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Michael BD, Dunai C, Needham EJ, Tharmaratnam K, Williams R, Huang Y, Boardman SA, Clark JJ, Sharma P, Subramaniam K, Wood GK, Collie C, Digby R, Ren A, Norton E, Leibowitz M, Ebrahimi S, Fower A, Fox H, Tato E, Ellul MA, Sunderland G, Held M, Hetherington C, Egbe FN, Palmos A, Stirrups K, Grundmann A, Chiollaz AC, Sanchez JC, Stewart JP, Griffiths M, Solomon T, Breen G, Coles AJ, Kingston N, Bradley JR, Chinnery PF, Cavanagh J, Irani SR, Vincent A, Baillie JK, Openshaw PJ, Semple MG, Taams LS, Menon DK. Author Correction: Para-infectious brain injury in COVID-19 persists at follow-up despite attenuated cytokine and autoantibody responses. Nat Commun 2024; 15:2918. [PMID: 38575615 PMCID: PMC10995197 DOI: 10.1038/s41467-024-47320-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024] Open
Affiliation(s)
- Benedict D Michael
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK.
- NIHR Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, L69 7BE, UK.
- The Walton Centre NHS Foundation Trust, Liverpool, L9 7BB, UK.
| | - Cordelia Dunai
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
- NIHR Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, L69 7BE, UK
| | - Edward J Needham
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, CB2 0QQ, UK
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Kukatharmini Tharmaratnam
- Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, L69 3GF, UK
| | - Robyn Williams
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
- Departments of Neurology and Neuroscience, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Yun Huang
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Sarah A Boardman
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Jordan J Clark
- University of Liverpool, Liverpool, L69 7BE, UK
- Department of Microbiology, Icahn School of Medicine, Mount Sinai, NY, 10029, USA
- Center for Vaccine Research and Pandemic Preparedness (C-VARPP), Icahn School of Medicine, Mount Sinai, NY, 10029, USA
| | - Parul Sharma
- Infection Biology & Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L3 5RF, UK
| | - Krishanthi Subramaniam
- Infection Biology & Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L3 5RF, UK
| | - Greta K Wood
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Ceryce Collie
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Richard Digby
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Alexander Ren
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Emma Norton
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Maya Leibowitz
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Soraya Ebrahimi
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Andrew Fower
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
| | - Hannah Fox
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
| | - Esteban Tato
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE5 8AF, UK
- NIHR Maudsley Biomedical Research Centre, King's College London, London, SE5 8AF, UK
| | - Mark A Ellul
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
- The Walton Centre NHS Foundation Trust, Liverpool, L9 7BB, UK
| | - Geraint Sunderland
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Marie Held
- Centre for Cell Imaging, Liverpool Shared Research Facilities, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, L69 7ZB, UK
| | - Claire Hetherington
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Franklyn N Egbe
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Alish Palmos
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE5 8AF, UK
- NIHR Maudsley Biomedical Research Centre, King's College London, London, SE5 8AF, UK
| | - Kathy Stirrups
- NIHR BioResource, Cambridge University Hospitals NHS Foundation, Cambridge, CB2 0QQ, UK
- Department of Haematology, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Alexander Grundmann
- Clinical Neurosciences, Clinical and Experimental Science, Faculty of Medicine, University of Southampton, Southampton, SO17 1BF, UK
- Department of Neurology, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Anne-Cecile Chiollaz
- Département de médecine interne des spécialités (DEMED), University of Geneva, Geneva, CH-1211, Switzerland
| | - Jean-Charles Sanchez
- Département de médecine interne des spécialités (DEMED), University of Geneva, Geneva, CH-1211, Switzerland
| | - James P Stewart
- Infection Biology & Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L3 5RF, UK
| | - Michael Griffiths
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Tom Solomon
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
- NIHR Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, L69 7BE, UK
- The Walton Centre NHS Foundation Trust, Liverpool, L9 7BB, UK
- The Pandemic Institute, Liverpool, L7 3FA, UK
| | - Gerome Breen
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE5 8AF, UK
- NIHR Maudsley Biomedical Research Centre, King's College London, London, SE5 8AF, UK
| | - Alasdair J Coles
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Nathalie Kingston
- NIHR BioResource, Cambridge University Hospitals NHS Foundation, Cambridge, CB2 0QQ, UK
- University of Cambridge, Cambridge, CB2 0QQ, UK
| | - John R Bradley
- NIHR BioResource, Cambridge University Hospitals NHS Foundation, Cambridge, CB2 0QQ, UK
- Department of Medicine, School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Patrick F Chinnery
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, CB2 0QQ, UK
- NIHR BioResource, Cambridge University Hospitals NHS Foundation, Cambridge, CB2 0QQ, UK
| | - Jonathan Cavanagh
- Centre for Immunology, School of Infection & Immunity, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, G12 8TA, UK
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
- Departments of Neurology and Neuroscience, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
| | - J Kenneth Baillie
- Roslin Institute, University of Edinburgh, Edinburgh, EH25 9RG, UK
- Intensive Care Unit, Royal Infirmary of Edinburgh, Edinburgh, EH10 5HF, UK
| | - Peter J Openshaw
- National Heart and Lung Institute, Imperial College London, London, SW7 2BX, UK
- Imperial College Healthcare NHS Trust, London, W2 1NY, UK
| | - Malcolm G Semple
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
- NIHR Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, L69 7BE, UK
- Respiratory Unit, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, L14 5AB, UK
| | - Leonie S Taams
- Centre for Inflammation Biology and Cancer Immunology, King's College London, London, SE1 9RT, UK
| | - David K Menon
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
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Kadambari S, Feng S, Liu X, Andersson M, Waterfield R, Fodder H, Jacquemot A, Galal U, Rafferty A, Drew RJ, Rodrigues C, Sadarangani M, Riordan A, Martin NG, Defres S, Solomon T, Pollard AJ, Paulus S. Evaluating the Impact of the BioFire FilmArray in Childhood Meningitis: An Observational Cohort Study. Pediatr Infect Dis J 2024; 43:345-349. [PMID: 38190645 DOI: 10.1097/inf.0000000000004236] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
BACKGROUND Multiplex polymerase chain reaction assays have the potential to reduce antibiotic use and shorten length of inpatient stay in children with suspected central nervous system infection by obtaining an early microbiological diagnosis. The clinical impact of the implementation of the BioFire FilmArray Meningitis/Encephalitis Panel on the management of childhood meningitis was evaluated at the John Radcliffe Hospital in Oxford and Children's Health Ireland at Temple Street in Dublin. METHODS Children who had lumbar punctures performed as part of a septic screen were identified retrospectively through clinical discharge coding and microbiology databases from April 2017 to December 2018. Anonymized clinical and laboratory data were collected. Comparison of antibiotic use, length of stay and outcome at discharge was made with a historical cohort in Oxford (2012-2016), presenting before implementation of the FilmArray. RESULTS The study included 460 children who had a lumbar puncture as part of an evaluation for suspected central nervous system infection. Twelve bacterial cases were identified on the FilmArray that were not detected by conventional bacterial culture. Bacterial culture identified one additional case of bacterial meningitis, caused by Escherichia coli , which had not been identified on the FilmArray. Duration of antibiotics was shorter in children when FilmArray was used than before its implementation; enterovirus meningitis (median: 4 vs. 5 days), human parechovirus meningitis (median: 4 vs. 4.5 days) and culture/FilmArray-negative cerebrospinal fluid (median: 4 vs. 6 days). CONCLUSIONS The use of a FilmArray can identify additional bacterial cases of meningitis in children that had been negative by traditional culture methods. Children with viral meningitis and culture-negative meningitis received shorter courses of antibiotics and had shorter hospital stays when FilmArray was used. Large studies to evaluate the clinical impact and cost effectiveness of incorporating the FilmArray into routine testing are warranted.
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Affiliation(s)
- Seilesh Kadambari
- From the Oxford Vaccine Group, Department of Paediatrics, University of Oxford, NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
- Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust
- Infection, Immunity and Inflammation department, University College London, Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Shuo Feng
- From the Oxford Vaccine Group, Department of Paediatrics, University of Oxford, NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Xinxue Liu
- From the Oxford Vaccine Group, Department of Paediatrics, University of Oxford, NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Monique Andersson
- Department of Microbiology, Oxford University Hospitals NHS Foundation Trust
- NDCLS, Radcliffe Department of Medicine
| | - Rebecca Waterfield
- From the Oxford Vaccine Group, Department of Paediatrics, University of Oxford, NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Harriet Fodder
- From the Oxford Vaccine Group, Department of Paediatrics, University of Oxford, NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Aimee Jacquemot
- From the Oxford Vaccine Group, Department of Paediatrics, University of Oxford, NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Ushma Galal
- Oxford Primary Care Clinical Trials Unit, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | | | - Richard J Drew
- Irish Meningitis and Sepsis Reference Laboratory, Children's Health Ireland at Temple Street
- Clinical Innovation Unit, Rotunda Hospital
- Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Republic of Ireland
| | - Charlene Rodrigues
- Department of Paediatric Infectious Diseases, St Mary's Hospital, Imperial College Healthcare NHS Trust
- Department of Infection Biology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Manish Sadarangani
- Vaccine Evaluation Center, BC Children's Hospital Research Institute
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrew Riordan
- Department of Paediatric Infectious Diseases and Immunology, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | - Natalie G Martin
- Department of Paediatrics, University of Otago Christchurch, Christchurch, New Zealand
| | - 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 Diseases Unit, Liverpool University Hospitals NHS Foundation Trust
- Department of Clinical Sciences and Education, Liverpool School of Tropical Medicine
| | - Tom Solomon
- The Pandemic Institute
- Department of Clinical Infection, Microbiology, and Immunology (CIMI)
- Institute of Infection, Veterinary & Ecological Sciences
- National Institute for Health and Care Research Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool
- Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Andrew J Pollard
- From the Oxford Vaccine Group, Department of Paediatrics, University of Oxford, NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Stephane Paulus
- From the Oxford Vaccine Group, Department of Paediatrics, University of Oxford, NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
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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] [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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Cho SM, Premraj L, Battaglini D, Fanning JP, Suen J, Bassi GL, Fraser J, Robba C, Griffee M, Solomon T, Semple MG, Baillie K, Sigfrid L, Scott JT, Citarella BW, Merson L, Arora RC, Whitman G, Thomson D, White N. Sex differences in post-acute neurological sequelae of SARS-CoV-2 and symptom resolution in adults after coronavirus disease 2019 hospitalization: an international multi-centre prospective observational study. Brain Commun 2024; 6:fcae036. [PMID: 38444907 PMCID: PMC10914448 DOI: 10.1093/braincomms/fcae036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/11/2023] [Accepted: 02/06/2024] [Indexed: 03/07/2024] Open
Abstract
Although it is known that coronavirus disease 2019 can present with a range of neurological manifestations and in-hospital complications, sparse data exist on whether these initial neurological symptoms of coronavirus disease 2019 are closely associated with post-acute neurological sequelae of SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2; PANSC) and whether female versus male sex impacts symptom resolution. In this international, multi-centre, prospective, observational study across 407 sites from 15 countries (30 January 2020 to 30 April 2022), we report the prevalence and risk factors of PANSC among hospitalized adults and investigate the differences between males and females on neurological symptom resolution over time. PANSC symptoms included altered consciousness/confusion, fatigue/malaise, anosmia, dysgeusia and muscle ache/joint pain, on which information was collected at index hospitalization and during follow-up assessments. The analysis considered a time to the resolution of individual and all neurological symptoms. The resulting times were modelled by Weibull regression, assuming mixed-case interval censoring, with sex and age included as covariates. The model results were summarized as cumulative probability functions and age-adjusted and sex-adjusted median times to resolution. We included 6862 hospitalized adults with coronavirus disease 2019, who had follow-up assessments. The median age of the participants was 57 years (39.2% females). Males and females had similar baseline characteristics, except that more males (versus females) were admitted to the intensive care unit (30.5 versus 20.3%) and received mechanical ventilation (17.2 versus 11.8%). Approximately 70% of patients had multiple neurological symptoms at the first follow-up (median = 102 days). Fatigue (49.9%) and myalgia/arthralgia (45.2%) were the most prevalent symptoms of PANSC at the initial follow-up. The reported prevalence in females was generally higher (versus males) for all symptoms. At 12 months, anosmia and dysgeusia were resolved in most patients, although fatigue, altered consciousness and myalgia remained unresolved in >10% of the cohort. Females had a longer time to the resolution (5.2 versus 3.4 months) of neurological symptoms at follow-up for those with more than one neurological symptom. In the multivariable analysis, males were associated with a shorter time to the resolution of symptoms (hazard ratio = 1.53; 95% confidence interval = 1.39-1.69). Intensive care unit admission was associated with a longer time to the resolution of symptoms (hazard ratio = 0.68; 95% confidence interval = 0.60-0.77). Post-discharge stroke was uncommon (0.3% in females and 0.5% in males). Despite the methodological challenges involved in the collection of survey data, this international multi-centre prospective cohort study demonstrated that PANSC following index hospitalization was high. Symptom prevalence was higher and took longer to resolve in females than in males. This supported the fact that while males were sicker during acute illness, females were disproportionately affected by PANSC.
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Affiliation(s)
- Sung-Min Cho
- Neuroscience Critical Care Division, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21278, USA
- Neuroscience Critical Care Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21278, USA
- Neuroscience Critical Care Division, Department of Anaesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21278, USA
| | - Lavienraj Premraj
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove 4059, Australia
- Griffith University School of Medicine, Gold Coast 4215, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane 4032, Australia
| | - Denise Battaglini
- Department of Surgical Science and Integrated Diagnostic, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, University of Genoa, Genoa 16132, Italy
- Department of Medicine, University of Barcelona, Barcelona 08036, Spain
| | - Jonathon Paul Fanning
- Critical Care Research Group, The Prince Charles Hospital, Brisbane 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane 4006, Australia
| | - Jacky Suen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane 4006, Australia
| | - Gianluigi Li Bassi
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove 4059, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane 4006, Australia
- Institut d’Investigacions Biomediques August Pi I Sunyer, Barcelona 08036, Spain
| | - John Fraser
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove 4059, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane 4006, Australia
- St Andrew’s War Memorial Hospital, UnitingCare, Spring Hill 4000, Australia
| | - Chiara Robba
- Department of Surgical Science and Integrated Diagnostic, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, University of Genoa, Genoa 16132, Italy
| | - Matthew Griffee
- Department of Anesthesiology, University of Utah, Salt Lake City, UT 84132, USA
| | - Tom Solomon
- Brain Infections Group, Institute of Infection and Global Health, University of Liverpool, Liverpool, L3 5TR, UK
- Department of Neuroscience, University of Liverpool, Liverpool, L3 5TR, UK
- Walton Centre NHS Foundation Trust, Liverpool, L9 7LJ, UK
| | - Malcolm G Semple
- Child Health and Outbreak Medicine, University of Liverpool, Liverpool, L3 5TR, UK
| | - Kenneth Baillie
- Experimental Medicine, University of Edinburgh, Edinburgh, EH4 2XU, UK
| | - Louise Sigfrid
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7LG, UK
| | - Janet T Scott
- Infectious Disease, University of Glasgow, Glasgow, G12 8QQ, UK
| | - Barbara Wanjiru Citarella
- International Severe Acute Respiratory and emerging Infections Consortium (ISARIC), Pandemic Sciences Institute, University of Oxford, Oxford, OX1 2JD, UK
| | - Laura Merson
- Institut d’Investigacions Biomediques August Pi I Sunyer, Barcelona 08036, Spain
| | - Rakesh C Arora
- Department of Surgery, University Hospitals/Case Western Reserve University, Cleveland, OH 44106, USA
| | - Glenn Whitman
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21278, USA
| | - David Thomson
- Department of Anaesthesia and Peri-operative Medicine, University of Cape Town, Cape Town 7700, South Africa
- Division of Critical Care, Groote Schuur Hospital, Cape Town 7925, South Africa
| | - Nicole White
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove 4059, Australia
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Michael BD, Dunai C, Needham EJ, Tharmaratnam K, Williams R, Huang Y, Boardman SA, Clark JJ, Sharma P, Subramaniam K, Wood GK, Collie C, Digby R, Ren A, Norton E, Leibowitz M, Ebrahimi S, Fower A, Fox H, Tato E, Ellul MA, Sunderland G, Held M, Hetherington C, Egbe FN, Palmos A, Stirrups K, Grundmann A, Chiollaz AC, Sanchez JC, Stewart JP, Griffiths M, Solomon T, Breen G, Coles AJ, Kingston N, Bradley JR, Chinnery PF, Cavanagh J, Irani SR, Vincent A, Baillie JK, Openshaw PJ, Semple MG, Taams LS, Menon DK. Para-infectious brain injury in COVID-19 persists at follow-up despite attenuated cytokine and autoantibody responses. Nat Commun 2023; 14:8487. [PMID: 38135686 PMCID: PMC10746705 DOI: 10.1038/s41467-023-42320-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 10/06/2023] [Indexed: 12/24/2023] Open
Abstract
To understand neurological complications of COVID-19 better both acutely and for recovery, we measured markers of brain injury, inflammatory mediators, and autoantibodies in 203 hospitalised participants; 111 with acute sera (1-11 days post-admission) and 92 convalescent sera (56 with COVID-19-associated neurological diagnoses). Here we show that compared to 60 uninfected controls, tTau, GFAP, NfL, and UCH-L1 are increased with COVID-19 infection at acute timepoints and NfL and GFAP are significantly higher in participants with neurological complications. Inflammatory mediators (IL-6, IL-12p40, HGF, M-CSF, CCL2, and IL-1RA) are associated with both altered consciousness and markers of brain injury. Autoantibodies are more common in COVID-19 than controls and some (including against MYL7, UCH-L1, and GRIN3B) are more frequent with altered consciousness. Additionally, convalescent participants with neurological complications show elevated GFAP and NfL, unrelated to attenuated systemic inflammatory mediators and to autoantibody responses. Overall, neurological complications of COVID-19 are associated with evidence of neuroglial injury in both acute and late disease and these correlate with dysregulated innate and adaptive immune responses acutely.
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Affiliation(s)
- Benedict D Michael
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK.
- NIHR Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, L69 7BE, UK.
- The Walton Centre NHS Foundation Trust, Liverpool, L9 7BB, UK.
| | - Cordelia Dunai
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
- NIHR Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, L69 7BE, UK
| | - Edward J Needham
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, CB2 0QQ, UK
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Kukatharmini Tharmaratnam
- Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, L69 3GF, UK
| | - Robyn Williams
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
- Departments of Neurology and Neuroscience, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Yun Huang
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Sarah A Boardman
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Jordan J Clark
- University of Liverpool, Liverpool, L69 7BE, UK
- Department of Microbiology, Icahn School of Medicine, Mount Sinai, NY, 10029, USA
- Center for Vaccine Research and Pandemic Preparedness (C-VARPP), Icahn School of Medicine, Mount Sinai, NY, 10029, USA
| | - Parul Sharma
- Infection Biology & Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L3 5RF, UK
| | - Krishanthi Subramaniam
- Infection Biology & Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L3 5RF, UK
| | - Greta K Wood
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Ceryce Collie
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Richard Digby
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Alexander Ren
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Emma Norton
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Maya Leibowitz
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Soraya Ebrahimi
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Andrew Fower
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
| | - Hannah Fox
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
| | - Esteban Tato
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE5 8AF, UK
- NIHR Maudsley Biomedical Research Centre, King's College London, London, SE5 8AF, UK
| | - Mark A Ellul
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
- The Walton Centre NHS Foundation Trust, Liverpool, L9 7BB, UK
| | - Geraint Sunderland
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Marie Held
- Centre for Cell Imaging, Liverpool Shared Research Facilities, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, L69 7ZB, UK
| | - Claire Hetherington
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Franklyn N Egbe
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Alish Palmos
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE5 8AF, UK
- NIHR Maudsley Biomedical Research Centre, King's College London, London, SE5 8AF, UK
| | - Kathy Stirrups
- NIHR BioResource, Cambridge University Hospitals NHS Foundation, Cambridge, CB2 0QQ, UK
- Department of Haematology, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Alexander Grundmann
- Clinical Neurosciences, Clinical and Experimental Science, Faculty of Medicine, University of Southampton, Southampton, SO17 1BF, UK
- Department of Neurology, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Anne-Cecile Chiollaz
- Département de médecine interne des spécialités (DEMED), University of Geneva, Geneva, CH-1211, Switzerland
| | - Jean-Charles Sanchez
- Département de médecine interne des spécialités (DEMED), University of Geneva, Geneva, CH-1211, Switzerland
| | - James P Stewart
- Infection Biology & Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L3 5RF, UK
| | - Michael Griffiths
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
| | - Tom Solomon
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
- NIHR Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, L69 7BE, UK
- The Walton Centre NHS Foundation Trust, Liverpool, L9 7BB, UK
- The Pandemic Institute, Liverpool, L7 3FA, UK
| | - Gerome Breen
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE5 8AF, UK
- NIHR Maudsley Biomedical Research Centre, King's College London, London, SE5 8AF, UK
| | - Alasdair J Coles
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Nathalie Kingston
- NIHR BioResource, Cambridge University Hospitals NHS Foundation, Cambridge, CB2 0QQ, UK
- University of Cambridge, Cambridge, CB2 0QQ, UK
| | - John R Bradley
- NIHR BioResource, Cambridge University Hospitals NHS Foundation, Cambridge, CB2 0QQ, UK
- Department of Medicine, School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Patrick F Chinnery
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, CB2 0QQ, UK
- NIHR BioResource, Cambridge University Hospitals NHS Foundation, Cambridge, CB2 0QQ, UK
| | - Jonathan Cavanagh
- Centre for Immunology, School of Infection & Immunity, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, G12 8TA, UK
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
- Departments of Neurology and Neuroscience, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
| | - J Kenneth Baillie
- Roslin Institute, University of Edinburgh, Edinburgh, EH25 9RG, UK
- Intensive Care Unit, Royal Infirmary of Edinburgh, Edinburgh, EH10 5HF, UK
| | - Peter J Openshaw
- National Heart and Lung Institute, Imperial College London, London, SW7 2BX, UK
- Imperial College Healthcare NHS Trust, London, W2 1NY, UK
| | - Malcolm G Semple
- Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK
- NIHR Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, L69 7BE, UK
- Respiratory Unit, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, L14 5AB, UK
| | - Leonie S Taams
- Centre for Inflammation Biology and Cancer Immunology, King's College London, London, SE1 9RT, UK
| | - David K Menon
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
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Boruah AP, Thakur KT, Gadani SP, Kothari KU, Chomba M, Guekht A, Heydari K, Hoo FK, Hwang S, Michael BD, Pandit MV, Pardo CA, Prasad K, Sardar Z, Seeher K, Solomon T, Winkler AS, Wood GK, Schiess N. Pre-existing neurological conditions and COVID-19 co-infection: Data from systematic reviews, meta-analyses, and scoping reviews. J Neurol Sci 2023; 455:120858. [PMID: 37948972 PMCID: PMC10751535 DOI: 10.1016/j.jns.2023.120858] [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: 08/10/2023] [Revised: 10/20/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Pre-existing neurological diseases have been identified as risk factors for severe COVID-19 infection and death. There is a lack of comprehensive literature review assessing the relationship between pre-existing neurological conditions and COVID-19 outcomes. Identification of high risk groups is critical for optimal treatment and care. METHODS A literature review was conducted for systematic reviews, meta-analyses, and scoping reviews published between January 1, 2020 and January 1, 2023. Literature assessing individuals with pre-existing neurological diseases and COVID-19 infection was included. Information regarding infection severity was extracted, and potential limitations were identified. RESULTS Thirty-nine articles met inclusion criteria, with data assessing >3 million patients from 51 countries. 26/51 (50.9%) of countries analyzed were classified as high income, while the remaining represented middle-low income countries (25/51; 49.0%). A majority of evidence focused on the impact of cerebrovascular disease (17/39; 43.5%) and dementia (5/39; 12.8%) on COVID-19 severity and mortality. 92.3% of the articles (36/39) suggested a significant association between neurological conditions and increased risk of severe COVID-19 and mortality. Cerebrovascular disease, dementia, Parkinson's disease, and epilepsy were associated with increased COVID severity and mortality. CONCLUSION Pre-existing neurological diseases including cerebrovascular disease, Alzheimer's disease and other dementias, epilepsy, and Parkinson's disease are significant risk factors for severity of COVID-19 infection and mortality in the acute infectious period. Given that 61.5% (24/39) of the current evidence only includes data from 2020, further updated literature is crucial to identify the relationship between chronic neurological conditions and clinical characteristics of COVID-19 variants.
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Affiliation(s)
| | - Kiran T Thakur
- Department of Neurology, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, USA
| | | | - Kavita U Kothari
- Consultant to Library & Digital Information Networks, World Health Organization, Geneva, Switzerland
| | | | - Alla Guekht
- Moscow Research and Clinical Center for Neuropsychiatry, Moscow, Russia; Pirogov Russian Medical Research University, Moscow, Russia
| | | | - Fan Kee Hoo
- Faculty of Medicine and Health Sciences, University Putra Malaysia, Kuala Lumpur, Malaysia
| | | | - Benedict D Michael
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Department of Neurology, Walton Centre NHS Foundation Trust, NIHR Health Protection Research Unit for Emerging and Zoonotic Infection, Liverpool, UK
| | | | | | - Kameshwar Prasad
- Department of Neurology Fortis Flt Lt, Rajan Dhall Hospital, Vasant Kunj, New Delhi, India
| | - Zomer Sardar
- Columbia University Irving Medical Center, New York, NY, USA
| | - Katrin Seeher
- Brain Health Unit, World Health Organization, Geneva, Switzerland
| | - Tom Solomon
- The Pandemic Institute, The Spine, Liverpool L7 3FA, UK; National Institute for Health and Care Research Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool L69 7BE, UK; Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool, Liverpool L69 7BE, UK; Walton Centre NHS Foundation Trust, Liverpool L9 7LJ, UK
| | - Andrea S Winkler
- Department of Neurology, Center for Global Health, Technical University of Munich, Munich, Germany; Department of Community Medicine and Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Greta K Wood
- Department of Clinical Infection, Microbiology & Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, UK
| | - Nicoline Schiess
- Brain Health Unit, World Health Organization, Geneva, Switzerland.
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Granerod J, Huang Y, Davies NWS, Sequeira PC, Mwapasa V, Rupali P, Michael BD, Solomon T, Easton A. Global Landscape of Encephalitis: Key Priorities to Reduce Future Disease Burden. Clin Infect Dis 2023; 77:1552-1560. [PMID: 37436770 PMCID: PMC10686956 DOI: 10.1093/cid/ciad417] [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: 03/16/2023] [Revised: 06/28/2023] [Accepted: 07/10/2023] [Indexed: 07/13/2023] Open
Abstract
Encephalitis affects people across the lifespan, has high rates of mortality and morbidity, and results in significant neurological sequelae with long-term consequences to quality of life and wider society. The true incidence is currently unknown due to inaccurate reporting systems. The disease burden of encephalitis is unequally distributed across the globe being highest in low- and middle-income countries where resources are limited. Here countries often lack diagnostic testing, with poor access to essential treatments and neurological services, and limited surveillance and vaccination programs. Many types of encephalitis are vaccine preventable, whereas others are treatable with early diagnosis and appropriate management. In this viewpoint, we provide a narrative review of key aspects of diagnosis, surveillance, treatment, and prevention of encephalitis and highlight priorities for public health, clinical management, and research, to reduce the disease burden.
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Affiliation(s)
- Julia Granerod
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, United Kingdom
- Dr JGW Consulting Ltd., London, United Kingdom
| | - Yun Huang
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, United Kingdom
- National Institute for Health and Care Research (NIHR) Health Protection Research Unit for Emerging and Zoonotic Infection, Liverpool, United Kingdom
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | | | | | - Victor Mwapasa
- University of Malawi, College of Medicine, Blantyre, Malawi
| | - Priscilla Rupali
- Department of Infectious Diseases, Christian Medical College Vellore, Vellore, Tamil Nadu, India
| | - Benedict D Michael
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, United Kingdom
- National Institute for Health and Care Research (NIHR) Health Protection Research Unit for Emerging and Zoonotic Infection, Liverpool, United Kingdom
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Tom Solomon
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, United Kingdom
- National Institute for Health and Care Research (NIHR) Health Protection Research Unit for Emerging and Zoonotic Infection, Liverpool, United Kingdom
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
- The Pandemic Institute, Liverpool, United Kingdom
| | - Ava Easton
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, United Kingdom
- The Encephalitis Society, Malton, United Kingdom
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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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Suma R, Netravathi M, Gururaj G, Thomas PT, Singh B, Solomon T, Desai A, Vasanthapuram R, Banandur PS. Profile of Acute Encephalitis Syndrome Patients from South India. J Glob Infect Dis 2023; 15:156-165. [PMID: 38292694 PMCID: PMC10824229 DOI: 10.4103/jgid.jgid_19_23] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 07/18/2023] [Accepted: 08/23/2023] [Indexed: 02/01/2024] Open
Abstract
Introduction Encephalitis is a major public health problem worldwide that causes huge emotional and economic loss to humanity. Encephalitis, being a serious illness, affects people of all ages. The aim is to describe the sociodemographic, clinical, etiological, and neuroimaging profile among 101 acute encephalitis syndrome (AES) patients visiting a tertiary neuro-specialty care hospital in India. Methods Record review of medical records of all patients attending neurology emergency and outpatient services at NIMHANS Hospital, diagnosed with AES in 2019, was conducted. Data were collected using standardized data collection forms for all cases in the study. Descriptive analyses (mean and standard deviation for continuous variables and proportions for categorical variables) were conducted. The Chi-square test/Fisher's exact test was used for the comparison of independent groups for categorical variables, and t-test for comparing means for continuous variables. Results About 42.6% of AES patients had viral etiology, while in 57.4%, etiology was not ascertained. Common presenting symptoms were fever (96%), altered sensorium (64.4%), seizures (70.3%), headache (42.6%), and vomiting (27.7%). Herpes simplex was the most common (21.8%) identified viral encephalitis, followed by chikungunya (5%), arboviruses (chikungunya and dengue) (4%), Japanese encephalitis (4%), rabies (3%), dengue (1%), and varicella virus (1%). About 40% of AES patients showed cerebrospinal fluid pleocytosis (44%), increased protein (39.6%), abnormal computed tomography brain (44.6%), and magnetic resonance imaging abnormalities (41.6%). Conclusion The study highlights the need to ascertain etiology and importance of evidence-based management of AES patients. A better understanding of opportunities and limitations in the management and implementation of standard laboratory and diagnostic algorithms can favor better diagnosis and management of AES.
