T., S.M.B.), The Hospital for Sick Children, University of Toronto, Canada; Children's Hospital of Philadelphia (A.T.W., S.N., B.B.), University of Pennsylvania; Paediatric Neurology and Rheumatology (E.M., A.S.), Texas Children's Hospital, Baylor College of Medicine, Houston; Assistance Publique-Hopitaux de Paris (K.D., M.T.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children, Pediatric Neurology Department and Université Paris-Sud, Inserm U1012, Le Kremlin-Bicêtre, France; Royal Children's Hospital Melbourne (E.A., A.K.), Australia; Great Ormond Street Hospital NHS Trust (M.R.E., C.H.), London; UCL Institute of Child Health (D.E., P.A.B.), London; Alder Hey Children's NHS Foundation Trust and the Institute of Infection and Global Health (R.K.), University of Liverpool, UK; Children's Hospital of Pittsburgh (G.A.), University of Pittsburgh, PA; Hacettepe University Child Neurology (B.A.), Turkey; Birmingham Children's Hospital (E.W.); John Radcliffe Hospital (K.H.), Oxford, UK; Neurosciences Unit and Mater Medical Research Institute (C.J.R.), Mater Children's Hospital, South Brisbane, University of Queensland, Australia; Alberta Children's Hospital (S.M.B.), Calgary, University of Calgary, Canada; and Evelina Children's Hospital (M.L.), London, UK
| | - Marc Tardieu
- From the Neuroimmunology Group (R.C.D., F.B.), Children's Hospital at Westmead, University of Sydney, Australia; Boston Children's Hospital (L.V.D., M.P.G.), MA; the Division of Rheumatology (M.T., S.M.B.), The Hospital for Sick Children, University of Toronto, Canada; Children's Hospital of Philadelphia (A.T.W., S.N., B.B.), University of Pennsylvania; Paediatric Neurology and Rheumatology (E.M., A.S.), Texas Children's Hospital, Baylor College of Medicine, Houston; Assistance Publique-Hopitaux de Paris (K.D., M.T.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children, Pediatric Neurology Department and Université Paris-Sud, Inserm U1012, Le Kremlin-Bicêtre, France; Royal Children's Hospital Melbourne (E.A., A.K.), Australia; Great Ormond Street Hospital NHS Trust (M.R.E., C.H.), London; UCL Institute of Child Health (D.E., P.A.B.), London; Alder Hey Children's NHS Foundation Trust and the Institute of Infection and Global Health (R.K.), University of Liverpool, UK; Children's Hospital of Pittsburgh (G.A.), University of Pittsburgh, PA; Hacettepe University Child Neurology (B.A.), Turkey; Birmingham Children's Hospital (E.W.); John Radcliffe Hospital (K.H.), Oxford, UK; Neurosciences Unit and Mater Medical Research Institute (C.J.R.), Mater Children's Hospital, South Brisbane, University of Queensland, Australia; Alberta Children's Hospital (S.M.B.), Calgary, University of Calgary, Canada; and Evelina Children's Hospital (M.L.), London, UK
| | - Amber Stocco
- From the Neuroimmunology Group (R.C.D., F.B.), Children's Hospital at Westmead, University of Sydney, Australia; Boston Children's Hospital (L.V.D., M.P.G.), MA; the Division of Rheumatology (M.T., S.M.B.), The Hospital for Sick Children, University of Toronto, Canada; Children's Hospital of Philadelphia (A.T.W., S.N., B.B.), University of Pennsylvania; Paediatric Neurology and Rheumatology (E.M., A.S.), Texas Children's Hospital, Baylor College of Medicine, Houston; Assistance Publique-Hopitaux de Paris (K.D., M.T.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children, Pediatric Neurology Department and Université Paris-Sud, Inserm U1012, Le Kremlin-Bicêtre, France; Royal Children's Hospital Melbourne (E.A., A.K.), Australia; Great Ormond Street Hospital NHS Trust (M.R.E., C.H.), London; UCL Institute of Child Health (D.E., P.A.B.), London; Alder Hey Children's NHS Foundation Trust and the Institute of Infection and Global Health (R.K.), University of Liverpool, UK; Children's Hospital of Pittsburgh (G.A.), University of Pittsburgh, PA; Hacettepe University Child Neurology (B.A.), Turkey; Birmingham Children's Hospital (E.W.); John Radcliffe Hospital (K.H.), Oxford, UK; Neurosciences Unit and Mater Medical Research Institute (C.J.R.), Mater Children's Hospital, South Brisbane, University of Queensland, Australia; Alberta Children's Hospital (S.M.B.), Calgary, University of Calgary, Canada; and Evelina Children's Hospital (M.L.), London, UK
| | - Brenda Banwell
- From the Neuroimmunology Group (R.C.D., F.B.), Children's Hospital at Westmead, University of Sydney, Australia; Boston Children's Hospital (L.V.D., M.P.G.), MA; the Division of Rheumatology (M.T., S.M.B.), The Hospital for Sick Children, University of Toronto, Canada; Children's Hospital of Philadelphia (A.T.W., S.N., B.B.), University of Pennsylvania; Paediatric Neurology and Rheumatology (E.M., A.S.), Texas Children's Hospital, Baylor College of Medicine, Houston; Assistance Publique-Hopitaux de Paris (K.D., M.T.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children, Pediatric Neurology Department and Université Paris-Sud, Inserm U1012, Le Kremlin-Bicêtre, France; Royal Children's Hospital Melbourne (E.A., A.K.), Australia; Great Ormond Street Hospital NHS Trust (M.R.E., C.H.), London; UCL Institute of Child Health (D.E., P.A.B.), London; Alder Hey Children's NHS Foundation Trust and the Institute of Infection and Global Health (R.K.), University of Liverpool, UK; Children's Hospital of Pittsburgh (G.A.), University of Pittsburgh, PA; Hacettepe University Child Neurology (B.A.), Turkey; Birmingham Children's Hospital (E.W.); John Radcliffe Hospital (K.H.), Oxford, UK; Neurosciences Unit and Mater Medical Research Institute (C.J.R.), Mater Children's Hospital, South Brisbane, University of Queensland, Australia; Alberta Children's Hospital (S.M.B.), Calgary, University of Calgary, Canada; and Evelina Children's Hospital (M.L.), London, UK
