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Bernardshaw E, Gynthersen RMM, Bremell D, Mens H, Stenør C, Lorentzen ÅR, Bodilsen J, Eikeland R, Lebech AM. Antibiotic therapy of neuroborreliosis: A survey among infectious disease specialists and neurologists in Norway, Sweden, and Denmark. Ticks Tick Borne Dis 2022; 13:102051. [PMID: 36228536 DOI: 10.1016/j.ttbdis.2022.102051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/05/2022] [Accepted: 09/28/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Neuroborreliosis (NB) is a prevalent tick-borne neuroinfection in Europe. To delineate current practice in antimicrobial management of adults with NB and to prioritize future trials needed to optimize treatment recommendations, a questionnaire-based survey was performed. METHODS A self-administered Internet-based survey of NB treatment practices among specialists in infectious diseases and neurology based in Norway, Sweden, and Denmark was carried out between October 2021 and February 2022. The participants were also asked to prioritize four pre-defined research questions for randomized controlled trials (RCTs) on therapy for NB. RESULTS In total, 290 physicians (45% female) from Norway (30%), Sweden (40%), and Denmark (30%) participated in the survey. Of the responders, 230 (79%) were infectious disease specialists and 56 (19%) were neurologists. The preferred antibiotic treatment for patients with early NB was oral doxycycline (n = 225, 78%). Intravenous (IV) penicillin, ceftriaxone, or cefotaxime for the full treatment course was favored by 12%. A preferred treatment duration of 10-14 days for patients with NB was reported by 245 respondents (85%), most common among participants from Sweden (97%). A total of 170 (59%) responders reported having local hospital guidelines on the treatment of NB, most often with recommendation of oral doxycycline (92%) for 10-14 days (90%) as first line treatment. The prioritization score for future RCTs was highest for adjunctive prednisone therapy in NB patients with facial palsy (median 5; IQR 4-6) and for placebo versus repeated antibiotics in patients with persistent symptoms after completed antibiotic therapy for NB (median 5, IQR 3-6). CONCLUSION In Sweden, all respondents preferred treating NB with oral doxycycline for 10-14 days, whereas 5% in Norway and 19% in Denmark still treat NB with IV antibiotics for the entire treatment course. RCTs to define the role of adjunctive prednisolone in NB patients with facial palsy and repeated antibiotics in patients with persistent symptoms are prioritized for future research.
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Affiliation(s)
- Emilie Bernardshaw
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Rigshospitalet, Copenhagen 2100, Denmark
| | - Rosa M M Gynthersen
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Rigshospitalet, Copenhagen 2100, Denmark.
| | - Daniel Bremell
- Department of Infectious Diseases, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Helene Mens
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Rigshospitalet, Copenhagen 2100, Denmark
| | - Christian Stenør
- Department of Neurology, University hospital-Herlev Hospital, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Åslaug R Lorentzen
- Department of Neurology, Sørlandet Hospital Trust, Kristiansand, Norway; The Norwegian National Advisory Unit on Tick-borne Diseases, Sorlandet Hospital Trust, Kristiansand, Norway
| | - Jacob Bodilsen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Randi Eikeland
- Department of Neurology, Sørlandet Hospital Trust, Kristiansand, Norway; The Faculty of health and sport sciences, University of Agder, Grimstad, Norway
| | - Anne-Mette Lebech
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Rigshospitalet, Copenhagen 2100, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
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Solheim AM, Lorentzen ÅR, Dahlberg AO, Flemmen HØ, Brune S, Forselv KJN, Pripp AH, Bø MH, Eikeland R, Reiso H, Mygland Å, Ljøstad U. Six versus 2 weeks treatment with doxycycline in European Lyme neuroborreliosis: a multicentre, non-inferiority, double-blinded, randomised and placebo-controlled trial. J Neurol Neurosurg Psychiatry 2022; 93:jnnp-2022-329724. [PMID: 35896378 PMCID: PMC9606522 DOI: 10.1136/jnnp-2022-329724] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/12/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND There is limited evidence regarding optimal duration of antibiotic treatment in neuroborreliosis. We aimed to compare efficacy and safety of oral doxycycline for 2 and 6 weeks in European Lyme neuroborreliosis (LNB). METHODS The trial had a randomised, double-blinded, placebo-controlled, non-inferiority design. Patients with LNB were recruited from eight Norwegian hospitals and randomised to doxycycline 200 mg once daily for 2 weeks, followed by 4 weeks of placebo, or doxycycline 200 mg once daily for 6 weeks. The primary endpoint was clinical improvement