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Affiliation(s)
- Rache Suma
- Department of Epidemiology NIMHANS, Bengaluru, Karnataka, India
| | - M. Netravathi
- Department of Neurology NIMHANS, Bengaluru, Karnataka, India
| | | | | | - Bhagteshwar Singh
- Clinical Research Fellow, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Tom Solomon
- Health Protection Research Unit in Emerging and Zoonotic Infections, National Institute of Health Research, University of Liverpool, Liverpool, UK
- The Walton Centre, Liverpool, UK
| | - Anita Desai
- Department of Neurovirology NIMHANS, Bengaluru, Karnataka, India
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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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11
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Tamborska AA, Wood GK, Westenberg E, Garcia-Azorin D, Webb G, Schiess N, Netravathi M, Baykan B, Dervaj R, Helbok R, Lant S, Özge A, Padovani A, Saylor D, Schmutzhard E, Easton A, Lilleker JB, Jackson T, Beghi E, Ellul MA, Frontera JA, Pollak T, Nicholson TR, Wood N, Thakur KT, Solomon T, Stark RJ, Winkler AS, Michael BD. Corrigendum to "Global uncertainty in the diagnosis of neurological complications of SARS-CoV-2 infection by both neurologists and non-neurologists: An international inter-observer variability study" [Journal of the Neurological Sciences. 2023 Jun 15;449:120646]. J Neurol Sci 2023; 451:120709. [PMID: 37385027 PMCID: PMC10294702 DOI: 10.1016/j.jns.2023.120709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Affiliation(s)
- A A Tamborska
- 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; Clinical Infection, Microbiology & Immunology, Institute of Infection, Veterinary and Ecological sciences, University of Liverpool, Liverpool, UK; Department of Neurology, Walton Centre NHS Foundation Trust, Liverpool L9 7LJ, UK
| | - G K Wood
- Clinical Infection, Microbiology & Immunology, Institute of Infection, Veterinary and Ecological sciences, University of Liverpool, Liverpool, UK; Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - E Westenberg
- Center for Global Health, Department of Neurology, Faculty of Medicine, Technical University of Munich, Germany
| | - D Garcia-Azorin
- Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - G Webb
- Clinical Infection, Microbiology & Immunology, Institute of Infection, Veterinary and Ecological sciences, University of Liverpool, Liverpool, UK; Department of Neurology, Walton Centre NHS Foundation Trust, Liverpool L9 7LJ, UK
| | - N Schiess
- Brain Health Unit, Mental Health and Substance Use Department, World Health Organization, USA
| | - M Netravathi
- Department of Neurology, National Institute of Mental Health & Neurosciences, Bangalore, India
| | - B Baykan
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology, Istanbul, Turkiye; EMAR Medical Center, Macka Istanbul, Turkiye
| | - R Dervaj
- Department of Neurology, Apollo Specialty Hospital, Bangalore, Karnataka, India
| | - R Helbok
- Department of Neurology, Division Neuro-Critical Care, Medical University Innsbruck, Austria
| | - S Lant
- Clinical Infection, Microbiology & Immunology, Institute of Infection, Veterinary and Ecological sciences, University of Liverpool, Liverpool, UK
| | - A Özge
- Mersin University Medical Faculty, Department of Neurology, Mersin, Turkey
| | - A Padovani
- Clinical and Experimental Sciences Department, Neurology Unit, University and SpedaliCivili, Brescia, Italy
| | - D Saylor
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - E Schmutzhard
- Department of Neurology, Division Neuro-Critical Care, Medical University Innsbruck, Austria
| | - A Easton
- Clinical Infection, Microbiology & Immunology, Institute of Infection, Veterinary and Ecological sciences, University of Liverpool, Liverpool, UK; Encephalitis Society, United Kingdom
| | - J B Lilleker
- Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK; Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - T Jackson
- Institute of Inflammation and Ageing, University of Birmingham, UK; Geriatric Medicine, University Hospitals Birmingham, Birmingham, UK
| | - E Beghi
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - M 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; Clinical Infection, Microbiology & Immunology, Institute of Infection, Veterinary and Ecological sciences, University of Liverpool, Liverpool, UK; Department of Neurology, Walton Centre NHS Foundation Trust, Liverpool L9 7LJ, UK
| | - J A Frontera
- Department of Neurology, New York University Grossman School of Medicine, NY, New York, USA
| | - T Pollak
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - T R Nicholson
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - N Wood
- Department of Clinical and Movement Neurosciences, University College London, UCL Queen Square Institute of Neurology, London, UK
| | - K T Thakur
- Columbia University Irving Medical Center-New York Presbyterian Hospital, NY, New York, USA
| | - T 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; Department of Neurology, Walton Centre NHS Foundation Trust, Liverpool L9 7LJ, UK; The Pandemic Institute, Liverpool, UK
| | - R J Stark
- Department of Neurology, Alfred Hospital, Melbourne, Australia; Department of Neuroscience, Monash University, Melbourne, Australia
| | - A S Winkler
- Center for Global Health, Department of Neurology, Faculty of Medicine, Technical University of Munich, Germany; Centre for Global Health, Institute of Health and Society, Faculty of Medicine, University of Oslo, Norway
| | - B D 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; Clinical Infection, Microbiology & Immunology, Institute of Infection, Veterinary and Ecological sciences, University of Liverpool, Liverpool, UK; Department of Neurology, Walton Centre NHS Foundation Trust, Liverpool L9 7LJ, UK.
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12
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Denaro F, Holmes RK, Sofowora I, Liadi Y, Solomon T, Dike P, Ladow J, Wachira J, Edelstein LR. Neuromorphological Analysis of the Primate Claustrum. Microsc Microanal 2023; 29:2119-2120. [PMID: 37613001 DOI: 10.1093/micmic/ozad067.1098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Affiliation(s)
- Frank Denaro
- Department of Biology Morgan State University, Baltimore, MD, USA
| | - R K Holmes
- Department of Biology Morgan State University, Baltimore, MD, USA
| | - I Sofowora
- Department of Biology Morgan State University, Baltimore, MD, USA
| | - Y Liadi
- Department of Biology Morgan State University, Baltimore, MD, USA
| | - T Solomon
- Department of Biology Morgan State University, Baltimore, MD, USA
| | - P Dike
- Department of Biology Morgan State University, Baltimore, MD, USA
| | - J Ladow
- Department of Biology Morgan State University, Baltimore, MD, USA
| | - J Wachira
- Department of Biology Morgan State University, Baltimore, MD, USA
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13
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Alam AM, Easton A, Nicholson TR, Irani SR, Davies NWS, Solomon T, Michael BD. Encephalitis: diagnosis, management and recent advances in the field of encephalitides. Postgrad Med J 2023; 99:815-825. [PMID: 37490360 DOI: 10.1136/postgradmedj-2022-141812] [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: 04/07/2022] [Accepted: 04/25/2022] [Indexed: 11/03/2022]
Abstract
Encephalitis describes inflammation of the brain parenchyma, typically caused by either an infectious agent or through an autoimmune process which may be postinfectious, paraneoplastic or idiopathic. Patients can present with a combination of fever, alterations in behaviour, personality, cognition and consciousness. They may also exhibit focal neurological deficits, seizures, movement disorders and/or autonomic instability. However, it can sometimes present non-specifically, and this combined with its many causes make it a difficult to manage neurological syndrome. Despite improved treatments in some forms of encephalitides, encephalitis remains a global concern due to its high mortality and morbidity. Prompt diagnosis and administration of specific and supportive management options can lead to better outcomes. Over the last decade, research in encephalitis has led to marked developments in the understanding, diagnosis and management of encephalitis. In parallel, the number of autoimmune encephalitis syndromes has rapidly expanded and clinically characteristic syndromes in association with pathogenic autoantibodies have been defined. By focusing on findings presented at the Encephalitis Society's conference in December 2021, this article reviews the causes, clinical manifestations and management of encephalitis and integrate recent advances and challenges of research into encephalitis.
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Affiliation(s)
- Ali M Alam
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
- NIHR Health Protection Unit for Emerging and Zoonotic Infection, Liverpool, UK
- Department of Clinical Infection, Microbiology, & Immunology, University of Liverpool, Liverpool, UK
| | - Ava Easton
- Department of Clinical Infection, Microbiology, & Immunology, University of Liverpool, Liverpool, UK
- Encephalitis Society, Malton, UK
| | | | - Sarosh R Irani
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Department of Neurology, John Radcliffe Hospital, Oxford, UK
| | | | - Tom Solomon
- NIHR Health Protection Unit for Emerging and Zoonotic Infection, Liverpool, UK
- The Pandemic Institute, Liverpool, UK
| | - Benedict D Michael
- NIHR Health Protection Unit for Emerging and Zoonotic Infection, Liverpool, UK
- Department of Clinical Infection, Microbiology, & Immunology, University of Liverpool, Liverpool, UK
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
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14
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Tamborska AA, Wood GK, Westenberg E, Garcia-Azorin D, Webb G, Schiess N, Netravathi M, Baykan B, Dervaj R, Helbok R, Lant S, Özge A, Padovani A, Saylor D, Schmutzhard E, Easton A, Lilleker JB, Jackson T, Beghi E, Ellul MA, Frontera JA, Pollak T, Nicholson TR, Wood N, Thakur KT, Solomon T, Stark RJ, Winkler AS, Michael BD. Global uncertainty in the diagnosis of neurological complications of SARS-CoV-2 infection by both neurologists and non-neurologists: An international inter-observer variability study. J Neurol Sci 2023; 449:120646. [PMID: 37100018 PMCID: PMC10085971 DOI: 10.1016/j.jns.2023.120646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/26/2023] [Accepted: 04/08/2023] [Indexed: 04/28/2023]
Abstract
INTRODUCTION Uniform case definitions are required to ensure harmonised reporting of neurological syndromes associated with SARS-CoV-2. Moreover, it is unclear how clinicians perceive the relative importance of SARS-CoV-2 in neurological syndromes, which risks under- or over-reporting. METHODS We invited clinicians through global networks, including the World Federation of Neurology, to assess ten anonymised vignettes of SARS-CoV-2 neurological syndromes. Using standardised case definitions, clinicians assigned a diagnosis and ranked association with SARS-CoV-2. We compared diagnostic accuracy and assigned association ranks between different settings and specialties and calculated inter-rater agreement for case definitions as "poor" (κ ≤ 0.4), "moderate" or "good" (κ > 0.6). RESULTS 1265 diagnoses were assigned by 146 participants from 45 countries on six continents. The highest correct proportion were cerebral venous sinus thrombosis (CVST, 95.8%), Guillain-Barré syndrome (GBS, 92.4%) and headache (91.6%) and the lowest encephalitis (72.8%), psychosis (53.8%) and encephalopathy (43.2%). Diagnostic accuracy was similar between neurologists and non-neurologists (median score 8 vs. 7/10, p = 0.1). Good inter-rater agreement was observed for five diagnoses: cranial neuropathy, headache, myelitis, CVST, and GBS and poor agreement for encephalopathy. In 13% of vignettes, clinicians incorrectly assigned lowest association ranks, regardless of setting and specialty. CONCLUSION The case definitions can help with reporting of neurological complications of SARS-CoV-2, also in settings with few neurologists. However, encephalopathy, encephalitis, and psychosis were often misdiagnosed, and clinicians underestimated the association with SARS-CoV-2. Future work should refine the case definitions and provide training if global reporting of neurological syndromes associated with SARS-CoV-2 is to be robust.
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Affiliation(s)
- A A Tamborska
- 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; Clinical Infection, Microbiology & Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK; Department of Neurology, Walton Centre NHS Foundation Trust, Liverpool L9 7LJ, UK
| | - G K Wood
- Clinical Infection, Microbiology & Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK; Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - E Westenberg
- Center for Global Health, Department of Neurology, Faculty of Medicine, Technical University of Munich, Germany
| | - D Garcia-Azorin
- Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - G Webb
- Clinical Infection, Microbiology & Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK; Department of Neurology, Walton Centre NHS Foundation Trust, Liverpool L9 7LJ, UK
| | - N Schiess
- Brain Health Unit, Mental Health and Substance Use Department, World Health Organization, Switzerland
| | - M Netravathi
- Department of Neurology, National Institute of Mental Health & Neurosciences, Bangalore, India
| | - B Baykan
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology, Istanbul, Turkiye; EMAR Medical Center, Macka Istanbul, Turkiye
| | - R Dervaj
- Department of Neurology, Apollo Specialty Hospital, Bangalore, Karnataka, India
| | - R Helbok
- Department of Neurology, Division Neuro-Critical Care, Medical University Innsbruck, Austria
| | - S Lant
- Clinical Infection, Microbiology & Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - A Özge
- Mersin University Medical Faculty, Department of Neurology, Mersin, Turkey
| | - A Padovani
- Clinical and Experimental Sciences Department, Neurology Unit, University and SpedaliCivili, Brescia, Italy
| | - D Saylor
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - E Schmutzhard
- Department of Neurology, Division Neuro-Critical Care, Medical University Innsbruck, Austria
| | - A Easton
- Clinical Infection, Microbiology & Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK; Encephalitis Society, UK
| | - J B Lilleker
- Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK; Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - T Jackson
- Institute of Inflammation and Ageing, University of Birmingham, UK; Geriatric Medicine, University Hospitals Birmingham, Birmingham, UK
| | - E Beghi
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - M 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; Clinical Infection, Microbiology & Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK; Department of Neurology, Walton Centre NHS Foundation Trust, Liverpool L9 7LJ, UK
| | - J A Frontera
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - T Pollak
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - T R Nicholson
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - N Wood
- Department of Clinical and Movement Neurosciences, University College London, UCL Queen Square Institute of Neurology, London, UK
| | - K T Thakur
- Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - T 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; Department of Neurology, Walton Centre NHS Foundation Trust, Liverpool L9 7LJ, UK; The Pandemic Institute, Liverpool, UK
| | - R J Stark
- Department of Neurology, Alfred Hospital, Melbourne, Australia; Department of Neuroscience, Monash University, Melbourne, Australia
| | - A S Winkler
- Center for Global Health, Department of Neurology, Faculty of Medicine, Technical University of Munich, Germany; Centre for Global Health, Institute of Health and Society, Faculty of Medicine, University of Oslo, Norway
| | - B D 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; Clinical Infection, Microbiology & Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK; Department of Neurology, Walton Centre NHS Foundation Trust, Liverpool L9 7LJ, UK.
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15
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Owolabi MO, Leonardi M, Bassetti C, Jaarsma J, Hawrot T, Makanjuola AI, Dhamija RK, Feng W, Straub V, Camaradou J, Dodick DW, Sunna R, Menon B, Wright C, Lynch C, Chadha AS, Ferretti MT, Dé A, Catsman-Berrevoets CE, Gichu M, Tassorelli C, Oliver D, Paulus W, Mohammed RK, Charway-Felli A, Rostasy K, Feigin V, Craven A, Cunningham E, Galvin O, Perry AH, Fink EL, Baneke P, Helme A, Laurson-Doube J, Medina MT, Roa JD, Hogl B, O'Bryan A, Trenkwalder C, Wilmshurst J, Akinyemi RO, Yaria JO, Good DC, Hoemberg V, Boon P, Wiebe S, Cross JH, Haas M, Jabalpurwala I, Mojasevic M, DiLuca M, Barbarino P, Clarke S, Zuberi SM, Olowoyo P, Owolabi A, Oyesiku N, Maly-Sundgren PC, Norrving B, Soekadar SR, van Doorn PA, Lewis R, Solomon T, Servadei F. Global synergistic actions to improve brain health for human development. Nat Rev Neurol 2023; 19:371-383. [PMID: 37208496 PMCID: PMC10197060 DOI: 10.1038/s41582-023-00808-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [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] [Accepted: 03/29/2023] [Indexed: 05/21/2023]
Abstract
The global burden of neurological disorders is substantial and increasing, especially in low-resource settings. The current increased global interest in brain health and its impact on population wellbeing and economic growth, highlighted in the World Health Organization's new Intersectoral Global Action Plan on Epilepsy and other Neurological Disorders 2022-2031, presents an opportunity to rethink the delivery of neurological services. In this Perspective, we highlight the global burden of neurological disorders and propose pragmatic solutions to enhance neurological health, with an emphasis on building global synergies and fostering a 'neurological revolution' across four key pillars - surveillance, prevention, acute care and rehabilitation - termed the neurological quadrangle. Innovative strategies for achieving this transformation include the recognition and promotion of holistic, spiritual and planetary health. These strategies can be deployed through co-design and co-implementation to create equitable and inclusive access to services for the promotion, protection and recovery of neurological health in all human populations across the life course.
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Affiliation(s)
- Mayowa O Owolabi
- Center for Genomic and Precision Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria.
- Neurology Unit, Department of Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria.
- African Stroke Organization, Ibadan, Nigeria.
- World Federation for Neurorehabilitation, North Shields, UK.
- Lebanese American University of Beirut, Beirut, Lebanon.
- Blossom Specialist Medical Center, Ibadan, Nigeria.
| | - Matilde Leonardi
- Neurology, Public Health, Disability Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Claudio Bassetti
- Neurology Department Inselspital - University of Bern, Bern, Switzerland
- European Academy of Neurology, Vienna, Austria
| | - Joke Jaarsma
- European Federation of Neurological Associations, Brussels, Belgium
| | - Tadeusz Hawrot
- European Federation of Neurological Associations, Brussels, Belgium
| | | | | | - Wuwei Feng
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Volker Straub
- John Walton Muscular Dystrophy Research Center, Newcastle University, Newcastle, UK
| | - Jennifer Camaradou
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
- One Neurology Initiative, Brussels, Belgium
| | - David W Dodick
- Department of Neurology, Mayo Clinic, Phoenix, AZ, USA
- Atria Academy of Science and Medicine, New York, NY, USA
- American Brain Foundation, Minneapolis, MN, USA
| | - Rosita Sunna
- Tics and Tourette Across the Globe, Hannover, Germany
- Australian Clinical Psychology Association, Sydney, New South Wales, Australia
| | - Bindu Menon
- Department of Neurology, Apollo Specialty Hospitals, Nellore, India
| | | | - Chris Lynch
- Alzheimer's Disease International, London, UK
| | | | | | - Anna Dé
- Women's Brain Project, Guntershausen, Switzerland
| | - Coriene E Catsman-Berrevoets
- Department of Paediatric Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- European Paediatric Neurology Society, Bolton, UK
| | - Muthoni Gichu
- Department of Non-Communicable Diseases, Ministry of Health, Nairobi, Kenya
- Global Brain Health Institute, San Francisco, CA, USA
| | - Cristina Tassorelli
- Department of Brain and Behavioral Sciences of the University of Pavia, Pavia, Italy
- IRCCS C. Mondino Foundation Neurological Institute, Pavia, Italy
- International Headache Society, London, UK
| | - David Oliver
- University of Kent, Canterbury, UK
- International Neuro-Palliative Care Society, Roseville, MN, USA
| | - Walter Paulus
- Department of Neurology, Ludwig-Maximilians University Munich, Klinikum Großhadern, Munich, Germany
- International Federation of Clinical Neurophysiology, Milwaukee, WI, USA
| | - Ramla K Mohammed
- Amal Neuro Developmental Centres, Gudalur, India
- Al Ameen Educational Trust, Gudalur, India
| | | | - Kevin Rostasy
- European Paediatric Neurology Society, Bolton, UK
- Department of Paediatric Neurology, Children's Hospital Datteln, University Witten/Herdecke, Witten, Germany
| | - Valery Feigin
- National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, Auckland, New Zealand
| | | | | | - Orla Galvin
- European Federation of Neurological Associations, Brussels, Belgium
| | | | - Ericka L Fink
- Department of Paediatric Neurology and Critical Care, University of Pittsburgh Medical Centre Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh Medical Centre Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Peer Baneke
- Multiple Sclerosis International Federation, London, UK
| | - Anne Helme
- Multiple Sclerosis International Federation, London, UK
| | | | - Marco T Medina
- National Autonomous University of Honduras, Tegucigalpa, Honduras
- Pan-American Federation of Neurological Societies, Santiago de Chile, Chile
| | - Juan David Roa
- HOMI Fundacion Hospital Paediatrico la Misericordia, Bogota, Colombia
| | - Birgit Hogl
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- World Sleep Society, Rochester, MN, USA
| | | | - Claudia Trenkwalder
- Paracelsus-Elena Hospital, Kassel, Department of Neurosurgery, University Medical Centre, Goettingen, Germany
| | - Jo Wilmshurst
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital Neuroscience Institute, University of Cape Town, Cape Town, South Africa
- International Child Neurology Association, London, UK
| | - Rufus O Akinyemi
- African Stroke Organization, Ibadan, Nigeria
- Neuroscience and Ageing Research Unit, Institute for Advanced Medical Research and Training, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Joseph O Yaria
- Department of Neurology, University College Hospital, Ibadan, Nigeria
| | - David C Good
- World Federation for Neurorehabilitation, North Shields, UK
- Department of Neurology, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Volker Hoemberg
- World Federation for Neurorehabilitation, North Shields, UK
- SRH Neurorehabilitation Hospital Bad Wimpfen, Bad Wimpfen, Germany
| | - Paul Boon
- European Academy of Neurology, Vienna, Austria
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Samuel Wiebe
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
- International League Against Epilepsy, Flower Mound, TX, USA
| | - J Helen Cross
- International League Against Epilepsy, Flower Mound, TX, USA
- Clinical Neurosciences Section, UCL Institute of Child Health, University College London, London, UK
| | - Magali Haas
- Cohen Veterans Bioscience, New York, NY, USA
| | | | | | - Monica DiLuca
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
- European Brain Council, Brussels, Belgium
| | | | - Stephanie Clarke
- World Federation for Neurorehabilitation, North Shields, UK
- Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Sameer M Zuberi
- European Paediatric Neurology Society, Bolton, UK
- Paediatric Neurosciences Research Group, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Paul Olowoyo
- Department of Medicine, Afe Babalola University, Ado-Ekiti, Nigeria
- Federal Teaching Hospital, Ido-Ekiti, Nigeria
| | | | - Nelson Oyesiku
- Department of Neurosurgery, University of North Carolina at Chapel Hill, North Carolina, NC, USA
- World Federation of Neurosurgical Societies, Prague, Czech Republic
| | - Pia C Maly-Sundgren
- Department of Clinical Sciences/Diagnostic Radiology, Lund University, Lund, Sweden
| | - Bo Norrving
- Department of Clinical Sciences/Neurology, Lund University, Lund, Sweden
| | - Surjo R Soekadar
- Clinical Neurotechnology Laboratory, Department of Psychiatry and Neurosciences, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Pieter A van Doorn
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Peripheral Nerve Society, Roseville, MN, USA
| | - Richard Lewis
- Peripheral Nerve Society, Roseville, MN, USA
- Department of Neurology, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Tom Solomon
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
- Encephalitis Society, Malton, North Yorkshire, UK
| | - Franco Servadei
- World Federation of Neurosurgical Societies, Prague, Czech Republic
- Department of Neurosurgery, Humanitas Clinical and Research Center - IRCCS, Humanitas University, Milan, Italy
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16
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Piamonte BLC, Easton A, Wood GK, Davies NWS, Granerod J, Michael BD, Solomon T, Thakur KT. Addressing vaccine-preventable encephalitis in vulnerable populations. Curr Opin Neurol 2023; 36:185-197. [PMID: 37078664 DOI: 10.1097/wco.0000000000001158] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
PURPOSE OF REVIEW Vaccinations have been pivotal in lowering the global disease burden of vaccine-preventable encephalitides, including Japanese encephalitis, tick-borne encephalitis, measles encephalitis, and rabies encephalitis, among others. RECENT FINDINGS Populations vulnerable to vaccine-preventable infections that may lead to encephalitis include those living in endemic and rural areas, military members, migrants, refugees, international travelers, younger and older persons, pregnant women, the immunocompromised, outdoor, healthcare and laboratory workers, and the homeless. There is scope for improving the availability and distribution of vaccinations, vaccine equity, surveillance of vaccine-preventable encephalitides, and public education and information. SUMMARY Addressing these gaps in vaccination strategies will allow for improved vaccination coverage and lead to better health outcomes for those most at risk for vaccine-preventable encephalitis.
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Affiliation(s)
- Bernadeth Lyn C Piamonte
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Ava Easton
- The Encephalitis Society, Malton
- Department of Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences
| | - Greta K Wood
- Department of Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences
- National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infection, University of Liverpool, Liverpool
| | - Nicholas W S Davies
- The Encephalitis Society, Malton
- Department of Neurology, Chelsea and Westminster Hospital, NHS Trust
| | - Julia Granerod
- Department of Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences
- Dr JGW Consulting Ltd., London
| | - Benedict D Michael
- The Encephalitis Society, Malton
- Department of Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences
- National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infection, University of Liverpool, Liverpool
- Department of Neurology, The Walton Centre NHS Foundation Trust
| | - Tom Solomon
- The Encephalitis Society, Malton
- Department of Clinical Infection, Microbiology, and Immunology, Institute of Infection, Veterinary and Ecological Sciences
- National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infection, University of Liverpool, Liverpool
- Department of Neurology, The Walton Centre NHS Foundation Trust
- Department of Neurological Science, University of Liverpool, Liverpool, United Kingdom
| | - Kiran T Thakur
- The Encephalitis Society, Malton
- Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, USA
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17
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Abstract
Japanese encephalitis (JE) is becoming an increasingly important issue among adults. The reasons for this are multifactorial. During the past decades, new areas of Japanese encephalitis virus (JEV) transmission have occurred in several locations, most notably in a markedly expanded area of Australia during 2021-2022. When JEV enters new areas, cases in adults frequently occur. This is unlike the typical pattern in endemic areas where the burden of disease is in children because most adults are protected through natural immunity following earlier exposure to the virus. Even in endemic areas, JEV has become relatively more important in adults because improved JE control through childhood immunization programs has resulted in a substantial decrease in pediatric JE cases and thus more prominence of adult JE cases. Finally, increases in tourism to JE risk areas have resulted in more exposure of adult travelers, who are usually non-immune, to infection in JE risk areas. In this review we describe the increasing importance of JE in adults in some areas and then consider the comparative clinical presentation and severity of illness among children and adults.
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Affiliation(s)
- Susan L. Hills
- Arboviral Diseases Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado
| | - M. Netravathi
- Department of Neurology, National Institute of Mental Health & Neurosciences, Bangalore, India
| | - Tom Solomon
- The Pandemic Institute and The National Institute for Health and Care Research (NIHR) Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, United Kingdom
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18
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Cho SM, White N, Premraj L, Battaglini D, Fanning J, Suen J, Bassi GL, Fraser J, Robba C, Griffee M, Singh B, Citarella ;W, Merson L, Solomon T, Thomson D. Neurological manifestations of COVID-19 in adults and children. Brain 2023; 146:1648-1661. [PMID: 36087305 PMCID: PMC9494397 DOI: 10.1093/brain/awac332] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [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: 05/30/2022] [Revised: 07/23/2022] [Accepted: 08/22/2022] [Indexed: 11/16/2022] Open
Abstract
Different neurological manifestations of coronavirus disease 2019 (COVID-19) in adults and children and their impact have not been well characterized. We aimed to determine the prevalence of neurological manifestations and in-hospital complications among hospitalized COVID-19 patients and ascertain differences between adults and children. We conducted a prospective multicentre observational study using the International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) cohort across 1507 sites worldwide from 30 January 2020 to 25 May 2021. Analyses of neurological manifestations and neurological complications considered unadjusted prevalence estimates for predefined patient subgroups, and adjusted estimates as a function of patient age and time of hospitalization using generalized linear models. Overall, 161 239 patients (158 267 adults; 2972 children) hospitalized with COVID-19 and assessed for neurological manifestations and complications were included. In adults and children, the most frequent neurological manifestations at admission were fatigue (adults: 37.4%; children: 20.4%), altered consciousness (20.9%; 6.8%), myalgia (16.9%; 7.6%), dysgeusia (7.4%; 1.9%), anosmia (6.0%; 2.2%) and seizure (1.1%; 5.2%). In adults, the most frequent in-hospital neurological complications were stroke (1.5%), seizure (1%) and CNS infection (0.2%). Each occurred more frequently in intensive care unit (ICU) than in non-ICU patients. In children, seizure was the only neurological complication to occur more frequently in ICU versus non-ICU (7.1% versus 2.3%, P < 0.001). Stroke prevalence increased with increasing age, while CNS infection and seizure steadily decreased with age. There was a dramatic decrease in stroke over time during the pandemic. Hypertension, chronic neurological disease and the use of extracorporeal membrane oxygenation were associated with increased risk of stroke. Altered consciousness was associated with CNS infection, seizure and stroke. All in-hospital neurological complications were associated with increased odds of death. The likelihood of death rose with increasing age, especially after 25 years of age. In conclusion, adults and children have different neurological manifestations and in-hospital complications associated with COVID-19. Stroke risk increased with increasing age, while CNS infection and seizure risk decreased with age.