| | - Mark P Gorman
- From the Neuroimmunology Group (R.C.D., F.B.), Children's Hospital at Westmead, University of Sydney, Australia; Boston Children's Hospital (L.V.D., M.P.G.), MA; the Division of Rheumatology (M.T., S.M.B.), The Hospital for Sick Children, University of Toronto, Canada; Children's Hospital of Philadelphia (A.T.W., S.N., B.B.), University of Pennsylvania; Paediatric Neurology and Rheumatology (E.M., A.S.), Texas Children's Hospital, Baylor College of Medicine, Houston; Assistance Publique-Hopitaux de Paris (K.D., M.T.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children, Pediatric Neurology Department and Université Paris-Sud, Inserm U1012, Le Kremlin-Bicêtre, France; Royal Children's Hospital Melbourne (E.A., A.K.), Australia; Great Ormond Street Hospital NHS Trust (M.R.E., C.H.), London; UCL Institute of Child Health (D.E., P.A.B.), London; Alder Hey Children's NHS Foundation Trust and the Institute of Infection and Global Health (R.K.), University of Liverpool, UK; Children's Hospital of Pittsburgh (G.A.), University of Pittsburgh, PA; Hacettepe University Child Neurology (B.A.), Turkey; Birmingham Children's Hospital (E.W.); John Radcliffe Hospital (K.H.), Oxford, UK; Neurosciences Unit and Mater Medical Research Institute (C.J.R.), Mater Children's Hospital, South Brisbane, University of Queensland, Australia; Alberta Children's Hospital (S.M.B.), Calgary, University of Calgary, Canada; and Evelina Children's Hospital (M.L.), London, UK
| | - Susanne M Benseler
- From the Neuroimmunology Group (R.C.D., F.B.), Children's Hospital at Westmead, University of Sydney, Australia; Boston Children's Hospital (L.V.D., M.P.G.), MA; the Division of Rheumatology (M.T., S.M.B.), The Hospital for Sick Children, University of Toronto, Canada; Children's Hospital of Philadelphia (A.T.W., S.N., B.B.), University of Pennsylvania; Paediatric Neurology and Rheumatology (E.M., A.S.), Texas Children's Hospital, Baylor College of Medicine, Houston; Assistance Publique-Hopitaux de Paris (K.D., M.T.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children, Pediatric Neurology Department and Université Paris-Sud, Inserm U1012, Le Kremlin-Bicêtre, France; Royal Children's Hospital Melbourne (E.A., A.K.), Australia; Great Ormond Street Hospital NHS Trust (M.R.E., C.H.), London; UCL Institute of Child Health (D.E., P.A.B.), London; Alder Hey Children's NHS Foundation Trust and the Institute of Infection and Global Health (R.K.), University of Liverpool, UK; Children's Hospital of Pittsburgh (G.A.), University of Pittsburgh, PA; Hacettepe University Child Neurology (B.A.), Turkey; Birmingham Children's Hospital (E.W.); John Radcliffe Hospital (K.H.), Oxford, UK; Neurosciences Unit and Mater Medical Research Institute (C.J.R.), Mater Children's Hospital, South Brisbane, University of Queensland, Australia; Alberta Children's Hospital (S.M.B.), Calgary, University of Calgary, Canada; and Evelina Children's Hospital (M.L.), London, UK
| | - Ming Lim
- From the Neuroimmunology Group (R.C.D., F.B.), Children's Hospital at Westmead, University of Sydney, Australia; Boston Children's Hospital (L.V.D., M.P.G.), MA; the Division of Rheumatology (M.T., S.M.B.), The Hospital for Sick Children, University of Toronto, Canada; Children's Hospital of Philadelphia (A.T.W., S.N., B.B.), University of Pennsylvania; Paediatric Neurology and Rheumatology (E.M., A.S.), Texas Children's Hospital, Baylor College of Medicine, Houston; Assistance Publique-Hopitaux de Paris (K.D., M.T.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children, Pediatric Neurology Department and Université Paris-Sud, Inserm U1012, Le Kremlin-Bicêtre, France; Royal Children's Hospital Melbourne (E.A., A.K.), Australia; Great Ormond Street Hospital NHS Trust (M.R.E., C.H.), London; UCL Institute of Child Health (D.E., P.A.B.), London; Alder Hey Children's NHS Foundation Trust and the Institute of Infection and Global Health (R.K.), University of Liverpool, UK; Children's Hospital of Pittsburgh (G.A.), University of Pittsburgh, PA; Hacettepe University Child Neurology (B.A.), Turkey; Birmingham Children's Hospital (E.W.); John Radcliffe Hospital (K.H.), Oxford, UK; Neurosciences Unit and Mater Medical Research Institute (C.J.R.), Mater Children's Hospital, South Brisbane, University of Queensland, Australia; Alberta Children's Hospital (S.M.B.), Calgary, University of Calgary, Canada; and Evelina Children's Hospital (M.L.), London, UK
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