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Boeddha NP, Atkins L, de Groot R, Driessen G, Hazelzet J, Zenz W, Carrol ED, Anderson ST, Martinon-Torres F, Agyeman PKA, Galassini R, Herberg J, Levin M, Schlapbach LJ, Emonts M. Group A streptococcal disease in paediatric inpatients: a European perspective. Eur J Pediatr 2023; 182:697-706. [PMID: 36449079 PMCID: PMC9709363 DOI: 10.1007/s00431-022-04718-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/13/2022] [Accepted: 11/14/2022] [Indexed: 12/05/2022]
Abstract
Group A streptococcal (GAS) disease shows increasing incidence worldwide. We characterised children admitted with GAS infection to European hospitals and studied risk factors for severity and disability. This is a prospective, multicentre, cohort study (embedded in EUCLIDS and the Swiss Pediatric Sepsis Study) including 320 children, aged 1 month to 18 years, admitted with GAS infection to 41 hospitals in 6 European countries from 2012 to 2016. Demographic, clinical, microbiological and outcome data were collected. A total of 195 (61%) patients had sepsis. Two hundred thirty-six (74%) patients had GAS detected from a normally sterile site. The most common infection sites were the lower respiratory tract (LRTI) (22%), skin and soft tissue (SSTI) (23%) and bone and joint (19%). Compared to patients not admitted to PICU, patients admitted to PICU more commonly had LRTI (39 vs 8%), infection without a focus (22 vs 8%) and intracranial infection (9 vs 3%); less commonly had SSTI and bone and joint infections (p < 0.001); and were younger (median 40 (IQR 21-83) vs 56 (IQR 36-85) months, p = 0.01). Six PICU patients (2%) died. Sequelae at discharge from hospital were largely limited to patients admitted to PICU (29 vs 3%, p < 0.001; 12% overall) and included neurodisability, amputation, skin grafts, hearing loss and need for surgery. More patients were recruited in winter and spring (p < 0.001). CONCLUSION In an era of observed marked reduction in vaccine-preventable infections, GAS infection requiring hospital admission is still associated with significant severe disease in younger children, and short- and long-term morbidity. Further advances are required in the prevention and early recognition of GAS disease. WHAT IS KNOWN • Despite temporal and geographical variability, there is an increase of incidence of infection with group A streptococci. However, data on the epidemiology of group A streptococcal infections in European children is limited. WHAT IS NEW • In a large, prospective cohort of children with community-acquired bacterial infection requiring hospitalisation in Europe, GAS was the most frequent pathogen, with 12% disability at discharge, and 2% mortality in patients with GAS infection. • In children with GAS sepsis, IVIG was used in only 4.6% of patients and clindamycin in 29% of patients.
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Affiliation(s)
- Navin P Boeddha
- Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
- Department of Pediatrics, Maasstad Hospital, Rotterdam, the Netherlands
| | - Lucy Atkins
- Paediatric Immunology, Infectious Diseases & Allergy Dept., Great North Children's Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, RVI, Clinical Resources Building, Queen Victoria Road, Newcastle Upon Tyne, NE1 4LP, UK
| | - Ronald de Groot
- Division of Pediatric Infectious Diseases and Immunology and Laboratory of Infectious Diseases, Department of Pediatrics, Radboud Institute of Molecular Life Sciences, Radboudumc, Nijmegen, the Netherlands
| | - Gertjan Driessen
- Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
- Department of Paediatrics, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Jan Hazelzet
- Department of Public Health, Erasmus MC, Rotterdam, the Netherlands
| | - Werner Zenz
- Department of General Pediatrics, Medical University of Graz, Graz, Austria
| | - Enitan D Carrol
- Institute of Infection, Veterinary and Ecological Sciences Global Health, University of Liverpool, Liverpool, UK
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | | | - Federico Martinon-Torres
- Translational Pediatrics and Infectious Diseases Section, Pediatrics Department, Santiago de Compostela, Spain
| | - Philipp K A Agyeman
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Rachel Galassini
- Section of Paediatrics Division of Infectious Disease, Imperial College of London, London, UK
| | - Jethro Herberg
- Section of Paediatrics Division of Infectious Disease, Imperial College of London, London, UK
| | - Michael Levin
- Section of Paediatrics Division of Infectious Disease, Imperial College of London, London, UK
| | - Luregn J Schlapbach
- Neonatal and Pediatric Intensive Care Unit, University Children`s Hospital Zürich and Children`s Research Center, Zurich, Switzerland
| | - Marieke Emonts
- Paediatric Immunology, Infectious Diseases & Allergy Dept., Great North Children's Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, RVI, Clinical Resources Building, Queen Victoria Road, Newcastle Upon Tyne, NE1 4LP, UK.