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Affiliation(s)
- Sung-Min Cho
- Neuroscience Critical Care Division, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- International Severe Acute Respiratory and emerging Infections Consortium (ISARIC), Pandemic Sciences Institute, University of Oxford, Oxford, UK
| | - Nicole White
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health & Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Lavienraj Premraj
- Griffith University School of Medicine, Gold Coast, Queensland, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Denise Battaglini
- San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Department of Surgical Science and Integrated Diagnostic, University of Genoa, Genoa, Italy
- Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Jonathon Fanning
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine University of Queensland, Brisbane, Queensland, Australia
| | - Jacky Suen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine University of Queensland, Brisbane, Queensland, Australia
| | - Gianluigi Li Bassi
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health & Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine University of Queensland, Brisbane, Queensland, Australia
- Institut d'Investigacions Biomediques August Pi I Sunyer, Barcelona, Spain
| | - John Fraser
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health & Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine University of Queensland, Brisbane, Queensland, Australia
- St Andrew's War Memorial Hospital, UnitingCare, Spring Hill, Queensland, Australia
| | - Chiara Robba
- San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Department of Surgical Science and Integrated Diagnostic, University of Genoa, Genoa, Italy
| | - Matthew Griffee
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - 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
| | - ;?>Barbara Wanjiru Citarella
- International Severe Acute Respiratory and emerging Infections Consortium (ISARIC), Pandemic Sciences Institute, University of Oxford, Oxford, UK
| | - Laura Merson
- International Severe Acute Respiratory and emerging Infections Consortium (ISARIC), Pandemic Sciences Institute, University of Oxford, Oxford, UK
| | - Tom Solomon
- Brain Infections Group, Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
- Department of Neuroscience, University of Liverpool, Liverpool, UK
- Walton Centre NHS Foundation Trust, Liverpool, UK
| | - David Thomson
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Division of General Surgery, Groote Schuur Hospital, Cape Town, South Africa
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19
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Alam AM, Easton A, Nicholson TR, Irani SR, Davies NWS, Solomon T, Michael BD. Encephalitis: diagnosis, management and recent advances in the field of encephalitides. Postgrad Med J 2023:7111273. [PMID: 37036001 DOI: 10.1136/postmj/postgradmedj-2022-141812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 04/25/2022] [Indexed: 04/11/2023]
Abstract
Encephalitis describes inflammation of the brain parenchyma, typically caused by either an infectious agent or through an autoimmune process which may be postinfectious, paraneoplastic or idiopathic. Patients can present with a combination of fever, alterations in behaviour, personality, cognition and consciousness. They may also exhibit focal neurological deficits, seizures, movement disorders and/or autonomic instability. However, it can sometimes present non-specifically, and this combined with its many causes make it a difficult to manage neurological syndrome. Despite improved treatments in some forms of encephalitides, encephalitis remains a global concern due to its high mortality and morbidity. Prompt diagnosis and administration of specific and supportive management options can lead to better outcomes. Over the last decade, research in encephalitis has led to marked developments in the understanding, diagnosis and management of encephalitis. In parallel, the number of autoimmune encephalitis syndromes has rapidly expanded and clinically characteristic syndromes in association with pathogenic autoantibodies have been defined. By focusing on findings presented at the Encephalitis Society's conference in December 2021, this article reviews the causes, clinical manifestations and management of encephalitis and integrate recent advances and challenges of research into encephalitis.
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Affiliation(s)
- Ali M Alam
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
- NIHR Health Protection Unit for Emerging and Zoonotic Infection, Liverpool, UK
- Department of Clinical Infection, Microbiology, & Immunology, University of Liverpool, Liverpool, UK
| | - Ava Easton
- Department of Clinical Infection, Microbiology, & Immunology, University of Liverpool, Liverpool, UK
- Encephalitis Society, Malton, UK
| | | | - Sarosh R Irani
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Department of Neurology, John Radcliffe Hospital, Oxford, UK
| | | | - Tom Solomon
- NIHR Health Protection Unit for Emerging and Zoonotic Infection, Liverpool, UK
- The Pandemic Institute, Liverpool, UK
| | - Benedict D Michael
- NIHR Health Protection Unit for Emerging and Zoonotic Infection, Liverpool, UK
- Department of Clinical Infection, Microbiology, & Immunology, University of Liverpool, Liverpool, UK
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
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20
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Ratcliffe C, Adan G, Marson A, Solomon T, Saini J, Sinha S, Keller SS. Neurocysticercosis-related Seizures: Imaging Biomarkers. Seizure 2023; 108:13-23. [PMID: 37060627 DOI: 10.1016/j.seizure.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/31/2023] [Accepted: 04/04/2023] [Indexed: 04/08/2023] Open
Abstract
Neurocysticercosis (NCC)-a parasitic CNS infection endemic to developing nations-has been called the leading global cause of acquired epilepsy yet remains understudied. It is currently unknown why a large proportion of patients develop recurrent seizures, often following the presentation of acute seizures. Furthermore, the presentation of NCC is heterogenous and the features that predispose to the development of an epileptogenic state remain uncertain. Perilesional factors (such as oedema and gliosis) have been implicated in NCC-related ictogenesis, but the effects of cystic factors, including lesion load and location, seem not to play a role in the development of habitual epilepsy. In addition, the cytotoxic consequences of the cyst's degenerative stages are varied and the majority of research, relying on retrospective data, lacks the necessary specificity to distinguish between acute symptomatic and unprovoked seizures. Previous research has established that epileptogenesis can be the consequence of abnormal network connectivity, and some imaging studies have suggested that a causative link may exist between NCC and aberrant network organisation. In wider epilepsy research, network approaches have been widely adopted; studies benefiting predominantly from the rich, multimodal data provided by advanced MRI methods are at the forefront of the field. Quantitative MRI approaches have the potential to elucidate the lesser-understood epileptogenic mechanisms of NCC. This review will summarise the current understanding of the relationship between NCC and epilepsy, with a focus on MRI methodologies. In addition, network neuroscience approaches with putative value will be highlighted, drawing from current imaging trends in epilepsy research.
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Affiliation(s)
- Corey Ratcliffe
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool, UK; Department of Neuro Imaging and Interventional Radiology, National Institute of Mental Health and Neuro Sciences, Bangalore, India.
| | - Guleed Adan
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool, UK; The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Anthony Marson
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Tom Solomon
- The Walton Centre NHS Foundation Trust, Liverpool, UK; Veterinary and Ecological Sciences, National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, University of Liverpool, Liverpool, UK; Tropical and Infectious Diseases Unit, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Jitender Saini
- Department of Neuro Imaging and Interventional Radiology, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Sanjib Sinha
- Department of Neurology, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Simon S Keller
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool, UK; The Walton Centre NHS Foundation Trust, Liverpool, UK
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21
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Damodar T, Singh B, Prabhu N, Marate S, Gowda VK, Lalitha AV, Dsouza FS, Sajjan SV, Kariyappa M, Kinhal UV, Prathyusha PV, Desai A, Thennarasu K, Solomon T, Ravi V, Yadav R. Association of Scrub Typhus in Children with Acute Encephalitis Syndrome and Meningoencephalitis, Southern India. Emerg Infect Dis 2023; 29:711-722. [PMID: 36957990 PMCID: PMC10045701 DOI: 10.3201/eid2904.221157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023] Open
Abstract
Scrub typhus is an established cause of acute encephalitis syndrome (AES) in northern states of India. We systematically investigated 376 children with AES in southern India, using a stepwise diagnostic strategy for the causative agent of scrub typhus, Orientia tsutsugamushi, including IgM and PCR testing of blood and cerebrospinal fluid (CSF) to grade its association with AES. We diagnosed scrub typhus in 87 (23%) children; of those, association with AES was confirmed in 16 (18%) cases, probable in 55 (63%), and possible in 16 (18%). IgM detection in CSF had a sensitivity of 93% and specificity of 82% compared with PCR. Our findings suggest scrub typhus as an emerging common treatable cause of AES in children in southern India and highlight the importance of routine testing for scrub typhus in diagnostic algorithms. Our results also suggest the potential promise of IgM screening of CSF for diagnosis of AES resulting from scrub typhus.
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22
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Kachingwe G, Carletti F, Adan G, Jäger H, Henrion M, Kampondeni S, Joekes E, Chetcuti K, Swayne O, Heyderman R, Allain T, Mwandumba H, Solomon T, Werring D, Benjamin L. CLINICAL AND RADIOLOGICAL CHARACTERISTICS OF HIV-ASSOCIATED INTRACEREBRAL HAEMORRHAGE IN MALAWI. J Stroke Cerebrovasc Dis 2023. [DOI: 10.1016/j.jstrokecerebrovasdis.2023.107009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023] Open
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23
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Michael BD, Walton D, Westenberg E, García-Azorín D, Singh B, Tamborska AA, Netravathi M, Chomba M, Wood GK, Easton A, Siddiqi OK, Jackson TA, Pollak TA, Nicholson TR, Nair S, Breen G, Prasad K, Thakur KT, Chou SHY, Schmutzhard E, Frontera JA, Helbok R, Padovani A, Menon DK, Solomon T, Winkler AS. Consensus Clinical Guidance for Diagnosis and Management of Adult COVID-19 Encephalopathy Patients. J Neuropsychiatry Clin Neurosci 2023; 35:12-27. [PMID: 35872617 DOI: 10.1176/appi.neuropsych.22010002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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] [Indexed: 01/17/2023]
Abstract
Encephalopathy, a common condition among patients hospitalized with COVID-19, can be a challenge to manage and negatively affect prognosis. While encephalopathy may present clinically as delirium, subsyndromal delirium, or coma and may be a result of systemic causes such as hypoxia, COVID-19 has also been associated with more prolonged encephalopathy due to less common but nevertheless severe complications, such as inflammation of the brain parenchyma (with or without cerebrovascular involvement), demyelination, or seizures, which may be disproportionate to COVID-19 severity and require specific management. Given the large number of patients hospitalized with severe acute respiratory syndrome coronavirus-2 infection, even these relatively unlikely complications are increasingly recognized and are particularly important because they require specific management. Therefore, the aim of this review is to provide pragmatic guidance on the management of COVID-19 encephalopathy through consensus agreement of the Global COVID-19 Neuro Research Coalition. A systematic literature search of MEDLINE, medRxiv, and bioRxiv was conducted between January 1, 2020, and June 21, 2021, with additional review of references cited within the identified bibliographies. A modified Delphi approach was then undertaken to develop recommendations, along with a parallel approach to score the strength of both the recommendations and the supporting evidence. This review presents analysis of contemporaneous evidence for the definition, epidemiology, and pathophysiology of COVID-19 encephalopathy and practical guidance for clinical assessment, investigation, and both acute and long-term management.
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Affiliation(s)
- Benedict D Michael
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Dean Walton
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Erica Westenberg
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - David García-Azorín
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Bhagteshwar Singh
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Arina A Tamborska
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - M Netravathi
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Mashina Chomba
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Greta K Wood
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Ava Easton
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Omar K Siddiqi
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Thomas A Jackson
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Thomas A Pollak
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Timothy R Nicholson
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Shalini Nair
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Gerome Breen
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Kameshwar Prasad
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Kiran T Thakur
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Sherry H-Y Chou
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Erich Schmutzhard
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Jennifer A Frontera
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Raimund Helbok
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Alessandro Padovani
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - David K Menon
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Tom Solomon
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Andrea S Winkler
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | -
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
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24
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Alam AM, Chen JPK, Wood GK, Facer B, Bhojak M, Das K, Defres S, Marson A, Granerod J, Brown D, Thomas RH, Keller SS, Solomon T, Michael BD. Correction: Increased volume of cerebral oedema is associated with risk of acute seizure activity and adverse neurological outcomes in encephalitis - regional and volumetric analysis in a multi-centre cohort. BMC Neurol 2022; 22:451. [PMID: 36464705 PMCID: PMC9721044 DOI: 10.1186/s12883-022-02995-6] [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: 12/11/2022] Open
Affiliation(s)
- Ali M. Alam
- grid.10025.360000 0004 1936 8470Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, UK ,The NIHR Health Protection Research Unit for Emerging and Zoonotic Infection, Liverpool, UK
| | - Jian P. K. Chen
- grid.139534.90000 0001 0372 5777Barts Health NHS Trust, London, UK
| | - Greta K. Wood
- grid.10025.360000 0004 1936 8470Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, UK ,The NIHR Health Protection Research Unit for Emerging and Zoonotic Infection, Liverpool, UK
| | - Bethany Facer
- grid.10025.360000 0004 1936 8470Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Maneesh Bhojak
- grid.416928.00000 0004 0496 3293Department of Neuroradiology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Kumar Das
- grid.416928.00000 0004 0496 3293Department of Neuroradiology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Sylviane Defres
- grid.10025.360000 0004 1936 8470Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, UK ,The NIHR Health Protection Research Unit for Emerging and Zoonotic Infection, Liverpool, UK ,grid.10025.360000 0004 1936 8470Tropical and Infectious Diseases Unit, Liverpool University Hospitals NHS Trust, Liverpool, UK
| | - Anthony Marson
- grid.10025.360000 0004 1936 8470Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK ,grid.416928.00000 0004 0496 3293Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Julia Granerod
- grid.271308.f0000 0004 5909 016XIndependent Scientific Consultant, formerly of Public Health England, London, UK
| | - David Brown
- UK Heath Security Agency, 61 Colindale Avenue, London, UK
| | - Rhys H. Thomas
- grid.1006.70000 0001 0462 7212Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Simon S. Keller
- grid.10025.360000 0004 1936 8470Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Tom Solomon
- grid.10025.360000 0004 1936 8470Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, UK ,The NIHR Health Protection Research Unit for Emerging and Zoonotic Infection, Liverpool, UK ,grid.416928.00000 0004 0496 3293Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Benedict D. Michael
- grid.10025.360000 0004 1936 8470Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, UK ,The NIHR Health Protection Research Unit for Emerging and Zoonotic Infection, Liverpool, UK ,grid.416928.00000 0004 0496 3293Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
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Wood GK, Thakur KT, Bharambe V, Chomba M, García-Azorín D, Prasad K, Souza MNP, Chou SHY, Giraldo JDR, Fink E, Hoo FK, Siddiqi OK, Solomon T, Winkler AS, Michael BD. The global brain health clinical exchange platform: Translating concepts to collaborations. J Neurol Sci 2022; 442:120447. [PMID: 36257124 DOI: 10.1016/j.jns.2022.120447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 09/27/2022] [Indexed: 10/31/2022]
Affiliation(s)
- Greta K Wood
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, UK
| | - Kiran T Thakur
- Department of Neurology, Columbia University Irving Medical Center-New York Presbyterian Hospital, NY, New York, USA
| | - Viraj Bharambe
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Mashina Chomba
- University Teaching Hospital - Adult Hospital, Lusaka, Zambia
| | - David García-Azorín
- Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Kameshwar Prasad
- Rajendra Institute of Medical Sciences, Ranchi 834009, Jharkhand, India
| | | | - Sherry Hsiang-Yi Chou
- Department of Neurology, Northwestern Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, IL 60611, United States
| | - Juan David Roa Giraldo
- Universidad Nacional de Colombia - La Fundación, Universitaria de Ciencias de la Salud, Bogotá, Colombia
| | - Ericka Fink
- Critical Care Medicine and Paediatrics, Dept of Critical Medicine, University of Pittsburgh, USA
| | - Fan Kee Hoo
- Department of Neurology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Omar K Siddiqi
- Global Neurology Program, Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Tom Solomon
- The Pandemic Institute and NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, UK
| | - Andrea S Winkler
- Department of Neurology, Center for Global Health, Technical University of Munich, Germany
| | - Benedict D Michael
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, UK.
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26
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Alam AM, Chen JPK, Wood GK, Facer B, Bhojak M, Das K, Defres S, Marson A, Granerod J, Brown D, Thomas RH, Keller SS, Solomon T, Michael BD. Increased volume of cerebral oedema is associated with risk of acute seizure activity and adverse neurological outcomes in encephalitis - regional and volumetric analysis in a multi-centre cohort. BMC Neurol 2022; 22:412. [PMID: 36344954 PMCID: PMC9639313 DOI: 10.1186/s12883-022-02926-5] [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: 07/22/2022] [Accepted: 10/17/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Seizures can occur unpredictably in patients with acute encephalitis syndrome (AES), and many suffer from poor long-term neurological sequelae. Establishing factors associated with acute seizures risk and poor outcomes could support clinical care. We aimed to conduct regional and volumetric analysis of cerebral oedema on magnetic resonance imaging (MRI) in patients with AES. We assessed the relationship of brain oedema with acute seizure activity and long-term neurological outcome. METHODS In a multi-centre cohort study, adults and children presenting with an AES were recruited in the UK. The clinical and brain MRI data were retrospectively reviewed. The outcomes variables were inpatient acute seizure activity and neurological disability at six-months post-discharge. A poor outcome was defined as a Glasgow outcome score (GOS) of 1-3. We quantified regional brain oedema on MRI through stereological examination of T2-weighted images using established methodology by independent and blinded assessors. Clinical and neuroimaging variables were analysed by multivariate logistic regression to assess for correlation with acute seizure activity and outcome. RESULTS The study cohort comprised 69 patients (mean age 31.8 years; 53.6% female), of whom 41 (59.4%) had acute seizures as inpatients. A higher Glasgow coma scale (GCS) score on admission was a negative predictor of seizures (OR 0.61 [0.46-0.83], p = 0.001). Even correcting for GCS on admission, the presence of cortical oedema was a significant risk factor for acute seizure activity (OR 5.48 [1.62-18.51], p = 0.006) and greater volume of cerebral oedema in these cortical structures increased the risk of acute seizures (OR 1.90 [1.12-3.21], p = 0.017). At six-month post-discharge, 21 (30.4%) had a poor neurological outcome. Herpes simplex virus encephalitis was associated with higher risk of poor outcomes in univariate analysis (OR 3.92 [1.08-14.20], p = 0.038). When controlling for aetiology, increased volume of cerebral oedema was an independent risk factor for adverse neurological outcome at 6 months (OR 1.73 [1.06-2.83], p = 0.027). CONCLUSIONS Both the presence and degree of cerebral oedema on MRIs of patients with AES may help identify patients at risk of acute seizure activity and subsequent long-term morbidity.
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Affiliation(s)
- Ali M Alam
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, UK
- The NIHR Health Protection Research Unit for Emerging and Zoonotic Infection, Liverpool, UK
| | | | - Greta K Wood
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, UK
- The NIHR Health Protection Research Unit for Emerging and Zoonotic Infection, Liverpool, UK
| | - Bethany Facer
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Maneesh Bhojak
- Department of Neuroradiology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Kumar Das
- Department of Neuroradiology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Sylviane Defres
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, UK
- The NIHR Health Protection Research Unit for Emerging and Zoonotic Infection, Liverpool, UK
- Tropical and Infectious Diseases Unit, Liverpool University Hospitals NHS Trust, Liverpool, UK
| | - Anthony Marson
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Julia Granerod
- Independent Scientific Consultant, formerly of Public Health England, London, UK
| | - David Brown
- UK Heath Security Agency, 61 Colindale Avenue, London, UK
| | - Rhys H Thomas
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Simon S Keller
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Tom Solomon
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, UK
- The NIHR Health Protection Research Unit for Emerging and Zoonotic Infection, Liverpool, UK
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Benedict D Michael
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, UK.
- The NIHR Health Protection Research Unit for Emerging and Zoonotic Infection, Liverpool, UK.
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK.
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27
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Alam AM, Gillespie CS, Goodall J, Damodar T, Turtle L, Vasanthapuram R, Solomon T, Michael BD. Neurological manifestations of scrub typhus infection: A systematic review and meta-analysis of clinical features and case fatality. PLoS Negl Trop Dis 2022; 16:e0010952. [PMID: 36441812 PMCID: PMC9731453 DOI: 10.1371/journal.pntd.0010952] [Citation(s) in RCA: 4] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 12/08/2022] [Accepted: 11/07/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Scrub typhus has become a leading cause of central nervous system (CNS) infection in endemic regions. As a treatable condition, prompt recognition is vital. However, few studies have focused on describing the symptomology and outcomes of neurological scrub typhus infection. We conducted a systematic review and meta-analysis to report the clinical features and case fatality ratio (CFR) in patients with CNS scrub typhus infection. METHODS A search and analysis plan was published in PROSPERO [ID 328732]. A systematic search of PubMed and Scopus was performed and studies describing patients with CNS manifestations of proven scrub typhus infection were included. The outcomes studied were weighted pooled prevalence (WPP) of clinical features during illness and weighted CFR. RESULTS Nineteen studies with 1,221 (656 adults and 565 paediatric) patients were included. The most common clinical features in CNS scrub typhus were those consistent with non-specific acute encephalitis syndromes (AES), such as fever (WPP 100.0% [99.5%-100.0%, I2 = 47.8%]), altered sensorium (67.4% [54.9-78.8%, I2 = 93.3%]), headache (65.0% [51.5-77.6%, I2 = 95.1%]) and neck stiffness 56.6% (29.4-80.4%, I2 = 96.3%). Classical features of scrub typhus were infrequently identified; an eschar was found in only 20.8% (9.8%-34.3%, I2 = 95.4%) and lymphadenopathy in 24.1% (95% CI 11.8% - 38.9%, I2 = 87.8%). The pooled CFR (95% CI) was 3.6% (1.5%- 6.4%, I2 = 67.3%). Paediatric cohorts had a CFR of 6.1% (1.9-12.1%, I2 = 77%) whilst adult cohorts reported 2.6% (0.7-5.3%, I2 = 43%). CONCLUSION Our meta-analyses illustrate that 3.6% of patients with CNS manifestations of scrub typhus die. Clinicians should have a high index of suspicion for scrub typhus in patients presenting with AES in endemic regions and consider starting empiric treatment whilst awaiting results of investigations, even in the absence of classical signs such as an eschar or lymphadenopathy.
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Affiliation(s)
- Ali M. Alam
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, United Kingdom
- Barts Health NHS Trust, London, United Kingdom
| | - Conor S. Gillespie
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Jack Goodall
- Tropical & Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Tina Damodar
- Department of Neurovirology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Lance Turtle
- Tropical & Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
- The Pandemic Institute, Liverpool, United Kingdom
- The NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, Liverpool, United Kingdom
| | - Ravi Vasanthapuram
- Department of Neurovirology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Tom Solomon
- The Pandemic Institute, Liverpool, United Kingdom
- The NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, Liverpool, United Kingdom
| | - Benedict D. Michael
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, United Kingdom
- The NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, Liverpool, United Kingdom
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
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Wood GK, Babar R, Ellul MA, Thomas RH, Van Den Tooren H, Easton A, Tharmaratnam K, Burnside G, Alam AM, Castell H, Boardman S, Collie C, Facer B, Dunai C, Defres S, Granerod J, Brown DWG, Vincent A, Marson AG, Irani SR, Solomon T, Michael BD. Acute seizure risk in patients with encephalitis: development and validation of clinical prediction models from two independent prospective multicentre cohorts. BMJ Neurol Open 2022; 4:e000323. [PMID: 36110928 PMCID: PMC9445799 DOI: 10.1136/bmjno-2022-000323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/23/2022] [Indexed: 11/10/2022] Open
Abstract
Objective In patients with encephalitis, the development of acute symptomatic seizures is highly variable, but when present is associated with a worse outcome. We aimed to determine the factors associated with seizures in encephalitis and develop a clinical prediction model. Methods We analysed 203 patients from 24 English hospitals (2005-2008) (Cohort 1). Outcome measures were seizures prior to and during admission, inpatient seizures and status epilepticus. A binary logistic regression risk model was converted to a clinical score and independently validated on an additional 233 patients from 31 UK hospitals (2013-2016) (Cohort 2). Results In Cohort 1, 121 (60%) patients had a seizure including 103 (51%) with inpatient seizures. Admission Glasgow Coma Scale (GCS) ≤8/15 was predictive of subsequent inpatient seizures (OR (95% CI) 5.55 (2.10 to 14.64), p<0.001), including in those without a history of prior seizures at presentation (OR 6.57 (95% CI 1.37 to 31.5), p=0.025).A clinical model of overall seizure risk identified admission GCS along with aetiology (autoantibody-associated OR 11.99 (95% CI 2.09 to 68.86) and Herpes simplex virus 3.58 (95% CI 1.06 to 12.12)) (area under receiver operating characteristics curve (AUROC) =0.75 (95% CI 0.701 to 0.848), p<0.001). The same model was externally validated in Cohort 2 (AUROC=0.744 (95% CI 0.677 to 0.811), p<0.001). A clinical scoring system for stratifying inpatient seizure risk by decile demonstrated good discrimination using variables available on admission; age, GCS and fever (AUROC=0.716 (95% CI 0.634 to 0.798), p<0.001) and once probable aetiology established (AUROC=0.761 (95% CI 0.6840.839), p<0.001). Conclusion Age, GCS, fever and aetiology can effectively stratify acute seizure risk in patients with encephalitis. These findings can support the development of targeted interventions and aid clinical trial design for antiseizure medication prophylaxis.
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Affiliation(s)
- Greta K Wood
- Institute of Infection, Veterinary, and Ecological Science, University of Liverpool Department of Clinical Infection Microbiology and Immunology, Liverpool, UK
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, UK
| | - Roshan Babar
- Institute of Infection, Veterinary, and Ecological Science, University of Liverpool Department of Clinical Infection Microbiology and Immunology, Liverpool, UK
| | - Mark A Ellul
- Institute of Infection, Veterinary, and Ecological Science, University of Liverpool Department of Clinical Infection Microbiology and Immunology, Liverpool, UK
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Rhys Huw Thomas
- Faculty of Medical Sciences, Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
- Neurosciences, Royal Victoria Infirmary, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Harriet Van Den Tooren
- Institute of Infection, Veterinary, and Ecological Science, University of Liverpool Department of Clinical Infection Microbiology and Immunology, Liverpool, UK
| | - Ava Easton
- Encephalitis Society, Malton, UK
- University of Liverpool Department of Clinical Infection Microbiology and Immunology, Liverpool, UK
| | - Kukatharmini Tharmaratnam
- Department of Health Data Science, University of Liverpool Faculty of Health and Life Sciences, Liverpool, UK
| | - Girvan Burnside
- Department of Health Data Science, University of Liverpool Faculty of Health and Life Sciences, Liverpool, UK
| | - Ali M Alam
- Institute of Infection, Veterinary, and Ecological Science, University of Liverpool Department of Clinical Infection Microbiology and Immunology, Liverpool, UK
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, UK
| | - Hannah Castell
- Institute of Infection, Veterinary, and Ecological Science, University of Liverpool Department of Clinical Infection Microbiology and Immunology, Liverpool, UK
- Institute of Infection, Veterinary, and Ecological Science, NIHR Health Protection Research Unit in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, UK
| | - Sarah Boardman
- Institute of Infection, Veterinary, and Ecological Science, University of Liverpool Department of Clinical Infection Microbiology and Immunology, Liverpool, UK
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, UK
| | - Ceryce Collie
- Institute of Infection, Veterinary, and Ecological Science, University of Liverpool Department of Clinical Infection Microbiology and Immunology, Liverpool, UK
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, UK
| | - Bethany Facer
- Institute of Infection, Veterinary, and Ecological Science, University of Liverpool Department of Clinical Infection Microbiology and Immunology, Liverpool, UK
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, UK
| | - Cordelia Dunai
- Institute of Infection, Veterinary, and Ecological Science, University of Liverpool Department of Clinical Infection Microbiology and Immunology, Liverpool, UK
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, UK
| | - Sylviane Defres
- Institute of Infection, Veterinary, and Ecological Science, University of Liverpool Department of Clinical Infection Microbiology and Immunology, Liverpool, UK
- Tropical and Infectious Diseases Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | | | - David W G Brown
- Virus Reference Department, UK Health Security Agency, London, UK
| | - Angela Vincent
- Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, UK
| | - Anthony Guy Marson
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
- Department of Pharmacology and Therapeutics, University of Liverpool Institute of Systems, Molecular and Integrative Biology, Liverpool, UK
| | - Sarosh R Irani
- Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, UK
| | - Tom Solomon
- Institute of Infection, Veterinary, and Ecological Science, University of Liverpool Department of Clinical Infection Microbiology and Immunology, Liverpool, UK
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, UK
| | - Benedict D Michael
- Institute of Infection, Veterinary, and Ecological Science, University of Liverpool Department of Clinical Infection Microbiology and Immunology, Liverpool, UK
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections at University of Liverpool, Liverpool, UK
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Walker JL, Schultze A, Tazare J, Tamborska A, Singh B, Donegan K, Stowe J, Morton CE, Hulme WJ, Curtis HJ, Williamson EJ, Mehrkar A, Eggo RM, Rentsch CT, Mathur R, Bacon S, Walker AJ, Davy S, Evans D, Inglesby P, Hickman G, MacKenna B, Tomlinson L, Ca Green A, Fisher L, Cockburn J, Parry J, Hester F, Harper S, Bates C, Evans SJ, Solomon T, Andrews NJ, Douglas IJ, Goldacre B, Smeeth L, McDonald HI. Safety of COVID-19 vaccination and acute neurological events: A self-controlled case series in England using the OpenSAFELY platform. Vaccine 2022; 40:4479-4487. [PMID: 35715350 PMCID: PMC9170533 DOI: 10.1016/j.vaccine.2022.06.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [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: 01/14/2022] [Revised: 05/20/2022] [Accepted: 06/02/2022] [Indexed: 02/06/2023]
Abstract
INTRODUCTION We investigated the potential association of COVID-19 vaccination with three acute neurological events: Guillain-Barré syndrome (GBS), transverse myelitis and Bell's palsy. METHODS With the approval of NHS England we analysed primary care data from >17 million patients in England linked to emergency care, hospital admission and mortality records in the OpenSAFELY platform. Separately for each vaccine brand, we used a self-controlled case series design to estimate the incidence rate ratio for each outcome in the period following vaccination (4-42 days for GBS, 4-28 days for transverse myelitis and Bell's palsy) compared to a within-person baseline, using conditional Poisson regression. RESULTS Among 7,783,441 ChAdOx1 vaccinees, there was an increased rate of GBS (N = 517; incidence rate ratio 2·85; 95% CI2·33-3·47) and Bell's palsy (N = 5,350; 1·39; 1·27-1·53) following a first dose of ChAdOx1 vaccine, corresponding to 11.0 additional cases of GBS and 17.9 cases of Bell's palsy per 1 million vaccinees if causal. For GBS this applied to the first, but not the second, dose. There was no clear evidence of an association of ChAdOx1 vaccination with transverse myelitis (N = 199; 1·51; 0·96-2·37). Among 5,729,152 BNT162b2 vaccinees, there was no evidence of any association with GBS (N = 283; 1·09; 0·75-1·57), transverse myelitis (N = 109; 1·62; 0·86-3·03) or Bell's palsy (N = 3,609; 0·89; 0·76-1·03). Among 255,446 mRNA-1273 vaccine recipients there was no evidence of an association with Bell's palsy (N = 78; 0·88, 0·32-2·42). CONCLUSIONS COVID-19 vaccines save lives, but it is important to understand rare adverse events. We observed a short-term increased rate of Guillain-Barré syndrome and Bell's palsy after first dose of ChAdOx1 vaccine. The absolute risk, assuming a causal effect attributable to vaccination, was low.