as measured by difference in a Composite Clinical Score (0-64 points) from baseline to 6 months. The non-inferiority margin was predetermined to 0.5 points. RESULTS One hundred and twenty-one patients were included. Fifty-two treated for 2 weeks and 53 for 6 weeks were included in the intention-to-treat analyses, and 52 and 51 in per-protocol analysis. Mean difference in clinical improvement between the groups was 0.06, 95% CI -1.2 to 1.2, p=0.99 in the intention-to-treat population, and -0.4, 95% CI -1.4 to 0.7, p=0.51 in the per-protocol population and non-inferiority could not be established. There were no treatment failures and no serious adverse events. The groups did not differ in secondary outcomes including clinical scores at 10 weeks and 12 months, cerebrospinal fluid data and patient-reported outcome measures. Patients receiving 6 weeks doxycycline reported slightly more side effects in week 5. CONCLUSION Our results strongly indicate that there are no benefits of doxycycline treatment beyond 2 weeks in European LNB. TRIAL REGISTRATION NUMBER 2015-001481-25.
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Affiliation(s)
- Anne Marit Solheim
- Department of Neurology, Sørlandet sykehus HF Kristiansand, Kristiansand, Norway
- Institute of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Åslaug Rudjord Lorentzen
- Department of Neurology, Sørlandet sykehus HF Kristiansand, Kristiansand, Norway
- The Norwegian National Advisory Unit on Tick-borne diseases, Sørlandet sykehus HF Arendal, Arendal, Norway
| | - Audun Olav Dahlberg
- Department of Neurology, Møre og Romsdal Hospital Trust, Molde, Norway
- Department of Neurology and Clinical Neurophysiology, Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Synne Brune
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | | | - Are Hugo Pripp
- Biostatistics and Epidemiology Unit, Oslo University Hospital, Oslo, Norway
- Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | | | - Randi Eikeland
- The Norwegian National Advisory Unit on Tick-borne diseases, Sørlandet sykehus HF Arendal, Arendal, Norway
- Institute of Health and Nursing Science, University of Agder, Kristiansand, Norway
| | - Harald Reiso
- The Norwegian National Advisory Unit on Tick-borne diseases, Sørlandet sykehus HF Arendal, Arendal, Norway
| | - Åse Mygland
- Department of Neurology, Sørlandet sykehus HF Kristiansand, Kristiansand, Norway
- Institute of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Unn Ljøstad
- Department of Neurology, Sørlandet sykehus HF Kristiansand, Kristiansand, Norway
- Institute of Clinical Medicine, University of Bergen, Bergen, Norway
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Kortela E, Kanerva MJ, Kurkela S, Oksi J, Koivisto M, Järvinen A. Consumption of healthcare services and antibiotics in patients with presumed disseminated Lyme borreliosis before and after evaluation of an infectious disease specialist. Ticks Tick Borne Dis 2021; 13:101854. [PMID: 34695770 DOI: 10.1016/j.ttbdis.2021.101854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 09/16/2021] [Accepted: 09/20/2021] [Indexed: 10/20/2022]
Abstract
Our objective was to study the consumption of healthcare services and antibiotics in patients with suspicion of disseminated Lyme borreliosis (LB) before and after consultation of an infectious disease specialist. We evaluated retrospectively all presumed disseminated LB patients (n = 256) with a referral to the Department of Infectious Diseases (DID) in Helsinki University Hospital in 2013. Medical records from all healthcare providers in the area were reviewed and the number of physician contacts because of symptoms leading to LB suspicion and antimicrobial purchases were calculated 1 year before and after consultation or treatment at the DID. Patients were divided into three groups according to certainty of LB: unlikely, possible or probable/definite LB. The number of healthcare contacts 1 year before referral was higher among 121 patients with unlikely LB (6; interquartile range [IQR] 3-10), than 65 possible (4; IQR 2.5-7; p = 0.018) or 66 probable/definite LB patients (4; IQR 2.8-7; p = 0.010). The median number of contacts to healthcare during one year after consultation or treatment was 3 (IQR 0.5-7), 1 (IQR 0-3) and 0.5 (IQR 0-2.3), respectively, with a statistically significant difference between the groups (p<0.001). Antibiotics were purchased by 151 (60%) patients one year before referral and by 127 (50%) patients year after consultation or treatment at DID without statistically significant difference between groups with different LB certainty. These antibiotic purchases do not include the treatments prescribed by infectious disease specialists. In the case of 27 patients, an antimicrobial treatment was recommended in the consultation reply. In conclusion, patients with unlikely LB used more healthcare services than patients with possible or probable/definite LB. Antimicrobial consumption was similar between groups of different LB certainty.