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK.
- NIHR Newcastle Biomedical Research Centre Based at Newcastle Upon Tyne Hospitals NHS Trust and Newcastle University, Newcastle Upon Tyne, UK.
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Boeddha NP, Schlapbach LJ, Driessen GJ, Herberg JA, Rivero-Calle I, Cebey-López M, Klobassa DS, Philipsen R, de Groot R, Inwald DP, Nadel S, Paulus S, Pinnock E, Secka F, Anderson ST, Agbeko RS, Berger C, Fink CG, Carrol ED, Zenz W, Levin M, van der Flier M, Martinón-Torres F, Hazelzet JA, Emonts M. Mortality and morbidity in community-acquired sepsis in European pediatric intensive care units: a prospective cohort study from the European Childhood Life-threatening Infectious Disease Study (EUCLIDS). Crit Care 2018; 22:143. [PMID: 29855385 PMCID: PMC5984383 DOI: 10.1186/s13054-018-2052-7] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [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: 01/30/2018] [Accepted: 04/29/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Sepsis is one of the main reasons for non-elective admission to pediatric intensive care units (PICUs), but little is known about determinants influencing outcome. We characterized children admitted with community-acquired sepsis to European PICUs and studied risk factors for mortality and disability. METHODS Data were collected within the collaborative Seventh Framework Programme (FP7)-funded EUCLIDS study, which is a prospective multicenter cohort study aiming to evaluate genetic determinants of susceptibility and/or severity in sepsis. This report includes 795 children admitted with community-acquired sepsis to 52 PICUs from seven European countries between July 2012 and January 2016. The primary outcome measure was in-hospital death. Secondary outcome measures were PICU-free days censured at day 28, hospital length of stay, and disability. Independent predictors were identified by multivariate regression analysis. RESULTS Patients most commonly presented clinically with sepsis without a source (n = 278, 35%), meningitis/encephalitis (n = 182, 23%), or pneumonia (n = 149, 19%). Of 428 (54%) patients with confirmed bacterial infection, Neisseria meningitidis (n = 131, 31%) and Streptococcus pneumoniae (n = 78, 18%) were the main pathogens. Mortality was 6% (51/795), increasing to 10% in the presence of septic shock (45/466). Of the survivors, 31% were discharged with disability, including 24% of previously healthy children who survived with disability. Mortality and disability were independently associated with S. pneumoniae infections (mortality OR 4.1, 95% CI 1.1-16.0, P = 0.04; disability OR 5.4, 95% CI 1.8-15.8, P < 0.01) and illness severity as measured by Pediatric Index of Mortality (PIM2) score (mortality OR 2.8, 95% CI 1.3-6.1, P < 0.01; disability OR 3.4, 95% CI 1.8-6.4, P < 0.001). CONCLUSIONS Despite widespread immunization campaigns, invasive bacterial disease remains responsible for substantial morbidity and mortality in critically ill children in high-income countries. Almost one third of sepsis survivors admitted to the PICU were discharged with some disability. More research is required to delineate the long-term outcome of pediatric sepsis and to identify interventional targets. Our findings emphasize the importance of improved early sepsis-recognition programs to address the high burden of disease.