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Affiliation(s)
- Jemma L Walker
- OpenSAFELY Collaborative, UK; London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; NIHR Health Protection Research Unit (HPRU) in Vaccines and Immunisation; UK Health Security Agency, 61 Colindale Ave, London NW9 5EQ, UK
| | - Anna Schultze
- OpenSAFELY Collaborative, UK; London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - John Tazare
- OpenSAFELY Collaborative, UK; London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Arina Tamborska
- NIHR Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Science, University of Liverpool, UK; Department of Neurology, Walton Centre NHS Foundation Trust, Liverpool L9 7LJ, UK
| | - Bhagteshwar Singh
- NIHR Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Science, University of Liverpool, UK; Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, Liverpool L7 8XP, UK
| | - Katherine Donegan
- Medicines and Healthcare products Regulatory Agency (MHRA), 10 South Colonnade, Canary Wharf, London E14 4PU, UK
| | - Julia Stowe
- UK Health Security Agency, 61 Colindale Ave, London NW9 5EQ, UK
| | - Caroline E Morton
- OpenSAFELY Collaborative, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, UK
| | - William J Hulme
- OpenSAFELY Collaborative, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, UK
| | - Helen J Curtis
- OpenSAFELY Collaborative, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, UK
| | - Elizabeth J Williamson
- OpenSAFELY Collaborative, UK; London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Amir Mehrkar
- OpenSAFELY Collaborative, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, UK
| | - Rosalind M Eggo
- OpenSAFELY Collaborative, UK; London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Christopher T Rentsch
- OpenSAFELY Collaborative, UK; London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Rohini Mathur
- OpenSAFELY Collaborative, UK; London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Sebastian Bacon
- OpenSAFELY Collaborative, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, UK
| | - Alex J Walker
- OpenSAFELY Collaborative, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, UK
| | - Simon Davy
- OpenSAFELY Collaborative, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, UK
| | - David Evans
- OpenSAFELY Collaborative, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, UK
| | - Peter Inglesby
- OpenSAFELY Collaborative, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, UK
| | - George Hickman
- OpenSAFELY Collaborative, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, UK
| | - Brian MacKenna
- OpenSAFELY Collaborative, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, UK
| | - Laurie Tomlinson
- OpenSAFELY Collaborative, UK; London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Amelia Ca Green
- OpenSAFELY Collaborative, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, UK
| | - Louis Fisher
- OpenSAFELY Collaborative, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, UK
| | - Jonathan Cockburn
- OpenSAFELY Collaborative, UK; TPP, TPP House, 129 Low Lane, Horsforth, Leeds LS18 5PX, UK
| | - John Parry
- OpenSAFELY Collaborative, UK; TPP, TPP House, 129 Low Lane, Horsforth, Leeds LS18 5PX, UK
| | - Frank Hester
- OpenSAFELY Collaborative, UK; TPP, TPP House, 129 Low Lane, Horsforth, Leeds LS18 5PX, UK
| | - Sam Harper
- OpenSAFELY Collaborative, UK; TPP, TPP House, 129 Low Lane, Horsforth, Leeds LS18 5PX, UK
| | - Christopher Bates
- OpenSAFELY Collaborative, UK; TPP, TPP House, 129 Low Lane, Horsforth, Leeds LS18 5PX, UK
| | - Stephen Jw Evans
- OpenSAFELY Collaborative, UK; London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Tom Solomon
- NIHR Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Science, University of Liverpool, UK; Department of Neurology, Walton Centre NHS Foundation Trust, Liverpool L9 7LJ, UK
| | - Nick J Andrews
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; NIHR Health Protection Research Unit (HPRU) in Vaccines and Immunisation; UK Health Security Agency, 61 Colindale Ave, London NW9 5EQ, UK
| | - Ian J Douglas
- OpenSAFELY Collaborative, UK; London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Ben Goldacre
- OpenSAFELY Collaborative, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, UK
| | - Liam Smeeth
- OpenSAFELY Collaborative, UK; London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; NIHR Health Protection Research Unit (HPRU) in Vaccines and Immunisation
| | - Helen I McDonald
- OpenSAFELY Collaborative, UK; London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; NIHR Health Protection Research Unit (HPRU) in Vaccines and Immunisation.
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Ellis J, Harvey D, Defres S, Chandna A, MacLachlan E, Solomon T, Heyderman RS, McGill F. Clinical management of community-acquired meningitis in adults in the UK and Ireland in 2017: a retrospective cohort study on behalf of the National Infection Trainees Collaborative for Audit and Research (NITCAR). BMJ Open 2022; 12:e062698. [PMID: 35831140 PMCID: PMC9315913 DOI: 10.1136/bmjopen-2022-062698] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES To assess practice in the care of adults with suspected community-acquired bacterial meningitis in the UK and Ireland. DESIGN Retrospective cohort study. SETTING 64 UK and Irish hospitals. PARTICIPANTS 1471 adults with community-acquired meningitis of any aetiology in 2017. RESULTS None of the audit standards, from the 2016 UK Joint Specialists Societies guideline on diagnosis and management of meningitis, were met in all cases. With respect to 20 of 30 assessed standards, clinical management provided for patients was in line with recommendations in less than 50% of cases. 45% of patients had blood cultures taken within an hour of admission, 0.5% had a lumbar puncture within 1 hour, 26% within 8 hours. 28% had bacterial molecular diagnostic tests on cerebrospinal fluid. Median time to first dose of antibiotics was 3.2 hours (IQR 1.3-9.2). 80% received empirical parenteral cephalosporins. 55% ≥60 years and 31% of immunocompromised patients received anti-Listeria antibiotics. 21% received steroids. Of the 1471 patients, 20% had confirmed bacterial meningitis. Among those with bacterial meningitis, pneumococcal aetiology, admission to intensive care and initial Glasgow Coma Scale Score less than 14 were associated with in-hospital mortality (adjusted OR (aOR) 2.08, 95% CI 0.96 to 4.48; aOR 4.28, 95% CI 1.81 to 10.1; aOR 2.90, 95% CI 1.26 to 6.71, respectively). Dexamethasone therapy was weakly associated with a reduction in mortality in both those with proven bacterial meningitis (aOR 0.57, 95% CI 0.28 to 1.17) and with pneumococcal meningitis (aOR 0.47, 95% CI 0.20 to 1.10). CONCLUSION This study demonstrates that clinical care for patients with meningitis in the UK is not in line with current evidence-based national guidelines. Diagnostics and therapeutics should be targeted for quality improvement strategies. Work should be done to improve the impact of guidelines, understand why they are not followed and, once published, ensure they translate into changed practice.
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Affiliation(s)
- Jayne Ellis
- Research Department of Infection, Division of Infection and Immunity, University College London, London, UK
| | - David Harvey
- Microbiology, Wirral University Teaching Hospital NHS Foundation Trust, Wirral, UK
| | - Sylviane Defres
- Institute of Infection, Veterinary and Ecological sciences, University of Liverpool, Liverpool, Merseyside, UK
- Tropical Infectious Diseases Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Arjun Chandna
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Eloisa MacLachlan
- University of Leeds, Leeds, UK
- National Student Association of Medical Research, Leeds, UK
| | - Tom Solomon
- Institute of Infection, Veterinary and Ecological sciences, University of Liverpool, Liverpool, Merseyside, UK
- Neurology, The Walton Centre NHS Foundation Centre, Liverpool, UK
| | - Robert S Heyderman
- Research Department of Infection, Division of Infection and Immunity, University College London, London, UK
| | - Fiona McGill
- Institute of Infection, Veterinary and Ecological sciences, University of Liverpool, Liverpool, Merseyside, UK
- Infectious Diseases and Medical Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Tamborska AA, Singh B, Leonhard SE, Hodel EM, Stowe J, Watson-Fargie T, Fernandes PM, Themistocleous AC, Roelofs J, Brennan K, Morrice C, Michael BD, Jacobs BC, McDonald H, Solomon T. Guillain-Barré syndrome following SARS-CoV-2 vaccination in the UK: a prospective surveillance study. BMJ Neurol Open 2022; 4:e000309. [PMID: 35856053 PMCID: PMC9277028 DOI: 10.1136/bmjno-2022-000309] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/13/2022] [Indexed: 12/25/2022] Open
Abstract
ObjectiveTo investigate features of Guillain-Barré syndrome (GBS) following SARS-CoV-2 vaccines and evaluate for a causal link between the two.MethodsWe captured cases of GBS after SARS-CoV-2 vaccination through a national, open-access, online surveillance system. For each case, the certainty of GBS was graded using the Brighton criteria, and the relationship to the vaccine was examined using modified WHO Causality Assessment criteria. We compared age distribution of cases with that of prepandemic GBS cases and clinical features with the International GBS Outcome Study (IGOS).ResultsBetween 1 January and 30 June 2021, we received 67 reports of GBS following the ChAdOx1 vaccine (65 first doses) and three reports following the BNT162b2 vaccine (all first doses). The causal association with the vaccine was classified as probable for 56 (80%, all ChAdOx1), possible for 12 (17%, 10 ChAdOx1) and unlikely for two (3%, 1 ChAdOx1). A greater proportion of cases occurred in the 50–59 age group in comparison with prepandemic GBS. Most common clinical variants were sensorimotor GBS (n=55; 79%) and facial diplegia with paraesthesias (n=10; 14%). 10% (n=7/69) of patients reported an antecedent infection, compared with 77% (n=502/652) of the IGOS cohort (p<0.00001). Facial weakness (63% (n=44/70) vs 36% (n=220/620); p<0.00001) and sensory dysfunction (93% (n=63/68) vs 69% (n=408/588); p=0.00005) were more common but disease severity and outcomes were similar to the IGOS study.InterpretationMost reports of GBS followed the first dose of ChAdOx1 vaccine. While our study cannot confirm or refute causation, this observation, together with the absence of alternative aetiologies, different than expected age distribution and the presence of unusual clinical features support a causal link. Clinicians and surveillance bodies should remain vigilant to the possibility of this very rare adverse event and its atypical variants.
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Affiliation(s)
- Arina A Tamborska
- National Institute for Health Research Health Protection Research Unit for Emerging and Zoonotic Infections, University of Liverpool, Liverpool, UK
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Bhagteshwar Singh
- National Institute for Health Research Health Protection Research Unit for Emerging and Zoonotic Infections, University of Liverpool, Liverpool, UK
- Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, Liverpool, UK
| | | | - Eva Maria Hodel
- National Institute for Health Research Health Protection Research Unit for Emerging and Zoonotic Infections, University of Liverpool, Liverpool, UK
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | | | - Taylor Watson-Fargie
- Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, UK
| | - Peter M Fernandes
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Jacob Roelofs
- Neurosciences Centre, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Kathryn Brennan
- Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, UK
| | - Caroline Morrice
- GAIN (Guillain-Barré & Associated Inflammatory Neuropathies) Charity, Sleaford, UK
| | - Benedict D Michael
- National Institute for Health Research Health Protection Research Unit for Emerging and Zoonotic Infections, University of Liverpool, Liverpool, UK
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Bart C Jacobs
- Department of Neurology and Immunology, Erasmus MC, Rotterdam, The Netherlands
| | - Helen McDonald
- NIHR Health Protection Research Unit in Vaccines and Immunisation, London School of Hygiene & Tropical Medicine, London, UK
| | - Tom Solomon
- National Institute for Health Research Health Protection Research Unit for Emerging and Zoonotic Infections, University of Liverpool, Liverpool, UK
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
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Singh B, Lant S, Cividini S, Cattrall JWS, Goodwin LC, Benjamin L, Michael BD, Khawaja A, Matos ADMB, Alkeridy W, Pilotto A, Lahiri D, Rawlinson R, Mhlanga S, Lopez EC, Sargent BF, Somasundaran A, Tamborska A, Webb G, Younas K, Al Sami Y, Babu H, Banks T, Cavallieri F, Cohen M, Davies E, Dhar S, Fajardo Modol A, Farooq H, Harte J, Hey S, Joseph A, Karthikappallil D, Kassahun D, Lipunga G, Mason R, Minton T, Mond G, Poxon J, Rabas S, Soothill G, Zedde M, Yenkoyan K, Brew B, Contini E, Cysique L, Zhang X, Maggi P, van Pesch V, Lechien J, Saussez S, Heyse A, Brito Ferreira ML, Soares CN, Elicer I, Eugenín-von Bernhardi L, Ñancupil Reyes W, Yin R, Azab MA, Abd-Allah F, Elkady A, Escalard S, Corvol JC, Delorme C, Tattevin P, Bigaut K, Lorenz N, Hornuss D, Hosp J, Rieg S, Wagner D, Knier B, Lingor P, Winkler AS, Sharifi-Razavi A, Moein ST, SeyedAlinaghi S, JamaliMoghadamSiahkali S, Morassi M, Padovani A, Giunta M, Libri I, Beretta S, Ravaglia S, Foschi M, Calabresi P, Primiano G, Servidei S, Biagio Mercuri N, Liguori C, Pierantozzi M, Sarmati L, Boso F, Garazzino S, Mariotto S, Patrick KN, Costache O, Pincherle A, Klok FA, Meza R, Cabreira V, Valdoleiros SR, Oliveira V, Kaimovsky I, Guekht A, Koh J, Fernández Díaz E, Barrios-López JM, Guijarro-Castro C, Beltrán-Corbellini Á, Martínez-Poles J, Diezma-Martín AM, Morales-Casado MI, García García S, Breville G, Coen M, Uginet M, Bernard-Valnet R, Du Pasquier R, Kaya Y, Abdelnour LH, Rice C, Morrison H, Defres S, Huda S, Enright N, Hassell J, D’Anna L, Benger M, Sztriha L, Raith E, Chinthapalli K, Nortley R, Paterson R, Chandratheva A, Werring DJ, Dervisevic S, Harkness K, Pinto A, Jillella D, Beach S, Gunasekaran K, Rocha Ferreira Da Silva I, Nalleballe K, Santoro J, Scullen T, Kahn L, Kim CY, Thakur KT, Jain R, Umapathi T, Nicholson TR, Sejvar JJ, Hodel EM, Tudur Smith C, Solomon T. Prognostic indicators and outcomes of hospitalised COVID-19 patients with neurological disease: An individual patient data meta-analysis. PLoS One 2022; 17:e0263595. [PMID: 35653330 PMCID: PMC9162376 DOI: 10.1371/journal.pone.0263595] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [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: 10/14/2021] [Accepted: 01/21/2022] [Indexed: 01/08/2023] Open
Abstract
Background Neurological COVID-19 disease has been reported widely, but published studies often lack information on neurological outcomes and prognostic risk factors. We aimed to describe the spectrum of neurological disease in hospitalised COVID-19 patients; characterise clinical outcomes; and investigate factors associated with a poor outcome. Methods We conducted an individual patient data (IPD) meta-analysis of hospitalised patients with neurological COVID-19 disease, using standard case definitions. We invited authors of studies from the first pandemic wave, plus clinicians in the Global COVID-Neuro Network with unpublished data, to contribute. We analysed features associated with poor outcome (moderate to severe disability or death, 3 to 6 on the modified Rankin Scale) using multivariable models. Results We included 83 studies (31 unpublished) providing IPD for 1979 patients with COVID-19 and acute new-onset neurological disease. Encephalopathy (978 [49%] patients) and cerebrovascular events (506 [26%]) were the most common diagnoses. Respiratory and systemic symptoms preceded neurological features in 93% of patients; one third developed neurological disease after hospital admission. A poor outcome was more common in patients with cerebrovascular events (76% [95% CI 67–82]), than encephalopathy (54% [42–65]). Intensive care use was high (38% [35–41]) overall, and also greater in the cerebrovascular patients. In the cerebrovascular, but not encephalopathic patients, risk factors for poor outcome included breathlessness on admission and elevated D-dimer. Overall, 30-day mortality was 30% [27–32]. The hazard of death was comparatively lower for patients in the WHO European region. Interpretation Neurological COVID-19 disease poses a considerable burden in terms of disease outcomes and use of hospital resources from prolonged intensive care and inpatient admission; preliminary data suggest these may differ according to WHO regions and country income levels. The different risk factors for encephalopathy and stroke suggest different disease mechanisms which may be amenable to intervention, especially in those who develop neurological symptoms after hospital admission.
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Affiliation(s)
- 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, United Kingdom
- Tropical and Infectious Diseases Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
- Department of Infectious Diseases, 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, United Kingdom
| | - Sofia Cividini
- Department of Health Data Science, University of Liverpool, Liverpool, United Kingdom
| | - Jonathan W. S. Cattrall
- 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, United Kingdom
| | - Lynsey C. Goodwin
- 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, United Kingdom
- Tropical and Infectious Diseases Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Laura Benjamin
- Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Benedict D. 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, United Kingdom
- The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Ayaz Khawaja
- Department of Neurology, Wayne State University, Detroit, Michigan, United States of America
| | | | - Walid Alkeridy
- Department of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Andrea Pilotto
- Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Brescia, Italy
| | - Durjoy Lahiri
- Bangur Institute of Neurosciences, Institute of Post-Graduate Medical Education and Research, Kolkata, India
| | - Rebecca Rawlinson
- 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, United Kingdom
| | - Sithembinkosi Mhlanga
- 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, United Kingdom
| | - Evelyn C. Lopez
- 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, United Kingdom
| | - Brendan F. Sargent
- 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, United Kingdom
| | - Anushri Somasundaran
- 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, United Kingdom
| | - Arina Tamborska
- 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, United Kingdom
| | - Glynn Webb
- 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, United Kingdom
| | - Komal Younas
- 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, United Kingdom
| | - Yaqub Al Sami
- Homerton University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Heavenna Babu
- Department of Neurovirology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Tristan Banks
- Department of Infection, Manchester University NHS Foundation Trust, Manchester, United Kingdom of Great Britain and Northern Ireland
| | - Francesco Cavallieri
- Neurology Unit, Neuromotor & Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Matthew Cohen
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom of Great Britain and Northern Ireland
| | - Emma Davies
- Department of Virology, UK Health Security Agency, Manchester University NHS Foundation Trust, Manchester, United Kingdom of Great Britain and Northern Ireland
| | - Shalley Dhar
- Department of Neurovirology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Anna Fajardo Modol
- 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, United Kingdom
| | - Hamzah Farooq
- Department of Virology, UK Health Security Agency, Manchester University NHS Foundation Trust, Manchester, United Kingdom of Great Britain and Northern Ireland
| | - Jeffrey Harte
- Barts Health NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Samuel Hey
- Department of Infectious Diseases & Tropical Medicine, North Manchester General Hospital, Manchester University Foundation NHS Trust, Manchester, United Kingdom of Great Britain and Northern Ireland
| | - Albert Joseph
- Homerton University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Dileep Karthikappallil
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom of Great Britain and Northern Ireland
| | - Daniel Kassahun
- Warrington Hospital, Warrington and Halton Teaching Hospitals NHS Foundation Trust, Warrington, United Kingdom of Great Britain and Northern Ireland
| | - Gareth Lipunga
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Rachel Mason
- Kingston Hospital NHS Foundation Trust, Kingston upon Thames, United Kingdom of Great Britain and Northern Ireland
| | - Thomas Minton
- Institute of Clinical Neurosciences, University of Bristol, Bristol, United Kingdom of Great Britain and Northern Ireland
| | - Gabrielle Mond
- North Manchester General Hospital, Manchester University Foundation NHS Trust, Manchester, United Kingdom of Great Britain and Northern Ireland
| | - Joseph Poxon
- Epsom and St Helier University Hospitals NHS Foundation Trust, United Kingdom of Great Britain and Northern Ireland
| | - Sophie Rabas
- King’s College Hospital NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Germander Soothill
- Regional Infectious Diseases Unit, NHS Lothian, Edinburgh, United Kingdom of Great Britain and Northern Ireland
| | - Marialuisa Zedde
- Neurology Unit, Neuromotor & Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Konstantin Yenkoyan
- Yerevan State Medical University named after Mkhitar Heratsi, Neuroscience Laboratory, Cobrain Center, Yerevan, Armenia
| | - Bruce Brew
- St Vincent’s Hospital, Sydney, Australia
| | | | | | - Xin Zhang
- St Vincent’s Hospital, Sydney, Australia
| | - Pietro Maggi
- Saint-Luc University Hospital, Brussels, Belgium
| | | | | | | | | | | | | | | | | | | | - Rong Yin
- The 940th Hospital of Joint Logistic Support Force of the People’s Liberation Army, Lanzhou, China
| | | | | | | | | | | | | | | | - Kévin Bigaut
- Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Norbert Lorenz
- Children’s Hospital, Dresden Municipal Hospital Teaching Hospital TUD, Dresden, Germany
| | - Daniel Hornuss
- Medical Center University of Freiburg, Freiburg, Germany
| | - Jonas Hosp
- Medical Center University of Freiburg, Freiburg, Germany
| | - Siegbert Rieg
- Medical Center University of Freiburg, Freiburg, Germany
| | - Dirk Wagner
- Medical Center University of Freiburg, Freiburg, Germany
| | - Benjamin Knier
- Department of Neurology, Technical University of Munich, Munich, Germany
| | - Paul Lingor
- Department of Neurology, Technical University of Munich, Munich, Germany
| | | | | | - Shima T. Moein
- Institute for Research in Fundamental Sciences (IPM), Tehran, Islamic Republic of Iran
| | | | | | - Mauro Morassi
- Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
| | | | | | | | - Simone Beretta
- San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | | | - Matteo Foschi
- Santa Maria delle Croci Hospital, AUSL Romagna, Ravenna, Italy
| | - Paolo Calabresi
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Guido Primiano
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | | | | | | | - Federica Boso
- Healthcare Trust of the Autonomous Region of Trento, Rovereto, Italy
| | - Silvia Garazzino
- Città della Salute e della Scienza di Torino, Regina Margherita Children’s Hospital, Turin, Italy
| | | | | | | | | | | | - Roger Meza
- Hospital Regional Docente de Trujillo, Trujillo, Peru
| | | | | | | | - Igor Kaimovsky
- Buyanov Moscow City Hospital, Moscow, Russian Federation
| | - Alla Guekht
- Moscow Research and Clinical Center for Neuropsychiatry and Buyanov Moscow City Hospital, Moscow, Russian Federation
| | - Jasmine Koh
- National Neuroscience Institute, Singapore, Singapore
| | | | | | | | | | | | | | | | | | | | - Matteo Coen
- Hopitaux Universitaires de Genève, Geneva, Switzerland
| | | | | | | | - Yildiz Kaya
- Acibadem Mehmet Ali Aydinlar University Medical School, Istanbul, Turkey
| | - Loay H. Abdelnour
- Ulster Hospital, Belfast, United Kingdom of Great Britain and Northern Ireland
| | - Claire Rice
- University of Bristol and North Bristol NHS Trust, Bristol, United Kingdom of Great Britain and Northern Ireland
| | - Hamish Morrison
- Gloucestershire Royal Hospital, Gloucester, United Kingdom of Great Britain and Northern Ireland
| | - Sylviane Defres
- Tropical and Infectious Diseases Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Saif Huda
- The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Noelle Enright
- Great Ormond Street Hospital for Children, London, United Kingdom of Great Britain and Northern Ireland
| | - Jane Hassell
- Great Ormond Street Hospital for Children, London, United Kingdom of Great Britain and Northern Ireland
| | - Lucio D’Anna
- Imperial College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Matthew Benger
- King’s College Hospital NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Laszlo Sztriha
- King’s College Hospital NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Eamon Raith
- The National Hospital for Neurology & Neurosurgery, London, United Kingdom of Great Britain and Northern Ireland
| | - Krishna Chinthapalli
- University College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Ross Nortley
- University College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Ross Paterson
- University College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Arvind Chandratheva
- University College London Queen Square Institute of Neurology, London, United Kingdom of Great Britain and Northern Ireland
| | - David J. Werring
- University College London Queen Square Institute of Neurology, London, United Kingdom of Great Britain and Northern Ireland
| | - Samir Dervisevic
- Eastern Pathology Alliance Department of Microbiology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom of Great Britain and Northern Ireland
| | - Kirsty Harkness
- Sheffield Teaching Hospitals Trust, Sheffield, United Kingdom of Great Britain and Northern Ireland
| | - Ashwin Pinto
- Wessex Neurological Centre, Southampton, United Kingdom of Great Britain and Northern Ireland
| | - Dinesh Jillella
- Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Scott Beach
- Massachusetts General Hospital / Harvard Medical School, Boston, Massachusetts, United States of America
| | - Kulothungan Gunasekaran
- Yale New Haven Health Bridgeport Hospital, Bridgeport, Connecticut, United States of America
| | | | - Krishna Nalleballe
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States of America
| | - Jonathan Santoro
- Children’s Hospital Los Angeles and Keck School of Medicine at the University of Southern California, Los Angeles, California, United States of America
| | - Tyler Scullen
- Ochsner Medical Center, New Orleans, Los Angeles, United States of America
| | - Lora Kahn
- Ochsner Medical Center, New Orleans, Los Angeles, United States of America
| | - Carla Y. Kim
- Columbia University Irving Medical Center, New York, New York, United States of America
| | - Kiran T. Thakur
- Columbia University Irving Medical Center, New York, New York, United States of America
| | - Rajan Jain
- New York University Grossman School of Medicine, New York, New York, United States of America
| | | | - Timothy R. Nicholson
- Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, London, United Kingdom
| | - James J. Sejvar
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Eva Maria Hodel
- 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, United Kingdom
| | | | - Catrin Tudur Smith
- Department of Health Data Science, University of Liverpool, Liverpool, United Kingdom
| | - 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, United Kingdom
- Tropical and Infectious Diseases Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
- The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
- * E-mail:
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Knight SR, Gupta RK, Ho A, Pius R, Buchan I, Carson G, Drake TM, Dunning J, Fairfield CJ, Gamble C, Green CA, Halpin S, Hardwick HE, Holden KA, Horby PW, Jackson C, Mclean KA, Merson L, Nguyen-Van-Tam JS, Norman L, Olliaro PL, Pritchard MG, Russell CD, Shaw CA, Sheikh A, Solomon T, Sudlow C, Swann OV, Turtle LCW, Openshaw PJM, Baillie JK, Docherty A, Semple MG, Noursadeghi M, Harrison EM. Prospective validation of the 4C prognostic models for adults hospitalised with COVID-19 using the ISARIC WHO Clinical Characterisation Protocol. Thorax 2022; 77:606-615. [PMID: 34810237 PMCID: PMC8610617 DOI: 10.1136/thoraxjnl-2021-217629] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [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: 05/14/2021] [Accepted: 10/11/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE To prospectively validate two risk scores to predict mortality (4C Mortality) and in-hospital deterioration (4C Deterioration) among adults hospitalised with COVID-19. METHODS Prospective observational cohort study of adults (age ≥18 years) with confirmed or highly suspected COVID-19 recruited into the International Severe Acute Respiratory and emerging Infections Consortium (ISARIC) WHO Clinical Characterisation Protocol UK (CCP-UK) study in 306 hospitals across England, Scotland and Wales. Patients were recruited between 27 August 2020 and 17 February 2021, with at least 4 weeks follow-up before final data extraction. The main outcome measures were discrimination and calibration of models for in-hospital deterioration (defined as any requirement of ventilatory support or critical care, or death) and mortality, incorporating predefined subgroups. RESULTS 76 588 participants were included, of whom 27 352 (37.4%) deteriorated and 12 581 (17.4%) died. Both the 4C Mortality (0.78 (0.77 to 0.78)) and 4C Deterioration scores (pooled C-statistic 0.76 (95% CI 0.75 to 0.77)) demonstrated consistent discrimination across all nine National Health Service regions, with similar performance metrics to the original validation cohorts. Calibration remained stable (4C Mortality: pooled slope 1.09, pooled calibration-in-the-large 0.12; 4C Deterioration: 1.00, -0.04), with no need for temporal recalibration during the second UK pandemic wave of hospital admissions. CONCLUSION Both 4C risk stratification models demonstrate consistent performance to predict clinical deterioration and mortality in a large prospective second wave validation cohort of UK patients. Despite recent advances in the treatment and management of adults hospitalised with COVID-19, both scores can continue to inform clinical decision making. TRIAL REGISTRATION NUMBER ISRCTN66726260.