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Affiliation(s)
- Elisa Kortela
- Division of infectious diseases, Inflammation Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland; Department of Clinical Medicine, University of Turku, Turku, Finland.
| | - Mari J Kanerva
- Division of infectious diseases, Inflammation Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Satu Kurkela
- Virology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jarmo Oksi
- Department of Infectious Diseases, Turku University Hospital and University of Turku, Turku, Finland
| | - Mari Koivisto
- Department of Biostatistics, University of Turku, Turku, Finland
| | - Asko Järvinen
- Division of infectious diseases, Inflammation Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Kortela E, Kanerva MJ, Puustinen J, Hurme S, Airas L, Lauhio A, Hohenthal U, Jalava-Karvinen P, Nieminen T, Finnilä T, Häggblom T, Pietikäinen A, Koivisto M, Vilhonen J, Marttila-Vaara M, Hytönen J, Oksi J. Oral Doxycycline Compared to Intravenous Ceftriaxone in the Treatment of Lyme Neuroborreliosis: A Multicenter, Equivalence, Randomized, Open-label Trial. Clin Infect Dis 2021; 72:1323-1331. [PMID: 32133487 DOI: 10.1093/cid/ciaa217] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 03/01/2020] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Lyme neuroborreliosis (LNB) is often treated with intravenous ceftriaxone even if doxycycline is suggested to be noninferior to ceftriaxone. We evaluated the efficacy of oral doxycycline in comparison to ceftriaxone in the treatment of LNB. METHODS Patients with neurological symptoms suggestive of LNB without other obvious reasons were recruited. The inclusion criteria were (1) production of Borrelia burgdorferi-specific antibodies in cerebrospinal fluid (CSF) or serum; (2) B. burgdorferi DNA in the CSF; or (3) an erythema migrans during the past 3 months. Participants were randomized in a 1:1 ratio to receive either oral doxycycline 100 mg twice daily for 4 weeks, or intravenous ceftriaxone 2 g daily for 3 weeks. The participants described their subjective condition with a visual analogue scale (VAS) from 0 to 10 (0 = normal; 10 = worst) before the treatment, and 4 and 12 months after the treatment. The primary outcome was the change in the VAS score at 12 months. RESULTS Between 14 September 2012 and 28 December 2017, 210 adults with suspected LNB were assigned to receive doxycycline (n = 104) or ceftriaxone (n = 106). The per-protocol analysis comprised 82 patients with doxycycline and 84 patients with ceftriaxone. The mean change in the VAS score was -3.9 in the doxycycline group and -3.8 in the ceftriaxone group (mean difference, 0.17 [95% confidence interval, -.59 to .92], which is within the prespecified equivalence margins of -1 to 1 units). Participants in both groups improved equally. CONCLUSIONS Oral doxycycline is equally effective as intravenous ceftriaxone in the treatment of LNB. CLINICAL TRIALS REGISTRATION NCT01635530 and EudraCT 2012-000313-37.