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Affiliation(s)
- Navin P. Boeddha
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children’s Hospital, University Medical Center Rotterdam, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
- Department of Pediatrics, Division of Pediatric Infectious Diseases & Immunology, Erasmus MC-Sophia Children’s Hospital, University Medical Center Rotterdam, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Luregn J. Schlapbach
- Faculty of Medicine, The University of Queensland, St Lucia Queensland, Brisbane, 4072 Australia
- Paediatric Critical Care Research Group, Mater Research Institute, The University of Queensland, Aubigny Place, Raymond Terrace, Brisbane, Australia
- Paediatric Intensive Care Unit, Lady Cilento Children’s Hospital, Children’s Health Queensland, 501 Stanley St, Brisbane, Australia
- Department of Pediatrics, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 8, 3010 Bern, Switzerland
| | - Gertjan J. Driessen
- Department of Pediatrics, Division of Pediatric Infectious Diseases & Immunology, Erasmus MC-Sophia Children’s Hospital, University Medical Center Rotterdam, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
- Department of Paediatrics, Juliana Children’s Hospital/Haga Teaching Hospital, Els Borst-Eilersplein 275, 2545 AA The Hague, The Netherlands
| | - Jethro A. Herberg
- Section of Pediatrics, Imperial College London, Level 2, Faculty Building South Kensington Campus, London, SW7 2AZ UK
| | - Irene Rivero-Calle
- Translational Pediatrics and Infectious Diseases Section- Pediatrics Department, Hospital Clínico Universitario de Santiago de Compostela, Travesía da Choupana, 15706 Santiago de Compostela, Spain
- Genetics- Vaccines- Infectious Diseases and Pediatrics research group GENVIP, Health Research Institute of Santiago IDIS/SERGAS, Travesía da Choupana, 15706 Santiago de Compostela, Spain
| | - Miriam Cebey-López
- Genetics- Vaccines- Infectious Diseases and Pediatrics research group GENVIP, Health Research Institute of Santiago IDIS/SERGAS, Travesía da Choupana, 15706 Santiago de Compostela, Spain
| | - Daniela S. Klobassa
- Department of General Paediatrics, Medical University of Graz, Auenbruggerplatz 34/2, A-8036 Graz, Austria
| | - Ria Philipsen
- Radboudumc Technology Center Clinical Studies, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
- Section of Pediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Institute for Molecular Life Sciences, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Ronald de Groot
- Section of Pediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Institute for Molecular Life Sciences, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - David P. Inwald
- Department of Paediatrics, Faculty of Medicine, Imperial College London, South Kensington Campus, London, SW7 2AZ UK
- St Mary’s Hospital, Imperial College Healthcare NHS Trust, Praed Street, London, W2 1NY UK
| | - Simon Nadel
- Department of Paediatrics, Faculty of Medicine, Imperial College London, South Kensington Campus, London, SW7 2AZ UK
- St Mary’s Hospital, Imperial College Healthcare NHS Trust, Praed Street, London, W2 1NY UK
| | - Stéphane Paulus
- Division of Paediatric Infectious Diseases, Alder Hey Children’s NHS Foundation Trust, Eaton Rd, Liverpool, L12 2AP UK
- Institute of Infection & Global Health, University of Liverpool, 8 West Derby St, Liverpool, L7 3EA UK
| | - Eleanor Pinnock
- Micropathology Ltd, University of Warwick Science Park, Venture Centre, Sir William Lyons Road, Coventry, CV4 7EZ UK
| | - Fatou Secka
- Medical research Council Unit, Atlantic Boulevard, Fajara, P. O. Box 273, Banjul, The Gambia
| | - Suzanne T. Anderson
- Medical research Council Unit, Atlantic Boulevard, Fajara, P. O. Box 273, Banjul, The Gambia
| | - Rachel S. Agbeko
- Department of Paediatric Intensive Care, Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Victoria Wing, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP UK
- Institute of Cellular Medicine, Newcastle University, 4th Floor, William Leech Building, Framlington Place, Newcastle upon Tyne, NE2 4HH UK
| | - Christoph Berger
- Division of Infectious Diseases and Hospital Epidemiology, and Children’s Research Center, University Children’s Hospital Zurich, Steinwiesenstrasse 75, 8032 Zurich, Switzerland
| | - Colin G. Fink
- Micropathology Ltd, University of Warwick Science Park, Venture Centre, Sir William Lyons Road, Coventry, CV4 7EZ UK
| | - Enitan D. Carrol
- Institute of Infection & Global Health, University of Liverpool, 8 West Derby St, Liverpool, L7 3EA UK
| | - Werner Zenz