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Affiliation(s)
- Stephen R Knight
- Centre for Medical Informatics, The University of Edinburgh, Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Rishi K Gupta
- University College London Institute for Global Health, London, UK
| | - Antonia Ho
- Medical Research Council University of Glasgow Centre for Virus Research, Glasgow, UK
| | - Riinu Pius
- Centre for Medical Informatics, The University of Edinburgh, Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Iain Buchan
- Manchester Academic Health Science Centre, Manchester, UK
- Department of Public Health and Policy, University of Liverpool, Liverpool, UK
| | - Gail Carson
- Nuffield Department of Clinical Medicine, ISARIC Global Support Centre, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Thomas M Drake
- Centre for Medical Informatics, The University of Edinburgh, Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Jake Dunning
- Public Health England National Infection Service, Salisbury, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Cameron J Fairfield
- Centre for Medical Informatics, The University of Edinburgh, Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Carrol Gamble
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Christopher A Green
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK
| | - Sophie Halpin
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Hayley E Hardwick
- NIHR Health Protection Research Unit, Institute of Infection, Veterinary and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Karl A Holden
- NIHR Health Protection Research Unit, Institute of Infection, Veterinary and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Peter W Horby
- Nuffield Department of Clinical Medicine, ISARIC Global Support Centre, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Clare Jackson
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Kenneth A Mclean
- Centre for Medical Informatics, The University of Edinburgh, Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Laura Merson
- Nuffield Department of Clinical Medicine, ISARIC Global Support Centre, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | | | - Lisa Norman
- Centre for Medical Informatics, The University of Edinburgh, Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Piero L Olliaro
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Mark G Pritchard
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Clark D Russell
- Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Catherine A Shaw
- Centre for Medical Informatics, The University of Edinburgh, Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Aziz Sheikh
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Tom Solomon
- NIHR Health Protection Research Unit, Institute of Infection, Veterinary and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | | | - Olivia V Swann
- Department of Child Life and Health, University of Edinburgh, Edinburgh, UK
| | - Lance C W Turtle
- Clinical Infection, Microbiology and Immunology, University of Liverpool Faculty of Health and Life Sciences, Liverpool, UK
- Liverpool University Hospitals Foundation Trust, Member of Liverpool Health Partners, Liverpool, UK
| | | | - J Kenneth Baillie
- Genetics and Genomics, Roslin Institute, University of Edinburgh, Edinburgh, UK
| | - Annemarie Docherty
- Centre for Medical Informatics, The University of Edinburgh, Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Malcolm G Semple
- NIHR Health Protection Research Unit, Institute of Infection, Veterinary and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
- Respiratory Medicine, Alder Hey Children's Hospital, University of Liverpool, Liverpool, UK
| | - Mahdad Noursadeghi
- Division of Infection and Immunity, University College London, London, UK
| | - Ewen M Harrison
- Centre for Medical Informatics, The University of Edinburgh, Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
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Pilbeam C, Tonkin-Crine S, Martindale AM, Atkinson P, Mableson H, Lant S, Solomon T, Sheard S, Gobat N. How do Healthcare Workers 'Do' Guidelines? Exploring How Policy Decisions Impacted UK Healthcare Workers During the First Phase of the COVID-19 Pandemic. Qual Health Res 2022; 32:729-743. [PMID: 35094621 PMCID: PMC8801764 DOI: 10.1177/10497323211067772] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
We describe how COVID-19-related policy decisions and guidelines impacted healthcare workers (HCWs) during the UK's first COVID-19 pandemic phase. Guidelines in healthcare aim to streamline processes, improve quality and manage risk. However, we argue that during this time the guidelines we studied often fell short of these goals in practice. We analysed 74 remote interviews with 14 UK HCWs over 6 months (February-August 2020). Reframing guidelines through Mol's lens of 'enactment', we reveal embodied, relational and material impacts that some guidelines had for HCWs. Beyond guideline 'adherence', we show that enacting guidelines is an ongoing, complex process of negotiating and balancing multilevel tensions. Overall, guidelines: (1) were inconsistently communicated; (2) did not sufficiently accommodate contextual considerations; and (3) were at times in tension with HCWs' values. Healthcare policymakers should produce more agile, acceptable guidelines that frontline HCWs can enact in ways which make sense and are effective in their contexts.
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Affiliation(s)
- Caitlin Pilbeam
- Nuffield Department of Primary Care
Health Sciences, University of
Oxford, Oxford, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care
Health Sciences, University of
Oxford, Oxford, UK
- NIHR Health Protection Research
Unit in Healthcare Associated Infections and Antimicrobial Resistance,
University of
Oxford, Oxford, UK
| | | | - Paul Atkinson
- Institute of Population Health,
University
of Liverpool, Liverpool, UK
| | - Hayley Mableson
- Institute of Infection, Veterinary
and Ecological Sciences, University of
Liverpool, Liverpool, UK
| | - Suzannah Lant
- Institute of Infection, Veterinary
and Ecological Sciences, University of
Liverpool, Liverpool, UK
| | - Tom Solomon
- Institute of Infection, Veterinary
and Ecological Sciences, University of
Liverpool, Liverpool, UK
| | - Sally Sheard
- Institute of Population Health,
University
of Liverpool, Liverpool, UK
| | - Nina Gobat
- Nuffield Department of Primary Care
Health Sciences, University of
Oxford, Oxford, UK
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35
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Netravathi M, Dhamija K, Gupta M, Tamborska A, Nalini A, Holla V, Nitish L, Menon D, Pal P, Seena V, Yadav R, Ravindranadh M, Faheem A, Saini J, Mahadevan A, Solomon T, Singh B. COVID-19 vaccine associated demyelination & its association with MOG antibody. Mult Scler Relat Disord 2022; 60:103739. [PMID: 35306244 PMCID: PMC8917969 DOI: 10.1016/j.msard.2022.103739] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 03/05/2022] [Accepted: 03/11/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND ChAdOx1-S (Covishield™/Vaxzervria, AstraZeneca) and BBV152 (Covaxin) SARS-CoV-2 vaccines are proven to be safe and effective, but rare complications have been reported. OBJECTIVE To describe reports of central nervous system (CNS) demyelination following ChAdOx1-S and BBV152 vaccinations. METHODS & RESULTS We report 29 (17 female; mean 38 years) cases of CNS demyelination; twenty-seven occurred in temporal association with ChAdOx1-S vaccine; two in association with BBV152 vaccine. Eleven patients had presentation with myelitis, six patients developed optic neuritis, five had acute demyelinating encephalomyelitis, three presented with brainstem demyelination, and four had multiaxial involvement. Myelin oligodendrocyte glycoprotein (MOG) antibodies were positive in ten patients. One patient with ADEM and tumefactive demyelinating lesions died after a prolonged intensive care unit stay and superimposed infection. As compared to the control group (87); the postvaccinial cases were found to have a significantly higher mean age, presence of encephalopathy (p value:0.0007), CSF pleocytosis (p value: 0.0094) and raised CSF protein (p value: 0.0062). CONCLUSIONS It is difficult to establish a causal relationship between vaccination and neurological adverse events such as demyelination. The temporal association with the vaccination and the presence of MOG antibodies raises the possibility of an immunogenic process triggered by the vaccine in susceptible individuals.
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Affiliation(s)
- M. Netravathi
- Department of Neurology, National Institute of Mental Health & Neurosciences, Bangalore, India,Corresponding author
| | - Kamakshi Dhamija
- Department of Neurology, National Institute of Mental Health & Neurosciences, Bangalore, India
| | - Manisha Gupta
- Department of Neurology, National Institute of Mental Health & Neurosciences, Bangalore, India
| | - Arina Tamborska
- National Institute for Health Research Health Protection Unit for Emerging and Zoonotic Infections, University of Liverpool, United Kingdom,Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom,Department of Clinical Infection Microbiology and Immunology, Institute for Infection, Veterinary and Ecological Sciences, University of Liverpool, United Kingdom
| | - A. Nalini
- Department of Neurology, National Institute of Mental Health & Neurosciences, Bangalore, India
| | - V.V. Holla
- Department of Neurology, National Institute of Mental Health & Neurosciences, Bangalore, India
| | - L.K. Nitish
- Department of Neurology, National Institute of Mental Health & Neurosciences, Bangalore, India
| | - Deepak Menon
- Department of Neurology, National Institute of Mental Health & Neurosciences, Bangalore, India
| | - P.K. Pal
- Department of Neurology, National Institute of Mental Health & Neurosciences, Bangalore, India
| | - V. Seena
- Department of Neurology, National Institute of Mental Health & Neurosciences, Bangalore, India
| | - Ravi Yadav
- Department of Neurology, National Institute of Mental Health & Neurosciences, Bangalore, India
| | - M. Ravindranadh
- Department of Neurology, National Institute of Mental Health & Neurosciences, Bangalore, India
| | - Arshad Faheem
- Department of Neurology, National Institute of Mental Health & Neurosciences, Bangalore, India
| | - J. Saini
- Department of Neuroimaging & Interventional Neuroradiology, National Institute of Mental Health & Neurosciences, Bangalore
| | - Anita Mahadevan
- Department of Neuropathology, National Institute of Mental Health & Neurosciences, Bangalore
| | - Tom Solomon
- National Institute for Health Research Health Protection Unit for Emerging and Zoonotic Infections, University of Liverpool, United Kingdom,Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom,Department of Clinical Infection Microbiology and Immunology, Institute for Infection, Veterinary and Ecological Sciences, University of Liverpool, United Kingdom
| | - Bhagteshwar Singh
- National Institute for Health Research Health Protection Unit for Emerging and Zoonotic Infections, University of Liverpool, United Kingdom,Department of Clinical Infection Microbiology and Immunology, Institute for Infection, Veterinary and Ecological Sciences, University of Liverpool, United Kingdom,Department of Infectious Diseases, Christian Medical College, Vellore, India
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Borek AJ, Pilbeam C, Mableson H, Wanat M, Atkinson P, Sheard S, Martindale AM, Solomon T, Butler CC, Gobat N, Tonkin-Crine S. Experiences and concerns of health workers throughout the first year of the COVID-19 pandemic in the UK: A longitudinal qualitative interview study. PLoS One 2022; 17:e0264906. [PMID: 35294450 PMCID: PMC8926177 DOI: 10.1371/journal.pone.0264906] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 08/31/2021] [Accepted: 02/21/2022] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To identify the experiences and concerns of health workers (HWs), and how they changed, throughout the first year of the COVID-19 pandemic in the UK. METHODS Longitudinal, qualitative study with HWs involved in patient management or delivery of care related to COVID-19 in general practice, emergency departments and hospitals. Participants were identified through snowballing. Semi-structured telephone or video interviews were conducted between February 2020 and February 2021, audio-recorded, summarised, and transcribed. Data were analysed longitudinally using framework and thematic analysis. RESULTS We conducted 105 interviews with 14 participants and identified three phases corresponding with shifts in HWs' experiences and concerns. (1) Emergency and mobilisation phase (late winter-spring 2020), with significant rapid shifts in responsibilities, required skills, and training, and challenges in patient care. (2) Consolidation and preparation phase (summer-autumn 2020), involving gradual return to usual care and responsibilities, sense of professional development and improvement in care, and focus on learning and preparing for future. (3) Exhaustion and survival phase (autumn 2020-winter 2021), entailing return of changes in responsibilities, focus on balancing COVID-19 and non-COVID care (until becoming overwhelmed with COVID-19 cases), and concerns about longer-term impacts of unceasing pressure on health services. Participants' perceptions of COVID-19 risk and patient/public attitudes changed throughout the year, and tiredness and weariness turned into exhaustion. CONCLUSIONS Results showed a long-term impact of the COVID-19 pandemic on UK HWs' experiences and concerns related to changes in their roles, provision of care, and personal wellbeing. Despite mobilisation in the emergency phase, and trying to learn from this, HWs' experiences seemed to be similar or worse in the second wave partly due to many COVID-19 cases. The findings highlight the importance of supporting HWs and strengthening system-level resilience (e.g., with resources, processes) to enable them to respond to current and future demands and emergencies.
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Affiliation(s)
- Aleksandra J. Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Caitlin Pilbeam
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Hayley Mableson
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Marta Wanat
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Paul Atkinson
- Institute of Population Health, University of Liverpool, Liverpool, United Kingdom
| | - Sally Sheard
- Institute of Population Health, University of Liverpool, Liverpool, United Kingdom
| | - Anne-Marie Martindale
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Tom Solomon
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
- National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, United Kingdom
- Department of Neurology, Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Nina Gobat
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Oxford, United Kingdom
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Van Den Tooren H, Easton A, Hooper C, Mullin J, Fish J, Carson A, Nicholson T, Solomon T, Michael BD. How should we define a 'good' outcome from encephalitis? A systematic review of the range of outcome measures used in the long-term follow-up of patients with encephalitis. Clin Med (Lond) 2022; 22:145-148. [PMID: 38589176 DOI: 10.7861/clinmed.2021-0505] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 11/27/2022]
Abstract
INTRODUCTION Encephalitis is typically caused by infection or autoimmunity. Most survivors suffer complex neurological and psychiatric sequelae. Standardised outcome measures are needed for accurate interpretation of observational studies and clinical trials. Step one in this process is understanding the strengths and weaknesses of those in use. METHODS We performed a systematic literature review searching six databases. One reviewer screened titles and abstracts, and two reviewers determined if shortlisted full-text articles met inclusion criteria. Key data were extracted from these papers and presented as a narrative summary. RESULTS Thirty-seven outcome measures were used for 3,133 patients across the 35 included papers, of which, only one was developed for encephalitis. The outcome measures used in most patients were the Glasgow Outcome Score used in 1,436 (46%), Barthel Index used in 1,173 (37%), Euro-QoL-5D used in 1,107 (35%) and modified Rankin Scale used in 1,034 (33%). CONCLUSION Most of the 37 measures assessed a single category of sequelae using 5-8-point scales and were not validated for use in encephalitis. Research is needed to develop a composite outcome measure for use in clinical practice and a core-outcomes set for use in clinical trials. For now, the Liverpool Outcome Score offers a good choice for clinicians.
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Affiliation(s)
| | - Ava Easton
- Encephalitis Society, Malton, UK and honorary lecturer, University of Liverpool, Liverpool, UK
| | - Cory Hooper
- The Walton Centre NHS Foundation Trust, Liverpool, UK and National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infection, Liverpool, UK
| | - Jenny Mullin
- The Walton Centre NHS Foundation Trust, Liverpool, UK
| | | | | | | | - Tom Solomon
- National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infection, Liverpool, UK and honorary consultant neurologist, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Benedict D Michael
- National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infection, Liverpool, Liverpool, UK and consultant neurologist, The Walton Centre NHS Foundation Trust, Liverpool, UK.
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Easton A, Solomon T. Encephalitis awareness: our ambitious global endeavour. Lancet Neurol 2022; 21:314. [DOI: 10.1016/s1474-4422(22)00079-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 02/11/2022] [Indexed: 10/19/2022]
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Gill C, Griffiths M, Easton A, Solomon T. Challenges for nurses in caring for patients with acute encephalitis: lack of knowledge, time and rehabilitation. Br J Nurs 2022; 31:40-45. [PMID: 35019745 DOI: 10.12968/bjon.2022.31.1.40] [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] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
AIM To explore the experiences of registered nurses providing care to adult patients affected by encephalitis, from admission into hospital through to discharge. STUDY DESIGN A qualitative phenomenological methodology was used. Sample and setting: Eight registered nurses in a city centre teaching hospital. METHODS Data collection took place using in-depth, semi-structured interviews. Data were analysed and themes identified using framework analysis. FINDINGS Three key findings were identified: nurses felt that they lacked knowledge of encephalitis, lacked time to give these patients the care they needed, and they lacked access to rehabilitation for patients with encephalitis. CONCLUSION This study provides the first evidence on nurses' experiences of providing care to patients affected by encephalitis. It has shown that they often lack the knowledge and time to give adequate support to patients. They also lack access to rehabilitation for these patients.
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Affiliation(s)
- Claire Gill
- PhD Candidate, Department of Health Sciences, University of York
| | - Mike Griffiths
- Clinical Lecturer, Institute of Infection and Global Heath, University of Liverpool
| | - Ava Easton
- CEO Encephalitis Society, Encephalitis Society, Malton, North Yorkshire
| | - Tom Solomon
- Professor, Encephalitis Society, Malton, North Yorkshire
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McGill F, Tokarz R, Thomson EC, Filipe A, Sameroff S, Jain K, Bhuva N, Ashraf S, Lipkin WI, Corless C, Pattabiraman C, Gibney B, Griffiths MJ, Geretti AM, Michael BD, Beeching NJ, McKee D, Hart IJ, Mutton K, Jung A, Miller A, Solomon T. Viral capture sequencing detects unexpected viruses in the cerebrospinal fluid of adults with meningitis. J Infect 2022; 84:499-510. [PMID: 34990710 DOI: 10.1016/j.jinf.2021.12.042] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 09/22/2021] [Revised: 12/20/2021] [Accepted: 12/29/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Many patients with meningitis have no aetiology identified leading to unnecessary antimicrobials and prolonged hospitalisation. We used viral capture sequencing to identify possible pathogenic viruses in adults with community-acquired meningitis. METHODS Cerebrospinal fluid (CSF) from 73 patients was tested by VirCapSeq-VERT, a probe set designed to capture viral targets using high throughput sequencing. Patients were categorised as suspected viral meningitis - CSF pleocytosis, no pathogen identified (n = 38), proven viral meningitis - CSF pleocytosis with a pathogen identified (n = 15) or not meningitis - no CSF pleocytosis (n = 20). RESULTS VirCapSeq-VERT detected virus in the CSF of 16/38 (42%) of those with suspected viral meningitis, including twelve individual viruses. A potentially clinically relevant virus was detected in 9/16 (56%). Unexpectedly Toscana virus, rotavirus and Saffold virus were detected and assessed to be potential causative agents. CONCLUSION VirCapSeq-VERT increases the probability of detecting a virus. Using this agnostic approach we identified Toscana virus and, for the first time in adults, rotavirus and Saffold virus, as potential causative agents in adult meningitis. Further work is needed to determine the prevalence of atypical viral candidates as well as the clinical impact of using sequencing methods in real time. This knowledge can help to reduce antimicrobial use and hospitalisations leading to both patient and health system benefits.
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Affiliation(s)
- Fiona McGill
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK; Tropical and Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK; Leeds Teaching Hospitals NHS Trust, Leeds, UK; National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, UK.
| | - Rafal Tokarz
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, NY, USA
| | - Emma C Thomson
- Institute of infection, immunity and inflammation, University of Glasgow, Glasgow, UK
| | - Ana Filipe
- Institute of infection, immunity and inflammation, University of Glasgow, Glasgow, UK
| | - Stephen Sameroff
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, NY, USA
| | - Komal Jain
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, NY, USA
| | - Nishit Bhuva
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, NY, USA
| | - Shirin Ashraf
- Institute of infection, immunity and inflammation, University of Glasgow, Glasgow, UK
| | - W Ian Lipkin
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, NY, USA
| | - Caroline Corless
- Liverpool Specialist virology centre, Department of Infection and Immunity, Liverpool Clinical Laboratories, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Chitra Pattabiraman
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK; National Institute for Mental Health and Neurosciences, Bangalore, India
| | - Barry Gibney
- UK Health Security Agency (previously Public Health England), UK
| | - Michael J Griffiths
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK; 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
| | - Anna Maria Geretti
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK; Tropical and Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK; Faculty of Medicine, University of Rome Tor Vergata
| | - Benedict D Michael
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK; Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK; National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, UK
| | - Nicholas J Beeching
- Tropical and Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK; Liverpool School of Tropical Medicine, Liverpool, UK; National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, UK
| | - David McKee
- Central Manchester Foundation Trust, Manchester, UK
| | - Ian J Hart
- Liverpool Specialist virology centre, Department of Infection and Immunity, Liverpool Clinical Laboratories, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Ken Mutton
- University of Manchester, Manchester, UK
| | - Agam Jung
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Alastair Miller
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Tom Solomon
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK; Department of Neurology, The Walton Centre 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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Misra S, Kolappa K, Prasad M, Radhakrishnan D, Thakur KT, Solomon T, Michael BD, Winkler AS, Beghi E, Guekht A, Pardo CA, Wood GK, Hsiang-Yi Chou S, Fink EL, Schmutzhard E, Kheradmand A, Hoo FK, Kumar A, Das A, Srivastava AK, Agarwal A, Dua T, Prasad K. Frequency of Neurologic Manifestations in COVID-19: A Systematic Review and Meta-analysis. Neurology 2021; 97:e2269-e2281. [PMID: 34635561 PMCID: PMC8665434 DOI: 10.1212/wnl.0000000000012930] [Citation(s) in RCA: 119] [Impact Index Per Article: 39.7] [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: 05/05/2021] [Accepted: 09/30/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES One year after the onset of the coronavirus disease 2019 (COVID-19) pandemic, we aimed to summarize the frequency of neurologic manifestations reported in patients with COVID-19 and to investigate the association of these manifestations with disease severity and mortality. METHODS We searched PubMed, Medline, Cochrane library, ClinicalTrials.gov, and EMBASE for studies from December 31, 2019, to December 15, 2020, enrolling consecutive patients with COVID-19 presenting with neurologic manifestations. Risk of bias was examined with the Joanna Briggs Institute scale. A random-effects meta-analysis was performed, and pooled prevalence and 95% confidence intervals (CIs) were calculated for neurologic manifestations. Odds ratio (ORs) and 95% CIs were calculated to determine the association of neurologic manifestations with disease severity and mortality. Presence of heterogeneity was assessed with I 2, meta-regression, and subgroup analyses. Statistical analyses were conducted in R version 3.6.2. RESULTS Of 2,455 citations, 350 studies were included in this review, providing data on 145,721 patients with COVID-19, 89% of whom were hospitalized. Forty-one neurologic manifestations (24 symptoms and 17 diagnoses) were identified. Pooled prevalence of the most common neurologic symptoms included fatigue (32%), myalgia (20%), taste impairment (21%), smell impairment (19%), and headache (13%). A low risk of bias was observed in 85% of studies; studies with higher risk of bias yielded higher prevalence estimates. Stroke was the most common neurologic diagnosis (pooled prevalence 2%). In patients with COVID-19 ≥60 years of age, the pooled prevalence of acute confusion/delirium was 34%, and the presence of any neurologic manifestations in this age group was associated with mortality (OR 1.80, 95% CI 1.11-2.91). DISCUSSION Up to one-third of patients with COVID-19 analyzed in this review experienced at least 1 neurologic manifestation. One in 50 patients experienced stroke. In those >60 years of age, more than one-third had acute confusion/delirium; the presence of neurologic manifestations in this group was associated with nearly a doubling of mortality. Results must be interpreted with the limitations of observational studies and associated bias in mind. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020181867.