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Affiliation(s)
- Elisa Kortela
- Department of Clinical Medicine, University of Turku, Turku, Finland.,Infectious Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mari J Kanerva
- Infectious Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juha Puustinen
- Unit of Neurology, Satakunta Central Hospital, Pori, Finland.,Department of Neurology, University of Turku, Turku, Finland.,Division of Pharmacology and Pharmacotherapy, University of Helsinki, Helsinki, Finland
| | - Saija Hurme
- Department of Biostatistics, University of Turku, Turku, Finland
| | - Laura Airas
- Division of Clinical Neurosciences, Turku University Hospital, Turku, Finland
| | | | - Ulla Hohenthal
- Department of Infectious Diseases, Turku University Hospital and University of Turku, Turku, Finland
| | - Päivi Jalava-Karvinen
- Department of Infectious Diseases, Turku University Hospital and University of Turku, Turku, Finland
| | - Tuomas Nieminen
- Infectious Diseases Unit, Satakunta Central Hospital, Pori, Finland
| | - Taru Finnilä
- Department of Infectious Diseases, Turku University Hospital and University of Turku, Turku, Finland
| | - Tony Häggblom
- Department of Infectious Diseases, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Mari Koivisto
- Department of Biostatistics, University of Turku, Turku, Finland
| | - Johanna Vilhonen
- Department of Infectious Diseases, Turku University Hospital and University of Turku, Turku, Finland
| | - Minna Marttila-Vaara
- Department of Infectious Diseases, Turku University Hospital and University of Turku, Turku, Finland
| | - Jukka Hytönen
- Institute of Biomedicine, University of Turku, Turku, Finland.,Clinical Microbiology, Turku University Hospital, Turku, Finland
| | - Jarmo Oksi
- Department of Infectious Diseases, Turku University Hospital and University of Turku, Turku, Finland
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Nordberg CL, Bodilsen J, Knudtzen FC, Storgaard M, Brandt C, Wiese L, Hansen BR, Andersen ÅB, Nielsen H, Lebech AM. Lyme neuroborreliosis in adults: A nationwide prospective cohort study. Ticks Tick Borne Dis 2020; 11:101411. [PMID: 32178995 DOI: 10.1016/j.ttbdis.2020.101411] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 01/23/2020] [Accepted: 02/21/2020] [Indexed: 02/07/2023]
Abstract
The goal of this paper is to characterize the clinical presentation, serological results, current antibiotic treatment practice, including compliance with current European guidelines, and outcome in adults with Lyme neuroborreliosis (LNB) diagnosed at departments of infectious diseases in Denmark. Using a nationwide prospective cohort of patients with central nervous system infections, we identified all adults (≥ 18 years of age) treated for LNB at departments of infectious diseases in Denmark from 2015 through 2017. The database contains information on baseline demographics, history of tick bite, erythema migrans, clinical presentation, laboratory results of blood samples, and cerebrospinal (CSF) biochemistry (e.g. specific Borrelia burgdorferi sensu lato (s.l.) antibodies in serum, B. burgdorferi s.l. intrathecal antibody index) as well as antibiotic therapy. Outcome was assessed by the Glasgow Outcome Scale (GOS) and the presence of residual symptoms at follow-up one month after discharge. We included 194 LNB patients with a median age of 59 years (range 18-85 years, interquartile range [IQR] 47-69 years). The female-to-male ratio was 0.8. A total of 177 of 191 (93 %) of patients had early (second stage) LNB. A history of tick bite or erythema migrans was registered in 75 (39 %) and 49 (25 %) patients, respectively. The median duration of neurological symptoms before first hospital contact was 21 days (range 0-600 days, IQR 10-42 days). Predominant symptoms consisted of radicular pain in 135 of 194 (70 %), cranial nerve paresis in 88 of 194 (45 %), headache in 71 of 185 (38 %), and extremity paresis in 33 of 194 (17 %) patients. Serum-B. burgdorferi s.l. IgM and/or IgG antibodies were detectable in 166 of 181 (92 %) patients at the time of first CSF investigation. Median duration of antibiotic treatment was 14 days (range 10-35 days, IQR 14-21 days) and 59 (39 %) of the patients received intravenous ceftriaxone and/or benzylpenicillin G throughout treatment. At the 1-month follow-up, GOS was unfavorable (< 5) in 54 of 193 (28 %) patients. An unfavorable GOS score was more often registered in patients with ≥ 45 days of symptom duration (20 of 45 (44 %) vs. 34 of 145 (23 %); P = 0.006). In conclusion, a European cohort of adult patients with LNB diagnosed between 2015-2017 presented with classic symptoms and CSF findings. However, a substantial diagnostic delay was still observed. In disagreement with current guidelines, a substantial part of LNB patients were treated with antibiotics longer than 14 days and/or intravenously as route of administration.