- Department of General Paediatrics, Medical University of Graz, Auenbruggerplatz 34/2, A-8036 Graz, Austria
| | - Michael Levin
- Section of Pediatrics, Imperial College London, Level 2, Faculty Building South Kensington Campus, London, SW7 2AZ UK
| | - Michiel van der Flier
- Radboudumc Technology Center Clinical Studies, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
- Section of Pediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Institute for Molecular Life Sciences, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
- Pediatric Infectious Diseases and Immunology Amalia Children’s Hospital, and Radboudumc Expertise Center for Immunodeficiency and Autoinflammation (REIA), Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Federico Martinón-Torres
- Translational Pediatrics and Infectious Diseases Section- Pediatrics Department, Hospital Clínico Universitario de Santiago de Compostela, Travesía da Choupana, 15706 Santiago de Compostela, Spain
- Genetics- Vaccines- Infectious Diseases and Pediatrics research group GENVIP, Health Research Institute of Santiago IDIS/SERGAS, Travesía da Choupana, 15706 Santiago de Compostela, Spain
| | - Jan A. Hazelzet
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Marieke Emonts
- Institute of Cellular Medicine, Newcastle University, 4th Floor, William Leech Building, Framlington Place, Newcastle upon Tyne, NE2 4HH UK
- Paediatric Infectious Diseases and Immunology Department, Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Victoria Wing, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP UK
- NIHR Newcastle Biomedical Research Centre based at Newcastle upon Tyne Hospitals NHS Trust and Newcastle University, Westgate Rd, Newcastle upon Tyne, NE4 5PL UK
| | - on behalf of the EUCLIDS consortium
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children’s Hospital, University Medical Center Rotterdam, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
- Department of Pediatrics, Division of Pediatric Infectious Diseases & Immunology, Erasmus MC-Sophia Children’s Hospital, University Medical Center Rotterdam, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
- Faculty of Medicine, The University of Queensland, St Lucia Queensland, Brisbane, 4072 Australia
- Paediatric Critical Care Research Group, Mater Research Institute, The University of Queensland, Aubigny Place, Raymond Terrace, Brisbane, Australia
- Paediatric Intensive Care Unit, Lady Cilento Children’s Hospital, Children’s Health Queensland, 501 Stanley St, Brisbane, Australia
- Department of Pediatrics, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 8, 3010 Bern, Switzerland
- Department of Paediatrics, Juliana Children’s Hospital/Haga Teaching Hospital, Els Borst-Eilersplein 275, 2545 AA The Hague, The Netherlands
- Section of Pediatrics, Imperial College London, Level 2, Faculty Building South Kensington Campus, London, SW7 2AZ UK
- Translational Pediatrics and Infectious Diseases Section- Pediatrics Department, Hospital Clínico Universitario de Santiago de Compostela, Travesía da Choupana, 15706 Santiago de Compostela, Spain
- Genetics- Vaccines- Infectious Diseases and Pediatrics research group GENVIP, Health Research Institute of Santiago IDIS/SERGAS, Travesía da Choupana, 15706 Santiago de Compostela, Spain
- Department of General Paediatrics, Medical University of Graz, Auenbruggerplatz 34/2, A-8036 Graz, Austria
- Radboudumc Technology Center Clinical Studies, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
- Section of Pediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Institute for Molecular Life Sciences, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
- Department of Paediatrics, Faculty of Medicine, Imperial College London, South Kensington Campus, London, SW7 2AZ UK
- St Mary’s Hospital, Imperial College Healthcare NHS Trust, Praed Street, London, W2 1NY UK
- Division of Paediatric Infectious Diseases, Alder Hey Children’s NHS Foundation Trust, Eaton Rd, Liverpool, L12 2AP UK
- Institute of Infection & Global Health, University of Liverpool, 8 West Derby St, Liverpool, L7 3EA UK
- Micropathology Ltd, University of Warwick Science Park, Venture Centre, Sir William Lyons Road, Coventry, CV4 7EZ UK
- Medical research Council Unit, Atlantic Boulevard, Fajara, P. O. Box 273, Banjul, The Gambia
- Department of Paediatric Intensive Care, Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Victoria Wing, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP UK
- Institute of Cellular Medicine, Newcastle University, 4th Floor, William Leech Building, Framlington Place, Newcastle upon Tyne, NE2 4HH UK