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Affiliation(s)
- Shubham Misra
- From the Department of Neurology (S.M., D.R., A.K., A.D., A.K.S., A.A.), All India Institute of Medical Sciences, New Delhi, India; Brain Health Unit (K.K., T.D.), World Health Organization, Geneva, Switzerland; Department of Clinical Research and Epidemiology (M.P.), Institute of Liver and Biliary Sciences, New Delhi, India; Columbia University Irving Medical Center-New York Presbyterian Hospital (K.T.T.), NY; Institute of Infection, Veterinary and Ecological Sciences (T.S., B.D.M., G.K.W.), University of Liverpool; Department of Neurology (T.S., B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.), Liverpool, UK; Center for Global Health (A.S.W.), Department of Neurology, Technical University of Munich, Germany; Centre for Global Health (A.S.W.), Institute of Health and Society, University of Oslo, Norway; Istituto di Ricerche Farmacologiche Mario Negri IRCCS (E.B.), Milan, Italy; Moscow Research and Clinical Center for Neuropsychiatry and Pirogov Russian National Research Medical University (A.G.), Russia; Departments of Neurology and Pathology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; University of Pittsburgh School of Medicine (S.H.-Y.C.); Department of Critical Care Medicine (E.L.F.), UPMC Children's Hospital of Pittsburgh, PA; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Departments of Neurology and Otolaryngology-Head & Neck Surgery (A.K.), The Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (F.K.H.), Faculty of Medicine and Health Sciences, University Putra Malaysia, Seri Kembangan; and Rajendra Institute of Medical Sciences (K.P.), Ranchi, Jharkhand, India
| | - Kavitha Kolappa
- From the Department of Neurology (S.M., D.R., A.K., A.D., A.K.S., A.A.), All India Institute of Medical Sciences, New Delhi, India; Brain Health Unit (K.K., T.D.), World Health Organization, Geneva, Switzerland; Department of Clinical Research and Epidemiology (M.P.), Institute of Liver and Biliary Sciences, New Delhi, India; Columbia University Irving Medical Center-New York Presbyterian Hospital (K.T.T.), NY; Institute of Infection, Veterinary and Ecological Sciences (T.S., B.D.M., G.K.W.), University of Liverpool; Department of Neurology (T.S., B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.), Liverpool, UK; Center for Global Health (A.S.W.), Department of Neurology, Technical University of Munich, Germany; Centre for Global Health (A.S.W.), Institute of Health and Society, University of Oslo, Norway; Istituto di Ricerche Farmacologiche Mario Negri IRCCS (E.B.), Milan, Italy; Moscow Research and Clinical Center for Neuropsychiatry and Pirogov Russian National Research Medical University (A.G.), Russia; Departments of Neurology and Pathology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; University of Pittsburgh School of Medicine (S.H.-Y.C.); Department of Critical Care Medicine (E.L.F.), UPMC Children's Hospital of Pittsburgh, PA; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Departments of Neurology and Otolaryngology-Head & Neck Surgery (A.K.), The Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (F.K.H.), Faculty of Medicine and Health Sciences, University Putra Malaysia, Seri Kembangan; and Rajendra Institute of Medical Sciences (K.P.), Ranchi, Jharkhand, India
| | - Manya Prasad
- From the Department of Neurology (S.M., D.R., A.K., A.D., A.K.S., A.A.), All India Institute of Medical Sciences, New Delhi, India; Brain Health Unit (K.K., T.D.), World Health Organization, Geneva, Switzerland; Department of Clinical Research and Epidemiology (M.P.), Institute of Liver and Biliary Sciences, New Delhi, India; Columbia University Irving Medical Center-New York Presbyterian Hospital (K.T.T.), NY; Institute of Infection, Veterinary and Ecological Sciences (T.S., B.D.M., G.K.W.), University of Liverpool; Department of Neurology (T.S., B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.), Liverpool, UK; Center for Global Health (A.S.W.), Department of Neurology, Technical University of Munich, Germany; Centre for Global Health (A.S.W.), Institute of Health and Society, University of Oslo, Norway; Istituto di Ricerche Farmacologiche Mario Negri IRCCS (E.B.), Milan, Italy; Moscow Research and Clinical Center for Neuropsychiatry and Pirogov Russian National Research Medical University (A.G.), Russia; Departments of Neurology and Pathology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; University of Pittsburgh School of Medicine (S.H.-Y.C.); Department of Critical Care Medicine (E.L.F.), UPMC Children's Hospital of Pittsburgh, PA; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Departments of Neurology and Otolaryngology-Head & Neck Surgery (A.K.), The Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (F.K.H.), Faculty of Medicine and Health Sciences, University Putra Malaysia, Seri Kembangan; and Rajendra Institute of Medical Sciences (K.P.), Ranchi, Jharkhand, India
| | - Divya Radhakrishnan
- From the Department of Neurology (S.M., D.R., A.K., A.D., A.K.S., A.A.), All India Institute of Medical Sciences, New Delhi, India; Brain Health Unit (K.K., T.D.), World Health Organization, Geneva, Switzerland; Department of Clinical Research and Epidemiology (M.P.), Institute of Liver and Biliary Sciences, New Delhi, India; Columbia University Irving Medical Center-New York Presbyterian Hospital (K.T.T.), NY; Institute of Infection, Veterinary and Ecological Sciences (T.S., B.D.M., G.K.W.), University of Liverpool; Department of Neurology (T.S., B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.), Liverpool, UK; Center for Global Health (A.S.W.), Department of Neurology, Technical University of Munich, Germany; Centre for Global Health (A.S.W.), Institute of Health and Society, University of Oslo, Norway; Istituto di Ricerche Farmacologiche Mario Negri IRCCS (E.B.), Milan, Italy; Moscow Research and Clinical Center for Neuropsychiatry and Pirogov Russian National Research Medical University (A.G.), Russia; Departments of Neurology and Pathology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; University of Pittsburgh School of Medicine (S.H.-Y.C.); Department of Critical Care Medicine (E.L.F.), UPMC Children's Hospital of Pittsburgh, PA; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Departments of Neurology and Otolaryngology-Head & Neck Surgery (A.K.), The Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (F.K.H.), Faculty of Medicine and Health Sciences, University Putra Malaysia, Seri Kembangan; and Rajendra Institute of Medical Sciences (K.P.), Ranchi, Jharkhand, India
| | - Kiran T Thakur
- From the Department of Neurology (S.M., D.R., A.K., A.D., A.K.S., A.A.), All India Institute of Medical Sciences, New Delhi, India; Brain Health Unit (K.K., T.D.), World Health Organization, Geneva, Switzerland; Department of Clinical Research and Epidemiology (M.P.), Institute of Liver and Biliary Sciences, New Delhi, India; Columbia University Irving Medical Center-New York Presbyterian Hospital (K.T.T.), NY; Institute of Infection, Veterinary and Ecological Sciences (T.S., B.D.M., G.K.W.), University of Liverpool; Department of Neurology (T.S., B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.), Liverpool, UK; Center for Global Health (A.S.W.), Department of Neurology, Technical University of Munich, Germany; Centre for Global Health (A.S.W.), Institute of Health and Society, University of Oslo, Norway; Istituto di Ricerche Farmacologiche Mario Negri IRCCS (E.B.), Milan, Italy; Moscow Research and Clinical Center for Neuropsychiatry and Pirogov Russian National Research Medical University (A.G.), Russia; Departments of Neurology and Pathology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; University of Pittsburgh School of Medicine (S.H.-Y.C.); Department of Critical Care Medicine (E.L.F.), UPMC Children's Hospital of Pittsburgh, PA; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Departments of Neurology and Otolaryngology-Head & Neck Surgery (A.K.), The Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (F.K.H.), Faculty of Medicine and Health Sciences, University Putra Malaysia, Seri Kembangan; and Rajendra Institute of Medical Sciences (K.P.), Ranchi, Jharkhand, India
| | - Tom Solomon
- From the Department of Neurology (S.M., D.R., A.K., A.D., A.K.S., A.A.), All India Institute of Medical Sciences, New Delhi, India; Brain Health Unit (K.K., T.D.), World Health Organization, Geneva, Switzerland; Department of Clinical Research and Epidemiology (M.P.), Institute of Liver and Biliary Sciences, New Delhi, India; Columbia University Irving Medical Center-New York Presbyterian Hospital (K.T.T.), NY; Institute of Infection, Veterinary and Ecological Sciences (T.S., B.D.M., G.K.W.), University of Liverpool; Department of Neurology (T.S., B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.), Liverpool, UK; Center for Global Health (A.S.W.), Department of Neurology, Technical University of Munich, Germany; Centre for Global Health (A.S.W.), Institute of Health and Society, University of Oslo, Norway; Istituto di Ricerche Farmacologiche Mario Negri IRCCS (E.B.), Milan, Italy; Moscow Research and Clinical Center for Neuropsychiatry and Pirogov Russian National Research Medical University (A.G.), Russia; Departments of Neurology and Pathology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; University of Pittsburgh School of Medicine (S.H.-Y.C.); Department of Critical Care Medicine (E.L.F.), UPMC Children's Hospital of Pittsburgh, PA; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Departments of Neurology and Otolaryngology-Head & Neck Surgery (A.K.), The Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (F.K.H.), Faculty of Medicine and Health Sciences, University Putra Malaysia, Seri Kembangan; and Rajendra Institute of Medical Sciences (K.P.), Ranchi, Jharkhand, India
| | - Benedict Daniel Michael
- From the Department of Neurology (S.M., D.R., A.K., A.D., A.K.S., A.A.), All India Institute of Medical Sciences, New Delhi, India; Brain Health Unit (K.K., T.D.), World Health Organization, Geneva, Switzerland; Department of Clinical Research and Epidemiology (M.P.), Institute of Liver and Biliary Sciences, New Delhi, India; Columbia University Irving Medical Center-New York Presbyterian Hospital (K.T.T.), NY; Institute of Infection, Veterinary and Ecological Sciences (T.S., B.D.M., G.K.W.), University of Liverpool; Department of Neurology (T.S., B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.), Liverpool, UK; Center for Global Health (A.S.W.), Department of Neurology, Technical University of Munich, Germany; Centre for Global Health (A.S.W.), Institute of Health and Society, University of Oslo, Norway; Istituto di Ricerche Farmacologiche Mario Negri IRCCS (E.B.), Milan, Italy; Moscow Research and Clinical Center for Neuropsychiatry and Pirogov Russian National Research Medical University (A.G.), Russia; Departments of Neurology and Pathology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; University of Pittsburgh School of Medicine (S.H.-Y.C.); Department of Critical Care Medicine (E.L.F.), UPMC Children's Hospital of Pittsburgh, PA; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Departments of Neurology and Otolaryngology-Head & Neck Surgery (A.K.), The Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (F.K.H.), Faculty of Medicine and Health Sciences, University Putra Malaysia, Seri Kembangan; and Rajendra Institute of Medical Sciences (K.P.), Ranchi, Jharkhand, India
| | - Andrea Sylvia Winkler
- From the Department of Neurology (S.M., D.R., A.K., A.D., A.K.S., A.A.), All India Institute of Medical Sciences, New Delhi, India; Brain Health Unit (K.K., T.D.), World Health Organization, Geneva, Switzerland; Department of Clinical Research and Epidemiology (M.P.), Institute of Liver and Biliary Sciences, New Delhi, India; Columbia University Irving Medical Center-New York Presbyterian Hospital (K.T.T.), NY; Institute of Infection, Veterinary and Ecological Sciences (T.S., B.D.M., G.K.W.), University of Liverpool; Department of Neurology (T.S., B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.), Liverpool, UK; Center for Global Health (A.S.W.), Department of Neurology, Technical University of Munich, Germany; Centre for Global Health (A.S.W.), Institute of Health and Society, University of Oslo, Norway; Istituto di Ricerche Farmacologiche Mario Negri IRCCS (E.B.), Milan, Italy; Moscow Research and Clinical Center for Neuropsychiatry and Pirogov Russian National Research Medical University (A.G.), Russia; Departments of Neurology and Pathology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; University of Pittsburgh School of Medicine (S.H.-Y.C.); Department of Critical Care Medicine (E.L.F.), UPMC Children's Hospital of Pittsburgh, PA; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Departments of Neurology and Otolaryngology-Head & Neck Surgery (A.K.), The Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (F.K.H.), Faculty of Medicine and Health Sciences, University Putra Malaysia, Seri Kembangan; and Rajendra Institute of Medical Sciences (K.P.), Ranchi, Jharkhand, India
| | - Ettore Beghi
- From the Department of Neurology (S.M., D.R., A.K., A.D., A.K.S., A.A.), All India Institute of Medical Sciences, New Delhi, India; Brain Health Unit (K.K., T.D.), World Health Organization, Geneva, Switzerland; Department of Clinical Research and Epidemiology (M.P.), Institute of Liver and Biliary Sciences, New Delhi, India; Columbia University Irving Medical Center-New York Presbyterian Hospital (K.T.T.), NY; Institute of Infection, Veterinary and Ecological Sciences (T.S., B.D.M., G.K.W.), University of Liverpool; Department of Neurology (T.S., B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.), Liverpool, UK; Center for Global Health (A.S.W.), Department of Neurology, Technical University of Munich, Germany; Centre for Global Health (A.S.W.), Institute of Health and Society, University of Oslo, Norway; Istituto di Ricerche Farmacologiche Mario Negri IRCCS (E.B.), Milan, Italy; Moscow Research and Clinical Center for Neuropsychiatry and Pirogov Russian National Research Medical University (A.G.), Russia; Departments of Neurology and Pathology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; University of Pittsburgh School of Medicine (S.H.-Y.C.); Department of Critical Care Medicine (E.L.F.), UPMC Children's Hospital of Pittsburgh, PA; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Departments of Neurology and Otolaryngology-Head & Neck Surgery (A.K.), The Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (F.K.H.), Faculty of Medicine and Health Sciences, University Putra Malaysia, Seri Kembangan; and Rajendra Institute of Medical Sciences (K.P.), Ranchi, Jharkhand, India
| | - Alla Guekht
- From the Department of Neurology (S.M., D.R., A.K., A.D., A.K.S., A.A.), All India Institute of Medical Sciences, New Delhi, India; Brain Health Unit (K.K., T.D.), World Health Organization, Geneva, Switzerland; Department of Clinical Research and Epidemiology (M.P.), Institute of Liver and Biliary Sciences, New Delhi, India; Columbia University Irving Medical Center-New York Presbyterian Hospital (K.T.T.), NY; Institute of Infection, Veterinary and Ecological Sciences (T.S., B.D.M., G.K.W.), University of Liverpool; Department of Neurology (T.S., B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.), Liverpool, UK; Center for Global Health (A.S.W.), Department of Neurology, Technical University of Munich, Germany; Centre for Global Health (A.S.W.), Institute of Health and Society, University of Oslo, Norway; Istituto di Ricerche Farmacologiche Mario Negri IRCCS (E.B.), Milan, Italy; Moscow Research and Clinical Center for Neuropsychiatry and Pirogov Russian National Research Medical University (A.G.), Russia; Departments of Neurology and Pathology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; University of Pittsburgh School of Medicine (S.H.-Y.C.); Department of Critical Care Medicine (E.L.F.), UPMC Children's Hospital of Pittsburgh, PA; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Departments of Neurology and Otolaryngology-Head & Neck Surgery (A.K.), The Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (F.K.H.), Faculty of Medicine and Health Sciences, University Putra Malaysia, Seri Kembangan; and Rajendra Institute of Medical Sciences (K.P.), Ranchi, Jharkhand, India
| | - Carlos A Pardo
- From the Department of Neurology (S.M., D.R., A.K., A.D., A.K.S., A.A.), All India Institute of Medical Sciences, New Delhi, India; Brain Health Unit (K.K., T.D.), World Health Organization, Geneva, Switzerland; Department of Clinical Research and Epidemiology (M.P.), Institute of Liver and Biliary Sciences, New Delhi, India; Columbia University Irving Medical Center-New York Presbyterian Hospital (K.T.T.), NY; Institute of Infection, Veterinary and Ecological Sciences (T.S., B.D.M., G.K.W.), University of Liverpool; Department of Neurology (T.S., B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.), Liverpool, UK; Center for Global Health (A.S.W.), Department of Neurology, Technical University of Munich, Germany; Centre for Global Health (A.S.W.), Institute of Health and Society, University of Oslo, Norway; Istituto di Ricerche Farmacologiche Mario Negri IRCCS (E.B.), Milan, Italy; Moscow Research and Clinical Center for Neuropsychiatry and Pirogov Russian National Research Medical University (A.G.), Russia; Departments of Neurology and Pathology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; University of Pittsburgh School of Medicine (S.H.-Y.C.); Department of Critical Care Medicine (E.L.F.), UPMC Children's Hospital of Pittsburgh, PA; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Departments of Neurology and Otolaryngology-Head & Neck Surgery (A.K.), The Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (F.K.H.), Faculty of Medicine and Health Sciences, University Putra Malaysia, Seri Kembangan; and Rajendra Institute of Medical Sciences (K.P.), Ranchi, Jharkhand, India
| | - Greta Karen Wood
- From the Department of Neurology (S.M., D.R., A.K., A.D., A.K.S., A.A.), All India Institute of Medical Sciences, New Delhi, India; Brain Health Unit (K.K., T.D.), World Health Organization, Geneva, Switzerland; Department of Clinical Research and Epidemiology (M.P.), Institute of Liver and Biliary Sciences, New Delhi, India; Columbia University Irving Medical Center-New York Presbyterian Hospital (K.T.T.), NY; Institute of Infection, Veterinary and Ecological Sciences (T.S., B.D.M., G.K.W.), University of Liverpool; Department of Neurology (T.S., B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.), Liverpool, UK; Center for Global Health (A.S.W.), Department of Neurology, Technical University of Munich, Germany; Centre for Global Health (A.S.W.), Institute of Health and Society, University of Oslo, Norway; Istituto di Ricerche Farmacologiche Mario Negri IRCCS (E.B.), Milan, Italy; Moscow Research and Clinical Center for Neuropsychiatry and Pirogov Russian National Research Medical University (A.G.), Russia; Departments of Neurology and Pathology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; University of Pittsburgh School of Medicine (S.H.-Y.C.); Department of Critical Care Medicine (E.L.F.), UPMC Children's Hospital of Pittsburgh, PA; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Departments of Neurology and Otolaryngology-Head & Neck Surgery (A.K.), The Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (F.K.H.), Faculty of Medicine and Health Sciences, University Putra Malaysia, Seri Kembangan; and Rajendra Institute of Medical Sciences (K.P.), Ranchi, Jharkhand, India
| | - Sherry Hsiang-Yi Chou
- From the Department of Neurology (S.M., D.R., A.K., A.D., A.K.S., A.A.), All India Institute of Medical Sciences, New Delhi, India; Brain Health Unit (K.K., T.D.), World Health Organization, Geneva, Switzerland; Department of Clinical Research and Epidemiology (M.P.), Institute of Liver and Biliary Sciences, New Delhi, India; Columbia University Irving Medical Center-New York Presbyterian Hospital (K.T.T.), NY; Institute of Infection, Veterinary and Ecological Sciences (T.S., B.D.M., G.K.W.), University of Liverpool; Department of Neurology (T.S., B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.), Liverpool, UK; Center for Global Health (A.S.W.), Department of Neurology, Technical University of Munich, Germany; Centre for Global Health (A.S.W.), Institute of Health and Society, University of Oslo, Norway; Istituto di Ricerche Farmacologiche Mario Negri IRCCS (E.B.), Milan, Italy; Moscow Research and Clinical Center for Neuropsychiatry and Pirogov Russian National Research Medical University (A.G.), Russia; Departments of Neurology and Pathology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; University of Pittsburgh School of Medicine (S.H.-Y.C.); Department of Critical Care Medicine (E.L.F.), UPMC Children's Hospital of Pittsburgh, PA; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Departments of Neurology and Otolaryngology-Head & Neck Surgery (A.K.), The Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (F.K.H.), Faculty of Medicine and Health Sciences, University Putra Malaysia, Seri Kembangan; and Rajendra Institute of Medical Sciences (K.P.), Ranchi, Jharkhand, India
| | - Ericka L Fink
- From the Department of Neurology (S.M., D.R., A.K., A.D., A.K.S., A.A.), All India Institute of Medical Sciences, New Delhi, India; Brain Health Unit (K.K., T.D.), World Health Organization, Geneva, Switzerland; Department of Clinical Research and Epidemiology (M.P.), Institute of Liver and Biliary Sciences, New Delhi, India; Columbia University Irving Medical Center-New York Presbyterian Hospital (K.T.T.), NY; Institute of Infection, Veterinary and Ecological Sciences (T.S., B.D.M., G.K.W.), University of Liverpool; Department of Neurology (T.S., B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.), Liverpool, UK; Center for Global Health (A.S.W.), Department of Neurology, Technical University of Munich, Germany; Centre for Global Health (A.S.W.), Institute of Health and Society, University of Oslo, Norway; Istituto di Ricerche Farmacologiche Mario Negri IRCCS (E.B.), Milan, Italy; Moscow Research and Clinical Center for Neuropsychiatry and Pirogov Russian National Research Medical University (A.G.), Russia; Departments of Neurology and Pathology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; University of Pittsburgh School of Medicine (S.H.-Y.C.); Department of Critical Care Medicine (E.L.F.), UPMC Children's Hospital of Pittsburgh, PA; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Departments of Neurology and Otolaryngology-Head & Neck Surgery (A.K.), The Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (F.K.H.), Faculty of Medicine and Health Sciences, University Putra Malaysia, Seri Kembangan; and Rajendra Institute of Medical Sciences (K.P.), Ranchi, Jharkhand, India
| | - Erich Schmutzhard
- From the Department of Neurology (S.M., D.R., A.K., A.D., A.K.S., A.A.), All India Institute of Medical Sciences, New Delhi, India; Brain Health Unit (K.K., T.D.), World Health Organization, Geneva, Switzerland; Department of Clinical Research and Epidemiology (M.P.), Institute of Liver and Biliary Sciences, New Delhi, India; Columbia University Irving Medical Center-New York Presbyterian Hospital (K.T.T.), NY; Institute of Infection, Veterinary and Ecological Sciences (T.S., B.D.M., G.K.W.), University of Liverpool; Department of Neurology (T.S., B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.), Liverpool, UK; Center for Global Health (A.S.W.), Department of Neurology, Technical University of Munich, Germany; Centre for Global Health (A.S.W.), Institute of Health and Society, University of Oslo, Norway; Istituto di Ricerche Farmacologiche Mario Negri IRCCS (E.B.), Milan, Italy; Moscow Research and Clinical Center for Neuropsychiatry and Pirogov Russian National Research Medical University (A.G.), Russia; Departments of Neurology and Pathology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; University of Pittsburgh School of Medicine (S.H.-Y.C.); Department of Critical Care Medicine (E.L.F.), UPMC Children's Hospital of Pittsburgh, PA; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Departments of Neurology and Otolaryngology-Head & Neck Surgery (A.K.), The Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (F.K.H.), Faculty of Medicine and Health Sciences, University Putra Malaysia, Seri Kembangan; and Rajendra Institute of Medical Sciences (K.P.), Ranchi, Jharkhand, India
| | - Amir Kheradmand
- From the Department of Neurology (S.M., D.R., A.K., A.D., A.K.S., A.A.), All India Institute of Medical Sciences, New Delhi, India; Brain Health Unit (K.K., T.D.), World Health Organization, Geneva, Switzerland; Department of Clinical Research and Epidemiology (M.P.), Institute of Liver and Biliary Sciences, New Delhi, India; Columbia University Irving Medical Center-New York Presbyterian Hospital (K.T.T.), NY; Institute of Infection, Veterinary and Ecological Sciences (T.S., B.D.M., G.K.W.), University of Liverpool; Department of Neurology (T.S., B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.), Liverpool, UK; Center for Global Health (A.S.W.), Department of Neurology, Technical University of Munich, Germany; Centre for Global Health (A.S.W.), Institute of Health and Society, University of Oslo, Norway; Istituto di Ricerche Farmacologiche Mario Negri IRCCS (E.B.), Milan, Italy; Moscow Research and Clinical Center for Neuropsychiatry and Pirogov Russian National Research Medical University (A.G.), Russia; Departments of Neurology and Pathology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; University of Pittsburgh School of Medicine (S.H.-Y.C.); Department of Critical Care Medicine (E.L.F.), UPMC Children's Hospital of Pittsburgh, PA; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Departments of Neurology and Otolaryngology-Head & Neck Surgery (A.K.), The Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (F.K.H.), Faculty of Medicine and Health Sciences, University Putra Malaysia, Seri Kembangan; and Rajendra Institute of Medical Sciences (K.P.), Ranchi, Jharkhand, India
| | - Fan Kee Hoo
- From the Department of Neurology (S.M., D.R., A.K., A.D., A.K.S., A.A.), All India Institute of Medical Sciences, New Delhi, India; Brain Health Unit (K.K., T.D.), World Health Organization, Geneva, Switzerland; Department of Clinical Research and Epidemiology (M.P.), Institute of Liver and Biliary Sciences, New Delhi, India; Columbia University Irving Medical Center-New York Presbyterian Hospital (K.T.T.), NY; Institute of Infection, Veterinary and Ecological Sciences (T.S., B.D.M., G.K.W.), University of Liverpool; Department of Neurology (T.S., B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.), Liverpool, UK; Center for Global Health (A.S.W.), Department of Neurology, Technical University of Munich, Germany; Centre for Global Health (A.S.W.), Institute of Health and Society, University of Oslo, Norway; Istituto di Ricerche Farmacologiche Mario Negri IRCCS (E.B.), Milan, Italy; Moscow Research and Clinical Center for Neuropsychiatry and Pirogov Russian National Research Medical University (A.G.), Russia; Departments of Neurology and Pathology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; University of Pittsburgh School of Medicine (S.H.-Y.C.); Department of Critical Care Medicine (E.L.F.), UPMC Children's Hospital of Pittsburgh, PA; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Departments of Neurology and Otolaryngology-Head & Neck Surgery (A.K.), The Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (F.K.H.), Faculty of Medicine and Health Sciences, University Putra Malaysia, Seri Kembangan; and Rajendra Institute of Medical Sciences (K.P.), Ranchi, Jharkhand, India
| | - Amit Kumar
- From the Department of Neurology (S.M., D.R., A.K., A.D., A.K.S., A.A.), All India Institute of Medical Sciences, New Delhi, India; Brain Health Unit (K.K., T.D.), World Health Organization, Geneva, Switzerland; Department of Clinical Research and Epidemiology (M.P.), Institute of Liver and Biliary Sciences, New Delhi, India; Columbia University Irving Medical Center-New York Presbyterian Hospital (K.T.T.), NY; Institute of Infection, Veterinary and Ecological Sciences (T.S., B.D.M., G.K.W.), University of Liverpool; Department of Neurology (T.S., B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.), Liverpool, UK; Center for Global Health (A.S.W.), Department of Neurology, Technical University of Munich, Germany; Centre for Global Health (A.S.W.), Institute of Health and Society, University of Oslo, Norway; Istituto di Ricerche Farmacologiche Mario Negri IRCCS (E.B.), Milan, Italy; Moscow Research and Clinical Center for Neuropsychiatry and Pirogov Russian National Research Medical University (A.G.), Russia; Departments of Neurology and Pathology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; University of Pittsburgh School of Medicine (S.H.-Y.C.); Department of Critical Care Medicine (E.L.F.), UPMC Children's Hospital of Pittsburgh, PA; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Departments of Neurology and Otolaryngology-Head & Neck Surgery (A.K.), The Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (F.K.H.), Faculty of Medicine and Health Sciences, University Putra Malaysia, Seri Kembangan; and Rajendra Institute of Medical Sciences (K.P.), Ranchi, Jharkhand, India
| | - Animesh Das
- From the Department of Neurology (S.M., D.R., A.K., A.D., A.K.S., A.A.), All India Institute of Medical Sciences, New Delhi, India; Brain Health Unit (K.K., T.D.), World Health Organization, Geneva, Switzerland; Department of Clinical Research and Epidemiology (M.P.), Institute of Liver and Biliary Sciences, New Delhi, India; Columbia University Irving Medical Center-New York Presbyterian Hospital (K.T.T.), NY; Institute of Infection, Veterinary and Ecological Sciences (T.S., B.D.M., G.K.W.), University of Liverpool; Department of Neurology (T.S., B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.), Liverpool, UK; Center for Global Health (A.S.W.), Department of Neurology, Technical University of Munich, Germany; Centre for Global Health (A.S.W.), Institute of Health and Society, University of Oslo, Norway; Istituto di Ricerche Farmacologiche Mario Negri IRCCS (E.B.), Milan, Italy; Moscow Research and Clinical Center for Neuropsychiatry and Pirogov Russian National Research Medical University (A.G.), Russia; Departments of Neurology and Pathology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; University of Pittsburgh School of Medicine (S.H.-Y.C.); Department of Critical Care Medicine (E.L.F.), UPMC Children's Hospital of Pittsburgh, PA; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Departments of Neurology and Otolaryngology-Head & Neck Surgery (A.K.), The Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (F.K.H.), Faculty of Medicine and Health Sciences, University Putra Malaysia, Seri Kembangan; and Rajendra Institute of Medical Sciences (K.P.), Ranchi, Jharkhand, India
| | - Achal K Srivastava
- From the Department of Neurology (S.M., D.R., A.K., A.D., A.K.S., A.A.), All India Institute of Medical Sciences, New Delhi, India; Brain Health Unit (K.K., T.D.), World Health Organization, Geneva, Switzerland; Department of Clinical Research and Epidemiology (M.P.), Institute of Liver and Biliary Sciences, New Delhi, India; Columbia University Irving Medical Center-New York Presbyterian Hospital (K.T.T.), NY; Institute of Infection, Veterinary and Ecological Sciences (T.S., B.D.M., G.K.W.), University of Liverpool; Department of Neurology (T.S., B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.), Liverpool, UK; Center for Global Health (A.S.W.), Department of Neurology, Technical University of Munich, Germany; Centre for Global Health (A.S.W.), Institute of Health and Society, University of Oslo, Norway; Istituto di Ricerche Farmacologiche Mario Negri IRCCS (E.B.), Milan, Italy; Moscow Research and Clinical Center for Neuropsychiatry and Pirogov Russian National Research Medical University (A.G.), Russia; Departments of Neurology and Pathology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; University of Pittsburgh School of Medicine (S.H.-Y.C.); Department of Critical Care Medicine (E.L.F.), UPMC Children's Hospital of Pittsburgh, PA; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Departments of Neurology and Otolaryngology-Head & Neck Surgery (A.K.), The Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (F.K.H.), Faculty of Medicine and Health Sciences, University Putra Malaysia, Seri Kembangan; and Rajendra Institute of Medical Sciences (K.P.), Ranchi, Jharkhand, India
| | - Ayush Agarwal
- From the Department of Neurology (S.M., D.R., A.K., A.D., A.K.S., A.A.), All India Institute of Medical Sciences, New Delhi, India; Brain Health Unit (K.K., T.D.), World Health Organization, Geneva, Switzerland; Department of Clinical Research and Epidemiology (M.P.), Institute of Liver and Biliary Sciences, New Delhi, India; Columbia University Irving Medical Center-New York Presbyterian Hospital (K.T.T.), NY; Institute of Infection, Veterinary and Ecological Sciences (T.S., B.D.M., G.K.W.), University of Liverpool; Department of Neurology (T.S., B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.), Liverpool, UK; Center for Global Health (A.S.W.), Department of Neurology, Technical University of Munich, Germany; Centre for Global Health (A.S.W.), Institute of Health and Society, University of Oslo, Norway; Istituto di Ricerche Farmacologiche Mario Negri IRCCS (E.B.), Milan, Italy; Moscow Research and Clinical Center for Neuropsychiatry and Pirogov Russian National Research Medical University (A.G.), Russia; Departments of Neurology and Pathology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; University of Pittsburgh School of Medicine (S.H.-Y.C.); Department of Critical Care Medicine (E.L.F.), UPMC Children's Hospital of Pittsburgh, PA; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Departments of Neurology and Otolaryngology-Head & Neck Surgery (A.K.), The Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (F.K.H.), Faculty of Medicine and Health Sciences, University Putra Malaysia, Seri Kembangan; and Rajendra Institute of Medical Sciences (K.P.), Ranchi, Jharkhand, India
| | - Tarun Dua
- From the Department of Neurology (S.M., D.R., A.K., A.D., A.K.S., A.A.), All India Institute of Medical Sciences, New Delhi, India; Brain Health Unit (K.K., T.D.), World Health Organization, Geneva, Switzerland; Department of Clinical Research and Epidemiology (M.P.), Institute of Liver and Biliary Sciences, New Delhi, India; Columbia University Irving Medical Center-New York Presbyterian Hospital (K.T.T.), NY; Institute of Infection, Veterinary and Ecological Sciences (T.S., B.D.M., G.K.W.), University of Liverpool; Department of Neurology (T.S., B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.), Liverpool, UK; Center for Global Health (A.S.W.), Department of Neurology, Technical University of Munich, Germany; Centre for Global Health (A.S.W.), Institute of Health and Society, University of Oslo, Norway; Istituto di Ricerche Farmacologiche Mario Negri IRCCS (E.B.), Milan, Italy; Moscow Research and Clinical Center for Neuropsychiatry and Pirogov Russian National Research Medical University (A.G.), Russia; Departments of Neurology and Pathology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; University of Pittsburgh School of Medicine (S.H.-Y.C.); Department of Critical Care Medicine (E.L.F.), UPMC Children's Hospital of Pittsburgh, PA; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Departments of Neurology and Otolaryngology-Head & Neck Surgery (A.K.), The Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (F.K.H.), Faculty of Medicine and Health Sciences, University Putra Malaysia, Seri Kembangan; and Rajendra Institute of Medical Sciences (K.P.), Ranchi, Jharkhand, India
| | - Kameshwar Prasad
- From the Department of Neurology (S.M., D.R., A.K., A.D., A.K.S., A.A.), All India Institute of Medical Sciences, New Delhi, India; Brain Health Unit (K.K., T.D.), World Health Organization, Geneva, Switzerland; Department of Clinical Research and Epidemiology (M.P.), Institute of Liver and Biliary Sciences, New Delhi, India; Columbia University Irving Medical Center-New York Presbyterian Hospital (K.T.T.), NY; Institute of Infection, Veterinary and Ecological Sciences (T.S., B.D.M., G.K.W.), University of Liverpool; Department of Neurology (T.S., B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.), Liverpool, UK; Center for Global Health (A.S.W.), Department of Neurology, Technical University of Munich, Germany; Centre for Global Health (A.S.W.), Institute of Health and Society, University of Oslo, Norway; Istituto di Ricerche Farmacologiche Mario Negri IRCCS (E.B.), Milan, Italy; Moscow Research and Clinical Center for Neuropsychiatry and Pirogov Russian National Research Medical University (A.G.), Russia; Departments of Neurology and Pathology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; University of Pittsburgh School of Medicine (S.H.-Y.C.); Department of Critical Care Medicine (E.L.F.), UPMC Children's Hospital of Pittsburgh, PA; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Departments of Neurology and Otolaryngology-Head & Neck Surgery (A.K.), The Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (F.K.H.), Faculty of Medicine and Health Sciences, University Putra Malaysia, Seri Kembangan; and Rajendra Institute of Medical Sciences (K.P.), Ranchi, Jharkhand, India.