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Affiliation(s)
- Cecilie Lerche Nordberg
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Jacob Bodilsen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark.
| | - Fredrikke Christie Knudtzen
- Clinical Centre for Emerging and Vector-borne Infections, Department of Infectious Diseases, Odense University Hospital, Denmark.
| | - Merete Storgaard
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark.
| | - Christian Brandt
- Department of Pulmonary and Infectious Diseases, Nordsjællands University Hospital, Hillerød, Denmark.
| | - Lothar Wiese
- Department of Infectious Diseases, Sjællands University Hospital, Roskilde, Denmark.
| | - Birgitte Rønde Hansen
- Department of Infectious Diseases, Hvidovre University Hospital, Copenhagen, Denmark.
| | - Åse Bengård Andersen
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Henrik Nielsen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark.
| | - Anne-Mette Lebech
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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Solheim AM, Ljøstad U, Mygland Å. Six versus two weeks treatment with doxycycline in Lyme neuroborreliosis: the protocol of a multicentre, non-inferiority, double-blinded and randomised controlled trial. BMJ Open 2019; 9:e027083. [PMID: 31201188 PMCID: PMC6576128 DOI: 10.1136/bmjopen-2018-027083] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Current treatment guidelines for European Lyme neuroborreliosis (LNB) recommend cephalosporins, penicillin or doxycycline for 14-28 days but evidence for optimal treatment length is poor. Treatment lengths in clinical practice tend to exceed the recommendations. Most patients experience a rapid improvement of symptoms and neurological findings within days of treatment, but some report long-term complaints. The underlying mechanisms of remaining complaints are debated, and theories as ongoing chronic infection with Borrelia burgdorferi, dysregulated immune responses, genetic predisposition, coinfection with multiple tick-borne pathogens, structural changes in CNS and personal traits have been suggested. The main purpose of our trial is to address the hypothesis of improved outcome after long-term antibiotic treatment of LNB, by comparing efficacy of treatment with 2 and 6 weeks courses of doxycycline. METHODS AND ANALYSIS The trial has a multicentre, non-inferiority, double-blinded design. One hundred and twenty patients diagnosed with LNB according to European Federation of Neurological Societies (EFNS)guidelines will be randomised to 6 or 2 weeks treatment with oral doxycycline. The patients will be followed for 12 months. The primary endpoint is improvement on a composite clinical score (CCS) from baseline to 6 months after inclusion. Secondary endpoints are improvements in the CCS 12 months after inclusion, fatigue scored on Fatigue Severity Scale, subjective symptoms on the Patient Health Questionnaire-15 scale, health-related quality of life scored on RAND 36-item short form health survey and safety as measured by side effects of the two treatment arms. Blood and cerebrospinal fluid (CSF) are collected from inclusion and throughout the follow-up and a biobank will be established. The study started including patients in November 2015 and will continue throughout December 2019. ETHICS AND DISSEMINATION The study is approved by the Norwegian regional committees for medical and health research ethics and the Norwegian Medicines Agency. Data from the study will be published in peer-reviewed medical journals. TRIAL REGISTRATION NUMBER 2015-001481-25.
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Affiliation(s)
- Anne Marit Solheim
- Department of Neurology, Sørlandet Hospital, Kristiansand, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Unn Ljøstad
- Department of Neurology, Sørlandet Hospital, Kristiansand, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Åse Mygland
- Department of Neurology, Sørlandet Hospital, Kristiansand, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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