- Division of Infectious Diseases and Hospital Epidemiology, and Children’s Research Center, University Children’s Hospital Zurich, Steinwiesenstrasse 75, 8032 Zurich, Switzerland
- Pediatric Infectious Diseases and Immunology Amalia Children’s Hospital, and Radboudumc Expertise Center for Immunodeficiency and Autoinflammation (REIA), Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
- Paediatric Infectious Diseases and Immunology Department, Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Victoria Wing, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP UK
- NIHR Newcastle Biomedical Research Centre based at Newcastle upon Tyne Hospitals NHS Trust and Newcastle University, Westgate Rd, Newcastle upon Tyne, NE4 5PL UK
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Branscheidt M, Schneider J, Michel P, Eskioglou E, Kaegi G, Stark R, Fischer U, Jung S, Arnold M, Wertli M, Held U, Wegener S, Luft A, Sarikaya H. No Impact of Body Mass Index on Outcome in Stroke Patients Treated with IV Thrombolysis BMI and IV Thrombolysis Outcome. PLoS One 2016; 11:e0164413. [PMID: 27727305 PMCID: PMC5058473 DOI: 10.1371/journal.pone.0164413] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 09/23/2016] [Indexed: 12/13/2022] Open
Abstract
Background and Purpose The impact of excess body weight on prognosis after stroke is controversial. Many studies report higher survival rates in obese patients (“obesity paradox”). Recently, obesity has been linked to worse outcomes after intravenous (IV) thrombolysis, but the number and sample size of these studies were small. Here, we aimed to assess the relationship between body weight and stroke outcome after IV thrombolysis in a large cohort study. Methods In a prospective observational multicenter study, we analyzed baseline and outcome data of 896 ischemic stroke patients who underwent IV thrombolysis. Patients were categorized according to body mass index (BMI) as underweight (<18.5 kg/m2), normal weight (18.5–24.9 kg/m2), overweight (25–29.9 kg/m2), obese (30–34.9 kg/m2) or severely obese (>35 kg/m2). Using uni- and multivariate modeling, we assessed the relationship of BMI with favorable outcome (defined as modified Rankin Scale 0 or 1) and mortality 3 months after stroke as well as the occurrence of symptomatic intracerebral hemorrhages (sICH). We also measured the incidence of patients that had an early neurological improvement of >40% on the National Institutes of Health Stroke Scale (NIHSS) after 24 hours. Results Among 896 patients, 321 were normal weight (35.8%), 22 underweight (2.5%), 378 overweight (42.2%), 123 obese (13.7%) and 52 severely obese (5.8%). Three-month mortality was comparable in obese vs. non-obese patients (8.1% vs. 8.3%) and did not differ significantly among different BMI groups. This was also true for favorable clinical outcome, risk of sICH and early neurological improvement on NIHSS at 24 hours. These results remained unchanged after adjusting for potential confounding factors in the multivariate analyses. Conclusion BMI was not related to clinical outcomes in stroke patients treated with IVT. Our data suggest that the current weight-adapted dosage scheme of IV alteplase is appropriate for different body weight groups, and challenge the existence of the obesity paradox after stroke.
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Affiliation(s)
- Meret Branscheidt
- Department of Neurology, University Hospital of Zurich, Switzerland
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland, United States of America
| | | | - Patrik Michel
- Department of Neurology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Switzerland
| | - Elissavet Eskioglou
- Department of Neurology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Switzerland
| | - Georg Kaegi
- Department of Neurology, Kantonsspital St. Gallen, Switzerland
| | - Robert Stark
- Department of Neurology, Kantonsspital St. Gallen, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, Switzerland
| | - Simon Jung
- Department of Neurology, University Hospital Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, University Hospital Bern, Switzerland
| | - Maria Wertli
- Horten Centre, University of Zurich, Switzerland
- Department of Internal Medicine, University Hospital Bern, Switzerland
| | - Ulrike Held
- Horten Centre, University of Zurich, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital of Zurich, Switzerland
| | - Andreas Luft
- Department of Neurology, University Hospital of Zurich, Switzerland
| | - Hakan Sarikaya
- Department of Neurology, University Hospital of Zurich, Switzerland
- Department of Neurology, University Hospital Bern, Switzerland
- * E-mail:
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