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Abbas A, Abdukahil SA, Abdulkadir NN, Abe R, Abel L, Absil L, Acharya S, Acker A, Adachi S, Adam E, Adrião D, Ageel SA, Ahmed S, Ain Q, Ainscough K, Aisa T, Ait Hssain A, Ait Tamlihat Y, Akimoto T, Akmal E, Al Qasim E, Alalqam R, Alam T, Al-dabbous T, Alegesan S, Alegre C, Alessi M, Alex B, Alexandre K, Al-Fares A, Alfoudri H, Ali I, Ali Shah N, Alidjnou KE, Aliudin J, Alkhafajee Q, Allavena C, Allou N, Altaf A, Alves J, Alves JM, Alves R, Amaral M, Amira N, Ammerlaan H, Ampaw P, Andini R, Andrejak C, Angheben A, Angoulvant F, Ansart S, Anthonidass S, Antonelli M, Antunes de Brito CA, Anwar KR, Apriyana A, Arabi Y, Aragao I, Arali R, Arancibia F, Araujo C, Arcadipane A, Archambault P, Arenz L, Arlet JB, Arnold-Day C, Aroca A, Arora L, Arora R, Artaud-Macari E, Aryal D, Asaki M, Asensio A, Ashley E, Ashraf M, Ashraf S, Asim M, Assie JB, Asyraf A, Atique A, Attanyake AMUL, Auchabie J, Aumaitre H, Auvet A, Azemar L, Azoulay C, Bach B, Bachelet D, Badr C, Baig N, Baillie JK, Baird JK, Bak E, Bakakos A, Bakar NA, Bal A, Balakrishnan M, Balan V, Bani-Sadr F, Barbalho R, Barbosa NY, Barclay WS, Barnett SU, Barnikel M, Barrasa H, Barrelet A, Barrigoto C, Bartoli M, Bartone C, Baruch J, Bashir M, Basmaci R, Basri MFH, Bastos D, Battaglini D, Bauer J, Bautista Rincon DF, Bazan Dow D, Bedossa A, Bee KH, Behilill S, Beishuizen A, Beljantsev A, Bellemare D, Beltrame A, Beltrão BA, Beluze M, Benech N, Benjiman LE, Benkerrou D, Bennett S, Bento L, Berdal JE, Bergeaud D, Bergin H, Bernal Sobrino JL, Bertoli G, Bertolino L, Bessis S, Betz A, Bevilcaqua S, Bezulier K, Bhatt A, Bhavsar K, Bianchi I, Bianco C, Bidin FN, Bikram Singh M, Bin Humaid F, Bin Kamarudin MN, Bissuel F, Biston P, Bitker L, Blanco-Schweizer P, Blier C, Bloos F, Blot M, Blumberg L, Boccia F, Bodenes L, Bogaarts A, Bogaert D, Boivin AH, Bolze PA, Bompart F, Bonfasius A, Borges D, Borie R, Bosse HM, Botelho-Nevers E, Bouadma L, Bouchaud O, Bouchez S, Bouhmani D, Bouhour D, Bouiller K, Bouillet L, Bouisse C, Boureau AS, Bourke J, Bouscambert M, Bousquet A, Bouziotis J, Boxma B, Boyer-Besseyre M, Boylan M, Bozza FA, Brack M, Braconnier A, Braga C, Brandenburger T, Brás Monteiro F, Brazzi L, Breen D, Breen P, Breen P, Brett S, Brickell K, Broadley T, Browne A, Browne S, Brozzi N, Brusse-Keizer M, Buchtele N, Buesaquillo C, Bugaeva P, Buisson M, Burhan E, Burrell A, Bustos IG, Butnaru D, Cabie A, Cabral S, Caceres E, Cadoz C, Callahan M, Calligy K, Calvache JA, Cam J, Campana V, Campbell P, Campisi J, Canepa C, Cantero M, Caraux-Paz P, Cárcel S, Cardellino CS, Cardoso F, Cardoso F, Cardoso N, Cardoso S, Carelli S, Carlier N, Carmoi T, Carney G, Carpenter C, Carqueja I, Carret MC, Carrier FM, Carroll I, Carson G, Carton E, Casanova ML, Cascão M, Casey S, Casimiro J, Cassandra B, Castañeda S, Castanheira N, Castor-Alexandre G, Castrillón H, Castro I, Catarino A, Catherine FX, Cattaneo P, Cavalin R, Cavalli GG, Cavayas A, Ceccato A, Cervantes-Gonzalez M, Chair A, Chakveatze C, Chan A, Chand M, Chantalat Auger C, Chapplain JM, Chas J, Chaudary M, Chávez Iñiguez JS, Chen A, Chen YS, Cheng MP, Cheret A, Chiarabini T, Chica J, Chidambaram SK, Chin-Tho L, Chirouze C, Chiumello D, Cho HJ, Cho SM, Cholley B, Chopin MC, Chow TS, Chow YP, Chua HJ, Chua J, Cidade JP, Cisneros Herreros JM, Citarella BW, Ciullo A, Clarke E, Clarke J, Claure Del Granado R, Clohisey S, Cobb JP, Coca N, Codan C, Cody C, Coelho A, Coles M, Colin G, Collins M, Colombo SM, Combs P, Connolly J, Connor M, Conrad A, Contreras S, Conway E, Cooke GS, Copland M, Cordel H, Corley A, Cormican S, Cornelis S, Cornet AD, Corpuz AJ, Cortegiani A, Corvaisier G, Costigan E, Couffignal C, Couffin-Cadiergues S, Courtois R, Cousse S, Cregan R, Crepy D'Orleans C, Croonen S, Crowl G, Crump J, Cruz C, Cruz Berm JL, Cruz Rojo J, Csete M, Cucino A, Cullen A, Cullen C, Cummings M, Curley G, Curlier E, Curran C, Custodio P, da Silva Filipe A, Da Silveira C, Dabaliz AA, Dagens A, Dahly D, Dalton H, Dalton J, Daly S, D'Amico F, Daneman N, Daniel C, Dankwa EA, Dantas J, D’Aragon F, de Boer M, de Loughry G, de Mendoza D, De Montmollin E, de Oliveira França RF, de Pinho Oliveira AI, De Rosa R, de Silva T, de Vries P, Deacon J, Dean D, Debard A, DeBenedictis B, Debray MP, DeCastro N, Dechert W, Deconninck L, Decours R, Defous E, Delacroix I, Delaveuve E, Delavigne K, Delfos NM, Deligiannis I, Dell'Amore A, Delmas C, Delobel P, Delsing C, Demonchy E, Denis E, Deplanque D, Depuydt P, Desai M, Descamps D, Desvallée M, Dewayanti S, Diallo A, Diamantis S, Dias A, Diaz P, Diaz R, Diaz Diaz JJ, Didier K, Diehl JL, Dieperink W, Dimet J, Dinot V, Diop F, Diouf A, Dishon Y, Dixit D, Djossou F, Docherty AB, Doherty H, Dondorp AM, Dong A, Donnelly CA, Donnelly M, Donohue C, Donohue S, Donohue Y, Doran C, Doran P, Dorival C, D'Ortenzio E, Douglas JJ, Douma R, Dournon N, Downer T, Downey J, Downing M, Drake T, Driscoll A, Dryden M, Duarte Fonseca C, Dubee V, Dubos F, Ducancelle A, Duculan T, Dudman S, Duggal A, Dunand P, Dunning J, Duplaix M, Durante-Mangoni E, Durham III L, Dussol B, Duthoit J, Duval X, Dyrhol-Riise AM, Ean SC, Echeverria-Villalobos M, Egan S, Eira C, El Sanharawi M, Elapavaluru S, Elharrar B, Ellerbroek J, Eloy P, Elshazly T, Elyazar I, Enderle I, Endo T, Eng CC, Engelmann I, Enouf V, Epaulard O, Escher M, Esperatti M, Esperou H, Esposito-Farese M, Estevão J, Etienne M, Ettalhaoui N, Everding AG, Evers M, Fabre I, Fabre M, Faheem A, Fahy A, Fairfield CJ, Fakar Z, Faria P, Farooq A, Farrar JJ, Farshait N, Fateena H, Fatoni AZ, Faure K, Favory R, Fayed M, Feely N, Feeney L, Fernandes J, Fernandes M, Fernandes S, Ferrand FX, Ferrand Devouge E, Ferrão J, Ferraz M, Ferreira B, Ferreira S, Ferrer-Roca R, Ferriere N, Ficko C, Figueiredo-Mello C, Fiorda J, Flament T, Flateau C, Fletcher T, Florio LL, Flynn B, Flynn D, Foley C, Foley J, Fomin V, Fonseca T, Fontela P, Forsyth S, Foster D, Foti G, Fourn E, Fowler RA, Fraher DM, Franch-Llasat D, Fraser C, Fraser JF, Freire MV, Freitas Ribeiro A, Friedrich C, Fritz R, Fry S, Fuentes N, Fukuda M, Gaborieau V, Gaci R, Gagliardi M, Gagnard JC, Gagné N, Gagneux-Brunon A, Gaião S, Gail Skeie L, Gallagher P, Gallego Curto E, Gamble C, Gani Y, Garan A, Garcia R, García Barrio N, Garcia-Diaz J, Garcia-Gallo E, Garimella N, Garot D, Garrait V, Gauli B, Gault N, Gavin A, Gavrylov A, Gaymard A, Gebauer J, Geraud E, Gerbaud Morlaes L, Germano N, ghisulal PK, Ghosn J, Giani M, Giaquinto C, Gibson J, Gigante T, Gilg M, Gilroy E, Giordano G, Girvan M, Gissot V, Gitahi J, Giwangkancana G, Glikman D, Glybochko P, Gnall E, Goco G, Goehringer F, Goepel S, Goffard JC, Goh JY, Golob J, Gomes R, Gomez K, Gómez-Junyent J, Gominet M, Gonzalez A, Gordon P, Gordon A, Gorenne I, Goubert L, Goujard C, Goulenok T, Grable M, Graf J, Grandin EW, Granier P, Grasselli G, Grazioli L, Green CA, Greene C, Greenhalf W, Greffe S, Grieco DL, Griffee M, Griffiths F, Grigoras I, Groenendijk A, Grosse Lordemann A, Gruner H, Gu Y, Guarracino F, Guedj J, Guego M, Guellec D, Guerguerian AM, Guerreiro D, Guery R, Guillaumot A, Guilleminault L, Guimarães de Castro M, Guimard T, Haalboom M, Haber D, Habraken H, Hachemi A, Hadri N, Haidash O, Haider S, Haidri F, Hakak S, Hall A, Hall M, Halpin S, Hamer A, Hamers R, Hamidfar R, Hammond T, Han LY, Haniffa R, Hao KW, Hardwick H, Harrison EM, Harrison J, Harrison SBE, Hartman A, Hashmi J, Hashmi M, Hayat M, Hayes A, Hays L, Heerman J, Heggelund L, Hendry R, Hennessy M, Henriquez A, Hentzien M, Herekar F, Hernandez-Montfort J, Herr D, Hershey A, Hesstvedt L, Hidayah A, Higgins D, Higgins E, HigginsOKeeffe G, Hinchion R, Hinton S, Hiraiwa H, Hitoto H, Ho A, Ho YB, Hoctin A, Hoffmann I, Hoh WH, Hoiting O, Holt R, Holter JC, Horby P, Horcajada JP, Hoshino K, Hoshino K, Houas I, Hough CL, Houltham S, Hsu JMY, Hulot JS, Hussain I, Ijaz S, Illes HG, Imbert P, Imran M, Imran Sikander R, Inácio H, Infante Dominguez C, Ing YS, Iosifidis E, Ippolito M, Isgett S, Ishani PGPI, Isidoro T, Ismail N, Isnard M, Itai J, Ito A, Ivulich D, Jaafar D, Jaafoura S, Jabot J, Jackson C, Jamieson N, Jaquet P, Jassat W, Jaud-Fischer C, Jaureguiberry S, Javidfar J, Jawad I, Jaworsky D, Jayakumar D, Jego F, Jelani AM, Jenum S, Jimbo-Sotomayor R, Job VDP, Joe OY, Jorge García RN, Joseph C, Joseph M, Joshi S, Jourdain M, Jouvet P, June J, Jung A, Jung H, Juzar D, Kafif O, Kaguelidou F, Kaisbain N, Kaleesvran T, Kali S, Kalicinska A, Kalomoiri S, Kamal S, Kamaluddin MAA, Kamaruddin ZAC, Kamarudin N, Kandamby DH, Kandel C, Kang KY, Kant R, Kanwal D, Kanyawati D, Karki B, Karpayah P, Karsies T, Kartsonaki C, Kasugai D, Kataria A, Katz K, Kaur A, Kaur Johal S, Kawasaki T, Kay C, Keane H, Keating S, Kellam P, Kelly A, Kelly A, Kelly C, Kelly N, Kelly S, Kelly Y, Kelsey M, Kennedy R, Kennon K, Kernan M, Kerroumi Y, Keshav S, Kestelyn E, Khalid I, Khalid O, Khalil A, Khan C, Khan I, Khanal S, Kho ME, Khoo D, Khoo R, Khoo S, Khoso N, Kiat KH, Kida Y, Kiiza P, Kildal AB, Kim JB, Kimmoun A, Kindgen-Milles D, King A, Kitamura N, Klenerman P, Klont R, Kloumann Bekken G, Knight S, Kobbe R, Kodippily C, Kohns Vasconcelos M, Koirala S, Komatsu M, Korten V, Kosgei C, Kpangon A, Krawczyk K, Krishnan S, Krishnan V, Kruglova O, Kumar A, Kumar D, Kumar G, Kumar M, Kumar Vecham P, Kuriakose D, Kurtzman E, Kusumastuti NP, Kutsogiannis D, Kutsyna G, Kyriakoulis K, Lachatre M, Lacoste M, Laffey JG, Lagrange M, Laine F, Lairez O, Lakhey S, Lalueza A, Lambert M, Lamontagne F, Langelot-Richard M, Langlois V, Lantang EY, Lanza M, Laouénan C, Laribi S, Lariviere D, Lasry S, Latif N, Launay O, Laureillard D, Lavie-Badie Y, Law A, Lawrence C, Lawrence T, Le M, Le Bihan C, Le Bris C, Le Falher G, Le Fevre L, Le Hingrat Q, Le Maréchal M, Le Mestre S, Le Moal G, Le Moing V, Le Nagard H, Le Turnier P, Leal E, Leal Santos M, Lee BH, Lee HG, Lee J, Lee SH, Lee TC, Lee YL, Leeming G, Lefebvre B, Lefebvre L, Lefevre B, LeGac S, Lelievre JD, Lellouche F, Lemaignen A, Lemee V, Lemeur A, Lemmink G, Lene HS, Lennon J, León R, Leone M, Leone M, Lepiller Q, Lescure FX, Lesens O, Lesouhaitier M, Lester-Grant A, Levy B, Levy Y, Levy-Marchal C, Lewandowska K, L'Her E, Li Bassi G, Liang J, Liaquat A, Liegeon G, Lim KC, Lim WS, Lima C, Lina B, Lina L, Lind A, Lingas G, Lion-Daolio S, Lissauer S, Liu K, Livrozet M, Lizotte P, Loforte A, Lolong N, Loon LC, Lopes D, Lopez-Colon D, Loschner AL, Loubet P, Loufti B, Louis G, Lourenco S, Lovelace-Macon L, Low LL, Lowik M, Loy JS, Lucet JC, Lumbreras Bermejo C, Luna CM, Lungu O, Luong L, Luque N, Luton D, Lwin N, Lyons R, Maasikas O, Mabiala O, MacDonald S, MacDonald S, Machado M, Macheda G, Macias Sanchez J, Madhok J, Maestro de la Calle G, Mahieu R, Mahy S, Maia AR, Maier LS, Maillet M, Maitre T, Malfertheiner M, Malik N, Mallon P, Maltez F, Malvy D, Manda V, Mandei JM, Mandelbrot L, Manetta F, Mangal K, Mankikian J, Manning E, Manuel A, Maria Sant`Ana Malaque C, Marino D, Marino F, Markowicz S, Maroun Eid C, Marques A, Marquis C, Marsh B, Marsh L, Marshal M, Marshall J, Martelli CT, Martin DA, Martin E, Martin-Blondel G, Martinelli A, Martin-Loeches I, Martinot M, Martin-Quiros A, Martins A, Martins J, Martins N, Martins Rego C, Martucci G, Martynenko O, Marwali EM, Marzukie M, Masa Jimenez JF, Maslove D, Maslove D, Mason P, Mason S, Masood S, Masood S, Mat Nor B, Matan M, Mateus Fernandes H, Mathew M, Mathieu D, Mattei M, Matulevics R, Maulin L, Maxwell M, Maynar J, Mazzoni T, Mc Sweeney L, McAndrew L, McArthur C, McCarthy A, McCarthy A, McCloskey C, McConnochie R, McDermott S, McDonald SE, McElroy A, McElwee S, McEneany V, McEvoy N, McGeer A, McKay C, McKeown J, McLean KA, McNally P, McNicholas B, McPartlan E, Meaney E, Mear-Passard C, Mechlin M, Meher M, Mehkri O, Mele F, Melo L, Memon K, Mendes JJ, Menkiti O, Menon K, Mentré F, Mentzer AJ, Mercier E, Mercier N, Merckx A, Mergeay-Fabre M, Mergler B, Merson L, Mesquita A, Metwally O, Meybeck A, Meyer D, Meynert AM, Meysonnier V, Meziane A, Mezidi M, Michelagnoli G, Michelanglei C, Michelet I, Mihelis E, Mihnovit V, Miranda-Maldonado H, Misnan NA, Mohamed NNE, Mohamed TJ, Moin A, Molina D, Molinos E, Molloy B, Mone M, Monteiro A, Montes C, Montrucchio G, Moore S, Moore SC, Morales Cely L, Moro L, Morocho Tutillo DR, Morton B, Motherway C, Motos A, Mouquet H, Mouton Perrot C, Moyet J, Mudara C, Mufti AK, Muh NY, Muhamad D, Mullaert J, Muller F, Müller KE, Munblit D, Muneeb S, Munir N, Munshi L, Murphy A, Murphy A, Murphy L, Murris M, Murthy S, Musaab H, Muyandy G, Myrodia DM, N N, Nagpal D, Nagrebetsky A, Narasimhan M, Narayanan N, Nasim Khan R, Nazerali-Maitland A, Neant N, Neb H, Nekliudov NA, Nelwan E, Neto R, Neumann E, Neves B, Ng PY, Nghi A, Nguyen D, Ni Choileain O, Ni Leathlobhair N, Nichol A, Nitayavardhana P, Nonas S, Noordin NAM, Noret M, Norharizam NFI, Norman L, Notari A, Noursadeghi M, Nowicka K, Nowinski A, Nseir S, Nunez JI, Nurnaningsih N, Nyamankolly E, O Brien F, O'Callaghan A, Occhipinti G, OConnor D, O'Donnell M, Ogston T, Ogura T, Oh TH, O'Halloran S, O'Hearn K, Ohshimo S, Oldakowska A, Oliveira J, Oliveira L, Olliaro PL, O'Neil C, Ong DS, Ong JY, Oosthuyzen W, Opavsky A, Openshaw P, Orakzai S, Orozco-Chamorro CM, Orquera A, Ortoleva J, Osatnik J, O'Shea L, O'Sullivan M, Othman SZ, Ouamara N, Ouissa R, Owyang C, Oziol E, Pabasara HMU, Pagadoy M, Pages J, Palacios A, Palacios M, Palmarini M, Panarello G, Panda PK, Paneru H, Pang LH, Panigada M, Pansu N, Papadopoulos A, Parke R, Parker M, Parra B, Parrini V, Pasha T, Pasquier J, Pastene B, Patauner F, Patel J, Pathmanathan MD, Patrão L, Patricio P, Patrier J, Patterson L, Pattnaik R, Paul C, Paul M, Paulos J, Paxton WA, Payen JF, Peariasamy K, Pedrera Jiménez M, Peek GJ, Peelman F, Peiffer-Smadja N, Peigne V, Pejkovska M, Pelosi P, Peltan ID, Pereira R, Perez D, Periel L, Perpoint T, Pesenti A, Pestre V, Petrou L, Petrov-Sanchez V, Pettersen FO, Peytavin G, Pharand S, Piagnerelli M, Picard W, Picone O, Piero MD, Pierobon C, Piersma D, Pimentel C, Pinto R, Pires C, Pironneau I, Piroth L, Pius R, Piva S, Plantier L, Plotkin D, Png HS, Poissy J, Pokeerbux R, Pokorska-Spiewak M, Poli S, Pollakis G, Ponscarme D, Popielska J, Post AM, Postma DF, Povoa P, Póvoas D, Powis J, Prapa S, Preau S, Prebensen C, Preiser JC, Prinssen A, Pritchard MG, Priyadarshani GDD, Proença L, Pudota S, Puéchal O, Pujo Semedi B, Pulicken M, Puntoni M, Purcell G, Quesada L, Quinones-Cardona V, Quirós González V, Quist-Paulsen E, Quraishi M, Rabaa M, Rabaud C, Rabindrarajan E, Rafael A, Rafiq M, Ragazzo G, Rahman AKHA, Rahman RA, Rahutullah A, Rainieri F, Rajahram GS, Rajapakse N, Ralib A, Ramakrishnan N, Ramanathan K, Ramli AA, Rammaert B, Ramos GV, Rana A, Rangappa R, Ranjan R, Rapp C, Rashan A, Rashan T, Rasheed G, Rasmin M, Rätsep I, Rau C, Ravi T, Raza A, Real A, Rebaudet S, Redl S, Reeve B, Rehan A, Rehman A, Reid L, Reid L, Reikvam DH, Reis R, Rello J, Remppis J, Remy M, Ren H, Renk H, Resende L, Resseguier AS, Revest M, Rewa O, Reyes LF, Reyes T, Ribeiro MI, Richardson D, Richardson D, Richier L, Ridzuan SNAA, Riera J, Rios AL, Rishu A, Rispal P, Risso K, Rivera Nuñez MA, Rizer N, Robb D, Robba C, Roberto A, Roberts S, Robertson DL, Robineau O, Roche-Campo F, Rodari P, Rodeia S, Rodriguez Abreu J, Roessler B, Roger C, Roger PM, Roilides E, Rojek A, Romaru J, Roncon-Albuquerque Jr R, Roriz M, Rosa-Calatrava M, Rose M, Rosenberger D, Rossanese A, Rossetti M, Rossignol B, Rossignol P, Rousset S, Roy C, Roze B, Rusmawatiningtyas D, Russell CD, Ryan M, Ryan M, Ryckaert S, Rygh Holten A, Saba I, Sadaf S, Sadat M, Sahraei V, Saint-Gilles M, Sakiyalak P, Salahuddin N, Salazar L, Saleem J, Saleem J, Sales G, Sallaberry S, Salmon Gandonniere C, Salvator H, Sanchez O, Sánchez Choez X, Sanchez de Oliveira K, Sanchez-Miralles A, Sancho-Shimizu V, Sandhu G, Sandhu Z, Sandrine PF, Sandulescu O, Santos M, Sarfo-Mensah S, Sarmento Banheiro B, Sarmiento ICE, Sarton B, Satyapriya S, Satyawati R, Saviciute E, Savio R, Savvidou P, Saw YT, Schaffer J, Schermer T, Scherpereel A, Schneider M, Schroll S, Schwameis M, Schwartz G, Scott JT, Scott-Brown J, Sedillot N, Seitz T, Selvanayagam J, Selvarajoo M, Semaille C, Semple MG, Senian RB, Senneville E, Sepulveda C, Sequeira F, Sequeira T, Serpa Neto A, Serrano Balazote P, Shadowitz E, Shahidan SA, Shahnaz Hasan M, Shamsah M, Shankar A, Sharjeel S, Sharma P, Shaw CA, Shaw V, Shi H, Shiban N, Shiekh M, Shiga T, Shime N, Shimizu H, Shimizu K, Shimizu N, Shindo N, Shrapnel S, Shum HP, Si Mohammed N, Siang NY, Sibiude J, Siddiqui A, Sigfrid L, Sillaots P, Silva C, Silva MJ, Silva R, Sim Lim Heng B, Sin WC, Singh BC, Singh P, Sitompul PA, Sivam K, Skogen V, Smith S, Smood B, Smyth C, Smyth M, Smyth M, Snacken M, So D, Soh TV, Solis M, Solomon J, Solomon T, Somers E, Sommet A, Song MJ, Song R, Song T, Song Chia J, Sonntagbauer M, Soom AM, Sotto A, Soum E, Sousa AC, Sousa M, Sousa Uva M, Souza-Dantas V, Sperry A, Spinuzza E, Sri Darshana BPSR, Sriskandan S, Stabler S, Staudinger T, Stecher SS, Steinsvik T, Stienstra Y, Stiksrud B, Stolz E, Stone A, Streinu-Cercel A, Streinu-Cercel A, Strudwick S, Stuart A, Stuart D, Subekti D, Suen G, Suen JY, Sukumar P, Sultana A, Summers C, Supic D, Suppiah D, Surovcová M, Suwarti S, Svistunov AA, Syahrin S, Syrigos K, Sztajnbok J, Szuldrzynski K, Tabrizi S, Taccone FS, Tagherset L, Taib SM, Talarek E, Taleb S, Talsma J, Tampubolon ML, Tan KK, Tan LV, Tan YC, Tanaka C, Tanaka H, Tanaka T, Taniguchi H, Tanveer H, Taqdees H, Taqi A, Tardivon C, Tattevin P, Taufik MA, Tawfik H, Tedder RS, Tee TY, Teixeira J, Tejada S, Tellier MC, Teoh SK, Teotonio V, Téoulé F, Terpstra P, Terrier O, Terzi N, Tessier-Grenier H, Tey A, Thabit AAM, Tham ZD, Thangavelu S, Thibault V, Thiberville SD, Thill B, Thirumanickam J, Thompson S, Thomson D, Thomson EC, Thurai SRT, Thuy DB, Thwaites RS, Tierney P, Tieroshyn V, Timashev PS, Timsit JF, Tirupakuzhi Vijayaraghavan BK, Tissot N, Toh JZY, Toki M, Tolppa T, Tonby K, Tonnii SL, Torres A, Torres M, Torres Santos-Olmo RM, Torres-Zevallos H, Towers M, Trapani T, Traynor D, Treoux T, Trieu HT, Tripathy S, Tromeur C, Trontzas I, Trouillon T, Truong J, Tual C, Tubiana S, Tuite H, Turmel JM, Turtle LC, Tveita A, Twardowski P, Uchiyama M, Udayanga PGI, Udy A, Ullrich R, Umer Z, Uribe A, Usman A, Vajdovics C, Val-Flores L, Valle AL, Valran A, Van de Velde S, van den Berge M, van der Feltz M, van der Valk P, Van Der Vekens N, Van der Voort P, Van Der Werf S, van Dyk M, van Gulik L, Van Hattem J, van Lelyveld S, van Netten C, Van Twillert G, van Veen I, Vanel N, Vanoverschelde H, Varghese P, Varrone M, Vasudayan SR, Vauchy C, Vaughan H, Veeran S, Veislinger A, Vencken S, Ventura S, Verbon A, Vidal JE, Vieira C, Vijayan D, Villanueva JA, Villar J, Villeneuve PM, Villoldo A, Vinh Chau NV, Visseaux B, Visser H, Vitiello C, Vonkeman H, Vuotto F, Wahab NH, Wahab SA, Wahid NA, Wainstein M, Wan Muhd Shukeri WF, Wang CH, Webb SA, Wei J, Weil K, Wen TP, Wesselius S, West TE, Wham M, Whelan B, White N, Wicky PH, Wiedemann A, Wijaya SO, Wille K, Willems S, Williams V, Wils EJ, Wing Yiu N, Wong C, Wong TF, Wong XC, Wong YS, Xian GE, Xian LS, Xuan KP, Xynogalas I, Yacoub S, Yakop SRBM, Yamazaki M, Yazdanpanah Y, Yee Liang Hing N, Yelnik C, Yeoh CH, Yerkovich S, Yokoyama T, Yonis H, Yousif O, Yuliarto S, Zaaqoq A, Zabbe M, Zacharowski K, Zahid M, Zahran M, Zaidan NZB, Zambon M, Zambrano M, Zanella A, Zawadka K, Zaynah N, Zayyad H, Zoufaly A, Zucman D. The value of open-source clinical science in pandemic response: lessons from ISARIC. Lancet Infect Dis 2021; 21:1623-1624. [PMID: 34619109 PMCID: PMC8489876 DOI: 10.1016/s1473-3099(21)00565-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/16/2021] [Indexed: 12/31/2022]
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Butler M, Tamborska A, Wood GK, Ellul M, Thomas RH, Galea I, Pett S, Singh B, Solomon T, Pollak TA, Michael BD, Nicholson TR. Considerations for causality assessment of neurological and neuropsychiatric complications of SARS-CoV-2 vaccines: from cerebral venous sinus thrombosis to functional neurological disorder. J Neurol Neurosurg Psychiatry 2021; 92:1144-1151. [PMID: 34362855 DOI: 10.1136/jnnp-2021-326924] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/21/2021] [Indexed: 12/26/2022]
Affiliation(s)
- Matt Butler
- Institute of Psychiatry Psychology and Neuroscience, London, UK
| | - Arina Tamborska
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK.,University of Liverpool, Liverpool, UK
| | - Greta K Wood
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK.,University of Liverpool, Liverpool, UK
| | - Mark Ellul
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Rhys H Thomas
- Department of Neuroscience, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK.,Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Ian Galea
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Sarah Pett
- MRC CTU at UCL, Institute for Global Health and Institute for Clinical Trials Methodology, University College London, London, UK
| | | | - Tom Solomon
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Thomas Arthur Pollak
- Department of Psychological Medicine, Institute of Psychiatry, King's College London, London, UK
| | - Benedict D Michael
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK.,University of Liverpool, Liverpool, UK
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Wilder-Smith A, Brickley EB, Ximenes RADA, Miranda-Filho DDB, Turchi Martelli CM, Solomon T, Jacobs BC, Pardo CA, Osorio L, Parra B, Lant S, Willison HJ, Leonhard S, Turtle L, Ferreira MLB, de Oliveira Franca RF, Lambrechts L, Neyts J, Kaptein S, Peeling R, Boeras D, Logan J, Dolk H, Orioli IM, Neumayr A, Lang T, Baker B, Massad E, Preet R. The legacy of ZikaPLAN: a transnational research consortium addressing Zika. Glob Health Action 2021; 14:2008139. [PMID: 35377284 PMCID: PMC8986226 DOI: 10.1080/16549716.2021.2008139] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Global health research partnerships with institutions from high-income countries and low- and middle-income countries are one of the European Commission's flagship programmes. Here, we report on the ZikaPLAN research consortium funded by the European Commission with the primary goal of addressing the urgent knowledge gaps related to the Zika epidemic and the secondary goal of building up research capacity and establishing a Latin American-European research network for emerging vector-borne diseases. Five years of collaborative research effort have led to a better understanding of the full clinical spectrum of congenital Zika syndrome in children and the neurological complications of Zika virus infections in adults and helped explore the origins and trajectory of Zika virus transmission. Individual-level data from ZikaPLAN`s cohort studies were shared for joint analyses as part of the Zika Brazilian Cohorts Consortium, the European Commission-funded Zika Cohorts Vertical Transmission Study Group, and the World Health Organization-led Zika Virus Individual Participant Data Consortium. Furthermore, the legacy of ZikaPLAN includes new tools for birth defect surveillance and a Latin American birth defect surveillance network, an enhanced Guillain-Barre Syndrome research collaboration, a de-centralized evaluation platform for diagnostic assays, a global vector control hub, and the REDe network with freely available training resources to enhance global research capacity in vector-borne diseases.
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Affiliation(s)
- Annelies Wilder-Smith
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.,Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
| | | | | | | | | | - Tom Solomon
- NIHR Health Protection Research Unit for Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences University of Liverpool, Liverpool, UK
| | - Bart C Jacobs
- Departments of Neurology and Immunology, Erasmus Universitair Medisch Centrum Rotterdam, The Netherlands
| | - Carlos A Pardo
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | | | - Suzannah Lant
- NIHR Health Protection Research Unit for Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences University of Liverpool, Liverpool, UK
| | - Hugh J Willison
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
| | - Sonja Leonhard
- Departments of Neurology and Immunology, Erasmus Universitair Medisch Centrum Rotterdam, The Netherlands
| | - Lance Turtle
- NIHR Health Protection Research Unit for Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences University of Liverpool, Liverpool, UK
| | | | | | - Louis Lambrechts
- Insect-Virus Interactions Unit, Institut Pasteur, UMR2000, CNRS, 75015 Paris, France
| | - Johan Neyts
- KU Leuven Department of Microbiology, Immunology and Transplantation, Rega Institute for Medical Research, Laboratory of Virology and Chemotherapy, Leuven, Belgium
| | - Suzanne Kaptein
- KU Leuven Department of Microbiology, Immunology and Transplantation, Rega Institute for Medical Research, Laboratory of Virology and Chemotherapy, Leuven, Belgium
| | - Rosanna Peeling
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - James Logan
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Helen Dolk
- Centre for Maternal, Fetal and Infant Research, Institute for Nursing and Health Research, Ulster University, Ulster, United Kingdom
| | - Ieda M Orioli
- RELAMC and ECLAMC at Genetics Department, Federal University of Rio de Janeiro, Brazil
| | - Andreas Neumayr
- Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Trudie Lang
- The Global Health Network, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Bonny Baker
- The Global Health Network, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Eduardo Massad
- School of Medicine, University of Sao Paulo and Fundacao Getulio Vargas, Sao Paulo, Brazil
| | - Raman Preet
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
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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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Perry RJ, Tamborska A, Singh B, Craven B, Marigold R, Arthur-Farraj P, Yeo JM, Zhang L, Hassan-Smith G, Jones M, Hutchcroft C, Hobson E, Warcel D, White D, Ferdinand P, Webb A, Solomon T, Scully M, Werring DJ, Roffe C. Cerebral venous thrombosis after vaccination against COVID-19 in the UK: a multicentre cohort study. Lancet 2021; 398:1147-1156. [PMID: 34370972 PMCID: PMC8346241 DOI: 10.1016/s0140-6736(21)01608-1] [Citation(s) in RCA: 110] [Impact Index Per Article: 36.7] [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: 05/27/2021] [Revised: 07/01/2021] [Accepted: 07/02/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND A new syndrome of vaccine-induced immune thrombotic thrombocytopenia (VITT) has emerged as a rare side-effect of vaccination against COVID-19. Cerebral venous thrombosis is the most common manifestation of this syndrome but, to our knowledge, has not previously been described in detail. We aimed to document the features of post-vaccination cerebral venous thrombosis with and without VITT and to assess whether VITT is associated with poorer outcomes. METHODS For this multicentre cohort study, clinicians were asked to submit all cases in which COVID-19 vaccination preceded the onset of cerebral venous thrombosis, regardless of the type of vaccine, interval between vaccine and onset of cerebral venous thrombosis symptoms, or blood test results. We collected clinical characteristics, laboratory results (including the results of tests for anti-platelet factor 4 antibodies where available), and radiological features at hospital admission of patients with cerebral venous thrombosis after vaccination against COVID-19, with no exclusion criteria. We defined cerebral venous thrombosis cases as VITT-associated if the lowest platelet count recorded during admission was below 150 × 109 per L and, if the D-dimer was measured, the highest value recorded was greater than 2000 μg/L. We compared the VITT and non-VITT groups for the proportion of patients who had died or were dependent on others to help them with their activities of daily living (modified Rankin score 3-6) at the end of hospital admission (the primary outcome of the study). The VITT group were also compared with a large cohort of patients with cerebral venous thrombosis described in the International Study on Cerebral Vein and Dural Sinus Thrombosis. FINDINGS Between April 1 and May 20, 2021, we received data on 99 patients from collaborators in 43 hospitals across the UK. Four patients were excluded because they did not have definitive evidence of cerebral venous thrombosis on imaging. Of the remaining 95 patients, 70 had VITT and 25 did not. The median age of the VITT group (47 years, IQR 32-55) was lower than in the non-VITT group (57 years; 41-62; p=0·0045). Patients with VITT-associated cerebral venous thrombosis had more intracranial veins thrombosed (median three, IQR 2-4) than non-VITT patients (two, 2-3; p=0·041) and more frequently had extracranial thrombosis (31 [44%] of 70 patients) compared with non-VITT patients (one [4%] of 25 patients; p=0·0003). The primary outcome of death or dependency occurred more frequently in patients with VITT-associated cerebral venous thrombosis (33 [47%] of 70 patients) compared with the non-VITT control group (four [16%] of 25 patients; p=0·0061). This adverse outcome was less frequent in patients with VITT who received non-heparin anticoagulants (18 [36%] of 50 patients) compared with those who did not (15 [75%] of 20 patients; p=0·0031), and in those who received intravenous immunoglobulin (22 [40%] of 55 patients) compared with those who did not (11 [73%] of 15 patients; p=0·022). INTERPRETATION Cerebral venous thrombosis is more severe in the context of VITT. Non-heparin anticoagulants and immunoglobulin treatment might improve outcomes of VITT-associated cerebral venous thrombosis. Since existing criteria excluded some patients with otherwise typical VITT-associated cerebral venous thrombosis, we propose new diagnostic criteria that are more appropriate. FUNDING None.
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Affiliation(s)
- Richard J Perry
- Comprehensive Stroke Service, National Hospital for Neurology and Neurosurgery, UCL Hospitals NHS Foundation Trust, London, UK; Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK.
| | - Arina Tamborska
- 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
| | - 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 University Hospital, Liverpool, UK
| | - Brian Craven
- Department of Haematology, UCL Hospitals NHS Foundation Trust, London, UK
| | - Richard Marigold
- Department of Stroke Medicine, University Hospital Southampton NHS Foundation Trust, Southampton UK
| | - Peter Arthur-Farraj
- John van Geest Centre for Brain Repair, Department of Clinical Neurosciences, Cambridge, UK
| | - Jing Ming Yeo
- Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Liqun Zhang
- Department of Neurology, St George's University Hospital NHS Foundation Trust, London, UK
| | - Ghaniah Hassan-Smith
- Department of Neurology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Matthew Jones
- Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, UK
| | - Christopher Hutchcroft
- Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, UK
| | - Esther Hobson
- Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Dana Warcel
- Department of Haematology, UCL Hospitals NHS Foundation Trust, London, UK
| | - Daniel White
- Department of Neurology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Phillip Ferdinand
- Stroke Service, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Alastair Webb
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - 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; Department of Neurology, Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Marie Scully
- Department of Haematology, UCL Hospitals NHS Foundation Trust, London, UK; Haemostasis Research Unit, University College London, London, UK
| | - David J Werring
- Comprehensive Stroke Service, National Hospital for Neurology and Neurosurgery, UCL Hospitals NHS Foundation Trust, London, UK; Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Christine Roffe
- Stroke Service, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK; Faculty of Medicine and Health Sciences, Keele University, Stoke-on-Trent, UK
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Mallucci CL, Jenkinson MD, Conroy EJ, Hartley JC, Brown M, Moitt T, Dalton J, Kearns T, Griffiths MJ, Culeddu G, Solomon T, Hughes D, Gamble C. Silver-impregnated, antibiotic-impregnated or non-impregnated ventriculoperitoneal shunts to prevent shunt infection: the BASICS three-arm RCT. Health Technol Assess 2021; 24:1-114. [PMID: 32238262 DOI: 10.3310/hta24170] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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: 01/18/2023] Open
Abstract
BACKGROUND Insertion of a ventriculoperitoneal shunt to treat hydrocephalus is one of the most common neurosurgical procedures worldwide. Shunt infection affects up to 15% of patients, resulting in long hospital stays, multiple surgeries and reduced cognition and quality of life. OBJECTIVES The aim of this trial was to determine whether or not antibiotic-impregnated ventriculoperitoneal shunts (hereafter referred to as antibiotic shunts) (e.g. impregnated with rifampicin and clindamycin) or silver-impregnated ventriculoperitoneal shunts (hereafter referred to as silver shunts) reduce infection compared with standard ventriculoperitoneal shunts (hereafter referred to as standard shunts). DESIGN This was a three-arm, superiority, multicentre, parallel-group randomised controlled trial. Patients and a central primary outcome review panel, but not surgeons or operating staff, were blinded to the type of ventriculoperitoneal shunt inserted. SETTING The trial was set in 21 neurosurgical wards across the UK and the Republic of Ireland. PARTICIPANTS Participants were patients with hydrocephalus of any aetiology who were undergoing insertion of their first ventriculoperitoneal shunt. INTERVENTIONS Participants were allocated 1 : 1 : 1 by pressure-sealed envelope to receive a standard non-impregnated, silver-impregnated or antibiotic-impregnated ventriculoperitoneal shunt at the time of insertion. Ventriculoperitoneal shunts are medical devices, and were used in accordance with the manufacturer's instructions for their intended purpose. MAIN OUTCOME MEASURES The primary outcome was time to ventriculoperitoneal shunt failure due to infection. Secondary outcomes were time to failure for any cause, reason for failure (infection, mechanical), types of ventriculoperitoneal shunt infection, rate of infection after first clean (non-infected) revision and health economics. Outcomes were analysed by intention to treat. RESULTS Between 26 June 2013 and 9 October 2017, 1605 patients from neonate to 91 years of age were randomised to the trial: n = 36 to the standard shunt, n = 538 to the antibiotic shunt and n = 531 to the silver shunt. Patients who did not receive a ventriculoperitoneal shunt (n = 4) or who had an infection at the time of insertion (n = 7) were not assessed for the primary outcome. Infection occurred in 6.0% (n = 32/533) of those who received the standard shunt, in 2.2% (n = 12/535) of those who received the antibiotic shunt and in 5.9% (n = 31/526) of those who received the silver shunt. Compared with the standard shunt, antibiotic shunts were associated with a lower rate of infection (cause-specific hazard ratio 0.38, 97.5% confidence interval 0.18 to 0.80) and a decreased probability of infection (subdistribution hazard ratio 0.38, 97.5% confidence interval 0.18 to 0.80). Silver shunts were not associated with a lower rate of infection than standard shunts (cause-specific hazard ratio 0.99, 97.5% confidence interval 0.56 to 1.74). The ventriculoperitoneal shunt failure rate attributable to any cause was 25.0% overall and did not differ between arms. Antibiotic shunts save £135,753 per infection avoided. There were no serious adverse events. LIMITATIONS It was not possible to blind treating neurosurgeons to the ventriculoperitoneal shunt type. The return rate for patient-reported outcomes was low. Limitations to the economic evaluation included failure to obtain Hospital Episode Statistics data from NHS Digital, as per protocol. Reliance on patient-level information and costing systems data mitigated these limitations. CONCLUSIONS Antibiotic shunts have a reduced infection rate compared with standard shunts, whereas silver shunts do not. Antibiotic shunts are cost-saving. FUTURE WORK A sample collection has been established that will enable the study of surrogate markers of ventriculoperitoneal shunt infection in cerebrospinal fluid or blood using molecular techniques. A post hoc analysis to study factors related to shunt failure will be performed as part of a future study. An impact analysis to assess change in practice is planned. TRIAL REGISTRATION Current Controlled Trials ISRCTN49474281. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 17. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Conor L Mallucci
- Department of Paediatric Neurosurgery, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Michael D Jenkinson
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK.,Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Elizabeth J Conroy
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - John C Hartley
- Department of Microbiology, Great Ormond Street Hospital for Children, London, UK
| | - Michaela Brown
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Tracy Moitt
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Joanne Dalton
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Tom Kearns
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Michael J Griffiths
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK.,Department of Paediatric Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Giovanna Culeddu
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Tom Solomon
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK.,Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Dyfrig Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Carrol Gamble
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
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Benjamin LA, Paterson RW, Moll R, Pericleous C, Brown R, Mehta PR, Athauda D, Ziff OJ, Heaney J, Checkley AM, Houlihan CF, Chou M, Heslegrave AJ, Chandratheva A, Michael BD, Blennow K, Vivekanandam V, Foulkes A, Mummery CJ, Lunn MP, Keddie S, Spyer MJ, Mckinnon T, Hart M, Carletti F, Jäger HR, Manji H, Zandi MS, Werring DJ, Nastouli E, Simister R, Solomon T, Zetterberg H, Schott JM, Cohen H, Efthymiou M. Antiphospholipid antibodies and neurological manifestations in acute COVID-19: A single-centre cross-sectional study. EClinicalMedicine 2021; 39:101070. [PMID: 34401683 PMCID: PMC8358233 DOI: 10.1016/j.eclinm.2021.101070] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND A high prevalence of antiphospholipid antibodies has been reported in case series of patients with neurological manifestations and COVID-19; however, the pathogenicity of antiphospholipid antibodies in COVID-19 neurology remains unclear. METHODS This single-centre cross-sectional study included 106 adult patients: 30 hospitalised COVID-neurological cases, 47 non-neurological COVID-hospitalised controls, and 29 COVID-non-hospitalised controls, recruited between March and July 2020. We evaluated nine antiphospholipid antibodies: anticardiolipin antibodies [aCL] IgA, IgM, IgG; anti-beta-2 glycoprotein-1 [aβ2GPI] IgA, IgM, IgG; anti-phosphatidylserine/prothrombin [aPS/PT] IgM, IgG; and anti-domain I β2GPI (aD1β2GPI) IgG. FINDINGS There was a high prevalence of antiphospholipid antibodies in the COVID-neurological (73.3%) and non-neurological COVID-hospitalised controls (76.6%) in contrast to the COVID-non-hospitalised controls (48.2%). aPS/PT IgG titres were significantly higher in the COVID-neurological group compared to both control groups (p < 0.001). Moderate-high titre of aPS/PT IgG was found in 2 out of 3 (67%) patients with acute disseminated encephalomyelitis [ADEM]. aPS/PT IgG titres negatively correlated with oxygen requirement (FiO2 R=-0.15 p = 0.040) and was associated with venous thromboembolism (p = 0.043). In contrast, aCL IgA (p < 0.001) and IgG (p < 0.001) was associated with non-neurological COVID-hospitalised controls compared to the other groups and correlated positively with d-dimer and creatinine but negatively with FiO2. INTERPRETATION Our findings show that aPS/PT IgG is associated with COVID-19-associated ADEM. In contrast, aCL IgA and IgG are seen much more frequently in non-neurological hospitalised patients with COVID-19. Characterisation of antiphospholipid antibody persistence and potential longitudinal clinical impact are required to guide appropriate management. FUNDING This work is supported by UCL Queen Square Biomedical Research Centre (BRC) and Moorfields BRC grants (#560441 and #557595). LB is supported by a Wellcome Trust Fellowship (222102/Z/20/Z). RWP is supported by an Alzheimer's Association Clinician Scientist Fellowship (AACSF-20-685780) and the UK Dementia Research Institute. KB is supported by the Swedish Research Council (#2017-00915) and the Swedish state under the agreement between the Swedish government and the County Councils, the ALF-agreement (#ALFGBG-715986). HZ is a Wallenberg Scholar supported by grants from the Swedish Research Council (#2018-02532), the European Research Council (#681712), Swedish State Support for Clinical Research (#ALFGBG-720931), the Alzheimer Drug Discovery Foundation (ADDF), USA (#201809-2016862), and theUK Dementia Research Institute at UCL. BDM is supported by grants from the MRC/UKRI (MR/V007181/1), MRC (MR/T028750/1) and Wellcome (ISSF201902/3). MSZ, MH and RS are supported by the UCL/UCLH NIHR Biomedical Research Centre and MSZ is supported by Queen Square National Brain Appeal.
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Affiliation(s)
- Laura A. Benjamin
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London WC1N 3BG, UK
- Laboratory of Molecular and Cell Biology, UCL, Gower St, Kings Cross, London WC1E 6BT, UK
- Brain Infections Group, University of Liverpool, Liverpool, Merseyside, UK
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Ross W. Paterson
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London WC1N 3BG, UK
- UCL Queen Square Institute of Neurology, London, UK
- Darent Valley Hospital, Dartford, Kent, UK
- UK Dementia Research Institute, London, UK
| | - Rachel Moll
- Haemostasis Research Unit, Department of Haematology, UCL, UK
- Department of Haematology, University College London Hospitals, UK
| | | | - Rachel Brown
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London WC1N 3BG, UK
- UCL Queen Square Institute of Neurology, London, UK
- Department of Infection and Immunity, University College London, UK
| | - Puja R. Mehta
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London WC1N 3BG, UK
- UCL Queen Square Institute of Neurology, London, UK
| | - Dilan Athauda
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London WC1N 3BG, UK
- UCL Queen Square Institute of Neurology, London, UK
| | - Oliver J. Ziff
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London WC1N 3BG, UK
- UCL Queen Square Institute of Neurology, London, UK
- Francis Crick Institute, London, UK
| | - Judith Heaney
- Department of Clinical Virology, University College London Hospitals NHS Foundation Trust, UK
- Advanced Pathogens Diagnostic Unit, University College London Hospitals NHS Foundation Trust, UK
| | - Anna M. Checkley
- Hospital of Tropical Medicine, University College London Hospitals, UK
| | - Catherine F. Houlihan
- Department of Infection and Immunity, University College London, UK
- Department of Clinical Virology, University College London Hospitals NHS Foundation Trust, UK
- Advanced Pathogens Diagnostic Unit, University College London Hospitals NHS Foundation Trust, UK
| | - Michael Chou
- UCL Queen Square Institute of Neurology, London, UK
- Neuroimmunology and CSF Laboratory, National Hospital for Neurology and Neurosurgery, UK
| | - Amanda J. Heslegrave
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London WC1N 3BG, UK
- UCL Queen Square Institute of Neurology, London, UK
- UK Dementia Research Institute, London, UK
| | - Arvind Chandratheva
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London WC1N 3BG, UK
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Benedict D. Michael
- Brain Infections Group, University of Liverpool, Liverpool, Merseyside, UK
- Veterinary and Ecological Sciences, National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, University of Liverpool, UK
- Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
| | - Vinojini Vivekanandam
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London WC1N 3BG, UK
- UCL Queen Square Institute of Neurology, London, UK
| | - Alexander Foulkes
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London WC1N 3BG, UK
| | - Catherine J. Mummery
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London WC1N 3BG, UK
- UCL Queen Square Institute of Neurology, London, UK
- UK Dementia Research Institute, London, UK
| | - Michael P. Lunn
- UCL Queen Square Institute of Neurology, London, UK
- Neuroimmunology and CSF Laboratory, National Hospital for Neurology and Neurosurgery, UK
| | - Stephen Keddie
- UCL Queen Square Institute of Neurology, London, UK
- Neuroimmunology and CSF Laboratory, National Hospital for Neurology and Neurosurgery, UK
| | - Moira J. Spyer
- Department of Clinical Virology, University College London Hospitals NHS Foundation Trust, UK
- Advanced Pathogens Diagnostic Unit, University College London Hospitals NHS Foundation Trust, UK
- Institute of Child Health, UCL, UK
| | - Tom Mckinnon
- Department of Immunology and Inflammation, Imperial College London, UK
| | - Melanie Hart
- UCL Queen Square Institute of Neurology, London, UK
- Neuroimmunology and CSF Laboratory, National Hospital for Neurology and Neurosurgery, UK
| | - Francesco Carletti
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London WC1N 3BG, UK
| | - Hans Rolf Jäger
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London WC1N 3BG, UK
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Hadi Manji
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London WC1N 3BG, UK
| | - Michael S. Zandi
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London WC1N 3BG, UK
- UCL Queen Square Institute of Neurology, London, UK
| | - David J. Werring
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London WC1N 3BG, UK
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Eleni Nastouli
- Francis Crick Institute, London, UK
- Department of Clinical Virology, University College London Hospitals NHS Foundation Trust, UK
- Advanced Pathogens Diagnostic Unit, University College London Hospitals NHS Foundation Trust, UK
- Institute of Child Health, UCL, UK
| | - Robert Simister
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London WC1N 3BG, UK
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Tom Solomon
- Brain Infections Group, University of Liverpool, Liverpool, Merseyside, UK
- Veterinary and Ecological Sciences, National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, University of Liverpool, UK
- Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Henrik Zetterberg
- UCL Queen Square Institute of Neurology, London, UK
- UK Dementia Research Institute, London, UK
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
| | - Jonathan M. Schott
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London WC1N 3BG, UK
- UCL Queen Square Institute of Neurology, London, UK
- UK Dementia Research Institute, London, UK
| | - Hannah Cohen
- Haemostasis Research Unit, Department of Haematology, UCL, UK
- Department of Haematology, University College London Hospitals, UK
| | - Maria Efthymiou
- Haemostasis Research Unit, Department of Haematology, UCL, UK
- Department of Haematology, University College London Hospitals, UK
| | - The UCLH Queen Square COVID-19 Biomarker Study group
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London WC1N 3BG, UK
- Laboratory of Molecular and Cell Biology, UCL, Gower St, Kings Cross, London WC1E 6BT, UK
- UCL Queen Square Institute of Neurology, London, UK
- Brain Infections Group, University of Liverpool, Liverpool, Merseyside, UK
- Darent Valley Hospital, Dartford, Kent, UK
- UK Dementia Research Institute, London, UK
- Haemostasis Research Unit, Department of Haematology, UCL, UK
- Department of Haematology, University College London Hospitals, UK
- Imperial College London, National Heart and Lung Institute, UK
- Department of Infection and Immunity, University College London, UK
- Francis Crick Institute, London, UK
- Department of Clinical Virology, University College London Hospitals NHS Foundation Trust, UK
- Advanced Pathogens Diagnostic Unit, University College London Hospitals NHS Foundation Trust, UK
- Hospital of Tropical Medicine, University College London Hospitals, UK
- Neuroimmunology and CSF Laboratory, National Hospital for Neurology and Neurosurgery, UK
- Veterinary and Ecological Sciences, National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, University of Liverpool, UK
- Walton Centre NHS Foundation Trust, Liverpool, UK
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Department of Immunology and Inflammation, Imperial College London, UK
- Institute of Child Health, UCL, UK
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
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50
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Rogers JP, Watson CJ, Badenoch J, Cross B, Butler M, Song J, Hafeez D, Morrin H, Rengasamy ER, Thomas L, Ralovska S, Smakowski A, Sundaram RD, Hunt CK, Lim MF, Aniwattanapong D, Singh V, Hussain Z, Chakraborty S, Burchill E, Jansen K, Holling H, Walton D, Pollak TA, Ellul M, Koychev I, Solomon T, Michael BD, Nicholson TR, Rooney AG. Neurology and neuropsychiatry of COVID-19: a systematic review and meta-analysis of the early literature reveals frequent CNS manifestations and key emerging narratives. J Neurol Neurosurg Psychiatry 2021; 92:932-941. [PMID: 34083395 DOI: 10.1136/jnnp-2021-326405] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [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: 02/16/2021] [Accepted: 05/12/2021] [Indexed: 12/18/2022]
Abstract
There is accumulating evidence of the neurological and neuropsychiatric features of infection with SARS-CoV-2. In this systematic review and meta-analysis, we aimed to describe the characteristics of the early literature and estimate point prevalences for neurological and neuropsychiatric manifestations.We searched MEDLINE, Embase, PsycINFO and CINAHL up to 18 July 2020 for randomised controlled trials, cohort studies, case-control studies, cross-sectional studies and case series. Studies reporting prevalences of neurological or neuropsychiatric symptoms were synthesised into meta-analyses to estimate pooled prevalence.13 292 records were screened by at least two authors to identify 215 included studies, of which there were 37 cohort studies, 15 case-control studies, 80 cross-sectional studies and 83 case series from 30 countries. 147 studies were included in the meta-analysis. The symptoms with the highest prevalence were anosmia (43.1% (95% CI 35.2% to 51.3%), n=15 975, 63 studies), weakness (40.0% (95% CI 27.9% to 53.5%), n=221, 3 studies), fatigue (37.8% (95% CI 31.6% to 44.4%), n=21 101, 67 studies), dysgeusia (37.2% (95% CI 29.8% to 45.3%), n=13 686, 52 studies), myalgia (25.1% (95% CI 19.8% to 31.3%), n=66 268, 76 studies), depression (23.0% (95% CI 11.8% to 40.2%), n=43 128, 10 studies), headache (20.7% (95% CI 16.1% to 26.1%), n=64 613, 84 studies), anxiety (15.9% (5.6% to 37.7%), n=42 566, 9 studies) and altered mental status (8.2% (95% CI 4.4% to 14.8%), n=49 326, 19 studies). Heterogeneity for most clinical manifestations was high.Neurological and neuropsychiatric symptoms of COVID-19 in the pandemic's early phase are varied and common. The neurological and psychiatric academic communities should develop systems to facilitate high-quality methodologies, including more rapid examination of the longitudinal course of neuropsychiatric complications of newly emerging diseases and their relationship to neuroimaging and inflammatory biomarkers.
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Affiliation(s)
- Jonathan P Rogers
- Division of Psychiatry, University College London, London, UK .,South London and Maudsley NHS Foundation Trust, London, UK
| | - Cameron J Watson
- Preventive Neurology Unit, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - James Badenoch
- Medical School, University of Birmingham, Birmingham, UK
| | | | - Matthew Butler
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Jia Song
- East London NHS Foundation Trust, London, UK
| | - Danish Hafeez
- School of Medical Sciences, The University of Manchester, Manchester, UK
| | | | | | - Lucretia Thomas
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Silviya Ralovska
- Department of Neurology, Psychiatry, Physiotherapy and Rehabilitation, Preventive Medicine, and Public Health, Sofia University St Kliment Ohridski, Sofia, Bulgaria
| | | | | | | | - Mao Fong Lim
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Daruj Aniwattanapong
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Zain Hussain
- College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, UK
| | - Stuti Chakraborty
- Department of Physical Medicine and Rehabilitation, Christian Medical College Vellore, Vellore, Tamil Nadu, India
| | - Ella Burchill
- Faculty of Medicine and Life Sciences, King's College London, London, UK
| | - Katrin Jansen
- Department of Psychology, University of Münster, Münster, Germany
| | - Heinz Holling
- Department of Psychology, University of Münster, Münster, Germany
| | - Dean Walton
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Thomas A Pollak
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Mark Ellul
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK.,National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infection, University of Liverpool, Liverpool, UK.,Institute of Infection, Veterinary, and Zoological Science, University of Liverpool, Liverpool, UK
| | - Ivan Koychev
- Department of Psychiatry, University of Oxford, Oxford, UK.,Department of Psychological Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Tom Solomon
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK.,National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infection, University of Liverpool, Liverpool, UK
| | - Benedict Daniel Michael
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK.,National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infection, University of Liverpool, Liverpool, UK.,Institute of Infection, Veterinary, and Zoological Science, University of Liverpool, Liverpool, UK
| | - Timothy R Nicholson
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Alasdair G Rooney
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
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